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February 2014 J15 Part B Medicare Bulletin

Posted January 28, 2014

Table of Contents

Coverage, LCDs, & NCDs

Fee Schedules

Claim Submission

Enrollment and Credentialing

Administration

Preventive Services

DME, Prosthetics, Orthotics, & Supplies

Drugs & Biologicals

 

 

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Duplicate Payments and Incarcerated Beneficiary Denials

CGS is aware that some providers may have received duplicate payments resulting from the recent refunds that were made for the incorrect incarcerated beneficiary denials. If you received a duplicate payment, please refer to the CGS web article “Overpayment Refund Form” for more information. 

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Breast Imaging Mammorgraphy LCD L31856 Update

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diagnosing breast cancer and tracking changes for high risk patients once established as at risk, this limitation is no longer valid.

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Annual Certification for CR3274

The acceptance of a voluntary refund as repayment for the claim specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

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

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

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

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

http://clinicaltrials.gov/

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

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

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

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

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

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CGS IDE Submission Requirements:

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

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

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

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

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

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

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

  1. FDA approval letter of the IDE
  2. IDE study protocol
  3. IRB approval letter
  4. NCT number
  5. Supporting materials, as needed

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

  1. The principal purpose of the study is to test whether the device improves health outcomes of appropriately selected patients.
  2. The rationale for the study is well supported by available scientific and medical information, or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.
  3. The study results are not anticipated to unjustifiably duplicate existing knowledge.
  4. The study design is methodologically appropriate and the anticipated number of enrolled subjects is adequate to confidently answer the research question(s) being asked in the study.
  5. The study is sponsored by an organization or individual capable of successfully completing the study.
  6. The study is in compliance with all applicable Federal regulations concerning the protection of human subjects found at 21 CFR parts 50, 56,and 812 and 45 CFR part 46.
  7. Where appropriate, the study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals. Studies of all medical technologies measuring therapeutic outcomes as one of the objectives may be exempt from this criterion only if the disease or condition being studied is life threatening and the patient has no other viable treatment options.
  8. The study is registered with the National Institutes of Health’s National Library of Medicine’s ClinicalTrials.gov.
  9. The study protocol describes the method and timing of release of results on all pre-specified outcomes, including release of negative outcomes and that the release should be hastened if the study is terminated early.
  10. The study protocol must describe how Medicare beneficiaries may be affected by the device under investigation, and how the study results are or are not expected to be generalizable to the Medicare beneficiary population. Generalizability to populations eligible for Medicare due to age, disability, or other eligibility status must be explicitly described.

Requests for IDE approval must include the following:

  1. CGS IDE Submission form
    1. CGS IDE Submission Form
  2. FULL copy of unredacted FDA approval letter including trial summary of the IDE
  3. Current IDE study protocol, (when submission is an extension include the most recent version)
  4. IRB approval letter (which must include the date of approval and expiration)
  5. NCT number
  6. Summary of study related Adverse Events
  7. Supporting materials, as requested by CGS

Resources:

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CGS Information Regarding HUD Approvals

The following is a synopsis of our position on HUDs:

Though there is no prior approval process in traditional Medicare, CGS will consider case by case coverage for a humanitarian use device when:

HUD Information to be submitted to the CGS with an introductory letter: CGS requires providers seeking to use a HUD in the diagnosis and treatment of Medicare beneficiaries to submit the following information:

Upon receipt of the required documentation, CGS will review the submission and respond as soon as possible. Again, while there is no prior approval process in traditional Medicare, the process outlined above will help ensure Medicare beneficiaries are receiving covered services and have adequate access to care.

Given the complexities of determining whether a device is reasonable and necessary when it has not been proven effective for its intended use, providers may wish to discuss this issue with their patients and consider the use of an advanced beneficiary notice (ABN). Additional information on the CMS beneficiary notice initiative may be found at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ payment decisions are made at the time of claims submission. Do not submit clinical records unless specifically asked to do so. Medical records, when submitted, should document why the benefits of use of the device outweigh the risks, considering both other available devices and other available therapies.

 

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

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

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

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

Reference:

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Patient Eligibility: Reminders for the New Year

With the new year, your Medicare patients may be making changes in their Medicare and supplemental insurance plans.  Patient eligibility is one of the top reasons Medicare claims are denied, including:

You can prevent claim denials for patient eligibility by verifying that the patient’s name (including spelling) and Medicare number are correct and match the patient’s red, white and blue Medicare card, the type of Medicare plan the patient has elected (fee-for-service or an MA plan), and the patient’s eligibility.  We recommend you obtain copies of the patient’s “insurance cards,” including their original Medicare card (even MA plan enrollees have an original Medicare card).

Check eligibility before you submit claims.  Options for verifying eligibility include:

Refer to the CMS website for more information regarding MA plans.

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MM8297 - Use of Claim Adjustment Reason Code 23

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

REVISED product from the Medicare Learning Network® (MLN):

MLN Matters® Number: MM8297
Related Change Request (CR) #: CR 8297
Related CR Release Date: November 15, 2013
Effective Date: April 1, 2014
Related CR Transmittal #: R13180TN
Implementation Date: April 7, 2014, except July 7, 2014, for suppliers billing DME MACs

Provider Types Affected
This MLN Matters® Article is intended for physicians, Home Health Agencies (HHAs), and other providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs),  Medicare Administrative Contractors (A/B MACs), or Durable Medical Equipment MACs (DME MACs)) for services to Medicare beneficiaries.

What You Need to Know
Change Request (CR) 8279, from which this article is taken, modifies Medicare claims processing systems to use Medicare Claim Adjustment Reason Codes (CARC) 23 to report impact of prior payers’ adjudication on Medicare payment in the case of a secondary claim.

Background
Effective April 1, 2013, CR8154 0 “remittance Advice Remark and Claims Adjustment Reason Code, Medicare Remit Easy Print, and PC Print Update modified CARC 23 (The impact of prior payer(s) adjudication including payments and/or adjustments (Use only with Group Code OA)); to include the instruction that it must be used with Group Code OA (Other Adjustment). The Centers for Medicare & Medicaid Services (CMS) has become aware that the modification to this CARC has resulted in some issues for Medicare.  (You can find the MLN Matters article associated with CR8154 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8154.pdf on the CMS website.)

CR8297, from which this article is taken, instructs the Medicare's Shared System Maintainers (SSMs) on how to use CARC 23 to report prior payers’ adjudication in the case of a secondary claim.

Medicare beneficiaries may have multiple coverages that occur either before or after Medicare. If (per Coordination Of Benefits) Medicare is the secondary payer, the adjudication process has to take into consideration how previous payers have adjudicated the claim, and report accordingly on the Remittance Advice (RA). The implementation guide for the current Electronic Remittance Advice (ERA) - ASC X12 Transaction 835 version 5010 - has explicit instruction in the Front Matter, Section 1.10.2.13 (Secondary Payment Reporting Consideration) to:

"Report the "impact" in the appropriate claim or service level CAS segment with reason code 23 (Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments); and Claim Adjustment Group Code OA (Other Adjustment). Code OA is used to identify this as an administrative adjustment.…….It is essential that any secondary payer report in the remittance advice only the primary amount that has actually impacted their secondary payment. In many cases, this "impact" is less than the actual primary payment." In these instances, reporting the actual payment would prevent the transaction from balancing.

Medicare does not have to report everything a previous payer has done, because that information is reported by that payer to the provider through the previous payer's Remittance Advice (RA). In order to generate and send a balanced Medicare RA and Coordination of Benefits (COB) Claim, Medicare should report only the part of previous payers’ adjudication that impacts Medicare calculation of payment and adjustments.

Specifically, CR8279 requires the Medicare SSMs to report:

  1. The Medicare allowed amount in the appropriate claim or service level “AMT” segment using qualifier AU (claim level) or B6 (service level) in AMT01 (Actual Amount Qualifier Code);
  2. Any patient responsibility, remaining after coordination of benefits with the previous payer(s), with Group Code "PR” (Patient Responsibility) and the appropriate Claim Adjustment Reason Code (for example: 1 - Deductible Amount, 2 - Coinsurance Amount); and
  3. Any further adjustment, taken by Medicare as a result of previous payer(s) payment and/or adjustment(s), with Group Code OA and Claim Adjustment Reason Code 23.

Additional Information
The official instruction, CR8279 issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1318OTN.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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SE1338 - Improve Your Patients: Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

REMINDER product from the Medicare Learning Network® (MLN)

MLN Matters ®Number: SE1338 Re-issued
Related Change Request (CR)#: NA
Related CR Release Date: NA
Effective Date: NA
Related CR Transmittal #: NA
Implementation Date: NA

Note: This article was re-issued on November 27, 2013.

Provider Types Affected

Health care professionals eligible to furnish the IPPE or AWV.

What You Need to Know

Medicare covers the following services for Medicare patients that meet certain eligibility requirements:

These preventive benefits allow you to assess your patients’ health on an annual basis to help you determine if they have any risk factors and if they are eligible for other preventive services and screenings that Medicare covers.

These preventive benefits are a great way for you to detect illnesses in their earliest stages when treatment works best. The average reimbursement level for the AWV is about $107 and about $150 for the IPPE with no patient deductible or co-pay.

Note: Please check the physician fee schedule for the exact amount of reimbursement for your locality and setting. You can view the physician fee schedule by visiting http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html on the Centers for Medicare & Medicaid Services (CMS) website.

The Initial Preventative Physical Exam IPPE (“Welcome to Medicare” Preventive Visit)

Medicare covers an IPPE for all patients who have newly enrolled in Medicare Part B.

For more information about the IPPE, please see “Quick Reference Information: The ABCs of the IPPE” at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf on the CMS website.

The AWV or Annual Wellness Visit

Medicare covers an annual AWV for patients:

Medicare pays for only one first AWV. Medicare will pay for a subsequent AWV for each patient annually. Note: The elements in first and subsequent AWVs, and the codes to bill them, are different.

For more information about the AWV, please see:

Additional Information

The Medicare Learning Network® has published a variety of additional educational material on
Medicare-covered Preventive Services, including:

For general information about Medicare-covered preventive services, visit the CMS Prevention page at http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html on the CMS website. For information to share with your Medicare patients, please visit http://www.medicare.gov on the Internet.

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MM8517 - Calendar Year (CY) 2014 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

The “September 2013 ICD-10-CM/PCS Billing and Payment Frequently Asked Questions” Fact Sheet (ICN 908974) was released and is now available in downloadable format. This fact sheet is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes the following information: ICD-10-CM/PCS compliance date and billing and payment Frequently Asked Questions.

MLN Matters® Number: MM8517
Related Change Request (CR) #: CR 8517
Related CR Release Date: November 22, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2823CP
Implementation Date: January 6, 2014

Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories who submit claims to Medicare Claims Administration Contractors (carriers, Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 8517 which provides instructions for the Calendar Year (CY) 2014 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. Be sure that your billing staff is aware of these updates.

Background
Update to Fees

In accordance with the Social Security Act (Section 1833(h)(2)(A)(i)), as amended by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Section 628), and further amended by the Affordable Care Act (Section 3401), the annual update to the local clinical laboratory fees for CY 2014 is (-0.75) percent. The annual update to local clinical laboratory fees for CY 2014 reflects an additional multi-factor productivity adjustment and a (-1.75) percentage point reduction as described by the Affordable Care Act. The annual update to payments made on a reasonable charge basis for all other laboratory services for CY 2014 is 1.80 percent (See 42 CFR 405.509(b)(1) at http://www.ecfr.gov/cgi-bin/text- idx?SID=40538fb2e20d60fb4d4de0ab33d0ca22&node=42:2.0.1.2.5&rgn=div5#
42:2.0.1.2.5.5.25.10
on the Internet). The Social Security Act Section 1833(a)(1)(D); (see http://www.ssa.gov/OP_Home/ssact/title18/1833.htm) provides that payment for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the national limitation amount (NLA).

For a cervical or vaginal smear test (pap smear), the Social Security Act (Section 1833(h)(7)) requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount (described below). However, for a cervical or vaginal smear test (pap smear), payment may also not exceed the actual charge. The Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule.

National Minimum Payment Amounts
For a cervical or vaginal smear test (pap smear), the Social Security Act (Section 1833(h)(7)) requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount. Also, payment may not exceed the actual charge. The CY 2014 national minimum payment amount is $14.42 ($14.53 plus (-0.75) percent update for CY 2014). The affected codes for the national minimum payment amount are: 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, and P3000.

National Limitation Amounts (Maximum)
For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of the local fees. For tests for which the NLAs are first established on or after January 1, 2001, the NLA is 100 percent of the median of the local fees in accordance with the Social Security Act (Section 1833(h)(4)(B)(viii)).

Access to Data File

The CY 2014 clinical laboratory fee schedule data file will be retrieved electronically through Centers for Medicare & Medicaid Services (CMS) mainframe telecommunications system. Carriers will retrieve the data file on or after November 19, 2013. Intermediaries will retrieve the data file on or after November 19, 2013. Internet access to the CY 2014 clinical laboratory fee schedule data file will be available after November 19, 2013, at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html on the CMS website.

Other interested parties, such as the Medicaid State agencies, the Indian Health Service, the United Mine Workers, and the Railroad Retirement Board, will use the Internet to retrieve the CY 2014 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text, and comma delimited.

Data File Format
For each test code, if your system retains only the pricing amount, load the data from the field named “60% Pricing Amt.” For each test code, if your system has been developed to retain the local fee and the NLA, you may load the data from the fields named “60% Local Fee Amt” and “60% Natl Limit Amt” to determine payment. For test codes for cervical or vaginal smears (pap smears), you should load the data from the field named “60% Pricing Amt” which reflects the lower of the local fee or the NLA, but not less than the national minimum payment amount. Fiscal Intermediaries should use the field “62% Pricing Amt” for payment to qualified laboratories of sole community hospitals.

Public Comments
On July 10, 2013, CMS hosted a public meeting to solicit input on the payment relationship between CY 2013 codes and new CY 2014 CPT codes. Notice of the meeting was published in the Federal Register on May 24, 2013 (see http://www.federalregister.gov/articles/2013/05/24/2013-12225/medicare-program-public-meeting-in-calendar-year-2013-for-new-clinical-laboratory-test-payment ), and on the CMS website approximately June 1, 2013. Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations on the website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/ClinicalLabFeeSched/index.html on the CMS website. Additional written comments from the public were accepted until October 30, 2013. CMS has posted a summary of the public comments and the rationale for the final payment determinations on the CMS website.

Pricing Information
The CY 2014 clinical laboratory fee schedule includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615). The fees have been established in accordance with Section 1833(h)(4)(B) of the Social Security Act.

The fees for clinical laboratory travel codes P9603 and P9604 are updated on an annual basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard mileage rate for CY 2014, CMS will issue a separate instruction on the clinical laboratory travel fees.

The CY 2014 clinical laboratory fee schedule also includes codes that have a “QW” modifier to both identify codes and determine payment for tests performed by a laboratory having only a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA).

Organ or Disease Oriented Panel Codes
Similar to prior years, the CY 2014 pricing amounts for certain organ or disease panel codes and evocative/suppression test codes were derived by summing the lower of the clinical laboratory fee schedule amount or the NLA for each individual test code included in the panel code. The NLA field on the data file is zero-filled.

Mapping Information
Existing code 82777 is priced at the same rate as code 84244. New code 80155 is priced at the same rate as code 80198. New code 80159 is priced at the same rate as code 80154. New code 80169 is priced at the same rate as code 80195. New code 80171 is priced at the same rate as code 80157. New code 80175 is priced at the same rate as code 80157. New code 80177 is priced at the same rate as code 80157. New code 80180 is priced at the same rate as code 80158. New code 80183 is priced at the same rate as code 80157. New code 80199 is priced at the same rate as code 82542. New code 80203 is priced at the same rate as code 80157. New code 81161 is to be gap filled.

New code 81287 is to be gap filled.

New code 87661 is priced at the same rate as code 87511.

Laboratory Costs Subject to Reasonable Charge Payment in CY 2011

For outpatients, the following codes are paid under a reasonable charge basis (See the Social Security Act (Section 1842(b)(3)) at http://www.ssa.gov/OP_Home/ssact/title18/1842.htm on the Internet). In accordance with 42 CFR 405.502 through 42 CFR 405.508 (see http://www.ecfr.gov/cgi-bin/text-idx?SID=ab7bf0a61515aca26cefc0f2e7dae3b9&c=ecfr&tpl=/ecfrbrowse/Title42/ 42cfrv2_02.tpl), the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update is calculated using the change in the applicable Consumer Price Index for the 12-month period ending June 30 of each year as set forth in 42 CFR 405.509(b)(1) (see http://www.ecfr.gov/cgi-bin/text-idx?SID=40538fb2e20d60fb4d4de0ab33d0ca22&node=42:2.0.1.2.5&rgn= div5#42:2.0.1.2.5.5.25.10). The inflation-indexed update for CY 2013 is 1.7 percent.

Manual instructions for determining the reasonable charge payment can be found in Publication 100-4, Medicare Claims Processing Manual, Chapter 23, Section 80 through 80.8 (see http://www.cms.gov/Regulations-and-guidance/Guidance/Manuals/Downloads/clm104c23.pdf ). If there is sufficient charge data for a code, the instructions permit considering charges for other similar services and price lists.

When services described by the Healthcare Common Procedure Coding System (HCPCS) in the following list are performed for independent dialysis facility patients, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 60.3 (see http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf) instructs that the reasonable charge basis applies. However, when these services are performed for hospital-based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the hospital outpatient prospective payment system (OPPS).

Blood Products
Blood products codes are: P9010, P9011, P9012, P9016, P9017, P9019, P9020, P9021, P9022, P9023, P9031, P9032, P9033, P9034, P9035, P9036, P9037, P9038, P9039, P9040, P9044, P9050, P9051, P9052, P9053, P9054, P9055, P9056, P9057, P9058, P9059, and P9060.

Also, payment for the following codes (including Transfusion Medicine, and Reproductive Medicine Procedures, listed below) should be applied to the blood deductible as instructed in the "Medicare General Information, Eligibility, and Entitlement Manual," Chapter 3, Section 20.5 through 20.5.4: P9010, P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9056, P9057, and P9058.

NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on the Social Security Act (Section 1842(o)). The payment limits based on the Social Security Act (Section 1842(o)), including the payment limits for codes P9041, P9043, P9045, P9046, P9047, and P9048, should be obtained from the Medicare Part B drug pricing files.

Transfusion Medicine
Transfusion Medicine codes are: 86850, 86860, 86870, 86880, 86885, 86886, 86890, 86891, 86900,86901, 86903, 86904, 86905, 86906, 86920, 86921, 86922, 86923, 86927, 86930, 86931, 86932,86945, 86950, 86960, 86965, 86970, 86971, 86972, 86975, 86976, 86977, 86978, and i.

Reproductive Medicine Procedures
Reproductive Medicine Procedures codes are: 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89342, 89343,89344, 89346, 89352, 89353, 89354, and 89356.

MACs will not search their files to either retract payment or retroactively pay claims processed prior to implementation of CR8517; however, they will adjust such claims that you bring to their attention.

Additional Information
You can find the official instruction, CR 8517, issued to your MAC regarding this change at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2823CP.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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MM8511 - Quarterly Update to the Correct Coding Initiative (CCI) Edits, version 20.1, Effective April 1, 2014

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

NEW product from the Medicare Learning Network® (MLN)

MLN Matters®Number: MM8511
Related Change Request (CR) #: CR 8511
Related CR Release Date: November 29, 2013
Effective Date: April 1, 2014
Related CR Transmittal #: R2830CP
Implementation Date: Arpil 7, 2014

Provider Types Affected

This MLN Matters®Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 8298 which informs Medicare contractors about the release of the latest package of CCI edits, Version 20.1, which will be effective April 1, 2014. Make sure that your billing staffs are aware of these changes.

Background
The Centers for Medicare & Medicaid Services (CMS) developed the National CCI to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims. The coding policies developed are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice, and review of current coding practice.

Version 20.1 will include all previous versions and updates from January 1, 1996, to the present. In the past, CCI was organized in two tables: Column 1/Column 2 Correct Coding Edits and Mutually Exclusive Code (MEC) Edits. In order to simplify the use of NCCI edit files (two tables), on April 1, 2012, CMS consolidated these two edit files into the Column One/Column Two Correct Coding edit file. Separate consolidations have occurred for the two practitioner NCCI edit files and the two NCCI edit files used for needs defined (OCE). It will only be necessary to search the Column One/Column Two Correct Coding edit file for active or previously deleted edits. CMS no longer publishes a Mutually Exclusive edit file on its website for either practitioner or outpatient hospital services, since all active and deleted edits will appear in the single Column One/Column Two Correct Coding edit file on each website. The edits previously contained in the Mutually Exclusive edit file are NOT being deleted but are being moved to the Column One/Column Two Correct Coding edit file.

Additional Information

The official instruction, CR 8511 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2830CP.pdf on the CMS website.

Additional information on the CCI edits is available at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

REVISED product from the Medicare Learning Network®(MLN)

MLN Matters®Number: MM8472 Revised
Related Change Request (CR) #: CR 8472
Related CR Release Date: December 13, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R177BP and R2839CP
Implementation Date: January 6, 2014

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

Provider Types Affected

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

Provider Action Needed

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

Background
In accordance with the Medicare Improvements for Patients and Providers Act (MIPPA; Section
153(b)), the Centers for Medicare & Medicaid Services (CMS) implemented the End Stage Renal Disease (ESRD) bundled Prospective Payment System (PPS) effective January 1, 2011. You can review MIPPA (Section 153(b)) at  http://www.gpo.gov/fdsys/pkg/PLAW-110publ275/pdf/PLAW-110publ275.pdf on the Internet.

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

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

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

Calendar Year (CY) 2014 Rate Updates

For CY 2014, CMS will make the following updates to the CY 2013 ESRD PPS base rate:

  1. The ESRDB market basket minus a productivity adjustment of 2.8 which results in $247.09 ($240.36 x 1.028 = $247.09).
  2. The wage index budget neutrality adjustment factor of 1.000454 which results in $247.20 ($247.09 x 1.000454 = $247.20).
  3. The home dialysis training add-on budget neutrality adjustment factor of 0.999912 which results in $247.28 ($247.20 x 0.999912 = $247.18).
  4. After the application of the ESRDB market basket, the wage index budget neutrality adjustment factor, and the home dialysis training add-on budget neutrality factor, the ESRD PPS base rate will be reduced by the drug utilization adjustment amount of $8.16.  Therefore, the ESRD PPS base rate for CY 2014 is $239.02 ($247.18 - $8.16 = $239.02).

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

  1. The wage index adjustment will be updated to reflect the latest available wage data.
  2. The wage index floor will be reduced from 0.50 to 0.45.

Transition Budget Neutrality Adjustment

Beginning CY 2014, there will no longer be a transition budget-neutrality adjustment.

Home Dialysis Training Add-On Payment

The home dialysis training add-on payment will increase from $33.44 to $50.16.

Outlier Policy Changes

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

  1. For adult patients, the adjusted average outlier service MAP amount per treatment is $50.25.
  2. For pediatric patients, average outlier service MAP amount per treatment is $40.49.

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

  1. The fixed dollar loss amount is $98.67 for adult patients.
  2. The fixed dollar loss amount is $54.01 for pediatric patients.

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

  1. The ESRD-related Part D drugs which are based on the most recent prices retrieved from the Medicare Prescription Drug Plan Finder will be updated to reflect the most recent mean unit cost. The list of ESRD-related Part D drugs will also be updated to reflect the most recent list of ESRD- related Part D drugs that are eligible for outlier payment. (See attachment A of CR8472, which is available at  http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2839CP.pdf on the CMS website.)
  2. The mean dispensing fee of the National Drug Codes (NDC) qualifying for outlier consideration is revised to $1.42 per NDC per month for claims with dates of service on or after January 1, 2014.

CR 8472 also revises the "Medicare Claims Processing Manual," (Chapter 8 (Section 20.1 (Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD Prospective Payment System Rate); Section 50.8 (Training and Retraining); and Section 60.2.1.2 (Facilities Billing for ESRD Drugs and Biologicals Equivalent to Injectable Drugs)). The manual revisions are attached to CR8472.

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

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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MM8488 - Revised Beneficiary Liability and Messages Associated with Denials for claims for Services Furnished to Incarcerated Beneficiaries

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

REMINDER product from the Medicare Learning Network®(MLN)

MLN Matters®Number: MM8488
Related change Request (CR) #: CR 8488
Related CR Release Date: November 22, 2013
Effective Date: February 24, 2014
Related CR Transmittal #: R13200TN
Implementation Date: February 24, 2014

Provider Types Affected
This MLN Matters® article is intended for physicians, other providers, and suppliers who submit claims to Medicare Administration Contractors (MACs), including Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services provided to Medicare beneficiaries while they are in Federal, State, or local custody.

Provider Action Needed
This article is based on Change Request (CR) 8488 which instructs Medicare Claims Administration Contractors to use an updated Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Group Code when denying claims for services furnished to incarcerated Medicare beneficiaries. See the Background and Additional Information Sections of this article for further details regarding these changes. Make sure that your billing staffs are aware of these changes.

Background
According to Federal regulations at 42 CFR 411.4, Medicare does not pay for services furnished to a beneficiary who has no legal obligation to pay for the service, and no other person or organization has a legal obligation to provide or pay for the service. Refer to the Electronic Code of Federal Regulations (e-CFR) at  http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=1270613eb7cae1ed8c62899034b0eca2&rgn=div8&view=
text&node=42:2.0.1.2.11.1.35.3&idno=42
on the Internet. This exclusion presumptively applies to individuals who are incarcerated.

Under 42 CFR 411.6, Medicare does not pay for services furnished by a federal provider of services or by a federal agency. Also, under 42 CFR 411.8, Medicare does not pay for services that are paid for directly or indirectly by a governmental entity.

As such, when claims for services furnished to beneficiaries who are incarcerated are submitted to Medicare, the claims are rejected by the Common Working File (CWF) and denied by the claims processing contractors. Per previously issued instructions (most recently, CR7678, Transmittal 1054, issued 3/7/2012; see related MLN Matters® article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7678.pdf ), MACs use the following remittance advice messages and Group Code when denying such claims:

CR8488 revises the remittance advice messages and group code used for denials of claims for services furnished to incarcerated beneficiaries.

MACs will begin using the following new CARC code when denying claims for services furnished to beneficiaries while they are in Federal, State, or local custody:

In addition, MACs will begin using the following revised RARC N103 language when denying claims for services furnished to beneficiaries while they are in Federal, State, or local custody:

RARC: N103 - "Medicare records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her healthcare while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts."

MACs will begin using the following Group Code to assign proper liability when denying claims for services furnished to beneficiaries while they are in Federal, State, or local custody so that the provider or supplier should seek repayment for the cost of its services provided from the authority that was in custody of the beneficiary on the date of service:

Other than the above, MACs will continue to use existing Remittance Advice codes and messages and MSN language already in place when denying claims for services furnished to beneficiaries while they are in Federal, State, or local custody.

Additional Information
The official instruction, CR8488 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1320OTN.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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MM8537 - Transcatheter Aortic Valve Replacement (TAVR) - Implementation of Permanent CPT Code

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

In September 2012, the Centers for Medicare & Medicaid Services (CMS) announced the availability of a new electronic mailing list for those who refer Medicare beneficiaries for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Referral agents play a critical role in providing information and services to Medicare beneficiaries. To ensure you give Medicare patients the most current DMEPOS Competitive Bidding Program information, CMS strongly encourages you to review the information sent from this new electronic mailing list. In addition, please share the information you receive from the mailing list and the link to the “mailing list for referral agentssubscriber webpage with others who refer Medicare beneficiaries for DMEPOS. Thank you for signing up!

MLN Matters®Number: MM8537
Related Change Request (CR) #: CR 8537
Related CR Release Date: November 29, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2827CP
Implementation Date: January 6, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Transcatheter Aortic Valve Replacement (TAVR) services to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 8537 which informs MACs that the Centers for Medicare & Medicaid Services (CMS) is retiring the remaining temporary CPT code 0318T and replacing it with permanent CPT code 33366 effective January 1, 2014. Make sure that your billing staffs are aware of these changes.

Background
Transcatheter aortic valve replacement (TAVR - also known as TAVI or transcatheter aortic valve implantation) is a new technology for use in treating aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. The procedure is performed in a cardiac catheterization lab or a hybrid operating room/cardiac catheterization lab with advanced quality imaging and with the ability to safely accommodate complicated cases that may require conversion to an open surgical procedure. The interventional cardiologist and cardiac surgeon jointly participate in the intra-operative technical aspects of TAVR. On May 1, 2012, CMS issued a National Coverage Determination (NCD) covering TAVR under Coverage with Evidence Development (CED). The policy is available at http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=355.

CR8537 is an update to CR 8168, dated January 7, 2013. CR8168 implemented replacement codes for TAVR claims with dates of service on and after January 1, 2013, and contains more detailed billing instructions for TAVR services.

Specifically, for dates of service on or after January 1, 2014, CMS is retiring the remaining temporary CPT code 0318T - Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical approach (e.g., left thoracotomy) with permanent CPT code 33366 - Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (e.g., left thoracotomy). This coding change appears in the January 2014 Medicare Physician Fee Schedule Database and Integrated Outpatient Code Editor updates.

Providers should also note that if a TAVR claim is denied because a Place of Service (POS) code other than POS code 21 was used, the following messages will also be used:

Additional Information
The official instruction, CR 8537 issued to your MAC regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2827CP.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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MM7350 - Implementation of Provider enrollment Provisions in CMS-06028-FC

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

News Flash – The revised brochure titled “The Medicare Appeals Process: Five Levels to Protect Providers, Physicians, and Other Suppliers” (revised January 2011), is now available in downloadable format from the Medicare Learning Network® at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareAppealsProcess.pdf on the Centers for Medicare & Medicaid Services website. This brochure is designed to provide an overview of the Medicare Part-A and Part-B administrative appeals process available to providers, physicians, and other suppliers who provide services and supplies to Medicare beneficiaries, as well as details on where to obtain more information about this appeals process.

MLN Matters® Number: MM7350 Revised
Related Change Request (CR) #: 7350
Related CR Release Date: March 23, 2011
Effective Date: March 25, 2011
Related CR Transmittal #: R371PI
Implementation Date: March 25, 2011

Note: This article was revised on December 9, 2013, to provide the application fee amount of $542.00 for calendar year 2014. All other information remains the same.

Provider Types Affected
All providers and suppliers submitting enrollment applications to Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Medicare Carriers, A/B Medicare Administrative Contractors (A/B MACs), and the National Supplier Clearinghouse (NSC) are affected by this article.

Provider Action Needed

STOP – Impact to You
The Centers for Medicare & Medicaid Services (CMS) published a final rule with comment period, entitled, “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers” (CMS-6028-FC). This rule was published in the February 2, 2011, edition of the “Federal Register.”

CAUTION – What You Need to Know
This rule finalized provisions related to the:

GO – What You Need to Do
This article is based on Change Request (CR) 7350, which describes how Medicare contractors will implement the changes related to provider enrollment screening, application fees, and temporary moratoria. (Payment suspensions will be addressed via separate CMS guidance.). Please ensure that your staffs are aware of these new provisions.

Background
CR7350 describes how Medicare will implement certain provisions of the final rule CMS-6028-FC. These details are provided in new sections 19 through 19.4 of Chapter 15 in the “Medicare Program Integrity Manual.” Those manual sections are attached to CR7350 and are summarized as follows:

Screening Processes
Beginning on March 25, 2011, Medicare will place newly-enrolling and existing providers and suppliers in one of three levels of categorical screening: limited, moderate, or high. The risk levels denote the level of the contractor’s screening of the provider or supplier when it initially enrolls in Medicare, adds a new practice location, or revalidates its enrollment information.

Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) provides the complete list of these three screening categories, and the provider types assigned to each category, and a description of the screening processes applicable to the three categories (effective on and after March 25, 2011), and procedures to be used for each category. Once again, that new section of the PIM is attached to CR7350.

Although fingerprinting and criminal background checks are included in CMS-6028- FC as requirements for providers and suppliers in the “high” category of screening, these requirements will be implemented at a later date and providers and suppliers will be notified well in advance of their implementation.

Application Fees
With the exception of physicians, non-physician practitioners, physician group practices and non-physician group practices, providers and suppliers that are (1) initially enrolling in Medicare, (2) adding a practice location, or (3) revalidating their enrollment information, must submit with their application:

This requirement applies to applications that your Medicare contractor receives on or after March 25, 2011. Note that a physician, non-physician practitioner, physician group, or non-physician practitioner group that is enrolling as a DMEPOS supplier via the CMS-855S application must pay the required application fee.

The application fee must be in the amount prescribed by CMS for the calendar year in which the application is submitted. The fee for January 1, 2013, through December 31, 2013, is $532.00. The fee for January 1, 2014, through December 31, 2014 is $542.00. Fee amounts for future years will be adjusted by the percentage change in the consumer price index (for all urban consumers) for the 12-month period ending on June 30 of the prior year. CMS will give Medicare contractors and the public advance notice of any change in the fee amount for the coming calendar year.

The application fee is non-refundable, except if it was submitted with one of the following:

The provider or supplier must pay the application fee electronically by going to https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do and paying their fee via credit card, debit card, or check. Providers and suppliers are strongly encouraged to submit with their application a copy of their receipt of payment. This may enable the contractor to more quickly verify that payment has been made.

Hardship Exception
A provider or supplier requesting a hardship exception from the application fee must include with its enrollment application a letter (and supporting documentation) that describes the hardship and why the hardship justifies an exception. If a paper CMS-855 application is submitted, the hardship exception letter must accompany the application. If the application is submitted via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), the hardship exception letter must accompany the certification statement. Hardship exception letters will not be considered if they were submitted separately from the application or certification statement, as applicable. If your Medicare contractor receives a hardship exception request separately from the application or certification statement, it will: (1) return it to you, and (2) notify you via letter, e-mail, or telephone, that it will not be considered.

Upon receipt of a hardship exception request with the application or certification statement, the contractor will send the request and all documentation accompanying the request to CMS. CMS will determine if the request should be approved. During this review period, the contractor will not begin processing the provider’s application. CMS will communicate its decision to the institutional provider and the contractor via letter.

IMPORTANT: In addition, the contractor will not begin to process the provider’s application until: (1) the fee has been paid, or (2) the hardship exception request has been approved. Once processing commences, the application will be processed in the order in which it was received.

Review of Hardship Exception Request
As already stated, the application fee for CY 2011 is $505. This generally should not represent a significant burden for an adequately capitalized provider or supplier. It is not enough for the provider to simply assert that the imposition of the application fee represents a financial hardship. The provider must instead make a strong argument to support its request, including providing comprehensive documentation (which may include, without limitation, historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.).

Other factors that may suggest that a hardship exception is appropriate include the following:

  1. Considerable bad debt expenses,
  2. Significant amount of charity care/financial assistance furnished to patients,
  3. Presence of substantive partnerships (whereby clinical, financial integration are present) with those who furnish medical care to a disproportionately low-income population;
  4. Whether an institutional provider receives considerable amounts of funding through disproportionate share hospital payments, or
  5. Whether the provider is enrolling in a geographic area that is a Presidentially-declared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-5206 (Stafford Act).

Note that if the provider fails to submit appropriate documentation to support its hardship exception request, the contractor is not required to contact the provider to request it. Ultimately, it is the provider’s responsibility to furnish the necessary supporting evidence at the time it submits its hardship exception request.

Appeal of the Denial of Hardship Exception Decision
If the provider or supplier is dissatisfied with CMS's decision, it may file a written reconsideration request with CMS within 60 calendar days from receipt of the notice of initial determination. The request must be signed by the individual provider or supplier, a legal representative, or any authorized official within the entity. Failure to file a reconsideration request within this timeframe is deemed a waiver of all rights to further administrative review. To file a reconsideration request, providers and suppliers should follow the procedures outlined in Chapter 15, Section 19 of the “Program Integrity Manual” (PIM), which is attached to CR7350.

Temporary Moratoria
CMS may impose a moratorium on the enrollment of new Medicare providers and suppliers of a particular type or the establishment of new practice locations of a particular type in a particular geographic area.

The announcement of a moratorium will be made via the Federal Register. For initial and new location applications involving the affected provider and supplier type, the moratorium:

If a particular moratorium is lifted, all applications pending with the contractor as of the effective date of the moratorium’s cessation are no longer subject to the moratorium and may be processed. However, such applications will be processed in accordance with the “high” level of categorical screening. In addition, any initial application received from a provider or supplier: (a) that is of a provider or supplier type that was subject to a moratorium, and (b) within 6 months after the applicable moratorium was lifted, the contractor will process the application using the “high” level of categorical screening.

Additional Information
The official instruction, CR7350, issued to your FI, RHHI, carrier, and A/B MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R371PI.pdf on the CMS website.

Complete details regarding this issue, as defined in the PIM revisions, are attached to CR7350.

MLN Matters® article SE1126, which is available at http://www.cms.gov/Outreach-and-education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf , has further details on the Affordable Care Act-required revalidation of provider enrollment information for all providers and suppliers who enrolled in the Medicare program prior to March 25, 2011.

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.

A sample letter requesting providers to review, update, and certify their enrollment information is available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf on the CMS website.

If you have any questions, please contact your FI, RHHI, carrier, or A/B MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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SE1126 - Further Details on the Revalidation of Provider Enrollment Information

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Several fact sheets that provide education to specific provider types on how to enroll in the Medicare Program and maintain their enrollment information using Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) have been recently updated and are available in downloadable format from the Medicare Learning Network® (MLN). Please visit http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/Medicare_Provider- Supplier_Enrollment_National_Education_Products.pdf for a complete list of all MLN products related to Medicare provider-supplier enrollment.

MLN Matters Number: SE1126 Revised
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A


Note: This article was revised on December 9, 2013, to include the 2014 application fee amount of $542.00. All other information remains the same.

Provider Types Affected
This Medicare Learning Network (MLN) Matters® Special Edition Article is intended for all providers and suppliers who enrolled in Medicare prior to March 25, 2011, via Medicare’s Contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Medicare Carriers, A/B Medicare Administrative Contractors (A/B MACs), and the National Supplier Clearinghouse (NSC)). These contractors are collectively referred to as MACs in this article.

Provider Action Needed

STOP – Impact to You
In Change Request (CR) 7350, the Centers for Medicare & Medicaid Services (CMS) discussed the final rule with comment period, titled, “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers” (CMS-6028-FC). This rule was published in the February 2, 2011, edition of the “Federal Register.” A related MLN Matters® Article is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7350.pdf on the CMS website. This article provides no new policy, but only provides further information regarding the revalidation requirements based on Section 6401 (a) of the Affordable Care Act.

CAUTION – What You Need to Know
All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notificaiton from their MAC.

Special Note: The Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Providers should continue to submit routine changes – address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc – 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
When you receive notification from your MAC to revalidate:

Background
Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are generally not impacted. Excluded from the revalidation requirements are providers enrolled solely to order and refer items or services to Medicare beneficiaries and practitioners who have opted out of the Medicare program.

CMS has reevaluated the revalidation requirement in the Affordable Care Act, and believes it affords the flexibility to extend the revalidation period for another 2 years. This will allow for a smoother process for providers and MACs. Revalidation notices will now be sent through March of 2015. IMPORTANT: This does not affect those providers which have already received a revalidation notice. If you have received a revalidation notice from your MAC respond to the request by completing the application either through internet-based PECOS or by completing the appropriate 855 application form.

Therefore, between now and 2015, MACs will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process for each -provider and supplier. Providers and suppliers must submit the revalidation application only after being asked by their MAC to do so. Please note that 42 CFR 424.515(d) provides CMS the authority to conduct these off-cycle revalidations.

CMS asks all providers who receive a request for revalidation to respond to that request.

CMS will provide the MACs with a list of providers/suppliers requiring revalidation every 60 days beginning October 2013. Within 60 days of receiving the CMS list, MACs will mail the revalidation notices.

Large groups (200+ members) accepting reassigned benefits from providers identified on the CMS list will receive a letter from their MACs informing them that providers linked to their group have been selected to revalidate. A spreadsheet detailing the applicable provider’s Name, National Provider Identifier (NPI) and Specialty will also be provided. The letter and spreadsheet will be mailed to the group’s correspondence address within 15 days of the MAC receiving the CMS list. This is informational only. Groups should not take any action to revalidate their providers until asked by their MAC to do so.

Groups with less than 200 reassignments will not receive a letter or spreadsheet from their MAC, but can utilize Internet-based PECOS or the CMS list available on CMS.gov to determine if their providers have been mailed a revalidation notice.

Note: CMS has structured the revalidation processes to reduce the burden on the providers by implementing innovative technologies and streamlining the enrollment and revalidation processes. CMS will continue to provide updates as progress is made on these efforts.

The 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 on the CMS website. PECOS allows you to review information currently on file, update and submit your revalidation via the Internet. Once completed, YOU MUST electronically sign the revalidation 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.

Section 6401(a) of the Affordable Care Act also requires the Secretary to impose a fee on each
“institutional provider of medical or other items or services and suppliers.” The application fee is $532.00 for Calendar Year (CY) 2013. The fee for CY 2014 is $542.00.  CMS has defined “institutional provider” to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS- 855S forms or associated Internet-based PECOS enrollment application.

All institutional providers (i.e., 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 an enrollment fee (reference 42 CFR 424.514) with their revalidation. You may submit your fee by ACH debit, or credit card. Revalidations are processed only when fees have cleared. 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 mail this receipt to the MAC along with the Certification Statement for the enrollment application. CMS will notify the MAC that the application fee has been paid.

Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges.

A 60-day extension is available if more time is needed to complete the revalidation process. Extension requests should be coordinated with your MAC and requested in writing (fax/email permissible) or via phone. The Individual provider, the Authorized or Delegated Official of the group or the enrollment contact person can request the extension.

A group may request an extension on behalf of individuals reassigned to their group. Group extensions shall also be coordinated through your MACs and must meet the following requirements.

  1. Only permitted if the provider reassigns all benefits to the group requesting the  extension,
  2. The extension is requested by the Authorized or Delegated Official of the group or the enrollment contact person, and
  3. The Providers’ name, National Provider Identifier (NPI) and justification as to why an extension is needed is provided. The extension can be requested in writing (fax/email permissible) or via phone.

Additional Information
To find out whether a provider/supplier has been mailed a revalidation notice go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html 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 can be found 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 on the CMS website.

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

 

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MM8393 - Additional Updates to Chapter 15 of the Program Integrity Manual (PIM)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

Revised products from the Medicare Learning Network® (MLN)

MLN Matters Number: MM8393
Related Change Request (CR) #: CR 8393
Related CR Release Date: December 6, 2013
Effective Date: January 7, 2014
Related CR Transmittal #: R492PI
Implementation Date: January 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice MACs, for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8393, which instructs MACs to implement several recent provider enrollment policy determinations that were incorporated into Chapter 15 of the Medicare Program Integrity Manual (PIM). Make sure that your billing staffs are aware of these updates.

Background
As stated in CR8393, the provider enrollment application fee for January 1, 2014 through December 31, 2014 is $542.00.

Additional Information
The official instruction, CR8393, issued to your MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R492PI.pdf on the CMS website. See CR 8393 to read other provider enrollment policy determinations that have been incorporated into Chapter 15 of the PIM. The revised Chapter of the PIM is attached to CR8393.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

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MM8408 - Informational Unsolicited Response (IUR) or Reject for Ambulance SNF to SNF Transfer

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

MLN Matters® Number: MM8408
Related Change Request (CR) #: CR 8408
Related CR Release Date: December 6, 2013
Effective Date: April 1, 2014
Related CR Transmittal #: R1326OTN
Implementation Date: April 7, 2014

Note: This article was revised on December 9, 2013, to reflect the revised CR8408 issued on December 6. In the article, the CR release date, transmittal number, and the Web address for accessing the CR are revised. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers submitting ambulance claims to A/B Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8408, implementing system changes to reject ambulance claims when suppliers are billing ambulance claims for Skilled Nursing Facility (SNF) to SNF transfer separately under Part B.

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

Background
The CMS Recovery Audit Contractor (RAC) program is responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The contractor claim data identified suppliers that were billing ambulance claims for SNF to SNF transfer separately under Part B resulting in overpayments.

The SNF discharging the beneficiary to another SNF is financially responsible for the transportation fees and the ambulance providers should seek payment from the transferring SNF.

The following Group Code, Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) will be used when creating an adjustment and a reject for impacted claims:

Note: Attachment A of CR8408 contains a list of specified Healthcare Common Procedure Coding System (HCPCS) codes affected by these edits.

Additional Information
The official instruction, CR 8408, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1326OTN.pdf on the CMS website.

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

 

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

REVISED product from the Medicare Learning Network® (MLN)

MLN Matters Number: MM8539
Related Change Request (CR) #: CR 8539
Related CR Release DAte: December 13, 2013
Effective Date: April 1, 2014
Related CR Transmittal #: R2835CP
Implemenation Date: April 7, 2014

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

Provider Action Needed
This article is based on Change Request (CR) 8539, which provides the annual update to Home Health (HH) consolidated billing effective for dates of service on or after April1, 2014.  The new codes were effective January 1, 2014, but were overlooked and a 2014 annual HH consolidated billing update was not published. The following of Healthcare Common Procedure Coding System (HCPCS)codes are added to the HH consolidated billing non-routine supply code list:

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

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

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

Background
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list that are submitted on claims to MACs will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing.

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

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

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider- compliance-interactive-map/index.html on the CMS website.

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MM8394 - Recalitrant Provider Procedures

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

The September 2013 ICD-10-CM/PCS Billing and Payment Frequently Asked QuestionsFact Sheet (ICN 908974) was released and is now available in downloadable format. This fact sheet is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes the following information: ICD-10-CM/PCS compliance date and billing and payment Frequently Asked Questions.

MLN Matters ®Number: MM8394
Related Change Request (CR) #: CR 8394
Related CR Release Date: December 13, 2013
Effective Date: January 15, 2014 - This process is currently in effect and this is a clarification through a manual update.
Related CR Transmittal #: R495PI
Implementation Date: January 15, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment Medicare Administrative Contractors (DME MACs), for services or items to Medicare beneficiaries.

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

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

Notes: In this context:

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

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

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

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

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

If you have any questions, please contact your MAC at their toll-free number, which is available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider- compliance-interactive-map/index.html on the CMS website.

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

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MM8523 - Change to the Reasonable charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

MLN Matters Number: MM8523
Related Change Rquest (CR) #: CR 8523
Related CR Release Date: December 13, 2013
Effective Date: January 1, 2014 for payment on a reasonable charge basis and April 1, 2014 for payment on a national fee schedule basis
Related CR Transmittal #: R2837CP
Implementation Date: January 6, 2014 for payment on a reasonable charge basis and April 7, 2014 for Payment on a national fee schedule basis

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

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

Background
Payment has been made on a reasonable charge basis for splints and casts, and intraocular lenses (IOLs) inserted in a physician’s office with the criteria for determining reasonable charges set forth at 42 CFR part 405, subpart E of CMS regulations. However, section 1842(s) of the Social Security Act provides the authority for replacing the reasonable charge payment methodology with statewide or other area wide fee schedules to be used for payment for these items. The final rule implementing fee schedules for splints and casts, and IOLs inserted in a physician’s office was published on December 2, 2013. Effective for dates of service on or after April 1, 2104, payment for splints and casts, and IOLs inserted in a physician’s office will be made using national fee schedule amounts, and reasonable charges will no longer be calculated for these items.

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

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

The reasonable charge amounts for splints and casts that are effective for dates of service January 1, 2014 through March 31, 2014 are shown in Attachment A of CR8523, which is available at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2837CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website. MACs will make payment for splints and casts based on the lower of the actual charge or the reasonable charge payment limits established for these codes. Payment will also be made on a reasonable charge basis for IOL codes V2630, V2631 and V2632 that are inserted in a physician’s office for dates of service January 1, 2014 through March 31, 2014.

MACs shall use the national fee schedule amounts listed in Attachment B of CR85

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

Additional Information
The official instruction, CR 8523 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2837CP.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider- compliance-interactive-map/index.html on the CMS website.

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

 

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MM8473 - New Influenza Virus Vaccine Code

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

MLN Matters® Number: MM8473
Related Change Request (CR) #: CR 8473
Related CR Release Date: November 22, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2824CP
Implementation Date: April 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers, including hospitals, Home Health Agencies, and Hospices submitting claims to Medicare contractors (carriers, Medicare Administrative Contractors (A/B MACs), Regional Home Health Intermediaries (RHHIs), and Home Health & Hospice Medicare Administrative Contractors (HH&H MACs) for services to Medicare beneficiaries.

Provider Action Needed
CR 8473, from which this article is taken, provides instructions for updating payment and Common Working File (CWF) edits to include influenza virus vaccine Common Procedural Terminology (CPT)  code 90673 (Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for intramuscular use), for claims with dates of service on or after January 1, 2014, that are processed on or after April 1, 2014. CR8473 also corrects the effective date of code Q2033 from January 1, 2013, to July 1, 2013. You should ensure that your billing staffs are aware of these code changes.

Background
CR 8473, from which this article is taken, provides that (effective for claims with dates of service on or after January 1, 2014) Medicare will pay for vaccine CPT code 90673 (Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for intramuscular use). All physicians, non-physicians practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine.

Your Medicare contractor will add influenza virus vaccine CPT code 90673 to existing influenza virus vaccine edits and accept it for claims with dates of service on or after January 1, 2014.

Effective for dates of service on and after January 1, 2014, they will:

Note: In all of the above instances, annual Part B deductible and coinsurance do not apply.

In addition, (effective for dates of service between January 1, 2014 and March 31, 2014) your Medicare contractor:

Additional Information
The official instruction, CR 8473, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2824CP.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which is available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

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

The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare &  Medicaid Services

REVISED product from the Medicare Learning Network® (MLN):

MLN Matters Number: MM8531
Related Change Request (CR)#: CR 8531
Related CR Release Date: December 13, 2013
Effective Date: January 1, 2014
Related CR Transmittal #: R2836CP
Implementation January 6, 2014

Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for DMEPOS items or services paid under the DMEPOS fee schedule.

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

Background and Key Points of CR8531
The DMEPOS fee schedules are updated on an annual basis in accordance with statute and regulations. The update process for the DMEPOS fee schedule is located in the "Medicare Claims Processing Manual," Chapter 23, Section 60, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf on the CMS website.

Payment on a fee schedule basis is required for Durable Medical Equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by Section1834 (a), (h), and (i) of the Social Security Act (the Act). Also, payment on a fee schedule basis is a regulatory requirement at 42 CFR Section 414.102 for Parenteral and Enteral Nutrition (PEN) and splints, casts, and certain intraocular
lenses.

Fee Schedule Files

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

Healthcare Common Procedure Coding System (HCPCS) Codes Added/ Deleted

The following new codes are effective January 1, 2014;

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

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

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

Factor

Category

0.469

Oxygen

0.472

Capped Rental

0.473

Prosthetics and Orthotics

0.600

Surgical Dressings

0.653

Parental and Enteral Nutrition

Specific Coding and Pricing Issues

As part of this update, fee schedules for the following codes will be added to the DMEPOS fee schedule file effective January 1, 2014:

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

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

As shown in the following table, 22 new codes are added to the HCPCS for OTS orthotics. In addition, as part of the review to determine which HCPCS codes for prefabricated orthotics describe OTS orthotics, it was determined that HCPCS codes for prefabricated orthotics describe items that are furnished OTS and items that require expertise in customizing the orthotic to fit the individual patient. Therefore, it was necessary to explode these codes into two sets of codes. One set is the existing codes revised, effective January 1, 2014, to only describe devices customized to fit a specific patient by an individual with expertise and a second set of new codes describing the OTS items.

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

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

Fee from Existing Code

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

L0454

L0455 and L0454

L0456

L0457 and L0456

L0466

L0467 and L0466

L0468

L0469 and L0468

L0626

L0641 and L0626

L0627

L0642 and L0627

L0630

L0643 and L0630

L0631

L0648 and L0631

L0633

L0649 and L0633

L0637

L0650 and L0637

L0639

L0651 and L0639

L1810

L1812 and L1810

L1832

L1833 and L1832

L1847

L1848 and L1847

L3807

L3809 and L3807

L3915

L3916 and L3915

L3917

L3918 and L3917

L3923

L3924 and L3923

L3929

L3930 and L3929

L4360

L4361 and L4360

L4386

L4387 and L4386

L4396

L4397 and L4396

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

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

Diabetic Testing Supplies
The fee schedule amounts for non-mail order diabetic testing supplies, without KL modifier, for codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, A4259 are not updated by the covered item update for CY 2014. In accordance with Section 636(a) of the American Taxpayer Relief Act of 2012, the fee schedule amounts for these codes were adjusted in CY 2013 so that they are equal to the single payment amounts for mail order Diabetic Testing Supplies (DTS) established in implementing the national mail order Competitive Bidding Program (CBP) under Section 1847 of the Act. The non- mail order payment amounts on the fee schedule file will be updated each time the single payment amounts are updated which can happen no less often than every three years as CBP contracts are recompeted. The national CBP for mail order diabetic supplies is effective July 1, 2013, to June 30, 2016. The program instructions reviewing these changes are Transmittal 2709, Change Request (CR) 8325, dated May 17, 2013, and Transmittal 2661, Change Request (CR) 8204, dated February 22, 2013. You may review the MLN Matters® Articles for these CRs at http://www.cms.gov/Outreach- and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8325.pdf and http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM8204.pdf on the CMS website.

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

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

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

2014 Update to the Labor Payment Rates

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

STATE

K0739

L4205

L7520

STATE K0739 L4205 L7520

AK

$27.40

$31.22

$36.73

NC 14.55 21.68 29.43

AL

14.55

21.68

29.43

ND 18.13 31.16 36.73

AR

14.55

21.68

29.43

NE 14.55 21.66 41.04

AZ

17.99

21.66

36.21

NH 15.62 21.66 29.43

CA

22.32

35.59

41.48

NJ 19.63 21.66 29.43

CO

14.55

21.68

29.43

NM 14.55 21.68 29.43

CT

24.30

22.16

29.43

NV 23.18 21.66 40.12

DC

14.55

21.66

29.43

NY 26.79 21.68 29.43

DE

26.79

21.66

29.43

OH 14.55 21.66 29.43

FL

14.55

21.68

29.43

OK 14.55 21.68 29.43

GA

14.55

21.68

29.43

OR 14.55 21.66 42.32

HI

17.99

31.22

36.73

PA 15.62 22.30 29.43

IA

14.55

21.66

35.23

PR 14.55 21.68 29.43

ID

14.55

21.66

29.43

RI 17.34 22.32 29.43

IL

14.55

21.66

29.43

SC 14.55 21.68 29.43

IN

KS

KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

14.55

14.55

14.55

14.55

24.30

14.55

24.30

14.55

14.55

14.55

14.55

14.55

21.66

21.66

27.76

21.68

21.66

21.66

21.66

21.66

21.66

21.66

21.68

21.66

29.43

36.73

37.64

29.43

29.43

29.43

29.43

29.43

29.43

29.43

29.43

36.73

SD

TN

TX

UT

VA

VI

VT

WA

WI

WV

WY

16.26

14.55

14.55

14.59

14.55

14.55

15.62

23.18

14.55

14.55

20.28

21.66

21.68

21.68

21.66

21.66

21.68

21.66

31.77

21.66

21.66

28.89

39.35

29.43

29.43

45.83

29.43

29.43

29.43

37.74

29.43

29.43

41.04

2014 National Monthly Payment Amounts for Stationary Oxygen Equipment
CR8531 implements the 2014 national monthly payment amount for stationary oxygen equipment (HCPCS codes E0424, E0439, E1390, and E1391), effective for claims with dates of service on or after January 1, 2014. As required by statute, the payment amount must be adjusted on an annual basis, as necessary, to ensure budget neutrality of the new payment class for Oxygen Generating Portable Equipment (OGPE). The updated 2014 monthly payment amount of $178.24 includes the 1.0 percent update factor for the 2014 DMEPOS fee schedule.

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

2014 Maintenance and Servicing Payment Amount for Certain Oxygen Equipment
CR8531 also updates the 2014 payment amount for maintenance and servicing for certain oxygen equipment. You can read more about payment for claims for maintenance and servicing for oxygen equipment in MLN Matters® Articles,MM6792 at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6792.pdf and MM6990 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM6990.pdf on the CMS website.

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

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

Additional Information
The official instruction, CR8531 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2836CP.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.htmlon the CMS website.

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Five Levels in the Appeals Process

The amount that must remain in controversy for ALJ hearing requests filed before December 31, 2013 is $140.00. This amount will remain at $140 for ALJ hearing requests filed on or after January 1, 2014. The amount that must remain in controversy for review in Federal District Court requested before December 31, 2013 is $1,400. This amount will increase to $1,430 for appeals to Federal District Court filed on or after January 1, 2014.

 

 


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