The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
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
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Quarterly Update to Correct Coding Initiative Edits, Version 17.0,effective <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>MLN Matters® Number: MM7210Related Change Request (CR) #: 7210Related CR Release Date: November 19, 2<strong>01</strong>0Effective Date: <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>Related CR Transmittal #: R2097CPImplementation Date: <strong>January</strong> 3, <strong>2<strong>01</strong>1</strong>Provider Types AffectedPhysicians and providers submitting claims to <strong>Medicare</strong> carriers and/or Part A/B <strong>Medicare</strong>administrative contractors (A/B MACs) for services provided to <strong>Medicare</strong> 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. <strong>The</strong> last quarterly release of the editmodule was issued in October 2<strong>01</strong>0.Background<strong>The</strong> Centers for <strong>Medicare</strong> & 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.<strong>The</strong> 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• <strong>Review</strong> of current coding practice.<strong>The</strong> latest package of CCI edits, Version 17.0, is effective <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>, and includes all previousversions and updates from <strong>January</strong> 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 Information<strong>The</strong> CCI and MEC file formats are defined in the CMS Internet-Only Manual (IOM) Publication 100-04,<strong>Medicare</strong> Claims Processing Manual, Chapter 23, Section 20.9, which is available athttp://www.cms.gov/manuals/downloads/clm104c23.pdf on the CMS Web site. <strong>The</strong> 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 2<strong>01</strong>0 American Medical Association (or such other date publication of CPT)<strong>The</strong> <strong>Medicare</strong> <strong>Monthly</strong> <strong>Review</strong> 53 <strong>MMR</strong> <strong>2<strong>01</strong>1</strong>-<strong>01</strong>, <strong>January</strong> <strong>2<strong>01</strong>1</strong>