Read 0312mrdraft text version

Medicare Report

A Quarterly Newsletter for Medicare Healthcare Professionals December 1, 2003

Icons Identify Articles

Icons will be used in the table of contents of the Medicare Report to identify articles that may be of interest to a particular type of provider. Articles of a general interest will have no associated icon. A Key, listing those icons used, will be included in each edition. We have exercised due diligence in identifying articles that pertain to particular types of practices. We strongly encourage you to review the entire table of contents to identify other articles and information that may also pertain to your specific practice. These are the icons that appear in this edition of the Medicare Report. Icon Description Ambulance Anesthesia/CRNA Clinical Diagnostic Lab Consolidated Billing/SNF Diagnostic Testing Eye Care Non Physician Practitioners Surgery Therapy/Rehab (OT/PT) Teaching Physicians

www.hgsa.com

In This Issue

Carrier Medical Director Column . 3 News .............................................. 5 Educational Calendar of Events . 6 Specialty News Ambulance ............................... 22 Laboratory ............................... 24 Reimbursement ............................ 27 Internet Spotlight ......................... 32 Fraud and Abuse .......................... 33 Claim Reporting ........................... 34 Medical Review Highlights .......... 42 Coverage Issues ........................... 45 Medical Policy ............................. 54 DMERC News .............................. 58 Request for Education .................. 60 Education & Training Feedback Form ........................................ 61 EDI Xcellence ......................... Insert

Happy Holidays!

Our office will be closed Dec. 25th, Dec. 26th, and Jan. 1st for the holidays.

This bulletin should be shared with all health care practitioners and managerial members of the physician/supplier staff. Medicare Reports are available at no cost from our web site at www.hgsa.com/professionals/med-reports.shtml

Table of Contents

Medicare Report December 1, 2003 The Medicare Report is published quarterly as an informational reference source by HGSAdministrators for health care professionals in Pennsylvania. This material is intended to complement and not replace Medicare program requirements as set forth in statute, regulations and manual instructions. It is the responsibility of each healthcare professional/supplier submitting claims to HGSAdministrators to familiarize themselves with Medicare coverage requirements. HGSAdministrators makes efforts to ensure the information contained in this publication is accurate and current. However, because the Medicare program is constantly changing, it is the responsibility of each provider/ supplier to remain abreast of the Medicare program requirements. Questions concerning this publication or its contents may be directed in writing to: HGSAdministrators Medicare Professional Services PO Box 890089 Camp Hill, PA 17089-0089 CPT codes, descriptors, and other data only are copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/ DFARS apply.

Icons Identify Articles ........................................ 1

Claim Reporting

2004 HCPCS Update ........................................ 34 Anesthesia Reimbursement Based on Jurisdictional Payment .................................. 34 Beneficiary Signature on Claim Form .............. 34 Cataract Surgery--Co-Management ................. 35 Changes to Code List for Therapy Services ...... 36 Compounded Drugs--Billing for ..................... 36 Hepatitis B Vaccine--CPT Codes ..................... 37 Influenza Virus Vaccine--Use Diagnosis Code V04.81 ................................................ 37 Mammography--Reporting CAD Codes ......... 37 Not Otherwise Classified (NOC) Codes for Injections ...................................................... 38 Outpatient Rehabilitation Services Billing Guidelines .................................................... 38 Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement--Correction ............................ 41 Purchased Services--Jurisdictional Reporting Clarification .................................................. 41 Radiation Therapy Modifier XJ ........................ 41 Transportation of Portable X-rays (R0075)-- Modifier Use ................................................ 42

Carrier Medical Director Column

Save Your Vision Week--First Week of March ... 3 Low Vision Awareness Month--February .......... 3

News

Alien Beneficiaries Who are Not Lawfully Present in the United States--Payment Will Be Denied for Medicare Services ............ 5 CCI Version 10.0 ................................................ 5 Consolidated Billing for SNF--2004 Updates ....... 6 Educational Calendar of Events .......................... 6 CMS Paper Manuals Being Transitioned to Web-Based System ......................................... 6 Freedom of Information Act (FOIA) Requests ... 8 Frequently Asked Questions ............................... 8 Holidays--2004 ............................................... 11 Home Health Consolidated Billing--2004 Update of HCPCS Codes ............................. 11 Mediation: The New Approach to Resolving Quality of Care Concerns ............................. 14 Medicare Deductible, Coinsurance, and Premiums for 2004 ....................................... 14 Medicare Secondary Payer (MSP) Working Aged Provision Clarification ........................ 15 Provider Enrollment News ............................... 16 Psychotherapy Medical Record Documentation--HIPAA Privacy Rule ......... 16 Psychotherapy Services and `Incident To' Billing--Update ........................................... 17 Quarterly Provider Update ................................ 17 Remittance Advice Remark and Reason Codes--New Codes ..................................... 18 Request for Hearing Form Developed for Your Use 18 Sign Up for a Listserv ...................................... 20 Timely Filing of Claims ................................... 20 Web Sites ......................................................... 22

Medical Review Highlights

Follow-up Consultations .................................. 42 Home Visit Codes (99347-99350) for Established Patients ...................................... 42 Hospital Discharge Day Management .................. 43 Implantable Infusion Pumps ............................. 43 Modifiers 22, 23, 52 and 53 .............................. 44 Nurse Practitioner Services ............................... 44 PET Scans--Documentation Must Accompany Claim ............................................................ 45

Coverage Issues

Artificial Hearts and Related Devices ............... 45 Drugs & Biologicals ......................................... 48 HBO Therapy--Expanded Coverage ................ 48 Implantable Automatic Defibrillators--National Coverage Determination ............................... 48 Lipid Panels ...................................................... 50 Lung Volume Reduction Surgery ...................... 51 PET Scans--Expanded Coverage for Thyroid Cancer and Perfusion of the Heart ................ 54

Specialty News

Ambulance Fee Information ................................................ 22 Payment Calculation for Ground Ambulance Services Provided In Rural Areas for 2004 ....... 22 Policy Clarifications ......................................... 23 Laboratory 2004 Clinical Laboratory Fee Schedule ............ 24 Clinical Laboratory Test National Coverage Determinations (NCDs) Changes .................... 25 Fecal Leukocyte Examination Reporting .......... 25 Guidelines for Medicare Part B Laboratory Testing .......................................................... 26 GY Modifier Usage For Clinical Laboratory Services ........................................................ 27

Customer Service/ARU 1-866-488-0548 Telephone Appeals 1-866-488-0551 EDI Services 1-866-488-0546 Telecommunications Devices for the Deaf 1-800-242-8471

Medical Policy

Implementation of Local Medical Review Policies (LMRPs) ......................................... 54 Local Medical Review Policy Updates ............. 55 Policies Revised Due to 2004 ICD-9-CM Update . 57

DMERC News

Individual Consideration (IC) Codes--Billing Reminder ...................................................... 58 Interim Final Rule for Electronic Submission of Medicare Claims ...................................... 58 Printed Copies of the DMERC A Supplier Manual 58 Region A Provider Information ........................ 58 Tips for Online Bulletins .................................. 59

Reimbursement

Influenza Virus Vaccine--CMS Updates Fee .... 27 Medicare Physician Fee Schedule Database Revisions ...................................................... 27 Drug Fees Revised ........................................... 28 Splint and Cast Fees for 2004 ........................... 32

Internet Spotlight

Twenty Interactive Training Modules Now Available! ..................................................... 32

www.hgsa.com

Fraud and Abuse

Sanctioned Providers ........................................ 33

Request for Education ................................ 60 Education & Training Feedback Form ...... 61 EDI Xcellence ........................................ Insert

2

Medicare Report / December 1, 2003

Carrier Medical Director Column

Save Your Vision Week--First Week of March Low Vision Awareness Month--February

The Congress, by joint resolution approved December 30, 1963, authorized and requested that the President of the United States proclaim the first week in March of each year as "Save Your Vision Week." In the March 2003 Proclamation, President George W. Bush encouraged "all Americans to learn more about ways to prevent eye problems and to help others maintain the precious gift of sight." President Bush also urged "all Americans to make eye care and eye safety an important part of their lives and to include dilated eye examinations in their regular health maintenance programs. I invite eye care professionals, teachers, the media, and all public and private organizations dedicated to preserving eyesight to join in activities that will raise awareness of measures all Americans can take to protect and sustain our vision." In keeping with this Presidential directive many individuals and organizations in the next couple of months will be sponsoring and promoting activities and education that encourages good eye health care. One of these initiatives is the recognition of February as Low Vision Awareness Month, sponsored by Prevent Blindness America. HGSAdministrators recognizes the importance of these efforts. As the Presidential Proclamation states, "Our sense of sight affects how we work, communicate, and learn." However, "each year the number of Americans who suffer from vision loss increases, yet half of all blindness can be prevented through early detection and treatment." The Social Security Act and the Centers for Medicare and Medicaid Services (CMS) provides specific guidelines to Medicare contractors related to routine eye services. The exclusions apply to eyeglasses or contact lenses and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors. The exclusions do not apply to physician services (and services incident to a physician's service) performed in conjunction with an eye disease (e.g., glaucoma or cataracts) or to postsurgical prosthetic lenses which are customarily used during convalescence from eye surgery in which the lens of the eye was removed or to permanent prosthetic lenses required by an individual lacking the organic lens of the eye, whether by surgical removal or congenital disease. Such prosthetic lens is a replacement for an internal body organ (the lens of the eye). In light of the President's focus on eye health and our own interest in providing services that are statutorily covered and beneficial to the health and well being of Pennsylvania's Medicare population, HGSA is listing in this article many of the services, drugs, and procedures related to eye care that are available to our Medicare beneficiaries in Pennsylvania. These services include those that help diagnose and treat the leading causes of blindness ­ macular degeneration and glaucoma. Macular degeneration is an incurable eye disease and is the leading cause of blindness for those 55 years and older in the United States, affecting more than 10 million Americans. Glaucoma is a group of eye diseases that gradually steals sight without warning and often without symptoms. Glaucoma vision loss is caused by damage to the optic nerve. It is estimated that over 3 million Americans have glaucoma, but only half of those know that they have glaucoma.

Medicare Report / December 1, 2003

3

The Benefits Improvements and Protection Act of 2000, §102, provides for the annual coverage for glaucoma screening for eligible Medicare beneficiaries, i.e., those with diabetes mellitus, a family history of glaucoma, African-Americans age 50 and over, and certain other individuals found to be at high risk for glaucoma. Coverage applies to glaucoma screening examination services performed on eligible beneficiaries on or after January 1, 2002. Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law. Screening for glaucoma is defined to include (1) a dilated eye examination with an intraocular pressure measurement; and (2) a direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination. Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed. Glaucoma screening is billed under the following HCPCS codes and "V" ICD-9 code: G0117 Glaucoma screening for high-risk patients furnished by a physician G0118 Glaucoma screening for high-risk patients furnished under the direct supervision of a physician V80.1 Special screening for neurological, eye, and ear disease, glaucoma The Local Medical Review Policies (LMRP) listed below provide the complete guidelines developed by HGSA in conjunction with our Carrier Advisory Committee (CAC). All policies are available on our web site at http:// www.hgsa.com/professionals/med-policy.shtml. LMRP G-38 LMRP M-36 LMRP M-37 LMRP M-42 LMRP M-44 LMRP M-47 LMRP M-62 LMRP M-63 LMRP M-65 LMRP S-14 LMRP S-41 LMRP S-112 LMRP S-134 LMRP X-7 LMRP Y-12 Photodynamic Therapy (PDT) ­ Specifically, Verteporfin (Visudyne) Fluorescein Angiography Fundus Photography General Ophthalmological Services Ophthalmoscopy, Extended Visual Fields Scanning Computerized Ophthalmic Diagnostic Imaging Indocyanine Green Angiography Corneal Pachymetry Cataract Surgery Corneal Surgery to Correct Refractive Errors YAG Capsulotomy Blepharoplasty/Blepharoptosis Ophthalmic Echography Visual Rehabilitation Program

Andrew Bloschichak, MD, MBA Vice President and Carrier Medical Director Pennsylvania Medicare Part B HGSAdministrators

4

Medicare Report / December 1, 2003

ew N ew s

Alien Beneficiaries Who are Not Lawfully Present in the United States-- Payment Will Be Denied for Medicare Services

Background

Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) prohibited aliens who are not "qualified aliens" from receiving Federal public benefits including Medicare. The term "qualified alien" is defined to include six groups of aliens as follows: (1) Aliens who are lawfully admitted for permanent residence under the Immigration and Nationality Act (Act); (2) Aliens who are granted asylum under section 208 of the Act; (3) Refugees admitted into the United States under section 207 of the Act; (4) Aliens who are paroled into the United States under section 212(d)(5) of the Act for a period of at least 1 year; (5) Aliens whose deportation is being withheld under section 243(h) of the Act; or (6) Aliens who are granted conditional entry pursuant to section 203(a)(7) of the Act as in effect prior to April 1, 1980. Two groups of qualified aliens were added to the statute after the original enactment of the restriction in the 1996 Welfare Reform statute. These groups are certain Cuban and Haitian entrants to the United States and certain "battered aliens." Under the terms of the PRWORA, non-qualified aliens could not receive Medicare benefits. Section 5561 of the Balanced Budget Act of 1997 (BBA) amended section 401 of the PRWORA to create a

Medicare exemption to the prohibition on eligibility for non-qualified alien beneficiaries, who are lawfully present in the United States and who meet certain other conditions. Under the provisions of the final rule, payment may be made for services furnished to an alien who is lawfully present in the United States (and, provided that with respect to benefits payable under Part A of Title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], who was authorized to be employed with respect to any wages attributable to employment which are counted for purposes of eligibility for Medicare benefits). The definition for "lawfully present in the United States" is found at 8 CFR 103.12.

Payment for Medicare Benefits

For claims processed, effective January 1, 2004, payment will be denied for Medicare services furnished to an alien beneficiary who is not lawfully present in the United States. Denial of these services will include the Medicare Summary Notice message, "Medicare payment may not be made for the item or service because, on the date of service, you were not lawfully present in the United States."

CCI Version 10.0

The Centers for Medicare and Medicaid Services has issued changes to the Correct Coding Initiative Edits. This update is Version 10.0, and is effective for dates of service on or after January 1, 2004. Services previously reduced or denied due to edits that have been deleted in Version 10.0 will not be automatically reprocessed. Affected providers should file a written or telephone appeal request. Written requests should be submitted via the Medicare Insurance Claim Review Request form and sent to HGSAdministrators, PO Box 890413, Camp Hill, PA 17089-0413. Copies of this form can be printed from our web site at http://www.hgsa.com/professionals/ forms.shtml. Telephone requests should be submitted by calling Telephone Appeals at 1-866-488-0551. The NCCI edits are posted at http://cms.hhs.gov/ physicians/cciedits/default.asp as a spreadsheet that allows users to sort by procedural code and by effective date. A "Find" feature allows users to look for a specific

Medicare Report / December 1, 2003

5

code. The edit files are indexed by procedural code ranges for easy navigation. Copies of the National Correct Coding Policy Manual for Part B Carriers and/or copies of Version 10.0 may also be purchased by contacting the National Technical Information Service. For the Sales Desk, call 800-5536847 or 703-605-6000; for subscriptions, call 800-3632068 or 703-605-6060.

CMS Paper Manuals Being Transitioned to Web-Based System

Beginning October 1, 2003, the Centers for Medicare and Medicaid Services will transition from a paperbased manual system to a web-based system. The process includes the streamlining, updating, and consolidating of CMS' various program instructions into an electronic web-based manual system for all users. The new system is called the online CMS Manual System and is located at http://www.cms.hhs.gov/ manuals. The new online CMS Manual System will be organized by functional area, (e.g., eligibility, entitlement, claims processing, benefit policy, program integrity). The functional orientation of the new manual will eliminate significant redundancy within the manuals and will streamline the updating process, thus making CMS program instructions available in a more timely and accessible fashion. Access the CMS web site for more information and to view the manuals.

Consolidated Billing for SNF--2004 Updates

The coding files for skilled nursing facility consolidated billing will be updated effective January 1, 2004. These updates will appear on the CMS web site at http:// cms.hhs.gov/medlearn/snfcodes.asp on or about December 1, 2003. In order to correctly bill services, physicians, non-physician practitioners, and suppliers should carefully review the revised codes files.

Educational Calendar of Events

Teleconference (No Registration Required)

To participate, please dial the telephone number listed on the date of the teleconference and enter the participant code when prompted. When the call has reached attendee capacity, you will hear the message, "Conference is full." Date December 17 January 21 February 25 March 24 Topic Medicare Updates Medicare Updates To be Determined To be Determined Time 2-4 pm 5:30-7:30 pm 9-11 am 2-4 pm 9-11 am 2-4 pm 2-4 pm 5:30-7:30 pm Dial In # 877-214-0402 877-214-0402 888-296-1938 888-296-1938 888-296-1938 888-296-1938 888-296-1938 888-296-1938 Participant Code 439847 439847 923187 923187 923187 923187 923187 923187

6

Medicare Report / December 1, 2003

Teleconference (Registration Required)

To participate, please register via the Online Registration at http://www.hgsa.com/professionals/events-tele.shtml or by Paper/Fax Registration as indicated below. The telephone number and participant code will be provided to you with your confirmation. Date December 9 January 6 January 7 February 4 April 7 July 7 Topic E & M Services vs. Routine Foot Care Ophthalmology Services New & Revised Local Medical Review Policies Drugs & Biologicals New & Revised Local Medical Review Policies New & Revised Local Medical Review Policies Time 9 am & 1 pm 9 am & 1 pm 9 am & 1 pm 9 am & 1 pm 9 am & 1 pm 9 am & 1 pm

New Physician/Office Training

Date December 4 February 27 Location Radisson, Monroeville Eden Resort, Lancaster Time 9 am-12 pm* 9 am-12 pm*

* Registration begins at 8:30 am

Medicare Workshop-- Physician Assistants, Nurse Practitioners and Clinical Nurse Specialists

Date January 28 February 18 March 18 Location Radisson Penn Harris, Camp Hill Holiday Inn, Fort Washington Radisson, Monroeville Time 9 am-12 pm* 9 am-12 pm* 9 am-12 pm*

* Registration begins at 8:30 am

Class - Evaluation and Management Services in the Office Setting

Date March 3 Location Highmark Offices, Camp Hill Time 1-3 pm

Class - Emergency Department Services

Date March 4 Location Highmark Offices, Camp Hill Time 1-3 pm

For additional information on all our events including registration and additional topics, visit our web site at http://www.hgsa.com/professionals/events.shtml.

Medicare Report / December 1, 2003

7

Freedom of Information Act (FOIA) Requests

The Freedom of Information Act (FOIA), found in Title 5 of the United States Code, section 552, was enacted in 1966 and provides that, upon request from any person, a Federal agency or Federal contractor must release any record unless that record falls within one of the nine statutory exemptions and three exclusions. The FOIA binds only Federal agencies, and covers only records in the possession and control of federal agencies. Any individual may submit a FOIA request to HGSAdministrators by mail, fax, or in person with an original signature (stamped signatures are not acceptable). We will not accept telephone requests. For your convenience, a FOIA Document Request form is now available to download from our web site at www.hgsa.com/professionals/forms.shtml. You are not required to use this form; it is intended to be a guide in submitting a FOIA request. Address your request to: HGSAdministrators FOIA PO Box 890700 Camp Hill, PA 17089-0700 Fax Number: (717) 302-3748 There may be a fee assessed for processing your request. To help reduce cost, please identify the record that you want. If you do not know the exact title of the record, you should provide a reasonable description of the record. The more details you can provide about the record, the better. Not having a good description could delay our response or prevent us from finding the records you want. We may ask you to clarify your request if we need more information to find the record.

Q. When a non-physician practitioner functions as a scribe (meaning that he/she writes notes in the patient's medical record while the physician is personally performing an allowable service), does Medicare consider this to be an `incident-to' service? A. No. However, there are certain documentation requirements for non-physician practitioners acting as scribes. The situation should be clearly indicated so the reviewer can identify the provider who performed the service, and both parties ­ the scribe and the physician, should sign the record. Q. Specifically, what types of non-physician practitioners (NPP) does Medicare allow to provide services under the "incident-to" provision? A. Physician assistants, certified nurse midwives, clinical psychologists, clinical social workers, nurse practitioners, and clinical nurse specialists are permitted to bill Medicare for `incident-to' services when all of the requirements are met. Q. What documentation requirements are associated with billing Medicare for `incident-to' services? A. The medical record must clearly document that the service was reasonable and necessary and the physician must document that the `incident-to' requirements were all met. Q. What is the Medicare definition of an `incident-to' service? A. Medicare defines `incident-to' services as those services furnished incident to a physician's professional services. This means that the services or supplies are furnished as an integral, although incidental, part of the physician's professional services in the course of the diagnosis and treatment of an injury or illness. Q. Why does the Local Medical Review Policies (LMRP) contain only part of the description of the procedure code? A. The Current Procedural Terminology (CPT®) is copyright by the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) and the AMA have a signed agreement regarding the use of this copyrighted

Frequently Asked Questions

The following are the frequently asked questions identified during the last quarter through inquiries to our staff, and through contacts with physicians and nonphysician providers. You can reference these, and many more FAQs, on our web site at http://www.hgsa.com/ cgi-bin/faqmanager.cgi?toc=faq.

8

Medicare Report / December 1, 2003

material. As part of this agreement, CPT codes and long descriptions may be used on contractors' web sites, as long as each document does not contain over 30 percent of a section or subsection of the CPT. Because of this restriction HGSAdministrators may only include short descriptors in our LMRPs and any other materials that are published on our web site. Q. What is the definition of medical necessity? A. Medical necessity is defined as the need for an item or service to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The need for the item or service must be clearly documented in the patient's medical record. Medically necessary services or items are: appropriate for the symptoms and diagnosis or treatment of the patient's condition, illness, disease or injury; and provided for the diagnosis or the direct care of the patient's condition, illness, disease or injury; and in accordance with current standards of good medical practice; and not primarily for the convenience of the patient or provider; and the most appropriate supply or level of service that can be safely provided to the patient. Q. Is a patient a new or an established patient when a physician in one specialty transfers the patient to a physician in a different specialty, and both physicians are under the same tax identification number? A. In this scenario the patient is considered a new patient. Please note that the CPT definitions for new and established patients refer to services rendered by physicians in the same specialty. When a physician transfers a patient within the group practice to a patient in another specialty (not subspecialty) the patient would be considered a new patient. However, patients referred to a subspecialist are considered established, unless the subspecialist has a different tax identification number.

Q. If the hospital determines that they cannot bill Medicare Part A for a patient's admission, is the physician correct in billing Medicare Part B for the services he rendered? A. Medicare is best viewed as a physician directed health program. The physician makes his/her diagnosis and initiates the treatment. As such, the physician orders the diagnostic tests and treatments that are vital to the patient's care. Therefore, as long as the medical record documentation supports that the service(s) rendered were "reasonable and necessary" as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A), it is appropriate for the physician to bill Medicare Part B. The fact that the hospital review process did not indicate that the admission was appropriate is not relevant to the billing of Medicare Part B. To restate, the physician ordered the admission, and as long as the medical record documentation supports that the services meet the "reasonable and necessary" guideline, the services may be billed to Medicare. Q. If we bill the patient's primary insurance and the claim is paid in full, should we send Medicare a claim? A. Yes. There is the potential that all or part of the patient's $100 Part B annual deductible may be applied to the claim. Failure to submit a secondary payer claim to Medicare can cheat the patient out of these credits. In order for Medicare to determine the amount that should be credited to the patient's deductible (if the deductible is outstanding), you must attach a copy of the primary insurance claim with the amount of payment received from the primary insurer to the Medicare claim. Q. May we use `rule out' (R/O) as the reporting diagnosis? A. Providers should not code a disease or condition unless there is a definitive diagnosis. If tests are performed to rule out a diagnosis and the diagnosis is not established when the claim is submitted, you should only code the chief complaint, or signs and symptoms related to the `rule out' or `possible' diagnosis.

Medicare Report / December 1, 2003

9

Q. Is it compliant to obtain history/diagnosis for diagnostic tests from the patient, and use that information for diagnosis coding? A. ICD-9-CM coding for diagnostic tests is either a physician confirmed diagnosis based on the results of the test, or sign(s) and/or symptom(s). The sign(s) and/or symptom(s) may be obtained by interfacing with the patient. Q. Is there a policy related to sequencing diagnosis codes? A. Yes. Physicians may report a maximum of four unique diagnosis codes per claim when billing for their services. In addition, for each line of service, the physician must indicate which one of the reported diagnosis codes relates to the service(s) reported on that line. Do not correlate more than one diagnosis code per line of service. Of the diagnosis codes reported, the physician must select only the primary diagnosis that best describes the reason for the procedure. Any line of service reported on an assigned claim that is not correlated to a primary diagnosis code will be rejected. Non-assigned claims will be delayed pending contact with the billing physician to obtain clarification. In instances where the patient has more than four conditions present at the time of treatment, the primary diagnosis code that is chiefly responsible for the services reported on the claim is to be listed in the first position. In selecting the other three diagnosis codes, those conditions for which the procedure codes are listed and to which the procedures were directed should be reported. Procedures that cannot be related to any of the four diagnoses must be reported on a separate claim with the appropriate diagnosis. Q. Does the provider need to submit the National Drug Code (NDC) when submitting claims for any drugs or biologicals? A. No. Neither HGSAdministrators, nor the Centers for Medicare and Medicaid Services (CMS) require

submission of the NDC codes with the claim. However, it may be a good practice to include this information with the claim, particularly if the claim is for an unlabeled or off-label use of an anti-cancer drug. Q. Can the E/M services of a hospital-employed physician provided in the outpatient department be billed on a CMS 1500 claim form to the carrier (i.e., HGSAdministrators)? A. Yes. However, services are only eligible if the group is a hospital-based group that has a Medicare Part B provider billing number. Q. What are the guidelines when a patient is admitted to and discharged from the hospital on the same day and the stay was greater than 8 hours? Does there have to be 2 separate entries (one admit note and one discharge note), or is it acceptable for one note to indicate both? A. The CMS Online Manual, Pub. 100-4, Chapter 12, Section 30.6.9C advises: "Carriers pay only the initial hospital care code when a patient is admitted as an inpatient and discharged on the same day. They do not pay the hospital discharge management code on the date of admission. Carriers must instruct physicians that they may not bill for both an initial hospital care code and hospital discharge management code on the same date." To further clarify, HGSA will allow payment for the initial hospital service (admission) and deny the discharge management service billed by a single physician on one date of service. However, if both of these services are billed on one date of service by more than one physician, we will verify specialties, and check to see if two hospital facilities were involved. Based on the concurrent care guidelines both services may be eligible for reimbursement. The documentation to support an admission and a discharge day management service rendered on a single date of service by the same physician may

10

Medicare Report / December 1, 2003

be provided in either separate or combined progress note(s). However, no matter which format the physician chooses, the admission service for which Medicare can reimburse must be clearly and thoroughly documented, and it must support the level of care billed. Finally, the possibility exists that Medicare Part A may not reimburse for all of the Part A services involved in your scenario. However, Medicare is best viewed as a physician directed health program. The physician makes his/her diagnosis and initiates the treatment. Therefore, as long as the medical record documentation supports that the service(s) rendered were "reasonable and necessary" as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A), it is appropriate for the physician to bill Medicare Part B. The fact that the hospital review process did not indicate that the admission was appropriate is not relevant to the billing of Medicare Part B. To restate, the physician ordered the admission, and as long as the medical record documentation supports that the services meet the "reasonable and necessary" guideline, the service(s) may be billed to Medicare.

Home Health Consolidated Billing--2004 Update of HCPCS Codes

The Centers for Medicare and Medicaid Services periodically updates the lists of Healthcare Common Procedure Coding System (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 which are submitted on claims to Medicare contractors 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. Medicare contractors include fiscal intermediaries (FIs), carriers, and durable medical equipment regional carriers (DMERCs). 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. This one-time notification provides the annual HH consolidated billing update for calendar year 2004. Quarterly updates may follow in the course of calendar year 2004 if necessary. The specific changes are described in the following code list.

Holidays--2004

HGSAdministrators' offices will be closed on: Thursday, January 1 Friday, April 9 Monday, May 31 Monday, July 5 Monday, September 6 Thursday, November 25 Friday, November 26 Thursday, December 23 Friday, December 24 Friday, December 31 New Year's Day Good Friday Memorial Day Independence Day Labor Day Thanksgiving Day Day after Thanksgiving Day before Christmas Eve Day Christmas Eve Day New Year's Eve Day

Medicare Report / December 1, 2003

11

Code Changes for January 2004 Annual Update of Medicare Home Health Consolidated Billing Code List Code Description Action Replacement Code or Code Being Replaced

Replacement Code: A4416 Replacement Code: A4417 Replacement Code: A4418 Replacement Code: A4419 Replacement Code: A4420 Replacement Code: A4423 Replacement Code: A4424 Replacement Code: A4425 Replacement Code: A4426 Replacement Code: A4427 Replacement Code: A4428 Replacement Code: A4429 Replacement Code: A4430 Replacement Code: A4431 Replacement Code: A4432 Replacement Code: A4433 Replacement Code: A4434 Replaces Code: K0581 Replaces Code: K0582 Replaces Code: K0583 Replaces Code: K0584 Replaces Code: K0585 Replaces Code: K0586 Replaces Code: K0587 Replaces Code: K0588 Replaces Code: K0589 Replaces Code: K0590 Replaces Code: K0591 Replaces Code: K0592 Replaces Code: K0593 Replaces Code: K0594 Replaces Code: K0595 Replaces Code: K0596 Replaces Code: K0597 Replacement codes: A4216 & A4217 Replacement codes: A4216 & A4217 Replaces A4319 & A4323 Replaces A4319 & A4323 Replacement codes: A7520, 7521, & A7522 Replaces code: A4622 Replaces code: A4622 Replaces code: A4622 From or related to discontinued code, A4622 and/or A4623: Tracheostomy

Non-Routine Supplies

K0581 K0582 K0583 K0584 K0585 K0586 K0587 K0588 K0589 K0590 K0591 K0592 K0593 K0594 K0595 K0596 K0597 A4416 A4417 A4418 A4419 A4420 A4423 A4424 A4425 A4426 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 A4319 A4323 A4216 A4217 A4712 A4622 A7520 A7521 A7522 A7523 Ost pch clsd w barrier/filtr Ost pch w bar/bltinconv/fltr Ost pch clsd w/o bar w filtr Ost pch for bar w flange/flt Ost pch clsd for bar w lk fl Ost pch for bar w lk fl/fltr Ost pch drain w bar & filter Ost pch drain for barrier fl Ost pch drain 2 piece system Ost pch drain/barr lk flng/f Urine ost pouch w faucet/tap Urine ost pouch w bltinconv Ost urine pch w b/bltin conv Ost pch urine w barrier/tapv Os pch urine w bar/fange/tap Urine ost pch bar w lock fln Ost pch urine w lock flng/ft Ost pch clsd w barrier/filtr Ost pch w bar/bltinconv/fltr Ost pch clsd w/o bar w filtr Ost pch for bar w flange/flt Ost pch clsd for bar w lk fl Ost pch for bar w lk fl/fltr Ost pch drain w bar & filter Ost pch drain for barrier fl Ost pch drain 2 piece system Ost pch drain/barr lk flng/f Urine ost pouch w faucet/tap Urine ost pouch w bltinconv Ost urine pch w b/bltin conv Ost pch urine w barrier/tapv Os pch urine w bar/fange/tap Urine ost pch bar w lock fln Ost pch urine w lock flng/ft Sterile H2O irrigation solution Saline irrigation solution Sterile water/saline up to 10 ml Sterile water/saline 500 ml Sterile water injection, per 10 ml Trachestomy or larngectomy Tracheostomy/larynectomy tube, non-cuffed Tracheostomy/larynectomy tube, cuffed Tracheostomy/larynectomy tube, stainless steel Tracheostomy shower protector, each Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Delete Add Add Add Add Add Add Add Add Add Add Add Add Add Add Add Add Add Delete Delete Add Add Delete Delete Add Add Add Add

12

Medicare Report / December 1, 2003

A7524

Tracheostomy stent/stud/button, each

Add

From or related to discontinued code, A4622 and/ or A4623: Tracheostomy

A4623 A7525 A7526 K0621 A6407 A4248 A4366 A6025 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451

Trachestomy, inner cannula Tracheostomy mask, each Tracheostomy tube collar/holder, each Gauze, non-impreg packing strip Packing strips, non-impregnated, up to 2 inches, per lin yd Chlorhexidine containing anticeptic, 1 ml Ostomy vent, any type, each Gel sheet for dermal or epidermal application (e.g. Silicone, hydrogel, other) Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard Light compression bandage, elastic, knitted/woven, width less than three inches, per yard Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard

Add Add Replaces code: A4623 Add Replaces code: A4623 Delete Replacement Code: A6407 Add Replaces: K0621 Add Add Add Add Add Add Add Add Add Add Add Add Add

Add

A6452

Add Add Add Add

A6453 A6454 A6455 A6456

Add Therapies 97755 Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes Add

Medicare Report / December 1, 2003

13

Mediation: The New Approach to Resolving Quality of Care Concerns

Quality Insights of Pennsylvania -- the Medicare Quality Improvement Organization that works with medical professionals, community organizations and Medicare beneficiaries to improve the quality of health care -- authored this article.

Medicare Deductible, Coinsurance, and Premiums for 2004

Hospital Insurance (Part A) Deductible: $876.00 per benefit period

Coinsurance: $219.00 a day for days 61-90 in each period $438.00 a day for days 91-150 for each "lifetime reserve" days used $109.50 a day in a skilled nursing facility for days 21-100 in each benefit period Premium: $343.00 per month for those who must pay a premium $377.30 per month for those who must pay both a premium and a 10 percent increase $189.00 per month for those who have 30-39 quarters of coverage $207.90 per month for those who have 30-39 quarters of coverage and must pay a 10 percent increase Medical Insurance (Part B) Deductible: $100.00 per year

Mediation is a new option available to Medicare beneficiaries to help resolve quality of care complaints. Historically, the Centers for Medicare & Medicaid Services (CMS) has found that many quality of care complaints have been borne out of miscommunication rather than actual poor quality. Under the new process, when we receive a complaint, a physician reviewer determines if the case meets CMS criteria for mediation. In the event that the physician reviewer identifies an actual quality concern, the case goes through the standard process; mediation is not recommended. For mediation to occur, the complainant and the provider must both agree to the meeting. With the agreement of the other party, each party may bring a designated representative to the session. A volunteer mediation advisor may also be available for assistance. In addition to the presence of a professional mediator, the mediation process differs from a standard quality review in several key ways: The meeting is face-to-face, or by teleconference, between the aggrieved party and the provider against whom the complaint is lodged. The meeting is strictly confidential. No notes are taken, and nothing that is discussed may be used for litigation purposes. The complainant and the health care provider come to agreement on an outcome with the help of the mediator. One concern of beneficiaries is that the mediation will damage the patient/provider relationship. However, those who have used mediation often report that their relationships have improved. Mediation is voluntary. Whether the parties agree to mediation or not, Medicare benefits or provider agreements are not affected. Mediation is available to both fee-forservice and managed care plan enrollees. For more information on the mediation process, contact CMS at 1-800-MEDICARE (1-800-633-4227), or visit the web site at www.cms.hhs.gov.

Coinsurance: 20 percent Premium: $66.60 per month

Background Information

Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to onefourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness.

14

Medicare Report / December 1, 2003

The coinsurance amount for these days is equal to onehalf of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to oneeighth of the inpatient hospital deductible per day for the 21st through the 100th day of skilled nursing facility services furnished during a spell of illness. Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person's initial enrollment period for HI benefits, the monthly premium increases by 10 percent. Under Supplementary Medical Insurance (SMI), all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When SMI enrollment takes place more than 12 months after a person's initial enrollment period, the monthly premium increases by 10 percent for each full 12-month period during which the individual could have been enrolled, but was not.

Individuals Not Subject to the Limitation on Payment

The Medicare secondary provision for working aged does not apply to: Individuals enrolled in Part B only. Individuals enrolled in Part A on the basis of a monthly premium. Anyone who is under age 65. (Medicare is secondary to large group health plans that cover at least one employer of 100 or more employees for certain disabled individuals under age 65.) Individuals covered by a health plan other than an group health plan (GHP) as defined above, e.g., one that is purchased by the individual privately, and not as a member of a group, and for which payment is not made through an employer. Employees of employers of fewer than 20 employees who are covered by a single employer plan. Members of multi-employer plans, which have been approved by CMS for the "multi-employer exemption", whom the plan identified as employees of employers with fewer than 20 employees. Retired beneficiaries who are covered by GHPs as a result of past employment and who do not have GHP coverage as the result of their own or a spouse's current employment status. Individuals enrolled in single employer GHPs of employers of fewer than 20 employees. Members of multi-employer plans whom the plan identified as employees of employers with fewer than 20 employees, provided the plan formally elected to exempt the plan from making primary payment for employees and spouses of employees of specifically identified employers with fewer than 20 employees. Domestic partners who are given "spousal" coverage by the group health plan. Federal law defines spouse as a person of the opposite sex who is a husband or a wife. Thus a domestic partner cannot be recognized as a spouse. This change is effective April 1, 2004.

Medicare Secondary Payer (MSP) Working Aged Provision Clarification

The Centers for Medicare and Medicaid Services has updated the Medicare secondary payer provision for working aged to include information on domestic partners who are given "spousal" coverage by the group health plan. Information on the working aged provision was previously found in the Medicare Carriers Manual (MCM) section 3336.1, but is now documented in the online CMS Manual, Pub. 100-5. These sections document indications when the working aged provision does not apply. For your convenience, we are printing Chapter 2, Section 10.2 in its entirety.

Medicare Report / December 1, 2003

15

Provider Enrollment News

Validation with the Social Security Administration

As part of the enrollment process, Medicare contractors are required to validate a Social Security Number (SSN) for the individual applicant and anyone else required to list their SSN (i.e. supervising physician, owner, partner, managing employee and etc.) on the application with the Social Security Administration (SSA). Updates and/ or changes to a Medicare provider file will also require verification of the data with the SSA. If the name, date of birth, or Social Security Number reported on the application does not match the SSA files, we will contact you to coordinate any corrections required to your application or the SSA files before we can finalize your request. In order to avoid processing delays, please ensure your reported information is consistent with SSA records or SSA files are updated in advance.

Physician Assistants ­ Section 2J.1

The CMS 855I application designates section 2.J.1 for the Physician Assistant's (PA) Supervising Physician. A recent update to Provider Enrollment guidelines eliminated the requirement for PA's to report supervising physicians in section 2.J.1. Therefore this section may be left blank.

Psychotherapy Medical Record Documentation-- HIPAA Privacy Rule

There is a growing concern among physicians and health care providers regarding the balance of protecting the patient's privacy while at the same time, provide sufficient documentation to satisfy Medicare Part B billing and audit requirements. The privacy rights of an individual become an even greater concern when the request for medical record information includes psychotherapy notes. As a result, health care professionals have questioned HGSAdministrators on the need to obtain beneficiary authorization prior to their release of medical record documentation to us. The medical record often includes the psychotherapy notes, which may also include confidential information discussed during the counseling session. As a Medicare Part B contractor, it is HGSAdministrators' responsibility to ensure the medical record supports the service that was rendered and billed to Medicare for reimbursement. Specifically, HIPAA privacy guidelines permit HGSAdministrators, in its role as administrator of the Part B Program in Pennsylvania, the access to psychotherapy notes without beneficiary authorization for the purpose of "oversight activities" (45 CFR 164.508 (a)(2)(ii) and 45 CFR 164.512 (d). Failure to provide the requested medical record information, including the psychotherapy notes, may result in the inability of HGSAdministrators allowing payment for the service rendered. A physician or health care provider is a covered entity under the Privacy Rule if they transmit health information or health information is submitted on their behalf in electronic standard format with any transaction referred to in section 1173(a)(1) of the Act. (45 CFR 164.104).

Change in Tax Number Requires New Provider Number

Clarification received from the Centers for Medicare and Medicaid Services (CMS) requires that HGSA issue a new Medicare Provider Identification Number (PIN) when an entity obtains a new Tax Identification Number (TIN), even if the legal business name and ownership of the supplier has not changed. Therefore, requests to update your Medicare file with a new TIN will require that a new 855 application be submitted and processed as an initial enrollment application.

Managing Employee Information for the CMS 855B Application

Medicare requires at least one managing employee be reported in Section 6 when enrolling on the CMS 855B application. A managing employee is defined as any individual, including a general manager, business manager, office manager or administrator, who exercises operational or managerial control over the supplier, or who conducts the day-to-day operations of the supplier. For Medicare enrollment purposes, a managing employee also includes individuals who are not actual employees of the supplier but, either under contract or through some other arrangement, manage the day-today operations of the supplier.

16

Medicare Report / December 1, 2003

Psychotherapy Services and `Incident To' Billing-- Update

HGSAdministrators published an article titled, "Psychotherapy Is Not Billable `Incident To'" in the December 1, 2002 issue of the Medicare Report (page 30). This article defined `incident to' services as those services and supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. The article further explained that to be covered `incident to' the services of a physician, services and supplies must be: an integral, although incidental, part of the physician's professional service; commonly rendered without charge or included in the physician's bill; of a type that is commonly furnished in physicians' offices or clinics; furnished under the physician's direct supervision; and furnished by the physician or by an auxiliary personnel acting under the direct supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician. The article further stated that the Centers for Medicare and Medicaid Services issued a statement in a letter to Medicare Carrier Medical Directors that, "psychotherapy services are self-contained and too significant to be considered an incidental service." Therefore, psychotherapy is considered a stand-alone service and is not merely an incidental part of a patient's care. Consequently, HGSAdministrators instructions per the December 1, 2002 notification were that psychotherapy should not be reported `incident to'. Since the publication of this article, HGSAdministrators has been contacted by several specialty societies and other interested parties expressing their concerns regarding how this directive may potentially affect

access to care for Pennsylvania's Medicare patients in need of psychotherapy services. In addition, we also received CMS Transmittal, AB-03-037, Change Request 2520, published on our web site on March 28, 2003, which clarifies CMS' position on psychotherapy services. Psychotherapy services provided `incident to' are eligible for Medicare coverage, but must be in keeping with the above stated `incident to' guidelines, as well as all national regulations, statutes, Local Medical Review Policies (e.g. LMRP V-41 on Psychiatric Therapeutic Procedures), and CMS directives, to include the CMS Transmittal, AB-03-037, Change Request 2520. There is no need to document that the psychotherapy service is being provided `incident to' due to access to care issues or concerns. However, as communicated in past announcements, LMRP V-41 states that psychotherapy services must be performed by a person licensed by the state to perform such services. Transmittal AB-03-037 on "Medicare Payments for Part B Mental Health Services" adds to this that "Certain nonphysician practitioners such as clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants may have services furnished `incident to' their professional services. To the extent that they are licensed or authorized by the State to furnish mental health services, these practitioners could have others provide some services as `incident to' overall mental health services." As per LMRP V-41 (for Pennsylvania Medicare Part B), the supervised individual delivering (performing) the service must be licensed or authorized by the State. HGSAdministrators interprets "licensed or authorized by the State" to include both individuals and facilities licensed or authorized by the State of Pennsylvania to perform such services.

Quarterly Provider Update

Don't forget to check the CMS Quarterly Provider Update, a source for national Medicare provider information at http://www.cms.gov/providerupdate.

Medicare Report / December 1, 2003

17

Remittance Advice Remark and Reason Codes--New Codes

The Centers for Medicare and Medicaid Services has issued an updated listing of remark and reason codes. Listed below are the new codes. Modified/retired codes have been listed on our web site. A complete listing of codes is available at http://www.wpc-edi.com. N202 N203 N204 N205 N206 N207 N208 N209 N210 N211 Additional information/explanation will be sent separately Missing/incomplete/invalid anesthesia time/units Services under review for possible pre-existing condition. Send medical records for prior 12 months Information provided was illegible The supporting documentation does not match the claim Missing/incomplete/invalid birth weight Missing/incomplete/invalid DRG code Missing/invalid/incomplete taxpayer identification number (TIN) You may appeal this decision You may not appeal this decision

Request for Hearing Form Developed for Your Use

Since the reverse side of the review letter no longer provides space to request a hearing, the Hearing Office has developed a form that will help ensure that all required information is submitted when you request a Medicare hearing. The use of this form will help you verify that all requirements for a hearing have been met and that all required information is submitted with your initial request. The Request for Hearing Part B Medicare Claim(s) form found on the next page can be copied. A printable version is also available on our web site at www.hgsa.com/professionals/forms.shtml.

18

Medicare Report / December 1, 2003

REQUEST FOR HEARING PART B MEDICARE CLAIM(S)

Medicare Hearing Office P. O. Box 890050 Camp Hill, PA 17089-0050 I disagree with the review determination(s) on my claim(s) and request a Medicare Part B Hearing on the claims identified in this correspondence. My reasons are:

I am requesting the following type of hearing: An on-the-record hearing A telephone hearing An in-person hearing Signature: _________________________________________ Title: _____________________________________________ Date: _____________________________________________ Telephone: ________________________________________ Checklist You can help us expedite your request for a hearing by using the following checklist. It has been developed to help you verify that all requirements for a hearing have been met and that all required information is submitted with your initial request. Has the initial claim determination been reviewed? Is there $100.00 or more in controversy? Is the date of the Review Notice within six months? INCLUDE A COPY OF EACH REVIEW NOTICE WITH YOUR REQUEST. Is the reason for your request explained? If Medicare is not the primary payer, is the primary EOB attached? Have you included copies of all pertinent medical record documentation not previously submitted? Is the documentation legible? If not, include a transcription with the original copy of the medical record. Please refer to the Medicare Part B Reference Manual, Chapter 18.5 for further details regarding the hearing process. This manual is available at: http://www.hgsa.com/professionals/refman.shtml.

Medicare Report / December 1, 2003

19

Sign Up for a Listserv

A listserv is an electronic mailing list that you choose to subscribe to and can help you filter information to receive only what is relevant to you. HGSAdministrators offers the following listservs as a free service: Ambulance Anesthesia (name changed from nurse anesthetist to encompass a broader scope of interest) Ambulatory Surgical Centers Chiropractic Clinical Diagnostic Labs Consolidated Billing Eye Care (name changed from optometry to encompass a broader scope of interest) General* Independent Diagnostic Testing Facilities Nonphysician Practitioners Physicians Podiatry Psychiatric Services (name changed from psychology) Therapy/Rehab

dated, then an article would be posted and those people who have subscribed to the anesthesia or the general listservs would receive an email message notifying them that an article pertaining to an anesthesia related matter was being posted. As a side note, providers are strongly encouraged to periodically review all web site postings to identify other articles and information that may also pertain to their specific practice. *The general listserv notifies subscribers each and every time an update is made to our web site. If you do not sign up for specific listservs, then by default if you subscribe to our web site, you will fall into the general listserv category. If you want to continue to be notified every time we update our site, then no action is necessary on your part and you will be on our general listserv. If you elect to be on the general listserv, there is no need to select an additional listserv as you will receive all updates to the web site for all categories automatically. You may choose to subscribe to as many listservs as you want. (Again, if you sign up for the general listserv, it is not necessary to sign up for any additional listservs.) If you choose to sign up for multiple listservs, (that do not include the general listserv) for example Clinical Diagnostic Labs and Consolidated Billing and an article is posted which is considered to be of interest to both listservs, you will receive one email notification for each listserv resulting in two email notices for the described scenario. If you are interested in signing up for one or more specific listservs, then go to http://www.hgsa.com/ mailinglist.shtml.

Deleted Listservs

CRNA (everyone on this list has been automatically moved to the anesthesia listserv) LMRP (everyone on this list has been automatically moved to the general listserv) Occupational Therapy (everyone on this list has been automatically moved to the Therapy/Rehab listserv) Physical Therapy (everyone on this list has been automatically moved to the Therapy/ Rehab listserv) When we post an article to our web site, we will exercise due diligence in identifying the listserv that will have an interest in the information being posted. For example, if the anesthesia conversion factor was up-

Timely Filing of Claims

Instructions for submitting claims to Medicare are contained in the online CMS Manual, Pub. 100-04, Chapter 1, Section 70.1. In order for a request for payment to be considered to have been filed timely in accordance with the Centers for Medicare and Medicaid Services instructions, the claim must not be considered to be unprocessable under the definition of an unprocessable claim found in the online CMS Manual,

20

Medicare Report / December 1, 2003

Pub. 100-04, Chapter 1, Section 80.3.1. HGSAdministrators returns unprocessable claims to the provider and does not suspend claims for development to allow for corrections. Such returned requests for payment do not constitute claims nor satisfy the timely filing requirements. In those instances, a processable claim that conforms to the requirements of the online CMS Manual, Pub. 100-04, Chapter 1, Section 80.3.1 at a minimum, must be resubmitted within the timely filing period. Medicare law prescribes specific time limits within which claims for benefits may be submitted with respect to physician and other Part B services payable on a reasonable charge or fee schedule basis (including those services for which the charge is related to cost). For these services, the terms of the law require that the claim be filed no later than the end of the calendar year following the year in which the service was furnished, except as follows:

The time limit on filing claims for service furnished in the last 3 months of a year is the same as if the services had been furnished in the subsequent year. Thus, the time limit on filing claims for services furnished in the last 3 months of the year is December 31 of the second year following the year in which the services were rendered. Also note that a claim received by the contractor more than one year after the service has been rendered is subject to a 10 percent reduction. Example: A beneficiary received surgery in August 2003. This claim must be filed for payment for such services on or before December 31, 2004. A service provided in October 2003 must be filed on or before December 31, 2005.

Claims Filing Time Limit Table Calculations

Date of Service in: Timely Filing Date Jan Dec 31: Service year plus 1 year 23 Feb Dec 31: Service year plus 1 year 22 Mar Dec 31: Service year plus 1 year 21 Apr Dec 31: Service year plus 1 year 20 May Dec 31: Service year plus 1 year 19 June Dec 31: Service year plus 1 year 18

Months to File

Date of Service in: Timely Filing Date

July Dec 31: Service year plus 1 year 17

Aug Dec 31: Service year plus 1 year 16

Sep Dec 31: Service year plus 1 year 15

Oct Dec 31: Service year plus 2 years 26

Nov Dec 31: Service year plus 2 years 25

Dec Dec 31: Service year plus 2 years 24

Months to File

* The number specified in "Months to file" represents the number of full months remaining after the month in which the service was rendered.

Medicare Report / December 1, 2003

21

Web Sites

The following important web sites are just a click away. Use the direct link through the HGSA web site http:// www.hgsa.com/professionals/index.shtml to obtain valuable information. CMS http://www.cms.hhs.gov CMS Fee Schedule Link http://www.cms.hhs.gov/physicians/mpfsapp/ step0.asp CMS Quarterly Provider Update http://www.cms.hhs.gov/providerupdate/ Correct Coding Initiative http://www.cms.hhs.gov/physicians/cciedits/ default.asp HIPAA Information http://www.cms.gov/hipaa/ Med Learn http://www.cms.hhs.gov/medlearn/ Pennsylvania Medicare http://www.pennsylvaniamedicare.com Reason and Remark Codes http://www.wpc-edi.com/codes/codes.asp SNF Consolidated Billing http://www.cms.hhs.gov/medlearn/ Web Based CMS Manuals http://www.cms.hhs.gov/manuals

New Specialty New s

Ambulance

Fee Information

The ambulance fee schedule became effective for claims with dates of service on or after April 1, 2002. The payment amounts for the remaining three years will be a blended payment amount -- part ambulance fee schedule and part reasonable charge reimbursement. The blended rate percentages for the remainder of the transition period are as follows: Transition Year Reasonable Fee Charge Schedule Percentage Percentage 40% 20% 0% 60% 80% 100%

1/1/2004 - 12/31/2004 1/1/2005 - 12/31/2005 1/1/2006 and after

Payment Calculation for Ground Ambulance Services Provided In Rural Areas for 2004

The payment calculation for rural mileage for ground ambulance services is changing for 2004. Payments for dates of service in 2003 will be calculated using the current three-tiered method. Effective January 1, 2004, if the point of pick up is in a rural location, the cumulative payment calculation for the ambulance mileage will be as follows: Reasonable Charge Portion of the Calculation Provider's lowest reasonable charge for A0425 x mileage x 40% Plus Ambulance Fee Schedule Portion of the Calculation First 17 miles (miles 1-17) Ambulance fee schedule amount for A0425 x 150% x number of miles up to 17 x 60%

22

Medicare Report / December 1, 2003

Plus All Remaining Rural Miles (Miles 18 and Greater) Ambulance fee schedule amount for A0425 x remaining miles x 60% Equals Total Blended Allowed Amount for A4025 in a Rural Area

An ABN is not needed, and should not be used, in the following situations: A transport where the patient could be transported safely by other means A transport that is based on not meeting an origin or destination requirement A transport for mileage that is beyond the nearest appropriate facility A transport where the physician certification statement or accepted alternative is not obtained A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family Ambulance transports that do not meet the medical necessity requirements as in the patients condition at the time of transport, such as, patient not bedbound or not stretcherbound are denied in accordance with Section 1861(s)(7) and therefore are not considered a waiverable issue. In these instances, an Advanced Notice is not required, and the patient is responsible for the denied service. The GY modifier should be applied in this situation.

Policy Clarifications

During the implementation of the ambulance fee schedule, issues concerning the interpretation of Medicare policy arose which required clarification from the Centers for Medicare and Medicaid Services (CMS). Listed below are those issues that required HGSA to revise their current policies:

Advance Beneficiary Notice (ABN) Requirements

The Advanced Beneficiary Notice (ABN) is a written notice a physician or provider/supplier gives to a Medicare beneficiary before items or services are furnished when the physician or provider/supplier believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of certain Medicare statutory exclusions. An ABN is rarely used for ambulance services, and may only be issued for non-emergency transports. An ABN may not be used when a beneficiary is under great duress. A beneficiary is considered to be under great duress when his or her medical condition requires emergency care. An ABN may be needed and may be used for nonemergency transports in the following situations: A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation. A level of care downgrade, e.g., from ALS-2 to ALS-1, or from ALS to basic life support (BLS), when the transport at the lower level of care is a covered transport.

Proof of Mailing PMNC

Before submitting a claim, ambulance suppliers must obtain a signed certification statement from the attending physician. If the ambulance supplier is unable to obtain the signed certification statement from the attending physician, a signed physician certification statement must be obtained from either the PA, NP, CNS, RN, or discharge planner, who has personal knowledge of the beneficiary's condition at the time that the ambulance transport is ordered or the service is furnished. This individual must be employed by the beneficiary's attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. When a Physician's Medical Necessity Certification/ Physician Certification Statement cannot be obtained, a provider/supplier may send a letter via U.S. Postal Service (USPS) certified mail with a return receipt proof of mailing or other similar commercial service

Medicare Report / December 1, 2003

23

demonstrating delivery of the letter as evidence of the attempt to obtain the PMNC/PCS.

PMNC/PCS Requirements for Repetitive Ambulance Services

The regulations governing PCS requirements for repetitive, scheduled, non-emergency ambulance services are specified at 42 CFR §410.40(d)(2). A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks. Dialysis and respiratory therapy are types of treatments for which repetitive ambulance services are often necessary. However, the requirement for submitting the PCS form for repetitive, scheduled, non-emergency ambulance services is based on the quantitative standard (three or more times during a ten-day period or at least once per week for at least three weeks). Similarly, regularly scheduled ambulance services for follow-up visits, whether routine or unexpected, are not "repetitive" for purposes of this requirement unless one of the quantitative standards is met. Medical Policy Bulletins T-2 and T-3 have been updated to reflect the above information. In addition, please refer to the Ambulance Billing Guide on our web site to ensure all documentation requirements are being met.

Billing for Air Mileage

Additional air mileage may be allowed by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilot's control. These circumstances include, but are not limited to, the following: Military base and other restricted zones, airdefense zones, and similar FAA restrictions and prohibitions. Hazardous weather. Variances in departure patterns and clearance routes required by an air traffic controller. If the air transport meets the criteria for medical necessity, Medicare claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing.

Unsuccessful ALS Interventions

An unsuccessful attempt to perform an ALS intervention (e.g., endotracheal intubation was attempted, but was unsuccessful) may qualify the transport for billing at the appropriate ALS level provided that the intervention would have been reasonable and necessary had it been successful.

Laboratory

2004 Clinical Laboratory Fee Schedule

The 2004 Clinical Laboratory Fee Schedule will only be issued in hard copy to clinical laboratories (specialty 69). All other healthcare professionals may obtain an electronic copy of the 2004 Clinical Laboratory Fee Schedule on our web site at www.hgsa.com/ professionals/letter.shtml on or about December 1, 2003.

Intra-facility Transports

An intra-facility transport, i.e., a transport within the certified campus of a facility, is not within the scope of the Medicare ambulance benefit because it fails to meet Medicare origin and destination requirements. Medicare payment to a facility for the cost of facilitybased treatment includes an allowance for intra-facility movement of the beneficiary. No separate Medicare payment may be made for such a transport. Moreover, it is improper for a provider to bill Medicare for an intra-facility transport to receive a Medicare denial since the Medicare facility payment constitutes payment in full for all medically necessary, Medicare-covered services furnished to the beneficiary while undergoing treatment at the facility. As such, billing the beneficiary or another insurer for such included services would be similarly improper.

24

Medicare Report / December 1, 2003

Clinical Laboratory Test National Coverage Determinations (NCDs) Changes

The Centers for Medicare and Medicaid Services (CMS) has announced the following changes to the clinical laboratory test NCDs. These changes will be effective for dates of service on or after January 1, 2004. NCD coding manuals and related CMS documents are available at the following web site: http:// www.cms.hhs.gov/ncd/labindexlist.asp. The NCD coding manuals, which are updated on a quarterly basis, provide the current list of eligible and ineligible diagnosis codes for the NCD procedure codes. 1. In accordance with the decision memorandum published on the CMS coverage Internet site on September 17, 2003 (http://cms.hhs.gov/mcd/ viewdecisionmemo.asp?id=97), the following diagnosis codes are being added to the list of ICD-9CM Codes Covered by Medicare for the prothrombin time (PT) and fecal occult blood test (FOBT) NCDs: 863.91, pancreas head with open wound into cavity 863.92, pancreas body with open wound into cavity 863.93, pancreas tail with open wound into cavity 863.94, pancreas multiple and unspecified sites with open wound into cavity 863.95, appendix with open wound into cavity 863.99, other gastrointestinal sites with open wound into cavity 2. In accordance with the decision memorandum published on the CMS coverage Internet site on September 23, 2003 (http://cms.hhs.gov/mcd/ viewdecisionmem.asp?id=93), the following diagnosis codes are being removed from the list of ICD-9-CM Codes Covered by Medicare for PT and partial thromboplastin time (PTT) NCDs:

V72.81, pre-operative cardiovascular examination (from PTT) V72.83, other specified pre-operative examination (from PTT) V72.84, pre-operative examination, unspecified (from PT and PTT) 3. As announced in our September Medicare Report, diagnosis code 401.1, benign essential hypertension, was added to the to the list of covered diagnoses for lipid testing effective October 1, 2003. The narrative of the lipid NCD has been revised to coincide with the addition of this eligible diagnosis code. The third bullet listed in the lipid NCD indications section is amended to read: "Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease." 4. In our September Medicare Report, we announced a number of ICD-9-CM codes that were deleted by the update in ICD-9-CM codes that became effective October 1, 2003. CMS provided a 90day grace period for the provider and laboratory community to adapt to these changes. This grace period expires effective January 1, 2004 and the following ICD-9-CM codes will be denied: 282.4, 331.1, 348.3, 530.2, 600.0, 600.1, 600.2, 600.9, 767.1, 790.2, V04.8, V43.2, V53.9, V54.0, V65.1.

Fecal Leukocyte Examination Reporting

The Clinical Laboratory Improvement Amendment requires a facility to be appropriately certified for each test performed. A facility that has a CLIA certificate for physician-performed microscopy (PPM) procedures may only perform tests that are categorized as either PPM procedures or waived tests under CLIA. HCPCS code G0026 (fecal leukocyte examination) was discontinued on December 31, 2002. HCPCS code 89055 (fecal leukocyte count) was a possible code to be used for the discontinued G0026. However, under CLIA the fecal leukocyte examination permitted for a PPM procedure certificate does not include a fecal leukocyte count.

Medicare Report / December 1, 2003

25

For services provided in 2003, facilities with a valid PPM procedure CLIA certificate should use HCPCS code Q0111 (Wet mounts, including preparations of vaginal, cervical or skin specimens) to report fecal leukocyte examination services. For services provided in 2004, the wording of HCPCS code 89055 was revised to read "Leukocyte assessment, fecal, qualitative or semiquantitative." he revised text meets the CLIA definition of the PPM procedure for the fecal leukocyte examination. Therefore, effective for services provided on or after January 1, 2004, facilities with a valid PPM procedure CLIA certificate should use procedure code 89055 to report fecal leukocyte examination services.

prostate cancer. PSA also serves as a marker in following the progress of most prostate tumors once a diagnosis has been established, as an aid in the management of prostate cancer patients, and in detecting metastatic or persistent disease in patients following treatment. The test is of proven value in differentiating benign from malignant disease men with lower urinary tract signs and symptoms (i.e., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, and incontinence) as well as patients with palpably abnormal prostate glands on physical exam, and in patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate disorder. The NCD for diagnostic PSA tests does not apply to screening PSA tests. Use CPT/HCPCS code 84153 for diagnostic PSA testing.

Guidelines for Medicare Part B Laboratory Testing

This article explains the Centers for Medicare & Medicaid Services' (CMS) coverage policies for diagnostic and screening prostate specific antigen (PSA) laboratory tests under Medicare Part B. It also explains the importance of including the date of service on orders for laboratory testing.

Screening PSA Laboratory Testing

Screening PSA testing measures the level of prostate specific antigen in the patient's blood for the early detection of the marker for adenocarcinoma of the prostate subject to coverage, frequency, and payment limitations as follows: Covered at a frequency of once every 12 months for men who have attained age 50 if at least 11 months have passed following the month in which the last Medicare-covered screening PSA test was performed; and Must be ordered by the patient's physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife who is authorized under State law to perform the examination, fully knowledgeable about patient's medical condition, and who would be responsible for using the results of any examination (test) performed in the overall management of the patient's specific medical problem which includes explaining the results of the test to the patient.

Diagnostic PSA Laboratory Testing

Under §4554(b)(1) of the Balanced Budget Act (BBA), Public Law 105-33 mandated the use of negotiated rulemaking with interested parties in the laboratory community in order to promote uniformity, administrative simplicity, and program integrity regarding coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B. As a result of this negotiated rulemaking, a National Coverage Decision (NCD) was developed for the diagnostic PSA test, which is a tumor marker for adenocarcinoma of the prostate and may be useful in the differential diagnosis of men presenting with as yet undiagnosed disseminated metastatic disease. When used in conjunction with other prostate cancer tests, such as digital rectal examination, the PSA test may assist in the decision-making process for diagnosing

26

Medicare Report / December 1, 2003

Use HCPCS code G0103 for the screening PSA test.

Date of Service for Laboratory Testing

During the clinical diagnostic laboratory services negotiated rulemaking, CMS learned that there was considerable variability regarding the date of service on laboratory claims. In order to promote uniformity, the committee recommended a national policy related to the date of service on laboratory claims. CMS published a proposed rule for public comment on March 10, 2000 (65 FR 13082) and published the rule final on November 23, 2001 (66 FR 58788). The final rule states that: The date of service for laboratory tests that is reported on the claim is to be the date the tested specimen was collected; and The person obtaining the specimen must furnish the date of collection of the specimen to the entity billing Medicare. Physicians or their staff who draw specimens for testing must report the date of collection of the specimen on orders for laboratory tests. Laboratories may refuse to perform tests on orders for laboratory tests that do not include the information they need in order to seek payment for services performed, i.e., the date of collection of the specimen.

Laboratories should append the GY modifier to the CPT procedure code for any service where the appropriate diagnosis for that service is on the list of diagnoses that are not covered by Medicare. Use of the GY modifier will result in a non-covered denial. Laboratories are permitted to bill beneficiaries for services that are noncovered by Medicare for reasons other than medical necessity without providing an Advance Beneficiary Notice (ABN).

Reimbursement

Influenza Virus Vaccine-- CMS Updates Fee

The Centers for Medicare and Medicaid Services has announced an increase in the fee paid for the influenza virus vaccine, CPT 90658. The new fee is $9.95 and is effective for dates of service on or after September 1, 2003. CMS has also indicated that the whole virus vaccine, CPT 90659 has not been produced for the 2003 flu season, thus providers should not be reporting 90659 when billing for the influenza virus vaccine. Providers should only be using 90658 when billing for the influenza virus vaccine.

GY Modifier Usage For Clinical Laboratory Services

Modifier GY should be used when submitting claims for services that are statutorily non-covered or not a Medicare benefit. The clinical laboratory national coverage determinations (NCDs) include lists of ICD-9-CM codes that are eligible on the basis of medical necessity and those that are not covered by Medicare. The ICD9-CM codes that are not covered by Medicare are codes that are excluded from coverage based on technical denials, such as routine screening services, rather than lack of medical necessity.

Medicare Physician Fee Schedule Database Revisions

The Centers for Medicare and Medicaid Services has announced changes to the 2003 Medicare Physician Fee Schedule Database. Unless otherwise stated, these changes are effective October 6, 2003 for dates of service on or after March 1, 2003.

Bilateral Surgery

The bilateral surgery reduction will no longer apply for procedure code 0025T for dates of service on or after January 1, 2002.

Medicare Report / December 1, 2003

27

The bilateral surgery reduction will no longer apply for procedure code 92136 26. The relative value units are already based on the procedure being performed as a bilateral procedure.

Status E (excluded from the MPFSDB) Q4076 Loc 01 Loc 99 Q4077 Loc 01 Loc 99 $0.62 $0.62 $37.05 $37.05

Multiple Surgery

The multiple surgery reduction will no longer apply for the following procedure codes: 78306 78306 TC 78306 26 78320 78320 TC 78320 26

Status X (statutory exclusion) Q4078

Drug Fees Revised

Fees for the following procedure codes have been recalculated by the Single Drug Pricer to reflect changes in the average wholesale price (AWP). The new fees are effective for claims processed on or after October 1, 2003 for dates of service on or after January 1, 2003. Note: The presence or absence of a particular drug on the SDP file does not represent a determination that the Medicare program either covers or does not cover that drug. The amounts shown on the SDP file indicate the maximum Medicare payment allowance, if the Medicare contractor determines that the drug meets the program's requirements for coverage. Similarly, the absence of a particular drug from the SDP file means that if the Medicare contractor determines that the drug is covered by Medicare, the local contractor must then determine the program's payment allowance by applying the program's standard drug payment policy rules. Medicare contractors separately determine whether a particular drug meets the program's general requirements for coverage and, if so, whether payment may be made for the drug in the particular circumstance under which it was furnished. Examples of this latter determination include but are not limited to determinations as to whether a particular drug and route of administration are reasonable and necessary to treat the beneficiary's condition, whether a drug may be excluded from payment because it is usually selfadministered, and whether a least costly alternative to the drug exists.

Relative Value Change

The relative value units have been changed for the following procedure code. 93012 Loc 01 Loc 99

$248.41 $208.97

The endoscopic base code for procedure code 52347 has been changed to 52010.

Physician Supervision

The physician supervision level for procedure codes G0248 and G0249 has changed to a level 1. This means that the technical component of these procedures require at least general physician supervision. The following changes are effective for dates of service on or after October 1, 2003.

Status Change

Status A (payable under the MPFSDB) G0296 26 Loc 01 $103.33 Loc 99 $94.97 Status C (carrier priced) G0296 G0296 TC

28

Medicare Report / December 1, 2003

Code 90385 90645 90704 90705 90732 J0282 J0300 J0456 J0500 J0592 J0600 J0620 J0640 J0670 J0690 J0725 J0745 J0780 J0850 J1020 J1030 J1040 J1051 J1056 J1070 J1080 J1120 J1170 J1190 J1245 J1410 J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1580 J1630 J1631 J1644

Description RHO(D) IG (RHLG), MINIDOSE, IM HEMOPHILUS INFLUENZA B VACCINE, HBOC, IM MUMPS VACCINE, SC MEASLES VACCINE, SC PNEUMOCOCCAL VACCINE INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG INJECTION, AMOBARBITAL, UP TO 125 MG INJECTION, AZITHROMYCIN, 500 MG INJECTION, DICYCLOMINE HCL, UP TO 20 MG INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CODEINE PHOSPHATE, PER 30 MG INJECTION, PROCHLORPERAZINE, UP TO 10 MG INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MG INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG INJECTION, HYDROMORPHONE, UP TO 4 MG INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, ESTROGEN CONJUGATED, PER 25 MG INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, HALOPERIDOL, UP TO 5 MG INJECTION, HALOPERIDOL DECANOATE, PER 50 MG INJECTION, HEPARIN SODIUM, PER 1000 UNITS

Unit of Measure Per dose Per dose Per dose Per dose Per dose 30 mg Up to 125 mg 500 mg Up to 20 mg 0.1 mg Up to 1000 mg Per 10 ml 50 mg 10 ml 500 mg Per 30 mg Up to 10 mg Per vial 20 mg 40 mg 80 mg 50 mg 5 mg/25 mg Up to 100 mg 1 cc, 200 mg Up to 500 mg Up to 4 mg Per 250 mg Per 10 mg Per 25 mg 1 cc 2 cc 3 cc 4 cc 5 cc 6 cc 7 cc 8 cc 9 cc 10 cc Up to 80 mg Up to 5 mg Per 50 mg Per 1000 units

95% of AWP 34.77 25.38 19.43 15.03 18.62 15.94 2.66 25.55 17.06 1.03 44.10 6.42 3.71 2.15 2.25 3.09 0.50 4.18 712.07 2.68 4.13 8.27 5.04 24.61 4.95 9.43 20.52 1.55 233.97 5.70 61.51 12.17 24.35 36.56 48.69 60.87 72.88 85.12 97.38 109.66 121.72 1.90 6.83 9.12 0.40

*Price Change L H H H H H H H H H H H L H H L H L H H L L H L L H L H H L H H H H H H H H H H H H L L H

**Status

INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS Per 1,000 USP units

Medicare Report / December 1, 2003

29

Code J1645 J1650 J1655 J1670 J1720 J1742 J1885 J1940 J1950 J2000 J2010 J2020 J2150 J2210 J2250 J2270 J2324 J2370 J2440 J2510 J2515 J2545 J2590 J2650 J2680 J2690 J2760 J2765 J2770 J2788 J2910 J2920 J2930 J2941 J2993 J2997 J3100 J3120 J3130 J3265 J3301 J3315 J3320 J3360 J3395 J3475

Description INJECTION, DALTEPARIN SODIUM, PER 2500 IU INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION, TINZAPARIN SODIUM, 1000 IU INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG INJECTION, IBUTILIDE FUMARATE, 1 MG INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG INJECTION, FUROSEMIDE, UP TO 20 MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, LIDOCAINE HCL, 50 CC INJECTION, LINCOMYCIN HCL, UP TO 300 MG INJECTION, LINEZOLID, 200MG INJECTION, MANNITOL, 25% IN 50 ML INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MORPHINE SULFATE, UP TO 10 MG INJECTION, NESIRITIDE, 0.5 MG INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML INJECTION, PAPAVERINE HCL, UP TO 60 MG INJECTION, PENTOBARBITAL SODIUM, PER 50 MG PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ADMINISTERED THROUGH INJECTION, OXYTOCIN, UP TO 10 UNITS INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG INJECTION, PROCAINAMIDE HCL, UP TO 1 GM INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, SOMATROPIN, 1 MG INJECTION, RETEPLASE, 18.1 MG INJECTION, ALTEPLASE RECOMBINANT, 1 MG INJECTION, TENECTEPLASE, 50MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG INJECTION, TORSEMIDE, 10 MG/ML INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG INJECTION, TRIPTORELIN PAMOATE, 3.75 MG INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM INJECTION, DIAZEPAM, UP TO 5 MG INJECTION, VERTEPORFIN, 15MG INJECTION, MAGNESIUM SULFATE, PER 500 MG

Unit of Measure Per 2500 IU 10 mg 1000 IU Up to 250 units Up to 100 mg 1 mg Per 15 mg Up to 20 mg 3.75 mg 50 cc Up to 300 mg 200 mg 25% in 50 ml Up to 0.2 mg Per 1 mg Up to 10 mg 0.5 mg Up to 1 ml Up to 60 mg Per 50 mg Per 300 mg Up to 10 units Up to 1 ml Up to 25 mg Up to 1 g Up to 5 mg Up to 10 mg 500 mg 50 mcg 50 mg Up to 40 mg 1 mg 18.1 mg 1 mg 50 mg Up to 100 mg Up to 200 mg 10 mg/ml Per 10 mg 3.75 mg Up to 2 g Up to 5 mg 15 mg Per 500 mg

95% of AWP 15.69 6.47 3.83 119.70 2.49 251.35 3.56 0.98 517.32 3.99 3.18 36.80 3.27 4.10 1.28 0.77 151.62 1.28 3.56 9.60 1.32 50.77 1.72 0.31 9.42 1.43 31.92 1.99 114.58 34.77 17.31 1.95 3.24 45.92 1364.44 36.70 2690.88 8.98 17.96 1.56 1.60 398.62 28.27 0.86 1603.13 0.27

*Price **Status Change H H H H H L L L H H L L H H H H H L H H H L H L L L L L H L H H H H H H H H H H H L H L H L

INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS Up to 600,000 units

INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG Up to 125 mg

30

Medicare Report / December 1, 2003

Code J7051 J7317 J7504 J7511 J9000 J9040 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9100 J9110 J9140 J9150 J9160 J9180 J9181 J9182 J9185 J9190 J9200 J9206 J9214 J9216 J9218 J9266 J9280 J9290 J9291 J9310 J9320 J9355 J9390 P9048 Q0187 Q4076 Q4077

Description STERILE SALINE OR WATER, UP TO 5 CC SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRAARTICULAR INJECTION LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG DOXORUBICIN HCL, 10 MG BLEOMYCIN SULFATE, 15 UNITS CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN, 50 MG INJECTION, CLADRIBINE, PER 1 MG CYCLOPHOSPHAMIDE, 100 MG CYCLOPHOSPHAMIDE, 200 MG CYCLOPHOSPHAMIDE, 500 MG CYCLOPHOSPHAMIDE, 1.0 GRAM CYCLOPHOSPHAMIDE, 2.0 GRAM CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG CYTARABINE, 100 MG CYTARABINE, 500 MG DACARBAZINE, 200 MG DAUNORUBICIN, 10 MG DENILEUKIN DIFTITOX, 300 MCG EPIRUBICIN HYDROCHLORIDE, 50 MG ETOPOSIDE, 10 MG ETOPOSIDE, 100 MG FLUDARABINE PHOSPHATE, 50 MG FLUOROURACIL, 500 MG FLOXURIDINE, 500 MG IRINOTECAN, 20 MG INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS INTERFERON, GAMMA 1-B, 3 MILLION UNITS LEUPROLIDE ACETATE, PER 1 MG PEGASPARGASE, PER SINGLE DOSE VIAL MITOMYCIN, 5 MG MITOMYCIN, 20 MG MITOMYCIN, 40 MG RITUXIMAB, 100 MG STREPTOZOCIN, 1 GM TRASTUZUMAB, 10 MG VINORELBINE TARTRATE, PER 10 MG INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 250ML FACTOR VIIA (COAGULATION FACTOR, RECOMBINANT) PER 1.2 MG DOPAMINE HYDROCHLORIDE, PER 40 MG TREPROSTINIL, PER 1 MG

Unit of Measure Up to 5 cc 20 to 25 mg 250 mg 25 mg 10 mg 15 units Per 10 mg 50 mg Per 1 mg 100 mg 200 mg 500 mg 1g 2g 100 mg 200 mg 100 mg 500 mg 200 mg 10 mg 300 mcg 50 mg 10 mg 100 mg 50 mg 500 mg 500 mg 20 mg 1 million units 3 million units 1 mg Per single dose vial 5 mg 20 mg 40 mg 100 mg 1g 10 mg 10 mg 5%, 250 ml Per 1.2 mg 40 mg 1 mg

95% of AWP 0.76 138.71 278.70 357.58 9.69 182.40 15.96 79.80 51.30 5.73 10.89 22.86 45.73 91.45 5.59 11.17 3.19 8.55 22.06 74.23 1330.95 690.99 1.71 17.10 356.07 2.07 136.80 145.74 14.88 209.22 70.28 1543.75 63.84 207.48 285.00 501.13 141.47 58.13 89.36 29.10 1681.50 0.62 37.05

*Price **Status Change L L L H L L L L L L L L L L L L L L L L H L L L H L H L H H H H L L L H H H L L H A A

* H = Higher; L = Lower ** A = New Code; D = Discontinued Code

Medicare Report / December 1, 2003

31

Splint and Cast Fees for 2004

Payments for splints and casts furnished in 2004 will continue to be based on gap-filled amounts. The 2004 gap-filled amounts for splints and casts are based on the 2003 amounts increased by 2.1%. The 2004 fees for splint and cast procedure codes are as follows: Splints and Casts Used to Reduce a Fracture or Dislocation Procedure Code A4565 Q4001 Q4002 Q4003 Q4004 Q4005 Q4006 Q4007 Q4008 Q4009 Q4010 Q4011 Q4012 Q4013 Q4014 Q4015 Q4016 Q4017 Q4018 Q4019 Q4020 Q4021 Q4022 Q4023 Q4024 2004 Fee 6.50 37.05 140.02 26.61 92.13 9.81 22.11 4.91 11.06 6.54 14.74 3.27 7.37 11.91 20.11 5.96 10.05 6.90 10.99 3.45 5.50 5.10 9.21 2.56 4.60 Procedure Code Q4025 Q4026 Q4027 Q4028 Q4029 Q4030 Q4031 Q4032 Q4033 Q4034 Q4035 Q4036 Q4037 Q4038 Q4039 Q4040 Q4041 Q4042 Q4043 Q4044 Q4045 Q4046 Q4047 Q4048 Q4049 2004 Fee 28.61 89.32 14.31 44.66 21.87 57.58 10.94 28.79 20.40 50.75 10.21 25.38 12.45 31.18 6.23 15.60 15.13 25.84 7.57 12.92 8.78 14.13 4.39 7.07 1.60

Internet Spotlight

www.hgsa.com

Twenty Interactive Training Modules Now Available!

As part of our continuing initiative to educate Medicare providers, we are proud to announce that HGSAdministrators interactive training module system has now grown to a catalog of 20 available modules. These are now available, free of charge, at the HGSA web site under the "Provider Education and Training" area. This web-based application allows providers access to an interactive multimedia training system, which includes material organized by modules and topics. Throughout each module, you will be quizzed on what you've read to test your skills. The twenty modules cover the following topics: Advanced Beneficiary Notice Anesthesia Modifiers Care Plan Oversight Chiropractic Services Consultations Determining Medical Necessity Drugs & Biologicals E&M Advanced E&M Introduction Eye Care Services. "Incident To" Services Medicare Preventive Services Nursing Facility Physical Medicine & Rehabilitation Services Podiatry Services Psychiatric Services Purchased Diagnostic Services Split E&M Teaching Physician Services The Medicare Coverage Process

32

Medicare Report / December 1, 2003

Providers who have had experience in any of these topics may also skip directly to quiz questions to test their knowledge, or read topics only of interest to them. Visual enhancements as well as more modules will be added to the system later this year. The system is compatible with all computer types. All that's required is a web browser and a connection to the Internet. To interact with the modules properly, your screen resolution must be set to a size of at least 800 pixels wide by 600 pixels tall. Most computers made in the past few years default to this setting, but if your machine isn't one of them, the software will instruct you how to make the change. Access to the training system is completely anonymous. Your quiz results will not be tracked and will be viewable only by yourself. These modules are provided as a training tool, and do not replace official Medicare program requirements. You can find instructions and a direct link to the new modules on our web site at http://www.hgsa.com/ professionals/training.shtml. If you have sound available, turn it on, as the modules do contain audio along with a very colorful navigation system. See you on the web!

Provider Toby Brandt, CSW 2610 Walbert Avenue Allentown, PA 18104 Ilona Dolinish, CRNA 25 Heckel Rd McKees Rocks, PA 15136 John Gain, MD 3 Hospital Drive Lewisburg, PA 17837 Scott H. Katine, DPM 2031 Locust Street Philadelphia, PA 19103 Joel Levin, CP Suite 110 A 7900 Old York Road Elkins Park, PA 19027 Paula A. Levin, Psy Suite 110 A 7900 Old York Road Elkins Park, PA 19027 John McIntyre, DDS 1336 Bristol Pke Bensalem, PA 19020 Constance Rambo-Murawski, CNM 3300 Henry Avenue Philadelphia, PA 19129 Peter Schmidt, CRNA 4800 Friendship Ave. Pittsburgh, PA 15224 J. Evans Thompson, Sr., DC 6161 Chestnut St. Philadelphia, PA 19139 Janie Vaughan-Schreiber, DC Suite H2 2370 York Road Jamison, PA 18929

Effective Date 4/20/03

9/19/03

4/20/03

5/20/03

5/20/03

5/20/03

8/20/03

Fraud and Abuse

Sanctioned Providers

HGSAdministrators will not issue payments for services performed, ordered, or referred by these providers after the indicated dates. Provider Stephen Batoff, CP 13050 Bustleton Ave Philadelphia, PA 19116 Bruce Bodganoff, MD Crozer Chester Med 15th St and Upland Ave Chester, PA 19013 Effective Date 1/30/03

9/19/03

6/19/03

6/19/03

5/20/03

6/19/03

Medicare Report / December 1, 2003

33

Claim Reporting

2004 HCPCS Update

The new Healthcare Common Procedure Coding System (HCPCS) becomes effective for dates of service January 1, 2004 and after. A 3-month grace period will apply to the discontinued codes for dates of service January 1 to March 31, 2004 for claims received prior to April 1, 2004. This means that Medicare will accept both the 2003 discontinued codes and the new 2004 codes during the January-March 2004 grace period. For claims received April 1, 2004 and after, for dates of service January 1, 2004 and after, Medicare will only accept the new codes.

per claim submission provided a corresponding service facility location and address is provided for each service at the line level if that location is different from the billing provider, pay-to-provider or claim level service facility location. Services will be reimbursed based on the zip code of the service facility location, billing provider address, or pay-to provider address depending upon which information is submitted at the corresponding line level.

Beneficiary Signature on Claim Form

Items 12 and 13 on the CMS-1500 claim form are for the patient's or authorized representative's signature. Item 12 requires a signature and six-digit (MMDDYY) date and authorizes the release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim. In lieu of signing the claim in Item 12, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with the online CMS Manual, Pub. 100-04, Chapter 1, Sections 50.1 and 80.3.2.C. In that case, this item on the claim form should contain the statement "signature on file." Chapter 9 of Medicare Part B Reference Manual contains additional information regarding signature requirements, including information regarding patients who are unable to sign or who sign via a mark (x). Failure to include an appropriate signature and six-digit date or a "signature on file" statement in Item 12 will result in a claim rejection. A signature in Item 13 on the CMS-1500 claim form authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 (and its subdivisions). The patient or his/her authorized representative signs this item, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier's office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Anesthesia Reimbursement Based on Jurisdictional Payment

Effective April 1, 2004 reimbursement for anesthesia services will be based on the zip code where the service was furnished. Services paid under the Medicare Physician Fee Schedule Data Base (MPFSDB), are subject to jurisdictional payment per the online CMS Manual, Pub. 100-4, Chapter 1, Section 10.1.1; anesthesia services were previously excluded from this requirement.

Reporting

Effective for paper claims received on or after April 1, 2004, Item 32 of the CMS-1500 claim form must contain the name, address and zip code where the service was rendered, for any place of service other than the beneficiary's home, or the claim will be returned as unprocessable per the online CMS Manual, Pub. 1004, Chapter 1, Section 80.3.1. It is acceptable for claims to contain place of service (POS) home and one additional POS code, provided the appropriate information is entered in Item 32 for the additional POS code submitted. This allows payment to be made based on the correct locality rate where the service was rendered. For electronic claims received on or after April 1, 2004, any number of additional POS codes will be accepted

34

Medicare Report / December 1, 2003

Because signatures in Items 12 and 13 mean different things, a signature (or statement) in one does not apply to the other. Therefore, all claims must have Item 12 completed, and claims with Medigap information in Item 9 must have Items 12 and 13 completed. Claims will be rejected when necessary signatures (or acceptable statements) are missing from these Items.

HCFA-1500 claim form. Only the range of dates is needed. Do not report each date for each visit performed.

When the physician provides only post-op care when "split" between physicians

Report the date of service using the date the surgery was performed. Report the procedure code for the surgical procedure performed. Report the 55 modifier with the procedure code. Report the range dates that post-op care was provided in the procedure description field on the electronic claims, or in block 19 of the HCFA-1500 claim form. Only the range of dates is needed. Do not report each date for each visit performed. Note: Post-op care begins the day after the surgery.

Cataract Surgery--CoManagement

The performing surgeon has the primary responsibility for the preoperative assessment and post-operative care for his/her patients. The decision to co-manage patient care should be the result of a determination which is best for the patient. As a result of an increase in billing for co-management of cataract surgery, we are re-publishing the June 2002 Medicare Report article, "Modifiers 54 and 55 (Post Operative Care)--Reporting" (page 26) in it's entirety. When the surgical procedure and post-operative care are co-managed between different physicians, use the following guidelines to correctly report the services.

Example:

Dr. Smith rendered cataract surgery on October 15, 2001. He provided the post-op care until November 4, 2001. Dr. Brown then assumed the patient's post-op care and continued to do so until the end of the post-op period. The post-op period would end on January 13, 2002 (90 days).

When the physician renders only the surgical care

Report the date the surgery was performed. Report the procedure code for the surgical procedure performed. Report the 54 modifier with the procedure code.

How should each physician report?

Dr. Smith: Line 1: Date surgery was performed (101501) Procedure code for surgical procedure along with modifier 54 for surgical care only (6698454) Date surgery was performed (101501) Procedure code for surgical procedure along with modifier 55 for post-op care provided (6698455)

When the surgeon provides only a part of the post-op care

Report the date the surgery was performed. Report the procedure code for the surgical procedure performed. Report the 55 modifier with the procedure code. Report the range dates that post-op care was provided in the procedure description field on the electronic claims, or in block 19 of the Line 2:

Narrative or 101601 - 110401 (post-op care provided, Block 19: or first 20 days would be acceptable).

Medicare Report / December 1, 2003

35

Dr. Brown: Line 1: Date surgery was performed (101501) Procedure code for surgical procedure along with modifier 55 for post-op care provided (6698455) Narrative or 110501 - post-op care provided from Block 19: 110501 - 011302, or post-op care provided from 110501 until end of the post-op period would be acceptable. When the post-op care is "split" between two physicians, payment is based on the percentage of postop care that each physician provides, not the number of visits performed during the post-op period. Failure to report the split of post-op care dates may result in denial of your claim. And, if you are performing post-op care only, failure to list the date of surgery as the date of service will also result in a denial.

97530 97532 97533 97535 97537 97542 97703 97750 97799 V5362 V5363 V5364 G0281 G0283 Codes requiring the GN, GO, or GP modifier, and appropriate plan of care, except if performed by an audiologist include: 92601 92602 92603 92604 Codes requiring the GN, GO, or GP modifier, and appropriate plan of care if reported by a physical therapist or occupational therapist (specialties 65, 67, 73 & 74) are listed below. Physician and non-physician practitioners should only use these therapy modifiers with the codes below when the services are provided under a therapy plan of care: 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29345 29355 29365 29405 29425 29445 29505 29515 29520 29530 29540 29550 29580 29590 64550 90901 90911 92610 92611 92612 92614 92616 95831 95832 95833 95834 95851 95852 96000 96001 96002 96003 96105 96110 96111 96115 97601 G0279 G0280 0020T 0029T Remember, a plan of care must be on file, when appropriate, for all outpatient therapy services. Any claims that were rejected for missing modifiers during July and August 2003 for codes in this third list may be resubmitted.

Changes to Code List for Therapy Services

The Centers for Medicare and Medicaid Services has modified the list of HCPCS codes for physical therapy, occupational therapy, and speech-language pathology, that require the use of modifiers GN, GO, and GP when submitting claims for Medicare beneficiaries. These modifications are effective July 1, 2003, and are being implemented on September 1, 2003. There are three lists of codes that apply to therapy services. The first list requires the use of the GN, GO, or GP modifier on all claim submissions. There must also be a plan of care on file for these outpatient therapy services. The second and third lists require the use of the modifiers under certain conditions as are listed. Codes always requiring the GN, GO, or GP modifier, and appropriate plan of care include: 92506 92507 92508 92526 92597 92607 92608 92609 97001 97002 97003 97004 97012 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97504 97520

Compounded Drugs-- Billing for

Compounded drugs created by a pharmacist in accordance with the Federal Food, Drug, and Cosmetic Act may be covered under Medicare under certain conditions. The following provides a clarification on the correct billing method for compounded drugs. Since these drugs are used frequently in implantable infusion pumps, this article also addresses the billing of the refilling and maintenance of the implantable pump.

36

Medicare Report / December 1, 2003

Only compounded medications that are not selfadministered are reimbursed by Medicare Part B. In addition, these drugs must represent an expense to the physician; therefore, drugs administered in a skilled nursing facility or hospital setting, or those that have not been purchased by the billing physician are noncovered under Medicare Part B. In a skilled nursing facility or hospital setting the compounded drug is a Medicare Part A service. Therefore, compounded drugs administered by the physician at a cost to the physician are considered for reimbursement under Medicare Part B. Most of the drugs used in compounding have valid HCPCS "J" codes specific to the drug and a particular dosage. The issue in billing the compounded medications is whether the dosage utilized by the pharmacist in the creation of the compounded drug equates with the code description. For example, if the compounded medication includes 5 mg of Baclofen, it is not appropriate to bill J0475 (injection, Baclofen, 10 mg); but rather, J3490 (unclassified drug) should be billed for the Baclofen component of the compounded drug. This said, it is appropriate to bill Medicare for each of the drugs used in a compounded drug on a separate line item of the CMS-1500 claim form or the electronic claim form. If one of the drugs utilized in the compounded medication is appropriately represented by a specific HCPCS code (name of the drug and dosage utilized coincides exactly with the code description), utilize the specific HCPCS code for that drug. If one of the drugs is not exactly represented by a specific HCPCS code, bill that component of the compounded drug under J3490. If two or more of the drugs are not exactly represented by a specific HCPCS code(s), bill each drug on separate lines under J3490. When utilizing J3490 report the name of each drug with its corresponding dosage in block 19 of the CMS-1500 claim form, or in the narrative area of the electronic claim. The descriptions listed in block 19 should correspond to the sequence of the J3490 codes in block 24D. Drugs billed under J3490 will be individually priced based on the information supplied on the claim. If the compounded drug is for the refilling of an implantable infusion pump, CPT code 95990 should be billed on the same claim as the compounded medication. It is always preferable that services rendered on the same day by the same physician be billed on a single claim.

95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular)

Hepatitis B Vaccine--CPT Codes

Continue to use CPT procedure codes 90740, 90743, 90744, 90746 and 90747 when billing for the Hepatitis B vaccine. The "Q" codes, which were established in January 2003 (Q3021-Q3023), were deleted by the Centers for Medicare and Medicaid Services. Please refer to our Medical Policy Bulletin I-6 for further information regarding coverage and billing procedures.

Influenza Virus Vaccine-- Use Diagnosis Code V04.81

All Medicare institutional providers, Part B physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccine must use the new diagnosis code ICD-9-CM, V04.81 for claims with dates of service on and after October 1, 2003.

Mammography--Reporting CAD Codes

Claims with Dates of Service January 1, 2004 and Later

Diagnostic Mammography - HCPCS code 76082 has been established for diagnostic mammography CAD services. List this new code separately in addition to the primary diagnostic mammography procedure code (76090, 76091, G0204, G0206). HCPCS CAD code G0236 is deleted as of December 31, 2003. Screening Mammography - HCPCS code 76083 has been established for screening mammography CAD services. List this new code separately in addition to the primary screening mammography procedure code (76092 and G0202). CAD code 76085 is deleted as of December 31, 2003.

Medicare Report / December 1, 2003

37

Claims with Dates of Service January 1, 2002 through December 31, 2003

Diagnostic Mammography - HCPCS code G0236 (CAD code for diagnostic mammography) must be billed as a separate line in conjunction with the primary service diagnostic mammography code 76090 or 76091. Note: For claims with dates of service April 1, 2003 December 31, 2003, add G0204 and G0206 to the list of codes to be billed in conjunction with G0236 (diagnostic mammography). Screening Mammography - Use HCPCS Code 76092 with CAD code 76085. Note: For claims with dates of service April 1, 2003 December 31, 2003, add G0202 to the list of codes to be billed in conjunction with 76085 (screening mammography). Screening and diagnostic mammographies (film and digital) are subject to the FDA certification. However, CAD codes are not subject to the FDA certification.

Outpatient Rehabilitation Services Billing Guidelines

This provider education article discusses the background of the outpatient rehabilitation services limitation regulation, therapy modifiers, applicable outpatient rehabilitation Healthcare Common Procedure Coding System (HCPCS) and revenue codes, and billing instructions. In addition, it includes information resources for outpatient rehabilitation services.

Background

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997 required payment under a prospective payment system for outpatient rehabilitation services, which includes the following services: Physical therapy, including outpatient speech-language pathology; and Occupational therapy. Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services. These limits do not apply to therapy rendered by outpatient departments of hospitals unless the beneficiary is a resident of either a Medicare-certified skilled nursing facility or a Medicare-certified portion of a skilled nursing facility. These limits were applied in 1999. However, due to a Congressionally imposed moratorium, the limits have not been effective during the years 2000, 2001, or 2002. The outpatient rehabilitation services financial limitations were initially planned to resume on July 1, 2003, but their implementation has been delayed. The limitations on outpatient rehabilitation therapy services have been implemented again on September 1, 2003.

Not Otherwise Classified (NOC) Codes for Injections

Always report a `1' in the number of units field when reporting a "not otherwise classified" (NOC) code for an injection. Include a detailed narrative description of the service (e.g., drug name and dosage for drug) in block 19 of the CMS-1500 claim form or the appropriate electronic claim record as indicated below. This will help expedite processing of the claim. Refer to Chapter 9 of the Medicare Part B Reference Manual for more information. X12N 837 Versions 4010, 4010.A1 Narrative Information Claim Level 2300-NTE02 Line Level 2400-NTE02 Paper Claim

Therapy Modifiers

For any applicable rehabilitation therapy service that is rendered, providers/suppliers must report one of the following therapy modifiers, which were effective on January 1, 2003: GN Services delivered under an outpatient speech-language pathology plan of care. GO Services delivered under an outpatient occupational therapy plan of care. GP Services delivered under an outpatient physical therapy plan of care.

Block 19

38

Medicare Report / December 1, 2003

Note: These therapy modifiers do not allow a provider to deliver services that they are not recognized by Medicare to perform.

*

Applicable Outpatient Rehabilitation HCPCS and Revenue Codes

The HCPCS code list for outpatient rehabilitation services was revised in Transmittal B-03-065 to include additional codes that will not apply to the financial limitations when billed by physicians and non-physician practitioners, as appropriate. These codes supersede the codes listed in §3653 of the Medicare Part A Intermediary Manual, Part 3. This listing of HCPCS codes does not imply that services are covered. HCPCS codes apply to each financial limitation except as noted below.

29065+ 29125+ 29220+ 29355+ 29505+ 29550+ 90911+ 92597 92607 92612+ 95833+ 96001+ 96111+ 97004 97022 97033 97110 97139 97530 97542 V5362* G0281 29075+ 29085+ 29126+ 29130+ 29240+ 29260+ 29365+ 29405+ 29515+ 29520+ 29580+ 29590+ 92506 92507 92601++ 92602++ 92608 92609 92614+ 92616+ 95834+ 95851+ 96002+ 96003+ 96115+ 97001 97012 97016 97024 97034 97112 97140 97026 97035 97113 97150 29086+ 29131+ 29280+ 29425+ 29530+ 64550+ 92508 92603++ 92610+ 95831+ 95852+ 96105+ 97002 97018 97028 97036 97116 97504** 97535 97750 29105+ 29200+ 29345+ 29445+ 29540+ 90901+ 92526 92604++ 92611+ 95832+ 96000+ 96110+* 97003 97020 97032 97039 97124 97520 97537 97799*

The physician fee schedule abstract file does not contain a price for codes 96110, 97799, V5362, V5363, and V5364, since they are priced by the carrier. Therefore, contact the carrier to obtain the appropriate fee schedule amount in order to make proper payment for these codes. Code 97504 should not be reported with code 97116. However, if code 97504 was performed on an upper extremity and code 97116 (gait training) was also performed, both codes may be billed with modifier 59 to denote a separate anatomic site.

**

*** The physician fee schedule abstract file does not contain a price for codes G0279, G0280, 0020T, 0029T since they are priced by the carrier. In addition, coverage for these codes is determined by the carrier. Therefore, contact the carrier to obtain the appropriate fee schedule amount. + These codes will not apply to the financial limits when they are not done under a therapy plan of care and they are billed by providers of services who are represented by any specialty codes except 65 and 67 (PT in Private Practice, OT in Private Practice), also 73 and 74 (which were incorrectly noted in AB-03-018 and have since been reassigned to specialties that are not therapy services.) Specialty codes 73 and 74 will be removed in a future instruction. Physicians and nonphysician practitioners should only use therapy modifiers (GN, GO, GP) with the above codes when the services are provided under a therapy plan of care. If an audiology procedure (HCPCS) code is performed by an audiologist, the above modifiers should not be reported, as these procedures are not subject to the financial limitation. When these HCPCS codes are billed under a speech-language pathology plan of care, they should be accompanied with a GN modifier and applied to the financial limitation.

++

97532 97533 97601+ 97703

V5363* V5364* G0279+*** 0280+*** G0283 0020T+*** 0029T+***

Medicare Report / December 1, 2003

39

Carrier Billing Instructions

Claims must include PT, OT, or SLP modifiers (GP, GO, and GN) when any of the HCPCS codes listed above are used (see exceptions noted by + and ++ in the footnote following the list above). Claims will be returned to providers/suppliers and processing will be delayed if the modifiers are not included. In addition, it has been noted that some providers are using modifiers inappropriately with HCPCS codes that are not on the above list. As a result, charges will be incorrectly applied to therapy caps.

practitioners who are licensed to provide therapy services and the services are not isolated medical services (e.g., a cast) but part of an episode of care whose goal is rehabilitation. When outpatient rehabilitation therapy services are billed, therapy modifiers must be used and all requirements for rehabilitation therapy services must be followed, including a plan of care. Diagnostic audiology codes do not require therapy modifiers (see audiology procedure footnote ++ in above list). Audiology services are not subject to therapy caps. Speech-language pathologists are not qualified to perform diagnostic audiology services. The audiology codes will be removed from the list in a future instruction.

Intermediary Billing Instructions

If the PT, OT, and SLP modifiers (GP, GO, and GN) are not billed with revenue codes 42x, 43x, or 44x, the claim will be returned to the provider. Claims with the appropriate modifiers under revenue codes 42x, 43x or 44x, but with HCPCS other than those identified above, may result in charges being incorrectly applied to the therapy caps.

Outpatient Rehabilitation Services Information Resources

Program Memorandums Transmittal B-03-065 dated August 22, 2003 Transmittal B-03-051 dated July 16, 2003 Transmittal AB-03-097 dated July 3, 2003 Transmittal AB-03-085 dated June 10, 2003 Transmittal AB-03-073 dated May 23, 2003 Transmittal AB-03-057 dated May 2, 2003 Transmittal AB-03-018 dated February 7, 2003 Therapy Resources Web Site www.cms.hhs.gov/medlearn/therapy Medicare therapy news Frequently asked questions General information documents Therapy medical review operations General research tools for therapy topics Research tools for specific therapy topics Evidence-based literature review Join therapy cap listserv (electronic mailing list)

General Billing Instructions

Providers should be aware that billing a modifier inappropriately with HCPCS or revenue codes that are not listed above may result in charges incorrectly applied to whichever therapy cap the modifier denotes. This incorrect billing deprives the recipient of benefits to which they are entitled and which are not subject to the financial limitation. The HCPCS codes marked + on the list above may or may not be considered outpatient rehabilitation services, depending on the circumstances and the practitioners involved. These codes always represent therapy services when done by therapists. They also represent rehabilitation therapy services when done by physicians and non-physician

40

Medicare Report / December 1, 2003

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

Program Memorandum AB-03-096, the third quarterly home health consolidated billing update for calendar year 2003, was published on July 3, 2003. Among other changes, it removed code A4421 from the list of supply codes subject to home health consolidated billing. Removing code A4421 was an error. This instruction is to notify providers that A4421 (Ostomy Supply misc) will not be deleted from home health consolidated billing enforcement Providers and suppliers interested in an updated complete list of codes subject to home health consolidated billing should refer to the home health consolidated billing master code list available at http:/ /cms.hhs.gov/providers/hhapps/.

Item 32 of the CMS-1500 paper claim form is limited to one service facility location name and address. In most cases when a test is purchased, it has been rendered at a different service facility location from where the interpretation is performed. Therefore, physicians may only bill for a purchased test and an interpretation on the same claim when the services are rendered on the same date, at the same facility location, and include the same place of service codes. Otherwise, providers billing for purchased tests on the CMS-1500 paper claim form, per the online CMS Manual, Pub. 100-4, Chapter 1, Section 30.2.9, must submit each test on a separate claim form. This will allow carriers to pay at the correct reimbursement rate based on the appropriate facility location zip code and purchase price of each test. If more than one purchased test is submitted, the claim will be returned as unprocessable. For electronic claims, multiple purchased tests may be submitted on one claim as long as the appropriate service facility location information and total purchased service amounts for each purchased test are entered at the line level when services are rendered at different locations. For paper and electronic claims, the technical and professional components of the service must be submitted on separate lines of the claim in order for services to be paid. If a global service is reported, but only one of the services was purchased, the claim will be returned as unprocessable.

Purchased Services-- Jurisdictional Reporting Clarification

Diagnostic tests and the associated interpretations are paid from the Medicare Physician Fee Schedule Data Base, and are subject to the same jurisdictional payment rules as all other services. As with any service, suppliers must meet current enrollment criteria as stated in Chapter 10 of the Program Integrity Manual in order to enroll and bill for purchased tests and interpretations. Physicians or other suppliers who furnish the technical component must also be enrolled in the Medicare program to be eligible for payment. In order to purchase a diagnostic test, the purchaser must perform the interpretation. The fact that these services are purchased does not negate the need for appropriate enrollment procedures with the carrier that has jurisdiction over the geographic area where the services were rendered. In order for the carrier to determine jurisdiction, price correctly, and apply the purchase price limitations, the following guidelines must be utilized to allow payment for purchased services on electronic or paper claim formats:

Radiation Therapy Modifier XJ

Effective immediately, modifier XJ should no longer be reported for radiation therapy treatments (77427) to indicate that the course of treatment has ended. When the treatment ends, providers may bill for three or four fractions as an entire week. The statement "course of treatment has ended" must be indicated in block 19 of the 1500 claim form or the electronic equivalent.

Medicare Report / December 1, 2003

41

Transportation of Portable X-rays (R0075)--Modifier Use

Effective January 1, 2004, one of five modifiers will be required on Medicare claims when reporting HCPCS code R0075 (Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than one patient seen). Only a single transportation payment for each trip the portable x-ray supplier makes to a particular location is allowed. When reporting a transportation service and more than one Medicare patient is x-rayed at the same location, payment of R0075 is prorated among all patients receiving the services.

R0075 must be billed in conjunction with the CPT radiology codes (70000 series) and only when the xray equipment used was actually transported to the location where the x-ray was taken. Below are the definitions for each modifier that must be reported with procedure code R0075. Only one of these modifiers can be reported with R0075. Failure to submit one of these new modifiers may result in a rejection/denial of your claim: UN UP UQ UR US Two patients served Three patients served Four patients served Five patients served Six patients or more served

Revie view Medical Review Highlights

Follow-up Consultations

Follow-up consultations, procedure codes 99261-99263, are visits to complete the initial consultation or a subsequent consultation visit requested by the attending physician. Follow-up inpatient consultation codes are to be used for hospital inpatients and nursing facility residents only. If the consultant is unable to complete the initial consultation on the first day, and a follow-up visit is required on another day, the appropriate follow-up consultation code should be billed for the follow-up visit. If the visit is a subsequent consultation visit and the attending physician has requested the consultant to see the patient again (e.g. reconsult), the follow-up consultation codes should be used. If subsequent to the completion of a consultation, the consultant assumes responsibility for the management of all or a portion of the patient's care, the follow-up consultation codes should not be used. The procedure codes for subsequent hospital care, 99231-99233, or subsequent nursing facility care, 99311-99313, should be used. All documentation requirements as outlined in Medicare Medical Policy Bulletin, C-2, "Consultations" need to be met to appropriately bill the follow-up consultation codes. This policy is available on the HGSAdministrators web site at www.hgsa.com.

Home Visit Codes (9934799350) for Established Patients

HGSAdministrators would like to emphasize the importance of including the required components for billing established patient home visits, procedure codes 99347-99350. It is important that all physician/non-physician practitioners who perform home visits bill for these services according to the parameters outlined in the Medicare Part B Reference Manual, Chapter 23.7, "Documentation Guidelines for Evaluation and Management Services." These guidelines clearly define the level of history, physical examination, and medical

42

Medicare Report / December 1, 2003

decision making that must be present in the documentation to support the service billed. During a review, HGSAdministrators will evaluate all evaluation and management (E/M) services according to these parameters, and may reduce or deny services as appropriate. All E/M services should be clearly and completely documented in the patient's medical record to reflect the level of service billed. The modifier `-25' may be reported with an E/M service when it was rendered in conjunction with a procedure only if a separately identifiable E/M service occurred during the visit. The medical record must clearly reflect the procedure rendered and all documentation requirements for the level of the E/M service billed. For additional information regarding E/M services, please refer to the Medicare Part B Reference Manual, Chapter 23.7, "Documentation Guidelines for Evaluation and Management Services." This information can be found on the HGSA web site at www.hgsa.com.

Implantable Infusion Pumps

An implantable infusion pump is a delivery system used to provide a continuous infusion of a specific medication (e.g. morphine, baclofen, heparin, chemotherapy) at a precise rate. Implantable infusion pumps are indicated in the Medicare population for patients with liver cancer, severe spasticity, or chronic intractable pain. Individual consideration may be given for other uses. Supporting documentation, as indicated for each of the conditions listed, must be submitted when billing for implantable infusion pumps. Liver cancer - indicated for intra-arterial infusion of 5FU or 5FUdr in patients with primary hepato-cellular carcinoma or Duke's Class D colorectal cancer, in whom the metastases are limited to the liver, and where the disease is un-resectable or where the patient refuses surgical excision of the tumor. Anti-spasmodics - indicated for patients who cannot be maintained on noninvasive methods of spasm control, such as oral antispasmodic drugs, either because these methods fail to adequately control the spasticity or produce intolerable side effects (as indicated by at least a six (6) week trial) and have responded favorably to a trial intrathecal dose of the anti-spasmodic drug, prior to installation of the pump. Opioid drugs - indicated for patients who have a life expectancy of at least three (3) months, have not responded adequately to non-invasive methods of pain control, such as systemic opioids (including attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain), and have had a preliminary trial of intraspinal opioids drug administration undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain relief and degree of side effects (including effects on the activities of daily living) and patient acceptance.

Hospital Discharge Day Management

Hospital discharge day management codes (99238, 30 minutes or less; 99239, more than 30 minutes) are to be used to report the total duration of time spent by a physician, or non-physician practitioner, for final hospital discharge of the patient. These procedure codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions, and referral forms. When reporting procedure codes 99238 or 99239, the medical record documentation should specify the amount of time involved in completing the patient's hospital discharge day management. From a review perspective, if a physician or non-physician practitioner bills the higher level of discharge day management, procedure code 99239, based on the amount of time spent rendering this service, the total time must be documented in the patient's medical record. If procedure code 99239 is billed and no time is documented in the patient's medical record, HGSA may reduce the service to the lower level of care, procedure code 99238.

Medicare Report / December 1, 2003

43

Other uses - indicated when the drug is reasonable and necessary for the treatment of the patient; it is medically necessary for the drug to be administered by an implanted infusion pump; and the FDA approved labeling specifies that the drug and its purposes be indicated for use by an implantable infusion pump. If insufficient documentation is received, the services may be denied. Please see Medicare Medical Policy Bulletin (MMPB), S-40, "Implantable Infusion Pumps" for additional information regarding coding guidelines, coverage issues, reasons for denial, etc. MMPB S-40, can be found on our web site at www.hgsa.com.

Modifier 53 (discontinued procedure) is used to indicate that the physician has elected to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that the surgical or diagnostic procedure was started but discontinued. Under these circumstances, modifier 53 is appended to the basic service, signifying the service was discontinued. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). To ensure prompt processing of claims and undue denials, supporting documentation must be attached when submitting services with the above modifiers. For additional information regarding modifiers, please refer to the Medicare Part B Reference Manual, Appendix B or the Current Procedural Terminology Manual (CPT).

Modifiers 22, 23, 52 and 53

Modifiers provide the means for indicating that a service or procedure that has been performed was altered by some specific circumstance but not changed in its definition or code. The application of modifiers eliminates the need for separate procedure listings that may describe the modifying circumstance. Modifier 22 (unusual procedure service) is indicated when the service provided was greater than usually required for the listed procedure. Note: For services on the physician fee schedule, modifier 22 is applicable only to those procedure codes for which the global surgery concept applies, whether the procedure code is surgical in nature or not. Supportive documentation, e.g., operative reports, progress notes, order sheets, pathology reports, etc., must be submitted with the claim. Modifier 23 (unusual anesthesia service) Occasionally, a procedure that usually requires either no anesthesia or local anesthesia, because of unusual circumstances, must be performed under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service. Modifier 52 (reduced service) is used to indicate that a service has been partially reduced or eliminated at the physician's discretion. Under these circumstances, the service can be identified by its usual procedure code and the addition of modifier 52, signifying that the service was reduced.

Nurse Practitioner Services

As a result of a recent medical record review, HGSAdministrators has identified that services performed by nurse practitioners (NP) in the hospital or nursing facility setting are being rendered in collaboration with the physician but, when billing Medicare, do not identify themselves as the rendering practitioner. The collaborating physician is billing Medicare for services wherein the documentation supports the services were rendered by NPs. Further, the documentation does not support physician presence or a face-to-face physician/patient visit as required per the evaluation and management (E/M) guidelines in order to bill Medicare under the physician's rendering number. Services rendered by a NP in the hospital or nursing facility setting should be billed under the NP rendering number.

44

Medicare Report / December 1, 2003

Medicare Medical Policy Bulletin, V-21, "Nurse Practitioner Services," outlines the indications and limitations of coverage, as well as the general billing and coverage guidelines for nurse practitioners and the services they render. The services of a NP may be covered under Part B if all of the following conditions are met: They are the types of services that are considered as physician's services if furnished by a doctor of medicine or osteopathy (MD/DO); They are furnished by a person who meets the NP qualifications; The NP is legally authorized to furnish the services in the State in which they are performed; They are furnished in collaboration with an MD/DO as required by State law; and They are not otherwise precluded from coverage because of one of the statutory exclusions. Services rendered by a NP as `incident to' a physician's services are only applicable in the office setting. Outside the office setting, direct supervision requires the physician to have face-to-face contact with the patient and be present in the room while the auxiliary personnel is rendering the service. Therefore, subsequent hospital visits rendered by a NP, supported by the co-signature of the physician and billed to Medicare under the physician's rendering number do not meet Medicare guidelines for `incident to' services. These services should be billed to Medicare utilizing the NP's rendering number. In the event that a non-physician practitioner, e.g. NP, acts as a scribe (writes notes in the medical records while the physician is personally performing the service), the documentation should clearly indicate this situation and be signed by both the "scribe" and the physician. A reviewer must be able to clearly identify the provider who performed the service in order to determine the appropriate payment for the service. For additional information, refer to Medicare Medical Policy Bulletin, V-21, "Nurse Practitioner Services" and the Medicare Part B Reference Manual, Chapter 3,

Section F, "Documentation of `Incident to' Services" which are available on our web site at www.hgsa.com. Also, refer to the June 2003 Medicare Report for information regarding split E/M services in an article entitled, "Billing Shared/Split E/M Services - Update."

PET Scans-- Documentation Must Accompany Claim

Individual consideration will be given for PET scans performed for the diagnosis of lung cancer, colorectal cancer, lymphoma, head and neck cancer, esophageal cancer and melanoma (G0210, G0213, G0216, G0220, G0223, and G0226). Medical record documentation must accompany the claim to support that the scan is reasonable and necessary, per Medicare Medical Policy Bulletin X-29. Claims submitted without supporting documentation will be denied. Please refer to Medicare Medical Policy Bulletin X-29.

ov C ov erage Issues

Artificial Hearts and Related Devices

The Centers for Medicare & Medicaid Services (CMS) has revised its National Coverage Decision (NCD) to reflect an expansion in Medicare coverage for artificial hearts and related devices. This information was previously found in the Medicare Coverage Issues Manual (CIM) section 65-15 but is now documented in the online CMS Manual, Pub. 100-3, Chapter 1, Section 20.9. For services performed on or after October 1, 2003, Ventricular Assist Devices (VADs) are covered when used as destination therapy if they have received approval from the Food and Drug Administration (FDA), the VAD is used according to FDA-approved labeling instructions, the patient meets specified criteria, and the procedure is performed in specified facilities. All other indications for use of VADs remain the same.

Medicare Report / December 1, 2003

45

For your convenience, we are printing the NCD in its entirety below. In addition to the expanded coverage for ventricular assist devices (VADs), Medicare will pay providers on a fee-for-service basis for the new indication of destination therapy when the beneficiary is enrolled in a risk Medicare+Choice (M+C) plan. Payment will be made in this manner until the capitation rates for M+C organizations are adjusted to account for the expanded coverage. Because the fee-for­service claims processing system automatically excludes claim services provided for risk M+C beneficiaries except in certain circumstances for which editing has been created, special billing instructions are required. These instructions are listed below. Coverage Guidelines A ventricular assist device (VAD) or left ventricular assist device (LVAD) is used to assist a damaged or weakened heart in pumping blood. These devices are used for support of blood circulation post-cardiotomy, as a bridge to a heart transplant, or as destination therapy.

b. The implanting site, if different than the Medicareapproved transplant center, must receive written permission from the Medicare-approved heart transplant center under which the patient is listed prior to implantation of the VAD. The Medicare-approved heart transplant center should make every reasonable effort to transplant patients on such devices as soon as medically reasonable. Ideally, the Medicare-approved heart transplant centers should determine patient-specific timetables for transplantation, and should not maintain such patients on VADs if suitable hearts become available. Destination Therapy (effective for services performed on or after October 1, 2003) Destination therapy is for patients that require permanent mechanical cardiac support. VADs used for destination therapy are covered only if they have received approval from the FDA for that purpose, and the device is used according to the FDA-approved labeling instructions. VADs are covered for patients who have chronic end-stage heart failure (New York Heart Association Class IV end-stage left ventricular failure for at least 90 days with a life expectancy of less than 2 years), are not candidates for heart transplantation, and meet all of the following conditions: a. The patient's Class IV heart failure symptoms have failed to respond to optimal medical management, including dietary salt restriction, diuretics, digitalis, beta-blockers, and ACE inhibitors (if tolerated) for at least 60 of the last 90 days; b. The patient has a left ventricular ejection fraction (LVEF) < 25%; c. The patient has demonstrated functional limitation with a peak oxygen consumption of < 12 ml/kg/ min; or the patient has a continued need for intravenous inotropic therapy owing to symptomatic hypotension, decreasing renal function, or worsening pulmonary congestion; and, d. The patient has the appropriate body size ( 1.5 m²) to support the VAD implantation. In addition, the Centers for Medicare & Medicaid Services (CMS) has determined that VAD implantation as destination therapy is reasonable and necessary only

Covered Indications

Post-cardiotomy (effective for services performed on or after October 18, 1993) Post-cardiotomy is the period following open-heart surgery. VADs used for support of blood circulation post-cardiotomy are covered only if they have received approval from the Food and Drug Administration (FDA) for that purpose, and the VADs are used according to the FDA- approved labeling instructions. Bridge-to-Transplant (effective for services performed on or after January 22, 1996) VADs used for bridge-to-transplant are covered only if they have received approval from the FDA for that purpose, and the VADs are used according to the FDAapproved labeling instructions. All of the following criteria must be fulfilled in order for Medicare coverage to be provided for a VAD used as a bridge-to-transplant: a. The patient is approved and listed as a candidate for heart transplantation by a Medicare-approved heart transplant center; and,

46

Medicare Report / December 1, 2003

when the procedure is performed in a Medicareapproved heart transplant facility that, between January 1, 2001, and September 30, 2003, implanted at least 15 VADs as a bridge-to-transplant or as destination therapy. These devices must have been approved by the FDA for destination therapy or as a bridge-to-transplant, or have been implanted as part of an FDA investigational device exemption (IDE) trial for one of these two indications. VADs implanted for other investigational indications or for support of blood circulation postcardiotomy do not satisfy the volume requirement for this purpose. Since the relationship between volume and outcomes has not been well established for VAD use, facilities that have minimal deficiencies in meeting this standard may apply and include a request for an exception based upon additional factors. Some of the factors CMS will consider are geographic location of the center, number of destination procedures performed, and patient outcomes from VAD procedures completed. Also, this facility must be an active, continuous member of a national, audited registry that requires submission of health data on all VAD destination therapy patients from the date of implantation throughout the remainder of their lives. This registry must have the ability to accommodate data related to any device approved by the FDA for destination therapy regardless of manufacturer. The registry must also provide such routine reports as may be specified by CMS, and must have standards for data quality and timeliness of data submissions such that hospitals failing to meet them will be removed from membership. CMS believes that the registry sponsored by the International Society for Heart and Lung Transplantation is an example of a registry that meets these characteristics. Hospitals also must have in place staff and procedures that ensure that prospective VAD recipients receive all information necessary to assist them in giving appropriate informed consent for the procedure so that they and their families are fully aware of the aftercare requirements and potential limitations, as well as benefits, following VAD implantation. CMS plans to develop accreditation standards for facilities that implant VADs and, when implemented, VAD implantation will be considered reasonable and necessary only at accredited facilities. A list of facilities eligible for Medicare reimbursement for VADs as destination therapy will be maintained on

our web site and available at www.cms.hhs.gov/ coverage/lvadfacility.asp. In order to be placed on this list, facilities must submit a letter to the Director, Coverage and Analysis Group, 7500 Security Blvd, Mail stop C1-09-06, Baltimore, MD 21244. This letter must be received by CMS within 90 days of the issue date on this transmittal. The letter must include the following information: Facility's name and complete address; Facility's Medicare provider number; List of all implantations between Jan. 1, 2001, and Sept. 30, 2003, with the following information: Date of implantation, Indication for implantation (only destination and bridge-to-transplant can be reported; post-cardiotomy VAD implants are not to be included), Device name and manufacturer, and, Date of device removal and reason (e.g., transplantation, recovery, device malfunction), or date and cause of patient's death; Point-of-contact for questions with telephone number; Registry to which patient information will be submitted; and, Signature of a senior facility administrative official. Facilities not meeting the minimal standards and requesting exception should, in addition to supplying the information above, include the factors that they deem critical in requesting the exception to the standards. CMS will review the information contained in the above letters. When the review is complete, all necessary information is received, and criteria are met, CMS will include the name of the newly Medicare-approved facility on the CMS web site. No reimbursement for destination therapy will be made for implantations performed before the date the facility is added to the CMS web site. Each newly approved facility will also receive a formal letter from CMS stating the official approval date it was added to the list.

Medicare Report / December 1, 2003

47

Noncovered Indications (effective for services performed on or after May 19, 1986)

Artificial Heart Since there is no authoritative evidence substantiating the safety and effectiveness of a VAD used as a replacement for the human heart, Medicare does not cover this device when used as an artificial heart. All Other Indications All other indications for the use of VADs not otherwise listed remain noncovered, except in the context of Category B IDE clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the NCD manual (old CIM 30-1).

Drugs & Biologicals

Supplies usually furnished by the physician in the course of performing his/her services, such as gauze, ointments, bandages, and oxygen, are also covered. Charges for such services and supplies must be included in the physicians' bills. To be covered, supplies, including drugs and biologicals, must be an expense to the physician or legal entity billing for the services or supplies. For example, where a patient purchases a drug and the physician administers it, the drug is not covered. However, the administration of the drug, regardless of the source, is a service that represents an expense to the physician. Therefore, the administration of the drug is payable if the drug would have been covered if the physician purchased it. This additional clarification has been included in Medical Policy Bulletin I-6.

Billing Instructions for Providers Who Render Services to Managed Care Patients

The following instructions apply to providers who render expanded destination therapy services to managed care patients: Providers are encouraged not to submit claims for services rendered on or after October 1, 2003, because Medicare will not be able to process the claims until January 5, 2004. Physicians must use modifier KZ (new coverage not implemented by managed care) when billing for services rendered on and after October 1, 2003 for destination therapy. Services rendered to managed care patients with existing covered indications should not report modifier KZ or submit their claims to fee-for-service Medicare. The physician should bill for the appropriate service with procedure code 33975 or 33976. Patients who receive these services must pay any applicable coinsurance amounts.

HBO Therapy--Expanded Coverage

All Medicare contractors have been advised that the "Conditions of Coverage" for Hyperbaric Oxygen Therapy has been expanded to include diagnosis code 707.15 (Ulcer of other part of foot) for the treatment of diabetic wounds of the lower extremities. In accordance with this directive, Medical Policy Bulletin Z-3 has been revised to reflect this change.

Implantable Automatic Defibrillators--National Coverage Determination

This article discusses the background of the National Coverage Determination (NCD) to expand coverage of implantable automatic defibrillators for services rendered on or after October 1, 2003, coverage guidelines, billing instructions for providers who render services to managed care patients, and billing instructions for providers who render services to feefor-service patients.

Billing Instructions for Providers Who Render Services to Fee-for- Service Patients

The following instructions apply to providers who render expanded destination therapy services to fee-forservice patients: Claims for these services cannot be billed using modifier KZ.

Background

The NCD will be effective on October 1, 2003, to expand coverage of implantable automatic defibrillators

48

Medicare Report / December 1, 2003

for Medicare managed care and fee-for-service patients. Providers will be reimbursed for services provided to managed care patients for implantable automatic defibrillators that fall under the expanded coverage indications effective October 1, 2003, according to the NCD on a fee-for-service basis until capitation rates are adjusted to account for this expanded coverage.

c) Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; d) Had an enzyme-positive MI within past month; e) Clinical symptoms or findings that would make them a candidate for coronary revascularization; or f) Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year. As stated in the NCD, effective October 1, 2003, the following additional coverage guidelines apply: All patients considered for implantation of a defibrillator must not have irreversible brain damage, disease, or dysfunction that precludes the ability to give informed consent; MIs must be documented by elevated cardiac enzymes or Q-waves on an electrocardiogram. Ejection fractions must be measured by angiography, radionuclide scanning, or echocardiography; and All other indications remain noncovered except in Category B IDE clinical trials (60 CFR 48417) or as a routine cost in clinical trials defined under Coverage Issues Manual, 30-1. Note: Refer to Coverage Issues Manual, Section 3585 (revisions effective October 1, 2003).

Coverage Guidelines

The following service is covered when rendered on or after July 1, 1991: Documented episode of cardiac arrest due to ventricular fibrillation (VF), not due to a transient or reversible cause. The following services are covered when rendered on or after July 1, 1999: Documented sustained ventricular tachyarrhythmia (VT), either spontaneous or induced by an electrophysiology (EP) study, not associated with an acute myocardial infarction (MI) and not due to a transient or reversible cause. Documented familial or inherited indications with a high risk of life-threatening VT, such as long QT syndrome or hypertropic cardiomyopathy. As stated in the NCD, the following indications will be covered when rendered on or after October 1, 2003: Coronary artery disease with a documented prior MI, a measured left ventricular ejection fraction 0.35, and inducible, sustained VT or VF at EP study. (The MI must have occurred more than 4 weeks prior to defibrillator insertion. The EP test must be performed more than 4 weeks after the qualifying MI.) Documented prior MI and a measured left ventricular ejection fraction 0.30 and a QRS duration of > 120 milliseconds. Patients must not have any of the following: a) New York Heart Association classification IV; b) Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm;

Billing Instructions for Providers Who Render Services to Managed Care Patients

The following instructions apply to providers who render expanded implantable automatic defibrillator services to managed care patients: Providers are encouraged not to submit claims for services rendered on or after October 1, 2003, because Medicare will not be able to process the claims until January 5, 2004.

Medicare Report / December 1, 2003

49

Physicians must use modifier KZ (new coverage not implemented by managed care) when billing for services rendered on and after October 1, 2003. Providers billing fiscal intermediaries on or after October 1, 2003, must use condition code 78 (payment for coverage not implemented by HMO). Providers who are paid under the Outpatient Prospective Payment System (OPPS) must bill all services related to this expanded coverage on one claim and for the same date of service, using condition code 78. Providers billing carriers and providers who are paid under the OPPS must split the bills if they overlap September 2003 and October 2003. Patients who receive these services must pay any applicable coinsurance amounts. For services rendered to managed care patients whose indications fall outside this expanded coverage, providers must not bill using condition code 78 or modifier KZ.

Note: The physician should bill for the appropriate service from the range of CPT codes below. These services should be billed to the appropriate Medicare carrier for payment. 33240 33241 33243 33244 33245 33246 33249

Lipid Panels

HGSAdministrators has identified an increase in the number of lipid panels being rendered. Reimbursement for lipid panels is based on the National Coverage Decision (NCD) policy, found in the online CMS Manual Pub. 100-3, Chapter 1, Section 40-12 at http:// cms.hhs.gov/manuals/103_cov_determ/ ncd103index.asp. NCDs are available in the Medicare Coverage Database at http://www.cms.gov/mcd/ indexes.asp. Medicare recognizes that some provider offices may utilize laboratory equipment that can perform lipid testing only as a panel and not as individual components. However, it is the provider's responsibility to bill Medicare only for the individual component that is necessary for the monitoring and/or treatment of the patient's signs and symptoms regardless of whether or not a whole panel was performed using this type of equipment. The following are the individual components of a lipid panel (procedure code 80061). 82465 Cholesterol, serum, total 83718 Lipoprotein, direct measurement; high-density cholesterol (HDL cholesterol) 84478 Triglycerides Per the NCD for lipid testing, any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked

Billing Instructions for Providers Who Render Services to Fee-for-Service Patients

The following instructions apply to providers who render expanded implantable automatic defibrillator services to fee-for-service patients: Claims for these services cannot be billed using modifier KZ, condition code 78, or for services outside of this expanded coverage.

Procedure Codes

Note: The new G codes listed below are payable under OPPS effective October 1, 2003. These new G codes are not payable under the Medicare Physician Fee Schedule and, therefore, should not be billed to Medicare carriers. G0297 G0298 G0299 G0300 ICD-9-CM Procedure Code 37.94 (for 11X TOBs)

50

Medicare Report / December 1, 2003

elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. If no dietary or pharmacological therapy is advised, monitoring is not necessary. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia. If a provider orders a lipid panel at a frequency greater than listed above, then medical record documentation must be submitted with the claim to justify the medical necessity of the increased frequency. Failure to provide documentation of the medical necessity of tests may result in a denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. Routine screening and prophylactic testing for lipid disorders is not covered by Medicare. While lipid screening may be medically appropriate, Medicare does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use, etc. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered.

is expanded to include patients who are: (1) Non highrisk and present with severe, upper-lobe emphysema; or, (2) Non high-risk and present with severe, non upperlobe emphysema with low exercise capacity. Patients must also meet all other criteria outlined in the National Coverage Decision. For your convenience, we are printing the NCD in its entirety below. In addition to the expanded coverage for lung volume reduction surgery (LVRS), Medicare will pay providers on a fee-for-service basis for the new coverage when the beneficiary is enrolled in a risk Medicare+Choice (M+C) plan. Payment will be made in this manner until the capitation rates for M+C organizations are adjusted to account for the expanded coverage. Because the feefor-service claims processing system automatically excludes claim services provided for risk M+C beneficiaries except in certain circumstances for which editing has been created, special billing instructions are required. These instructions are listed below. Coverage Guidelines Lung volume reduction surgery (LVRS) or reduction pneumoplasty, also referred to as lung shaving or lung contouring, is performed on patients with severe emphysema in order to allow the remaining compressed lung to expand, and thus, improve respiratory function. A. Covered Indications Medicare-covered LVRS approaches are limited to bilateral excision of a damaged lung with stapling performed via median sternotomy or video-assisted thoracoscopic surgery. 1. National Emphysema Treatment Trial (NETT) participants (effective for services performed on or after August 11, 1997): Medicare provides coverage to those beneficiaries who are participating in the NETT trial for all services integral to the study and for which the Medicare statute does not prohibit coverage. 2. Medicare will only consider LVRS reasonable and necessary when all of the following requirements are met (effective for services performed on or after January 1, 2004): a. The patient satisfies all the criteria outlined below:

Lung Volume Reduction Surgery

The Centers for Medicare & Medicaid Services has revised its National Coverage Decision (NCD) to reflect an expansion in Medicare coverage for lung volume reduction surgery (LVRS). Information can be found in the online CMS Manual, Publication 100-03, Section 240.1. For services performed on or after January 1, 2004, Medicare coverage for lung volume reduction surgery

Medicare Report / December 1, 2003

51

Assessment History and physical examination

Criteria Consistent with emphysema BMI, < 31.1 kg/m2 (men) or < 32.3 kg/m2 (women) Stable with < 20 mg prednisone (or equivalent) qd

Radiographic Pulmonary function (pre-rehabilitation)

High Resolution Computer Tomography (HRCT) scan evidence of bilateral emphysema Forced expiratory volume in one second (FEV1) < 45% predicted (> 15% predicted if age > 70 years) Total lung capacity (TLC) > 100% predicted postbronchodilator Residual volume (RV) > 150% predicted postbronchodilator

Arterial blood gas level (pre-rehabilitation)

PCO2 < 60 mm Hg (PCO2 < 55 mm Hg if 1-mile above sea level) PO2 > 45 mm Hg on room air (PO2 > 30 mm Hg if 1-mile above sea level)

Cardiac assessment

Approval for surgery by cardiologist if any of the following are present: Unstable angina; left-ventricular ejection fraction (LVEF) cannot be estimated from the echocardiogram; LVEF < 45%; dobutamine-radionuclide cardiac scan indicates coronary artery disease or ventricular dysfunction; arrhythmia (> 5 premature ventricular contractions per minute; cardiac rhythm other than sinus; premature ventricular contractions on EKG at rest) Approval for surgery by pulmonary physician, thoracic surgeon, and anesthesiologist post-rehabilitation Post-rehabilitation 6-min walk of > 140 m; able to complete 3 min unloaded pedaling in exercise tolerance test (pre- and post-rehabilitation) Signed consents for screening and rehabilitation Plasma cotinine level < 13.7 ng/mL (or arterial carboxyhemoglobin < 2.5% if using nicotine products) Nonsmoking for 4 months prior to initial interview and throughout evaluation for surgery

Surgical assessment Exercise

Consent Smoking

Preoperative diagnostic and therapeutic program adherence

Must complete assessment for and program of preoperative services in preparation for surgery

52

Medicare Report / December 1, 2003

b. In addition, the patient must have: Severe upper lobe predominant emphysema (as defined by radiologist assessment of upper lobe predominance on CT scan), or Severe non-upper lobe emphysema with low exercise capacity. Patients with low exercise capacity are those whose maximal exercise capacity is at or below 25 watts for women and 40 watts for men after completion of the preoperative therapeutic program in preparation for LVRS. Exercise capacity is measured by incremental, maximal, symptom-limited exercise with a cycle ergometer utilizing 5 or 10 watt/minute ramp on 30% oxygen after 3 minutes of unloaded pedaling. c. The surgery must be performed at facilities that were identified by the National Heart, Lung, and Blood Institute to meet the thresholds for participation in the NETT, and at sites that have been approved by Medicare as lung transplant facilities. These facilities are listed on the CMS web site at http://www.cms.hhs.gov/coverage/ lvrsfacility.pdf. CMS is currently working to develop accreditation standards for facilities to perform LVRS and when implemented, will consider LVRS to be reasonable and necessary only at accredited facilities. d. The surgery must be preceded and followed by a program of diagnostic and therapeutic services consistent with those provided in the NETT and designed to maximize the patient's potential to successfully undergo and recover from surgery. The program must include a 6 to 10-week series of at least 16, and no more than 20, preoperative sessions, each lasting a minimum of 2 hours. It must also include at least 6, and no more than 10, postoperative sessions, each lasting a minimum of 2 hours, within 8 to 9 weeks of the LVRS. This program must be consistent with the care plan developed by the treating physician following performance of a comprehensive evaluation of the patient's medical, psychosocial and nutritional needs, be consistent with the

preoperative and provided in the monitored, and coordination of the takes place.

postoperative services NETT, and arranged, performed under the facility where the surgery

B. Noncovered Indications 1. LVRS is not covered in any of the following clinical circumstances: a. Patient characteristics carry a high risk for perioperative morbidity and/or mortality; b. The disease is unsuitable for LVRS; c. Medical conditions or other circumstances make it likely that the patient will be unable to complete the preoperative and postoperative pulmonary diagnostic and therapeutic program required for surgery; d. The patient presents with FEV1 20% of predicted value, and either homogeneous distribution of emphysema on CT scan, or carbon monoxide diffusing capacity of 20% of predicted value (high-risk group identified October 2001 by the NETT); or e. The patient satisfies the criteria outlined above in section 2(a), and has severe, nonupper lobe emphysema with high exercise capacity. High exercise capacity is defined as a maximal workload at the completion of the preoperative diagnostic and therapeutic program that is above 25 watts for women and 40 watts for men (under the measurement conditions for cycle ergometry specified above). 2. All other indications for LVRS not otherwise specified remain noncovered.

Billing Instructions for Providers Who Render Services to Managed Care Patients

The following instructions apply to providers who render lung volume reduction surgery to managed care patients: Providers are encouraged not to submit claims for services rendered on or after January 1, 2004 through March 31, 2004

Medicare Report / December 1, 2003

53

because Medicare will not be able to process the claims until April 5, 2004.

Policy

Physicians must use modifier KZ (new coverage not implemented by managed care) when billing for services rendered on and after January 1, 2004. The physician should bill for the appropriate service with procedure code 32491. Patients who receive these services must pay any applicable coinsurance amounts.

HCPCS codes G0030-G0047. The Centers for Medicare and Medicaid Services (CMS) has established two codes when billing for these radio-tracers. Use procedure code Q4078 to report Ammonia N-13 and A4641 to report Rubidium 82. In addition, also report your acquisition cost in block 24D of the 1500 claim form or the EMC narrative line. All other tracers will be considered an integral part of the diagnostic test and therefore not separately payable. This information will be added to our Medical Policy Bulletin X-29 during the next scheduled update.

Billing Instructions for Providers Who Render Services to Fee-for-Service Patients

The following instructions apply to providers who render lung volume reduction surgery to fee-for-service patients: Claims for these services cannot be billed using modifier KZ. The physician should bill for the appropriate service with procedure code 32491.

Medical Policy

Implementation of Local Medical Review Policies (LMRPs)

The Centers for Medicare and Medicaid Services (CMS) instructs contractors to provide a forty-five (45) day comment period and a notification period of fortyfive (45) days prior to implementing LMRPs which fall into one of the following categories: 1. New LMRP 2. Revised LMRP that restricts an existing LMRP 3. Revised LMRP that makes a substantive correction During the comment period recommendations and comments are solicited from: Carrier Advisory Committee members Appropriate groups of health professionals and provider organizations Representatives of specialty societies Other carriers/intermediaries Quality Improvement Organizations (formerly known as PROs) within the region Other Contractor Medical Directors within the region General public through the contractor draft LMRP web site

PET Scans--Expanded Coverage for Thyroid Cancer and Perfusion of the Heart

Thyroid Cancer

Effective for services furnished on or after October 1, 2003, Medicare covers the use of FDG Positron Emission Tomography for thyroid cancer only for restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin greater than 10ng/ml and negative I-131 whole body scan. All other uses of FDG PET in the diagnosis and treatment of thyroid cancer remain noncovered. Use the new HCPCS code G0296 to report this service.

Perfusion of the Heart Using Ammonia N-13 or Rubidium 82

Effective for services performed on or after October 1, 2003, only two radiopharmaceutical tracers will be covered for PET scans for the perfusion of the heart --

54

Medicare Report / December 1, 2003

Presenters at draft LMRP Open Sessions CMS Regional Office, associate regional administrator The mandated notification has traditionally been provided through full-text publication of the policies in this quarterly newsletter. Recent directions from CMS revise the method by which notification will be provided. Beginning with publication of the September 2002 Medicare Report, HGSA will print only a summary of the policies. The full-text version, however, will be posted to our web site at http://www.hgsa.com/ professionals/policy-notice.shtml. Title Body Surface Mapping (M-68) Bortezo mib (VelcadeTM (I-55) Brachytherapy (X-41) Chemotherapy Services (G-16Q) C-Reactive Protein Testing (L-69) Oprelvekin (Neumega®) (I-54)

Having satisfied the mandated 45-day comment period, the required 45-day notice period relative to the following policies begins with their posting to the HGSA web site. They will become effective on December 29, 2003. You may also obtain copies of current policies by writing to HGSAdministrators, PO Box 890413, Camp Hill, PA 17089-0413 or calling 1-866-488-0548. Some copies of previous versions and recently retired policies are also available on our web site at http://www.hgsa.com/ professionals/retiredpolicy.shtml. Those that are not may be obtained by writing to the address above.

Policy

Rationale/Summary New policy to describe non-coverage. New policy identifying coverage requirements. New policy to identify billing and documentation requirements. Revised policy to clarify documentation and billing requirements for unlabeled uses of drugs in an anti-cancer chemotherapeutic regimen. New policy to provide coverage and address screening. New policy establishing coverage criteria.

Urinary Tumor Markers for Bladder Revised policy to address the major tumor markers used to monitor Cancer Monitoring (L-33G) patients with previously diagnosed bladder cancer. Transpupillary Thermotherapy (TTT) (S-135) New policy to create coverage guidelines for this procedure.

Local Medical Review Policy Updates

Policy Title Office-Based Anesthesia (A-16) Update Rationale Policy revised to define "direct supervision" CMS Online Manual, Pub. 100-2, Chapter 15, Section 60.1B. Revision effective 06/30/2003. Revised to include procedure code J7197 for coverage effective for dates of service on or after January 1, 2003. Also revised to include procedure code Q2022 for coverage effective for dates of service on or after January 1, 2001. Clarification that as per CMS Transmittal #B-03-048, CR 2798, added new Q code Q4053 for the reporting of Pegfilgrastim injection. Effective for dates of service on or after 07/01/03. This new code revision was incorrectly reported in the September 2003 Medicare Report as Q4052.

Hemophilia Clotting Factors (I-4)

Pegfilgrastim (NeulastaTM (I-45)

Medicare Report / December 1, 2003

55

Policy Title Amevive® for Injection (Alefacept) (I-49A) Screening Pap Smears and Pelvic Examinations (L-1)

Update Rationale Revised to include information on the discontinuance of the intravenous form of the drug by the manufacturer effective October 3, 2003. Revised policy to expand coverage for low risk pap smears and low risk pelvic examinations. Effective for claims processed on or after 10/01/2003, the list of eligible diagnosis codes has been expanded to include V76.49 for screening pap smears and V76.47 for both pap smears and screening pelvic examinations as per Transmittal AB-03-054, CR 2637.

Policy

Medical Necessity Guidelines for Corrected typographical error in ICD-9 code from incorrect 196.82 Prostate Specific Antigen (PSA) and to correct 198.82 as published in prior policy versions. Prostate Cancer Screening (L-52) Implantable Cardiac Loop Recorder Revised policy to clarify the "Indications and Limitations of Coverage (M-50) and/or Medical Necessity" section and to provide reference to other Carrier's policies on this topic. This revision is effective 09/02/2003. Transesophageal Echocardiography (TEE) (M-51F) Single Photon Emission Computed Tomography (SPECT) (R-6) Revised to include ICD-9 codes 423.0-423.9 for coverage effective for dates of service on or after October 13, 2003. Revised policy to provide coverage for SPECT studies of the kidneys (78710) and clarify non-coverage of SPECT studies for inflammatory processes (78807). Revision effective for services provided on or after 07/09/2003. Procedure code 95990 added for coverage indications effective for dates of service on or after January 1, 2003. Effective for dates of service on or after 9/18/2003 endovenous laser ablation has been added for coverage. Code 92510 removed from policy, code no longer valid for Medicare. Code status change effective 03/01/2003.

Implantable Infusion Pump (S-40) Treatment of Varicose Veins of the Lower Extremities (S-55) Cochlear Implantation (S-67)

Cryosurgical Ablation of the Prostate Removed outdate information referring to services provided prior to (CSAP) (S-108) 1/1/2001 and codes G0160 & G0161. Added reference to NCD for Cryosurgery of Prostate. The revision effective date is 10/13/2003. Cystourethroscopy with Insertion of Procedure codes 52310 and 52315 removed from policy effective for Urethral Stent (S-121) dates of service on or after 10/07/2003. Clinical Psychologist Services (V-10) Policy revised to include CPT codes 96150-96155. Physical Therapy and Rehabilitation Revised policy to correctly list the following ICD-9 codes: 045.00Services (Y-1) 045.93, 494.0-494.1, 712.10, 716.89, 720.9, 730.00-730.99, 805.9, 807.6, 820.9, 839.9, 880.00, and 928.8. These corrections are effective for services provided on or after 10/02/03.

56

Medicare Report / December 1, 2003

Policies Revised Due to 2004 ICD-9-CM Update

The following medical policies have been revised as a result of the 2004 ICD-9-CM update effective for claims received on or after January 1, 2004 (for dates of service on and after October 1, 2003). A 90-day grace period will apply. For claims received for dates of service October 1, 2003 through December 31, 2003 both the old and the updated ICD-9-CM codes will be accepted. A-4F G-24F I-8M L-31E L-42G L-52G Monitored Anesthesia Care (MAC) Obesity Immunizations Medical Necessity Guidelines for Magnesium Testing Molecular Diagnostics Medical Necessity Guidelines for Prostatic Specific Antigen (PSA) and Prostate Cancer Screening Hepatitis Testing Morphometric Analysis Electromyography (EMG) Studies Nerve Conduction Velocity Studies Fluorescein Angiography Transthoracic Echocardiography (TTE) General Ophthalmological Services Electrocardiography Cardiovascular Stress Testing Transesophageal Echocardiography (TEE) Debridement of Mycotic Nails Myocardial SPECT (Single Photon Emission Computed Tomography) Pheresis Therapy (Apheresis)

S-73F S-97E S-110E S-120A S-121C S-131B S-142A X-2L X-3J X-16G X-24N X-25G X-29H X-31I X-32G X-34F X-36F X-37E X-38C X-39F Y-10K Z-5B

Stem Cell Transplantation Laser Ablation of the Prostate

Policy

Transurethral Microwave Thermotherapy of the Prostate (TUMT) Transurethral Radiofrequency Thermotherapy of the Prostate (TUNA) Cystourethroscopy with Insertion of Urethral Stent Water-induced Thermotherapy (WIT) Treatment of Gastroesophageal Reflux Disease (GERD) Magnetic Resonance Imaging (MRI) Computerized Axial Tomography (CT) Scan Low Osmolar Contrast Medium (LOCM) Bone Mass Measurements Transrectal Ultrasound Positron Emission Tomography (PET) Scans Radiologic Examination of the Chest Pelvic Ultrasound Procedures Magnetic Resonance Imaging (MRI) of the Head and Neck Computerized Axial Tomography (CT) Scan, Abdominal and Pelvic Computerized Axial Tomography (CT) Scan, Heal or Brain Bladder Capacity Ultrasound Diagnostic Mammography Respiratory Therapy Services External Ocular Photography

L-60E L-66B M-28F M-34I M-36B M-38K M-42G M-45F M-49H M-51E P-3I R-11B S-11H

Medicare Report / December 1, 2003

57

New DMERC New s

HealthNow, the Region A Durable Medical Equipment Regional Carrier, has asked us to publish the following articles. Please address all inquiries concerning DMERC issues to HealthNow, PO Box 6800, WilkesBarre, PA 18773-6800, or call 1-866-419-9458.

The rule is available at http://a257.g.akamaitech.net/7/ 257/2422/14mar20010800/edocket.access.gpo.gov/ 2003/pdf/03-20955.pdf

Printed Copies of the DMERC A Supplier Manual

The current stock of supplier manuals has been depleted, therefore, the Region A Durable Medical Equipment Regional Carrier (DMERC A) will not offer additional copies for a fee until further notice. Current suppliers, including those enrolled in the Medicare Program during fiscal year 2002, must access the supplier manual on our Web site at www.umd.nycpic.com/ suppmancopy.html. The new edition of the supplier manual was targeted to be posted to our Web site by July 1, 2003. Due to circumstances beyond our control, the new edition will not be posted until further notice. Notification of its availability will be posted to the "What's New" page at www.umd.nycpic.com/dme_what's_new.html. Newly enrolled providers will receive hardcopy manuals, as mandated by the Centers for Medicare & Medicaid Services (CMS), once the new edition is available. The new edition will only be available to current providers via our Web site. We apologize for this inconvenience.

Individual Consideration (IC) Codes--Billing Reminder

When submitting claims for items considered as Individual Consideration codes (codes without a reimbursement amount on the fee schedule, codes with `IC' on the fee schedule, or codes with zeros on the fee schedule), include the manufacturer's name and product name/model number for the item. Failure to furnish this information will result in a denial.

Interim Final Rule for Electronic Submission of Medicare Claims

On August 15, 2003, the Department of Health and Human Services (HHS) published the Final Rule for Electronic Submission of Medicare Claims. This rule implements the statutory requirement found in the Administrative Simplification Compliance Act (ASCA). ASCA requires (with a few exceptions) all claims sent to the Medicare program be submitted electronically starting October 16, 2003. ASCA was enacted by Congress to improve the administration of the Medicare program by increasing efficiencies gained through additional electronic claims submission. Although 86.1 percent of Medicare claims are submitted electronically, the volume of paper claims is substantial, and moving from paper to electronic submissions has the potential for significant savings for Medicare physicians, practitioners, suppliers, and other healthcare providers, as well as for the program itself. This Rule sets forth the details for implementation of the Medicare electronic claims submission requirement and who may be exempt from these requirements.

Region A Provider Information

Both the Region A Durable Medical Equipment Regional Carrier (DMERC A) and Program Safeguard Contractor (PSC), TriCenturion, LLC, maintain separate Web sites. Providers should visit the DMERC A Web site (www.umd.nycpic.com) for information regarding billing, educational updates and events, electronic data interchange (EDI), fee schedules, what's new, etc. Online versions of the DMERC Medicare News are also available via this Web site. Providers can gain access to the PSC Web site via the TriCenturion, LLC link on the DMERC A Web site (www.umd.nycpic.com/dmprovlink.html) or directly at www.tricenturion.com. Providers should access the PSC Web site for information on Fraud and Abuse, Healthcare Common Procedure Coding System (HCPCS), and Local Medical Review Policies

58

Medicare Report / December 1, 2003

(LMRPs). Recent updates involving medical policy development, medical review, or benefit integrity are under the PSC what's new section (www.tricenturion.com/content/whatsnew_dyn.cfm). Providers can obtain additional information by visiting the following Centers for Medicare & Medicaid Services (CMS) Web sites: www.cms.hhs.gov/medicare (Medicare Professional and Technical Information) www.cms.hhs.gov/coverage (Medicare Coverage Database) www.cms.hhs.gov/manuals/memos (Program Memos) www.cms.hhs.gov/manuals/transmittals (Program Transmittals) www.cms.hhs.gov/manuals/108_pim (Medicare Program Integrity Manual) www.cms.hhs.gov/manuals/14_car (Medicare Carriers Manual) www.cms.hhs.gov/manuals/06_cim Coverage Issues Manual) (Medicare

Choose "Save Link As..." or "Save Target As..." Choose the location on your computer where you'd like to save the PDF. It is important that you remember this location because you will need it to open the PDF. Click on "Save."

To open a PDF:

Open the Adobe Acrobat Reader software. From the "File" menu, choose "Open." Find the location on your computer where you saved the PDF file. Click "Open." Once you have the PDF file open, you can print the entire bulletin or select pages using the print option within the Adobe Acrobat Reader software.

To print a PDF:

From the "File" menu, choose "Print." A menu will pop up on the screen. Under the section for "Print Range," choose the option you prefer. Click "OK." If you select the "All" option for your print range, you can save paper by specifying odd or even page printing and print on both sides; thereby, making your printed copy look similar to a printed bulletin. If your printer cannot accommodate duplex printing, you will need to feed the paper through twice; once for the odd pages, and again for the even pages. (Note: Make sure you put the pages in the correct order and face them in the proper direction for printing on the reverse side). Another way to save paper is by choosing specific pages to print, when you don't need to read or refer to the entire bulletin. This way, you will have just the pertinent information on hand when it is needed. While visiting the DMERC A Web site, please take a few moments to complete our Online Newsletter Survey at www.umd.nycpic.com/dmercbulletinsurvey.html. Your responses will assist us in meeting your needs and improving our online bulletins.

Tips for Online Bulletins

The Region A Durable Medical Equipment Regional Carrier (DMERC A) provides the DMERC Medicare News in two formats on our Web site. Both contain the same information, however, they will look different when viewing and printing. One format is Web-based. The second format is Adobe's Portable Document Format (PDF), which maintains the look of printed bulletins. To properly view PDF bulletins on the DMERC A Web site, it is strongly recommended that you download the PDF to your computer first, then open the PDF with Adobe Acrobat Reader(R), rather than opening it within your Web browser.

To download a PDF:

Right click on the link for the PDF you wish to download. A menu will pop up on the screen.

Medicare Report / December 1, 2003

59

Request for Education

Training and education is paramount to the overall success of administering the Medicare program. To that end, HGSAdministrators is committed to educating healthcare professionals and their staff about: Fundamental Medicare programs and policies New Medicare initiatives Significant changes to the Medicare program We also focus on training for new healthcare professionals and office staff. Our objectives are to inform and educate our customers through mass media including printed and electronic communications, Internet, workshops, classes and meetings. Our Education Specialists will be happy to educate healthcare practitioners/ professionals and/or office personnel. In order to optimize our resources, we generally prefer groups of 10 or more. To request such education, please complete the information below and mail to:

HGSAdministrators Attn: PET Coordinator PO Box 890089 Camp Hill, PA 17089-0089 Name _______________________________________________________ Office Name _________________________________________________ Provider # ________________ Phone # ____________________________ Topic Requested for Education ___________________________________

60

Medicare Report / December 1, 2003

Education & Training Feedback

Training and education is paramount to the overall success of administering the Medicare program. To that end, HGSAdministrators is committed to educating healthcare professionals and their staff about fundamental Medicare programs and policies, new Medicare initiatives and significant changes to the Medicare program. We also focus on training for new healthcare professionals and office staff. In order to determine the effectiveness of our efforts we need feedback from you. Tell us how we are doing and what we can do better. Your comments can make a difference in how we design our programs and publications. We would very much appreciate your taking the time to answer a few questions to let us know how you really feel.

Medicare Report

Do you read it? Always Occasionally Never Do you prefer to read the paper copy or the copy on our web site? Both Paper Web Site How satisfied are you with the Medicare Report? Very Somewhat Not at all Did you find that the information you read is accurate and up-to-date? Always Usually Occasionally Rarely Are the articles clear and easy to read and understand? Mostly Sometimes Never How easy is it to find the information you're looking for? Very Somewhat Not at all What topics are most important to you? Claim Reporting Coverage Issues EDI Fraud & Abuse Internet Spotlight Medical Director Column Medical Review Highlights News Policy Reimbursement Specialty News

Web Site

How often do you visit our web site at www.hgsa.com? Daily Several Times a Week Occasionally Never What topics are you looking for when you visit our web site? Policy Billing Contacts What's New Medical Review Forms Education and Training Electronic Data Interchange Reimbursement Enrollment Manuals/Publications Using the Search Feature to find a topic, article or reference How easy is it to find the information you're looking for? Very Somewhat Not at all How useful did you find our web-based training modules in developing a better understanding of that topic? Very Somewhat Not at all

Medicare Report / December 1, 2003

61

Part B Reference Manual

Do you subscribe to our Medicare Part B Reference Manual? Yes No How often do you use the Medicare Part B Reference Manual? Often Occasionally Never Do you prefer to read the paper copy or the copy on our web site? Paper Web Site Both What information are you looking for when using the Medicare Part B Reference Manual? Appeals Coding Completion of the Claim Form Coverage Issues Diagnosis Coding EDI Services Enrollment Medigap Patient Eligibility Reimbursement Secondary Payer Other_____________________

Billing Guides

Do you refer to any of our Billing Guides? Yes No Which of our Billing Guides do you use? Ambulance ASC Chiropractic Clinical Lab Flu & Pneumonia Vaccine IDTF Occupational Therapy Optometry Podiatry Portable X-Ray How helpful do you find the Billing Guides? Very Somewhat Not at all

Anesthesia ESRD Nurse Practitioner Physical Therapy Teaching Physician

Seminars/Meetings

In the past year, how many of our seminars/meetings have you attended? More than 2 1 or 2 None If you attended any of our seminars/meetings, how helpful did you find them? Not at all? Very Somewhat Who generally attends? Healthcare Practitioner/Professional Office Staff

Provide any additional comments and/or suggestions regarding the above education activities:

Optional

Name ___________________________________________________ Office Name ______________________________________________ Mail to: HGSAdministrators Attn: PET Coordinator PO Box 890089 Camp Hill, PA 17089-0089 Provider # _____________________ Phone # _____________________

62

Medicare Report / December 1, 2003

ate -D t B To p- Par ? n d U re ee dica atio Medicare Part B Reference Manual Subscription Coupon N e m M nfor I Subscriber's Name _______________________________________________________________

Business Name _________________________________________________________________ Mailing Address (no PO Boxes) ____________________________________________________ _____________________________________________________________________________ (Manuals are shipped viaFedEx Ground. FedEx Ground cannot deliver to PO Boxes) City ________________________________________ State ______________ Zip ___________ Telephone ( ________ ) ______________________________ Please send me the following: Medicare Part B Reference Manual only ($50) Medicare Part B Reference Manual and quarterly revisions ($150)

Return this form with your payment to: HGSAdministrators Medicare Professional Services PO Box 890162 Camp Hill, PA 17089-0162

Medicare Report / December 1, 2003

63

Have a safe and enjoyable holiday!

P.O. Box 890089 Camp Hill, PA 17089-0089

PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA Permit No. 320

Information

0312mrdraft

64 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

208723

You might also be interested in

BETA
Microsoft PowerPoint - Shore-RCCB Review- Reviewed by AC_KM.ppt [Compatibility Mode]
INFUSION BILLING UPDATE :2006
First Step Book