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

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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
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Centers for Medicare & Medicaid Ser
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National Government Services Articl
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R4 (effective 12/16/2010): Due to a
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Article for Cardiovascular Nuclear
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For dates of service prior to 01/01
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Article for Magnetic Resonance Imag
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LCD for Scanning Computerized Ophth
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Article for Determination of Cardia
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• CMS Internet-Only Manual (IOM),
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Page 27 and 28: • HCPCS codes Q2026, Q2027, and G
Page 29 and 30: Calendar Year 2011 Annual Update fo
Page 31 and 32: Mapping Information• New code 829
Page 33 and 34: Waiver of Coinsurance and Deductibl
Page 35 and 36: Ambulance Inflation Factor for CY 2
Page 37 and 38: Key Points of CR 7049CMS is adding
Page 39 and 40: Medicare-covered preventive service
Page 41 and 42: staff, please visit http://www.cms.
Page 43 and 44: CMS has decided to follow the same
Page 45 and 46: 2011. This amendment’s expanded c
Page 47 and 48: • Rural Health Clinics (TOB 71X)
Page 49 and 50: Note: CMS requests provider, physic
Page 51 and 52: If you have any questions, please c
Page 53 and 54: Quarterly Update to Correct Coding
Page 55 and 56: • Peak oxygen consumption.Note: V
Page 57 and 58: more than 12 months after a person
Page 59 and 60: last year, increased by 1.1 percent
Page 61 and 62: CodePayment LimitQ4027 $17.23Q4028
Page 63 and 64: BillingIn general, it is inappropri
Page 65 and 66: Provider Action NeededImpact to You
Page 67 and 68: IntroductionAnnual outbreaks of sea
Page 69 and 70: • CMS Frequently Asked Questions
Page 71 and 72: Primary Care ServicesThe Affordable
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Page 77 and 78: Home Health Face-to-Face Encounter
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Page 81 and 82: News Flash - A revised Medicare Lea
Page 83 and 84: DisclaimerThis article was prepared
Page 85 and 86: Provider Types AffectedThis program
Page 87 and 88: News Flash - Each Office Visit is a
Page 89 and 90: Provider Types AffectedPhysicians,
Page 91 and 92: On January 28, 2010, CMS made avail
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Page 95 and 96: • Doctor of podiatric medicine;
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The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

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