Medicare Bulletin - May 2017 · 2017. 5. 1. · Internal Medicine. The Medicare Learning Network ® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes

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Medicare BulletinJurisdiction 15

M AY 201 7 • W W W.C G S M E D I C A R E .CO M

Reaching Out to the Medicare

Community

© 2017 Copyright, CGS Administrators, LLC.

http://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 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2017-05 MAY 2017 2

HOME HEALTH PROVIDERS

Home Health Ordering/Referring Requirements 3

MM9898: Manual Updates to Clarify Payment Policy Changes for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device and the Outlier Payment Methodology for Home Health Services 5

MM9968: Extension of the Transition to the Fully Adjusted Durable Medical Equipment Prosthetics, Orthotics, and Supplies Payment Rates Under Section 16007 of the 21st Century Cures Act 7

MM9988: April Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule 9

Reducing Home Health Errors for Reason Codes (RC) 38107 11

SE17009: Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information 13

HOME HEALTH & HOSPICE PROVIDERS

A New Look for the CGS Website 14

Attention myCGS Web Portal Users: Multi-Factor Authentication (MFA) is Mandatory 15

CGS Overpayment Demand Letter is Required to Appeal Decisions from the Supplemental Medical Review Contractor (SMRC) and the Recovery Audit (RA) Contractor 17

CGS Website Updates 17

Evaluate Our Services! 18

Interest Payment on Claims 19

MLN Connects™ Provider eNews 20

MM9869: Healthcare Provider Taxonomy Codes (HPTCs) April 2017 Code Set Update 21

MM9878: Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update 22

MM10002: April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1 23

MM10005: April 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) 25

Provider Contact Center (PCC) Training 29

Quarterly Provider Update 30

SE1605 (Revised): Provider Enrollment Revalidation – Cycle 2 31

Upcoming Educational Events 37

Valid/Invalid G-Codes for Home Health and Hospice 37

http://go.cms.gov/MLNGenInfo

Attention myCGS Web Portal Users: Multi-Factor Authentication (MFA) is Mandatory Due to increased security requirements mandated by the Centers for Medicare & Medicaid (CMS), all myCGS portal Users MUST sign up for Multi-Factor Authentication (MFA) by July 1, 2017. Go to http://www.cgsmedicare.com/articles/cope2540.html for important information about the MFA timeline and instructions for activating MFA.

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http://go.cms.gov/MLNGenInfo

http://www.cgsmedicare.com/articles/cope2540.html

http://www.cgsmedicare.com/articles/cope2540.html

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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. © 2017 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN • GR 2017-05 MAY 2017

RETURN TO TABLE OF CONTENTS

3

For Home Health Providers

Home Health Ordering/Referring Requirements

This article serves as a reminder for home health providers about the ordering/referring billing requirements. Please share this information with your billing staff.

Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). In addition, the physician who orders/refers a patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS).

The Fiscal Intermediary Standard System (FISS) edits home health claims to ensure the attending physician’s and referring physician’s National Provider Identifier (NPI) is valid and that the attending physician and referring physician is enrolled in Medicare, and is in the PECOS file. Providers enter the ordering/referring physician’s NPI and name on FISS Claim Page 03 as shown below.

FISS Claim Page 03

ATT PHYS NPI ########## L LNAME F FNAME M SCOPR PHYS NPI L F M SCOTH OPR NPI L F M SCREN PHYS NPI L F M SC

REF PHYS NPI ########## L LNAME F FNAME M SC

Taking the following steps will help to avoid denial of your home health claims.

Step 1: Access the “Order and Referring” data file at https://data.cms.gov/ to verify the physician’s NPI, last name, and first name. This file does not include the physician’s specialty code.

Step 2: Access the NPPES website at https://npiregistry.cms.hhs.gov/ to verify the physician’s specialty is a valid home health ordering/referring specialty. Use the information under the “Primary Taxonomy” field to cross reference the list (found below) of valid home health ordering/referring specialty codes. In the example below, the specialty code is 11 for Internal Medicine.

The Medicare Learning Network® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more.

To stay informed about all of the CMS MLN products, refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf and subscribe to the CMS electronic mailing lists. Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.

Medicare Learning Network®

A Valuable Educational Resource!


https://data.cms.gov

https://npiregistry.cms.hhs.gov

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



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

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NPPES Example:

Step 3: Prior to submitting your claim, verify that the following matches the ordering/referring data file at https://data.cms.gov/ exactly.

yy The NPI of the physician

yy The first four letters of the physician’s last name

yy The first letter of the physician’s first name

Your home health claim will deny with reason code 37236, or 37237 (adjustments) when:

yy The attending physician NPI on the claim is not found in the eligible attending physician file from PECOS; or

yy The attending physician NPI on the claim is found in the eligible attending physician file from PECOS but the name on the claim does not match the name in the PECOS file; or

yy The specialty code is not a valid eligible code (see below for a list of valid home health ordering/referring specialty codes).

NOTE: There may be times when a physician has an enrollment record in PECOS, but they are not located on the ordering/referring data file. This is often due to the physician not completing the necessary information in PECOS which allows them to be included in the ordering/referring data file. You may want to contact the physician and ask that they complete the necessary information in PECOS.

Valid Home Health Ordering/Referring Physician Specialty Codes

Code Physician Specialty Code Physician Specialty 02 General Surgery 36 Nuclear Medicine 03 Allergy/Immunology 37 Pediatric Medicine 04 Otolaryngology 38 Geriatric Medicine 05 Anesthesiology 39 Nephrology 06 Cardiology 40 Hand Surgery 07 Dermatology 44 Infectious Disease 08 Family Practice 46 Endocrinology 09 Interventional Pain Management 48 Podiatry 10 Gastroenterology 66 Rheumatology 11 Internal Medicine 72 Pain Management 12 Osteopathic Manipulative Therapy 76 Peripheral Vascular Disease 13 Neurology 77 Vascular Surgery 14 Neurosurgery 78 Cardiac Surgery 16 Obstetrics/Gynecology 79 Addiction Medicine 17 Hospice and Palliative Care 81 Critical Care (Intensivists)20 Orthopedic Surgery 82 Hematology 22 Pathology 83 Hematology/Oncology 24 Plastic and Reconstructive Surgery 84 Preventive Medicine 25 Physical Medicine and Rehabilitation 85 Maxillofacial Surgery 26 Psychiatry 86 Neuropsychiatry 27 Geriatric Psychiatry 90 Medical Oncology 28 Colorectal Surgery (Formerly Proctology) 91 Surgical Oncology


https://data.cms.gov

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Code Physician Specialty Code Physician Specialty 28 Colorectal Surgery (Formerly Proctology) 92 Radiation Oncology29 Pulmonary Disease 93 Emergency Medicine30 Diagnostic Radiology 94 Interventional Radiology33 Thoracic Surgery 98 Gynecological/Oncology 34 Urology C6 Hospitalist

Additional Resourcesyy CGS Ordering/Referring Physician Checklist for Home Health Agencies Quick Resource Tool (QRT) - http://www.cgsmedicare.com/hhh/education/materials/pdf/ord_ref_phys_checklist_hha.pdf

yy SE1305 – Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856) - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf

yy SE1413 – Certifying Physicians and the Phase 2 Ordering and Referring Denial Edits for Home Health Agencies (HHAs) - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1413.pdf

Please share this information with your billing staff.


MM9898: Manual Updates to Clarify Payment Policy Changes for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device and the Outlier Payment Methodology for Home Health Services

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: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html

MLN Matters® Number: MM9898Related CR Release Date: February 24, 2017Related CR Transmittal #: R233BP

Change Request (CR) #: CR 9898 Effective Date: January 1, 2017Implementation Date: March 27, 2017

Provider Types AffectedThis MLN Matters® Article is intended for Home Health Agencies (HHAs) submitting claims to Home Health & Hospice Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action NeededChange Request (CR) 9898 updates the “Medicare Benefit Policy Manual” policies discussed in the Calendar Year (CY) 2017 Home Health (HH) Prospective Payment System (PPS) (HH PPS) Final Rule, published November 3, 2016. These policies relate to payment for furnishing of Negative Pressure Wound Therapy (NPWT) using a disposable device, as well as changes to the methodology used to calculate outlier payments to Home Health Agencies (HHAs). These changes relate to multiple revised sections of Chapter 7 in the “Medicare Benefit Policy Manual.” Please make sure that your billing staffs are aware of these changes.


http://www.cgsmedicare.com/hhh/education/materials/pdf/ord_ref_phys_checklist_hha.pdf


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf




https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html


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BackgroundIn the CY 2017 HH PPS Final Rule, CMS finalized clarifications and revisions to policies related to payment for furnishing of NPWT using a disposable device, as well as change to the methodology used to calculate outlier payments to HHAs.

Negative Pressure Wound Therapy Using a Disposable DeviceThe Consolidated Appropriations Act of 2016 (Pub. L. 114-113) requires a separate payment to a HHA for an applicable disposable device when furnished on or after January 1, 2017, to an individual who receives Home Health Services for which payment is made under the Medicare home health benefit. The legislation defines an applicable device as a disposable NPWT device that is an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy used in lieu of a conventional NPWT DME system. The separate payment amount for a disposable NPWT device is to be set equal to the amount of the payment that would be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS) using the Level I HCPCS code, otherwise referred to as Current Procedural Terminology (CPT® 4) codes, for which the description for a professional service includes the furnishing of such a device.

Payment for HH visits related to wound care, but not requiring the furnishing of an entirely new disposable NPWT device, will be covered by the HH PPS episode payment and must be billed using the HH claim. Where a HH visit is exclusively for the purpose of furnishing NPWT using a disposable device, the HHA will submit only a type of claim that will be paid for separately outside the HH PPS (Type of Bill (TOB) 34x). Where, however, the home health visit includes the provision of other home health services in addition to, and separate from, furnishing NPWT using a disposable device, the HHA will submit both a home health claim and a TOB 34x—the home health claim covering the other home health services, and the TOB 34x capturing the furnishing of NPWT using a disposable device.

EXAMPLE: A patient requires NPWT for the treatment of a wound. On Monday, a nurse assesses a patient’s wound, applies a new disposable NPWT device, and provides wound care education to the patient and family. The nurse returns on Thursday for wound assessment and replaces the fluid management system (or dressing) for the existing disposable NPWT, but does not replace the entire device. The nurse returns the following Monday, assesses the patient’s condition and the wound, and replaces the device that had been applied on the previous Monday with a new disposable NPWT device. In this scenario, the billing procedures are as follows:

For both Monday visits, all the services provided by the nurse were associated with furnishing NPWT using a disposable device. The nurse did not provide any services that were not associated with furnishing NPWT using a disposable device. Therefore, all the nursing services for both Monday visits should be reported on TOB 34x with CPT code 97607 or 97608. None of the services should be reported on the HH claim.

For the Thursday visit, the nurse checked the wound, but did not apply a new disposable NPWT device. Thus, even though the nurse provided care related to the wound, those services would not be considered furnishing NPWT using a disposable device.

Therefore, the services should be reported on TOB 32x and no services should be reported on TOB 34x.

For instructions on billing for NPWT using a disposable device, see the “Medicare Claims Processing Manual,” Chapter 10, Section 90.3, “Billing Instructions for Disposable Negative Pressure Wound Therapy Services” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf)


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf


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Outlier PaymentsThe Centers for Medicare & Medicaid Services (CMS) finalized the proposal to change the methodology used to calculate outlier payments, moving from a cost-per-visit approach to a cost-per-unit approach (1 unit = 15 minutes). This approach more accurately reflects the cost of an outlier episode of care and thus better aligns outlier payments with episode costs than the cost-per-visit approach.

Additional InformationThe official instruction, CR9898 issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R233BP.pdf.

If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.


MM9968: Extension of the Transition to the Fully Adjusted Durable Medical Equipment Prosthetics, Orthotics, and Supplies Payment Rates Under Section 16007 of the 21st Century Cures Act


MLN Matters® Number: MM9968Related CR Release Date: February 10, 2017 Related CR Transmittal #: R3716CP

Change Request (CR) #: CR 9968Effective Date: July 1, 2016 Implementation Date: July 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for providers who bill Medicare Administrative Contractors (MACs) for Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) and services provided to Medicare beneficiaries.

Provider Action NeededChange Request (CR) 9968 provides instructions regarding the implementation of revised 2016 DMEPOS fee schedule amounts based on changes mandated by Section 16007 of the 21st Century Cures Act. These changes relate to the new Chapter 20, Section 20.6 (Phase-In for Competitive Bidding Rates in Areas Not in a Competitive Bid Area) of the “Medicare Claims Processing Manual,” which is part of CR9968. Please make sure your billing staff is aware of these instructions.

BackgroundEffective January 1, 2017, legislation requires changes to the July and October 2016 fee schedule amounts for certain items. Section 1834(a)(1)(F)(ii) of the Social Security Act (the Act) mandates adjustments to the fee schedule amounts for certain DME items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DME.

Regulations at Section 414.210(g)(9) phased in these adjusted fees so that from January 1, 2016, through June 30, 2016, the fee schedule amount in non-bid areas was based on 50


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R233BP.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R233BP.pdf



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percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount (the 2015 fee schedule amount updated by the 2016 covered item update). Beginning July 1, 2016, the fee schedule amounts for non-bid areas reverted to 100 percent of the adjusted payment amounts determined using competitive bidding information.

Section 16007 of the 21st Century Cures Act changes the 2016 fee schedule transition period so that payment based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount extends from June 30, 2016, to December 31, 2016. Section 16007 also changes from July 1, 2016, to January 1, 2017, the date that payment based on 100 percent of the adjusted payment amounts in non-bid areas is effective.

To supplement Section 16007 for dates of service July 1, 2016, through December 31, 2016, the 50/50 blend fee schedules have been recalculated so that the adjusted portion of the payment blend utilizes July 1, 2016, adjusted fees. Also, the KE modifier fee schedules for items bid in the initial Round 1 Competitive Bidding Program (CBP) have been added back to the fee schedule file for this extended phase-in period. The KE modifier was added to the DMEPOS fee schedule file as part of the January 2009 fee schedule update and described items that were bid under the initial Round 1 CBP but were used with non-competitive bid base equipment. Suppliers should submit a request for reopening if their claim for dates of service between July 1, 2016, and December 31, 2016, should have been processed with the KE modifier.

The revised July 1, 2016, through December 31, 2016, DMEPOS and parenteral and enteral nutrition (PEN) fee schedule files will be made available to the DME MACs. The previously posted July 2016 and October 2016 DMEPOS and PEN public use files will be revised to reflect the new fee schedule amounts associated with the extension of the transition period. MACs will accept the KE modifier on the adjusted claims. In addition, for claims that the KE modifier would have been applicable to, the supplier may adjust the claim or notify MACs to adjust the claims after the mass adjustments for the 50/50 fee blend have been completed.

Your MAC will reprocess affected claims and adjust claims that were previously paid. The MACS will begin this claim adjustment process once the revised fee schedule files are available.

Additional InformationThe official instruction, CR9968, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3716CP.pdf.



https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3716CP.pdf


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MM9988: April Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule


MLN Matters® Number: MM9988Related CR Release Date: March 3, 2017 Related CR Transmittal #: R3729CP

Change Request (CR) #: CR9988 Effective Date: April 1, 2017Implementation Date: April 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services paid under the DMEPOS fee schedule.

What You Need to KnowChange Request (CR) 9988 provides the April 2017 quarterly update for the Medicare DMEPOS fee schedule, and it includes information, when necessary, to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes.

BackgroundThe DMEPOS fee schedules are updated on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. The quarterly update process for the DMEPOS fee schedule is located in the “Medicare Claims Processing Manual” (Pub.100-04, Chapter 23, Section 60) at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf.

Payment on a fee schedule basis is required for durable medical equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by the Social Security Act (§1834(a), (h), and (i)) (https://www.ssa.gov/OP_Home/ssact/title18/1834.htm). Also, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulations (CFR) §414.102 (https://www.ecfr.gov/cgi-bin/text-idx?SID=becd20e512ac4c175ad81e37e4583f85&mc=true&node=pt42.3.414&rgn=div5&wb48617274=BBDDE408#se42.3.414_1102) for parenteral and enteral nutrition (PEN), splints and casts, and intraocular lenses (IOLs) inserted in a physician’s office.

Additionally, Section §1834(a)(1)(F)(ii) of the Act (https://www.ssa.gov/OP_Home/ssact/title18/1834.htm) mandates adjustments to the fee schedule amounts for certain items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs (CBPs) for DME. The Social Security Act (§1842(s)(3)(B)) provides authority for making adjustments to the fee schedule amount for enteral nutrients, equipment, and supplies (enteral nutrition) based on information from CBPs. Also, the adjusted fees apply a rural payment rule. The DMEPOS and PEN fee schedule files contain HCPCS codes that are subject to the adjustments as well as codes that are not subject to the fee schedule adjustments. Additional information on adjustments to the fee schedule amounts based on information from CBPs is available in CR 9642 (Transmittal 3551, dated June 23, 2016).






https://www.ssa.gov/OP_Home/ssact/title18/1834.htm

https://www.ecfr.gov/cgi-bin/text-idx?SID=becd20e512ac4c175ad81e37e4583f85&mc=true&node=pt42.3.414&rgn=div5&wb48617274=BBDDE408#se42.3.414_1102

https://www.ecfr.gov/cgi-bin/text-idx?SID=becd20e512ac4c175ad81e37e4583f85&mc=true&node=pt42.3.414&rgn=div5&wb48617274=BBDDE408#se42.3.414_1102



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The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. ZIP codes for non-continental Metropolitan Statistical Areas (MSA) are not included in the DMEPOS Rural ZIP code file. The DMEPOS Rural ZIP code file is updated on a quarterly basis as necessary.

The Calendar Year (CY) 2017 DMEPOS and PEN fee schedules and the April 2017 DMEPOS Rural ZIP code file public use files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the data files at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched.

KU Modifier for Complex Rehabilitative Power Wheelchair Accessories & Seat and Back Cushions

Section 16005 of the 21st Century Cures Act extends the effective date through June 30, 2017, to exclude adjustments to fees using information from CBPs for certain wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs (codes K0848 through K0864). As a result, the KU modifier fees have been added back to the DMEPOS fee schedule file effective January 1, 2017, and are effective for dates of service through June 30, 2017. The fees for items denoted with the HCPCS modifier ‘KU’ represent the unadjusted fee schedule amounts (the CY 2015 fee schedule amount updated by the 2016 and 2017 DMEPOS covered item update factor of 0.7 percent). The applicable complex rehabilitative wheelchair accessory codes are listed in CR 9520 (Transmittal 3535, dated June 7, 2016).

Note for Change Request 8822 Reclassification of Certain DME to the Capped Rental Payment Category

For dates of service on or after January 1, 2017, payment for the following HCPCS codes in all geographic areas is made on a capped rental basis: E0197, E0140, E0149, E0985, E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015, K0070, and E0955.

For dates of service on or after July 1, 2016, through December 31, 2016, these HCPCS codes were reclassified from the payment category for inexpensive and routinely purchased DME to payment on a capped rental basis in all areas except the nine Round 1 Recompete (Round 1 2014) Competitive Bidding Areas (CBAs). Program instructions on these changes were issued in CR 8822 (Transmittal 1626, dated February 19, 2016) and CR 8566 (Transmittal 1332, dated January 2, 2014). Related MLN Matters articles are at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8822.pdf and https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8566.pdf, respectively.

When submitting claims, suppliers that submit claims with more than four modifiers including when the claim is being billed with both the RT (right) and the LT (left) modifiers will include the NU (Purchase of new equipment) or RR (Rental) modifier as appropriate, the RT and LT modifiers and then the 99 modifier to signify that there are additional modifiers in use. On the narrative line, the supplier will include all applicable modifiers including the NU or RR, RT and LT modifiers.

Example

yy Procedure code: E2370

yy Units of Service = 2

yy Modifiers: RR, LT, RT, 99 (RB, KX reported in additional narrative)


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

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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8822.pdf





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Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment

CR 9848 (Transmittal 3679, dated December 16, 2016) titled Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment, updated the “Medicare Claims Processing Manual” (Pub.100-04, chapter 20, section 130.6) to clarify billing when the prescribed amount of stationary oxygen exceeds 4 liters per minute (LPM) and portable oxygen is prescribed. The QF modifier is used to denote when the oxygen flow exceeds 4 LPM and portable oxygen is prescribed.

The Social Security Act (§ 1834(a)(5)(C) and (D)) requires that when there is an oxygen flow rate that exceeds 4 LPM that the Medicare payment amount be the higher of 50 percent of the stationary payment amount (codes E0424, E0439, E1390, or E1392) or the portable oxygen add-on amount (E0431, E0433, E0434, E1392, or K0738), and never both.

To facilitate this payment calculation, the QF modifier is added to the DMEPOS fee schedule file effective April 1, 2017, for both stationary and portable oxygen. The stationary oxygen QF modifier fee schedule amounts represent 100 percent of the stationary oxygen fee schedule amount. The portable oxygen QF fee schedule amounts represent the higher of 50 percent of the monthly stationary oxygen payment amount or the fee schedule amount for the portable oxygen add-on amount.

Effective April 1, 2017, the modifier “QF” should be used in conjunction with claims submitted for stationary oxygen (codes E0424, E0439, E1390, or E1391) and portable oxygen (codes E0431, E0433, E0434, E1392, or K0738) when the prescribed amount of oxygen is greater than 4 liters per minute (LPM).

Additional InformationTo view the official instruction, CR 9988 issued to your MAC regarding this change, refer https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3729CP.pdf.


Document History

Date of Change DescriptionMarch 6, 2017 Article released


Reducing Home Health Errors for Reason Codes (RC) 38107

Home health agencies (HHAs) are reminded of the following Medicare billing requirements to ensure their Requests for Anticipated Payment (RAPs) and final claims process and pay timely in the Fiscal Intermediary Standard System (FISS).

RC 38107When a final claim is submitted to Medicare, FISS will search for a matching RAP. FISS will send the final claim to the return to provider (RTP) file (status/location T B9997) with reason code 38107 when a matching RAP is not found, or when one or more of the following fields does not match between the RAP and the final claim.

March analysis of claim submission errors (CSEs) showed that 38107 accounted for 23% of all CSEs received by HHAs who bill to CGS.




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FISS Field Name

FISS Page

UB-04 Form Locator (FL) Data Entered

NPI 1 60 National Provider Identifier (NPI) of the billing providerSTMT DATES FROM

1 6 Start of care (SOC) episodes only: Date of first Medicare billable visit in the episode Recertification (subsequent) episodes: First calendar day of the episode of care

ADMIT DATE 1 12 Date of first Medicare billable visit in the beneficiary’s initial episode with the primary HHAHCPC 2 44 0023 revenue code line: Health Insurance Prospective Payment System (HIPPS) code.

FISS compares the first four positions of the HIPPS code between the RAP and final claim for the same episode of care

SERV DATE 2 45 0023 revenue code line: First Medicare billable visit in the episode

Examples of FISS page 1 and page 2 are shown below with the matching fields indicated.

MAP1711 PAGE 01 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXX SC INST CLAIM ENTRY C2012200 HH:MM:SS HIC TOB S/LOC S B0100 OSCAR SV: UB-FORM NPI XXXXXXXXXX TRANS HOSP PROV PROCESS NEW HIC PAT.CNTL#: TAX#/SUB: TAXO.CD: STMT DATES FROM MMDDYY TO DAYS COV N-C CO LTR LAST FIRST MI DOB ADDR 1 2 3 4 CARR: 5 6 LOC: ZIP SEX MS ADMIT DATE MMDDYY HR TYPE SRC D HM STAT

MAP1712 PAGE 02 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXX SC INST CLAIM ENTRY C2012200 HH:MM:SS REV CD PAGE 01 HIC TOB S/LOC S B0100 PROVIDER UTN PROG TOT COV SERV RED CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE IND 0023 XXXXX MMDDYY

For additional information regarding how to avoid or reduce billing errors for this reason, see the CGS Web page, Top Claim Submission Errors for Home Health Providers: Error 38107 http://www.cgsmedicare.com/hhh/education/materials/38107.html

For additional information on the data elements entered on RAPs and final claims, please see the Medicare Claims Processing Manual (Pub. 100-04, Ch. 10) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf on the Centers for Medicare & Medicaid Services (CMS) website. Additional information about entering RAPs and final claims is available on the CGS Home Health Claims Filing Web pages at: http://www.cgsmedicare.com/hhh/education/materials/HHE_Claims_Main.html


PAT.CNTL

TAXO.CD

http://www.cgsmedicare.com/hhh/education/materials/38107.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf


http://www.cgsmedicare.com/hhh/education/materials/HHE_Claims_Main.html

http://www.cgsmedicare.com/hhh/education/materials/HHE_Claims_Main.html

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SE17009: Denial of Home Health Payments When Required Patient Assessment Is Not Received – Additional Information


MLN Matters® Number: SE17009Related CR Release Date: March 24, 2017Related CR Transmittal #: R3629CP

Change Request (CR) #: CR9585 Effective Date: April 1, 2017Implementation Date: April 3, 2017

Provider Type AffectedThis MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.

Provider Action NeededIn Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.

BackgroundPer the Code of Federal Regulations (CFR) at 42 CFR 484.210(e) (https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf), submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health (HH) episodes of care is a condition of payment. In MLN Matters article MM9585 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm9585.pdf), Medicare notified HHAs that effective for claims with dates of service on or after April 1, 2017, Medicare systems will increase enforcement of this condition of payment.

Claims Denied When an OASIS Assessment Has Not Been Submitted

OASIS reporting regulations require the OASIS to be transmitted within 30 days of completion. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. Upon receipt of a final claim with service dates after April 1, 2017, Medicare systems will check whether the corresponding OASIS assessment is present in the Quality Information and Evaluation System (QIES). If the OASIS assessment is not found AND the receipt date of the claim is more than 30 days after the assessment completion date reported on the claim, Medicare systems will deny the HH claim.

While the regulation requires the assessment to be submitted within 30 days of completion, the initial implementation of this process will allow 40 days. Medicare systems will check for assessments used to determine the HIPPS code on the claim (Start of Care, Recertification and certain Resumption of Care assessments). Again, for the claim to be denied, the assessment must be both missing AND past due. When denying the claim, Medicare will apply the following remittance messages:




https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf

https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm9585.pdf



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yy Group Code of CO

yy Claim Adjustment Reason Code 272

Refer to OASIS Validation Reports

Before submitting an HH claim to your MAC, the HHA should ensure the OASIS assessment has completed processing and was successfully accepted into the QIES National Database. The HHA can verify this by reviewing their OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report for the submission which included the assessment. This may require communication between the provider’s billing office and their clinical staff that submits the OASIS to CMS.

There is no need to call the QIES Technical Support Office (QTSO) help desk for such billing issues. The OASIS Agency Final Validation Report and OASIS Submitter Final Validation Report provide all the information needed (that is, confirmation of an assessment’s receipt, the date of receipt, and any fatal or warning errors encountered) in order to prevent claims denials or to understand why a denial occurred.

HHAs should ensure, prior to submission of the OASIS assessment and the claim, that the following information is correct:

yy HHA CMS Certification Number (OASIS item M0010)

yy Beneficiary Medicare Number (OASIS item M0063)

yy Assessment Completion Date (OASIS item M0090)

yy Reason for Assessment (OASIS Item M0100) equal to 01, 03 or 04

These items will be used to match claims and assessments, so accuracy of submission can help prevent claim denials.

Additional InformationYou may also want to review MLN Matters Article MM9585, which is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm9585.pdf.


Document History

Date of Change DescriptionMarch 24, 2017 Initial article released

For Home Health and Hospice Providers

A New Look for the CGS Website

Recently, the Customer Service (https://www.cgsmedicare.com/hhh/cs/index.html) and Education & Resources (https://www.cgsmedicare.com/hhh/education/index.html) Web pages were updated with a new look. The new look provides icons that direct you to the information you’re looking for. No more text to read, or skim through to figure out where you need to go. All the same valuable information is still available, but is easier to find. CGS plans to implement this new look to other website pages in the future.

As always, CGS welcomes your feedback. Access the Website Feedback page at https://www.cgsmedicare.com/feedback.html or participate in the ForeSee Website Satisfaction





https://www.cgsmedicare.com/hhh/cs/index.html

https://www.cgsmedicare.com/hhh/education/index.html

https://www.cgsmedicare.com/feedback.html

https://www.cgsmedicare.com/feedback.html

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Survey when it presents itself when you access the CGS website and let us know what you think.


Attention myCGS Web Portal Users: Multi-Factor Authentication (MFA) is Mandatory

Due to increased security requirements mandated by the Centers for Medicare & Medicaid (CMS), all myCGS portal Users MUST sign up for Multi-Factor Authentication (MFA) by July 1, 2017. This article explains what MFA is, the timeline and instructions for activating MFA.

What is MFA? MFA is an extra layer of security that will help ensure your myCGS account and your patient’s Medicare information is protected. Each time you access myCGS, you will receive an eight-digit verification code via the option you selected (text, or email). Once the verification code is entered, you will have access to the myCGS website portal. Refer to the “How It Works” information below.

Important Timelines yy Now: myCGS Users may voluntarily sign up for MFA for each active user ID.

NOTE: CGS encourages Users to sign up early! You may feel that this process is cumbersome, but soon you will realize it only takes a few more seconds to complete.

yy May 1, 2017 to June 30, 2017: myCGS Users will be required to sign up for MFA at enrollment, password reset and account update.

yy July 1, 2017: myCGS Users not signed up for MFA will automatically be set to MFA with the email address associated with the user ID.

How It WorksTo activate MFA, enter your password as usual and access the ‘My Account’ tab. MFA information is located toward the bottom of the page. Instructions are also available in the myCGS User Manual, Chapter 1: Overview of myCGS (http://cgsmedicare.com/pdf/mycgs/chapter1.pdf).


http://cgsmedicare.com/pdf/mycgs/chapter1.pdf

http://cgsmedicare.com/pdf/mycgs/chapter1.pdf

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1. Multi-factor Authentication: Select “Yes”

2. MFA E-mail Address: Verify your email address of your active email account in myCGS

3. MFA Mobile Opt-in: Select “Yes” to receive your verification code via text message. Select “No” to receive your verification code via email.

4. Mobile Phone: If you selected “Yes” for the MFA Mobile Opt-in, enter your mobile phone number.

5. Carrier: If you selected “Yes” for the MFA Mobile Opt-in, enter the name of your mobile phone carrier.

6. Click the Submit button.


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Once activated, signing in to your myCGS account will work a little differently: Each time you will be logging in to the myCGS portal, you will be provided with a verification code via the selected method. Once you receive your verification code, you will enter it in the verification box and you’re in. It may seem cumbersome at first, but once you get used to it, this added security will allow you to enjoy peace of mind that will make this extra step more than worth it!


CGS Overpayment Demand Letter is Required to Appeal Decisions from the Supplemental Medical Review Contractor (SMRC) and the Recovery Audit (RA) Contractor

When a SMRC or RA contractor identifies improper payments, they notify the provider via a determination letter (also referred to as a review results letter). They also notify CGS to initiate the overpayment process. Once CGS is notified, the claim is adjusted and a remittance advice and overpayment demand letter is generated. At that time, if you disagree with the SMRC or RA decision, you may request a redetermination (first level of appeal) within 120 days from the date of the CGS demand letter or remittance advice. It has come to our attention that some providers are requesting an appeal upon receipt of the SMRC and RA determination letter and prior to the claim adjustment.

If a provider decides to appeal the denial decision, they MUST wait until the CGS demand letter or remittance advice is received. If an appeal request is submitted prior to the CGS demand letter being issued, it cannot be processed as an appeal since the overpayment does not yet exist.


CGS Website Updates

CGS has recently made updates to their website, giving providers additional resources to assist with billing Medicare-covered services appropriately.

Please review the following updates:

yy The HHH Quick Links located on the right side of the J15 HHH Web page at http://www.cgsmedicare.com/hhh/index.html were reviewed to ensure the links are still valid and updates were made as necessary.

yy The revenue code 0659 information provided on the Hospice Medicare Billing Codes Sheet quick resource tool at http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_medicare_billing_codes_sheet.pdf was updated to indicate that charges for this revenue code should be submitted as non-covered charges.

yy The details about accessing home health and hospice provider name, number and address information was updated in the Provider ID Information article at http://www.


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


http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_medicare_billing_codes_sheet.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_medicare_billing_codes_sheet.pdf

http://www.cgsmedicare.com/hhh/education/materials/Provider_ID.html

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cgsmedicare.com/hhh/education/materials/Provider_ID.html, which is located under the More Quick Links list on the located on the right side of the J15 HHH Web page at http://www.cgsmedicare.com/hhh/index.html

yy The questions and answers located on the Frequently Asked Questions (FAQs) at http://www.cgsmedicare.com/hhh/education/faqs/index.html were reviewed and updated accordingly.

yy The Comprehensive Error Rate Testing (CERT) Program Web page at http://www.cgsmedicare.com/hhh/education/materials/cert.html was revised based on the changes made to the CERT Contractors redesigned website.

yy The Ordering/Referring Physician Checklist for Home Health Agencies quick resource tool at http://www.cgsmedicare.com/hhh/education/materials/pdf/ord_ref_phys_checklist_hha.pdf was updated to add the specialty code C6 (Hospitalist) to the list of valid home health ordering/referring physician specialty codes.

yy The Hospice Claims Filing Web page at http://www.cgsmedicare.com/hhh/education/materials/hospice_cf.html was updated to better organize the information and to remove outdated information related to 2014 Change Requests, 8877 and 8358.

yy The REV and HCPC field descriptions on the Claim Page 02 – Entering a Hospice Claim Web page at http://www.cgsmedicare.com/hhh/education/materials/claim_page_2.html were updated to better organize the information by adding headings for specific instructions and information about entering the National Drug Code (NDC) information when revenue code 250 is submitted.

yy The new Web page, MAP171E – Entering National Drug Code (NDC) at http://www.cgsmedicare.com/hhh/education/materials/map171e.html was added to the Hospice Claims Filing page with instructions on how to enter the non-injectable drugs via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) based on Change Request 8358.

yy The new quick resource tool, “Notice of Election (NOE) Timely Filing and Exceptional Circumstance Guidelines” available at http://www.cgsmedicare.com/hhh/education/materials/pdf/noe_timely_filing_except_circumstances_guide.pdf was developed to assist providers when required billing elements for the NOE cause it to be untimely. This tool can also be found on the Hospice Quick Resource Tools Web page at http://www.cgsmedicare.com/hhh/education/materials/hospice_qrt.html.

yy In the left side menu of the J15 HHH Web page at https://www.cgsmedicare.com/hhh/index.html, the title “Tools” has been changed to “Self-Service Options.”


Evaluate Our Services!

The MAC Satisfaction Indicator (MSI) is the best way to share your opinions directly with the Centers for Medicare & Medicaid Services (CMS) about your experience with us. These survey results will help us find ways to better serve you.

https://cfigroup.qualtrics.com/jfe/form/SV_3WeVjGWpc5NQXOJ?MAC_BRNC=16&MAC=J15 – CGS

Thank you for your feedback.


http://www.cgsmedicare.com/hhh/education/materials/Provider_ID.html



http://www.cgsmedicare.com/hhh/education/faqs/index.html

http://www.cgsmedicare.com/hhh/education/materials/cert.html

http://www.cgsmedicare.com/hhh/education/materials/cert.html



http://www.cgsmedicare.com/hhh/education/materials/hospice_cf.html

http://www.cgsmedicare.com/hhh/education/materials/hospice_cf.html

http://www.cgsmedicare.com/hhh/education/materials/claim_page_2.html

http://www.cgsmedicare.com/hhh/education/materials/claim_page_2.html

http://www.cgsmedicare.com/hhh/education/materials/map171e.html

http://www.cgsmedicare.com/hhh/education/materials/map171e.html

http://www.cgsmedicare.com/hhh/education/materials/pdf/noe_timely_filing_except_circumstances_guide.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/noe_timely_filing_except_circumstances_guide.pdf

http://www.cgsmedicare.com/hhh/education/materials/hospice_qrt.html

https://www.cgsmedicare.com/hhh/index.html

https://www.cgsmedicare.com/hhh/index.html

https://cfigroup.qualtrics.com/jfe/form/SV_3WeVjGWpc5NQXOJ?MAC_BRNC=16&MAC=J15 - CGS

https://cfigroup.qualtrics.com/jfe/form/SV_3WeVjGWpc5NQXOJ?MAC_BRNC=16&MAC=J15 - CGS

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Interest Payment on Claims

The Provider Contact Center has received telephone calls from providers asking why they received an interest payment on their remittance advice. According to the Medicare Claims Processing Manual, (Pub 100-04, Ch. 1, §80.2.2) at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf, interest is paid on clean claims if payment is not made within 30 days after the date of receipt. The interest rate is determined by the Treasury Department on a 6-month basis, effective every January and July 1. Effective, January 1, 2017, the interest amount is 2.500%. Refer to Pub 100-04, Ch. 1, §80.2 for the definition of a clean claim.

Note: Interest is not paid on home health request for anticipated payment (RAP) types of bill.

The following provides information about how you can determine if your claim received an interest payment. The interest amount will display in the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE), standard paper remittance (SPR) and the electronic remittance advice (ERA)

FISS DDE Claim Page 01Value Code 70 will display the interest amount paid on your claim.

V A L U E C O D E S - A M O U N T S - A N S I MSP APP IND 01 XX XXXXX.00 02 XX $$$$.00 03 70 $.$$ 04 05 06 07 08 0937185 <== REASON CODES PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD PF8-NEXT

FISS DDE Claim page 06The PROVIDER INTEREST field will display the interest amount paid on your claim.

MAP1716 PAGE 06 CGS J15 MAC - HHH REGION ACPFA052 MM/DD/YY XXXXXXX SC INST CLAIM INQUIRY C201714P HH:MM:SS HIC XXXXXXXXXA TOB XXX S/LOC P B9997 PROVIDER XXXXXXXXXX MSP ADDITIONAL INSURER INFORMATION 1ST INSURERS ADDRESS 1 1ST INSURERS ADDRESS 2 CITY ST ZIP 2ND INSURERS ADDRESS 1 2ND INSURERS ADDRESS 2 CITY ST ZIP PAYMENT DATA --- DEDUCTIBLE COIN CROSSOVER IND PARTNER ID PAID DATE MMDDYY PROVIDER PAYMENT $$$$.$$ PAID BY PATIENT REIMB RATE $$.$$ RECEIPT DATE MMDDYY PROVIDER INTEREST $.$$ CHECK/EFT NO EFTXXXXXXX CHECK/EFT ISSUE DATE MMDDYY PAYMENT CODE ACH PIP PAY AS CASH PRICER DATA DRG OUTLIER AMT TTL BLNDED PAYMT FED SPEC GRAMM RUDMAN ORIG REIMBURSEMENT AMT .00 NET INL TECH PROV DAYS TECH PROV CHARGES OTHER INS ID CLINIC CODE 37186 <== REASON CODES PRESS PF3-EXIT PF7-PREV PAGE




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ERAMedicare providers using the PC-Print software to view and print the ERA can find the interest amount paid on an individual claim by reviewing the Single Claim (SC) screen (see below). For more information about the ERA, refer to the CGS Interactive Medicare Electronic Remittance Advice (ERA) Web page at http://www.cgsmedicare.com/hhh/education/era_tool.html. If you use another type of software, we suggest contacting your vendor for assistance.

SPRIf you receive a SPRA, the interest amount paid for an individual claim appears on the All Claims (AC) page (see below). For more information about the SPRA, refer to the CGS Interactive Medicare Standard Paper Remittance (SPR) Advice Web page at http://www.cgsmedicare.com/hhh/education/spr_tool.html.

For additional information about when interest is paid on a claim, and how to calculate the interest, refer to the Medicare Claims Processing Manual, (Pub 100-04, Ch. 1., §80.2.2) at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf on the Centers for Medicare & Medicaid Services (CMS) website. Current and past interest rate amounts can be viewed on the Treasury Department website at http://fms.treas.gov/prompt/rates.html.


MLN Connects™ Provider eNews

The MLN Connects™ Provider eNews contains a weeks 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/hhh/education/era_tool.html

http://www.cgsmedicare.com/hhh/education/era_tool.html

http://www.cgsmedicare.com/hhh/education/spr_tool.html

http://www.cgsmedicare.com/hhh/education/spr_tool.html



http://fms.treas.gov/prompt/rates.html

http://fms.treas.gov/prompt/rates.html

mailto:[email protected]


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yy March 16, 2017 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-03-16-eNews.pdf



yy April 6, 2017 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-04-06-eNews.pdf

yy April 13, 2017 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-04-13-eNews.pdf


MM9869: Healthcare Provider Taxonomy Codes (HPTCs) April 2017 Code Set Update


MLN Matters® Number: MM9869Related CR Release Date: February 24, 2017Related CR Transmittal #: R3723CP

Change Request (CR) #: CR9869 Effective Date: July 1, 2017Implementation Date: July 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice MACs and Durable Medical Equipment MACs, for services provided to Medicare beneficiaries.

Provider Action NeededChange Request (CR) 9869 instructs MACs to obtain the most recent Healthcare Provider Taxonomy Code (HPTC) set and to update their internal HPTC tables and/or reference files.

BackgroundThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that covered entities use the standards adopted under this law for electronically transmitting certain health care transactions, including health care claims. The standards include implementation guides which dictate when and how data must be sent, including specifying the code sets which must be used. The institutional and professional claim electronic standard implementation guides (X12 837-I and 837-P) each require use of valid codes contained in the HPTC set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.

The National Uniform Claim Committee (NUCC) maintains the HPTC set for standardized classification of health care providers, and updates it twice a year with changes effective April 1 and October 1. These changes include the addition of a new code and addition of definitions to existing codes.

You should note that:

1. Valid HPTCs are those that the NUCC has approved for current use.


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-03-16-eNews.pdf












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2. Terminated codes are not approved for use after a specific date.

3. Newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears.

4. Specialty and/or provider type codes issued by any entity other than the NUCC are not valid.

CR9869 implements the NUCC HPTC code set that is effective on April 1, 2017, and instructs MACs to obtain the most recent HPTC set and use it to update their internal HPTC tables and/or reference files. MACs will implement the April 2017 HPTC update as soon as they can after April 1, 2017, but not beyond July 3, 2017. The HPTC set is available for view or for download from the Washington Publishing Company (WPC) at http://www.wpc-edi.com/codes.

When reviewing the Health Care Provider Taxonomy code set online, you can identify revisions made since the last release by the color code:

yy New items are green yy Modified items are orange yy Inactive items are red

Additional InformationThe official instruction, CR 9869, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3723CP.pdf.



MM9878: Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update


MLN Matters® Number: MM9878Related CR Release Date: February 24, 2017Related CR Transmittal #: R3725CP

Change Request (CR) #: CR9878 Effective Date: July 1, 2017Implementation Date: July 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action NeededChange Request (CR) 9878 updates the Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) lists. CR9878 also calls for an update to Medicare Remit Easy Print (MREP) and PC Print software. If you use MREP and/or PC Print software, be sure to obtain the latest version that is released on or before July 3, 2017. Make sure that your billing staffs are aware of these changes.


http://www.wpc-edi.com/codes

http://www.wpc-edi.com/codes





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BackgroundThe Health Insurance Portability and Accountability Act (HIPAA) of 1996 (https://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf) instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states that CARCs and RARCs, as appropriate, that provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment, are required in the remittance advice and coordination of benefits transactions.

The Centers for Medicare & Medicaid Services (CMS) instructs MACs to conduct updates based on the code update schedule that is published three times per year – around March 1, July 1, and November 1.

CR9878 provides notification indicating when updates to CARC and RARC lists are made available on the Washington Publishing Company (WPC) website. Medicare’s Shared System Maintainers (SSMs) have the responsibility to implement code deactivation, 1) making sure that any deactivated code is not used in original business messages, and 2) allowing the deactivated code in derivative messages. SSMs must make sure that Medicare does not report any deactivated code on or after the effective date for deactivation as posted on the WPC website. If any new or modified code has an effective date past the implementation date specified in CR9878, MACs must implement on the date specified on the WPC website.

A discrepancy between the dates may arise as the WPC website is only updated three times per year and may not match the CMS release schedule. For CR9878, MACs and SSMs must determine the changes that are included on the code list since the last code update CR (CR 9774) or its corresponding MM Article (MM9774) at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9774.pdf.




MM10002: April 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.1


MLN Matters® Number: MM10002Related CR Release Date: March 10, 2017Related CR Transmittal #: R3735CP

Change Request (CR) #: CR10002 Effective Date: April 1, 2017 Implementation Date: April 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for providers who submit institutional claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH+H) MACs for services provided to Medicare beneficiaries.


https://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf

https://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf







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What You Need to KnowChange Request (CR) 10002 provides instructions and specifications for the Integrated Outpatient Code Editor (I/OCE) used for Outpatient Prospective Payment System (OPPS) and non-OPPS claims. This is for hospital outpatient departments, community mental health centers, all non-OPPS providers and for limited services when provided in a home health agency not under the Home Health Prospective Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. Make sure your billing staff is aware of these changes. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/. These specifications contain the appendices mentioned in the table below.

Key I/OCE Changes for April 2017The following table summarizes the modifications of the I/OCE for the April 2017 v18.1 release. Note that some I/OCE modifications in the update may be retroactively added to prior releases. If so, the retroactive date appears in the “Effective Date” column.

Effective Date Edits Affected Modification1/1/2017 101 Update Section 603 logic to remove observation and change Payment Method Flag assignment to

8 (see Appendix E, Appendix Q of attachment to CR10002).1/1/2017 Update Section 603 logic to change the Payment Method Flag to 8 for New Technology

Ambulatory Payment Classifications (APC) (see Appendix Q).1/1/2015 Update comprehensive APC logic to clear Composite Adjustment Flag assignment (if present)

from the output when reported on a comprehensive APC claim (see Special processing logic, Appendix K - multiple imaging composite and Appendix L).

1/1/2017 Update logic to output Status Indicator (SI) = E1 for revenue codes reported without HCPCS codes that previously had SI = E (see Appendix N).

1/1/2017 Update logic for Advance Care Planning (ACP) to revert to processing at the day level (not claim level). Additionally, update logic for add-on ACP code 99498 to retain SI = N when reported on a claim with the Annual Wellness Visit (AWV) but without primary ACP code 99497 (see Special processing logic).

2/1/2017 68 Implement mid-quarter coverage for new Proprietary Laboratory Analysis (PLA) codes 0001U, 0002U, and 0003U.

4/1/2017 84 Terminate the editing requirements for Partial Hospitalization Program (PHP)/ Community Mental Health Centers (CMHC) add-on codes reported without a primary PHP procedure (see notes in Table 4 and Appendix F-a).

1/1/2017 Correct conditional APC program logic to assign standard SI/APC for critical care ancillary service codes 36600, 43752 and 94660 that have SI = Q1 when the codes are reported without critical care or other payable HCPCS.

4/1/2017 Revised documentation in the special processing logic section for Conditional APC processing and Critical Care Ancillary Services processing for clarity; this clarification does not represent any changes to the processing logic.

4/1/2017 Update the following lists for the release (see quarterly data files):yy Edit 99 exclusion listyy Device procedure list (edit 92)yy Skin substitute product list (edit 87 and Appendix O)yy Complexity-adjusted comprehensive APC pairs (new table, CapcPairs)yy Terminated Device-Procedures (terminated procedures or those submitted for device credit):

note several codes with corrected device credit amountsyy Code Pairs (termination of PHP pairs for edit 84; move complexity-adjusted pairs to new

table CapcPair)yy Offset APC (Contrast APCs subject to pass-through offset)yy Radiation HCPCS (new table listing HCPCS subject to Section 603 exclusion logic)

4/1/2017 Make all HCPCS/APC/SI changes as specified by CMS (quarterly data files).4/1/2017 20, 40 Implement version 23.1 of the NCCI (as modified for applicable outpatient institutional providers).


http://www.cms.gov/OutpatientCodeEdit

http://www.cms.gov/OutpatientCodeEdit

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Document History

Date of Change DescriptionMarch 10, 2017 Initial article released


MM10005: April 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)


MLN Matters® Number: MM10005Related CR Release Date: March 3, 2017Related CR Transmittal #: R3728CP

Change Request (CR) #: CR10005 Effective Date: April 1, 2017 Implementation Date: April 3, 2017

Provider Types AffectedThis MLN Matters® Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MAC), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries paid under the Outpatient Prospective Payment System (OPPS).

Provider Action NeededChange Request (CR) 10005 describes changes to and billing instructions for various payment policies implemented in the April 2017 OPPS update. The April 2017 Integrated Outpatient Code Editor (I/OCE) will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier and Revenue Code additions, changes and deletions identified in CR 10005. Make sure your billing staff is aware of these changes.

BackgroundKey changes to and billing instructions for various payment policies implemented in the April 2017 OPPS updates are as follows:

Proprietary Laboratory Analyses (PLA) CPT Codes Effective February 1, 2017

The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel established three new PLA CPT codes, specifically CPT codes 0001U, 0002U and 0003U. The long descriptors for the codes are listed in Table 1. Because the codes were effective February 1, 2017, they were not included in the January 2017 I/OCE update and the January 2017 OPPS Addendum B.






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Table 1 − PLA CPT Codes Effective February 1, 2017CPT Code Long Descriptor OPPS SI 0001U Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35

antigens from 11 blood groups, utilizing whole blood, common RBC alleles reportedA

0002U Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps

Q4

0003U Oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score

Q4

Under the hospital OPPS, CPT code 0001U is assigned to status indicator “A” and CPT codes 0002U and 0003U are assigned to status indicator “Q4” (conditionally packaged laboratory tests) effective February 1, 2017. For more information on OPPS SI “A” and “Q4,” refer to OPPS Addendum D1 of the Calendar Year (CY) 2017 OPPS/ASC final rule for the latest definitions to the OPPS status indicators for CY 2017.

CPT codes 0001U, 0002U and 0003U have been added to the April 2017 I/OCE with an effective date of February 1, 2017. These codes, along with their short descriptors and status indicators, are also listed in the April 2017 OPPS Addendum B at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html.

Coding Changes for Presumptive Drug Tests Effective January 1, 2017

Prior to CY 2017, HCPCS codes G0477, G0478 and G0479 were used to describe presumptive drug tests. For the CY 2017 update, the AMA CPT Editorial Panel established three new CPT codes, specifically CPT codes 80305, 80306, and 80307, to describe the same presumptive drug tests as the HCPCS G-codes. Consequently, the HCPCS G-codes were terminated on December 31, 2016. Because CPT codes 80305, 80306 and 80307 describe the same presumptive drug tests as the HCPCS G-codes, the Centers for Medicare & Medicaid Services (CMS) assigned these new CPT codes to the same OPPS status indicator as its predecessor HCPCS G-codes effective January 1, 2017. Table 2 shows the HCPCS codes, long descriptors, status indicators, and replacement codes for the HCPCS G-codes.

Table 2 − Coding Changes for Presumptive Drug Tests Effective January 1, 2017

HCPCS Long DescriptorOPPS SI Add Date

Termination Date

Replacement Code

G0477 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

N/A 01/01/2016 12/31/2016 80305

G0478 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

N/A 01/01/2016 12/31/2016 80306

G0479 Drug test(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, tof, maldi, ldtd, desi, dart, ghpc, gc mass spectrometry), includes sample validation when performed, per date of service.

N/A 01/01/2016 12/31/2016 80307


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html



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Table 2 − Coding Changes for Presumptive Drug Tests Effective January 1, 2017

HCPCS Long DescriptorOPPS SI Add Date

Termination Date

Replacement Code

80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service.

Q4 01/01/2017 N/A

80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

Q4 01/01/2017 N/A

80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., eia, elisa, emit, fpia, ia, kims, ria]), chromatography (e.g., gc, hplc), and mass spectrometry either with or without chromatography, (e.g., dart, desi, gc-ms, gc-ms/ms, lc-ms, lc-ms/ms, ldtd, maldi, tof) includes sample validation when performed, per date of service.

Q4 01/01/2017 N/A

Because CMS was unable to delete HCPCS codes G0477, G0478 and G0479 in the January 2017 I/OCE update, CMS is deleting these codes in the April 2017 I/OCE update effective December 31, 2016. The short descriptors for CPT codes 80305, 80306 and 80307, along with their status indicators, are available in the April 2017 OPPS Addendum B.

Clarification regarding HCPCS Code G0498

Under the OPPS, HCPCS code G0498 is assigned status indicator “S” (Procedure or Service, Not discounted when multiple) effective January 1, 2016. HCPCS code G0498 (Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (for example, home, domiciliary, rest home or assisted living) is intended to describe a service where the facility incurred a facility expense specific to the provision of the non-implantable, external infusion pump. Because HCPCS code G0498 includes the chemotherapy administration, providers should not report HCPCS code G0498 with CPT code 96416 (Initiation of prolonged chemotherapy infusion - more than 8 hours - requiring use of a portable or implantable pump). In addition, a hospital should append modifier 52 (reduced service) to HCPCS code G0498 when a component of the service is not performed.

As a reminder, hospitals are expected to report all drug administration CPT codes in a manner consistent with their descriptors, CPT instructions and correct coding principles. Also, hospitals are reminded to bill for all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided.

Argus Retinal Prosthesis Add-on Code (C1842)

As stated in the January 2017 update, HCPCS code C1842 (Retinal prosthesis, includes all internal and external components; add-on to C1841) was established to resolve a claims processing issue for Ambulatory Surgery Centers (ASC) and should not be reported on institutional claims by hospital outpatient department providers. Therefore, the status indicator for HCPCS code C1842 will change from status indicator (SI)=N (Paid under OPPS; payment is packaged into payment for other services) to SI=E1 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type) in the April 2017 update. This correction to status indicator will be retroactive to January 1, 2017.


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Drugs, Biologicals and Radiopharmaceuticals

A. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective April 1, 2017

For CY 2017, payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals is made at a single rate of ASP + 6 percent, which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug, biological or therapeutic radiopharmaceutical. In CY 2017, a single payment of ASP + 6 percent for pass-through drugs, biologicals and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead cost of these pass-through items. Payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available. Updated payment rates effective April 1, 2017, and drug price restatements are available in the April 2017 update of the OPPS Addendum A and Addendum B (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/).

B. Drugs and Biologicals with OPPS Pass-Through Status Effective April 1, 2017

Seven drugs and biologicals have been granted OPPS pass-through status effective April 1, 2017. These items, along with their descriptors and Ambulatory Payment Classification (APC) assignments, are identified in Table 3.

Table 3 – Drugs and Biologicals with OPPS Pass-Through Status Effective April 1, 2017HCPCS Code Long Descriptor APC Status IndicatorC9484 Injection, eteplirsen, 10 mg 9484 GC9485 Injection, olaratumab, 10 mg 9485 GC9486 Injection, granisetron extended release, 0.1 mg 9486 GC9487 Ustekinumab, for intravenous injection, 1 mg 9487 GC9488 Injection, conivaptan hydrochloride, 1 mg 9488 GJ7328 Hyaluronan or derivative, gel-syn, for intra-articular injection, 0.1 mg 1862 GQ5102 Injection, infliximab, biosimilar, 10 mg 1847 G

C. Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates

Some drugs and biologicals based on ASP methodology will have payment rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected payments rates will be accessible at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates.html on the first date of the quarter. Providers may resubmit claims that were impacted by adjustments to previous quarter’s payment files.

D. Revised Status Indicator for HCPCS Code J1130

The status indicator for HCPCS code J1130 (Injection, diclofenac sodium, 0.5 mg) will change from SI=E2 (Items and Services for which pricing information and claims data are not available) to SI=K (Paid under OPPS; separate APC payment) in the April 2017 update. This correction to status indicator will be retroactive to January 1, 2017. See Table 4.

Table 4 – Revised Status Indicator for HCPCS Code J1130HCPCS Code Long Descriptor APC Status Indicator Effective DateJ1130 Injection, diclofenac sodium, 0.5 mg 1863 K 01/01/2017

E. HCPCS code C9744

As a reminder to hospital providers, HCPCS code C9744 (Ultrasound, abdominal, with contrast) may be used to describe use of a contrast agent in ultrasonography of the liver, kidneys and/or bladder.


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html?redirect=/HospitalOutpatientPPS/

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates.html



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F. Reassignment of Skin Substitute Product from the Low Cost Group to the High Cost Group

Four skin substitute products have been reassigned from the low cost skin substitute group to the high cost skin substitute group based on updated pricing information. The HCPCS codes are Q4161, Q4169, Q4173 and Q4175. These products are listed in Table 5.

Table 5 – Reassignment of Skin Substitute Product from the Low Cost Group to the High Cost Group Effective April 1, 2017CY 2017 HCPCS Code CY 2017 Short Descriptor CY 2017 SI Low/High Cost Skin SubstituteQ4161 Bio-Connekt per square cm N HighQ4169 Artacent wound, per square cm N HighQ4173 Palingen or palingen xplus, per sq cm N HighQ4175 Miroderm, per square cm N High

G. Removal of Skin Substitute Product from the High/Low Cost Skin Substitute Table

One HCPCS code, Q4171, was inadvertently included in the High/Low Cost Skin Substitute table. Effective April 2017, Q4171 is removed from the High/Low Cost Skin Substitute table. This product is listed in Table 6.

Table 6 – Skin Substitute Product removed from High/Low Cost Skin Substitute Table Effective April 1, 2017CY 2017 HCPCS Code CY 2017 Short Descriptor CY 2017 SIQ4171 Interfyl, 1 mg N

Coverage Determinations

As a reminder, the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program. Instead, it only indicates how the product, procedure or service may be paid if covered by the program. Medicare Administrative Contractors (MAC) determine whether a drug, device, procedure or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.

Additional InformationTo view the official instruction, CR 9982 issued to your MAC regarding this change, refer to https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3728CP.pdf.



Provider Contact Center (PCC) Training

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 list below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will be closed for training.

Date PCC Training/ClosuresThursday, May 11 2017 8:00 a.m. – 10:00 a.m. Central Time




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Date PCC Training/ClosuresThursday, May 25, 2017 8:00 a.m. – 10:00 a.m. Central TimeMonday, May 29, 2017 (Memorial Day) Office closed

The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For additional information, go to http://www.cgsmedicare.com/hhh/index.html and click the “myCGS” button on the left side of the Web page.

For your reference, access the “Home Health & Hospice 2017 Holiday/Training Closure Schedule” at http://www.cgsmedicare.com/hhh/help/pdf/2017_hhh_calendar_FINAL.pdf for a complete list of PCC closures.


Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all nonregulatory changes to Medicare including transmittals, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to:

yy Inform providers about new developments in the Medicare program;

yy Assist providers in understanding CMS programs and complying with Medicare regulations and instructions;

yy Ensure that providers have time to react and prepare for new requirements;

yy Announce new or changing Medicare requirements on a predictable schedule; and

yy Communicate the specific days that CMS business will be published in the Federal Register.

To receive notification when regulations and program instructions are added throughout the quarter, go to https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/CMS-Quarterly-Provider-Updates-Email-Updates.html to sign up for the Quarterly Provider Update (electronic mailing list).

We encourage you to bookmark the Quarterly Provider Update website at https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html and visit it often for this valuable information.



http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf


http://www.cgsmedicare.com/hhh/help/pdf/2017_hhh_calendar_FINAL.pdf

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/CMS-Quarterly-Provider-Updates-Email-Updates.html

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/CMS-Quarterly-Provider-Updates-Email-Updates.html

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html



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SE1605 (Revised): Provider Enrollment Revalidation – Cycle 2

The Centers for Medicare & Medicaid Services (CMS) has revised 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: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html

MLN Matters® Number: SE1605 RevisedRelated CR Release Date: N/ARelated CR Transmittal #: N/A

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

Note: This article was revised on March 15, 2017, to update the table on page 6 and added additional information after that table. All other information is unchanged.

Provider Types AffectedThis Medicare Learning Network (MLN) Matters® Special Edition Article is intended for all providers and suppliers who are enrolled in Medicare and required to revalidate through their Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), Medicare Carriers, Fiscal Intermediaries, and the National Supplier Clearinghouse (NSC)). These contractors are collectively referred to as MACs in this article.

Provider Action Needed STOP – Impact to You

Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. The Centers for Medicare & Medicaid Services (CMS) has completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance with 42 CFR §424.515. In an effort to streamline the revalidation process and reduce provider/supplier burden, CMS has implemented several revalidation processing improvements that are captured within this article.

CAUTION – What You Need to Know

Special Note: The Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Providers/suppliers should continue to submit changes (for example, changes of ownership, change in practice location or reassignments, final adverse action, changes in authorized or delegated officials or, any other changes) as they always have. If you also receive a request for revalidation from the MAC, respond separately to that request.

GO – What You Need to Do

1. Check http://go.cms.gov/MedicareRevalidation for the provider/suppliers due for revalidation;

2. If the provider/supplier has a due date listed, CMS encourages you to submit your revalidation within six months of your due date or when you receive notification from your MAC to revalidate. When either of these occur:

- Submit a revalidation application through Internet-based PECOS located at https://pecos.cms.hhs.gov/pecos/login.do, the fastest and most efficient way to submit your revalidation information. Electronically sign the revalidation application and upload your supporting documentation or sign the paper certification statement and mail it along with your supporting documentation to your MAC; or




http://go.cms.gov/MedicareRevalidation

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


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- Complete the appropriate CMS-855 application available at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html;

- If applicable, pay your fee by going to https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do; and

- Respond to all development requests from your MAC timely to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges.

BackgroundSection 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. CMS has completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance with 42 CFR §424.515. This cycle of revalidation applies to those providers/suppliers that are currently and actively enrolled.

What’s ahead for your next Medicare enrollment revalidation?

Established Due Dates for Revalidation

CMS has established due dates by which the provider/supplier’s revalidation application must reach the MAC in order for them to remain in compliance with Medicare’s provider enrollment requirements. The due dates will generally be on the last day of a month (for example, June 30, July 31 or August 31). Submit your revalidation application to your MAC within 6 months of your due date to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges. Generally, this due date will remain with the provider/supplier throughout subsequent revalidation cycles.

yy The list will be available at http://go.cms.gov/MedicareRevalidation and will include all enrolled providers/suppliers. Those due for revalidation will display a revalidation due date, all other providers/suppliers not up for revalidation will display a “TBD” (To Be Determined) in the due date field. In addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be available at http://go.cms.gov/MedicareRevalidation on the CMS website.

IMPORTANT: The list identifies billing providers/suppliers only that are required to revalidate. If you are enrolled solely to order, certify, and/or prescribe via the CMS-855O application or have opted out of Medicare, you will not be asked to revalidate and will not be reflected on the list.

yy Due dates are established based on your last successful revalidation or initial enrollment (approximately 3 years for DME suppliers and 5 years for all other providers/suppliers).

yy In addition, the MAC will send a revalidation notice within 2-3 months prior to your revalidation due date either by email (to email addresses reported on your prior applications) or regular mail (at least two of your reported addresses: correspondence, special payments and/or your primary practice address) indicating the provider/supplier’s due date.

Revalidation notices sent via email will indicate “URGENT: Medicare Provider Enrollment Revalidation Request” in the subject line to differentiate from other emails. If all of the emails addresses on file are returned as undeliverable, your MAC will send a paper revalidation notice to at least two of your reported addresses: correspondence, special payments and/or primary practice address.

NOTE: Providers/suppliers who are within 2 months of their listed due dates on http://go.cms.gov/MedicareRevalidation but have not received a notice from their MAC to revalidate, are encouraged to submit their revalidation application.


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



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







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yy To assist with submitting complete revalidation applications, revalidation notices for individual group members, will list the identifying information of the organizations that the individual reassigns benefits.

Large Group Coordination

Large groups (200+ members) accepting reassigned benefits from providers/suppliers identified on the CMS list will receive a letter from their MACs listing the providers linked to their group that are required to revalidate for the upcoming 6 month period. A spreadsheet detailing the applicable provider’s Name, National Provider Identifier (NPI) and Specialty will also be provided. CMS encourages the groups to work with their practicing practitioners to ensure that the revalidation application is submitted prior to the due date. We encourage all groups to work together as only one application from each provider/supplier is required, but the provider must list all groups they are reassigning to on the revalidation application submitted for processing. MACs will have dedicated provider enrollment staff to assist in the large group revalidations.

Groups with less than 200 reassignments will not receive a letter or spreadsheet from their MAC, but can utilize PECOS or the CMS list available on http://go.cms.gov/MedicareRevalidation to determine their provider/supplier’s revalidation due dates.

Unsolicited Revalidation Submissions

All unsolicited revalidation applications submitted more than 6 months in advance of the provider/supplier’s due date will be returned.

yy What is an unsolicited revalidation?

y� If you are not due for revalidation in the current 6 month period, your due date will be listed as “TBD” (To Be Determined). This means that you do not yet have a due date for revalidation. Please do not submit a revalidation application if there is NOT a listed due date.

y� Any off-cycle or ad hoc revalidations specifically requested by CMS or the MAC are not considered unsolicited revalidations.

yy If your intention is to submit a change to your provider enrollment record, you must submit a ‘change of information’ application using the appropriate CMS-855 form.

Submitting Your Revalidation Application

IMPORTANT: Each provider/supplier is required to revalidate their entire Medicare enrollment record.

A provider/supplier’s enrollment record includes information such as the provider’s individual practice locations and every group that benefits are reassigned (that is, the group submits claims and receives payments directly for services provided). This means the provider/supplier is recertifying and revalidating all of the information in the enrollment record, including all assigned NPIs and Provider Transaction Access Numbers (PTANs).

If you are an individual who reassigns benefits to more than one group or entity, you must include all organizations to which you reassign your benefits on one revalidation application. If you have someone else completing your revalidation application for you, encourage coordination with all entities to which you reassign benefits to ensure your reassignments remain intact.

The fastest and most efficient way to submit your revalidation information is by using the Internet-based PECOS.

To revalidate via the Internet-based PECOS, go to https://pecos.cms.hhs.gov/pecos/login.do. PECOS allows you to review information currently on file and update and submit your revalidation via the Internet. Once completed, YOU MUST electronically sign the revalidation






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application and upload any supporting documents or print, sign, date, and mail the paper certification statement along with all required supporting documentation to your appropriate MAC IMMEDIATELY.

PECOS ensures accurate and timelier processing of all types of enrollment applications, including revalidation applications. It provides a far superior alternative to the antiquated paper application process.

To locate the paper enrollment applications, refer to https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html on the CMS website.

Getting Access to PECOS:

To use PECOS, you must get approved to access the system with the proper credentials which are obtained through the Identity and Access Management System, commonly referred to as “I&A.” The I&A system ensures you are properly set up to submit PECOS applications. Once you have established an I&A account you can then use PECOS to submit your revalidation application as well as other enrollment application submissions.

To learn more about establishing an I&A account or to verify your ability to submit applications using PECOS, please refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf.

If you have questions regarding filling out your application via PECOS, please contact the MAC that sent you the revalidation notice. You may also find a list of MAC’s at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf.

For questions about accessing PECOS (such as login, forgot username/password) or I&A, contact the External User Services (EUS) help desk at 1.866.484.8049 or at [email protected].

Deactivations Due to Non-Response to Revalidation or Development Requests

It is important that you submit a complete revalidation application by your requested due date and you respond to all development requests from your MACs timely. Failure to submit a complete revalidation application or respond timely to development requests will result in possible deactivation of your Medicare enrollment.

If your application is received substantially after the due date, or if you provide additional requested information substantially after the due date (including an allotted time period for US or other mail receipt) your provider enrollment record may be deactivated. Providers/suppliers deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges. The provider/supplier will maintain their original PTAN; however, an interruption in billing will occur during the period of deactivation resulting in a gap in coverage.

NOTE: The reactivation date after a period of deactivation will be based on the receipt date of the new full and complete application. Retroactive billing privileges back to the period of deactivation will not be granted. Services provided to Medicare patients during the period between deactivation and reactivation are the provider’s liability.

Revalidation Timeline and Example

Providers/suppliers may use the following table /chart as a guide for the sequence of events through the revalidation progression.




https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf



https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf





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Action Timeframe ExampleRevalidation list posted Approximately 6 months prior to

due dateMarch 30, 2017

Issue large group notifications Approximately 6 months prior to due date

March 30, 2017

MAC sends email/letter notification 75 – 90 days prior to due date July 2 - 17, 2017MAC sends letter for undeliverable emails

75 – 90 days prior to due date July 2 - 17, 2017

Revalidation due date September 30, 2017Apply payment hold/issue reminder letter (group members)

Within 25 days after due date October 25, 2017

Deactivate 60 – 75 days after due date November 29 – December 14, 2017

CGS Note: The Deactivate Example in the above table is a correction to what this revised MLN article provided (shown below)

Deactivate 60 - 75 days after due date 7

Deactivations Due to Non-Billing

Providers/suppliers that have not billed Medicare for the previous 12 consecutive months will have their Medicare billing privileges deactivated in accordance with 42 CFR §424.540. The effective date of deactivation will be 5 days from the date of the corresponding deactivation letter issued by the MACs notifying the providers/suppliers of the deactivation action.

Providers/suppliers who Medicare billing privileges are deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges. The provider/supplier will maintain their original PTAN; however, an interruption in billing will occur during the period of deactivation resulting in a gap in coverage.

Application Fees

Institutional providers of medical or other items or services and suppliers are required to submit an application fee for revalidations. The application fee is $560.00 for Calendar Year (CY) 2017. CMS has defined “institutional provider” to mean any provider or supplier that submits an application via PECOS or a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S forms.

All institutional providers (that is, all providers except physicians, non-physicians practitioners, physician group practices and non-physician practitioner group practices) and suppliers who respond to a revalidation request must submit the 2017 enrollment fee (reference 42 CFR 424.514) with their revalidation application. You may submit your fee by ACH debit, or credit card. To pay your application fee, go to https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do and submit payment as directed. A confirmation screen will display indicating that payment was successfully made. This confirmation screen is your receipt and you should print it for your records. CMS strongly recommends that you include this receipt with your uploaded documents on PECOS or mail it to the MAC along with the Certification Statement for the enrollment application. CMS will notify the MAC that the application fee has been paid. Revalidations are processed only when fees have cleared.

SUMMARY:

yy CMS will post the revalidation due dates for the upcoming revalidation cycle on http://go.cms.gov/MedicareRevalidation for all providers/suppliers. This list will be refreshed periodically. Check this list regularly for updates.






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yy MACs will continue to send revalidation notices (either by email or mail) within 2-3 months prior to your revalidation due date. When responding to revalidation requests, be sure to revalidate your entire Medicare enrollment record, including all reassignment and practice locations. If you have multiple reassignments/billing structures, you must coordinate the revalidation application submission with all parties.

yy If a revalidation application is received but incomplete, the MACs will develop for the missing information. If the missing information is not received within 30 days of the request, the MACs will deactivate the provider/supplier’s billing privileges.

yy If a revalidation application is not received by the due date, the MAC may place a hold on your Medicare payments and deactivate your Medicare billing privileges.

yy If the provider/supplier has not billed Medicare for the previous 12 consecutive months, the MAC will deactivate their Medicare billing privileges.

yy If billing privileges are deactivated, a reactivation will result in the same PTAN but an interruption in billing during the period of deactivation. This will result in a gap in coverage.

yy If the revalidation application is approved, the provider/supplier will be revalidated and no further action is needed.

Additional InformationTo find out whether a provider/supplier has been mailed a revalidation notice go to http://go.cms.gov/MedicareRevalidation on the CMS website.

A sample revalidation letter is available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf on the CMS website. A revalidation checklist is available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html on the CMS website.

For more information about the enrollment process and required fees, refer to MLN Matters® Article MM7350, which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7350.pdf on the CMS website.

For more information about the application fee payment process, refer to MLN Matters Article SE1130, which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1130.pdf on the CMS website.

The MLN fact sheet titled “The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations” is designed to provide education to provider and supplier organizations on how to use Internet-based PECOS to enroll in the Medicare Program and is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf on the CMS website.

To access PECOS, your Authorized Official must register with the PECOS Identification and Authentication system. To register for the first time go to https://pecos.cms.hhs.gov/pecos/PecosIAConfirm.do?transferReason=CreateLogin to create an account.

For additional information about the enrollment process and Internet-based PECOS, please visit the Medicare Provider-Supplier Enrollment Web page at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html.

If you have questions, contact your MAC. Medicare provider enrollment contact information for each State can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf.




http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf

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

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

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7350.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7350.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1130.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1130.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf



https://pecos.cms.hhs.gov/pecos/PecosIAConfirm.do?transferReason=CreateLogin

https://pecos.cms.hhs.gov/pecos/PecosIAConfirm.do?transferReason=CreateLogin

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

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

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf

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Document History

Date of Change DescriptionMarch 15, 2017 The updated article revised the table on page 6 and added additional information after

that table.February 22. 2016 Initial article released


Upcoming Educational Events

The CGS Provider Outreach and Education department offers educational events through webinars and teleconferences throughout the year. Registration for live events is required. For upcoming events, please refer to the Calendar of Events Home Health & Hospice Education Web page at http://www.cgsmedicare.com/hhh/education/Education.html. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.


Valid/Invalid G-Codes for Home Health and Hospice

CGS has seen providers continuing to submit G-codes that are not valid for the dates of services being billed. Please review the following list of valid and invalid codes with your billing staff to ensure the appropriate code is submitted. The validity of the HCPCS codes is based on the date services were provided.

Home Health Invalid HCPCS CodesHCPCS Code Invalid For Dates of Service DescriptionG0154 Services provided on or after

January 1, 2016Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes.

G0163 Services provided on or after January 1, 2017

Skilled services of a licensed nurse (LPN or RN) for the observation and assessment of the patient's condition, each 15 minutes.


Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

Home Health Valid HCPCS CodesHCPCS Code Invalid For Dates of Service DescriptionG0299 Services provided on or after

January 1, 2016Direct skilled nursing services of a registered nurse (RN) in home health or hospice setting, each 15 minutes.


Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.


Skilled services of a registered nurse (RN) for the observation and assessment of the patient’s condition, each 15 minutes.NOTE: Only valid for home health providers.


Skilled services of a licensed practical nurse (LPN) for the observation and assessment of a patient’s condition, each 15 minutes.NOTE: Only valid for home health providers.


Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. NOTE: Only valid for home health providers.


http://www.cgsmedicare.com/hhh/education/Education.html

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Home Health Valid HCPCS CodesHCPCS Code Invalid For Dates of Service DescriptionG0496 Services provided on or after

January 1, 2017Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. NOTE: Only valid for home health providers.

For home health episodes that span 2015/2016 or 2016/2017, report the appropriate G-code on the detail line based on the date of service.

Hospice Invalid HCPCS CodesHCPCS Code Invalid For Dates of Service DescriptionG0154 Services provided on or after

January 1, 2016Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes.

Hospice Valid HCPCS CodesHCPCS Code Invalid For Dates of Service DescriptionG0299 Services provided on or after

January 1, 2016Direct skilled nursing services of a registered nurse (RN) in home health or hospice setting, each 15 minutes.


Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.

Resources yy MM9736, Implementation of Policy Changes for the CY 2017 Home Health Prospective Payment (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9736.pdf)

yy MM9369, Additional G-Codes Differentiating RNs and LPNs in the Home Health and Hospice Settings (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9369.pdf)






Documents

Medicare Bulletin - May 2017 · 2017. 5. 1. · Internal Medicine. The Medicare Learning Network ® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes