The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

Centers for Medicare & Medicaid Services – Articles for Part A and Part B Providers Page A BMetastasis of Cancer in the Context of a Clinical Trial (MM7125)Quarterly Update to Correct Coding Initiative Edits, Version 17.0, effective January 1, 53 A P2011 (MM7210)Ventricular Assist Devices as Destination Therapy (MM7220 Revised) 54 A PUpdate to Medicare Deductible, Coinsurance and Premium Rates for 2011 (MM7224) 56 A A,PReasonable Charge Update for 2011 for Splints, Casts, and Certain Intraocular Lenses 58 A P(MM7225)New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines (MM7234 Revised) 61 A A,PClinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of 64 A LSpecimens (MM7239)2010–2011 Seasonal Influenza Resources for Health Care Professionals (SE1031Revised)66 A N,PCenters for Medicare & Medicaid Services – Articles for Part A Providers Page A BIncentive Payment Program for Primary Care Services, Section 5501(a) of the Patient 70 AProtection and Affordable Care Act, Payment to a Critical Access Hospital Paid Underthe Optional Method (MM7115)Systems Changes Necessary to Implement “Technical Correction Related to Critical 73 AAccess Hospital Services,” Section 3128 of the Affordable Care Act, Pub. L. 111-148(MM7219)Implementation of Changes in End-Stage Renal Disease Payment for Calendar Year 75 A2011 (MM7237)Home Health Face-to-Face Encounter - A New Home Health Certification Requirement(SE1038)77 MAnnouncement of Medicare Rural Health Clinics (RHCs) and Federally QualifiedHealth Centers (FQHCs) Payment Rate Increases (MM7101)79 A, F,RCenters for Medicare & Medicaid Services – Articles for Part B Providers Page A BEnd-Stage Renal Disease Home Dialysis Monthly Capitation Payment (MM7003) 81 A,PEdit to Deny Payment to Physicians and Other Suppliers for the Technical Component 83 A,P(TC) of Pathology Services Furnished on Same Date as Inpatient and OutpatientServices and Implements New Messages (MM7061)Section 5501(b) Incentive Payment Program for Major Surgical Procedures Furnished in 84 AHealth Professional Shortage Areas Under the Affordable Care Act (MM7063)New Physician Specialty Codes for Cardiac Electrophysiology and Sports Medicine 87 N,P(MM7209)Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 88 N,P6417, 6421, and 6696) (SE1011 Revised)Physicians and Nonphysician Practitioners Excluded from Deactivation in Medicare 94 N,PDue to Inactivity with Medicare (SE1034)Recovery Audit Contractor Demonstration High-Risk Vulnerabilities for Physicians(SE1036)95 PCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 2 MMR 2011-01, January 2011

This key is provided as a convenience to alert providers/suppliers to articles with topics that may pertain to their particular field.This key is not a guarantee that information in other articles will not also apply. It is each provider’s/supplier’s responsibility tobecome familiar with the contents of each newsletter:Part A Key: A-All Providers, C-Community Mental Health Centers (CMHC), E-Renal Dialysis (ESRD) Providers, F-Federally Qualified Health Centers (FQHC), H-Hospitals, M-Home Health Providers, O-Comprehensive OutpatientRehabilitation Facilities (CORF) and Outpatient Physical Therapy Providers, P-Hospice Providers, R-Rural Health Center(RHC), S-Skilled Nursing Facilities (SNF), NA-Not ApplicablePart B Key: A-All Providers, B-Ambulance, C-Cardiovascular, D-DMEPOS, E-Drugs & Biologicals, F-ASC, G-Anesthesia,H-Physical & Occupational Therapy, I-Beneficiaries, J-Insurers, K-Home Health Care, L-Laboratory, M-Medicine, N-Non-Physician Practitioner, O-Nuclear Medicine, P-Physicians, Q-Mental Health R-Radiology, S-Surgery, T-Nephrology, U-Urology, V-Chiropractor, W-Ophthalmology & Optometry, X-Podiatry, Y-Radiation Z-Oncology, NA-Not ApplicableContact Information can be found on our Web site at: http://www.NGSMedicare.com.Medicare policies can be accessed from the Medical Policy Center section of our Web site. Providers without access to theInternet can request hard copies from National Government Services.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 3 MMR 2011-01, January 2011

National Government Services Articles for Part A & B ProvidersAppeals for Inpatient Hospital Medical Review DenialsDecember 2010The National Government Services Appeals Department has received a large volume of appeals based onthe medical review of inpatient hospital claims. An educational opportunity has been identified due to aportion of these appeals being inappropriate requests.IssueProviders are submitting/requesting an appeal on the denied inpatient claim, and in the appeal they arerequesting appeals to change the claim to an outpatient claim (13X bill type). When an inpatient stay isdenied as “not medically necessary” providers may submit an outpatient claim for the covered Part Bservices.* Providers may not change the patient status on appeal or after discharge. Requesting a 13X billtype is requesting a change in patient status; as if the inpatient admission never occurred. ConditionCode 44 is not applicable in this scenario.Resolutions• Providers do not need to request an appeal on an inpatient claim unless they disagree with themedical review determination of noncoverage for the inpatient portion.• Providers may not adjust a claim under or after medical review.• Providers may, after receiving the medical review denial, submit a 12X bill type for the covered PartB services. A 12X bill type is handled as an outpatient claim but does not change the patient status; itis an inpatient Part B only claim. This bill type recognizes the noncoverage or unavailability of Part Abenefits.• With the submission of a 12X claim after an inpatient denial, the Part A portion remains providerliable based on the medical review determination.Additional Observation and Condition Code 44 Resources• The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 1 Section 50.3 (2.2 MB)• Observation article under the Clinical Education section of www.NGSMedicare.com* Medicare pays under Part B for physician services and for nonphysician medical and other healthservices listed in Section 240 above when furnished by a participating hospital to an inpatient of thehospital when patients are not eligible or entitled to Part A benefits or the patient has exhausted their PartA benefits.• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 4 Section 240.1 (921 KB)Billing and Documentation Instructions for Use and Administration ofLumizymePlease refer to the following guidelines when submitting documentation for use and administration ofLumizyme (alglucosidase alfa):• Be sure to include not only clinical notes related to the administration of the drug on the day ofadministration, but also the required background data and testing information. The recordsshould reflect the fact that cardiac hypertrophy was not present prior to beginning the patient’sCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 4 MMR 2011-01, January 2011

In accordance with Title XVIII Section 1833 of the Social Security Act, providers/suppliers must submitmedical record documentation to support claims for Medicare services upon request. It is theresponsibility of the billing facility/physician/supplier to obtain additional supporting documentationfrom a third party (hospital, nursing home, etc.), as necessary.Providing medical records of Medicare patients to the CERT contractor does not violate the HealthInsurance Portability and Accountability Act (HIPAA). Patient authorization is not required torespond to this request.Additional information on CERT and these special studies (supplemental measures) can be found onwww.paymentaccuracy.gov.For specific questions about CERT or these special studies, please contact the Clinical Provider Outreachand Education team at 800-338-6101 or by e-mail at Clinical.Education@wellpoint.com. Please provide theCERT CID number, business type (e.g., Part A, Part B, and DME) and region (state).Updates for January 2011LCD for Magnetic Resonance Angiography (MRA) (L25367)R8 (effective 01/01/2011):CORRECTION/CLARIFICATION - ICD-9-CM code 435.9 (Unspecified transientcerebral ischemia) was added as a payable diagnosis for all head and neck codes (CPT codes 70544,70545,70546, 70547, 70548, 70549) for claims submitted on or after 08/01/2010. The descriptor for CPT code74185 was revised for the 2011 annual CPT code update. Minor changes made to update for NationalGovernment Services template. No notice given and none required.New LCD/Articles:Colorectal Cancer Screening – Medical Policy Article (A50548)Article published January 2011: This article replaces Local Coverage Determination L26402 andSupplemental Instructions Article A45928 on Colorectal Cancer Screening.Article for TheraSkin® – Related to LCD L26003 (A50504)Article published January 2011: Original version of article.LCD for Posterior Tibial Nerve Stimulation for Voiding Dysfunction (L31391)Effective 01/03/2011: Revised during the notice period for annual 2011 CPT code update. CPT codes64999, 97014, and 97032 were deleted from the policy and replaced with CPT code 64566.Article for Posterior Tibial Nerve Stimulation for Voiding Dysfunction – Supplemental InstructionsArticle (A50267)Article published January 2011: Revised during the notice period for annual 2011 CPT code update. CPTcodes 64999, 97014, and 97032 were deleted from the policy and replaced with CPT code 64566.LCD/Article Revisions:December Revision:LCD for Nesiritide Infusion for Heart Failure (L26418)CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 6 MMR 2011-01, January 2011

R4 (effective 12/16/2010): Due to a typographical error, ICD-9-CM code 428.22 was included in the “ICD-9-CM Codes that Support Medical Necessity” section. The correct ICD-9-CM code is 428.23. Coverage forICD-9-CM code 428.23 is retroactive to the original effective date of April 1, 2008. Minor changes weremade to reflect current template language. No comment and notice periods required and none given.LCD for Outpatient Physical and Occupational Therapy Services – L26884R7 (published 12/22/2010, effective retroactive to 11/1/2011): The requirement for the use of the V57.1-V57.89 codes to identify the therapy plan under which service are provided has been deleted, per CMSclarification that such coding is not required in the LCD. Bill type 11X deleted. No comment or noticeperiod required and none given.Article for Outpatient Physical and Occupational Therapy Services – Supplemental InstructionsArticle (A49932)Article published December 2010: The LCD and SIA were revised to delete coding instructions thatrequired ICD-9-CM codes V57.1-V57.89 to be included as the primary diagnosis on all therapy claims(retroactive to 11/01/2010). Furthermore, National Government Services will not require these diagnosiscodes whether as primary or subsequent codes. National Government Services does, however, note thatsuch a recommendation does exist in the ICD-9-CM manual. If providers use these codes, they must alsoinclude the diagnosis code of the specific medical condition for which each therapy service was provided.Bill type 11X removed.January Revisions:LCD for Allergy Immunotherapy (L28451)R3 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed, and no changes required other than for minor formatting for NationalGovernment Services and CMS template language. No comment and notice periods required and nonegiven.Article for Allergy Immunotherapy - Supplemental Instructions Article (A47997)Article published January 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed and no changes required other than minor formatting for NationalGovernment Services and CMS template language.Article for Apligraf® – Related to LCD L26003 (A46092)Article published January 2011: Due to the annual HCPCS update for 2011, HCPCS codes G0440 andG0441 were added to the following coding guideline:Payable places of service for the application of Apligraf® (CPT codes 15340 and 15341 for dates of serviceprior to January 1, 2011 and HCPCS codes G0440 and G0441 for dates of service on or after January 1,2011): office (11), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), hospitalemergency room (23), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32)and independent clinic (49).HCPCS codes G0440 and G0441 were added to the “CPT/HCPCS Codes” section of the SIA. Thefollowing explanatory notes regarding the usage of HCPCS codes G0440 and G0441 and CPT codes 15340and 15341 were added to this section:Effective for dates of service on or after 01/01/2011, HCPCS codes G0440 and G0441 should be reportedfor the application of Apligraf® to the lower extremity.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 7 MMR 2011-01, January 2011

Article for B-type Natriuretic Peptide (BNP) Testing – Supplemental Instructions Article (A45906)Article published January 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed and no changes needed.Article for Capsaicin 8% patch (Qutenza®) - Related to LCD L25820 (A49948)Article published January 2011: Based on the annual HCPCS update for 2011, HCPCS code C9268 hasbeen deleted for dates of service after 12/31/2010 and HCPCS code J7335 has been added to the articleeffective for dates of service on or after 01/01/2011 for services billed to the carriers or intermediaries orPart A or Part B MACs. In the “Coding Guidelines” section the following places of service have beenadded for claims submitted to the carrier or Part B MAC: office (11) and independent clinic (49).LCD for Cardiac Catheterization and Coronary Angiography – L26880R11 (effective 01/01/2011): LCD revised for HCPCS updates for 2011. CPT codes 93501, 93508, 93510,93511, 93514, 93524, 93526-93529, 93539-93545, 93555, 93556 deleted, and CPT codes 93451-93464, 93563-93568 added. The covered ICD-9 lists have been updated into tables related to specific CPT codes,reflecting the CPT updates. No comment or notice periods required and none given.Article for Cardiac Catheterization and Coronary Angiography – Supplemental Instructions Article(A48368)Article published January 2011: SIA revised to accommodate the 2011 CPT coding changes for cardiaccatheterization. CPT codes 93501, 93508, 93510, 93511, 93514, 93524, 93526-93529, 93539-93545, 93555,93556 deleted, and CPT codes 93451-93464, 93563-93568 added.LCD for Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography(CCTA) (L25907)R6 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The references in the “CMS National Coverage Policy” section and the coding requirements inthe LCD were reviewed. Minor template changes were made to reflect current template language. Nocomment and notice periods required and none given.Article for Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography(CCTA) - Supplemental Instructions Article (A45020)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The coding requirements in the SIA were reviewed. Minor template changes were madeto reflect current template language.LCD for Cardiac Event Detection – L26415R4 (effective 01/01/2011): LCD revised for annual HCPCS update for 2011. The descriptors for CPT codes93228, 93229, 93268, 93270, 93271 and 93272 have been revised. No comment or notice periods requiredand none given.Article for Cardiac Event Detection – Supplemental Instructions Article (A45929)Article published January 2011: SIA revised for annual HCPCS update for 2011. The descriptors for CPTcodes 93228, 93229, 93268, 93270, 93271 and 93272 have been revised.LCD for Cardiovascular Nuclear Medicine (L26859)R7 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The references in the “CMS National Coverage Policy” section and the coding requirements inthe LCD were reviewed. Minor template changes were made to reflect current template language. Nocomment and notice periods required and none given.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 9 MMR 2011-01, January 2011

Article for Cardiovascular Nuclear Medicine - Supplemental Instructions Article (A46181)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The coding requirements in the SIA were reviewed. Minor template changes were madeto reflect current template language.LCD for Category III CPT® Codes (L25275)R9 (effective 01/01/2011): based on the annual HCPCS update the following articles have been retired asthese Category III codes have been replaced with Category I codes:• A48043 - Anterior segment scanning computerized ophthalmic diagnostic imaging (0187T) –Related to LCD L25275• A49865 - Determination of Cardiac Output by Inert Gas Rebreathing (0105T) – Related to LCDL25275• A49350 - Transpupillary Thermotherapy (0016T) – Related to LCD L25275• A49616 - Transurethral, radiofrequency micro-remodeling of the female bladder neck andproximal urethra for stress urinary incontinence (0193T) – Related to LCD L25275No comment period required and none given.Article for Category III CPT® Code Coverage – Related to LCD L25275 (A46075)Article published January 2011: Based on the annual HCPCS update, CPT codes 0176T and 0177T havebeen deleted and replaced with Category I codes 66174 and 66175. The description for CPT code 0073Thas changed.Article for Collagenase clostridium histolyticum (e.g., Xiaflex ) – Related to LCD L25820 (A49949)Article published January 2011: Based on the annual HCPCS update for 2011, HCPCS code C9266 hasbeen deleted for dates of service after 12/31/2010 and HCPCS code J0775 has been added effective fordates of service on or after 01/01/2011 for services billed to the carriers or intermediaries or Part A or PartB MACs.LCD for Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L26404)R6 (effective 01/01/2011): The following limitation was removed:Marking of neoplasm for localization (tattooing) is covered, but is not separately payable.Minor template changes were made to reflect current template language. No comment and notice periodsrequired and none given.LCD for Computed Tomography (L28516)R9 (effective 01/01/2011): Due to the annual HCPCS update for 2011, CPT codes 74176, 74177 and 74178were added to the “CPT/HCPCS Codes” section. CPT codes 74176, 74177 and 74178 were also added tothe explanatory note in the “ICD-9-CM Codes that Support Medical Necessity” section for CT Abdomenand Pelvis.No comment and notice periods required and none given.Article for Computed Tomography – Supplemental Instructions Article (A48015)Article published January 2011: Due to the annual HCPCS update for 2011, the following codingguideline was revised:CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 10 MMR 2011-01, January 2011

For dates of service prior to January 1, 2011, a CT scan of the abdomen and a CT scan of the pelvisperformed on the same day must be reported on the same claim.The following coding guideline was added:For dates of service on or after January 1, 2011, if a CT scan of the abdomen and pelvis are done on thesame day, the service should be billed with CPT code 74176, 74177 or 74178 as appropriate.CPT codes 74176, 74177 and 74178 were added to the “CPT/HCPCS Codes” section.Minor template changes were made to reflect current template language.LCD for Computerized Corneal Topography (L28201)R3 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed, and no changes required other than for minor formatting. No comment andnotice periods required and none given.Article for Computerized Corneal Topography – Supplemental Instructions Article (A48365)Article published January 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed and no changes needed.LCD for Debridement Services (L27373)R8 (effective 01/01/2011): Due to the annual HCPCS update for 2011, the CPT code range of 11040 and11044 was revised to include 11045, 11046 and 11047 in the following paragraph in the “Indications”section:CPT codes 11042-11047 should be used for debridement of relatively localized areas depending upon theinvolvement of contiguous underlying structures. These codes are appropriate for treatment of skinulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, anddebridement of deep-seated debris from any number of injury types.CPT codes 11040 and 11041 were deleted 12/31/2010 and removed from the listing in the “CPT/HCPCSCodes” section of the LCD. An explanatory note regarding the code deletions was added to this section.CPT codes 11045, 11046 and 11047 were added. The terminology for CPT codes 11042, 11043 and 11044has been revised for dates of service on or after 01/01/2011.The following paragraph was removed from the “Utilization Guidelines” section:Debridement services of the feet is limited to two services per foot per clinical encounter, provided twodiscrete lesions are debrided to the level(s) coded. Services exceeding this parameter will be considerednot medically necessary.The following paragraph was added to the “Utilization Guidelines” section:Debridement services are now defined by body surface area of the debrided tissue and not by individualulcers or wounds. For example, debridement of two ulcers on the foot to the level of subcutaneous tissue,total area of 6 sq cm should be billed as CPT code 11042 with unit of service of “1”.The CPT codes 11046 and 11047 were added to the following paragraph was removed from the“Utilization Guidelines” section:CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 11 MMR 2011-01, January 2011

For dates of service prior to 01/01/2011, CPT codes 15365 and 15366 should be reported for the applicationof Dermagraft®.Article for Denosumab (Prolia , Xgeva ) - Related to LCD L25820 (A50361)Article published 01/01/2011: The “Indications” section of the article has been revised to include FDAapproved indication for denosumab Xgeva for the treatment of bone metastases from solid tumorseffective 11/18/2010. The following indication has also been added to the “Indications” section of thearticle:• For patients with significant renal failure where treatment with biphosphonate is not indicated,CrCl less than 35 ml/min.The “Limitations” section of the article has been revised to include that denosumab (Xgeva) is notapproved for patients with multiple myeloma or other cancer of the blood. The “Documentation” sectionof the article has been revised to include that the patients medical record should include documentationof bone metastasis from a solid tumor and adequate calcium levels as well as the use of Vitamin D ifindicated for denosumab (Xgeva). The “Utilization” section of the article has been revised to includethat denosumab (Xgeva) is administered at a dose of 120mg every four weeks as a subcutaneousinjection. In the “ICD-9 Codes that Are Covered” section ICD-9-CM code 198.5 has been added as aprimary diagnoses and ICD-9 codes 585.3, 585.4 and 585.5 have been added to the secondary diagnosislist effective for dates of service on or after 01/01/2011. In the “General Guidelines” section Xgeva hasbeen added to Coding Guidelines 1 and 2. The article has been revised to indicate that effective for datesof service on or after 01/01/2011, HCPCS code C9272 should be used to report denosumab (Prolia,Xgeva) for claims submitted to the FI or Part A MAC.LCD for Dialysis Access Maintenance (L30737)R2 (effective date 01/01/2011): LCD revised for annual CPT code updates. CPT codes 35473, 35474, and75964 were deleted from the policy. Descriptors were changed for CPT codes 36832, 37205, 37206, 75710,75791, 75820, 75822, 75825, 75827, 75896, and 75960. Minor formatting changes were made to update forNational Government Services template changes. No notice given and none required.Article for Dialysis Access Maintenance – Supplemental Instructions Article (A49635)Article published January 2011: Updated for annual CPT code updates. CPT codes 35473, 35474, 75962,and 75964 were deleted from the policy. Descriptors were changed for CPT codes 36832, 37205, 37206,75710, 75791, 75820, 75822, 75825, 75827, 75896, and 75960. Minor formatting changes were made toupdate for NATIONAL GOVERNMENT SERVICES template changes.LCD for Dynamic Electrocardiography (EKG, ECG) – L26409R4 (effective 01/01/2011): LCD revised for annual HCPCS updates for 2011: descriptors for CPT codes93224, 93225, 93226, and 93227 revised and CPT codes 93230, 93231, 93232, 93233, 93235, 93236, and 93237deleted. References to 24-hour recording replaced by reference to up to 48 hours, to reflect revised CPTcodes. Information added to Limitations and Documentation Requirements for recordings of less than 12hours. No comment and notice periods required and none given.Article for Dynamic Electrocardiography (EKG, ECG) – Supplemental Instructions Article (A45925)Article published January 2011: SIA revised for annual HCPCS updates for 2011: descriptors for CPTcodes 93224, 93225, 93226, and 93227 revised and CPT codes 93230, 93231, 93232, 93233, 93235, 93236, and93237 deleted, effective January 1, 2011. Modifier instruction added for reporting scans of less than 12hours.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 13 MMR 2011-01, January 2011

LCD for Endoscopy by Capsule (L25468)R6 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The references in the “CMS National Coverage Policy” section and the coding requirements inthe LCD were reviewed. Minor template changes were made to reflect current template language. Nocomment and notice periods required and none given.Article for Endoscopy by Capsule – Supplemental Instructions Article (A48399)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The coding requirements in the SIA were reviewed. Minor template changes were madeto reflect current template language.LCD for Extracorporeal Shock Wave Therapy (ESWT) For Musculoskeletal Indications (L28470)R2 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The references in the “CMS National Coverage Policy” section and the coding requirements inthe LCD were reviewed. Minor template changes were made to reflect current template language. Nocomment and notice periods required and none given.Article for Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications -Supplemental Instructions Article (A48009)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The coding requirements in the SIA were reviewed. Minor template changes were madeto reflect current template language.LCD for High Sensitivity C-Reactive Protein (hsCRP) Testing (L26445)R4 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed, and LCD updated for current National Government Services and CMStemplate changes. CPT code 86141 descriptor revised with 2011 CPT annual code update. No commentand notice periods required and none given.High Sensitivity C-Reactive Protein (hsCRP) Testing –- Supplemental Instructions Article (A45939)Article published January 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed and article updated for current NATIONAL GOVERNMENT SERVICES andCMS template changes. CPT code 86141 descriptor revised with 2011 CPT annual code update.LCD for Hyperbaric Oxygen Therapy (HBO) (L25204)R6 (effective date 01/01/2011): The Limitations section was updated with the following statement:“Training and/or certification for providers currently providing HBO will not be required until 12 months(11/1/2011) after the effective date of this LCD.” No notice given and none required.Article for Intravenous Immune Globulin (IVIG) - Related to LCD L25820 (A47381)Article published January 2011: the article has been revised to indicate that effective for dates of serviceon or after 01/01/2011, HCPCS code C9270 should be used to report injection, immune globulin(Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg for claims submitted to the FI or Part AMAC. Based on the annual HCPCS update HCPCS code J1599 injection, immune globulin, intravenous,non-lyophilized (e.g., liquid), not othererwise specified, 500 mg has been added effective for dates ofservice on or after 01/01/2011.Article for Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article(A47355)Article published January 2011: The fax number for reconsideration requests was changed.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 14 MMR 2011-01, January 2011

Article for Magnetic Resonance Imaging – Supplemental Instructions Article (A48016)Article published January 2011: An assisted living facility (13), ambulatory surgical center (24), nursingfacility (32- for Medicare patient not in a Part A stay), custodial care facility (33), community mentalhealth center (53) and state or local public health clinics (71) were removed from the coding guidelines forthe payable places of service under Part B for the professional component (modifier 26).LCD for Nonvascular Extremity Ultrasound (L28178)R4 (effective 01/01/2011): Due to the annual HCPCS update for 2011, CPT code 76880 was removed andCPT codes 76881 and 76882 were added to the following statement in the “Limitations” section:Extremity ultrasound (CPT codes 76881 or 76882) is limited to studies of the arms and legs.CPT code 76880 was deleted 12/31/2010 and removed from the listing in the “CPT/HCPCS Codes” sectionof the LCD. An explanatory note regarding the code deletion was added to this section. CPT codes 76881and 76882 were added as the replacement codes.Minor template changes were made to reflect current template language. No comment and notice periodsrequired and none given.Article for Nonvascular Extremity Ultrasound – Supplemental Instructions Article (A48353)Article published January 2011: Due to the annual HCPCS update for 2011, CPT code 76880 was removedand CPT codes 76881 and 76882 were added to the following coding guidelines in the “Article Text”section and a paragraph in the “Other Comments” section:Use CPT code 76942 when billing for ultrasonic guidance for needle biopsy. It would be inappropriate touse CPT codes 76881 or 76882 in this situation.Claims for ultrasound of the extremity, CPT codes 76881 or 76882, must be reported with the appropriatesite modifier (LT or RT or both).CPT codes 76881 and 76882 are nonvascular by definition. For vascular studies of the extremities, refer toCPT codes 93922-93931 for arteries and 93965-93971 for veins.CPT code 76880 was deleted 12/31/2010 and removed from the listing in the “CPT/HCPCS Codes” sectionof the LCD. An explanatory note regarding the code deletion was added to this section. CPT codes 76881and 76882 were added as the replacement codes.Minor template changes were made to reflect current template language.LCD for Ophthalmic Biometry for Intraocular Lens Power Calculation (L26441)R4 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed, and LCD updated for current National Government Services and CMStemplate changes. No comment and notice periods required and none given.Article for Ophthalmic Biometry for Intraocular Lens Power Calculation – Supplemental InstructionsArticle (A45936)Article published January 2011: Annual review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed and article updated for current National Government Services and CMStemplate changes.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 15 MMR 2011-01, January 2011

LCD for Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and FundusPhotography) – L25466R6 (effective 01/01/2011) LCD revised for annual 2011 HCPCS update. CPT code 92227 added as anoncovered service (screening) and CPT code 92228 added to the LCD under coverage criteria for fundusphotography.Article for Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and FundusPhotography) – Supplemental Instructions Article (A44439)Article published January 2011: SIA revised for annual 2011 HCPCS update. CPT code 92227 added as anoncovered service (screening) and CPT code 92228 added to the SIA under fundus photographyguidelines sections.Article for Pain Management – Supplemental Instructions Article (A48042)Article published January 2011: HCPCS coding update for 2011. Descriptor changes were made to CPTcodes 20552 and 20553 in Group 1, 20526 in Group 2, 62318 descriptor in Group 3, 64479, 64480, 64483,and 64484 in Group 4, 62318 in Group 5, and 77003 in Group 10. Coding guidelines for EpiduralInjections - Transforaminal were updated as follows: “Effective January 1, 2011 fluoroscopic or computedtomography (CT) image guidance and any injection of contrast are inclusive components of CPT codes64479 – 64484 and should not be separately billed.” Minor changes were made to update for NationalGovernment Services template.LCD for Polysomnography and Sleep Studies (L26428)R7 (effective 01/01/2011): Based on the annual HCPCS update, CPT codes 95800 and 95801 have beenadded to the third paragraph in the “Limitations” section of the LCD, added to the “CPT/HCPCS Codes”section and to the “ICD-9 Codes that Support Medical Necessity” section for sleep studies done due tosleep apnea effective for dates of service on or after 01/01/2011. Minor changes were made to reflectcurrent template language. No notice required and none given.Article for Polysomnography and Sleep Studies – Supplemental Instructions Article (A48396)Article published January 2011: Based on the annual HCPCS update, CPT codes 95800 and 95801 havebeen added to the coding guideline for sleep studies done due to sleep apnea and to the paragraph onunattended sleep studies. These codes have also been added to the fourth paragraph in the CodingGuidelines for claims submitted to the carrier or Part B MAC and to the CPT/HCPC Codes section of theSIA. Minor changes were made to reflect current template language.LCD for Qualitative Drug Screening (L28145)R7 (effective 01/01/2011): Revised for annual 2011 CPT code update. CPT code G0430 was deleted andreplaced with CPT code G0434. Descriptors were changed for CPT code 80100 and HCPCS code G0431.ICD-9 code 305.90 was added to the ICD-9 Codes that Support Medical Necessity. Minor changes madeto update for National Government Services and CMS template changes. No notice given and nonerequired.Article for Qualitative Drug Screening – Supplemental Instructions Article (A48395)Article published January 2011: Revised for annual 2011 CPT code update. CPT code G0430 was deletedand replaced with CPT code G0434. Descriptors were changed for CPT code 80100 and HCPCS codeG0431. The following statement was added the “Specific coding guidelines for this policy: “For dates ofservice on, or after 01/01/2011, append modifier QW to G0434 to indicate a CLIA waived test.” for claimssubmitted to the carrier or Part B MAC. Minor changes made to update for National GovernmentServices and CMS template changes.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 16 MMR 2011-01, January 2011

LCD for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L28488)R2 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. Content reviewed. LCD revised for annual 2011 CPT code update. CPT code 92135 was deletedfrom the policy and replaced with CPT codes 92133 and 92134. Utilization guidelines for Glaucoma wereupdated to replace CPT code 92135 with CPT code 92133. Utilization Guidelines for Retinal Damage wereupdated with the following statement: “It is expected that no more than four (4) tests (CPT code 92134)per year would be appropriate with the following exceptions.” Minor changes were made to update forNATIONAL GOVERNMENT SERVICES and CMS template changes. No notice given and none required.Article for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) – SupplementalInstructions Article (A48003)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. Content reviewed. Article revised for annual 2011 CPT code update. CPT code 92135 wasdeleted from the policy and replaced with CPT codes 92133 and 92134. The following statement wasremoved from the coding guidelines: “CPT 92135 is a unilateral code. For unilateral services, the modifierRT or LT must be submitted with the CPT code to indicate the eye being treated. For bilateral services,report CPT code 92135 with the –50 modifier.” Minor changes were made to update for NationalGovernment Services and CMS template changes.Article for Sipuleucel-T (Provenge®) Related to LCD L25820 (A50060)Article published January 2011: HCPCS code C9273 has been added to the “CPT/HCPCS Codes” sectionof the article.LCD for Syphilis Tests (L28535)R2 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The entire LCD was reviewed. Minor template changes were made to reflect current templatelanguage. No comment and notice periods required and none given.Article for Syphilis Tests - Supplemental Instructions Article (A48037)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The entire SIA was reviewed. Minor template changes were made to reflect currenttemplate language.Article for Topotecan Hydrochloride (Hycamtin®) – Related to LCD L25820 (A47580)Article published January 2011: Based on the annual HCPCS updates, HCPCS code J9350 has beendeleted for dates of service after 12/31/2010 and HCPCS code J9351 has been added effective for dates ofservice on or after 01/01/2011.LCD for Urodynamics (L26851)R4 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The entire LCD was reviewed. Minor template changes were made to reflect current templatelanguage. No comment and notice periods required and none given.Article for Urodynamics – Supplemental Instructions Article (A46189)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The entire SIA was reviewed. Minor template changes were made to reflect currenttemplate language.Article for Vagus Nerve Stimulation – Medical Policy Article (A49273)Article published January 2011: Article revised for 2011 HCPCS code update. CPT code 64585 was deletedand replaced with CPT codes 64568, 64569, 64570. Descriptors for CPT codes 95970, 95971, 95974, andCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 17 MMR 2011-01, January 2011

95975 were changed. CPT code 61886 was added to the policy. Minor changes were made to update forNational Government Services and CMS template changes.LCD for Varicose Veins of the Lower Extremity, Treatment of (L25519)R6 (effective 01/01/2011): Annual LCD review per CMS Program Integrity Manual, Chapter 13, Section13.4[C]. The entire LCD was reviewed. Minor template changes were made to reflect current templatelanguage. No comment and notice periods required and none given.Article for Varicose Veins of the Lower Extremity, Treatment of - Supplemental Instructions Article(A44614)Article published January 2011: Annual LCD review per CMS Program Integrity Manual, Chapter 13,Section 13.4[C]. The entire SIA was reviewed. CPT codes 36470, 36471, 37765 and 37766 were added to thefollowing coding guideline:Claims for treatment of varicose veins services are payable under Medicare Part B in the following placesof service: office (11); inpatient hospital (21); outpatient hospital (22), ambulatory surgical center (ASC)(24) and independent clinic (49). CPT codes 36470, 36471, 36475, 36476, 36478, 36479, 37700, 37718, 37722,37735, 37760, 37761, 37765, 37766 and 37780 are the only procedures that qualify for an (ASC) ambulatorysurgical center (24) facility fee payment.Minor template changes were made to reflect current template language.LCD for Vertebroplasty and Vertebral Augmentation (Percutaneous) (L26439)R8 (effective 01/01/2011): Indications for percutaneous vertebral augmentation were updated as follows:“The principal indications for percutaneous vertebral augmentation include:• A “recent” osteoporotic compression fracture of the lumbar or thoracic vertebrae with persistentdebilitating pain that has not responded to accepted standard medical treatment; and/or• Osteolytic vertebral collapse secondary to multiple myeloma or osteolytic metastatic diseasecausing persisting or progressive pain.”No notice given and none required.LCD for Viral Hepatitis Serology Tests (L28427)R3 (effective 01/01/2011): CPT coding update for 2011Indications were updated for Hepatitis B surfaceantigen testing (CPT codes 87340, 87341) and Hepatitis B core antibody testing (CPT codes 86704, 86705)and Hepatitis C antibody testing (CPT code 86803). References were updated. Minor changes made toupdate for National Government Services template. No notice given and none required.Retired LCD/Article:Article for Anterior segment scanning computerized ophthalmic diagnostic imaging (0187T) – Relatedto LCD L25275 (A48043)This article will no longer be in effect for services performed after 12/31/2010.CPT code 0187T has been deleted effective 12/31/2010. Effective for dates of service on or after 01/01/2011,Category I CPT code 92132 should be used to report scanning computerized ophthalmic diagnosticimaging, anterior segment, with interpretation and report, unilateral or bilateral.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 18 MMR 2011-01, January 2011

Article for Determination of Cardiac Output by Inert Gas Rebreathing (0105T) – Related to LCDL25275 (A49865)This article will no longer be in effect for services performed after 12/31/2010.CPT code 0105T has been deleted effective 12/31/2010. Effective for dates of service on or after 01/01/2011,Category I CPT code 93799 should be used to report inert gas rebreathing for cardiac outputmeasurement during rest.Article for Colorectal Cancer Screening – Supplemental Instructions Article (A45928)The following article has been retired effective December 31, 2010. Details of the revisions are available inthe published documents and will also be included in the Updates notice published for February 1, 2011.Article for Transpupillary Thermotherapy (0016T) – Related to LCD L25275 (A49350)This article will no longer be in effect for services performed after 12/31/2010.CPT code 0016T has been deleted effective 12/31/2010. Effective for dates of service on or after 01/01/2011,Category I CPT code 67299 should be used to report destruction of localized lesion of choroid bytranspupillary thermotherapy.Article for Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximalurethra for stress urinary incontinence (0193T) – Related to LCD L25275 (A49616)This article will no longer be in effect for services performed after 12/31/2010.CPT code 0193T has been deleted effective 12/31/2010. Effective for dates of service on or after 01/01/2011,Category I CPT code 53860 should be used to report transurethral radiofrequency micro-remodeling ofthe female bladder neck and proximal urethra for stress urinary incontinence.National Government Services Articles for Part A ProvidersTherapy Documentation Requirements for Part A Skilled NursingFacility ClaimsObjectiveThere are many elements involved in the review of a Part A skilled nursing facility (SNF) claim, but theprimary focus of this article is to address the therapy documentation requirements.Background• The Balanced Budget Act of 1997 changed the payment methodology for SNF to a prospectivepayment system (PPS). The eligibility and level of care requirements for SNF services as outlined in42 Code of Federal Regulations (CFR) 409.30 - 409.31, http://law.justia.com/us/cfr/title42/42-2.0.1.2.9.4.35.1.html did not change with the implementation of SNF PPS. The need for theserequirements to be met, in order for the beneficiary to qualify for a SNF admission, continued withSNF PPS. In addition, per 1862(a)(1)(A) of the Social Security Act,http://www.ssa.gov/OP_Home/ssact/title18/1833.htm, the services must be reasonable and necessaryfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed bodymember.Under SNF PPS, facilities receive per diem rates based on the beneficiary’s classification into a resourceutilization group (RUG). The minimum data set (MDS) is the clinical assessment tool utilized to classifybeneficiaries into each RUG group. Per CMS Internet-Only Manuals (IOMs), Publication 100-08, Chapter6, Section 6.1, http://www.cms.gov/manuals/downloads/pim83c06.pdf, “Medical review decisions areCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 19 MMR 2011-01, January 2011

ased on documentation provided to support medical necessity of services recorded on the MDS for theclaim period billed.”Key PointsThe beneficiary’s medical record should contain all documentation to fully support the medical necessityfor the RUG code/services billed. In the case of a rehabilitation RUG, the provision of therapy servicesmust be supported by the following:• Therapy logs must document the actual minutes of therapy the beneficiary participated in per dayo Logs should be provided for the look back period for each MDS assessment related to the claimdates of service being reviewed; and for the claim dates of service being reviewed• Documented time should be a record of the time the beneficiary spent receiving therapyo Minutes should be actual (NOT rounded)o Time should be recorded in minutes (NOT units)• Documented time should NOT include the following:o The initial evaluationo Rest breaks taken by the beneficiary during the therapy sessiono The therapist’s time spent documenting the initial evaluation, treatment notes and/or progressnoteso The therapist’s time spent establishing the plan of treatment and short term/long term goalsPer the National Government Services local coverage determination for Skilled Nursing Facilities(#L26861), http://apps.ngsmedicare.com/sia/ARTICLE_A46184.htm “To support the provision of therapyservices the documentation in the medical record must include entries of attendance, scheduled activitiesand participation at each session. Then a weekly progress note is acceptable from the therapist basedupon the information documented for each session.”In addition, the services must be directly related to an active treatment plan established by a therapistand approved by the physician. The services must be of a level of complexity that the judgment,knowledge, and skills of a therapist are necessary to safely provide the services. There must be areasonable expectation that the patient will improve in a reasonable and generally predictable period oftime. Finally, the amount, frequency, and duration of the services must be reasonable and necessary forthe treatment of the patient’s condition.When a claim is selected for review, all pertinent medical record documentation associated with the datesof service will be reviewed by the medical reviewer. The reviewer will determine if the types of service,as well as the intensity of services are appropriate based on the clinical picture that the medical recordprovides.Sources:• Section 1833(e) of Title XVIII of the Social Security Act;http://www.ssa.gov/OP_Home/ssact/title18/1833.htm• Section 1862(a)(1)(A) of Title XVIII of the Social Security Act;http://www.ssa.gov/OP_Home/ssact/title18/1833.htm• 42 CFR Sections 409.30-409.33; http://law.justia.com/us/cfr/title42/42-2.0.1.2.9.4.35.1.html• CMS Internet-Only Manual (IOM), Publication 100-02, Chapter 8;http://www.cms.gov/manuals/Downloads/bp102c08.pdfCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 20 MMR 2011-01, January 2011

• CMS Internet-Only Manual (IOM), Publication 100-08, Chapter 6; Resident Assessment Instrument(RAI) User’s Manual for the Minimum Data Set (MDS);http://www.cms.gov/manuals/downloads/pim83c08.pdf• National Government Services LCD #L26861 for SNFs (Including Swing Beds),http://apps.ngsmedicare.com/sia/ARTICLE_A46184.htmNational Government Services Articles for Part B ProvidersNational Government Services J13 Part B to Transition to HealthcareIntegrated General Ledger Accounting System (HIGLAS)Effective February 11, 2011, National Government Services will be transitioning our Jurisdiction 13 (J13)(Connecticut and New York) Part B financial accounting system from the Multi-Carrier System (MCS) tothe Healthcare Integrated General Ledger Accounting System (HIGLAS). This transition involves onlyour financial accounting system. We will continue to use MCS for all of our claims processingactivities.Implementation of HIGLAS will enable the Centers for Medicare & Medicaid Services (CMS) to trackMedicare payments and to accurately pay claims for over 40 million Medicare beneficiaries. Thetransition will also provide CMS with enhanced oversight of contractors’ accounting systems, as well asaccess to more accurate, timely, and consistent data for decision-making and for performanceevaluations.National Government Services HIGLAS TransitionThe purpose of this letter is to explain the impact that the National Government Services HIGLAS transition willhave on your organization’s Medicare payments. It also provides a detailed transition timeline, revised paymentschedules, and other important information regarding upcoming changes. In an attempt to make the transition assmooth as possible, we are providing you with this information to ensure minimal disruption in your Medicarepayments.We ask that you please take time to carefully read this information and that you share it with theappropriate staff in your organization.Introduction to HIGLASA HIGLAS training module will be available soon on the National Government Services Web site.Updated information regarding our HIGLAS implementation will be provided via the NationalGovernment Services HIGLAS Web site at www.NGSMedicare.com or by accessing NationalGovernment Services Web site at www.NGSMedicare.com and selecting “HIGLAS Transition for Part B –Connecticut and New York Providers” under Hot Topics. This same information will be issued in our e-mail updates and published in the Medicare Monthly Review.Temporary Waiver of the Claims Processing Payment FloorCMS has approved National Government Services’ waiver request to reduce the payment floor for both paper andEDI claims. Beginning February 9, 2011, the payment floor will be reduced to zero for both EDI and paper claims,and payments will be released for claims that have already been approved for payment.This temporary reduction of the payment floor will result in payments being issued early (checksand electronic funds transfers (EFTs)). This may give the appearance that your cash revenues haveincreased when in fact; payments for some of your claims may have simply been made earlier thannormal. Providers are encouraged to monitor their payments and make adjustments as necessary toprevent cash flow problems during the transition period.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 21 MMR 2011-01, January 2011

HIGLAS Transition ActivitiesOn February 9, 2011, National Government Services will run the last MCS payment cycle and begin theHIGLAS transition. (See National Government Services HIGLAS Transition Timeline below.)• Waiver of the payment floor will result in claim payments (checks and EFTs) being issued earlier thannormal.• Providers are encouraged to continue submitting claims as normal.• Following our transition to HIGLAS, National Government Services will resume normal scheduledpayments.• Distribution of Remittance Advices (RAs) will resume the week of February 14, 2011.HIGLAS Remittance AdvicesNational Government Services will not be issuing payments from February 10 through February 14, 2011.Electronic remittance advices (ERAs) and paper RAs will not be available. National Government Serviceswill resume normal payment cycles and issuance of payments on February 15, 2011, at which timeproviders will be able to retrieve their ERAs.National Government Services HIGLAS Transition TimelineDateActionFebruary 9, 2011Release payments for all claims already approved to payFebruary 9, 2011Last MCS payment cycle (payment floors reduced to zero)February 10, 2011 HIGLAS transition beginsFebruary 10 throughFebruary 14, 2011February 14, 2011February 15, 2011February 14, 2011February 14, 2011through February 28,2011No payments will be issued - ERAs and paper RAs are notproducedHIGLAS transition completed – payment floors reinstatedProduction & distribution of ERAs and paper RAs resumeBegin processing backlogged files and issuing paymentsProviders may experience a significant reduction in paymentsdue to the early claim payments issued immediately prior to thetransition. Providers need to monitor and manage their cashflows during this time period.Changes Providers Will See as a Result of HIGLASClaim Payments Less than $1Current CMS instructions require carriers to hold claim payments of less than $1 until another paymentgreater than $1 is generated and then to combine the two payments. Payments less than $1 will now beissued because HIGLAS functionality at this time will not suppress these payments.Claims and Refund Payments Subject to a Hold, e.g., Do Not Forward (DNF), Bankruptcy, andPayment SuspensionProviders may be placed on a hold due to a forwarding address, bankruptcy, and payment suspension.Currently, the holds are applied to the net payment after any eligible overpayment receivables have beenoffset. In HIGLAS, the holds will be applied at the claim level. As a result, the held money will not beapplied to eligible receivables until the hold has been released.Claims and Refund Payments Subject to Third Party Payer (TPP) Offset, e.g., IRS Backup WithholdingA provider payment may be subject to offsetting to a third party, such as the IRS. In the currentenvironment, when a provider is subject to TPP, a provider check is pulled and the payment is remittedCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 22 MMR 2011-01, January 2011

to the third party but no notification is provided on the RA. HIGLAS will communicate a TPP offset of aprovider’s payment on the provider’s RA.HIGLAS Impact on Claims ProcessingCurrently, our online system is available on federal holidays and National Government Servicesprocesses claims on some federal holidays. After transitioning to HIGLAS, our online system willcontinue to be available but claims will no longer be processed on federal holidays. There will be nochange to provider payments because National Government Services currently does not issue checks orEFTs on federal holidays.For further information, please visit our Web site by selecting “HIGLAS Transition for Part B –Connecticut and New York Providers” from the Jurisdiction 13 Part B home page atwww.NGSMedicare.com. If you have any questions regarding the information contained in this letter,please contact our Provider Contact Center toll-free at 866-837-0241.Centers for Medicare & Medicaid Services Articles for Part A and Part BProvidersCommon Working File Unsolicited Response Adjustments for CertainClaims Denied Due to an Open Medicare Secondary Payer GroupHealth Plan Record Where the GHP Record Was Subsequently Deletedor TerminatedMLN Matters® Number: MM6625 RevisedRelated Change Request (CR) #: 6625Related CR Release Date: December 3, 2010Effective Date: April 1, 2011Related CR Transmittal #: R2112CPImplementation Date: July 5, 2011Note: This article was revised on December 6, 2010, to reflect a revision to CR 6625. The implementationdate has been changed to July 5, 2011. The CR release date, transmittal number, and the Web address foraccessing CR 6625 has been revised. All other information is the same.Provider Types AffectedPhysicians, providers, and suppliers who bill Medicare contractors (fiscal intermediaries [FI], regionalhome health intermediaries [RHHI], carriers, Medicare administrative contractors [A/B MAC], or durablemedical equipment contractors [DME MAC] for services provided, or supplied, to Medicare beneficiaries.What You Need to KnowCR 6625, from which this article is taken, instructs Medicare contractors (FIs, RHHIs, carriers, A/B MACs,and DME MACs) and shared system maintainers (SSM) to implement (effective April 1, 2011) anautomated process to reopen Group Health Plan (GHP) Medicare Secondary Payer (MSP) claims whenrelated MSP data is deleted or terminated after claims were processed subject to the beneficiary record onMedicare’s database. Make sure that your billing staffs are aware of these new Medicare contractorinstructions. Please see the Background section, below, for more details.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 23 MMR 2011-01, January 2011

BackgroundMSP GHP claims were not automatically reprocessed in situations where Medicare became the primarypayer after an MSP GHP record had been deleted or when an MSP GHP record was terminated afterclaims were processed subject to MSP data in Medicare files. It was the responsibility of the beneficiary,provider, physician or other suppliers to contact the Medicare contractor and request that the deniedclaims be reprocessed when reprocessing was warranted. However, this process places a burden on thebeneficiary, physician, or other supplier and CR 6625 eliminates this burden. As a result of CR 6625,Medicare will implement an automated process to:1. Reopen certain MSP claims when certain MSP records are deleted, or2. Under some circumstances when certain MSP records are terminated and claims are denied due toMSP or Medicare made a secondary payment before the termination date is accreted.Basically, where Medicare learns, retroactively, that MSP data for a beneficiary is no longer applicable,Medicare will require its systems to search claims history for claims with dates of service within 180 daysof a MSP GHP deletion date or the date the MSP GHP termination was applied, which were processed forsecondary payment or were denied (rejected for Part A only claims). If claims were processed, theMedicare contractors will reprocess them in view of the more current MSP GHP information and makeany claims adjustments that are appropriate. If providers, physicians or other suppliers believe someclaim adjustments were missed please contact your Medicare contractor regarding those missingadjustments.Additional InformationYou can find the official instruction, CR 6625, issued to your FI, RHHI, carrier, A/B MAC, or DME MACby visiting http://www.cms.gov/Transmittals/downloads/R2112CP.pdf on the Centers for Medicare &Medicaid Services (CMS) Web site.If you have any questions, please contact your FI, RHHI, carrier, A/B MAC, or DME MAC at their tollfreenumber, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Implementation of Section 2902 of the Affordable Care Act for IndianHealth Service Part B Services and All Inclusive Rate Billing for ReturnVisitsMLN Matters® Number: MM6908Related Change Request (CR) #: 6908Related CR Release Date: October 28, 2010Effective Date: January 1, 2010Related CR Transmittal #: R2075CPImplementation Date: January 28, 2011CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 24 MMR 2011-01, January 2011

Provider Types AffectedThis article is for Indian Health Service (IHS) providers receiving payment under the All Inclusive Rate(AIR) payment methodology for Part B hospital outpatient services.Provider Action NeededThis article is based on Change Request (CR) 6908 which clarifies billing for return visits to IHS providersunder the AIR payment methodology. See the Background and Additional Information Sections of thisarticle for further details regarding this clarification.CR 6908 also implements Section 2902 of the Affordable Care Act, which extends indefinitely Section 630of The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), retroactive toJanuary 1, 2010. Special Edition MLN Matters article SE0930 contains more details on this extension ofSection 630 of the MMA. The article is available athttp://www.cms.gov/MLNMattersArticles/downloads/SE0930.pdf on the Centers for Medicare &Medicaid Services (CMS) Web site.BackgroundCR 6908 updates the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM)Publication 100-04, Medicare Claims Processing Manual, Chapter 19, Section100.5.1, to clarify that, while atleast one face-to-face encounter with a physician (or nonphysician practitioner) is required for an initialvisit to count as a billable AIR encounter, the same is not always true of return visits to obtain follow-upcare ordered by the physician (or nonphysician practitioner) during the initial visit.CR 6908 further states that it is appropriate for a return encounter to be billed on the date the procedureor test is furnished and for the provider to receive an additional AIR payment (even if the beneficiary didnot interact with a physician or non-physician practitioner during the return visit) if:• A physician (or nonphysician practitioner) orders a specific procedure or test which cannot befurnished until a later date after the date of the initial visit with the physician (or nonphysicianpractitioner); and• The procedures or tests are medically necessary.Examples of medically necessary reasons for return visits would include a requirement that:1. The beneficiary fast for 12 hours prior to an ordered test; or2. A chest X-ray be provided two weeks following the initiation of antibiotic treatment for pneumonia.Also, a return visit would be considered medically necessary if a beneficiary must return on another dayfor a medically necessary test ordered during an initial visit because the test cannot be performed on theday it is ordered due to provider or patient constraints that cannot be overcome.Additional InformationThe official instruction, CR 6908, issued to your carrier, DME MAC and/or A/B MAC regarding thischange may be viewed at http://www.cms.gov/Transmittals/downloads/R2075CP.pdf on the CMS Website.If you have any questions, please contact your Medicare contractor at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 25 MMR 2011-01, January 2011

Dermal Injections for Treatment of Facial Lipodystrophy SyndromeMLN Matters® Number: MM6953 RevisedRelated Change Request (CR) #: 6953Related CR Release Date: June 4, 2010Effective Date: March 23, 2010Related CR Transmittal #: R122NCD and R1978CPImplementation Date: July 6, 2010Note: This article was revised on November 26, 2010, to reflect a revised CR 6953, which was issued onNovember 24, 2010. CR 6953 was revised to clarify billing procedures for services performed in theoutpatient hospital setting and to update the claims adjustment reason code (CARC) for line item denialsfor relevant services performed prior to March 23, 2010. This article was revised to reflect this clarificationand update.Provider Types AffectedThis article is for physicians, hospitals, and other providers submitting claims to Medicare contractors(carriers, fiscal intermediaries [FIs], and/or A/B Medicare administrative contractors [A/B MACs]) forfacial lipodystrophy services provided to Medicare beneficiaries.What You Need to KnowThis article is based on Change Request (CR) 6953, which informs Medicare contractors that effective forclaims with dates of service on and after March 23, 2010, dermal injections for facial lipodystrophysyndrome (LDS) are only reasonable and necessary using dermal fillers approved by the Food and DrugAdministration (FDA) for this purpose, and then only in human immunodeficiency virus (HIV)-infectedMedicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment.BackgroundThe Centers for Medicare & Medicaid Services (CMS) received a request for national coverage oftreatments for facial LDS for human immunodeficiency virus (HIV)-infected Medicare beneficiaries. LDSis often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks.This fat loss can arise as a complication of HIV and/or highly active antiretroviral therapy (HAART). Dueto their appearance, patients with LDS may become depressed, socially isolated, and in some cases maystop their HIV treatments in an attempt to halt or reverse this complication.Nationally Covered IndicationsEffective for claims with dates of service on and after March 23, 2010, dermal injections for LDS are onlyreasonable and necessary using dermal fillers approved by the FDA for this purpose, and then only inHIV-infected beneficiaries who manifest depression secondary to the physical stigma of HIV treatment.Nationally Noncovered Indications• Dermal fillers that are not approved by the FDA for the treatment of LDS, and• Dermal fillers that are used for any indication other than LDS in HIV-infected individuals whomanifest depression as a result of their antiretroviral HIV treatments.Claims Coding/Pricing InformationEffective with the July 2010 Healthcare Common Procedure Coding System (HCPCS) update, the JulyMedicare Physician Fee Schedule (MPFS), and the July Integrated Outpatient Code Editor (IOCE):CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 26 MMR 2011-01, January 2011

• HCPCS codes Q2026, Q2027, and G0429 will be designated for dermal fillers Sculptra® andRadiesse®;• HCPCS codes Q2026, Q2027, and G0429 are effective for dates of service on or after March 23, 2010;• HCPCS codes Q2026 and Q2027 are contractor-priced under the July MPFS; and• HCPCS code G0429 is payable under the July MPFS.However, because HCPCS Q2026, Q2027 and G0429 are not considered valid HCPCS untilimplementation of the July 2010 HCPCS update, providers will not be able to bill and receive payment forthese HCPCS codes prior to July 6, 2010.Therefore, included in the July 2010 HCPCS update and in the July IOCE is a temporary HCPCS codeC9800, which was created to describe both the injection procedure and the dermal filler product. Thiscode provides a payment mechanism to hospital outpatient prospective payment system (OPPS) andambulatory surgery center (ASC) providers until average sales price (ASP) or wholesale acquisition cost(WAC) pricing information becomes available. When ASP or WAC pricing information becomesavailable, the temporary HCPCS code will be deleted and separate payment will be made under theOPPS and ASC payment systems for HCPCS Q2026, Q2027, and G0429.For hospital institutional non-OPPS claims, Medicare contractors will use current paymentmethodologies for claims for dermal injections for treatment of LDS.Hospital and ASC Billing InstructionsFor ASC claims, providers must bill covered dermal injections for treatment of LDS by having all therequired elements on the claim:• A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March23, 2010;• A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010; and• ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy).Medicare will line item deny institutional claims where the LIDOS is prior to March 23, 2010.Note to ASCs: For line item dates of service on or after March 23, 2010, and until pricing information ismade available to price OPPS claims, LDS claims shall contain the temporary HCPCS code C9800, insteadof HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.For outpatient facilities, hospitals should bill:• HCPCS code G0429 with a date of service on or after March 23, 2010; and• ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Liposystophy).Note on all hospital claims: An ICD-9-CM diagnosis code for a depression comorbidity may also berequired for coverage on an outpatient and/or inpatient basis as determined by the individual Medicarecontractor’s policy.Practitioner Billing InstructionsPractitioners must bill covered claims for dermal injections for treatment of LDS by having all therequired elements on the claim:• A date of service (LIDOS) on or after March 23, 2010;• HCPCS codes Q2026 0r Q2027;• A line with HCPCS code G0429; and• ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy).CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 27 MMR 2011-01, January 2011

Note: An ICD-9-CM diagnosis code for a depression comorbidity may also be required for coveragebased on the individual Medicare contractor’s policy.Billing for Services Prior to Medicare CoverageASCs and practitioners billing for dermal injections for treatment of LDS prior to the coverage date ofMarch 23, 2010, will receive the following messages upon their Medicare denial:• Remittance advice remark code (RARC) N386: This decision was based on a national coveragedetermination (NCD). An NCD provides a coverage determination as to whether a particular item orservice is covered. A copy of this policy is available at http://www.cms.gov/mcd/search.asp. If you donot have Web access, you may contact your local contractor to request a copy of the NCD.• Group Code: Contractual Obligation (CO)Medicare beneficiaries whose provider bills Medicare for dermal injections for treatment of LDS prior tothe coverage date of March 23, 2010, will receive the following Medicare Summary Notice (MSN)message upon the Medicare denial:• 21.11 - This service was not covered by Medicare at the time you received it.Billing for Services Not Meeting Comorbidity Coverage RequirementsHospitals and practitioners billing for dermal injections for treatment of LDS on patients that do not haveon the claim both ICD-9-CM diagnosis codes of 042 and 272.6, indicating HIV and lipodystrophy willreceive the following messages upon their Medicare claims denial:• CARC 50: These are noncovered services because this is not deemed a ‘medical necessity’ by thepayer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service PaymentInformation REF), if present.• RARC M386: This decision was based on an NCD. An NCD provides a coverage determination as towhether a particular item or service is covered. A copy of this policy is available athttp://www.cms.gov/mcd/search.asp. If you do not have Web access, you may contact your localcontractor to request a copy of the NCD.• Group Code: Contractual Obligation (CO)Medicare beneficiaries who do not meet Medicare comorbidity requirements of HIV and lipodystrophy(or even depression if deemed required by the Medicare contractor) and whose provider bills Medicarefor dermal injections for treatment of LDS will receive the following MSN message upon the Medicaredenial:• 15.4 - The information provided does not support the need for this service or item.Additional InformationThe official instruction, CR 6953, issued to your carrier, FI, and A/B MAC regarding this change via twotransmittals. The first transmittal revised the Medicare NCD Manual and it may be viewed athttp://www.cms.gov/transmittals/downloads/R122NCD.pdf on the CMS Web site. The second transmittalrevises the Medicare Claims Processing Manual and it is athttp://www.cms.gov/Transmittals/downloads/R1978CP.pdf on the CMS Web site.If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 28 MMR 2011-01, January 2011

Calendar Year 2011 Annual Update for Clinical Laboratory FeeSchedule and Laboratory Services Subject to Reasonable ChargePaymentMLN Matters® Number: MM6991 RevisedRelated Change Request (CR) #: 6991Related CR Release Date: November 24, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2106CPImplementation Date: January 3, 2011Note: This article was revised on December 1, 2010, to correct the annual update percentage shown onpage 2 for laboratory tests paid on a reasonable charge basis. All other information is the same.Provider Types AffectedClinical laboratories billing Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicareadministrative contractors (A/B MACs) are affected.Impact on ProvidersThe Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6991 which providesinstructions for the calendar year (CY) 2011 clinical laboratory fee schedule, mapping for new codes forclinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment.BackgroundIn accordance with the Social Security Act (Section 1833(h)(2)(A)(i); seehttp://www.ssa.gov/OP_Home/ssact/title18/1833.htm on the Internet), and further amended by Section3401 of the Affordable Care Act, the annual update to the local clinical laboratory fees for CY 2011 is -1.75percent. The annual update to local clinical laboratory fees for CY 2011 reflects an additional multi-factorproductivity adjustment as described by the Affordable Care Act. The annual update to payments madeon a reasonable charge basis for all other laboratory services for CY 2011 is 1.1 percent (See 42 CFR405.509(b)(1)). Section 1833(a)(1)(D) of the Social Security Act (the Act) provides that payment for aclinical laboratory test is the lesser of:• The actual charge billed for the test;• The local fee; or• The national limitation amount (NLA).For a cervical or vaginal smear test (pap smear), Section 1833(h)(7) of the Act requires payment to be thelesser of the local fee or the NLA, but not less than a national minimum payment amount (describedbelow). However, for a cervical or vaginal smear test (Pap smear), payment may also not exceed theactual charge.Note: The Part B deductible and coinsurance do not apply for services paid under the clinical laboratoryfee schedule.National Minimum Payment AmountsFor a cervical or vaginal smear test (Pap smear), the Social Security Act (Section 1833(h)(7)) requirespayment to be the lesser of the local fee or the NLA, but not less than a national minimum paymentamount. Also, payment may not exceed the actual charge. The CY 2011 national minimum paymentCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 29 MMR 2011-01, January 2011

amount is $14.87 percent ($15.13 minus the 1.75 percent update for CY 2011). The affected codes for thenational minimum payment amount are shown in the following table:88142 88143 88147 88148 88150 8815288153 88154 88164 88165 88166 8816788174 88175 G0123 G0144 G0145 G0147G0148P3000National Limitation Amounts (Maximum)For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median ofthe local fees. For tests for which the NLAs are first established on or after January 1, 2001, the NLA is 100percent of the median of the local fees in accordance with Section 1833(h)(4)(B)(viii) of the Act.Access to Data FileInternet access to the CY 2011 clinical laboratory fee schedule data file will be available after November19, 2010, at http://www.cms.gov/ClinicalLabFeeSched/ on the CMS Web site. Other interested parties,such as the Medicaid state agencies, the Indian Health Service, the United Mine Workers, and theRailroad Retirement Board, should use the Internet to retrieve the CY 2011 clinical laboratory feeschedule. It will be available in multiple formats: Excel, text, and comma delimited.Public CommentsOn July 22, 2010, CMS hosted a public meeting to solicit input on the payment relationship between CY2010 codes and new CY 2011 current procedural terminology (CPT) codes. CMS posted a summary of themeeting and the tentative payment determinations at http://www.cms.gov/ClinicalLabFeeSched/ on theCMS Web site. Additional written comments from the public were accepted until October 29, 2010 and asummary of the public comments and the rationale for the final payment determinations are posted onthe same CMS Web site.Pricing InformationThe CY 2011 clinical laboratory fee schedule includes separately payable fees for certain specimencollection methods (codes 36415, P9612, and P9615). The fees have been established in accordance withSection 1833(h)(4)(B) of the Act.The fees for clinical laboratory travel codes P9603 and P9604 are updated on an annual basis. The clinicallaboratory travel codes are billable only for traveling to perform a specimen collection for either a nursinghome or homebound patient. If there is a revision to the standard mileage rate for CY 2011, CMS willissue a separate instruction on the clinical laboratory travel fees.The CY 2011 clinical laboratory fee schedule also includes codes that have a “QW” modifier to bothidentify codes and determine payment for tests performed by a laboratory having only a certificate ofwaiver under the Clinical Laboratory Improvement Amendments (CLIA).Organ or Disease Oriented Panel CodesSimilar to prior years, the CY 2011 pricing amounts for certain organ or disease panel codes andevocative/suppression test codes were derived by summing the lower of the clinical laboratory feeschedule amount or the NLA for each individual test code included in the panel code. The NLA field onthe data file is zero-filled.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 30 MMR 2011-01, January 2011

Mapping Information• New code 82930 is priced at the same rate as code 82926.• New code 83861 is priced at the same rate as code 83909.• New code 84112 is priced at the same rate as code 82731.• New code 85598 is priced at the same rate as code 85597.• New code 86481 is priced at the same rate as code 86480.• New code 86902 is priced at the same rate as code 86905.• New code 87501 is priced at the sum of the rates of codes 87521 and 83902.• New code 87502 is priced at the sum of the rates of codes 87801 and 83902.• New code 87503 is priced at the sum of the rates of codes 83901 and 83896.• New code 87906 is priced at half of code 87901.• Healthcare Common Procedure Coding System (HCPCS) Code G0434 is priced at the same rate ascode G0430.• HCPCS Code G9143 is priced at the sum of the rates of codes 83891, 83900, 83901, 83912, three timesthe rate of code 83896, and three times the rate of code 83908. A two-character modifier indicates thatthis test’s use is limited to a Coverage with Evidence Development (CED) study.• HCPCS Code G0432 is priced at the same rate as code 86703.• HCPCS Code G0433 is priced at the same rate as code 86703.• HCPCS Code G0435 is priced at the same rate as code 87804.• Reconsidered code 84145 is priced at the same rate as code 82308.• Reconsidered code 84431 is priced at the same rate as code 84443.• Reconsidered code 86352 is priced at twice the sum of the rates of codes 86353 and 82397.• HCPCS Code G0430 is deleted beginning January 1, 2011.• HCPCS Code G0431 is priced at five times the rate of HCPCS Code G0430.• New Code 84155QW is priced at the same rate as code 84155 beginning January 1, 2010.• New Code 87809QW is priced at the same rate as code 87809 beginning January 1, 2008.For CY 2011, there are no new test codes that need to be gap-filled.Laboratory Costs Subject to Reasonable Charge Payment in CY 2011For outpatients, the following codes are paid under a reasonable charge basis (See Section 1842(b)(3) ofthe Act). In accordance with 42 CFR 405.502 through 42 CFR 405.508, (seehttp://www.access.gpo.gov/nara/cfr/waisidx_01/42cfr405_01.html on the Internet) the reasonable chargemay not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update iscalculated using the change in the applicable Consumer Price Index for the 12-month period ending June30 of each year as set forth in 42 CFR 405.509(b)(1)(seehttp://www.ssa.gov/OP_Home/ssact/title18/1842.htm on the Internet). The inflation-indexed update forCY 2011 is 1.1 percent.Manual instructions for determining the reasonable charge payment can be found in the CMS Internet-Only Manual (IOM) Publication 100-4, Medicare Claims Processing Manual, Chapter 23, Section 80 through80.8 (see http://www.cms.gov/manuals/downloads/clm104c23.pdf on the CMS Web site). If there issufficient charge data for a code, the instructions permit considering charges for other similar servicesand price lists.When these services are performed for independent dialysis facility patients, the CMS IOM Publication100-04, Medicare Claims Processing Manual, Chapter 8, Section 60.3; seehttp://www.cms.gov/manuals/downloads/clm104c08.pdf on the CMS Web site, instructs that thereasonable charge basis applies. However, when these services are performed for hospital-based renalCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 31 MMR 2011-01, January 2011

dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services areperformed for hospital outpatients, payment is made under the hospital outpatient prospective paymentsystem (OPPS).Blood ProductsP9010 P9011 P9012 P9016 P9017 P9019P9020 P9021 P9022 P9023 P9031 P9032P9033 P9034 P9035 P9036 P9037 P9038P9039 P9040 P9044 P9050 P9051 P9052P9053 P9054 P9055 P9056 P9057 P9058P9059 P9060Also, the following codes should be applied to the blood deductible as instructed in the Medicare GeneralInformation, Eligibility and Entitlement Manual (Chapter 3, Section 20.5 through 20.54; seehttp://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS website):P9010 P9016 P9021 P9022 P9038 P9039P9040 P9051 P9054 P9056 P9057 P9058NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on the SocialSecurity Act (Section 1842(o)). The payment limits based on that provision, including the payment limitsfor codes P9041, P9043, P9046, P9047, and P9048, should be obtained from the Medicare Part B drugpricing files.Transfusion Medicine86850 86860 86870 86880 86885 8688686890 86891 86900 86901 86903 8690486905 86906 86920 86921 86922 8692386927 86930 86931 86932 86945 8695086960 86965 86970 86971 86972 8697586976 86977 86978 86985Reproductive Medicine Procedures89250 89251 89253 89254 89255 8925789258 89259 89260 89261 89264 8926889272 89280 89281 89290 89291 8933589342 89343 89344 89346 89352 8935389354 89356Additional InformationIf you have questions, please contact your Medicare A/B MAC, carrier and/or FI at their toll-free numberwhich may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zipon the CMS Web site. The official instruction associated with this CR6991, issued to your Medicare A/BMAC, and/or FI regarding this change may be viewed athttp://www.cms.gov/Transmittals/downloads/R2106CP.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 32 MMR 2011-01, January 2011

Waiver of Coinsurance and Deductible for Preventive Services, Section4104 of the Affordable Care Act, Removal of Barriers to PreventiveServices in MedicareMLN Matters® Number: MM7012Related Change Request (CR) #: 7012Related CR Release Date: July 30, 2010Effective Date: January 1, 2011Related CR Transmittal #: R739OTNImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, hospitals, and other providers who submit claims to Medicare fiscalintermediaries (FI), carriers, or Medicare administrative contractors (A/B MAC) for providing preventiveservices to Medicare beneficiaries.What You Need to KnowChange Request (CR) 7012, from which this article is taken, implements the changes in Section 4104 of theAffordable Care Act. The CR announces that (effective for dates of service on or after January 1, 2011)Medicare will provide 100 percent payment (in other words, will waive any coinsurance or copayment)for the initial preventive physical examination (IPPE), the annual wellness visit (AWV), and for thosepreventive services that: 1) Are identified with a grade of A or B by the United States Preventive ServicesTask Force (USPSTF) for any indication or population; and 2) Are appropriate for the individual.BackgroundSections of the Affordable Care Act amend sections of the Social Security Act to require changes inpayment (with respect to deductible and coinsurance/copayment) for identified preventive services: Inaddition, The Affordable Care Act waives the deductible and coinsurance/copayment for the IPPE andthe AWV. The changes apply in all settings in which the services are furnished.The following preventive services are covered by Medicare:• Pneumococcal, influenza, and hepatitis B vaccine and administration;• Screening mammography;• Screening pap smear and screening pelvic examination;• Prostate cancer screening tests;• Colorectal cancer screening tests;• Diabetes outpatient self-management training (DSMT);• Bone mass measurement;• Screening for glaucoma;• Medical nutrition therapy (MNT) services;• Cardiovascular screening blood test;• Diabetes screening tests;• Ultrasound screening for Abdominal Aortic Aneurysm (AAA); and• Additional preventive services (identified for coverage through the national coverage determination[NCD] process. Currently, these are limited to Human Immunodeficiency Virus [HIV] testing).Preventive Services That Do Not Have a USPSTF Grade A or BThe Affordable Care Act waives the deductible and coinsurance/copayment for many of the preventiveservices listed above because those services have a recommendation grade of A or B by the USPSTF. InCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 33 MMR 2011-01, January 2011

other cases, the deductible and coinsurance are waived because the preventive services are clinicallaboratory tests to which the deductible and coinsurance do not apply according to another section of thestatute.Several preventive services covered by Medicare do not have a USPSTF recommendation grade of A or B.These include digital rectal examinations provided as prostate screening tests; glaucoma screening;DSMT services; and barium enemas provided as colorectal cancer screening tests. In the case of ascreening barium enema, the deductible is waived under another section of the statute. The deductiblecontinues to apply to the other services and coinsurance/copayment also continue to apply to all of them.The table in CR7012 provides a complete list of the Healthcare Common Procedure Coding System(HCPCS) codes that are defined as preventive services under Medicare and also identifies the HCPCScodes for the IPPE and the AWV. CR7012 is available athttp://www.cms.gov/Transmittals/downloads/R739OTN.pdf on Centers for Medicare & MedicaidServices (CMS) Web site.Extension of Waiver of Deductible to Services Furnished in Connection with or in Relation to aColorectal Screening Test that Becomes Diagnostic or TherapeuticThe Affordable Care Act waives the Part B deductible for colorectal cancer screening tests that becomediagnostic. The Medicare policy is that the deductible is waived for all surgical procedures (currentprocedural terminology [CPT] code range of 10000 to 69999) furnished on the same date and in the sameencounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectalcancer screening services. Modifier “PT” has been created effective January 1, 2011 and providers andpractitioners should append the modifier “PT” to a least one CPT code in the surgical range of 10000 to69999 on a claim for services furnished in this scenario.Additional InformationYou can find more information about the waiver of coinsurance and deductible for preventive services bygoing to CR7012, located at http://www.cms.gov/Transmittals/downloads/R739OTN.pdf on the CMSWeb site.If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 34 MMR 2011-01, January 2011

Ambulance Inflation Factor for CY 2011 and Productivity AdjustmentMLN Matters® Number: MM7042Related Change Request (CR) #: 7042Related CR Release Date: November 19, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2104CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for providers and suppliers of ambulance services who bill Medicare carriers, fiscalintermediaries (FIs), or Part A/B Medicare administrative contractors (A/B MACs) for those services.Provider Action NeededChange Request (CR) 7042, from which this article is taken, provides the ambulance inflation factor (AIF)for calendar year (CY) 2011. The AIF for CY 2011 is -0.1 percent. CR7042 also includes updates to theCenters for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 20.4 to incorporate a multi-factor productivityadjustment. Be sure billing staff are aware of the changes.BackgroundSection 1834(l) (3) (B) of the Social Security Act (the Act) provides the basis for updating payment limitsthat carriers, FIs, and A/B MACs use to determine how much to pay you for the claims that you submitfor ambulance services.Remember that Part B coinsurance and deductible requirements apply to these services. Specifically, thissection of the Act provides for a 2011 payment update that is equal to the percentage increase in theurban consumer price index (CPI-U), for the 12-month period ending with June of the previous year.Section 3401 of the Affordable Care Act (ACA) amended Section 1834(l)(3) of the Act to apply aproductivity adjustment to this update equal to the 10-year moving average of changes in economy-wideprivate nonfarm business multi-factor productivity beginning January 1, 2011. The resulting updatepercentage is referred to as the AIF.The following table displays the AIF for CY 2011 and for the previous eight years.Ambulance Inflation Factor by Calendar Year2011 -0.1%2010 0.0%2009 5.0%2008 2.7%2007 4.3%2006 2.5%2005 3.3%2004 2.1%2003 1.1%CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 35 MMR 2011-01, January 2011

Additional InformationThe official instruction, CR 7042, issued to your carrier, FI, and/or A/B MAC regarding this change maybe viewed at http://www.cms.gov/Transmittals/downloads/R2104CP.pdf on the CMS Web site.If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Expansion of Medicare Telehealth Services for Calendar Year 2011MLN Matters® Number: MM7049Related Change Request (CR) #: 7049Related CR Release Date: August 20, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2032CP and R131BPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, nonphysician practitioners (NPP), hospitals, and skilled nursing facilities(SNFs) submitting claims to Medicare contractors (carriers, fiscal intermediaries [FIs], and/or Part A/BMedicare administrative contractors [A/B MACs]) for telehealth services provided to Medicarebeneficiaries.Provider Action NeededThe Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 7049 to alert providersthat 14 Healthcare Common Procedure Coding System (HCPCS) codes were added to the list of Medicaretelehealth services for:• Individual and group kidney disease education (KDE) services;• Individual and group diabetes self-management training (DSMT) services;• Group medical nutrition therapy (MNT) services;• Group health and behavior assessment and intervention (HBAI) services; and• Subsequent hospital care and nursing facility care services.• Make sure your billing staffs are aware of these changes.BackgroundAs noted in the 2011 Medicare Physician Fee Schedule Final Rule published on November 29, 2010, CMSis adding14 codes to the list of Medicare distant site telehealth services for individual and group KDEservices, individual and group DSMT services, group MNT services, group HBAI services, andsubsequent hospital care and nursing facility care services. Payment for these services will be made at theapplicable physician fee schedule (PFS) payment amount for the service of the physician or practitioner.CR 7049 adds the relevant policy instructions to the CMS Internet-Only Manual (IOM) Publication 100-04,Medicare Claims Processing Manual and Publication 100-02, Medicare Benefit Policy Manual and thosechanges may be reviewed by consulting CR 7049 athttp://www.cms.gov/Transmittals/downloads/R2032CP.pdf andhttp://www.cms.gov/Transmittals/downloads/R131BP.pdf, respectively, on the CMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 36 MMR 2011-01, January 2011

Key Points of CR 7049CMS is adding the following requested services to the list of Medicare telehealth services for CY 2011:• Individual and group KDE services:o HCPCS code G0420 (Face-to-face educational services related to the care of chronic kidneydisease; individual, per session, per one hour); ando HCPCS code G0421 (Face-to-face educational services related to the care of chronic kidneydisease; group, per session, per one hour).o Individual and group DSMT services (with a minimum of 1 hour of in-person instruction to befurnished in the initial year training period to ensure effective injection training):o HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30minutes); ando HCPCS code G0109 (Diabetes outpatient self-management training services, group session (2 ormore) per 30 minutes).• Group MNT and HBAI services, current procedural terminology (CPT) codes: 97804 (Medicalnutrition therapy; group (2 or more individual(s)), each 30 minutes), 96153 (Health and behaviorintervention, each 15 minutes, face-to-face; group (2 or more patients), and 96154 (Health andbehavior intervention, each 15 minutes, face-to-face; family (with the patient present));• Subsequent hospital care services, with the limitation of one telehealth visit every 3 days; CPT codes:o 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, whichrequires at least two of these three key components: A problem focused interval history; Aproblem focused examination; Medical decision making that is straightforward or of lowcomplexity. Counseling and/or coordination of care with other providers or agencies areprovided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes atthe bedside and on the patient's hospital floor or unit),o 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, whichrequires at least two of these three key components: An expanded problem focused intervalhistory; an expanded problem focused examination; Medical decision making of moderatecomplexity. Counseling and/or coordination of care with other providers or agencies areprovided consistent with the nature of the problem(s) and the patient's and/or family's needs.Usually, the patient is responding inadequately to therapy or has developed a minorcomplication), ando 99233(Subsequent hospital care, per day, for the evaluation and management of a patient, whichrequires at least two of these three components: A detailed interval history; a detailedexamination; Medical decision making of high complexity. Counseling and/or coordination ofcare with other providers or agencies are provided consistent with the nature of the problem(s)and the patient's and/or family's needs. Usually, the patient is unstable or has developed asignificant complication or a significant new problem. Physicians typically spend 35 minutes atthe bedside and on the patient's hospital floor or unit); and• Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days,CPT codes:o 99307 (Subsequent nursing facility care, per day, for the evaluation and management of a patient,which requires at least two of these three key components: A problem focused interval history; Aproblem focused examination; Straightforward medical decision making. Counseling and/orcoordination of care with other providers or agencies are provided consistent with the nature ofthe problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering,or improving. Physicians typically spend 10 minutes at the bedside and on the patient's facilityfloor or unit),o 99308 (Subsequent nursing facility care, per day, for the evaluation and management of a patient,which requires at least two of these three key components: An expanded problem focusedCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 37 MMR 2011-01, January 2011

oointerval history; an expanded problem focused examination; Medical decision making of lowcomplexity. Counseling and/or coordination of care with other providers or agencies areprovided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.Usually, the patient is responding inadequately to therapy or has developed a minorcomplication. Physicians typically spend 15 minutes at the bedside and on the patient's facilityfloor or unit),99309 (Subsequent nursing facility care, per day, for the evaluation and management of a patient,which requires at least two of these three key components: A detailed interval history; a detailedexamination; Medical decision making of moderate complexity. Counseling and/or coordinationof care with other providers or agencies are provided consistent with the nature of the problem(s)and the patient’s and/or family’s needs. Usually, the patient has developed a significantcomplication or a significant new problem. Physicians typically spend 25 minutes at the bedsideand on the patient's facility floor or unit), and99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient,which requires at least two of these three key components: A comprehensive interval history; acomprehensive examination; Medical decision making of high complexity. Counseling and/orcoordination of care with other providers or agencies are provided consistent with the nature ofthe problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may havedeveloped a significant new problem requiring immediate physician attention. Physicianstypically spend 35 minutes at the bedside and on the patient's facility floor or unit.Note: The frequency limitations on subsequent hospital care and subsequent nursing facility caredelivered through telehealth do not apply to inpatient telehealth consultations. Consulting practitionersshould continue to use the inpatient telehealth consultation HCPCS codes (G0406, G0407, G0408, G0425,G0426, or G0427) when reporting consultations furnished via telehealth.Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities viatelehealth at the request of the physician of record, the attending physician, or another appropriatesource. The physician or practitioner who furnishes the initial inpatient consultation via telehealth cannotbe the physician or practitioner of record or the attending physician or practitioner, and the initialinpatient telehealth consultation would be distinct from the care provided by the physician orpractitioner of record or the attending physician or practitioner.• For dates of service (DOS) on or after January 1, 2011, Medicare contractors will accept and pay theadded codes according to the appropriate physician or practitioner fee schedule amount whensubmitted with a GQ or GT modifier.• For dates of service on or after January 1, 2011, Medicare contractors will accept and pay the addedcodes according to the appropriate physician or practitioner fee schedule amount when submittedwith a GQ or GT modifier by critical access hospitals (CAHs) that have elected Method II on TOB85X.Additional InformationIf you have questions, please contact your Medicare A/B MAC, carrier and/or FI at their toll-free numberwhich may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zipon the CMS Web site.News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 38 MMR 2011-01, January 2011

Medicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Fractional Mileage Amounts Submitted on Ambulance ClaimsMLN Matters® Number: MM7065Related Change Request (CR) #: 7065Related CR Release Date: November 19, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2103CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for providers and suppliers of ambulance services who bill Medicare contractors (carriers,fiscal intermediaries [FIs], or Part A/B Medicare administrative contractors [A/B MACs]) for thoseservices.What You Need to KnowChange Request (CR) 7065, from which this article is taken, provides a new procedure for reportingfractional mileage amounts on ambulance claims, effective for claims for dates of service on or afterJanuary 1, 2011. Prior to that date, mileage is reported by rounding the total mileage up to the nearestwhole mile. Be sure billing personnel are aware of this change that requires ambulance providers andsuppliers to report to the nearest tenth of a mile for total mileage of less than 100 miles on ambulanceclaims as of January 1, 2011.BackgroundCurrently, the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication100-04, Medicare Claims Processing Manual, Chapter 15, Sections 30.1.2 and 30.2.1 require that ambulanceproviders and suppliers submitting claims to Medicare contractors use the appropriate HealthcareCommon Procedure Coding System (HCPCS) code for ambulance mileage to report the number of milestraveled during a Medicare-reimbursable trip for the purpose of determining payment for mileage.According to these instructions from CMS, providers and suppliers are required to round the totalmileage up to the nearest whole mile, including trips of less than one whole mile. For example, if the totalnumber of round trip miles traveled equals 9.5 miles, the provider or supplier enters 10 units on the claimform or the corresponding loop and segment of the ANSI X12N 837 electronic claim. For ambulancesuppliers submitting claims to the Medicare carriers or A/B MACs, the CMS IOM Publication 100-04,Medicare Claims Processing Manual, Chapter 26, Section10.4 additionally states that at least one (1) unitCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 39 MMR 2011-01, January 2011

must be billed in Item 24G on the CMS-1500 claim form or the corresponding loop and segment of theANSI X12N 837P electronic claim. Therefore, if a supplier travels less than one mile during a covered trip,the supplier would enter 1 unit on the claim form with the appropriate HCPCS code for mileage.In the calendar year (CY) 2011 Medicare Physician Fee Schedule (MPFS) final rule, CMS established anew procedure for reporting fractional mileage amounts on ambulance claims to improve reporting andpayment accuracy. The final rule requires that, effective January 1, 2011, all Medicare ambulanceproviders and suppliers bill mileage that is accurate to a tenth of a mile.Note: Currently the hardcopy UB-04 form cannot accommodate fractional billing, therefore, hardcopybillers will continue to use previous ambulance billing instructions provided in effect prior to January 1,2011, that is, providers that are permitted to file paper UB-04 claims will continue to round up to thenearest whole mile until further notice from CMS.Effective for claims with dates of service on and after January 1, 2011, ambulance providers and suppliersmust report mileage units rounded up to the nearest tenth of a mile for all claims (except hard copybillers that use the UB-04) for mileage totaling less than 100 covered miles. Providers and suppliers mustsubmit fractional mileage using a decimal in the appropriate place (e.g., 99.9). Medicare contractors willtruncate mileage units with fractional amounts reported to greater than one decimal place (e.g., 99.99 willbecome 99.9 after truncating the hundredths place).For trips totaling 100 miles and greater, suppliers must continue to report mileage rounded up to thenearest whole number mile (e.g., 999). Medicare contractors will truncate mileage units totaling 100 andgreater that are reported with fractional mileage; (e.g., 100.99 will become 100 after truncating the decimalplaces).For mileage totaling less than 1 mile, providers and suppliers must include a “0” prior to the decimalpoint (e.g., 0.9). For ambulance mileage HCPCS only, Medicare contractors will automatically default“0.1” unit when the total mileage units are missing in Item 24G of the CMS-1500 claim form.Additional InformationThe official instruction, CR 7065, issued to your Medicare contractor regarding this change may beviewed at http://www.cms.gov/Transmittals/downloads/R2103CP.pdf on the CMS Web site.If you have any questions, please contact your Medicare contractor at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.News Flash – Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 40 MMR 2011-01, January 2011

staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Instructions for PLB Code Reporting on Remittance Advice and RACRecoupment Reporting on Remittance Advice for Durable MedicalEquipment, Prosthetics, Orthotics, and Supplies ClaimsMLN Matters® Number: MM7068Related Change Request (CR) #:7068Related CR Release Date: November 12, 2010Effective Date: April 1, 2011Related CR Transmittal #: R812OTNImplementation Date: April 4, 2011; July 5, 2011 for Institutional providers and DME SuppliersProvider Types AffectedAll physicians, providers and suppliers submitting claims to Medicare contractors (fiscal intermediaries[FIs], regional home health intermediaries [RHHIs], carriers, A/B Medicare administrative contractors[MACs] and durable medical equipment MACs [DME MACs]) for Medicare beneficiaries are affected...Provider Action NeededChange Request (CR) 7068 provides instructions to Medicare carriers, MACs, FIs, and RHHIs about usingand reporting provider adjustment codes (PLB codes) on the remittance advice (RA). It also includesinstruction for DME MACs for reporting recovery audit contractor (RAC) recoupment when there is atime difference between the creation of the accounts receivable and actual recoupment of money.The attachment in CR 7068 provides a list of PLB codes to be reported on the 835 as well as the paperremittance advice and a crosswalk between the Healthcare Integrated General Ledger Accounting System(HIGLAS) PLB codes and the ASC X12 Transaction 835 PLB codes to ensure that PLB code reporting onthe RA is consistent and uniform across the board.BackgroundIn the Tax Relief and Health Care Act of 2006, Congress required a permanent and national RAC programto be in place by January 1, 2010. The goal of the recovery audit program is to identify improperpayments made on claims of health care services provided to Medicare beneficiaries. The RACs reviewclaims on a post-payment basis, and can go back three years from the date the claim was paid. Tominimize provider burden, the maximum look back date is October 1, 2007.Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)(Publication. L.108-173) which amended Title XVIII of the Social Security Act (the Act) has added a newparagraph (f) to §1893 of the Act, the Medicare Integrity Program. The statute requires Medicare tochange how certain overpayments are recouped. These new changes to recoupment and interest are tiedto the Medicare fee-for-service claims appeal process and structure.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 41 MMR 2011-01, January 2011

Recoupment under the provisions of Section 935 of the MMA can begin no earlier than the 41st day (seeCR6183 – Transmittal 141, issued September 12, 2008), and can happen only when a valid request for aredetermination has not been received within that period of time.Under the scenario just described, the RA has to report the actual recoupment in two steps:• Step I: Reversal and Correction to report the new payment and negate the original payment (actualrecoupment of money does not happen here)• Step II: Report the actual recoupment.In a previous CR (Transmittal 659, CR6870), Medicare carriers, FIs and A/B MACs were instructed toprovide enough detail in the RA to enable providers to track and update their records to reconcileMedicare payments. The Front Matter 1.10.2.17 – Claim Overpayment Recovery – in ASCX12N/005010X221 provides a step-by-step process, regarding how to report in the RA when funds are notrecouped immediately, and a manual reporting (demand letter) is also done. CR7068 instructs DMEMACs how to report on the RA when an overpayment is identified and also when Medicare actuallyrecoups the overpayment in a future RA.RAC Recoupment Reporting – DME Claims OnlyStep I:Claim LevelThe original claim payment is taken back and the new payment is established (Reversal and Correction).Provider Level• PLB03-1 – PLB reason code FB (Forward Balance)• PLB 03-2 shows the detail:• PLB-03-2• 1-2: 00• 3-19: Adjustment CCN#• 20-30: HIC#• PLB04 shows the adjustment amount to offset the net adjustment amount shown at the service level.If the service level net adjustment amount is positive, the PLB amount would be negative and viceversa.Step II:Claim LevelNo additional information at this stepProvider Level• PLB03-1 – PLB reason code WO (Overpayment Recovery)• PLB 03-2 shows the detail:• PLB-03-2• 1-2: 00• 3-19: Adjustment CCN#• 20-30: HIC#• PLB04 shows the actual amount being recoupedA demand letter is also sent to the provider when the accounts receivable (A/R) is created – Step I. Thisdocument contains a control number for tracking purpose that is also reported on the RA.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 42 MMR 2011-01, January 2011

CMS has decided to follow the same reporting protocol for all other recoupments in addition to the 935RAC recoupment mentioned above.Note: CR 7068 instructions, regarding recoupment, apply to both 004010A1 and 005010 versions of ASCX12 Transaction 835 and Standard Paper Remittance (SPR). In some very special cases the HIC # mayhave to be truncated to be compliant with the 004010A1 Implementation Guide.PLB Code ReportingThe RA reports payments and adjustments to payments at 3 levels: a) service, b) claim, and c) provider.The adjustments at the service and the claim level are reported using 3 sets of codes:• Group codes,• Claim adjustment reason codes (CARCs), and• Remittance advice remark codes (RARCs).Provider level adjustments are reported using the PLB codes. The PLB code list is an internal code listthat can be changed only when there is a change in the version.In Version 004010A1, the following PLB codes are available for use: 50, 51, 72, 90, AM, AP, B2, B3, BD,BN, C5, CR, CS, CT, CV, CW, DM, E3, FB, FC, GO, IP, IR, IS, J1, L3, L6, LE, LS, OA, OB, PI, PL, RA, RE,SL, TL, WO, WU, AND ZZ. In version 005010, two new codes – AH and HM – have been added, andcode ZZ has been deleted. The other change in Version 005010 is the way situational field PLB03-2 forreference identification is used.Field Version 00401A1 Version 005010PLB03-1AH – additional codeHM – additional codeZZ – deleted codePLB03-2 Max: 30Position 1-2: Medicare intermediariesmust enter the applicable MedicarecodePosition 3-19: Financial controlnumber or the provider leveladjustment.number or other pertinentidentifierPosition 20-30: Health InsuranceClaim (HIC) NumberMax: 50Required when a control, account ortracking number applies to thisadjustment as reported in field PLB03-1No Medicare specific codes.HIGLAS uses additional PLB codes from the X12 Standard that are not in the Implementation Guide (IG)or Technical Report (TR) 3. Medicare must use only those codes that are included in the IG/TR3 to reporton the 835.HIGLAS PLB Codes and ASC X12 CrosswalkCurrently CMS is transitioning to HIGLAS, and some contractors are still not under HIGLAS. CR 7068applies to both HIGLAS and Non-HIGLAS contractors with the goal of uniform and consistent reportingon the 835 across the board. Secondly, CMS is also in the process of implementing version005010/005010A1. Attachment – 835 PLB Code Mapping is applicable to Version 004010A1 as well as005010A1.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 43 MMR 2011-01, January 2011

The PLB codes to report on the 835 and HIGLAS and HIPAA PLB Crosswalk may be found in theattachment in CR 7068Additional InformationFor complete details regarding this Change Request (CR) please see the official instruction (Transmittal812/CR 7068) issued to your Medicare contractor athttp://www.cms.gov/transmittals/downloads/R812OTN.pdf on the CMS Web site.You may also want to review the following MLN Matters articles:• Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments athttp://www.cms.gov/MLNMattersArticles/downloads/MM6183.pdf and• Reporting of Recoupment for Overpayment on the Remittance Advice (RA) athttp://www.cms.gov/MLNMattersArticles/downloads/MM6870.pdf on the CMS Web site.If you have questions, please contact your Medicare contractor at their toll-free number which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. Note HIGLAS stands for Healthcare Integrated General Ledger Accounting System (HIGLAS), which is CMS accounting systemAnnual Wellness Visit, Including Personalized Prevention Plan ServicesMLN Matters® Number: MM7079 RevisedRelated Change Request (CR) #: 7079Related CR Release Date: December 3, 2010Effective Date: January 1, 2011Related CR Transmittal #: R134BP and R2109CPImplementation Date: April 4, 2011Note: This article was revised on December 16, 2010, to make corrections to the method of payments toinstitutional providers shown on page 5. All other information is the same.Provider Types AffectedThis article is for physicians, nonphysician practitioners, and providers submitting claims to Medicarecontractors (carriers, Medicare administrative contractors [MACs], and/or fiscal intermediaries [FIs]) forservices provided to Medicare beneficiaries.Provider Action NeededThe Affordable Care Act provides for an annual wellness visit (AWV), including personalized preventionplan services (PPPS) for Medicare beneficiaries as of January 1, 2011. CR 7079 provides the requirementsfor the AWV, which are summarized in this article. Make sure billing staff are aware of these services andhow to bill for them.BackgroundPursuant to section 4103 of the Affordable Care Act of 2010 , the Centers for Medicare & MedicaidServices (CMS) amended sections 411.15(a)(1) and 411.15 (k)(15) of 42 CFR (list of examples of routinephysical examinations excluded from coverage) effective for services furnished on or after January 1,CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 44 MMR 2011-01, January 2011

2011. This amendment’s expanded coverage is subject to certain eligibility and other limitations thatallow payment for an AWV, including PPPS, for an individual who is no longer within 12 months afterthe effective date of his or her first Medicare Part B coverage period and has not received either an initialpreventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance andPart B deductibles do not apply to the AWV. The AWV will include the establishment of, or update to,the individual’s medical and family history, measurement of his or her height, weight, body-mass index(BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and diseasedetection and fostering the coordination of the screening and preventive services that may already becovered and paid for under Medicare Part B.Who is Eligible to Provide the AWV with PPPS?• A physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the SocialSecurity Act (the Act); or,• A physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5)of the Act); or,• A medical professional (including a health educator, registered dietitian, or nutrition professional orother licensed practitioner) or a team of such medical professionals, working under the directsupervision (as defined in CFR 410.32(b)(3)(ii)) of a physician as defined in the first bullet point of thissection.What is Included in an Initial AWV with PPPS?The initial AWV providing PPPS provides for the following services to an eligible beneficiary by a healthprofessional:• Establishment of an individual’s medical/family history.• Establishment of a list of current providers and suppliers that are regularly involved in providingmedical care to the individual.• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, andother routine measurements as deemed appropriate, based on the beneficiary’s medical/familyhistory.• Detection of any cognitive impairment that the individual may have as defined in this section.• Review of the individual’s potential (risk factors) for depression, including current or pastexperiences with depression or other mood disorders, based on the use of an appropriate screeninginstrument for persons without a current diagnosis of depression, which the health professional mayselect from various available standardized screening tests designed for this purpose and recognizedby national medical professional organizations.• Review of the individual’s functional ability and level of safety based on direct observation, or theuse of appropriate screening questions or a screening questionnaire, which the health professionalmay select from various available screening questions or standardized questionnaires designed forthis purpose and recognized by national professional medical organizations.• Establishment of a written screening schedule for the individual, such as a checklist for the next fiveto 10 years, as appropriate, based on recommendations of the United States Preventive Services TaskForce (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as theindividual’s health status, screening history, and age-appropriate preventive services covered byMedicare.• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiaryinterventions are recommended or are underway for the individual, including any mental healthconditions or any such risk factors or conditions that have been identified through an IPPE, and a listof treatment options and their associated risks and benefits.• Furnishing of personalized health advice to the individual and a referral, as appropriate, to healtheducation or preventive counseling services or programs aimed at reducing identified risk factorsCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 45 MMR 2011-01, January 2011

and improving self-management, or community-based lifestyle interventions to reduce health risksand promote self-management and wellness, including weight loss, physical activity, smokingcessation, fall prevention, and nutrition.• Voluntary advance care planning (as defined in this section) upon agreement with the individual.• Any other element(s) determined appropriate by the Secretary of Health and Human Servicesthrough the national coverage determination (NCD) process.What would be Included in a Subsequent AWV/PPPS?In subsequent AWVs, the following services would be provided to an eligible beneficiary by a healthprofessional:• An update of the individual’s medical/family history.• An update of the list of current providers and suppliers that are regularly involved in providingmedical care to the individual, as that list was developed for the first AWV providing PPPS.• Measurement of an individual’s weight (or waist circumference), BP, and other routinemeasurements as deemed appropriate, based on the individual’s medical/family history.• Detection of any cognitive impairment that the individual may have as defined in this section.• An update to the written screening schedule for the individual as that schedule is defined in thissection, that was developed at the first AWV providing PPPS.• An update to the list of risk factors and conditions for which primary, secondary, or tertiaryinterventions are recommended or are under way for the individual, as that list was developed at thefirst AWV providing PPPS.• Furnishing of personalized health advice to the individual and a referral, as appropriate, to healtheducation or preventive counseling services or programs.• Voluntary advance care planning (as defined in this section) upon agreement with the individual.• Any other element(s) determined by the Secretary through the NCD process.Note: Voluntary Advanced Care Planning refers to verbal or written information regarding anindividual’s ability to prepare an advance directive in the case where an injury or illness causes theindividual to be unable to make health care decisions and whether or not the physician is willing tofollow the individual’s wishes as expressed in an advance directive.Billing RequirementsTwo new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan ofservice (PPPS), first visit, (Short descriptor – Annual wellness first) and G0439 - Annual wellness visit,includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annualwellness subseq) will be implemented January 1, 2011, through the Medicare Physician Fee ScheduleDatabase (MPFSDB) and Integrated Outpatient Code Editor (IOCE).Effective for services on or after January 1, 2011, Medicare contractors will pay claims containing thesecodes provided the requirements for coverage and eligibility are met. Institutional providers need tosubmit these claims via Types of Bill (TOB) 12X, 13X, 22X, 23X, 71X, 77X, or 85X. Institutional providerswill be paid as follows:• For services performed on a 12X TOB and 13X TOB, hospital inpatient Part B and hospital outpatient,payment shall be made under the MPFS.• For TOBs 22X and 23X, skilled nursing facilities will be paid based on the MPFS.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 46 MMR 2011-01, January 2011

• Rural Health Clinics (TOB 71X) and Federally Qualified Health Centers (TOB 77X) will be paid basedon the all-inclusive rate.• For services performed on an 85X TOB, Critical Access Hospital (CAH), pay based on reasonable cost.• CAHs claims (submitted on TOB 85X with revenue codes 096X, 097X, and 098X) will be paid basedon MPFS.• For inpatient or outpatient services in hospitals in Maryland, make payment according to the HealthServices Cost Review Commission.Other Billing RequirementsRemember that G0438 is for the first AWV only. Thus, submission of G0438 for a beneficiary for whom aclaim with code G0438 has already been paid will result in a denial of the later G0438 with a claimadjustment reason code (CARC) of 149 (Lifetime benefit maximum has been reached for theservice/benefit category.) and a remittance advice remarks code (RARC) of N117 (This service is paid onlyonce in a patient’s lifetime.).Remember also that the G0438 or G0439 must not be billed within 12 months of a previous billing of aG0402 (IPPE), G0438, or G0429 for the same beneficiary. Such subsequent claims will be denied with aCARC of 119 (Benefit maximum for this time period or occurrence has been reached) and a RARC ofN130 (Consult plan benefit documents/guidelines for information about restrictions for this service).If a claim for a G0438 or G0439 is submitted within the first 12 months after the effective date of thebeneficiary’s first Medicare Part B coverage, it will also be denied as that beneficiary is eligible for theIPPE or “Welcome to Medicare” physical. Such claims with G0438 or G0439 will be denied with a CARCof 26 (Expenses incurred prior to coverage) and a RARC of N130.Additional InformationThe official instruction, CR 7079, was issued to your carrier, FI, or A/B MAC via two transmittals. Thefirst modified the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims ProcessingManual and it is available at http://www.cms.gov/Transmittals/downloads/R2109CP.pdf on the CMS Website. The second transmittal updates the CMS IOM Publication 100-02, Medicare Benefit Policy Manual,which is at http://www.cms.gov/Transmittals/downloads/R134BP.pdf on the CMS Web site. See these twotransmittals for more complete details regarding this benefit.If you have questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 47 MMR 2011-01, January 2011

National Modifier and Condition Code to Identify Items or ServicesRelated to the 2010 Oil Spill in the Gulf of MexicoMLN Matters® Number: MM7087Related Change Request (CR) #: 7087Related CR Release Date: August 6, 2010Effective Date: April 20, 2010Related CR Transmittal #: R2021CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers,fiscal intermediaries [FIs], and/or Part A/B Medicare administrative contractors [MACs]) for servicesprovided to Medicare beneficiaries related, in whole or in part, to the 2010 oil spill in the Gulf of Mexico.Provider Action NeededThis article is based on Change Request (CR) 7087 which identifies a new modifier and a new conditioncode that must be used to identify items or services related to the 2010 oil spill in the Gulf of Mexico. Besure your billing staff is aware of these changes. You should begin to place the modifier or condition codeon claims submitted as of January 3, 2011.BackgroundAs a result of the oil spill in the Gulf of Mexico, the Centers for Medicare & Medicaid Services (CMS)plans to monitor the potential health and cost impacts of the oil spill on Medicare beneficiaries, in boththe short- and long-term. In order to ensure that such health care services and costs are properlyidentified, CMS is requiring that every Medicare fee-for-service (FFS) claim be specifically identified if itis for an item or service furnished to a Medicare beneficiary, where the provision of such item or serviceis related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by theeffects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico (hereafter referred to as the “Gulf oilspill”) and/or circumstances related to such oil spill, including but not limited to subsequent clean-upactivities.Claims from physicians, other practitioners, and suppliers must be annotated with the modifier “CS” foreach line item where the item or service is so related. Similarly, claims from institutional billers must beannotated with a condition code of “BP” when the entire claim is so related or with the “CS” modifier foreach relevant line item when only certain line items are so related. The modifier and condition code are tobe used for claims with dates of service on or after April 20, 2010.The long description of the CS modifier is as follows: “Item or service related, in whole or in part, to anillness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.”The short description of the CS modifier is: “Gulf Oil Spill Related”.The title of the BP condition code is “Gulf oil spill related” and its definition is as follows: “This codeidentifies claims where the provision of all services on the claim are related, in whole or in part, to anillness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010oil spill in the Gulf of Mexico and/or circumstances related to such spill, including but not limited tosubsequent clean-up activities.”CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 48 MMR 2011-01, January 2011

Note: CMS requests provider, physician and supplier assistance in identifying previously processedclaims related to an illness, injury or condition caused or exacerbated either directly or indirectly by the2010 Gulf oil spill. CMS encourages providers, physicians and suppliers to contact their Medicarecontractor to identify services or claims – submitted and processed prior to the creation of the Gulf oilspill modifier and condition code – that should have the CS modifier and/or the BP condition codeappended.Additional InformationIf you have questions, please contact your Medicare MAC or FI at their toll-free number which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.The official instruction (CR7087) issued to your Medicare MAC, carrier and/or FI is available athttp://www.cms.gov/Transmittals/downloads/R2021CP.pdf on the CMS Web site.News Flash – Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90% of these deaths occur in people 65 years of age and older. Pleasetalk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Influenza Vaccine Payment Allowances - Annual Update for 2010-2011SeasonMLN Matters® Number: MM7120 RevisedRelated Change Request (CR) #: 7120Related CR Release Date: October 22, 2010Effective Date: September 1, 2010Related CR Transmittal #: R2071CPImplementation Date: November 24, 2010Note: This article was revised on November 26, 2010, to reflect a correction to the payment rate for CPT90655, as announced in CR 7234, issued on November 19, 2010. The corrected payment rate for 90655, asof September 1, 2010, is $14.858. All other information is the same.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 49 MMR 2011-01, January 2011

Provider Types AffectedThis article is for physicians and providers submitting claims to Medicare contractors (carriers, fiscalintermediaries [FIs], and/or Part A/B Medicare administrative contractors [A/B MACs]) for influenzavaccines provided to Medicare beneficiaries.What You Need to KnowThe Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 7120 in order toupdate payment allowances, effective September 1, 2010, for influenza vaccines when payment is basedon 95 percent of the Average Wholesale Price (AWP). CR 7120 refers only to the seasonal influenzavaccines. According to CR 6617, only the Level II Healthcare Common Procedure Coding System(HCPCS) code G9142 is used to identify the H1N1 vaccine on Medicare claims. Therefore, commonprocedure terminology (CPT) codes 90663, 90664, 90666, 90666, 90667, and 90668 will not be recognizedon Medicare claims for the H1N1 vaccine.The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent ofthe AWP as reflected in the published compendia except where the vaccine is furnished in a hospitaloutpatient department, rural health clinic (RHC), or federally qualified health center (FQHC). Where thevaccine is furnished in the hospital outpatient department, RHC, or FQHC, payment for the vaccine isbased on reasonable cost.CR 7120 provides the payment allowances for the following seasonal influenza virus vaccines: CPT codes90655, 90656, 90657, 90658, 90660, and 90662 when payment is based on 95 percent of the AWP. Thepayment allowances for influenza vaccines are updated on an annual basis effective September 1 of eachyear.The Medicare Part B payment allowance in these situations for:• CPT 90655 is $14.858;• CPT 90656 is $12.375;• CPT 90657 is $6.297; and• CPT 90658 (for dates of service September 1, 2010 through December 31, 2010) is $11.368.CPT 90660 (FluMist, a nasal influenza vaccine) or CPT 90662 (Fluzone High-Dose) may be covered if yourMedicare claims processing contractor determines the use is medically reasonable and necessary for thebeneficiary. When payment is based on 95 percent of the AWP, the Medicare Part B payment allowanceeffective September 1, 2010, for CPT 90660 is $22.316, and for CPT 90662 is $29.213.Annual Part B deductible and coinsurance amounts do not apply. All physicians, nonphysicianpractitioners and suppliers who administer the influenza virus vaccination and the pneumococcalvaccination must take assignment on the claim for the vaccine. The current payment allowances forpneumococcal vaccines can be found on the quarterly drug pricing files.Additional InformationNote that Medicare contractors will not search their files to adjust claims already processed prior toimplementation of CR7120. However they will adjust those claims that you bring to their attention.The official instruction, CR7120 issued to your carrier, FI, or A/B MAC regarding this change may beviewed at http://www.cms.gov/Transmittals/downloads/R2071CP.pdf on the CMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 50 MMR 2011-01, January 2011

If you have any questions, please contact your carrier, FI or A/B MAC at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Billing Clarification for Positron Emission Tomography (NaF-18) forIdentifying Bone Metastasis of Cancer in the Context of a Clinical TrialMLN Matters® Number: MM7125Related Change Request (CR) #: 7125Related CR Release Date: November 19, 2010Effective Date: February 26, 2010Related CR Transmittal #: R2096CPImplementation Date: February 22, 2011Provider Types AffectedThis article is for physicians, providers and suppliers who bill Medicare carriers, fiscal intermediaries(FIs), or Part A/B Medicare administrative contractors (A/B MACs) for providing NaF-18 PET scans toidentify bone metastasis of cancer for Medicare beneficiaries.Provider Action NeededThis article is based on Change Request (CR) 7125, which is being issued to clarify a requirement in CR6861 regarding how these claims should be billed. Specifically, CR 7125 amends instructions for claimssubmitted for the professional component (PC), technical (TC) or global components. This article explainsthe specific claims handling instructions for claims submitted for each of these components. Please ensurethat your billing staffs are aware of this clarification.BackgroundThis article explains that CR 7125 clarifies the requirement originally discussed in MLN Matters articleMM6861, which may be viewed at http://www.cms.gov/MLNMattersArticles/downloads/MM6861.pdf onthe Centers for Medicare & Medicaid Services (CMS) Web site. That requirement is being amended tostate that only claims for the TC or global service require the radioactive tracer, Healthcare CommonProcedure Coding System (HCPCS) A9580. Claims for the PC do not require HCPCS A9580, but mustcontain the appropriate –PI or –PS modifier, positron emission tomography (PET)/CT HCPCS procedurecode, diagnosis code, and the Q0 modifier.CR 7125 also corrects the list of applicable PET or PET with CT CPT codes that can be used for bonemetastasis on the claim and to remove HCPCS 78608 and t8459 as they cannot be paid for bone metastasiswith NaF-18. Finally, modifier KX (Requirements specified in the medical policy have been met) will beaccepted for PC claims (modifier 26) for PET for bone metastasis (PET NaF-18) to differentiate theseclaims from PET for FDG in the context of a clinical trial. This modifier is not required on claimssubmitted to FIs, nor is it required on claims for the technical or global service.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 51 MMR 2011-01, January 2011

Key Points in CR 71251. Effective for claims with dates of service on or after February 26, 2010, positron emission tomography(NaF-18 PET) oncologic claims billed with modifier TC or globally to inform the initial treatmentstrategy or subsequent treatment strategy for bone metastasis that must include all of the following:• PI or –PS modifier and• PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816) AND• ICD-9 cancer diagnosis code and• Q0 modifier – Investigational clinical service provided in a clinical research study, are present onthe claim.2. Effective for claims with dates of service on or after February 26, 2010, PET oncologic claims billedwith modifier 26 and modifier KX to inform the initial treatment strategy or strategy or subsequenttreatment strategy for bone metastasis must include all of the following:• PI or –PS modifier and• PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816) AND• ICD-9 cancer diagnosis code and• Q0 modifier – Investigational clinical service provided in a clinical research study, are present onthe claim.3. Claims failing the requirements stated above will be returned as unprocessable with the followingmessages:• Claim adjustment reason code (CARC) 4 (The procedure code is inconsistent with the modifierused or a required modifier is missing.);• Remittance advice remark code (RARC) MA-130 (Your claim contains incomplete and/or invalidinformation, and no appeal rights are afforded because the claim is unprocessable. Submit a newclaim with the complete/correct information.);• RARC M16 (Alert: See our Web site, mailings, or bulletins for more details concerning thispolicy/procedure/decision.); and/or• CARC 167 (This (these) diagnosis(es) is (are) not covered.)4. Claims billed with modifiers 26 and KX to inform the initial treatment strategy or subsequenttreatment strategy for bone metastasis billed with HCPCS A9580 will be returned as unprocessableusing CARC 97 (The benefit for this service is included in the payment/allowance for anotherservice/procedure that has already been adjudicated.).Additional InformationThe official instruction, CR 7125, issued to your carrier, FI, or A/B MAC regarding this change, may beviewed at http://www.cms.gov/Transmittals/downloads/R2096CP.pdf on the CMS Web site.If you have any questions, please contact your Medicare contractor at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 52 MMR 2011-01, January 2011

Quarterly Update to Correct Coding Initiative Edits, Version 17.0,effective January 1, 2011MLN Matters® Number: MM7210Related Change Request (CR) #: 7210Related CR Release Date: November 19, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2097CPImplementation Date: January 3, 2011Provider Types AffectedPhysicians and providers submitting claims to Medicare carriers and/or Part A/B Medicareadministrative contractors (A/B MACs) for services provided to Medicare beneficiaries are impacted bythis issue.Provider Action NeededThis article is based on Change Request (CR) 7210, which provides a reminder for physicians to take noteof the quarterly updates to Correct Coding Initiative (CCI) edits. The last quarterly release of the editmodule was issued in October 2010.BackgroundThe Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative(CCI) to promote national correct coding methodologies and to control improper coding that leads toinappropriate payment in Part B claims.The coding policies developed are based on coding conventions defined in the:• American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Manual,• National and local policies and edits,• Coding guidelines developed by national societies,• Analysis of standard medical and surgical practice, and by• Review of current coding practice.The latest package of CCI edits, Version 17.0, is effective January 1, 2011, and includes all previousversions and updates from January 1, 1996, to the present. It will be organized in the following two tables:• Column 1/ Column 2 Correct Coding Edits, and• Mutually Exclusive Code (MEC) Edits.Additional information about CCI, including the current CCI and MEC edits, is available athttp://www.cms.gov/NationalCorrectCodInitEd on the CMS Web site.Additional InformationThe CCI and MEC file formats are defined in the CMS Internet-Only Manual (IOM) Publication 100-04,Medicare Claims Processing Manual, Chapter 23, Section 20.9, which is available athttp://www.cms.gov/manuals/downloads/clm104c23.pdf on the CMS Web site. The official instruction(CR 7081) issued to your carrier or A/B MAC regarding this change is athttp://www.cms.gov/Transmittals/downloads/R2097CP.pdf on the CMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 53 MMR 2011-01, January 2011

If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSweb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Ventricular Assist Devices as Destination TherapyMLN Matters® Number: MM7220 RevisedRelated Change Request (CR) #: 7220Related CR Release Date: December 8, 2010Effective Date: November 9, 2010Related CR Transmittal #: R129NCDImplementation Date: January 6, 2011Note: This article was revised on December 9, 2010 to reflect the revised CR 7220 released on December 8,2010. The CR release date, transmittal number, and the Web address for accessing CR were revised. Allother information is the same.Provider Types AffectedThis article is for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers,fiscal intermediaries [FIs], and/or A/B Medicare administrative contractors [A/B MACs]) for ventricularassist device (VAD) implantation services provided to Medicare beneficiaries.What You Need to KnowEffective for claims with dates of service on or after November 19, 2010, the Centers for Medicare &Medicaid Services (CMS) has expanded coverage for VAD implantation as destination therapy asreasonable and necessary when the device has received Food and Drug Administration (FDA) approvalfor a destination therapy indication and only for patients with New York Heart Association (NYHA)Class IV end-stage ventricular heart failure who are not candidates for a heart transplant and who meetall specific conditions as outlined in the revised CMS Internet-Only (IOM) Publication 100-03, MedicareNational Coverage Determinations (NCD) Manual, Chapter 1, Section 20.9.BackgroundA VAD or left ventricular assist device (LVAD) is surgically attached to one or both intact ventricles andis used to assist a damaged or weakened native heart in pumping blood. Medicare currently covers thesedevices for three general indications:1. Postcardiotomy,2. Bridge to transplantation, and3. Destination therapy.Destination therapy is for patients who are not candidates for heart transplantation and requirepermanent mechanical cardiac support. Coverage for destination therapy is currently restricted based onpatient selection criteria including:• New York Heart Association (NYHA) class,• Time on optimal medical management,• Left ventricular ejection fraction, andCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 54 MMR 2011-01, January 2011

• Peak oxygen consumption.Note: VADs implanted for destination therapy are only covered when performed in a hospital that isMedicare-approved to provide this procedure.CR 7220 instructs that, effective for claims with dates of service on and after November 9, 2010, CMS hasdetermined that the evidence is adequate to conclude that VAD implantation as destination therapyimproves health outcomes and is reasonable and necessary when:• The device has received FDA approval for a destination therapy indication, and only for patientswith New York Heart Association (NYHA) Class IV end-stage ventricular heart failure who are notcandidates for heart transplant, and• Who meet all of the following conditions:o Have failed to respond to optimal medical management (including beta-blockers, andAntiotensin-Converting Enzyme (ACE) inhibitors if tolerated) for at least 45 of the last 60 days, orhave been balloon pump-dependent for 7 days, or IV inotrope-dependent for 14 days;o Have a left ventricular ejection fraction (LVEF) < 25%; and,o Have demonstrated functional limitation with a peak oxygen consumption of ≤14 ml/kg/minunless balloon pump ot inotrope dependent or physicially unable to perform the test.Note: There are no changes to existing claims processing requirements/editing for VADs as destinationtherapy.Additional InformationThe official instruction, CR 7220, issued to your carriers, FIs, and A/B MACs regarding this change maybe viewed at http://www.cms.gov/Transmittals/downloads/R129NCD.pdf on the CMS Web site.If you have any questions, please contact your carriers, FIs, or A/B MACs at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 55 MMR 2011-01, January 2011

Update to Medicare Deductible, Coinsurance and Premium Rates for2011MLN Matters® Number: MM7224Related Change Request (CR) #: 7224Related CR Release Date: November 19, 2010Effective Date: January 1, 2011Related CR Transmittal #: R65GIImplementation Date: January 3, 2011Provider Types AffectedPhysicians, providers, and suppliers submitting claims to Medicare contractors (carriers, durable medicalequipment Medicare administrative contractors [DME MACs], fiscal intermediaries [FIs], A/B Medicareadministrative contractors [A/B MACs], and/or regional home health intermediaries [RHHIs]) for servicesprovided to Medicare beneficiaries.Impact on ProvidersThis article is based on Change Request (CR) 7224 which provides the Medicare rates for deductible,coinsurance, and premium payment amounts for calendar year (CY) 2011.Background2011 Part A – Hospital Insurance (HI)A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from theamount payable by the Medicare Program to the hospital for inpatient hospital services furnished in aspell of illness.When a beneficiary receives such services for more than 60 days during a spell of illness, he or she isresponsible for a coinsurance amount that is equal to one-fourth of the inpatient hospital deductible perdayfor the 61st-90th day spent in the hospital.Note: An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90thday in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatienthospital deductible.In addition, a beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatienthospital deductible per day for the 21st through the 100th day of skilled nursing facility (SNF) servicesfurnished during a spell of illness. The 2011 inpatient deductible is $1,132. The coinsurance amounts areshown below in the following table:Hospital CoinsuranceSkilled Nursing Facility CoinsuranceDays 61-90 Days 91-150 (Lifetime Reserve Days) Days 21-100$283.00 $566.00 $141.50Most individuals age 65 and older (and many disabled individuals under age 65) are insured for HealthInsurance (HI) benefits without a premium payment. In addition, The Social Security Act provides thatcertain aged and disabled persons who are not insured may voluntarily enroll, but are subject to thepayment of a monthly Part A premium. Since 1994, voluntary enrollees may qualify for a reduced Part Apremium if they have 30-39 quarters of covered employment. When voluntary enrollment takes placeCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 56 MMR 2011-01, January 2011

more than 12 months after a person’s initial enrollment period, a two-year 10 percent penalty is assessedfor every year they had the opportunity to (but failed to) enroll in Part A.The 2011 Part A premiums are as follows:Voluntary Enrollees Part A Premium Schedule for 2011Base Premium (BP)$450.00 per monthBase Premium with 10% Surcharge$495.00 per monthBase premium with 45% Reduction (for thosewith 30-39 quarters of coverage)Base premium with 45% Reduction and 10%surcharge$248.00 (for those who have 30-39 quarters ofcoverage)$272.80 per month2011 Part B - Supplementary Medical Insurance (SMI)Under Part B, the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthlypremium. In addition, most SMI services are subject to an annual deductible and coinsurance (percent ofcosts that the enrollee must pay), which are set by statute. Further, when Part B enrollment takes placemore than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increasein the premium for each year the beneficiary had the opportunity to (but failed to) enroll.For 2011, the standard premium for SMI services is $115.40 a month; the deductible is $162 a year; and thecoinsurance is 20 percent. The Part B premium is influenced by the beneficiary’s income and can besubstantially higher based on income. The higher premium amounts and relative income levels for thoseamounts are contained in CR 7224, which is available athttp://www.cms.gov/Transmittals/downloads/R65GI.pdf on the Centers for Medicare & MedicaidServices (CMS) Web site.Additional InformationThe official instruction, CR 7224, issued to your carriers, DME MACs, FIs, A/B MACs, and RHHIsregarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R65GI.pdf on theCMS Web site.If you have any questions, please contact your carriers, DME MACs, FIs, A/B MACs, or RHHIs at theirtoll-free number, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.News Flash – Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 57 MMR 2011-01, January 2011

DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Reasonable Charge Update for 2011 for Splints, Casts, and CertainIntraocular LensesMLN Matters® Number: MM7225Related Change Request (CR) #: 7225Related CR Release Date: November 19, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2100CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers billing Medicare contractors (carriers, fiscalintermediaries [FIs], Medicare administrative contractors [MACs], and durable medical equipmentMedicare administrative contractors [DME MACs]) for splints, casts, dialysis supplies, dialysisequipment, and certain intraocular lenses.Provider Action NeededChange Request (CR) 7225, from which this article is taken, instructs your carriers, FIs, and MACs how tocalculate reasonable charges for the payment of claims for splints, casts, and intraocular lenses furnishedin calendar year 2011. Make sure your billing staff is aware of these changes.BackgroundPayment continues to be made on a reasonable charge basis for splints, casts, and for intraocular lensesimplanted (codes V2630, V2631, and V2632) in a physician’s office. For splints and casts, the Q-codes areto be used when supplies are indicated for cast and splint purposes. This payment is in addition to thepayment made under the Medicare physician fee schedule for the procedure for applying the splint orcast.Beginning January 1, 2011, reasonable charges will no longer be calculated for payment of home dialysissupplies and equipment for Method II End-Stage Renal Disease (ESRD) patients. Section 153 of MedicareImprovements for Patients and Providers Act (MIPPA) amended section 1881(b) of the Act to require theimplementation of an ESRD bundled payment system effective January 1, 2011. The ESRD prospectivepayment will provide an all-inclusive single payment to ESRD facilities (i.e. hospital-based providers ofservices and renal dialysis facilities) that will cover all the resources used in providing outpatient dialysistreatment, including dialysis supplies and equipment that are currently separately payable to Method IIDME suppliers.CR 7225 provides instructions regarding the calculation of reasonable charges for payment of claims forsplints, casts, and intraocular lenses furnished in calendar year 2011. Payment on a reasonable chargebasis is required for these items by regulations contained in 42 CFR 405.501. The Inflation Indexed Charge(IIC) is calculated using the lowest of the reasonable charge screens from the previous year updated by aninflation adjustment factor or the percentage change in the Consumer Price Index (CPI) for all urbanconsumers (United States city average) or CPI-U for the 12-month period ending with June of 2010. The2011 payment limits for splints and casts will be based on the 2010 limits that were announced in CR 6691CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 58 MMR 2011-01, January 2011

last year, increased by 1.1 percent, the percentage change in the CPI-U for the 12-month period endingJune 30, 2010. The IIC update factor for 2011 is 1.1 percent.A list of the 2011 payment limits for splints and casts are as follows:Code Payment LimitA4565 $7.84Q4001 $44.60Q4002 $168.58Q4003 $32.04Q4004 $110.92Q4005 $11.81Q4006 $26.62Q4007 $5.92Q4008 $13.31Q4009 $7.89Q4010 $17.75Q4011 $3.94Q4012 $8.88Q4013 $14.36Q4014 $24.21Q4015 $7.18Q4016 $12.10Q4017 $8.30Q4018 $13.23Q4019 $4.16Q4020 $6.62Q4021 $6.14Q4022 $11.08Q4023 $3.09Q4024 $5.54Q4025 $34.44Q4026 $107.54Q4027 $17.23Q4028 $53.78Q4029 $26.34Q4030 $69.33Q4031 $13.17Q4032 $34.66Q4004 $110.92Q4005 $11.81Q4006 $26.62Q4007 $5.92Q4008 $13.31Q4009 $7.89Q4010 $17.75CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 59 MMR 2011-01, January 2011

CodePayment LimitQ4011 $3.94Q4012 $8.88Q4013 $14.36Q4014 $24.21Q4015 $7.18Q4016 $12.10Q4017 $8.30Q4018 $13.23Q4019 $4.16Q4020 $6.62Q4021 $6.14Q4022 $11.08Q4023 $3.09Q4024 $5.54Q4025 $34.44Q4026 $107.54Q4027 $17.23Q4028 $53.78Q4029 $26.34Q4030 $69.33Q4031 $13.17Q4032 $34.66Q4004 $110.92Q4005 $11.81Q4006 $26.62Q4007 $5.92Q4008 $13.31Q4009 $7.89Q4010 $17.75Q4011 $3.94Q4012 $8.88Q4013 $14.36Q4014 $24.21Q4015 $7.18Q4016 $12.10Q4017 $8.30Q4018 $13.23Q4019 $4.16Q4020 $6.62Q4021 $6.14Q4022 $11.08Q4023 $3.09Q4024 $5.54Q4025 $34.44Q4026 $107.54CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 60 MMR 2011-01, January 2011

CodePayment LimitQ4027 $17.23Q4028 $53.78Q4029 $26.34Q4030 $69.33Q4031 $13.17Q4032 $34.66Additional InformationThe official instruction, CR 7225 issued to your carrier, FI, A/B MAC, and DME/MAC regarding thischange may be viewed at http://www.cms.gov/Transmittals/downloads/R2100CP.pdf on the CMS Website.If you have any questions, please contact your carrier, FI, A/B MAC, or DME MAC at their toll-freenumber, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.New HCPCS Q-codes for 2010-2011 Seasonal Influenza VaccinesMLN Matters® Number: MM7234 Revised (3)Related Change Request (CR): 7234Related CR Release Date: November 19, 2010Effective Date: October 1, 2010 unless otherwise specifiedRelated CR Transmittal #: R815OTNImplementation Date: January 3, 2011Note: This article was revised on December 9, 2010, to correct the short descriptor for code Q2039 on page2. All other information is the same.Provider Types AffectedThis article is for physicians and providers submitting claims to Medicare contractors (carriers, fiscalintermediaries [FIs], and/or Part A/B Medicare administrative contractors [A/B MACs]) for influenzavaccines provided to Medicare beneficiaries.Provider Action NeededThe article is based on Change Request (CR) 7234 which establishes separate billing codes for each brandnameinfluenza vaccine product under common procedure terminology (CPT) code 90658 and describesthe process for updating the new specific Healthcare Common Procedure Coding System (HCPCS) codesand their payment allowances for Medicare during the 2010-2011 influenza season.BackgroundCMS has created specific HCPCS codes and payment allowances to replace CPT code 90658 for Medicarebilling purposes for the 2010-2011 influenza season.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 61 MMR 2011-01, January 2011

Key Points of CR7234The following describes the process for updating these specific HCPCS codes for Medicare paymenteffective for dates of service on or after October 1, 2010.Effective for claims with dates of service on or after January 1, 2011, the following CPT code will nolonger be payable for Medicare:CPT Code Short Description Long Description90658 Flu vaccine, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular useEffective for claims with dates of service on or after October 1, 2010, the following HCPCS codes will bepayable for Medicare:HCPCS Code Short Description Long DescriptionQ2035 Afluria vacc, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular use (Afluria)Q2036 Flulaval vacc, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular use (Flulaval)Q2037 Fluvirin vacc, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular use (Fluvirin)Q2038 Fluzone vacc, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular use (Fluzone)Q2039 NOS flu vacc, 3 yrs & >, im Influenza virus vaccine, split virus, whenadministered to individuals 3 years of age and older,for intramuscular use (Not Otherwise Specified)Take Note:CPT 90658 describes the regular dose vaccine that is supplied in a multi-dose vial for use in patients overthree years of age. For dates of service on or after October 1, 2010, HCPCS codes Q2035, Q2036, Q2037,Q2038 and Q2039 (as listed in the table above) will replace the CPT code 90658 for Medicare paymentpurposes during the 2010 – 2011 influenza season. However, these HCPCS codes will not be recognizedby the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer berecognized.This instruction does not affect any other CPT codes. It is very important to distinguish between thevarious CPT and HCPCS codes which describe the different formulations of the influenza vaccines (i.e.,pediatric dose, regular dose, high dose, preservative free, etc.). As a reference, the quarterly Part B drugpricing files includes a set of national drug code (NDC) to HCPCS crosswalks available online athttp://www.cms.gov/McrPartBDrugAvgSalesPrice/ on the Centers for Medicare & Medicaid Services(CMS) Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 62 MMR 2011-01, January 2011

BillingIn general, it is inappropriate for a provider to submit two claims for the same service on the same date.For dates of service between October 1, 2010 and December 31, 2010, the CPT 90658 and the Q-codes willbe valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on anydate between October 1, 2010 and December 31, 2010, the provider may either bill Medicare immediatelyusing CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the mostappropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there isno need to use the Q-code for that same service.For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCScodes that appropriately describes the specific vaccine product administered.PaymentThe Medicare Part B payment limits for influenza vaccines are 95 percent of the average wholesale price(AWP) except where the vaccine is furnished in a setting that follows a cost-based or prospectivepayment system under Medicare. For example, where the vaccine is furnished in the hospital outpatientdepartment, rural health clinic (RHC), or federally qualified health center (FQHC), payment for thevaccine is based on reasonable cost.For dates of service on or after October 1, 2010, the Medicare Part B payment allowances in othersituations are:HCPCS CodeAllowanceQ2036 $7.439Q2037 $13.253Q2038 $12.593No national payment limits are available for Q2035 and Q2039. The payment limits for these two codeswill be determined by the local claims processing contractor.For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance forCPT 90655 is $14.858.Important Notes:Annual Part B deductible and coinsurance amounts do not apply to these vaccines. All physicians, nonphysicianpractitioners and suppliers who administer the influenza virus vaccination and thepneumococcal vaccination must take assignment on the claim for the vaccine.Be aware that Medicare contractors will not search their files to adjust payment on claims paid incorrectlyprior to implementing CR7324. However, they will adjust such claims that you bring to their attention.Additional InformationIf you have questions, please contact your Medicare A/B MAC, carrier or FI at their toll-free number,which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zipon the CMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 63 MMR 2011-01, January 2011

For complete details regarding this CR please see the official instruction (CR7234) issued to yourMedicare A/B MAC, carrier or FI. That instruction may be viewed by going tohttp://www.cms.gov/Transmittals/downloads/R815OTN.pdf on the CMS Web site.CMS would like providers to be aware that educational products are available through the MLNCatalogue free of charge. The MLN Catalogue is available athttp://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf on the CMS Web site. The specificproducts that may be of interest to providers who use the information in MM7234 are as follows:1. The Medicare Preventive Services Quick Reference Information Chart: Medicare Part B ImmunizationBilling (Influenza, Pneumococcal, and Hepatitis B) is available athttp://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf on the CMS Web site.2. The Adult Immunizations brochure provides a basic overview of Medicare’s influenza,pneumococcal and hepatitis B vaccine benefits and is available athttp://www.cms.gov/MLNProducts/downloads/Adult_Immunization.pdf on the CMS Web site.News Flash – Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenzavaccine and its administration, as well as related educational resources for health care professionals andtheir staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees forCollection of SpecimensMLN Matters® Number: MM7239Related Change Request (CR) #: 7239Related CR Release Date: December 3, 2010Effective Date: January 1, 2010Related CR Transmittal #: R2110CPImplementation Date: January 3, 2011Provider Types AffectedClinical laboratories submitting claims to Medicare contractors (carriers, fiscal intermediaries [FIs],and/or Part A/B Medicare administrative contractors [A/B MACs]) for clinical laboratory servicesprovided to Medicare beneficiaries are affected.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 64 MMR 2011-01, January 2011

Provider Action NeededImpact to YouThis article is based on Change Request (CR) 7239 which revises the payment of travel allowances, eitheron a per mileage basis (P9603) or on a flat rate basis (P9604) for calendar year (CY) 2010.What You Need to KnowNote that Medicare contractors will not re-process claims that were processed before the new rates wereimplemented unless you bring such claims to their attention.What You Need to DoSee the Background and Additional Information Sections of this article for further details regarding thesechanges.BackgroundMedicare, under Part B, covers a specimen collection fee and travel allowance for a laboratory technicianto draw a specimen from either a nursing home patient or homebound patient. Also, the travel codesallow for payment of the travel allowance either on a per mileage basis (P9603) or on a flat rate per tripbasis (P9604), and payment of the travel allowance is made only if a specimen collection fee is alsopayable.Under either method, when one trip is made for multiple specimen collections (e.g., at a nursing home),the travel payment component is prorated based on the number of specimens collected on that trip, forboth Medicare and non-Medicare patients, either at the time the claim is submitted by the laboratory orwhen the flat rate is set by the contractor.The per flat rate trip basis travel allowance (P9604) for 2010 is $9.50. The per mile travel allowance (P9603)is $0.95 cents per mile and is used in situations where the average trip to the patients’ home is longer than20 miles round trip, and is to be prorated in situations where specimens are drawn from non-Medicarepatients in the same trip.The allowance per mile was computed using the Federal mileage rate of $0.50 per mile plus an additional$0.45 per mile to cover the technician’s time and travel costs. Medicare contractors have the option ofestablishing a higher per mile rate in excess of the minimum $0.95 per mile if local conditions warrant it.At no time is a laboratory allowed to bill for more miles than are reasonable or for miles that are notactually traveled by the laboratory technician.The Centers for Medicare & Medicaid Services (CMS) reviews the minimum mileage rate and updates itin conjunction with the Clinical Laboratory Fee Schedule (CLFS) as needed.Note: Because of confusion that some laboratories have had regarding the per mile fee basis and the needto claim the minimum distance necessary for a laboratory technician to travel for specimen collection,some Medicare contractors have established local policy to pay based on a flat rate basis only.Additional InformationThe official instruction, CR 7239 issued to your carrier, A/B MAC, or FI regarding this change may beviewed at http://www.cms.gov/Transmittals/downloads/R2110CP.pdf on the CMS Web site.If you have any questions, please contact your carrier, A/B MAC, or FI at their toll-free number, whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 65 MMR 2011-01, January 2011

To review examples of scenarios that further clarify the travel allowances you may go tohttp://www.cms.gov/MLNMattersArticles/downloads/MM6195.pdf on the CMS Web site and read theAdditional Information section of MM6195.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no copay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenzavaccine and its administration, as well as related educational resources for health care professionals andtheir staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.2010–2011 Seasonal Influenza Resources for Health CareProfessionalsMLN Matters Number: SE1031 RevisedRelated Change Request (CR) #: N/ARelated CR Release Date: N/AEffective Date: N/ARelated CR Transmittal #: N/AImplementation Date: N/ANote: This article was revised on November 29, 2010, to include a reference to MLN Matters articleMM7234, “New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines.” All other information is thesame.Provider Types AffectedAll Medicare fee-for-service (FFS) physicians, nonphysician practitioners, providers, suppliers, and otherhealth care professionals who order, refer, or provide seasonal flu vaccines and vaccine administrationprovided to Medicare beneficiariesProvider Action Needed• Keep this MLN Matters Special Edition article and refer to it throughout the 2010–2011 flu season.• Take advantage of each office visit as an opportunity to encourage your patients to protectthemselves from the seasonal flu and serious complications by getting a seasonal flu shot.• Continue to provide the seasonal flu shot as long as you have vaccine available, even after the newyear.• Don’t forget to immunize yourself and your staff.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 66 MMR 2011-01, January 2011

IntroductionAnnual outbreaks of seasonal flu typically occur from the late fall through early spring. Typically, 5 to 20percent of Americans catch the seasonal flu, with about 36,000 people dying from flu-related causes.1Complications of flu can include pneumonia, ear infections, sinus infections, dehydration, and evendeath.The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that MedicarePart B reimburses health care providers for seasonal flu vaccines and their administration. (Medicareprovides coverage of the seasonal flu vaccine without any out-of-pocket costs to the Medicare patient. Nodeductible or copayment/coinsurance applies.) All adults 65 and older should get seasonal flu vaccine.People with Medicare who are under 65 but have chronic illness, including heart disease, lung disease,diabetes or end-stage renal disease should get a seasonal flu shot.Get the Flu Vaccine, Not the Flu!Unlike last flu season patients needed to get both a seasonal vaccine and a separate vaccine for the H1N1virus, this season, a single seasonal flu vaccine will protect your patients, your staff, and yourself.The seasonal flu vaccine continues to be the most effective method for preventing flu virus infection andits potentially severe complications. You can help your Medicare patients reduce their risk for contractingseasonal flu and serious complications by using every office visit as an opportunity to recommend theytake advantage of the annual seasonal flu shot benefit covered by Medicare. And don’t forget, health careproviders and their staff can spread the highly contagious flu virus to their patients. Don’t forget toimmunize yourself and your staff.The following educational products have been developed by CMS to be used by Medicare FFS healthcare professionals and are not intended for distribution to Medicare beneficiaries.Educational Products for Health Care ProfessionalsCMS has developed a variety of educational resources to help Medicare FFS health care professionalsunderstanding coverage, coding, billing, and reimbursement guidelines for seasonal flu vaccines andtheir administration.1. MLN Matters Seasonal Influenza Articles• MM7120: Influenza Vaccine Payment Allowances - Annual Update for 2010-2011 Season athttp://www.cms.gov/MLNMattersArticles/downloads/MM7120.pdf on the CMS Web site.• SE1026: Important News About Flu Shot Frequency for Medicare Beneficiaries athttp://www.cms.gov/MLNMattersArticles/downloads/SE1026.pdf.• MM7124: 2010 Reminder for Roster Billing and Centralized Billing for Influenza andPneumococcal Vaccinations athttp://www.cms.gov/MLNMattersArticles/downloads/MM7124.pdf 1 Flu.gov. 2010. About theFlu [online]. Washington D.C.: The U.S. Department of Health and Human Services, 2010 [cited16 August 2010]. Available from the World Wide Web:http://www.flu.gov/individualfamily/about/index.html.• MM6608: Influenza Vaccine Payment Allowances – Annual Update for 2009-2010 Season athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6608.pdf.• MM5511: Update to Medicare Claims Processing Manual, Chapter 18, Section 10 for Part BInfluenza Billing at http://www.cms.gov/MLNMattersArticles/downloads/MM5511.pdf on theCMS Web site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 67 MMR 2011-01, January 2011

• MM4240: Guidelines for Payment of Vaccine (Pneumococcal Pneumonia Virus, Influenza Virus,and Hepatitis B Virus) Administration athttp://www.cms.gov/MLNMattersArticles/downloads/MM4240.pdf on the CMS Web site.• MM5037: Reporting of Diagnosis Code V06.6 on Influenza Virus and/or PneumococcalPneumonia Virus (PPV) Vaccine Claims and Acceptance of Current Procedural Terminology(CPT) Code 90660 for the Reporting of the Influenza Virus Vaccine athttp://www.cms.gov/MLNMattersArticles/downloads/MM5037.pdf on the CMS Web site.• MM7234: New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines athttp://www.cms.gov/MLNMattersArticles/downloads/MM7234.pdf on the CMS Web site.2. MLN Seasonal Influenza Related Products for Health Care Professionals• Quick Reference Information: Medicare Part B Immunization Billing - This two-sided laminatedchart provides Medicare FFS physicians, providers, suppliers, and other health care professionalswith quick information to assist with filing claims for the seasonal influenza, pneumococcal, andhepatitis B vaccines and their administration. Available in print and as a downloadable PDF athttp://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf (447 KB) on the CMS Website.• The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and OtherHealth Care Professionals, Third Edition - This updated comprehensive guide to Medicarecoveredpreventive services and screenings provides Medicare FFS physicians, providers,suppliers, and other health care professionals information on coverage, coding, billing, andreimbursement guidelines of preventive services and screenings covered by Medicare. The guideincludes a chapter on seasonal influenza, pneumococcal, and hepatitis B vaccines and theiradministration. Also includes suggestions for planning a flu clinic and information for massimmunizers and roster billers. Available as a downloadable PDF file athttp://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf (6.4 MB) on theCMS Web site.• Medicare Preventive Services Adult Immunizations Brochure - This two-sided tri-fold brochureprovides health care professionals with an overview of Medicare’s coverage of influenza,pneumococcal, and hepatitis B vaccines and their administration. Available as a downloadablePDF file at http://www.cms.gov/MLNProducts/downloads/Adult_Immunization.pdf (1 MB) onthe CMS Web site.• Quick Reference Information: Medicare Preventive Services - This two-sided laminated chartgives Medicare FFS physicians, providers, suppliers, and other health care professionals a quickreference to Medicare’s preventive services and screenings, identifying coding requirements,eligibility, frequency parameters, and copayment/coinsurance and deductible information foreach benefit. This chart includes seasonal influenza, pneumococcal, and hepatitis B vaccines.Available in print or as a downloadable PDF file athttp://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf (475 KB) onthe CMS Web site.• MLN Preventive Services Educational Products Web Page - This Medicare Learning Network(MLN) Web page provides descriptions of all MLN preventive services related educationalproducts and resources designed specifically for use by Medicare FFS health care professionals.PDF files provide product ordering information and links to all downloadable products,including those related to the seasonal influenza vaccine and its administration. This Web page isupdated as new product information becomes available. Bookmark this page(http://www.cms.gov/MLNProducts/35_PreventiveServices.asp) for easy access.3. Other CMS Resources• CMS Adult Immunizations Web Page is at http://www.cms.gov/AdultImmunizations/ on theInternet.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 68 MMR 2011-01, January 2011

• CMS Frequently Asked Questions are available at http://questions.cms.hhs.gov/app/answers/liston the Internet.• CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,Section 50.4.4.2 – Immunizations available athttp://www.cms.gov/manuals/Downloads/bp102c15.pdf on the Internet.• CMS, IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive andScreening Services available at http://www.cms.gov/manuals/downloads/clm104c18.pdf on theInternet.• Medicare Part B Drug Average Sales Price Payment Amounts• Influenza and Pneumococcal Vaccines Pricing found athttp://www.cms.gov/McrPartBDrugAvgSalesPrice/01_overview.asp on the Internet.4. Other ResourcesThe following non-CMS resources are just a few of the many available in which clinicians may finduseful information and tools to help increase seasonal flu vaccine awareness and utilization duringthe 2009 –2010 flu season:• Advisory Committee on Immunization Practices are athttp://www.cdc.gov/vaccines/recs/acip/default.htm on the Internet.• American Lung Association’s Influenza (Flu) Center is at http://www.lungusa.org on the Internet.This Web site provides a flu clinic locator at http://www.flucliniclocator.org on the Internet.Individuals can enter their ZIP code to find a flu clinic in their area. Providers can also obtaininformation on how to add their flu clinic to this site.• Other sites with helpful information include:• Centers for Disease Control and Prevention - http://www.cdc.gov/flu;• Flu.gov - http://www.flu.gov;• Food and Drug Administration - http://www.fda.gov;• Immunization Action Coalition - http://www.immunize.org;• Indian Health Services - http://www.ihs.gov/;• National Alliance for Hispanic Health - http://www.hispanichealth.org;• National Foundation For Infectious Diseases - http://www.nfid.org/influenza/;• National Library of Medicine and NIH Medline Plus -http://www.nlm.nih.gov/medlineplus/immunization.html;• National Network for Immunization Information - http:/www.immunizationinfo.org;• National Vaccine Program - http://www.hhs.gov/nvpo;• Office of Disease Prevention and Promotion - http://odphp.osophs.dhhs.gov;• Partnership for Prevention - http://www.prevent.org; and• World Health Organization - http://www.who.int/en on the Internet.Beneficiary InformationFor information to share with your Medicare patients, please visit http://www.medicare.gov on theInternet.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 69 MMR 2011-01, January 2011

Centers for Medicare & Medicaid Services Articles for Part A ProvidersIncentive Payment Program for Primary Care Services, Section 5501(a)of the Patient Protection and Affordable Care Act, Payment to aCritical Access Hospital Paid Under the Optional MethodMLN Matters® Number: MM7115Related Change Request (CR) #: 7115Related CR Release Date: December 3, 2010Effective Date: April 1, 2011Related CR Transmittal #: R2081CPImplementation Date: April 4, 2011Provider Types AffectedCritical access hospital (CAH) under the optional method who provide primary care services to Medicarebeneficiaries and bill Medicare administrative contractors (A/B MACs) or fiscal intermediaries (FIs) areimpacted by this issue.Provider Action NeededImpact to YouThe Affordable Care Act provides for a 10 percent Medicare incentive payment for primary care serviceseffective 2011 through 2015. Payments will be made on a quarterly basis.What You Need to KnowThe Affordable Care Act defines a primary care practitioner as: (1) a physician who has a primaryspecialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or(2) a Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant, and in all cases, for whomprimary care services accounted for at least 60 percent of the allowed charges under the MedicarePhysician Fee Schedule (MPFS) for the practitioner in a prior period as determined appropriate by thesecretary.What You Need to DoSee the Background section below for specifics.BackgroundSection 5501(a) of The Affordable Care Act revises section 1833 of The Social Security Act and will add anew paragraph “Incentive Payments for Primary Care Services.” The Social Security Act now states thatin the case of primary care services furnished on or after January 1, 2011 and before January 1, 2016 by aprimary care practitioner, there also shall be paid on a monthly or quarterly basis an amount equal to 10percent of the payment amount for such services under the MPFS.Note: The former “Quarterly Health Professional Shortage Area (HPSA) and Scarcity Report for CriticalAccess Hospital (CAHs)” is now known as the “Special Incentive Remittance for CAHs.” This change isnecessary as Primary Care Incentive Program (PCIP) payments are made for all primary care servicesfurnished by eligible primary care practitioners, regardless of the geographic location where the primarycare services are furnished.The PCIP payments will be based on 10 percent of 115 percent of the MPFS amount that the CAH waspaid for the professional service.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 70 MMR 2011-01, January 2011

Primary Care ServicesThe Affordable Care Act defines primary care services as those services identified by the following CPTcodes:• 99201 through 99215 for new and established patient office or other outpatient evaluation andmanagement (E&M) visits;• 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E&M services; newand established patient domiciliary, rest home (e.g., boarding home), or custodial care E&M services;and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; and• 99341 through 99350 for new and established patient home E&M visits.These codes are displayed in the table below. All of these codes remain active in calendar year (CY) 2011and there are no other codes used to describe these services.Primary Care Services Eligible for Primary Care Incentive Payments in CY 2011CPT Code Description99201 Level 1 new patient office or other outpatient visit99202 Level 2 new patient office or other outpatient visit99203 Level 3 new patient office or other outpatient visit99204 Level 4 new patient office or other outpatient visit99205 Level 5 new patient office or other outpatient visit99211 Level 1 established patient office or other outpatient visit99212 Level 2 established patient office or other outpatient visit99213 Level 3 established patient office or other outpatient visit99214 Level 4 established patient office or other outpatient visit99215 Level 5 established patient office or other outpatient visit99304 Level 1 initial nursing facility care99305 Level 2 initial nursing facility care99306 Level 3 initial nursing facility care99307 Level 1 subsequent nursing facility care99308 Level 2 subsequent nursing facility care99309 Level 3 subsequent nursing facility care99310 Level 4 subsequent nursing facility care99315 Nursing facility discharge day management; 30 minutes99316 Nursing facility discharge day management; more than 30 minutes99318 Other nursing facility services; evaluation and management of a patient involving anannual nursing facility assessment.99324 Level 1 new patient domiciliary, rest home, or custodial care visit99325 Level 2 new patient domiciliary, rest home, or custodial care visit99326 Level 3 new patient domiciliary, rest home, or custodial care visit f99327 Level 4 new patient domiciliary, rest home, or custodial care visit99328 Level 5 new patient domiciliary, rest home, or custodial care visit99334 Level 1 established patient domiciliary, rest home, or custodial care visit99335 Level 2 established patient domiciliary, rest home, or custodial care visit99336 Level 3 established patient domiciliary, rest home, or custodial care visit99337 Level 4 established patient domiciliary, rest home, or custodial care visit99339 Individual physician supervision of a patient in home, domiciliary or rest homerecurring complex and multidisciplinary care modalities; 30 minutesCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 71 MMR 2011-01, January 2011

CPT CodeDescription99340 Individual physician supervision of a patient in home, domiciliary or rest homerecurring complex and multidisciplinary care modalities; 30 minutes or more99341 Level 1 new patient home visit99342 Level 2 new patient home visit99343 Level 3 new patient home visit99344 Level 4 new patient home visit99345 Level 5 new patient home visit99347 Level 1 established patient home visit99348 Level 2 established patient home visit99349 Level 3 established patient home visit99350 Level 4 established patient home visitEligibility for Payment under the Primary Care Incentive Payment ProgramFor primary care services furnished on or after January 1, 2011 and before January 1, 2016, a 10 percentincentive payment will be provided to primary care practitioners, identified as: (1) in the case ofphysicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internalmedicine, 37-pediatrics, or 38-geriatrics; or (2) in the case of nonphysician practitioners, enrolled inMedicare with a primary care specialty designation of 50-Nurse Practitioner, 89-certified Clinical NurseSpecialist, or 97-Physician Assistant; and (3) for whom the primary care services displayed in the abovetable accounted for at least 60 percent of the allowed charges under the MPFS (excluding hospitalinpatient care and emergency department visits) for such practitioner during the time period that hasbeen specified by the Secretary of Health and Human Services.If a claim for a primary care service is submitted by a CAH paid under the optional method for an eligibleprimary care physician’s or nonphysician practitioner’s professional services, the “other provider” fieldon the claim must be populated by the eligible primary care practitioner’s National Provider Identifier(NPI) in order for the primary care service to qualify for the incentive payment. Primary care servicespotentially eligible for the incentive payment and furnished on different days must be submitted onseparate CAH claims so a determination about the eligibility of the service based on the renderingpractitioner can be made. If the CAH claim for a single date of service includes more than one primarycare professional service, the incentive payment for all primary care services for that date, shall be madeto the CAH on behalf of the eligible primary care practitioner based on the NPI in the “other provider”field. In addition to the CAH NPI, the “other provider” NPI shall be shown on the Special IncentiveRemittance for CAHs.PCIP Payments to CAHsPhysicians and nonphysician practitioners billing on type of bill (TOB) 85X for professional servicesrendered in a CAH paid under the optional method have the option of reassigning their billing rights tothe CAH. When the billing rights are reassigned to the CAH, payment is made to the CAH forprofessional services (Revenue Codes (RC) 96X, 97X or 98X).The 10 percent PCIP payment is payable to a CAH billing under the optional method for the primary careprofessional services of eligible primary care physicians and nonphysician practitioners who havereassigned their billing rights to CAH. The incentive payment is paid based on 10 percent of the 115percent of the MPFS amount paid to the CAH for those professional services. PCIP payments arecalculated by Medicare contractors and made quarterly on behalf of the eligible primary care physician ornonphysician practitioner to the CAH for the primary care services furnished by the practitioner in thatquarter.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 72 MMR 2011-01, January 2011

The Affordable Care Act authorizes payment under the PCIP beginning in CY 2011 as an additionalpayment amount for specified primary care services without regard to any additional payment for theservice under the existing health professional shortage area (HPSA) physician bonus payment program.Therefore, eligible primary care physicians and nonphysician practitioners furnishing a primary careservice in a HPSA may receive both a HPSA physician bonus payment under the established programand a PCIP payment under the new program beginning in CY 2011.Additional InformationThe official instruction, CR7115 issued to your A/B MAC or FI regarding this change may be viewed athttp://www.cms.gov/Transmittals/downloads/R2081CP.pdf on the Centers for Medicare & MedicaidServices (CMS) Web site.If you have any questions, please contact your A/B MAC or FI at their toll-free number, which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no copay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services (CMS) Website.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Systems Changes Necessary to Implement “Technical CorrectionRelated to Critical Access Hospital Services,” Section 3128 of theAffordable Care Act, Pub. L. 111-148MLN Matters® Number: MM7219Related Change Request (CR): 7219Related CR Release Date: November 19, 2010Effective Date: April 1, 2011Related CR Transmittal #: R2102CPImplementation Date: April 4, 2011CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 73 MMR 2011-01, January 2011

Provider Types AffectedThis article is for critical access hospitals (CAHs) paid for outpatient services under the optional method(also referred to as “method II”) and for CAHs and entities owned and operated by CAHs that billMedicare administrative contractors (A/B MACs) or fiscal intermediaries (FIs) for ambulance servicesprovided to Medicare beneficiaries.Provider Action NeededThe article is based on Change Request (CR) 7219 and implements section 3128 of the Affordable CareAct. Section 3128 increased payment for outpatient facility services for CAHs paid under the optionalmethod from 100 percent of reasonable cost to 101 percent of reasonable cost and increased payment forambulance services furnished by CAHs or an entity owned and operated by a CAH where there is noother supplier or provider of ambulance services within a 35 mile drive of the CAH or the entity from 100percent of reasonable cost to 101 percent of reasonable cost, applicable to services furnished on and afterJanuary 1, 2004. CR 7219 is effective April 1, 2011. (Although these adjustments apply to servicesprovided on or after January 1, 2004, no prior adjustments are needed to payments as these CAHs werealready paid at 101 percent of reasonable cost due to cost reporting instructions.)Key Points of CR7219• Effective April 1, 2011, Medicare will pay for CAH ambulance services, including Indian HealthService (IHS) CAHs, with a hospital-based ambulance service on type of bill (TOB) 85X with revenuecode 054X (ambulance) and condition code B2 (Critical Access Hospital ambulance attestation) basedon 101 percent of reasonable cost.• Effective April 1, 2011, Medicare will pay for CAH outpatient facility services under the optionalmethod based on 101 percent of reasonable cost.• When the 35 mile rule for cost-based payment is not met, the CAH ambulance service or theambulance service furnished by the entity that is owned and operated by the CAH is paid based onthe ambulance fee schedule.When the 35 mile rule for cost-based payment is not met, the IHS/Tribal CAH ambulance service or theambulance service furnished by the entity that is owned and operated by the IHS/Tribal CAH is paidbased on the ambulance fee schedule.Additional InformationIf you have questions, please contact your Medicare A/B MAC or FI at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCenters for Medicare & Medicaid Services (CMS) Web site.If you would like to see the changes that detail payment for ambulance services furnished by certainCAHs (CMS Internet-Only Manual [IOM] Publication 100-04, Medicare Claims Processing Manual, Chapter4 - Part B Hospital [Including Inpatient Hospital Part B and OPPS]) and Indian Health Service/TribalBilling (CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15 – Ambulance) aswell as complete details regarding this CR please see the official instruction (CR7219) issued to yourMedicare A/B MAC or FI. That instruction may be viewed by going tohttp://www.cms.gov/Transmittals/downloads/R2102CP.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 74 MMR 2011-01, January 2011

Implementation of Changes in End-Stage Renal Disease Payment forCalendar Year 2011MLN Matters® Number: MM7237Related Change Request (CR) #: 7237Related CR Release Date: December 10, 2010Effective Date: January 1, 2011Related CR Transmittal #: R135BPImplementation Date: January 3, 2011Provider Types AffectedProviders and suppliers submitting claims to Medicare contractors (fiscal intermediaries [FIs] and/or A/BMedicare administrative contractors [A/B MACs]) for end-stage renal disease (ESRD) services providedto Medicare beneficiaries.Provider Action NeededImpact to YouThis article is based on Change Request (CR) 7237 which implements changes in ESRD payment forcalendar year (CY) 2011.What You Need to KnowCR 7237 implements the following changes in ESRD payment for CY 2011:• a 2.5 percent increase to the ESRD composite rate portion of the blended payment amount, whichresults in a CY 2011 composite rate of $138.53 ($135.15 x 1.025) [note: This 2.5 percent increase doesnot apply to the drug add-on adjustment to the composite rate]; a wage index adjustment to reflectthe current wage data; a reduction in the wage index floor from 0.6500 to 0.6000, then after• applying a budget neutrality of 1.056929, the wage index floor is 0.64320; a drug add-on adjustmentof 14.7 percent (14.7%); updated wage index values for the ESRD composite rate (to include thebudget neutrality factor of 1.056929); and updated wage index values for the ESRD prospectivepayment system (PPS) (which does not include the budget neutrality factor).What You Need to DoSee the Background and Additional Information Sections of this article for further details regarding thesechanges.BackgroundThe Social Security Act (Section 1881(b)(12)) as amended by the Medicare Prescription DrugImprovement and Modernization Act (MMA) of 2003 (Section 623), resulted in the Centers for Medicare& Medicaid Services (CMS) making a number of revisions to the composite rate payment system, as wellas payment for separately billable drugs furnished by ESRD facilities. You can review the Social SecurityAct (Section 1881(b)(12)) at http://www.ssa.gov/OP_Home/ssact/title18/1881.htm and MMA Section 623 athttp://aspe.hhs.gov/mits/text/titleVI/623.html on the Internet.The Social Security Act (Section 1881(b)(14)(F)) [as added by the Medicare Improvements for Patients andProviders Act of 2008 (MIPPA; Section 153(b)) and amended by the Affordable Care Act, Section 3401(h))]required that the composite rate portion of the blended payment amount be increased in CY 2011 by theESRD market basket percentage increase factor (the “ESRD market basket”).CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 75 MMR 2011-01, January 2011

CR 7237 implements the following changes in ESRD payment for CY 2011:• A 2.5 percent increase to the ESRD composite rate portion of the blended payment amount, whichresults in a CY 2011 composite rate of $138.53 ($135.15 x 1.025)Note: This 2.5 percent increase does not apply to the drug add-on adjustment to the composite rate;• A wage index adjustment to reflect the current wage data;• A reduction in the wage index floor from 0.6500 to 0.6000, then after applying a budget neutrality of1.056929, the wage index floor is 0.64320;• A drug add-on adjustment of 14.7 percent;• Updated wage index values for the ESRD composite rate (to include the budget neutrality factor of1.056929); and• Updated wage index values for the ESRD PPS (which does not include the budget neutrality factor).In addition to the updates listed above, there have been several changes that affect how payment is madeto ESRD facilities beginning January 1, 2011. The Social Security Act (Section 1881(b)(14)(E)(i)) requires afour-year transition (phase-in) from the current composite payment system to the ESRD PPS, and Section1881(b)(14)(E)(ii) requires ESRD facilities to make a one-time election to be excluded from the transition:• Electing to be excluded from the four-year transition means that the ESRD facility would receivepayment for renal dialysis services based on 100 percent of the payment rate established under theESRD PPS, rather than a blended rate under each year of the transition based in part on the paymentrate under the current payment system and in part on the payment rate under the ESRD PPS.• Electing to go through the four-year transition means that (as of January 1, 2011) the ESRD facilitywould be paid in the first year a blended amount that will consist of 75 percent of the basic case-mixadjusted composite payment system and the remaining 25 percent would be based on the ESRD PPSpayment. For further details regarding the ESRD PPS transition, see the MLN Matters article related toCR 7064 (Transmittal R2033CP; dated August 20, 2010). That article is athttp://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf on the CMS Web site.For CY 2011, CMS will continue to update the basic case-mix composite payment system for purposes ofdetermining the composite rate portion of the blended payment amount during the ESRD PPS four-yeartransition (CYs 2011 through 2013).Additional InformationThe official instruction, CR 7237, issued to your FIs and A/B MACs regarding this change may be viewedat http://www.cms.gov/Transmittals/downloads/R135BP.pdf on the CMS Web site.If you have any questions, please contact your FIs or A/B MACs at their toll-free number, which may befound at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 76 MMR 2011-01, January 2011

Home Health Face-to-Face Encounter - A New Home HealthCertification RequirementMLN Matters® Number: SE1038Related Change Request (CR) #: N/ARelated CR Release Date: N/AEffective Date: January 1, 2011Related CR Transmittal #: N/AImplementation Date: N/AProvider Types AffectedThis article is for physicians certifying Medicare patients’ need/eligibility for home health benefits, homehealth agencies (HHAs), and beneficiaries.What You Need to KnowAs a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’seligibility for the home health benefit, the certifying physician must document that he or she, or anallowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient.Documentation regarding these encounters must be present on certifications for patients with starts ofcare on and after January 1, 2011. See the remainder of this article for details.BackgroundSince the inception of the benefit, the Social Security Act has required physicians to order and certify theneed for Medicare home health services. This new mandate assures that the physician’s order is based oncurrent knowledge of the patient’s condition.As a condition for payment, the Affordable Care Act mandates that prior to certifying a patient’seligibility for the home health benefit, the certifying physician must document that he or she, or anallowed NPP has had a face-to-face encounter with the patient.The Affordable Care Act describes NPPs who may perform this face-to-face patient encounter as a nursepractitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)of the SocialSecurity Act), who is working in collaboration with the physician in accordance with State law, or acertified nurse-midwife (as defined in section 1861(gg)of the Social Security Act, as authorized by Statelaw), or a physician assistant (as defined in section 1861(aa)(5)of the Social Security Act), under thesupervision of the physician.Home Health Prospective Payment System (HHPPS) Final Rule Implementation ProvisionsThe Centers for Medicare & Medicaid Services (CMS) implemented this provision of the Affordable CareAct via the HHPPS Calendar Year (CY) 2011 rulemaking. In that rule, CMS finalized the following:• Documentation regarding these face-to-face encounters must be present on certifications for patientswith starts of care on and after January 1, 2011.• As part of the certification form itself, or as an addendum to it, the physician must document whenthe physician or allowed NPP saw the patient, and document how the patient’s clinical condition asseen during that encounter supports the patient’s homebound status and need for skilled services.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 77 MMR 2011-01, January 2011

• The face-to-face encounter must occur within the 90 days prior to the start of home health care, orwithin the 30 days after the start of care.• In situations when a physician orders home health care for the patient based on a new condition thatwas not evident during a visit within the 90 days prior to start of care, the certifying physician orNPP must see the patient within 30 days after admission. Specifically:• If the certifying physician or NPP had not seen the patient in the 90 days prior to the start of care, avisit within 30 days of start of care would be required.• If a patient saw the certifying physician or NPP within the 90 days prior to start of care, anotherencounter would be needed if the patient’s condition had changed to the extent that acceptedstandards of practice would preclude the physician from ordering services without the physician oran NPP first examining the patient.The Affordable Care Act and the final rule include several features to accommodate physician practice:• In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allows a physician whoattended to the patient in an acute or post-acute setting, but does not follow patient in the community(such as a hospitalist) to certify the need for home health care based on their contact with the patient,and establish and sign the plan of care. The acute/post-acute physician would then “hand off” thepatient’s care to his or her community-based physician.• Medicare will also allow physicians who attended to the patient in an acute or post-acute setting tocertify the need for home health care based on their contact with the patient, initiate the orders forhome health services, and “hand off” the patient to his or her community-based physician to reviewand sign off on the plan of care.• The law allows the face-to-face encounter to occur via telehealth, in rural areas, in an approvedoriginating site.Plan of Care (POC) and Certification ClarificationsLong-standing regulations have described the distinct content requirements for the POC and certification.The Affordable Care Act requires the face-to-face encounter and corresponding documentation as acertification requirement. Providers have the flexibility to implement the content requirements for boththe POC and certification in a manner that best makes sense for them.Prior to CY 2011, CMS manual guidance required the same physician to sign the certification and thePOC. Beginning in CY 2011, CMS will allow additional flexibility associated with the POC when a patientis admitted to home health from an acute or post-acute setting. For such patients, CMS will allowphysicians who attend to the patient in acute and post-acute settings to certify the need for home healthcare based on their face to face contact with the patient (which includes documentation of the face-to-faceencounter), initiate the orders (POC) for home health services, and “hand off” the patient to his or hercommunity-based physician to review and sign off on the plan of care. As described in the final HHPPSregulation, CMS continues to expect that, in most cases, the same physician will certify and establish andsign the POC. But the flexibility exists for HH post-acute patients if needed.Certain non-physician practitioners can play an important role in the face to face encounter. For example,an allowed non-physician practitioner who attends to a patient in an acute setting or emergency room canCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 78 MMR 2011-01, January 2011

collaborate with and inform the community certifying physician regarding his/her contact with thepatient. The community physician could document the encounter and certify based on this information.Additional InformationMedicare home health plays a vital role in allowing patients to receive care at home as an alternative toextended hospital or nursing home care. Questions and answers regarding this requirement will beavailable the via Medicare’s home health agency website, http://www.cms.gov/center/hha.asp on theCMS Web site.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenzavaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part Dcovered drug. For information about Medicare’s coverage of the influenza vaccine and its administration,as well as related educational resources for health care professionals and their staff, please visithttp://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services (CMS) Website.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Announcement of Medicare Rural Health Clinics (RHCs) and FederallyQualified Health Centers (FQHCs) Payment Rate IncreasesMLN Matters® Number: MM7101Related Change Request (CR) #: 7101Related CR Release Date: October 8, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2063CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers submitting claims to Medicare contractors (FiscalIntermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for RHC and FQHCservices provided to Medicare beneficiaries.What You Need to KnowThis article is based on Change Request (CR) 7101 which provides instructions for the calendar year (CY)2011 Payment Rate Increases for Rural Health Clinic (RHC) and Federally Qualified Health Center(FQHC) services.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 79 MMR 2011-01, January 2011

BackgroundIn accordance with the Social Security Act (Section 1833(f) athttp://www.ssa.gov/OP_Home/ssact/title18/1833.htm on the Internet), the Centers for Medicare &Medicaid Services (CMS) is increasing the calendar year (CY) payment rates for Rural Health Clinics(RHCs) and Federally Qualified Health Centers (FQHCs) effective for services on or after January 3, 2011,through December 31, 2011 (i.e., CY 2011) as follows:• The Rural Health Clinic (RHC) upper payment limit per visit is increased from $77.76 to $77.99effective January 3, 2011, through December 31, 2011 (i.e., CY 2011). The 2011 rate reflects a 0.3percent increase over the 2010 payment limit in accordance with the rate of increase in the MedicareEconomic Index (MEI).• The Federally Qualified Health Center (FQHC) upper payment limit per visit for urban FQHCs isincreased from $125.72 to $126.10 effective January 3, 2011, through December 31, 2011 (i.e., CY 2011);and the maximum Medicare payment limit per visit for rural FQHCs is increased from $108.81 to$109.14 effective January 3, 2011, through December 31, 2011. The 2011 FQHC rates reflect a 0.3percent increase over the 2010 rates in accordance with the rate of increase in the MEI.Medicare contractors will not retroactively adjust individual RHC/FQHC bills paid at previous upperpayment limits. However, they have the discretion to make adjustments to the interim payment rate or alump sum adjustment to total payments already made to take into account any excess or deficiency inpayments to date.Additional InformationThe official instruction, CR 7101, issued to your FI or MAC regarding this change may be viewed athttp://www.cms.gov/Transmittals/downloads/R2063CP.pdf on the CMS Web site. If you have anyquestions, please contact your FI or MAC at their toll-free number, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenzavaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part Dcovered drug. For information about Medicare’s coverage of the influenza vaccine and its administration,as well as related educational resources for health care professionals and their staff, please visithttp://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services(CMS) Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 80 MMR 2011-01, January 2011

News Flash – A revised Medicare Learning Network® publication titled “Rural Health Clinic”(September 2010), which provides information about Rural Health Clinic (RHC) services, Medicarecertification as a RHC, RHC visits, RHC payments, cost reports, and annual reconciliation, is nowavailable in print format. To place your order, visit http://www.cms.gov/MLNGenInfo , scroll down to“Related Links Inside CMS” and select “MLN Product Ordering Page”.Centers for Medicare & Medicaid Services Articles for Part B ProvidersEnd-Stage Renal Disease Home Dialysis Monthly Capitation PaymentMLN Matters® Number: MM7003Related Change Request (CR) #: 7003Related CR Release Date: July 9, 2010Effective Date: January 1, 2011Related CR Transmittal #: R1999CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians and providers submitting claims to Medicare contractors (carriers and/or A/BMedicare administrative contractors [A/B MACs]) for home dialysis monthly capitation payment (MCP)services provided to Medicare ESRD beneficiaries.Provider Action NeededImpact to YouThis article is based on Change Request (CR) 7003 which instructs that, effective January 1, 2011, themonthly capitation payment (MCP) physician (or practitioner) must furnish at least one face-to-facepatient visit per month for the home dialysis MCP service as described by current procedure terminology(CPT) codes 90963, 90964, 90965, and 90966.What You Need to KnowPhysicians and practitioners managing Medicare beneficiaries with end-stage renal disease (ESRD) whodialyze at home are paid a single monthly rate based on the age of the beneficiary, and currently, theCenters for Medicare & Medicaid Services (CMS) does not require a frequency of required visits for thehome dialysis monthly capitation payment (MCP) service. CR 7003 instructs that, effective January 1,2011, the MCP physician (or practitioner) must furnish at least one face-to-face patient visit per month forthe home dialysis MCP service. In addition, documentation by the MCP physician (or practitioner)should support at least one face-to-face encounter per month with the home dialysis patient. However,Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysisMCP service on a case by case basis; for example, when the nephrologist’s notes indicate that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.The management of home dialysis patients who remain a home dialysis patient the entire month shouldbe coded using the ESRD-related services for home dialysis patients Healthcare Common ProcedureCoding System (HCPCS) codes.What You Need to DoSee the Background and Additional Information Sections of this article for further details regarding thesechanges.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 81 MMR 2011-01, January 2011

BackgroundIn the calendar year (CY) 2004 physician fee schedule (PFS) final rule (68 FR 63216, November 7, 2003; seehttp://edocket.access.gpo.gov/2003/pdf/03-27639.pdf on the Internet), the CMS established new HCPCS Gcodes for ESRD MCPs.For center based patients, payment for the G codes varied based on the age of the beneficiary and thenumber of face-to-face visits furnished each month (e.g., 1 visit, 2-3 visits and 4 or more visits). Under thismethodology, the lowest payment amount applies when a physician provides one visit per month; ahigher payment is provided for two to three visits per month. To receive the highest payment amount, aphysician would have to provide at least four ESRD-related visits per month. However, payment for thehome dialysis MCP only varied by the age of beneficiary. CMS stated that they “will not specify thefrequency of required visits at this time but expect physicians to provide clinically appropriate care tomanage the home dialysis patient.”Effective January 1, 2009, the American Medical Association’s (AMA’s) Current Procedural Terminology(CPT) Editorial Panel created CPT codes to replace the HCPCS G codes for monthly ESRD-relatedservices, and CMS accepted these new codes. The clinical vignettes used for the valuation of the homedialysis MCP services (as described by CPT codes 90963 through 90966) include scheduled (andunscheduled) examinations of the ESRD patient.CR 7003 instructs that, effective January 1, 2011, the MCP physician (or practitioner) must furnish at leastone face-to-face patient visit per month for the home dialysis MCP service as described by CPT codes90963, 90964, 90965, and 90966 shown in the following table. Documentation by the MCP physician (orpractitioner) should support at least one face-to-face encounter per month with the home dialysis patient.However, Medicare contractors may waive the requirement for a monthly face-to-face visit for the homedialysis MCP service on a case by case basis; for example, when the nephrologist’s notes indicate that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.CPT Code Descriptor90963 End-stage renal disease (ESRD)-related services for home dialysis per full month,for patients younger than 2 years of age to include monitoring for the adequacyof nutrition, assessment of growth and development, and counseling of parents90964 End-stage renal disease (ESRD)-related services for home dialysis per full month,for patients 2-11 years of age to include monitoring for the adequacy of nutrition,assessment of growth and development, and counseling of parents90965 End-stage renal disease (ESRD)-related services for home dialysis per full month,for patients 12-19 years of age to include monitoring for the adequacy ofnutrition, assessment of growth and development, and counseling of parents90966 End-stage renal disease (ESRD)-related services for home dialysis per full month,for patients 20 years of age and olderAdditional InformationThe official instruction, CR 7003, issued to your carrier and A/B MAC regarding this change may beviewed at http://www.cms.gov/Transmittals/downloads/R1999CP.pdf on the CMS Web site.If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 82 MMR 2011-01, January 2011

DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Edit to Deny Payment to Physicians and Other Suppliers for theTechnical Component (TC) of Pathology Services Furnished on SameDate as Inpatient and Outpatient Services and Implements NewMessagesMLN Matters Number: MM7061Related Change Request (CR) #: 7061Related CR Release Date: October 29, 2010Effective Date: April 1, 2011Related CR Transmittal #: R795OTNImplementation Date: April 4, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers billing Medicare contractors (carriers and Part A/BMedicare administrative contractors [A/B MACs]) for services provided to Medicare beneficiaries.What You Need to KnowChange Request (CR) 7061, from which this article is taken, instructs your carriers and A/B MACs tomodify previously implemented edits that prevent payments to physicians, practitioners, independentdiagnostic testing facilities (IDTFs) and independent laboratories for the technical component (TC)portion of the radiology and pathology services furnished to an inpatient or outpatient of a hospital. TheCR also revises certain claim adjustment reason code (CARC), remittance advice remark code (RARC),and Medicare Summary Notice messages for both radiology and pathology because the current codeslisted are obsolete. Make sure your billing staff is aware of these changes.BackgroundCR7061 amends CR5347, issued on April 18, 2007, (see the related MLN Matters ® article athttp://www.cms.gov/MLNMattersArticles/downloads/MM5347.pdf), which implemented edits toprevent payments to physicians, practitioners, IDTFs and independent laboratories for the TC portion ofthe radiology and pathology services furnished to a hospital inpatient or outpatient. Payment for the TCof physician pathology services provided to a hospital inpatient or outpatient is included in the bundledpayment to the hospital. The only exception to this policy is that independent laboratories may bill for theTC of pathology services to an inpatient or outpatient of a hospital according to Section 3104 of theAffordable Care Act.CR7061 also implements an edit to prevent payments for the TC of pathology services billed by any entityother than an independent laboratory for dates of service coincident with hospital inpatient andoutpatient services.The Centers for Medicare & Medicaid Services (CMS) will provide your contractors with a file containingphysician pathology Healthcare Common Procedure Coding System (HCPCS) codes that are subject tothe edit. In addition, CMS will make updates to the file to add and/or delete codes, as needed, inconjunction with the Medicare Physician Fee Schedule Database (MPFSDB) quarterly updates.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 83 MMR 2011-01, January 2011

Payments for independent laboratories are not affected by CR 7061.Your Medicare contractor will deny the TC or globally billed physician pathology service line items thatshould be bundled to the hospital. The denied services are the TC or globally billed radiology andphysician pathology service line items that fall within the admission and discharge dates, inclusive, of acovered hospital inpatient stay or outpatient service billed on type of bill 11X, 12X, 13X, or 85X (exceptthose billed by specialty code 69 [independent laboratory]). Appeal rights are offered on all denials.When denying these services/line items, Medicare will use a CARC of 96 (Noncovered Charge[s]) and aRARC of N70 (Consolidated Billing and Payment Applies).Additional InformationFor complete details regarding this change request (CR) please see the official instruction (CR 7061)issued to your Medicare carrier or A/B MAC. That instruction may be viewed by going tohttp://www.cms.gov/Transmittals/downloads/R795OTN.pdf on the CMS Web site.If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which maybe found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90% of these deaths occur in people 65 years of age and older. Pleasetalk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are coveredPart B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information aboutMedicare’s coverage of the influenza vaccine and its administration, as well as related educationalresources for health care professionals and their staff, please visithttp://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Section 5501(b) Incentive Payment Program for Major SurgicalProcedures Furnished in Health Professional Shortage Areas Under theAffordable Care ActMLN Matters® Number: MM7063Related Change Request (CR) #: 7063Related CR Release Date: August 27, 2010Effective Date: January 1, 2011Related CR Transmittal #: R2040CPImplementation Date: January 3, 2011CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 84 MMR 2011-01, January 2011

Provider Types AffectedThis program is for general surgeons submitting claims to Medicare contractors (carriers and Medicareadministrative contractors [MAC]) for major surgical procedures furnished in health professionalshortage areas (HPSAs) to Medicare beneficiaries.Provider Action NeededImpact to YouThis article, based on change request (CR) 7063, explains that Section 5501(b) of the Affordable Care Act(ACA) revises section 1833(m) of the Social Security Act, referred to as the Act, and authorizes anincentive payment program for major surgical services furnished by general surgeons in HPSAs. Thissection of the ACA provides for payments on a monthly or quarterly basis in an amount equal to 10percent of the payment for physicians’ professional services under Medicare Part B.What You Need to KnowThis new program will be known as the HPSA Surgical Incentive Payment Program (HSIP). The incentivepayment applies to major surgical procedures, defined as 10-day and 90-day global procedures, under thePhysician Fee Schedule (PFS) and furnished on or after January 1, 2011, and before January 1, 2016, by ageneral surgeon with a primary specialty code of 02 (General Surgery) in an area designated undersection 332(a)(1)(A) of the Public Health Service Act as a HPSA.Section 5501(b)(4) of the ACA provides payment under the HSIP as an additional payment amount forspecified surgical services without regard to any additional payment for the service under section1833(m) of the Act. Therefore, a general surgeon may receive both a HPSA physician bonus paymentunder the established program and an HSIP payment under the new program beginning in calendar year(CY) 2011.What You Need to DoModifier AQ is to be used to denote claims that were furnished in HPSAs approved by December 31 ofthe preceding calendar year, but that are not recognized for automatic payment. The modifier must beappended to the surgical procedure for the service to be eligible for the 10 percent additional HSIPpayment, unless the services are provided in a ZIP code on the list of HPSA ZIP codes where automaticincentive payments are made. The list of these ZIP codes is available athttp://www.cms.gov/HPSAPSAPhysicianBonuses/01_overview.asp on the Centers for Medicare &Medicaid Services (CMS) Web site. Please ensure that your billing staffs of aware of this change.BackgroundSection 5501(b) of the Affordable Care Act revises section 1833(m) of the Act and authorizes an incentivepayment program for major surgical services furnished by general surgeons in HPSAs. The sectionindicates that there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent ofthe payment for physicians’ professional services under Part B.Note: The new HSIP and the new Primary Care Incentive Payment Program (PCIP) will be implementedin conjunction with one another for CY 2011. CMS issued CR 7060 with requirements specific to the PCIP.(The MLN Matters article related to CR 7060 is available athttp://www.cms.gov/MLNMattersArticles/downloads/MM7060.pdf on the CMS Web site.) The former“special HPSA remittance” will now be known as the “special incentive remittance.”The incentive payment applies to major surgical procedures, defined as 10-day and 90-day globalprocedures, under the PFS and furnished on or after January 1, 2011, and before January 1, 2016, by aCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 85 MMR 2011-01, January 2011

general surgeon in an area designated under section 332(a)(1)(A) of the Public Health Service Act as aHPSA.HPSA Surgical Incentive Payment Program (HSIP)For services furnished on or after January 1, 2011 and before January 1, 2016, a 10 percent incentivepayment will be paid to general surgeons, identified by their enrollment in Medicare with a primaryspecialty code of 02 (General Surgery), in addition to the amount they would otherwise be paid for theirprofessional services under Part B, when they furnish a major surgical procedure in an area designatedby the Secretary of Health and Human Services, as of December 31 of the prior year as a HPSA.To be consistent with the original Medicare HPSA physician bonus program, HSIP payments will becalculated by Medicare contractors based on the identification criteria for payment discussed below andpaid on a quarterly basis on behalf of the qualifying general surgeon, for the qualifying major surgicalprocedures. The surgeon’s professional services are paid under the PFS based on a claim for professionalservices.IdentificationQualifying general surgeons would be identified on a claim in the incentive payment program year for amajor surgical procedure based on the primary specialty of 02 of the rendering physician, identified byhis or her National Provider Identifier (NPI). If the claim is submitted by a physician group or practice,the rendering physician’s NPI must be included on the line-item for the major surgical procedure in orderfor a determination to be made regarding whether or not the procedure is eligible for payment under theHSIP.Each year, a list of ZIP codes eligible for automatic payment for the established HPSA bonus is published.This list of ZIP codes will be utilized for automatic payments of the incentive payment for eligibleservices furnished by general surgeons. Modifier AQ is used to identify circumstances when generalsurgeons furnish services in areas that are designated as HPSAs as of December 31 of the prior year, butthat are not on the list of ZIP codes eligible for automatic payment. Modifier AQ should be appended tothe major surgical procedure on claims submitted for payment, similar to the current process for paymentof the original Medicare HPSA physician bonus when the HPSA is not a HPSA identified for automaticpayment.CMS is defining major surgical procedures as those for which a 10-day or 90-day global period is used forpayment under the PFS.Computation of PaymentMedicare contractors will compute the payment and pay general surgeons an additional incentivepayment 10 percent of the amount actually paid for the service, not the Medicare approved paymentamount. Claim adjustment reason code LE will identify the incentive payment as noted on the specialremittance generated with the incentive payment.Additional InformationIf you have questions, please contact your Medicare carrier and/or MAC at their toll-free number whichmay be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.The official instruction, CR 7063, issued to your Medicare carrier and/or MAC regarding this incentiveprogram may be viewed at http://www.cms.gov/Transmittals/downloads/R2040CP.pdf on the CMS Website.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 86 MMR 2011-01, January 2011

News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.New Physician Specialty Codes for Cardiac Electrophysiology andSports MedicineMLN Matters® Number: MM7209Related Change Request (CR) #: 7209Related CR Release Date: November 19, 2010Effective Date: April 1, 2011Related CR Transmittal #: R2098Implementation Date: April 4, 2011Provider Types AffectedThis article is for physicians and non-physician practitioners who bill Medicare carriers and Medicareadministrative contractors (A/B MAC) for providing cardiac electrophysiology and sports medicineservices to Medicare beneficiaries.What You Need to KnowMedicare physician and nonphysician practitioner specialty codes describe the specific/unique types ofmedicine that physicians and nonphysician practitioners (and certain other suppliers) practice. Specialtycodes are used by the Centers for Medicare & Medicaid Services (CMS) for programmatic and claimsprocessing purposes, each code becoming associated with the claims that a physician or nonphysicianpractitioner submits.Note: Physicians, who enroll in Medicare, self-designate their Medicare physician specialty on theMedicare enrollment application (CMS-855I) or Internet-based Provider Enrollment, Chain andOwnership System; however, nonphysician practitioners are assigned a Medicare specialty code whenthey enroll.Change Request (CR) 7209, from which this article is taken, announces that (effective April 1, 2011) CMSwill establish new physician specialty codes for Cardiac Electrophysiology and Sports Medicine. Thesecodes are:CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 87 MMR 2011-01, January 2011

• Cardiac Electrophysiology – 21; and• Sports Medicine – 23.You should ensure that your billing staffs are aware of these new physician specialty codes.Additional InformationYou can find CR 7209, located at http://www.cms.gov/Transmittals/downloads/R2098CP.pdf on the CMSWeb site. If you have any questions, please contact your carrier or A/B MAC at their toll-free number,which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zipon the CMS website.News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not gettingtheir annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United Stateseach year, on average. More than 90 percent of these deaths occur in people 65 years of age and older.Please talk with your Medicare patients about the importance of getting their annual flu vaccination. ThisMedicare-covered preventive service will protect them for the entire flu season. And remember,vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’tforget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself.Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Edits on the Ordering/Referring Providers in Medicare Part B Claims(Change Requests 6417, 6421, and 6696)MLN Matters Number: SE1011 RevisedRelated Change Request (CR) #: 6421, 6417, and 6696Related CR Release Date: N/AEffective Date: N/ARelated CR Transmittal #: R642OTN, R643OTN, and R328PIImplementation Date: N/A*Note: This article was revised on November 26, 2010 to include the following statement: The Centers forMedicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certainPart B billed items and services require an ordering/referring provider and the ordering/referringprovider is not in the claim, is not of a profession that is permitted to order/refer, or does not have anenrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), theclaim will not be paid. The automated edits will not be turned on effective January 3, 2011. We areworking diligently to resolve enrollment backlogs and other system issues and will provide ampleadvanced notice to the provider and beneficiary communities before we begin any automaticnonpayment actions.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 88 MMR 2011-01, January 2011

Provider Types AffectedPhysicians, nonphysician practitioners (including residents, fellows, and also those who are employed bythe Department of Veterans Affairs (DVA) or the Public Health Service (PHS)) who order or refer items orservices for Medicare beneficiaries, Part B providers and suppliers who submit claims to carriers, Part BMedicare administrative contractors (MACs), and durable medical equipment (DME) MACs for items orservices that they furnished as the result of an order or a referral should be aware of this information.Provider Action NeededIf you order or refer items or services for Medicare beneficiaries and you do not have an enrollmentrecord in the Provider Enrollment, Chain and Ownership System (PECOS), you need to submit anenrollment application to Medicare. You can do this using Internet-based PECOS or by completing thepaper enrollment application (CMS-855I). If you reassign your Medicare benefits to a group or clinic, youwill also need to complete the CMS-855R.What Providers Need to KnowPhase 1: Beginning October 5, 2009, if the billed Part B service requires an ordering/referring providerand the ordering/referring provider is not reported on the claim, the claim will not be paid. If theordering/referring provider is reported on the claim but does not have a current enrollment record inPECOS or is not of a specialty that is eligible to order and refer, the claim will be paid and the billingprovider will receive an informational message in the remittance indicating that the claim failed theordering/referring provider edits.Phase 2: Beginning January 3, 2011, (*See “Note” statement delaying implementation of phase 2.),Medicare will reject Part B claims that fail the Ordering/Referring Provider edits. Physicians and otherswho are eligible to order and refer items or services need to establish their Medicare enrollment recordsin PECOS and must be of a specialty that is eligible to order and refer.Enrolled physicians and nonphysician practitioners who do not have enrollment records in PECOS andwho submit enrollment applications in order to get their enrollment information into PECOS should notexperience any disruption in Medicare payments, as a result of submitting enrollment applications.Enrollment applications must be processed in accordance with existing Medicare instructions. It ispossible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to processenrollment applications. All enrollment applications, including those submitted over the Web, requireverification of the information reported. Sometimes, Medicare enrollment contractors may requestadditional information in order to process the enrollment application.Waiting too late to begin this process could mean that your enrollment application will not be able to beprocessed prior to the implementation date of Phase 2 of the Ordering/Referring Provider edits, which isJanuary 3, 2011.BackgroundThe Centers for Medicare & Medicaid Services (CMS) has implemented edits on Ordering and ReferringProviders when they are required to be identified in Part B claims from Medicare providers or supplierswho furnished items or services as a result of orders or referrals.• Below are examples of some of these types of claims:o Claims from laboratories for ordered tests;o Claims from imaging centers for ordered imaging procedures;CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 89 MMR 2011-01, January 2011

o Claims from suppliers of durable medical equipment, prosthetics, orthotics and supplies(DMEPOS) for ordered DMEPOS; ando MLN Matters number: SE1011 Related Change Request Numbers: 6417, 6421, 6696o Claims from specialists or specialty groups for referred services.• Only physicians and certain types of nonphysician practitioners are eligible to order or refer items orservices for Medicare beneficiaries. They are as follows:o Physician (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery,doctor of podiatric medicine, doctor of optometry, doctor of chiropractic medicine),o Physician Assistant,o Certified Clinical Nurse Specialist,o Nurse Practitioner,o Clinical Psychologist,o Certified Nurse Midwife, ando Clinical Social Worker.Questions and Answers Relating to the Edits1. What will the edits do?The edits will determine if the Ordering/Referring Provider (when required to be identified in a Part Bclaim) (1) has a current Medicare enrollment record (i.e., the enrollment record is in PECOS and itcontains the National Provider Identifier (NPI)), and (2) is of a type that is eligible to order or refer forMedicare beneficiaries (see list above).2. Why did Medicare implement these edits?These edits help protect Medicare beneficiaries and the integrity of the Medicare Program.3. How and when will these edits be implemented?These edits are being implemented in two phases:• Phase 1 began on October 5, 2009, and is scheduled to end on January 2, 2011. In Phase 1, if theOrdering/Referring Provider does not pass the edits, the claim will be processed and paid(assuming there are no other problems with the claim) but the Billing Provider (the provider whofurnished the item or service that was ordered or referred) will receive an informationalmessage* from Medicare in the remittance advice+.The informational message will indicate that the identification of the Ordering/Referringprovider is missing, incomplete, or invalid, or that the Ordering/Referring Provider is not eligibleto order or refer. The informational message on an adjustment claim that does not pass the editswill indicate that the claim/service lacks information that is needed for adjudication.Note: if the billed service requires an ordering/referring provider and the ordering/referringprovider is not on the claim, the claim will not be paid.• Phase 2 is scheduled to begin on January 3, 2011, and will continue thereafter. In Phase 2, if theOrdering/Referring Provider does not pass the edits, the claim will be rejected. This means thatthe Billing Provider will not be paid for the items or services that were furnished based on theorder or referral.CMS has taken actions to reduce the number of informational messages.In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physiciansand nonphysician practitioners who are eligible to order and refer but who had not updated their PECOSenrollment records with their NPIs++.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 90 MMR 2011-01, January 2011

On January 28, 2010, CMS made available to the public, via the Downloads section of the “OrderingReferring Report” page on the Medicare provider/supplier enrollment Web site, a file containing the NPIsand the names of physicians and nonphysician practitioners who have current enrollment records inPECOS and are of a type/specialty that is eligible to order and refer. The file, called the OrderingReferring Report, lists, in alphabetical order based on last name, the NPI and the name (last name, firstname) of the physician or nonphysician practitioner. To keep the available information up to date, CMSwill replace the Report on a periodic basis. At any given time, only one Report (the most current) will beavailable for downloading. To learn more about the Report, and to download it, go tohttp://www.cms.gov/MedicareProviderSupEnroll; click on “Ordering Referring Report” (on the left).Information about the Report will be displayed.* The informational messages vary depending on the claims processing system.+ DMEPOS suppliers who submit paper claims will not receive an informational message on theRemittance Advice.++ NPIs were added only when the matching criteria verified the NPI.Effect of Edits on ProvidersA. I order and refer. How will I know if I need to take any sort of action with respect to these twoedits?In order for the claim from the billing provider (the provider who furnished the item or service) to bepaid by Medicare for furnishing the item or service that you ordered or referred, you—theOrdering/Referring Provider—need to ensure that:1. You have a current Medicare enrollment record (that is, your enrollment record is in PECOSand it includes your NPI).• If you enrolled in Medicare after 2003, your enrollment record is in PECOS and CMS mayhave added your NPI to it.• If you enrolled in Medicare prior to 2003 but submitted an update(s) to your enrollmentinformation since 2003, your enrollment record is in PECOS and CMS may have added yourNPI to it.• If you enrolled in Medicare prior to 2003 and have not submitted an update to your Medicareenrollment information in 6 or more years, you do not have an enrollment record in PECOS.You need to take action to establish one. See the last bullet in this section.• If you are not sure, you may: (1) check the Ordering Referring Report mentioned above, andif you are on that report, you have a current enrollment record in Medicare (that is, yourenrollment record is in PECOS and it contains your NPI); (2) contact your designatedMedicare enrollment contractor and ask if you have an enrollment record in PECOS thatcontains the NPI; or (3) use Internet-based PECOS to look for your PECOS enrollment record(if no record is displayed, you do not have an enrollment record in PECOS). If you choose (3),please read the information on the Medicare provider/supplier enrollment Web page aboutInternet-based PECOS before you begin.• If you do not have an enrollment record in PECOS:• You need to submit an enrollment application to Medicare in one of two ways:a. Use Internet-based PECOS to submit your enrollment application over the Internetto your designated Medicare enrollment contractor. You will have to print, sign, anddate the Certification Statement and mail the Certification Statement, and anyrequired supporting paper documentation, to your designated Medicare enrollmentcontractor. The designated enrollment contractor cannot begin working on yourapplication until it has received the signed and dated Certification Statement. If youwill be using Internet-based PECOS, please visit the Medicare provider/supplierenrollment Web page to learn more about the Web-based system before you attemptCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 91 MMR 2011-01, January 2011

to use it. Go to http://www.cms.gov/MedicareProviderSupEnroll, click on “InternetbasedPECOS” on the left-hand side, and read the information that has been postedthere. Download and read the documents in the Downloads Section on that page thatrelate to physicians and nonphysician practitioners. A link to Internet-based PECOSis included on that Web page.Note for physicians/nonphysician practitioners who reassign all their Medicarebenefits to a group/clinic: If you reassign all of your Medicare benefits to agroup/clinic, the group/clinic must have an enrollment record in PECOS in order foryou to enroll via the Web. You should check with the officials of the group/clinic orwith your designated Medicare enrollment contractor if you are not sure if thegroup/clinic has an enrollment record in PECOS. If the group/clinic does not have anenrollment record in PECOS, you will not be able to use the Web to submit yourenrollment application to Medicare. You will need to submit a paper application, asdescribed in the bullet below.b. Obtain a paper enrollment application (CMS-855I), fill it out, sign and date it, andmail it, along with any required supporting paper documentation, to yourdesignated Medicare enrollment contractor. If you reassign all your Medicarebenefits to a group/clinic, you will also need to fill out, sign and date the CMS-855R,obtain the signature/date signed of the group’s Authorized Official, and mail theCMS-855R, along with the CMS-855I, to the designated Medicare enrollmentcontractor. Enrollment applications are available for downloading from the CMSforms page http://www.cms.gov/cmsforms or by contacting your designatedMedicare enrollment contractor.Note about physicians/nonphysician practitioners who have opted-out ofMedicare but who order and refer: Physicians and nonphysician practitioners whohave opted out of Medicare may order items or services for Medicare beneficiaries.Their opt-out information must be current (an affidavit must be completed every twoyears, and the NPI is required on the affidavit). Opt-out practitioners whoseaffidavits are current should have enrollment records in PECOS that contain theirNPIs.2. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries.When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialtyand only the nonphysician practitioner specialties listed above in this article are eligible to orderor refer in the Medicare Program.B. I bill Medicare for items and services that were ordered or referred. How can I be sure that myclaims for these items and services will pass the Ordering/Referring Provider edits?As the billing provider, you need to ensure that your Medicare claims for items or services that youfurnished based on orders or referrals will pass the two edits on the Ordering/Referring Provider sothat you will not receive informational messages in Phase 1 and so that your claims will be paid inPhase 2.You need to use due diligence to ensure that the physicians and nonphysician practitioners fromwhom you accept orders and referrals have current Medicare enrollment records (i.e., they haveenrollment records in PECOS that contain their NPIs) and are of a type/specialty that is eligible toorder or refer in the Medicare Program. If you are not sure that the physician or nonphysicianpractitioner who is ordering or referring items or services meets those criteria, it is recommended thatyou check the Ordering Referring Report described earlier in this article. Ensure you are correctlyCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 92 MMR 2011-01, January 2011

spelling the Ordering/Referring Provider’s name. If you furnished items or services from an order orreferral from someone on the Ordering Referring Report, your claim should pass theOrdering/Referring Provider edits. Keep in mind that this Ordering Referring Report will be replacedabout once a month to ensure it is as current as practicable. It is possible, therefore, that you mayreceive an order or a referral from a physician or nonphysician practitioner who is not listed in theOrdering Referring Report but who may be listed on the next Report. You may resubmit a claim thatdid not initially pass the Ordering/Referring Provider edits.Make sure your claims are properly completed. Do not use “nicknames” on the claim, as their usecould cause the claim to fail the edits (e.g., Bob Jones instead of Robert Jones will cause the claim tofail the edit, as the edit will look for R, not B, as the first letter of the first name). Do not enter acredential (e.g., “Dr.”) in a name field. On paper claims (CMS-1500), in Item 17, you should enter theOrdering/Referring Provider’s first name first, and last name second (e.g., John Smith). Ensure thatthe name and the NPI you enter for the Ordering/Referring Provider belong to a physician ornonphysician practitioner and not to an organization, such as a group practice that employs thephysician or nonphysician practitioner who generated the order or referral. Make sure that thequalifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1 (person). Organizations(qualifier 2) cannot order and refer. If there are additional questions about the informationalmessages, Billing Providers should contact their local carrier, A/B MAC, or DME MAC.Billing Providers should be aware that claims that are rejected because they failed theOrdering/Referring Provider edits are not denials of payment by Medicare that would expose theMedicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate.Additional Guidance1. Orders or referrals by interns or residents. Interns are not eligible to enroll in Medicare because theydo not have medical licenses. Unless a resident (with a medical license) has an enrollment record inPECOS, he/she may not be identified in a Medicare claim as the Ordering/Referring Provider. Theteaching, admitting, or supervising physician is considered the Ordering/Referring Provider wheninterns and residents order and refer, and that physician’s name and NPI would be reported on theclaim as the Ordering/Referring Provider.2. Orders or referrals by physicians and nonphysician practitioners who are of a type/specialty that iseligible to order and refer who work for the Department of Veterans Affairs (DVA), the PublicHealth Service (PHS), or the Department of Defense(DoD)/Tricare. These physicians andnonphysician practitioners will need to enroll in Medicare in order to continue to order or refer itemsor services for Medicare beneficiaries. They may do so by filling out the paper CMS-855I or they mayuse Internet-based PECOS. They must include a covering note with the paper application or with thepaper Certification Statement that is generated when submitting a Web-based application that statesthat they are enrolling in Medicare only to order and refer. They will not be submitting claims toMedicare for services they furnish to Medicare beneficiaries.3. Orders or referrals by dentists. Most dental services are not covered by Medicare; therefore, mostdentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and refer items orservices for Medicare beneficiaries (e.g., to send specimens to a laboratory for testing). To do so, theymust be enrolled in Medicare. They may enroll by filling out the paper CMS-855I or they may useInternet-based PECOS. They must include a covering note with the paper application or with thepaper Certification Statement that is generated when submitting a Web-based application that statesthat they are enrolling in Medicare only to order and refer. They will not be submitting claims toMedicare for services they furnish to Medicare beneficiaries.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 93 MMR 2011-01, January 2011

Additional InformationYou may want to review the following related CRs:• CR 6417 at http://www.cms.gov/Transmittals/downloads/R642OTN.pdf on the CMS Web site;• CR 6421 at http://www.cms.gov/Transmittals/downloads/R643OTN.pdf on the CMS Web site; and• CR 6696 at http://www.cms.gov/Transmittals/downloads/R328PI.pdf on the CMS Web site.If you have questions, please contact your Medicare carrier, Part A/B Medicare administrative contractor(A/B MAC), or durable medical equipment Medicare administrative contractor (DME/MAC), at their tollfreenumbers, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.Physicians and Nonphysician Practitioners Excluded from Deactivationin Medicare Due to Inactivity with MedicareMLN Matters® Number: SE1034Related Change Request (CR) #: N/ARelated CR Release Date: N/AEffective Date: N/ARelated CR Transmittal #: N/AImplementation Date: N/AProvider Types AffectedPhysicians and nonphysician practitioners (NPPs) who need to enroll in the Medicare Program for thesole purpose of ordering and referring items and services for Medicare beneficiaries are excluded fromthe process that would deactivate them after 12 consecutive months of nonbilling.Provider Action NeededThis article is for certain physicians and NPPs who have the unique enrollment scenarios of enrolling forthe sole purpose of ordering and referring items and services for Medicare beneficiaries. These physiciansand NPPs do not and will not send claims to a Medicare contractor for the services they furnish and shallbe excluded from the 12-month nonbilling deactivation process. The supplier types affected are listed inthe Background section of this article.BackgroundThe Centers for Medicare & Medicaid Services (CMS) instructs Medicare contractors to deactivate therecords of physicians and NPPs who have had no activity in submitting claims to Medicare contractorsfor 12 consecutive months. However, CMS excludes certain physicians and NPPs from this deactivationprocess and has instructed Medicare contractors accordingly. The supplier types that are excluded fromdeactivation for nonbilling include the following physicians and NPPs who are employees of Departmentof Veterans Affairs (DVA), Department of Defense (DOD), or public health service (PHS) and employeesof Medicare enrolled federally qualified health center (FQHC), critical access hospital (CAH), and ruralhealth clinic (RHCs):• Doctor of medicine or osteopathy;• Doctor of dental medicine;• Doctor of dental surgery;CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 94 MMR 2011-01, January 2011

• Doctor of podiatric medicine;• Doctor of optometry;• Doctor of chiropractic medicine;• Physician assistant;• Certified clinical nurse specialist;• Nurse practitioner;• Clinical psychologist;• Certified nurse midwife; and• Clinical social worker.In addition, the following supplier types, regardless of their employment, are excluded from thedeactivation process:• Pediatric medicine physicians (specialty 37); and• Oral surgery (dentist only, specialty 19)Additional InformationIf you have questions, contact your designated Medicare contractor at its toll free number, which isavailable at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Recovery Audit Contractor Demonstration High-Risk Vulnerabilities forPhysiciansMLN Matters® Number: SE1036Related Change Request (CR) #: N/ARelated CR Release Date: N/AEffective Date: N/ARelated CR Transmittal #: N/AImplementation Date: N/AThis is the fourth in a series of articles that will disseminate information on recovery audit contractor(RAC) demonstration high dollar improper payment vulnerabilities. The purpose of this article is toprovide education to physicians on two vulnerabilities in an effort to prevent these same problems fromoccurring in the future. With the expansion of the RAC Program nationally, it is essential that physiciansunderstand the lessons learned from the demonstration and implement appropriate corrective actions.Physician Types AffectedThis article is for all physicians that submit Fee-For-Service claims to Medicare carriers or Part A/BMedicare administrative contractors (MACs).Physician Action NeededReview the article and take steps, if necessary, to meet Medicare’s billing requirements to avoidunnecessary denial of your claims.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 95 MMR 2011-01, January 2011

BackgroundThe primary goal of the RAC demonstration was to determine if recovery auditing could be effective inMedicare. The Centers for Medicare & Medicaid Services (CMS) directed the RAC staff to organize theirefforts primarily to attain that goal.Supplemental goals, such as correcting identified vulnerabilities, were identified after the fact and werenot required tasks. CMS did collect improper payment information from the RACs. However, it was on avoluntary basis, and was done at the claim level and focused on the collection. Two high riskvulnerabilities for physician claims are listed in Table 1. These claims were denied because thedemonstration RACs determined that either a duplicate claim was billed and paid or the physicianreported an incorrect number of units for current procedural terminology (CPT) code billed based on theCPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy.Table 1ItemProviderTypeImproper PaymentAmount (preappeal)RAC Demonstration Findings1 Physician $6,635,558 Other Services with Excessive Units - Units billedexceeded the number of units per day based on theCPT code descriptor, reporting instructions in theCPT book, and/or other CMS local or nationalpolicy.2 Physician $1,094,751 Duplicate Claims - Physician billed and was paidfor two claims for the same beneficiary, for thesame date of service, same CPT code, and samephysician.Note: The two findings identified in Table 1 impacted multiple codes and no specific coding trends wereself-reported by the RACs for these categories.Summary of RAC Demonstration FindingsThe two high-risk vulnerabilities for physician claims listed in Table 1 were identified because thedemonstration RACs determined that either a duplicate claim was billed and paid or the units billedexceeded the number of units per day according to the CPT code descriptor, instructions in the CPT book,and/or other CMS local or national policy.Physician Billing and Documentation RemindersAn overpayment exists when a physician bills and is paid for services that have been previouslyprocessed and paid. See the CMS Internet-Only Manual (IOM), Medicare Financial Management Manual,Chapter 3, Section 10.2 at http://www.cms.gov/manuals/downloads/fin106c03.pdf on the CMS Web site.For more specific information on what criteria constitutes a duplicate claim see the CMS IOM, MedicareClaim Processing Manual, Chapter 1, Section 120 found athttp://www.cms.gov/manuals/downloads/clm104c01.pdf on the CMS Web site. CMS reminds physiciansthat routinely submitting duplicate claims to Part B carriers and MACs for a single service encounter isinappropriate. CMS asks physicians to discontinue this practice. For more information on avoidingduplicate billing, please review Medicare Learning Network (MLN) Matters article SE0415 found athttp://www.cms.gov/MLNMattersArticles/downloads/SE0415.pdf on the CMS Web site.CMS guidance requires physicians to bill using the appropriate CPT code and to accurately report theunits of service. Physicians should ensure that the units billed do not exceed the number of units per dayCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 96 MMR 2011-01, January 2011

ased on the CPT code descriptor, reporting instructions in the CP book, and/or other CMS local ornational policy.Additional InformationPhysicians are also encouraged to visit the CMS RAC Web site at http://www.cms.gov/RAC for updateson the National RAC Program. On the Web site you can register to receive e-mail updates and viewcurrent RAC activities nationwide.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu.Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenzavaccine is not a Part D covered drug. For information about Medicare’s coverage of the influenza vaccineand its administration, as well as related educational resources for health care professionals and theirstaff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 97 MMR 2011-01, January 2011