Medicare Monthly Review MMR 2009-5 - CGS

A CMS Contracted AgentMedicare Monthly ReviewIssue No. MMR 2009‐5 May 2009ContentsInformation Issued by National Government Services for Part A and Part B ProvidersPage Part A Part BComprehensive Error Rate Testing (CERT) Contacts and Web Sites....................................... 4 A AComprehensive Error Rate Testing Documentation Requirements......................................... 4 A AThe E‐Commerce Connection............................................................................................................ 5 A AMedical Policy Part A & B Updates: Revised Local Coverage Determinations...................... 5 A AInformation Issued by National Government Services for Part A ProvidersPage Part ADental Services .............................................................................................................................. 12AMay Is National Stroke Prevention Month................................................................................ 12ATransition of the Region I Home Health and Hospice Medical Review Workload ............. 13 M, PJurisdiction 14 (J14) Part A and Part B Medicare AdministrativeContractor New Workload Numbers................................................................................. 13AInformation Issued by the Centers for Medicare & Medicaid Services for Part A and Part B ProvidersPage Part A Part BImplementation of New Provider Authentication Requirements forMedicare Contractor Provider Telephone and Written Inquiries (CR6139).................. 16 A AIncorporation of Physician Fee Schedule Regulatory Changes intoChapter 10 PIM (CR6310)..................................................................................................... 18 A AMedicare Claims Processing Manual Clarifications for SNF and Therapy Billing (CR6407) .. 20 S ABilling Routine Costs of Clinical Trials (CR6431) ..................................................................... 22 A AClarification on Provider Information Required on MedicareClaims for Routine Foot Care Services (SE0907)............................................................... 23 A AThis key is provided as a convenience to alert providers/suppliers to articles with topics that may pertain to theirparticular field. This key is not a guarantee that information in other articles will not also apply. It is eachprovider’s/supplier’s responsibility to become 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 Outpatient Rehabilitation 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‐RadiationZ‐Oncology, NA‐Not ApplicableCPT five-digit codes, descriptions, and other data only are copyright 2008 American Medical Association. All Rights Reserved. No fee schedules, basicunits, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMAassumes no liability for data contained or not contained herein. Applicable FARS/DFARS clauses apply.This bulletin should be shared with all health care practitioners and managerial members of the providers/suppliers staff. Bulletinsissued beginning January 2006 are available at no cost from our Web site at www.NGSMedicare.com..

Information Issued by the Centers for Medicare & Medicaid Services for Part A ProvidersPage Part AInitial Enrollment Assignment for FQHCs, ESRD Facilities and RHCs (CR6207)................26 E, F, RHospice Cap Calculations Letters and Administrative Appeals (CR6400) ...........................28PPayment for Maintenance and Servicing of Certain Oxygen Equipment as aResult of the MIPPA (CR6404).............................................................................................29AInstructions on Utilizing 837 Institutional CAS for MSP Part A Claims(This CR Rescinds and Fully Replaces CR 6275) (CR6426)..............................................30AImplementation of Capital to IPPS Indirect Medical Education (IME) and LTCHProvisions from the ARRA of 2009 (CR6444) ....................................................................34AJurisdiction14 (J14) Part A and Part B Medicare Administrative Contractor (A/B MAC)New Workload Numbers for the States of Maine, Massachusetts,New Hampshire, Rhode Island, and Vermont (CR6406).................................................33AInformation Issued by the Centers for Medicare & Medicaid Services for Part B ProvidersPage Part BProgram Overview: 2009 PQRI and the 2009 Electronic Prescribing (E‐Prescribing)Incentive Program.................................................................................................................36AInstructions for Utilizing 837 Professional Claim Adjustment Segments (CAS)for MSP Part B Claims (This CR rescinds and fully replaces CR6211) (CR6427) ..........43DNational Government Services Training and Seminar Information for Part A and Part B ProvidersPage Part A Part BMedicare Part A & RHHI FY 2009 Education Sessions............................................................46AUpcoming Medicare Part B Provider Outreach & Education Seminars ................................47A2009 Holiday ScheduleMonday, May 25Memorial DayFriday, July 3Independence DayMonday, September 7Labor DayMonday, October 12 (Call Center Only) Columbus DayWednesday, November 11 (Call Center Only) Veterans DayThursday, November 26Thanksgiving DayFriday, November 27Day after ThanksgivingFriday, December 25Christmas DayContact Information can be found on our Web site at: http://www.NGSMedicare.com.Medicare policies can be found on our Web site in the Local Coverage Determination section. You can access thesethrough the http:// www.NGSMedicare.com homepage. Providers without access to the Internet can request hardcopies from National Government Services.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 2 MMR 2009‐5, May 2009

Information Issued by NationalGovernment ServicesforPart A and Part B ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 3 MMR 2009‐5, May 2009

Comprehensive Error Rate Testing(CERT) Contacts and Web SitesNational Government Services CERT ContactsWest, Midwest, J‐B DME MAC InquiriesPhone – 800‐338‐6101E‐mail – Clinical.Education@wellpoint.comEast InquiriesPhone – 866‐918‐0301E‐mail – EastClinicalEducation@wellpoint.comCERT Documentation Contractor InformationCERT Documentation ContractorAttention: CID #: XXXXXXXSuite 99090 Junction DriveAnnapolis Junction, MD 20701Phone – 888‐779‐7477 or 301‐957‐2380Fax – 240‐568‐6222Web Site – www.certprovider.orgComprehensive Error Rate TestingDocumentation RequirementsThe Centers for Medicare & Medicaid Services(CMS) developed the Comprehensive Error RateTesting (CERT) program to produce a nationalerror rate. Error rates are determined based onreview of medical records from regularly sampledclaims submitted to Medicare for payment.Records are reviewed to ensure that claims werepaid or denied correctly.When submitting records for review:• Please be sure documentation submitted islegible• Please submit records for all dates of serviceon the claim• Please ensure that the medical recordssubmitted provide proof that the service(s)was ordered by the MD and rendered. Alsoprovide justification to support the medicalnecessityFor medical record requests received from theCERT Contractor, please complete the followingsteps:• Photocopy the requested record as identifiedin the CERT contractor request• Submit the bar coded sheet with a copy of themedical records or cover sheet with the CID #• Preferred method of receiving records is viafax at 240‐568‐6222• If unable to fax ‐ records should be mailed to:CERT Documentation OfficeAttn: CID #9090 Junction Drive, Suite 9Annapolis Junction, MD 20701For questions related to the CERT process:East providers may call 866‐918‐0301 or e‐mailyour questions toEastClinicalEducation@wellpoint.com.West providers may call 800‐338‐6101 or e‐mailyour questions toClinicalEducation@wellpoint.com.Suggested DocumentationThe following list is not all inclusive and dependson the actual services billed; please senddocumentation to support all billed services onthe claim in question. Be sure to include anyadditional documentation you feel may supportthese billed services, e.g., EKG interpretation,radiology reports, physical therapy treatmentsattempted prior to surgery, MD signed treatmentplans, flu or other vaccine records or anyinformation you deem appropriate.CERT Operation’s record request letter includes alist of medical record components that need to besubmitted. These may include the following:• Physician progress notes and orders• Nurses notes• Medication records• Graphic reports• Operative reports• Pathology reports• Consultation notes• Referring physician report• All lab reportsCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 4 MMR 2009‐5, May 2009

• Diagnostic test results (regardless of wherethey are performed)• History and physical notes• Hospice records• Home health progress notes• Certificate of Medical Necessity• Skilled nursing facility records (includingMDS look back periods)• Ambulance records• Emergency room records• Therapy progress notes and reports• Treatment logs with documentation of totaltreatment time for timed modalities• Current treatment plan with MD signature• Physician order for diagnostic and/ortherapeutic services• Initial evaluations and current re‐evaluationsfor ongoing therapeutic services with MDsignature and diagnoses showing medicalnecessity• Admission evaluation and information tosupport medical necessity of inpatientadmissions. In the case of inpatient admissionfor surgery, include documentation ofconservative treatment prior to surgery andradiologic evidence showing need for surgery• Inpatient rehabilitation assessmentinstrument for inpatient rehabilitationservice(s) (IRFPAI)• Chiropractic treatment plan/notes/logsincluding the previous six months treatmentdocumentation if for the same condition assampled claimThe E-Commerce ConnectionEffective immediately, National GovernmentServices will discontinue publishing the quarterlyElectronic Data Interchange (EDI) onlinenewsletter, the E‐Commerce Connection. TheE‐Commerce Connection was created to provideinformation specifically geared towards electronicsubmitters, software vendors, billing services andclearinghouses. Over 98 percent of the claims thatare received by National Government Services aresent electronically. Because most providers arenow electronic, National Government Services nolonger felt the need to provide a separatenewsletter for this target group. NationalGovernment Services will continue to provide EDIarticles through the Listserv, Web site and in theEDI section of the monthly bulletin, the MedicareMonthly Review. Adding EDI related articles to theMedicare Monthly Review will provide MedicarePart A and Part B providers one newsletter thatcontains all updated information.All previously published copies of the E‐CommerceConnection are still available on the NationalGovernment Services Web site.All future EDI articles will be included in theMedicare Monthly Review, beginning with the May2009 publication.Medical Policy Part A & B Updates:Revised Local CoverageDeterminations and SupplementalInstructions ArticlesRevisions Effective May 1, 2009Brachytherapy (L28433)(R1) (effective 05/01/2009): Source of revision –Internal/External (reconsideration request).Added the following paragraphs to the “Abstract”section:Brachytherapy is a type of radiation therapy thatutilizes natural or manufactured radioactiveisotopes or radionuclides that are temporarily orpermanently implanted to treat malignancies orcertain benign conditions. Brachytherapy may beused by itself or as an adjunctive treatment incombination with external beam therapy.There are two distinct phases required tocomplete the process known as brachytherapy:the insertion of nonradioactive applicators orconduits that receive or transmit the radioactivematerial into the body, and the loading of theradioactive material (the active or therapeuticagent) into the conduits or directly into tissue.Low Dose Rate (LDR) and High Dose Rate (HDR)procedures may be given with intent to cure, topalliate, or to obtain local control.Brachytherapy requires the expertise of a team oftrained personnel (physician, physicist,dosimetrist, radiation therapist, nurse, andradiation safety officer) to implement theCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 5 MMR 2009‐5, May 2009

individualized treatment plan designed by theradiation oncologist. The typical requirements ofbrachytherapy are discussed.Intra‐vascular brachytherapy is the application ofradiation therapy in the management of in‐stentrestenosis of the coronary artery. The onlycovered indication for the application ofintravascular brachytherapy is the management ofthe status post coronary stent placement patientwho presents with symptoms of chest painsattributable to in‐stent restenosis.The patient’s medical record must containdocumentation that fully supports the medicalnecessity for these services. The treatment goalmust be documented (curative, palliative ortumor control) in the medical record. Given themultiplicity of services that are inherent inbrachytherapy, it is essential that the medicalrecords reflect each service in a clear linear andtemporally logical form. Flow charts, wherehelpful, are recommended. All services should bedocumented with a procedural note.Added the following statement to the “OtherComments” section:Refer to local coverage determination (LCD)L26876 on Transrectal Ultrasound for coverageinformation regarding CPT code 76873(Ultrasound, transrectal; prostate volume studyfor brachytherapy treatment planning (separateprocedure).Removed CPT code 76873 from the “CPT/HCPCSCodes” section.Moved CPT code 76965 from the listing of CPTcodes which are designated for use by theurologist when providing brachytherapy servicesto the first CPT code listing in the “CPT/HCPCSCodes” section.Added ICD‐9‐CM code 233.0 to the first ICD‐9‐CM code listing in the “ICD‐9‐CM Codes thatSupport Medical Necessity” section. Due to anoversight by the contactor, this change will beeffective for dates of service on or after January 1,2009.Corrected the format of seven sources in the“Sources of Information and Basis for Decision”section.The changes listed in this revision do NOT applyto the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, coverage provisions, andrequirements in the LCD remain in effect for thesestates.Brachytherapy ‐ Supplemental InstructionsArticle (A47995)Article published May 2009. Source of revision –Internal/External (reconsideration request):Removed the following coding guideline:CPT code 76873 (echography, transrectal; prostatevolume study for brachytherapy treatmentplanning [separate procedure]) is used to reportthe plan for treatment protocol for prostatecancer.Removed CPT code 76873 from the “CPT/HCPCSCodes” section.Moved CPT code 76965 from the listing of CPTcodes which are designated for use by theurologist when providing brachytherapy servicesto the first CPT code listing in the “CPT/HCPCSCodes” section.The changes listed in this latest version of thesupplemental instructions article (SIA) do NOTapply to the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states.Computed Tomographic (CT) Colonography(L25233)(R3) (Effective 05/01/2009): Source of revisioninternal. CT colonography is not reimbursablewhen used for screening (ICD‐9‐CM code V76.51).CPT code 0066T is not a covered service andtherefore is removed from this LCD. No commentor notice period required or given.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 6 MMR 2009‐5, May 2009

Computed Tomographic (CT) Colonography ‐Supplemental Instructions Article (A44376)Article published May 2009: This SIA wasrevised to clarify that CT colonography is notreimbursable when used for screening (ICD‐9‐CMcode V76.51). CPT code 0066T is not a coveredservice and therefore is removed from this SIA.Computed Tomography (L28516)(R1)(Effective 05/01/2009): Source of revisionexternal.Revision due to a valid reconsiderationrequest. ICD‐9‐CM code: 198.5 (Secondarymalignant neoplasm of bone and bone marrow)added to the CT: Abdomen and Pelvis section.CPT codes for the abdominal/pelvis section are:72192, 72193, 72194, 74150, 74160, 74170, 76376,and 76377. This change applies for Dates ofService beginning 01/01/2009. The changes listedin this revision do NOT apply to the states ofMaine (contract 00180), Massachusetts (contract00181), or Vermont and New Hampshire (contract00270); however, all other instructions, coverageprovisions, and requirements in the LCD remainin effect for these states. No comment and noticerequired or given.Debridement Services (L27373)(R2) (effective 05/01/2009): Source of revision –External. Added two additional sentences to thefollowing limitation:Removing a collar of callus (hyperkeratotic tissue)around an ulcer is not debridement of skin ornecrotic tissue and should not be billed as such.The service should be billed under CPT code11055 or 11056. Please refer to NGS LCD RoutineFoot Care and Debridement of Nails (L26426) forinformation regarding these CPT codes.Removed CPT codes 11055 and 11056 from the“CPT/HCPCS Codes” section. Removed CPTcodes 11055 and 11056 from the CPT codes whichapply to the second listing of ICD‐9‐CM codes inthe “ICD‐9‐CM Codes that Support MedicalNecessity” section. Minor template changes weremade to reflect current template language.The changes listed in this revision do NOT applyto the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, coverage provisions, andrequirements in the LCD remain in effect for thesestates.Debridement Services ‐ SupplementalInstructions Article (A47396)Article published May 2009. Source of revision –External. Removed CPT codes 11055 and 11056from the “CPT/HCPCS Codes” section. Minortemplate changes were made to reflect currenttemplate language.The changes listed in this latest version of thesupplemental instructions article (SIA) do NOTapply to the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states.Drugs and Biologicals, Coverage of, for Labeland Off‐Label Uses (L25820)(R7) (Effective 05/01/2009): External: The“Limitations” section has been revised to addclarification on IV vs oral anti‐emetic therapy. Thechanges listed in this revision do NOT apply tothe states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, coverage provisions, andrequirements in the LCD remain in effect for thesestates. Minor changes were made to reflect currenttemplate language. No notice period required andnone given.Drugs and Biologicals, Coverage of, for Labeland Off‐Label Uses ‐ Supplemental InstructionsArticle (A44930)Article published May, 2009: Source of revision –External/internal ‐ the guideline for IV drugs thathave an available oral form has been revised toindicate that the list of ICD‐9‐CM codes belowthis statement is not all inclusive. The guidelinesfor reporting unlisted drug codes J3490, J3590,J9999 and C9399 have been separated into Part Afiscal intermediary or MAC and Part B carrier andMAC. The changes listed in this latest version ofthe supplemental instructions article (SIA) doNOT apply to the states of Maine (contract 00180),CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 7 MMR 2009‐5, May 2009

Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states. Minor changeswere made to reflect current template language.Noninvasive Vascular Studies (L27355)(R1) (Effective Date 05/01/2009): Source ofRevision External – Reconsideration request.The following reference was added to CMSNational Coverage Policy: 42CFR, Section 410.33provides guidelines for independent diagnostictesting facilities (IDTFs) including requirementsfor technician personnel and supervisingphysicians.The General Indications were updated in theCredentialing and Accreditation Standardssection as follows:Examples of appropriate personnel certificationinclude, but are not limited to the RegisteredPhysician in Vascular Interpretation (RPVI),Registered Vascular Technologist (RVT), theRegistered Cardiovascular Technologist (RCVT),Registered Vascular Specialist (RVS), and theAmerican Registry of Radiologic Technologists(ARRT) credentials in vascular technology.Appropriate laboratory accreditation includes theAmerican College of Radiology (ACR) VascularUltrasound Program, and the IntersocietalCommission for the Accreditation of VascularLaboratories (ICAVL).Please Note: 42 CFR Section 410.33, IndependentDiagnostic Testing Facilities, includescredentialing requirements that supersede thoseabove:The supervising physician must evidenceproficiency in the performance and interpretationof each type of diagnostic procedure performedby the IDTF. The proficiency may be documentedby certification in specific medical specialties orsubspecialties or by criteria established by thecarrier for the service area in which the IDTF islocated. See 42 CFR Section 410‐33 (2) (b).Nonphysician personnel. Any nonphysicianpersonnel used by the IDTF to perform tests mustdemonstrate the basic qualifications to performthe tests in question and have training andproficiency as evidenced by licensure orcertification by the appropriate state health oreducation department. In the absence of a Statelicensing board, the technician must be certifiedby an appropriate national credentialing body.The IDTF must maintain documentation availablefor review that these requirements are met. See 42CFR Section 410‐33 (2) (c).The ICD‐9‐CM coding section was updated withthe addition of CPT codes 93930 and 93931 to thetitle as follows:Pre‐surgical Conduit Mapping for CoronaryArtery Bypass Graft Procedures (93930, 93931,93965, 93970, and 93971)The ICD‐9‐CM coding section was updated withthe deletion of 93930 and 93931 from the title ofthe Pre‐Surgical Vein‐Mapping for PeripheralArterial Bypass section. These codes werepreviously included in error.The Utilization Guidelines were updated with thefollowing statement:Pre‐surgical conduit mapping of the radialartery(ies) should only be accompanied by veinmappingstudies when the arterial studiesdemonstrate a non‐acceptable conduit or aninsufficient conduit is available for multiplebypass procedures.The Sources of Information section was updatedto include references reviewed due toreconsideration request.Other changes include minor corrections oftypographical errors and updates for current NGStemplate language.The changes listed in this revision do NOT applyto the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, coverage provisions, andCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 8 MMR 2009‐5, May 2009

equirements in the LCD remain in effect for thesestates.Noninvasive Vascular Studies — SupplementalInstructions Article (A48042)Article published May, 2009: Source of revision –External – Reconsideration Request L27355The following statement was added to the sectionon claims submitted to the carrier or Part B MAC:“All services/procedures performed on the sameday for the same beneficiary by thephysician/provider should be billed on the sameclaim.”For claims submitted to the carrier or Part B MACplace of services codes were updated as follows:“Claims for noninvasive vascular studies arepayable under Medicare Part B in the followingplaces of service:Global: office (11), home (12), assisted livingfacility (13), group home (14), mobile unit (15),temporary lodging 16, urgent care facility (20),nursing facility (32), custodial care facility (33),independent clinic (49), and intermediate carefacility/MHMR (54).Professional: office (11), home (12), assisted livingfacility (13), group home (14), mobile unit (15),temporary lodging 16, urgent care facility (20),inpatient hospital (21), outpatient hospital (22),emergency room hospital (23), skilled nursingfacility (31), nursing facility (32), custodial carefacility (33), hospice (34), independent clinic (49),inpatient psychiatric facility (51), intermediatecare facility/MHMR (54), comprehensive inpatientrehabilitation facility (61), end stage renal diseasetreatment facility (65).Technical: office (11), home (12), assisted livingfacility (13), group home (14), mobile unit (15),temporary lodging 16, urgent care facility (20),nursing facility (32), custodial care facility (33),independent clinic (49), intermediate carefacility/MHMR (54), and rural health clinic (72).”This article was reorganized and revised toincorporate updated National GovernmentServices template language.The changes listed in this latest version of thesupplemental instructions article (SIA) do NOTapply to the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states.Pain Management – Supplemental InstructionsArticle (A48042)Article Published May 2009: Source of Revision— ExternalThe General Guidelines for claims submitted tocarriers or intermediaries or Part A or Part B MACwere updated by adding the following:Use ICD‐9‐CM code V72.5 only when procedurecodes 62310, 62311, 62318, 62319 are used forinjection of agents for diagnostic proceduresunrelated to pain management (e.g.,cisternography).The Carrier Billing Guidelines under “Interlaminaror Caudal Epidural and/or Intrathecal InjectionsIncluding Those Treating Spasticity,Transforaminal Epidural Injections,Paravertebral Joint/Nerve Injections AndDenervation, And Sacroiliac Joint Injections”were updated by adding the following:Ambulatory surgery centers (ASCs) must appendmodifier ‐KX (Requirements in the medical policyhave been met) to all procedures for whichfluoroscopy‐ or CT‐guidance is medicallynecessary to attest to the use of such imaging.Procedures requiring medically necessaryfluoroscopy‐ or CT‐guidance includetransforaminal epidural injections, paravertebraljoint/nerve injections or denervations, andsacroiliac joint injections. In addition, subsequentepidural (interlaminar or caudal) injections after afailed or inadequate response to a blind injection,if performed, should be under fluoroscopicvisualization or CT‐guidance.No change was made to the local coveragedetermination associated with this supplementalinstructions article.The changes listed in this latest version of thesupplemental instructions article (SIA) do notCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 9 MMR 2009‐5, May 2009

apply to the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states.Psychiatric Partial Hospitalization Programs(L26398)(R2) (Correction) (published 05/01/2009): Sourceof revision ‐ Internal: In the “CPT/HCPCS Codes”section a clarification was added to indicate thatHCPCS codes G0410 and G0411 replace CPTcodes 90853 and 90857 for PHP services effective01/01/2009. In the “CPT/HCPCS Codes” sectionand in the “Appendices, Part B professionalservices” in the “Documentation Requirements”section a clarification was added to indicate thatCPT codes 90899 and 90849 are no long acceptedas billable PHP codes effective 01/01/2009. Nochange in the original 02/01/2009 revision effectivedate. No notice period required and none given.Psychiatric Partial Hospitalization Programs –Supplemental Instructions Article (A45932)Correction article published 05/01/2009: Source ofrevision – Internal: In the “CPT/HCPCS Codes”section a clarification was added to indicate thatHCPCS codes G0410 and G0411 replace CPTcodes 90853 and 90857 for PHP services effective01/01/2009. Effective 01/01/2009, CPT codes 90899and 90849 are no long accepted as billable PHPcodes.Varicose Veins of the Lower Extremity,Treatment of (L25519) (R4)(R4) (effective 05/01/2009): Source of revision –Internal. The LCD was revised as follows:As a result of conflicting information, thelimitation listed below was revised:Cosmetic surgery is statutorily excluded fromcoverage by Medicare. The followinginterventional treatments are considered to becosmetic and will be denied as such:CPT Codes 36470, 36471, 36475, 36476, 36478,36479, 37700, 37718, 37722, 37735, 37760, 37765,37766, 37780 and 37799 were added as anexplanatory note to the “ICD‐9‐CM Codes thatSupport Medical Necessity” section.ICD‐9‐CM codes 459.10, 459.11, 459.12, 459.13 and459.19 were inadvertently included in the “ICD‐9‐CM Codes that Support Medical Necessity”section and were removed.CPT code 36468 was removed from theexplanatory note in the “ICD‐9‐CM Codes thatDO NOT Support Medical Necessity” section.Corrected several sources in the “Sources ofInformation and Basis for Decision” section toreflect the guidelines in the AMA Manual of Style.The changes listed in this revision do NOT applyto the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, coverage provisions, andrequirements in the LCD remain in effect for thesestates.Varicose Veins of the Lower Extremity,Treatment of – Supplemental InstructionsArticle (A44614)Article published May 2009. Source of revision –Internal. The SIA was revised as follows:As a result of conflicting information, the codingguideline listed below was revised:CPT Code 36468 (Single or multiple injections ofsclerosing solutions, spider veins (telangiectasia);limb or trunk) is NOT COVERED as it isconsidered cosmetic and will be denied as such.CPT code 36438 was removed from the followingcoding guideline:CPT codes 36470, 36471, 36475, 36476, 36478,36479, 37700, 37718, 37722, 37735, 37760, 37765,37766, 37780, and 37799 (when used to reportʺTrivex Procedureʺ), submitted for any of thefollowing ICD‐9‐CM codes will be denied for lackof medical necessity:The changes listed in this latest version of theSupplemental Instructions Article (SIA) do NOTapply to the states of Maine (contract 00180),Massachusetts (contract 00181), or Vermont andNew Hampshire (contract 00270); however, allother instructions, and requirements in the SIAremain in effect for these states.”CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 10 MMR 2009‐5, May 2009

Information Issued by NationalGovernment ServicesforPart A ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 11 MMR 2009‐5, May 2009

Dental ServicesPublication 100‐02, Chapter 16, Section 140 states“Items and services in connection with the care,treatment, filling, removal, or replacement ofteeth, or structures directly supporting the teethare not covered. Structures directly supportingthe teeth mean the periodontium, which includesthe gingivae, dentogingival junction, periodontalmembrane, cementum, and alveolar process.”It also states: “The hospitalization ornonhospitalization of a patient has no directbearing on the coverage or exclusion of a givendental procedure.When an excluded service is the primaryprocedure involved, it is not covered regardless ofits complexity or difficulty. For example, theextraction of an impacted tooth is not covered.Similarly, an alveoplasty (the surgicalimprovement of the shape and condition of thealveolar process) and a frenectomy are excludedfrom coverage when either of these procedures isperformed in connection with an excludedservice, e.g., the preparation of the mouth fordentures. In like manner, the removal of the toruspalatinus (a bony protuberance of the hard palate)could be a covered service. However, with rareexception, this surgery is performed in connectionwith an excluded service, i.e., the preparation ofthe mouth for dentures. Under suchcircumstances, reimbursement is not made for thispurpose.”“Whether such services as the administration ofanesthesia, diagnostic x‐rays, and other relatedprocedures are covered depends upon whetherthe primary procedure being performed by thedentist is itself covered. Thus, an x‐ray taken inconnection with the reduction of a fracture of thejaw or facial bone is covered. However, a single x‐ray or x‐ray survey taken in connection with thecare or treatment of teeth or the periodontium isnot covered.”“Hospitals …report condition codes 20 and 21when they realize the services are excluded fromcoverage but:• The beneficiary has requested a formaldetermination (condition code 20) (claim maycontain both covered and noncoveredcharges); or• The provider is requesting a denial noticefrom Medicare to bill Medicaid or otherinsurers (condition code 21).”We advise hospitals “when billing condition code21 that a separate claim must be submitted.Claims with condition code 21 must be submittedwith all noncovered charges.”May Is National Stroke PreventionMonthStroke has a major impact on the life andeconomy in the United States. Stroke is a leadingcause of death and disability in the United States.Indiana is one of the states serviced by NationalGovernment Services as its Medicare contractorand stroke is the fourth leading cause of death inIndiana. The Indiana Stroke Prevention TaskForce was created by legislation in 2004. The taskforce has created guidelines to provide a basis andminimum standard for the management of stroketreatment. The guidelines include signs andsymptoms, risk factors, hospital care,rehabilitation and emergency care. Other statesmay have similar resources available to providersin their states. The complete guidelines created bythe Indiana Stroke Prevention Taskforce can befound on the Indiana State Department of HealthWeb site atwww.in.gov/isdh/publications/pdfs/indianastroke/guidelines.pdf.Publication 100‐04, Chapter 4, Section 180.5includes information regarding proper reportingof Condition Codes 20 and 21:CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 12 MMR 2009‐5, May 2009

Transition of the Region I HomeHealth and Hospice Medical ReviewWorkloadAttention Home Health and Hospice Providersin Region 1In preparation for the transition to the Jurisdiction14 (J14) Medicare Administrative Contractor(MAC) National Government Services hasdetermined that the Region 1 Home Health andHospice Medical Review (MR) will be movedfrom the Milwaukee, Wisconsin MR Departmentto the South Portland, Maine MR Department.This transition will occur without affecting thequality of service for our providers andbeneficiaries.The transition of the Region I‐Maine Home Healthand Hospice Medical Review workload to theSouth Portland office will be finalized by April 1,2009. Providers will continue to mail theirAdditional Development Requests (ADR) to theSyracuse, NY mail site at the following addressuntil the J14 MAC transition is finalized:National Government Services, Inc.Attention: Home Health/Hospice Medical ReviewP.O. Box 4767Syracuse, NY 13221‐4767If you have any questions concerning thistransition, please contact the Manager of theSouth Portland MR Department at the followingnumber:Donna TrufantManager of Medical ReviewPhone: (207) 253‐3624The Medical Review Department looks forward toworking with you and will strive to make this aseamless transition.(CMS) needs to change the contractor workloadnumbers (contractor numbers) for the Part A andPart B workloads in the states of Maine,Massachusetts, New Hampshire, Rhode Island,and Vermont when that workload is transitionedto the J14 A/B MAC. These changes need to bemade because certain CMS applications need toindividually identify each workload. The newcontractor numbers will be effective for the J14A/B MAC as indicated below.Part AMACWorkloadNo.EffectiveDateCurrentContractorNo.Maine 14101 05/18/2009 00180Massachusetts 14201 05/18/2009 00181New14301 06/08/2009 00270HampshireRhode Island 14401 06/01/2009 00021Vermont 14501 06/08/2009 00270Part BMACWorkloadNo.EffectiveDateCurrentContractorNo.Maine 14102 06/01/2009 31142Massachusetts 14202 06/01/2009 31143New14302 06/01/2009 31144HampshireRhode Island 14402 05/02/2009 00524Vermont 14502 06/01/2009 31145Home Healthand HospiceAll J14 StatesplusConnecticutMACWorkloadNo.EffectiveDateCurrentContractorNo.14004 05/18/2009 00180Reference: CR6406http://www.cms.hhs.gov/transmittals/downloads/R463OTN.pdf 04‐01‐09Jurisdiction 14 (J14) Part A and PartB Medicare AdministrativeContractor New Workload NumbersNHIC, Corp. is the Jurisdiction 14 Part A and PartB Medicare administrative contractor (A/B MAC).The Centers for Medicare & Medicaid ServicesCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 13 MMR 2009‐5, May 2009

NOTESCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 14 MMR 2009‐5, May 2009

Information Issued by the Centersfor Medicare & Medicaid Services(CMS) Pertaining toPart A and Part B ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 15 MMR 2009‐5, May 2009

calls with a Customer Service Representative(CSR).Part A and B InformationImplementation of New ProviderAuthentication Requirements forMedicare Contractor ProviderTelephone and Written InquiriesMLN Matters Number: MM6139 RevisedRelated Change Request (CR) #: 6139Related CR Release Date: March 4, 2009Effective Date: April 6, 2009Related CR Transmittal #: R25COMImplementation Date: April 6, 2009 for providersNote: This article was revised on March 5, 2009, toreflect the revised CR 6139, which CMS re‐issuedon March 4, 2009. (The effective andimplementation dates for providers werepreviously changed to April 6, 2009 byTransmittal R23COM on February 10.) In thisrevision of the article, the CR release date,transmittal number, and the Web address of theCR have been changed. All other informationremains the same.Provider Types AffectedCR 6139 impacts all physicians, providers, andsuppliers (or their staffs) who make inquiries toMedicare contractors (carriers, FiscalIntermediaries (FIs), Regional Home HealthIntermediaries (RHHIs), Medicareadministrative contractors (A/B MACs), orDurable Medical Equipment MedicareAdministrative Contractors (DME MACs)).Inquiries include written inquiries or calls madeto Medicare contractor provider contact centers,including calls to Interactive Voice Response(IVR) systems.What You Need to KnowCR 6139, from which this article is taken,addresses the necessary provider authenticationrequirements to complete IVR transactions andEffective April 6, 2009, when you call either theIVR system, or a CSR, the Centers for Medicare &Medicaid Services (CMS) will require you toprovide three data elements for authentication: 1)Your National Provider Identifier (NPI); 2) YourProvider Transaction Access Number (PTAN);and 3) The last five‐digits of your taxidentification number (TIN).Make sure that your staffs are aware of thisrequirement for provider authentication.BackgroundIn order to comply with the requirements of thePrivacy Act of 1974 and of the Health InsurancePortability and Accountability Act, customerservice staff at Medicare fee‐for‐service providercontact centers must properly authenticate callersand writers before disclosing protected healthinformation.Because of issues with the public availability ofprevious authentication elements, CMS hasaddressed the current provider authenticationprocess for providers who use the IVR system orcall a CSR. To better safeguard providers’information before sharing information on claimsstatus, beneficiary eligibility, and other providerrelated questions, CR 6139, from which this articleis taken, announces that CMS has added the lastfive‐digits of the provider’s TIN as an additionalelement in the provider authentication process.Your Medicare contractor’s system will verify thatthe NPI, PTAN, and last five‐digits of the TIN arecorrect and belong to you before providing theinformation you request.Note: You will only be allowed three attempts tocorrectly provide your NPI, PTAN, and last fivedigitsof your TIN.As a result of CR 6139, the Disclosure DeskReference for Provider Contact Centers, whichcontains the information Medicare contractors useto authenticate the identity of callers and writers,is updated in the Medicare Contractor BeneficiaryCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 16 MMR 2009‐5, May 2009

and Provider Communications Manual, Chapter 3(Provider Inquiries), Section 30 (Disclosure ofInformation) and Chapter 6 (Provider CustomerService Program), Section 80 (Disclosure ofInformation) to reflect these changes.New information in these manual chapters alsoaddresses other authentication issues. This newinformation is summarized as follows:• Authentication of Providers with No NPIOccasionally, providers will never be assigned anNPI (for example providers who areretired/terminated), or inquiries may be madeabout claims submitted by a provider who hassince deceased.Most IVRs use the NPI crosswalk to authenticatethe NPI and PTAN. The NPI is updated on a dailybasis and does not maintain any history aboutdeactivated NPIs or NPI/PTAN pairs. Therefore,if a provider enters an NPI or NPI/PTAN pair thatis no longer recognized by the crosswalk, the IVRsmay be unable to authenticate them; or if theclaim was processed using a different NPI/PTANpair that has since been deactivated, the IVR maynot be able to find the claim and return claimsstatus information.Since these types of inquiries are likely to result inadditional CSR inquiries, before releasinginformation to the provider, CSRs willauthenticate using at least two other dataelements available in the provider’s record, suchas provider name, TIN, remittance address, andprovider master address.Beneficiary AuthenticationBefore disclosing beneficiary information(whether from either an IVR or CSR telephoneinquiry), and regardless of the date of the call,four beneficiary data elements are required forauthentication:1. Last name;2. First name or initial;3. Health Insurance Claim Number (HICN; and4. Either date of birth (eligibility, next eligibledate, Durable Medical Equipment MedicareAdministrative Contractor Information Form(DIF) (pre‐claim)) or date of service (claimstatus, CMN/DIF (post‐claim)).• Written InquiriesIn general, three data elements (NPI, PTAN, andlast five‐digits of the TIN) are required forauthenticating providers’ written inquiries. Thisincludes inquiries received without letterhead(including hardcopy, fax, email, pre‐formattedinquiry forms or inquiries written on RemittanceAdvice (RAs) or Medicare Summary Notices(MSNs)).The exception to this requirement is writteninquiries received on the provider’s officialletterhead (including emails with an attachmenton letterhead). In this case, providerauthentication will be met if the provider’s nameand address are included in the letterhead andclearly establish their identity. Therefore, theprovider’s practice location and name on theletterhead must match the contractor’s file for thisprovider. (However, your Medicare contractormay use discretion if the file does not exactlymatch the letterhead, but it is clear that theprovider is one and the same.) In addition, theletterhead information on the letter or email needsto match, either, the NPI, the PTAN, or last fivedigitsof the TIN. Providers will also include onthe letterhead either the NPI, PTAN, or last fivedigitsof the TIN. Medicare contractors will askyou for additional information, if necessary.• Overlapping ClaimsWhen claims overlap (that is, multiple claims withthe same or similar dates of service or billingperiods), the contractor that the provider initiallycontacts will authenticate that provider byverifying his/her name, NPI, PTAN, last fivedigitsof the TIN, beneficiary name, HICN, anddate of service for post‐claim information, or dateof birth for pre‐claim information.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 17 MMR 2009‐5, May 2009

Additional InformationYou can find more information about the newprovider authentication requirements forMedicare inquiries by going to CR 6139, located athttp://www.cms.hhs.gov/Transmittals/downloads/R23COM.pdf on the CMS Web site.If you have any questions, please contact yourMedicare contractor (carrier, FI, RHHI, A/B/MAC,or DME MAC) at their toll‐free number, whichmay be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents.Part A and B InformationIncorporation of Physician FeeSchedule Regulatory Changes intoChapter 10 of the Program IntegrityManual (PIM)MLN Matters Number: MM6310 RevisedRelated Change Request (CR) #: 6310Related CR Release Date: April 15, 2009Effective Date: January 1, 2009Related CR Transmittal #: R289PIImplementation Date: April 1, 2009Note: This article was revised on April 16, 2009, toreflect a revision made to CR 6310. Specifically,the Centers for Medicare & Medicaid Servicesmodified two requirements of CR6310. Thespecific change in this article is in the last bulletpoint under “Timeframes for reporting changes ofinformation” on page 3. That bullet point waschanged to show that an overpayment may beassessed. Previously, it stated an overpaymentwill be assessed. The CR release date, transmittalnumber, and the Web address for accessing theCR have also been revised. All other informationremains the same.Provider Types AffectedPhysicians, providers, and suppliers submittingclaims to Medicare contractors (carriers, fiscalintermediaries (FIs), and/or Part A/B Medicareadministrative contractors (A/B MACs)) forservices provided to Medicare beneficiariesProvider Action NeededAll Medicare physicians, providers, and suppliers,as well as those who are considering applying toparticipate in the program should be aware of thenew rule and of upcoming changes to theMedicare enrollment process.BackgroundChange Request (CR) 6310 implements regulatorychanges found in the CY 2009 Medicare PhysicianFee Schedule final rule with comment (CMS‐1403‐FC). Significant changes are summarized below.Effective date of Medicare billing for physicians,certain nonphysician practitioners, andPhysician and Nonphysician PractitionerOrganizations• Carriers and Part A and Part B Medicareadministrative contractors (A/B MACs) willestablish the effective date of Medicare billingprivileges (see 42 CFR 424.520(d)) forphysicians, nonphysician practitioners, andphysician or non‐physician practitionerorganizations. Physicians, nonphysicianpractitioners and physician and nonphysicianpractitioner organizations will no longer beallowed to establish retrospective Medicareeffective billing dates.• Carriers and A/B MACs will establish aneffective date of Medicare billing privilegesfor the following individuals andorganizations: physicians, physicianassistants, nurse practitioners, clinical nursespecialists, certified registered nurseanesthetists, certified nurse‐midwives; clinicalsocial workers; clinical psychologists;registered dietitians or nutritionprofessionals; and physician and non‐CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 18 MMR 2009‐5, May 2009

physician practitioner organizations (e.g.,clinics/group practices).• The effective date of Medicare billingprivileges for the individuals andorganizations identified above is the later ofthe date of filing or the date they first beganfurnishing services at a new practice location.Note: The date of filing for Internet‐basedProvider Enrollment, Chain and OwnershipSystem (PECOS) applications for theseindividuals and organizations is the date thatthe contractor received an electronic versionof the enrollment application and a signedcertification statement that were bothprocessed to completion.• The individuals and organizations identifiedabove may, however, retrospectively bill forservices when:• The supplier has met all programrequirements, including state licensurerequirements, and• The services were provided at theenrolled practice location for up to—• 30 days prior to their effective date ifcircumstances precluded enrollmentin advance of providing services toMedicare beneficiaries, or• 90 days prior to their effective date ifa Presidentially‐declared disasterunder the Robert T. Stafford DisasterRelief and Emergency Assistance Act,42 U.S.C. Sections 5121‐5206 (StaffordAct) precluded enrollment in advanceof providing services to Medicarebeneficiaries.Timeframes for reporting changes ofinformation• Physicians, physician assistants, nursepractitioners, clinical nurse specialists,certified registered nurse anesthetists,certified nurse‐midwives; clinical socialworkers; clinical psychologists; registereddietitians or nutrition professionals; andorganizations (e.g., group practices)consisting of any of the categories ofindividuals identified in this paragraph; thefollowing changes must be reported within 30days:• A change of ownership;• A final adverse action; or• A change in practice location.• If an individual or organization identifiedabove does not comply with the reportingrequirements relating to, respectively, finaladverse actions and practice location changes,the supplier may be assessed an overpaymentback to the date of the final adverse action orchange in practice location.Application rejections and denials for physicianand certain nonphysician practitionerapplications• Carriers and A/B MACs will deny, rather thanreject, incomplete applications submitted byphysicians, non‐physician practitioners, andphysician or nonphysician practitionerorganizations.• This change will allow the individuals andorganizations identified above to preservetheir effective date of filing by submitting acorrective action plan or an appeal andsubmitting the missing information/documentation to allow the carrier or A/BMAC to adjudicate the enrollment applicationto completion.Revocation effective dates• A revocation based on a: (1) Federal exclusionor debarment, (2) felony conviction, (3) licensesuspension or revocation, or (4) determinationthat the provider or supplier is no longeroperational, is effective with the date of theexclusion, debarment, felony conviction,license suspension or revocation, or the datethat the Centers for Medicare & MedicaidServices (CMS) or its contractor determinedthat the provider or supplier is no longeroperational.• Any physician, physician assistant, nursepractitioner, clinical nurse specialist, certifiedregistered nurse anesthetist, certified nursemidwife,clinical social worker, clinicalpsychologist, registered dietitian or nutritionprofessional, organization (e.g., clinic/grouppractices) consisting of the individualspreviously identified, or IDTF who/that isrevoked from the Medicare program must,within 60 calendar of the effective date of theCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 19 MMR 2009‐5, May 2009

evocation, submit all claims for items andservices furnished.Requirements for maintaining ordering andreferring documentation• Carriers or A/B MACs may revoke the billingprivileges of any provider or supplier thatfails to comply with Medicare’s ordering andreferring documentation requirements asspecified in 42 CFR 424.5216 (f).• Such revocation is also possible in caseswhere the physician or nonphysicianpractitioner fails to maintain written orderingand referring documentation for seven (7)years from the date of service.• Off‐site or electronic storage of the orderingand referring documentation described in 42CFR Section 424.516(f) is not precluded, aslong as these records are readily accessibleand retrievable.Other changes• Final adverse action is defined.Additional InformationThe official instruction (CR 6310) issued to yourcarrier, FI, and A/B MAC, regarding this changemay be viewed athttp://www.cms.hhs.gov/transmittals/downloads/R289PI.pdf on the CMS Web site.If you have any questions, please contact yourcarrier, FI, or A/B MAC at their toll‐free number,which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents.Part A and B InformationMedicare Claims Processing ManualClarifications for Skilled NursingFacility (SNF) and Therapy BillingMLN Matters Number: MM6407Related Change Request (CR) #: 6407Related CR Release Date: March 27, 2009Effective Date: October 1, 2006Related CR Transmittal #: R1706CPImplementation Date: April 27, 2009Provider Types AffectedSkilled nursing facilities and other providerssubmitting claims to Medicare contractors (fiscalintermediaries (FIs) and/or A/B Medicareadministrative contractors (A/B MACs)) forservices provided to Medicare beneficiariesProvider Action NeededThis article is based on Change Request (CR) 6407,which includes clarifications to the MedicareClaims Processing Manual for skilled nursingfacility (SNF) and therapy billing. Be sure billingstaff are aware of the clarifications.BackgroundChange Request (CR) 6407 provides clarificationsand updates to the Medicare Claims ProcessingManual, Chapter 5 (Part B OutpatientRehabilitation Billing), Section 20 (HCPCS CodingRequirements). These clarifications indicate thateffective January 1, 2009, the new CurrentProcedural Terminology (CPT) code 95992(Canalith repositioning procedure(s) (e.g., Epleymaneuver, Semont maneuver), per Day) isbundled under the Medicare Physician FeeSchedule (MPFS).Regardless of whether CPT code 95992 is billedalone or in conjunction with another therapycode, separate Medicare payment is never madefor this code. If billed alone, this code will bedenied. On remittance advice notices for claims soCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 20 MMR 2009‐5, May 2009

denied, Medicare contractors will use group codeCO and claim adjustment reason code 97(“Payment is included in the allowance foranother service/procedure.”). Alternatively,reason code B15, which has the same intent, mayalso be used by your Medicare contractor.In addition, CR 6407 provides clarifications andupdates to the Medicare Claims Processing Manual(Pub 100‐04), Chapter 6 (Skilled Nursing Facility(SNF) Inpatient Part A Billing), Section 40 (SpecialInpatient Billing Instructions) to indicate that bothfull and partial benefits exhaust claims must besubmitted by SNFs monthly. For benefits exhaustbills, an SNF must submit a benefits exhaust billmonthly for those patients who continue toreceive skilled care and also when there is achange in the level of care regardless of whetherthe benefits exhaust bill will be paid by Medicaid,a supplemental insurer, or private payer. Thereare two types of benefits exhaust claims:1. Full benefits exhaust claims: no benefit daysremain in the beneficiary’s applicable benefitperiod for the submitted statement coversfrom/through date of the claim; and2. Partial benefits exhaust claims: only one orsome benefit days, in the beneficiary’sapplicable benefit period, remain for thesubmitted statement covers from/throughdate of the claim.Monthly claim submission of both types ofbenefits exhaust bills are required in order toextend the beneficiary’s applicable benefit period.Furthermore, when a change in level of careoccurs after exhaustion of a beneficiary’s covereddays of care, the provider must submit thebenefits exhaust bill in the next billing cycleindicating that active care has ended for thebeneficiary.of care but continue to reside in a Medicarecertifiedarea of the facility. Consolidated billing(CB) legislation indicates that physical therapy,occupational therapy, and speech‐languagepathology services furnished to SNF residents arealways subject to SNF CB. This applies even whena resident receives the therapy during a noncoveredstay in which the beneficiary who is noteligible for Part A extended care benefit stillresides in an institution (or part thereof) that isMedicare‐certified as a SNF. SNF CB edits requirethe SNF to bill for these services on a 22x (SNFinpatient part B) bill type.Note: Unlike with benefits exhaust claims, Part B22x bill types may be submitted prior to thesubmission of bill type 210 (SNF no‐payment billtype).Additional InformationThe official instruction (CR 6407) issued to your FIand A/B MAC regarding this change may beviewed athttp://www.cms.hhs.gov/transmittals/downloads/R1706CP.pdf on the Centers for Medicare &Medicaid Services (CMS) Web site.If you have any questions, please contact your FIor A/B MAC at their toll‐free number, which maybe found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents.Note: Part B 22x (SNF inpatient part B) bill typesmust be submitted after the benefits exhaust claimhas been submitted and processed.In addition, SNF providers must submit nopaymentbills for beneficiaries that havepreviously received Medicare‐covered skilled careand subsequently dropped to a non‐covered levelCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 21 MMR 2009‐5, May 2009

Part A and B InformationBilling Routine Costs of ClinicalTrialsMLN Matters Number: MM6431Related Change Request (CR) #: 6431Related CR Release Date: April 10, 2009Effective Date: July 10, 2009Related CR Transmittal #: R1710CPImplementation Date: July 10, 2009Provider Types AffectedPhysicians and nonphysician practitionerssubmitting claims to Medicare administrativecontractors (MACs) and carriers for clinical trialsProvider Action NeededThis article is based on Change Request (CR) 6431that alerts providers that they should continue toreport the International Classification of Diseasesdiagnosis code V70.7 (Examination of participantin clinical trial) on clinical trial claims. It is nolonger necessary to make a distinction between adiagnostic and therapeutic clinical trial serviceon the claim.BackgroundCR 6431 revises the Medicare Claims ProcessingManual, Chapter 32, Section 69.6 (Requirements forBilling Routine Costs of Clinical Trails). The revisedmanual section is attached to CR 6431. TheCenters for Medicare & Medicaid Services (CMS)is clarifying that there no longer remains a need tomake a distinction between a diagnostic versustherapeutic clinical trial service on the claim.If the QV or Q1 modifier is billed and diagnosiscode V70.7 is submitted by practitioners as asecondary rather than the primary diagnosis, yourMedicare contractor will not consider the serviceas having been furnished to a diagnostic trialvolunteer. Instead, they will process the service asa therapeutic clinical trial service.• Effective for claims processed 90 days afterissuance of CR 6431 with dates of service onor after January 1, 2008, claims submittedwith either the modifier QV or the modifierQ1 will be returned as unprocessable if thediagnosis code V70.7 is not submitted on theclaim.• Providers will see the following messagesfrom their Medicare contractor with thereturned claim:• Claims adjustment Reason Code 16 –Claim/service lacks information which isneeded for adjudication; and• As least one Remark Code, which may becomprised of either:• The Remittance Advice Code (M76,Missing/incomplete/invalid diagnosisor condition) or• National Council for PrescriptionDrug Programs Reject Reason Code.Note: Healthcare Common Procedure CodingSystem (HCPCS) codes are not reported oninpatient claims. Therefore, the HCPCS modifierrequirements (i.e., QV or Q1) as outlined in theoutpatient clinical trial section immediatelybelow, are not applicable to inpatient clinical trialclaims.On all outpatient clinical trial claims, providersneed to do the following:• Report condition code 30;• Report a secondary diagnosis code of V70.7;and• Identify all lines that contain aninvestigational item/service with a HCPCSmodifier of:• QA/QR for dates of service before January1, 2008; or• Q0 for dates of service on or after January1, 2008.• Identify all lines that contain a routine servicewith a HCPCS modifier of:• QV for dates of service before January 1,2008; or• Q1 for dates of service on or after January1, 2008.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 22 MMR 2009‐5, May 2009

Institutional providers should also note that theymust not bill outpatient clinical trial services andnonclinical trial services on the same claim forMedicare beneficiaries enrolled in managed careplans.Additional InformationIf you have questions, please contact yourMedicare MAC and/or carrier at their toll‐freenumber, which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.The official instruction (CR6431) issued to yourMedicare MAC, or carrier is available athttp://www.cms.hhs.gov/Transmittals/downloads/R1710CP.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents.Part A and B InformationClarification on Provider InformationRequired on Medicare Claims forRoutine Foot Care ServicesMLN Matters Number: SE0907Related Change Request (CR) #: SE0907Related CR Release Date: N/AEffective Date: N/ARelated CR Transmittal #: N/AImplementation Date: N/AProvider Types AffectedThis article is for informational purposes only forproviders billing Medicare contractors (carriers orPart A/B Medicare administrative contractors(MACs)) for routine foot care services. It is anoverview of existing policy and no change inpolicy is being conveyed.Provider Action NeededImpact to YouRoutine foot care services are covered only if thepatient is under the active care of a doctor ofmedicine (M.D.) or osteopathy (D.O.) whodocuments a condition that under Medicarecoverage policies warrants the coverage of routinefoot care. Therefore, when submitting foot careclaims for services furnished to Medicarebeneficiaries, you must report the name of theM.D. or D.O., providing the active care, theNational Provider Identifier (NPI) of thatphysician, and the approximate date that thebeneficiary was last seen by the indicatedphysician.What You Need to KnowThe NPI of the physician providing the active carefor the condition that warrants Medicare coverageof the routine foot care and the date the patientwas last seen by that physician must be present inItem 19 of the CMS‐1500 (or in Data Element Loop2300 Segment NTE on the 837P). Claims will bereturned as unprocessable (using ClaimAdjustment Reason Code 16‐ “Claim/service lacksinformation which is needed for adjudication”)for the above service without the NPI of thephysician providing the active care for thecondition that warrants Medicare coverage of theroutine foot care and the date the patient was lastseen by that physician on the claim.When returning claims as unprocessable, theMedicare contractor will use remittance adviceremark codes:• N253‐ Missing/incomplete/invalid attendingprovider primary identifier.• N324‐ Missing/incomplete/invalid lastseen/visit date.What You Need to DoMake sure that your billing staffs are includingthe NPI and date last seen by the physicianproviding the active care for the condition thatwarrants Medicare coverage of the routine footcare in Item 19 on the CMS‐1500 form or in DataElement Loop 2300 Segment NTE on the 837P.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 23 MMR 2009‐5, May 2009

BackgroundThe Medicare Benefit Policy Manual (MBPM),Chapter 15, Section 290, only covers podiatryservices which are medically necessary andreasonable. (That manual is available athttp://www.cms.hhs.gov/manuals/IOM/list.asp onthe Centers for Medicare & Medicaid Services(CMS) website.) When routine services arerendered by a podiatrist, your Medicare carrier orA/B MAC may deem the active care requirementmet if the claim or other evidence availablediscloses that the patient has seen a M.D. or D.O.for treatment and/or evaluation of thecomplicating disease process during the sixmonthperiod prior to the rendition of the routinetypeservices.The carrier or A/B MAC may also accept thepodiatrist’s statement that the diagnosing andtreating M.D. or D.O. also concurs with thepodiatrist’s findings as to the severity of theperipheral involvement indicated.Additional InformationIf you have any questions, please contact yourMedicare contractor at their toll‐free numberwhich may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.You can find more information about the NationalProvider Identifier (NPI) by going to the NPI page athttp://www.cms.hhs.gov/NationalProvIdentStand/on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.When submitting claims for services furnished toMedicare beneficiaries who have complicatingconditions, the name and NPI of the M.D. or D.O.who diagnosed the complicating condition mustbe submitted with the claim, along with theapproximate date that the beneficiary was lastseen by the indicated physician.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 24 MMR 2009‐5, May 2009

Information Issued by the Centersfor Medicare & Medicaid Services(CMS) Pertaining toPart A ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 25 MMR 2009‐5, May 2009

Part A InformationInitial Enrollment Assignment forFederally Qualified Health Centers(FQHCs), End-Stage Renal Disease(ESRD) Facilities, and Rural HealthClinics (RHCs)MLN Matters Number: MM6207Related Change Request (CR) #: 6207Related CR Release Date: March 27, 2009Effective Date: April 27, 2009Related CR Transmittal #: R1707CPImplementation Date: April 27, 2009Provider Types AffectedFederally qualified health centers (FQHCs), Endstagerenal disease (ESRD) facilities, and ruralhealth clinics (RHCs) that are currently enrolledwith a fiscal intermediary (FI) or a Medicareadministrative contractor (MAC), and FQHCs,RHCs, and ESRD facilities that are planning tosubmit an 855 initial enrollment application.Provider Action NeededImpact to YouThis article is based on Change Request (CR) 6207,which describes initial enrollment policy forassignment of FQHCs, ESRD facilities, and RHCs.What You Need to KnowAs FQHCs, ESRD facilities, and RHCs seek toenroll in the Medicare program, they should filetheir enrollment applications with the legacy FI orMAC that covers the state where they are located.Exceptions to the geographic assignment rule areset forth in MM5979, which can be found athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5979.pdf on the Centers forMedicare & Medicaid Services (CMS) Web site.This represents a shift from legacy‐worldassignment policy where there existed regionaland national FIs for these distinct provider types.What You Need to DoSee the Background and Additional InformationSections of this article for further details regardingthese changes.BackgroundThe Medicare Prescription Drug, Improvement,and Modernization Act of 2003 (MMA; Section911) amended the Social Security Act (the Act;Title XVIII) to add Section 1874A (Contracts withMedicare administrative contractors (MACs))which replaces the prior Medicare intermediaryand carrier contracting authorities formerly foundin Sections 1816 and 1842 of the Act. CMSprocured the first Part A/B Medicareadministrative contractor (A/B MAC) in 2006 andcontinues to award the fifteen A/B MACcontracts. The process of moving workload fromlegacy contractors to the MACs continues.The MMA also repealed the provider nominationprovision of the Social Security Act and replaced itwith the geographic assignment rule. Generally, aprovider or supplier will be assigned to the MACthat covers the state where the provider orsupplier is located. Exceptions to the geographicassignment rule are described in MM 5979, whichcan be found athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5979.pdf on the CMS Web site.In the legacy FI environment, FQHCs, RHCs, andESRD facilities were concentrated within theworkloads of several regional and national FIs.Most of the providers that were assigned toregional or national FIs represent “out‐ofjurisdictionproviders” (OJPs). An OJP is definedas a provider that is not currently serviced by theFI or MAC that covers the state where theprovider is located. Regional and nationalMedicare contractors for FQHCs, RHCs, andESRD facilities will not exist in the MACenvironment.FQHCsMost FQHCs are currently within the workloadserviced by National Government ServicesWisconsin. The Jurisdiction 6 MAC will absorbthis workload. FQHCs in the NationalGovernment Services workload will beCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 26 MMR 2009‐5, May 2009

transferred to their destination MACs during theOJP migration. The destination MAC will notalways be the geographic MAC.Indian Health Service (IHS) facilities will beassigned to the Jurisdiction 4 MAC. For purposesof CR6207, “tribal FQHC” means a MedicareFQHC operated by a tribe or tribal organizationunder the Indian Self‐Determination Act (25 USCS40(b)) or by an Urban Indian organizationreceiving funds under Title V of the Indian HealthCare Improvement Act (25 USCS 13). All otherfreestanding FQHCs, not meeting that tribaldescription, will be assigned to the MAC thatcovers the state where the facility is located.CMS is implementing the geographic assignmentrule for initial enrollment FQHCs now to avoidcreating additional OJPs. An initial enrollment foran IHS FQHC will be submitted to the Jurisdiction4 MAC. A new, non‐tribal FQHC will submit itsinitial CMS‐855A application to the FI or MACthat covers the state where the facility is located.Some classes of FQHCs may present latentchallenges for the geographic assignment rule.However, CMS will make accommodations forthese providers. For example, if an initialenrollment FQHC satellite is located in thejurisdiction of a MAC other than the audit MAC,then the geographic MAC will service the claims,and the audit MAC will service the cost report.RHCs and ESRD FacilitiesRHCs and many ESRD facilities have beenserviced by a limited set of regional FIs in thelegacy environment. Those legacy FI workloadswill be absorbed by incoming MACs. Out‐ofjurisdictionRHCs and ESRD facilities will betransferred to their destination MACs during theOJP migration. An initial enrollment for a RHC orESRD facility will be submitted to the MAC or FIthat serves the state where the RHC or ESRDfacility is located.Note: If the FQHC, RHC or ESRD facility isprovider‐based, it will be assigned to the FI orMAC that covers the state where the mainprovider is located.Misfiled CMS 855‐A ApplicationsIf a FQHC, RHC or ESRD facility submits a CMS‐855A initial application to an incorrect Medicarecontractor, the receiving contractor will mail theapplication to the appropriate contractor andnotify the provider that its application has beensent to the new contractor and that all futurequestions regarding the application should bedirected to the new contractor.Internet‐based PECOSFQHCs, RHCs, and ESRD facilities will not beable to use Internet‐based PECOS for the filing ofCMS‐855A initial applications, changes ofownership, or changes of information. Only paperforms will be accepted for these transactions.The following is a table that summarizes thechanges of CR 6207:FacilityFQHCRHCESRDIHS FQHCProviderbasedFQHCNew EnrollmentApplicationsFI/MAC covering the statewhere they are locatedFI/MAC covering the statewhere they are locatedFI/MAC covering the statewhere they are locatedJ4 MACFI/MAC servicing the mainproviderAdditional InformationThe official instruction (CR 6207) issued to yourMedicare contractor, regarding this change maybe viewed athttp://www.cms.hhs.gov/Transmittals/downloads/R1707CP.pdf on the CMS Web site.A listing of contractor addresses can be found athttp://www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS Web site.If you have any questions, please contact your FIor A/B MAC at their toll‐free number, which maybe found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 27 MMR 2009‐5, May 2009

DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.Part A InformationHospice Cap Calculations Lettersand Administrative AppealsMLN Matters Number: MM6400Related Change Request (CR) #: 6400Related CR Release Date: April 3, 2009Effective Date: July 1, 2009Related CR Transmittal #: R1708CPImplementation Date: July 6, 2009Provider Types AffectedHospice providers submitting claims to Medicarecontractors (fiscal intermediaries (FIs), Part A/BMedicare administrative contractors (A/B MACs),and/or regional home health intermediaries(RHHIs)) for services provided to Medicarebeneficiaries.Provider Action NeededThis article is based on Change Request (CR) 6400which requires Medicare contractors to send eachof their providers a letter which serves as adetermination of program reimbursement,regardless of whether or not they have exceeded acap. The letter you receive will include theinpatient and aggregate cap calculation results.Additionally, it will include appeals language inevery determination of program reimbursementletter. If you have exceeded the cap, the letter willinclude a demand for repayment.BackgroundThe law governing payment for hospice caresubjects hospice payments to two statutory caps:• A cap on payments for inpatient days,described in Section 1861(dd)(2)(A)(iii) of theSocial Security Act and• An aggregate cap on total payments,described in Section 1814(i)(2)(A)‐(C).These statutory caps limit total hospice paymentsduring a cap year. Payments in excess of eithercap must be refunded. Currently, after the end ofthe cap year, the applicable contractor (RHHI, FI,or A/B MAC) computes both cap amounts, anddetermines the amount of programreimbursement for each hospice provider theyserve.Important InformationThe latest hospice cap amount for the cap yearending October 31, 2008 is $22,386.15. The hospicecap is discussed further in the Medicare ClaimsProcessing Manual (Chapter 11 ‐ ProcessingHospice Claims, Section 80.2) which is available athttp://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf on the Centers for Medicare &Medicaid Services Web site. Your contractor(RHHI, FI, or AB MAC) will issue a letter to notifyyou of the results of the contractor’s capcalculations and to serve as your determination ofprogram reimbursement. If there is a capoverpayment, there will be an accompanyingdemand for repayment.Administrative AppealsAs indicated in section 418.311 of 42 CFR, if youbelieve that your payments have not beenproperly determined, you may request a reviewfrom the applicable contractor if the amount incontroversy is $1,000 or more, but less than$10,000, or from the provider reimbursementreview board (PRRB) if the amount in controversyis $10,000 or more. Appeal requests must be inwriting and be filed within 180 days from the dateof the determination. Your appeal rights arediscussed further in the Medicare Claims ProcessingManual (Chapter 11 ‐ Processing Hospice Claims,Section 80.3), which is attached to CR 6400.Additional InformationThe official instruction, CR 6400, issued to yourRHHI, FI or A/B MAC regarding this change maybe viewed atCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 28 MMR 2009‐5, May 2009

http://www.cms.hhs.gov/Transmittals/downloads/R1708CP.pdf on the CMS Web site.If you have any questions, please contact yourRHHI, FI, or A/B MAC at their toll‐free number,which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.Part A InformationPayment for Maintenance andServicing of Certain OxygenEquipment as a Result of theMedicare Improvements for Patientsand Providers Act (MIPPA) of 2008MLN Matters Number: MM6404Related Change Request (CR) #: 6404Related CR Release Date: March 20, 2009Effective Date: July 1, 2009Related CR Transmittal #: R461OTNImplementation Date: July 6, 2009Provider Types AffectedSuppliers submitting claims to Medicarecontractors (regional home health intermediaries(RHHIs), and/or durable medical equipmentMedicare administrative contractors (DMEMACs)) for oxygen services provided to Medicarebeneficiaries.Provider Action NeededThis article is based on change request (CR) 6404which provides additional instructions regardingmaintenance and servicing of oxygenconcentrators and transfilling equipment resultingfrom implementation of section 144(b) of theMIPPA. Earlier instructions pertaining to theMIPPA changes for oxygen equipment wereissued as part of CRs 6297 and 6296 and the MLNMatters articles for these CRs are available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/mm6297.pdf andhttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6296.pdf, respectively, on theCenters for Medicare & Medicaid (CMS) Web site.BackgroundSection 144(b) of the MIPPA repeals the transfer ofownership provision established by the DeficitReduction Act (DRA) of 2005 for oxygenequipment and establishes new payment rulesand supplier responsibilities after the 36 monthpayment cap. Section 144(b) of MIPPA mandatespayment for reasonable and necessarymaintenance and servicing of oxygen equipmentfurnished after the 36‐month rental cap. The 36‐month cap applies to stationary and portableoxygen equipment furnished on or after January1, 2006; therefore, the 36‐month cap may end asearly as January 1, 2009, for beneficiaries usingoxygen equipment on a continuous basis sinceJanuary 1, 2006.CMS has determined that, for services furnishedduring calendar year 2009, it is reasonable andnecessary to make payment for periodic, in‐homevisits by suppliers to inspect certain oxygenequipment and provide general maintenance andservicing after the 36‐month rental cap. Thesepayments only apply to equipment falling underHCPCS codes E1390, E1391, E1392, and K0738,and only when the supplier physically makes anin‐home visit to inspect the equipment andprovide any necessary maintenance and servicing.Payment may be made every six months,beginning 6 months after the 36‐month rental cap(as early as July 1, 2009, in some cases), and theallowed payment amount for each visit is equal tothe lesser of the supplier’s actual charge or the2009 fee for code K0739, multiplied by 2, for theState in which the in‐home visit takes place.Key Points• Medicare contractors will pay claims withdates of service from July 1, 2009 thruCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 29 MMR 2009‐5, May 2009

December 31, 2009, for maintenance andservicing for oxygen concentrators no moreoften than every six months beginning sixmonths after the end of the 36th month ofcontinuous use when billed with one of thefollowing HCPCS codes and modifiers:• E1390MS;• E1391MS; or• E1392MS.• In addition to payment for maintenance andservicing for stationary oxygen concentrators(HCPCS codes E1390 or E1391) Medicarecontractors will pay claims with dates ofservice from July 1, 2009 thru December 31,2009, for maintenance and servicing forportable oxygen transfilling equipment(HCPCS code K0738) no more often thanevery six months beginning six months afterthe end of the 36th month of continuous use.HCPCS code K0738 must be billed with theHCPCS modifier “MS” to obtain suchpayment.• Medicare contractors will not pay formaintenance and servicing of both a portableoxygen concentrator (E1392MS) and portableoxygen transfilling equipment (K0738MS).• If maintenance and servicing is billed for acolumn I code, additional payment for themaintenance and servicing of any of thecolumn II codes shall not be made:Column IE1390 MSE1391 MSE1392 MSK0738 MSColumn IIE1391 MS, E1392 MSE1390 MS, E1392 MSE1390 MS, E1391 MS, K0738 MSE1392 MS• For the oxygen equipment codes E1390,E1391, E1392, and K0738, billed with themodifier “MS”, Medicare contractors willmake maintenance and servicing paymentsfor covered services equal to the lesser of thesupplier’s actual charge or two units of K0739every six months.• Medicare contractors will deny claims formaintenance and servicing of oxygenequipment when billed with the HCPCScodes E0424, E0439, E0431, E0434, E1405 orE1406 and the “MS” modifier.Additional InformationIf you have questions, please contact yourMedicare DME MAC, and/or RHHI at their tollfreenumber which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site. The official instruction, CR6404, issuedto your Medicare DME MAC, and/or RHHIregarding this change may be viewed athttp://www.cms.hhs.gov/Transmittals/downloads/R461OTN.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents.Part A InformationInstructions on Utilizing 837Institutional Claim AdjustmentSegments (CAS) for MedicareSecondary Payer (MSP) Part AClaims. (This CR Rescinds and FullyReplaces CR 6275)MLN Matters Number: MM6426Related Change Request (CR) #: 6426Related CR Release Date: March 27, 2009Effective Date: July 1, 2009Related CR Transmittal #: R66MSPImplementation Date: July 6, 2009Provider Types AffectedProviders submitting claims to Medicarecontractors (fiscal intermediaries (FIs), Medicareadministrative contractors (MACs), and/orregional home health intermediaries (RHHIs)) forservices provided to Medicare beneficiariesWhat You Need to KnowCR 6426, from which this article is taken, alertsyour Medicare Part A contractors (FIs, MACs, andRHHIs) and their associated systems to theCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 30 MMR 2009‐5, May 2009

changes they will need to follow when calculatingMSP payment amounts from incoming AmericanNational Standards Institute (ANSI) ASC X12N837 4010‐A1 claims transactions. It specificallyaddresses their use of data reported in ANSI ASCX12N 837 institutional CAS segments for MSPPart A Claims.CR 6426 only affects providers submitting Part Aclaims. It is important for such providers to codethe CAS segments of their claims accurately sothat Medicare will make the correct MSPpayments. See the Background and AdditionalInformation Sections of this article for furtherdetails regarding these changes.BackgroundThe Medicare Secondary Payer (MSP) provisionsapply to situations where Medicare is not thebeneficiary’s primary insurance. Medicare’ssecondary payment for Part A MSP claims isbased on:• Medicare‐covered charges, or the amount thephysician (or other supplier) is Obligated toAccept as Payment in Full (OTAF), whicheveris lower;• What Medicare would have paid as theprimary payer; and• The primary payer(s) payment.The Health Insurance Portability andAccountability Act (HIPAA) requires thatMedicare, and all other health insurance payers inthe United States, comply with the Electronic DataInterchange (EDI) standards for health care asestablished by the Secretary of Health and HumanServices. The X12N 837 implementation guideshave been established as the standards ofcompliance for claim transactions and theimplementation guides for each transaction areavailable at http://www.wpc‐edi.com on theInternet.This article is to remind you to include CASsegment related group codes, claim adjustmentreason codes and associated adjustment amountson your MSP 837 claims you send to yourMedicare contractor. Medicare contractors needthese adjustments to properly process your MSPclaims and for Medicare to make a correctpayment. This includes all adjustments made bythe primary payer, which, for example, explainswhy the claim’s billed amount was not fully paid.The instructions detailed by CR 6426 arenecessary to ensure:• Medicare complies with HIPAA transactionand code set requirements;• Providers code for the CAS segments claimsto reflect any adjustments made by primarypayers; and• MSP claims are properly calculated byMedicare contractors (and their associatedshared systems) using payment informationderived from the incoming 837 Institutionalclaim.Adjustments made by the payer are reported inthe CAS segment on the 835 electronic remittanceadvice (ERA) or on hardcopy remittance advices.Providers must take the CAS segmentadjustments (as found on the 835 ERA) and reportthese adjustments on the 837 (unchanged) whensending the claim to Medicare for secondarypayment.Note: If you are obligated to accept, or voluntarilyaccept, an amount as payment in full from theprimary payer (a.k.a. your contractual obligation),you must identify this amount as Value Code 44in the 2300 HI Value Information. This amount isalso known as the Obligated to accept as paymentin full amount (OTAF). Details of the MSPpayment provisions may be found in the CMSMedicare Secondary Payer Manual and in the federalregulations at 42 CFR 411.32 and 411.33.Additional InformationYou can find the official instruction (CR6426)issued to your FI, RHHI, or MAC by visitinghttp://www.cms.hhs.gov/transmittals/downloads/R66MSP.pdf on the Centers for Medicare &Medicaid Services (CMS) Web site. You will findthe updated Medicare Secondary Payer (MSP)Manual, Chapter 5 (Contractor PrepaymentProcessing Requirements), Section 40.7.3.2(Medicare Secondary Payment Part A ClaimsDetermination for Services Received on 837Institutional Electronic or Hardcopy ClaimsFormat) as an attachment to that CR.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 31 MMR 2009‐5, May 2009

If you have any questions, please contact your FI,RHHI, or MAC at their toll‐free number, whichmay be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.Part A InformationImplementation of Capital toInpatient Prospective PaymentSystem (IPPS) Indirect MedicalEducation (IME) and Long Term CareHospital (LTCH) Provisions from theAmerican Recovery andReinvestment Act (ARRA) of 2009MLN Matters Number: MM6444Related Change Request (CR) #: 6444Related CR Release Date: March 27, 2009Effective Date: February 17, 2009Related CR Transmittal #: R466OTNImplementation Date: April 6, 2009Provider Types AffectedInpatient acute care hospitals and LTCHs that billMedicare fiscal intermediaries (FIs) or Medicareadministrative contractors (MACs) for servicesprovided to Medicare beneficiaries.Provider Action NeededThis article discusses provisions of the ARRA thatimpact capital IPPS payments to hospitals forindirect medical education (IME) and changes tocertain LTCH Prospective Payment System (PPS)payment policies. Please note that FIs and MACswill reprocess any claims with discharge dates onor after October 1, 2008, that were previouslyprocessed with an incorrect payment amount forIME and/or short‐stay outlier claims of LTCHswith a teaching program. You need take noaction to initiate the reprocessing of the claims.You should notify your billing office staff thatadjustments to payments will be made within sixmonths of Pricer software installation at yourcontractor. That installation is scheduled to occuron or before April 6, 2009.BackgroundThe ARRA was signed into law on February 17,2009. Change Request (CR) 6444 provides asummary of the legislation as well asimplementation instructions on certain provisionsthat affect the Medicare Fee‐for‐Service program.The first key point of the legislation affects capitalIPPS IME payments for fiscal year (FY) 2009.Beginning in FY 2009, hospitals were to receive 50percent of the capital IME adjustment providedunder the current formula. Section 4301(b)(1) ofthe ARRA removes the 50 percent adjustment thatapplied for FY 2009 and gives teaching hospitalsthe full capital IME amount for dischargesoccurring on or after October 1, 2008, throughSeptember 30, 2009. The AARA also explicitlyspecifies that the elimination of the capital IMEadjustment in FY 2010 and subsequent years is notto be affected. Therefore, beginning in FY 2010and after, under current law, hospitals will nolonger receive a teaching adjustment under thecapital IPPS. This provision also affects LTCH PPSpayments as part of the Short Stay Outlier (SSO)calculation. The revision to the capital IPPS IMEadjustment for FY 2009 provided for by section4301(b)(1) of the ARRA also affects the paymentsfor some SSO cases from LTCHs with teachingprograms since the calculation of the “IPPScomparable amount” component of the SSO“blend” option must also be revised to reflect thechange to the capital IME adjustment for FY 2009provided for in the ARRA. In the same way aswith the SSO calculation, changes to the capitalIME payments specified by the ARRA of 2009affect LTCH PPS payments governed by the “25percent” threshold payment adjustments. Underthese policies, those cases in excess of theapplicable thresholds are paid an amount basedon an amount equivalent to what would be paidCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 32 MMR 2009‐5, May 2009

under the IPPS. Therefore, the revision to thecapital IPPS IME adjustment for FY 2009 providedfor in section 4301(b) would apply to those LTCHswith teaching programs.A second key point of the legislation affectsLTCHs. The Medicare, Medicaid and SCHIPExtension Act (MMSEA) of 2007 placed amoratorium on new LTCHs or new LTCHsatellites and expansions in the number of beds inexisting LTCHs, effective December 29, 2007.MMSEA allowed for limited exceptions to themoratorium. The ARRA makes one additionalexception to the moratorium that will allowexisting LTCHs to expand the number of beds inthe LTCH or its satellite if the hospital obtained acertificate of need for an increase in beds in a statefor which such certificate of need is required thatwas issued on or after April 1, 2005, and beforeDecember 29, 2007.A third key point of the legislation also affectsLTCHs. As noted above, CMS regulations createspecial payment provisions for LTCHs or LTCHsatellites that receive more than 25 percent of theiradmissions from a single referral source. TheARRA amended the MMSEA changes to the 25percent threshold policy by adding anothercategory of LTCHs that would be subject to thethree‐year delay in application of the 25 percentpayment provision, i.e., LTCHs or LTCH satellitesthat were co‐located with provider‐basedlocations of an IPPS hospital that did not deliverservices payable under the IPPS at thosecampuses where the LTCHs or LTCH satelliteswere located. The ARRA also extended theincrease in percentages under the 25 percentthreshold policy to include “grandfathered”LTCH satellites, i.e., those in existence prior toOctober 1, 1999 and changed the implementationdate of all changes to the 25 percent thresholdpayment adjustment from the date of enactmentof the MMSEA (December 29, 2007), to either July1, 2007 or October 1, 2007, as appropriate for thespecific provision.Additional InformationIf you have questions, please contact yourMedicare MAC or FI at their toll‐free numberwhich may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on theCenters for Medicare & Medicaid Services (CMS)Web site.The official instruction (CR6444) issued to yourMedicare MAC and/or FI is available athttp://www.cms.hhs.gov/Transmittals/downloads/R466OTN.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.Part A InformationJurisdiction14 (J14) Part A and PartB Medicare AdministrativeContractor (A/B MAC) New WorkloadNumbers for the States of Maine,Massachusetts, New Hampshire,Rhode Island, and VermontChange Request (CR) #: 6406 Pub 100‐20 One‐Time NotificationEffective Date: May 2, 2009Transmittal #: 463Implementation Date: May 2, 2009I. GENERAL INFORMATIONA. Background: The purpose of this changerequest (CR) is to notify all interestedparties that the Centers for Medicare &Medicaid Services (CMS) needs to changethe contractor workload numbers for thePart A and Part B workloads in the Statesof Maine, Massachusetts, NewHampshire, Rhode Island, and Vermontwhen that workload is transitioned to theJ14 A/B MAC. These changes need to bemade because certain CMS applicationsCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 33 MMR 2009‐5, May 2009

Part Aneed to individually identify eachworkload. These workloads will betransitioned to the J14 A/B MAC asindicated below.MACWorkloadNo.EffectiveDateCurrentContractorNo.Maine 14101 05/18/2009 00180Massachusetts 14201 05/18/2009 00181New14301 06/08/2009 00270HampshireRhode Island 14401 06/01/2009 00021Vermont 14501 06/08/2009 00270Part BMACWorkloadNo.EffectiveDateCurrentContractorNo.Maine 14102 06/01/2009 31142Massachusetts 14202 06/01/2009 31143New14302 06/01/2009 31144HampshireRhode Island 14402 05/02/2009 00524Vermont 14502 06/01/2009 31145HomeHealth andHospiceAll J14States plusConnecticutMACWorkloadNo.EffectiveDateCurrentContractorNo.14004 05/18/2009 00180Note that the effective date of all transitions willfall on Monday, with the exception of the Part BRhode Island transition which, due to thesoftware being used to create and populate thatCICS production region, will have an effectivedate of Saturday,May 2, 2009.NHIC, Corp. (NHIC) will be the Jurisdiction 14A/B MAC. It currently processes the Maine,Massachusetts, New Hampshire, and VermontPart B workloads, and it is located at thefollowing address.NHIC, Corp.75 Sgt. William B. Terry DriveHingham, MA 02043The Rhode Island Part A and Part B workload iscurrently processed by:Pinnacle Business Solutions, Inc.515 West Pershing BoulevardNorth Little Rock, AR 72144The Part A workloads for Maine, Massachusetts,New Hampshire, and Vermont and the RegionalHome Health Intermediary Region A (RHHI‐A)workload is currently processed by:National Government Services8115 Knue RoadIndianapolis, IN 46250The following applications or entities will need toaccommodate the new MAC workload numbersfor both testing and production: BESS, CAFM,CERT, CMIS, the CMS BALTIMORE DC, COBA,CROWD, CSAMS, PIES, CWF, DCS, ECRS, FISS,HCIS, HIGLAS, IRIS, LOLA, NGD, the NPIcrosswalk, QIES (formerly known as OSCAR),PECOS, PIMR, PORS, PS&R, the PSC, PSOR,PULSE, REMAS, REMIS, STAR and the ExpertClaims Processing System or ECPS (formerlyknown as SuperOps).In the event the MAC transition needs to bedelayed, the CMS will provide as much notice aspossible to the above system owners, but no lessthan five business days prior to the plannedeffective date. The above listed systems will needto be able to accommodate such a delay to thestart of the MAC transition.Finally, the CMS is studying how best totransition to the applicable MACs the workloadcovered by contractor workload number 52280,which was formerly processed by Mutual ofOmaha and is currently processed by WisconsinPhysicians Service (WPS). The CMS will notify allparties as soon as its instructions are final.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 34 MMR 2009‐5, May 2009

Information Issued by theCenters for Medicare & MedicaidServices (CMS) Pertaining toPart B ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 35 MMR 2009‐5, May 2009

Part B InformationProgram Overview: 2009 PhysicianQuality Reporting Initiative (PQRI)and the 2009 Electronic Prescribing(E-Prescribing) Incentive ProgramMLN Matters Number: MM6394Related Change Request (CR) #: 6394Related CR Release Date: March 20, 2009Effective Date: January 1, 2009Related CR Transmittal #: R459OTNImplementation Date: June 22, 2009Provider Types AffectedPhysicians and other practitioners who qualify aseligible professionals to participate in the Centersfor Medicare & Medicaid Services (CMS)Physician Quality Reporting Initiative (PQRI) orthe new 2009 E‐Prescribing Incentive Program.Provider Action NeededThis article is based on Change Request (CR) 6394,which gives high‐level overviews of the 2009PQRI implementation and the new 2009 E‐Prescribing Incentive Program implementation.Make sure that your billing staffs are aware of thePQRI reporting changes and the E‐PrescribingIncentive Program.BackgroundThe 2006 Tax Relief and Health Care Act (P.L. 109‐432) (TRHCA) required CMS to establish aphysician quality reporting system, including anincentive payment for eligible professionals whosatisfactorily report data on quality measures forcovered services furnished to Medicarebeneficiaries during the second half of 2007. CMSnamed this program the Physician QualityReporting Initiative (PQRI).measures for 2009 through rulemaking and toestablish alternative reporting criteria andalternative reporting periods for reportingmeasures groups and for registry‐based reporting.In addition, the Medicare Improvements forPatients and Providers Act (P.L. 110‐275) (MIPPA),which was enacted on July 15, 2008, includesmany provisions that impact the 2009 PQRI. The2009 PQRI requirements are outlined in the 2009Medicare Physician Fee Schedule (MPFS) finalrule with comment period that was published inthe Federal Register on November 19, 2008 (visithttp://edocket.access.gpo.gov/2008/pdf/E8‐26213.pdf on the Internet) and are summarizedbelow.Section 132 of the MIPPA also authorizes a newand separate incentive program for eligibleprofessionals who are successful electronicprescribers (e‐prescribers) as defined by MIPPA.This new incentive is separate from and is inaddition to the PQRI. The 2009 programrequirements for the E‐Prescribing IncentiveProgram are also outlined in the 2009 MPFS finalrule with comment period and summarizedbelow.The purpose of this article is to give high‐leveloverviews of the 2009 PQRI implementation andthe new 2009 E‐Prescribing Incentive Programimplementation, as directed by the statute.Detailed information, educational materials, andsupportive tools for the 2009 PQRI and the 2009 E‐Prescribing Incentive Program will be posted asthey become available on the CMS PQRI Web siteat http://cms.hhs.gov/PQRI and the CMS E‐Prescribing Incentive Program Web site athttp://cms.hhs.gov/ERXIncentive, respectively. Inaddition, there are fact sheets available for the2009 PQRI and E‐Prescribing programs athttp://www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf andhttp://www.cms.hhs.gov/ERxIncentive/Downloads/erx_incentive_program_simple_factsheet.pdf,respectively.For the 2009 PQRI, the Medicare, Medicaid, andState Children’s Health Insurance Program(SCHIP) Extension Act of 2007 (P.L. 110‐173)(MMSEA) required the Secretary to selectThe 2009 PQRI overview section below highlightschanges from the 2008 PQRI with respect to: (1)eligible professionals, (2) form and manner ofCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 36 MMR 2009‐5, May 2009

eporting, (3) reporting periods, (4) payment forreporting, (5) individual quality measures, (6)measures groups, (7) determination of satisfactoryreporting, (8) validation, (9) appeals, and (10)confidential feedback reports.The 2009 E‐Prescribing Incentive Programoverview section of this article addresses: (1)eligible professionals, (2) form and manner ofreporting, (3) reporting periods, (4) payment forreporting, (5) determination of a successful e‐prescriber, and (6) confidential feedback reports.2009 PQRI Overview1. Eligible ProfessionalsBeginning with the 2009 PQRI, the definitionof “eligible professional” has been expandedto include qualified audiologists, as requiredby the MIPPA. Therefore, for the 2009 PQRI,the following professionals are eligible toparticipate in PQRI:1. Medicare physicians• Doctor of Medicine;• Doctor of Osteopathy;• Doctor of Podiatric Medicine;• Doctor of Optometry;• Doctor of Oral Surgery;• Doctor of Dental Medicine; and• Doctor of Chiropractic.2. Practitioners• Physician Assistant;• Nurse Practitioner;• Clinical Nurse Specialist;• Certified Registered NurseAnesthetist (and AnesthesiologistAssistant);• Certified Nurse Midwife;• Clinical Social Worker;• Clinical Psychologist;• Registered Dietician;• Nutrition Professional; and• Audiologists (as of January 1, 2009)3. Therapists• Physical Therapist;• Occupational Therapist; and• Qualified Speech‐LanguageTherapist.All Medicare‐enrolled professionals in thesecategories are eligible to participate in the2009 PQRI, regardless of whether theprofessional has signed a Medicareparticipation agreement to accept assignmenton all claims. However, some professionalsare eligible to participate but are not able toparticipate for one or more reasons.Professionals eligible to participate but notable to participate include:1. Professionals paid under or based uponthe MPFS billing Medicare Carriers orMedicare Administrative Contractors(MACs) who do not bill directly. Forexample, Qualified Speech‐LanguageTherapists do not currently bill Medicaredirectly. It is anticipated that QualifiedSpeech‐Language Therapists will beginbilling Medicare directly on July 1, 2009,at which point they would be able toparticipate.2. Professionals paid under the MPFS billingMedicare fiscal intermediaries (FIs) orMACs. The FI/MAC claims processingsystems currently cannot accommodatebilling at the individual physician orpractitioner level:• Critical access hospital (CAH),method II payment, where thephysician or practitioner hasreassigned his or her benefits to theCAH. In this situation, the CAH billsthe FI/MAC for the professionalservices provided by the physician orpractitioner.• All institutional providers that bill foroutpatient therapy provided byphysical and occupational therapistsand speech language pathologists (forexample, hospital, skilled nursingfacility Part B, home health agency,comprehensive outpatientrehabilitation facility, or outpatientrehabilitation facility). This does notapply to skilled nursing facilitiesunder Part A.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 37 MMR 2009‐5, May 2009

Services payable under fee schedules ormethodologies other than the MPFS are notincluded in PQRI (for example, servicesprovided in federally qualified health centers,independent diagnostic testing facilities,independent laboratories, hospitals [includingmethod I critical access hospitals], rural healthclinics, ambulance providers, and ambulatorysurgery center facilities).2. Form and Manner of ReportingFor 2009, eligible professionals can continueto choose whether to report through claimsbasedsubmission or through a qualified PQRIregistry. In addition, eligible professionals cancontinue to choose to report on individualquality measures or on measures groups.• For claims‐based submission, there is noneed to enroll or register to begin claimsbasedreporting for the 2009 PQRI.Participating eligible professionals whoseMedicare patients fit the specifications ofthe 2009 PQRI quality measures and/ormeasures groups will simply report theappropriate current proceduralterminology (CPT) Category II codes orG‐codes (where CPT Category II codesare not yet available) on their claims. CPTCategory II codes and G‐codes areHealthcare Common Procedure CodingSystem (HCPCS) codes for reportingquality data. Claims‐based reporting maybe via: (1) the paper‐based CMS 1500Claim form or (2) the equivalentelectronic transaction claim, the 837‐P.The applicable CPT Category II code or G‐code quality data must be reported on thesame claim as the patient diagnosis andservice to which the quality‐data code applies.Additional guidance about how to implement2009 PQRI claims‐based reporting ofmeasures to facilitate satisfactory reporting ofquality data codes by eligible professionals forthe 2009 PQRI is available in the 2009 PQRIImplementation Guide, which is available as adownloadable document in theMeasures/Codes section of the CMS PQRIWeb site at http://www.cms.hhs.gov/PQRI onthe CMS Web site.• For registry‐based reporting, eligibleprofessionals should submit informationto a qualified PQRI clinical data registryand authorize or instruct the registry tosubmit quality measures results andnumerator and denominator data onquality measures to CMS on their behalf.For 2009, CMS will conduct another selfnominationprocess for registries soadditional registries can potentially beapproved for submitting quality measuresdata for the 2009 PQRI. Registries qualified tosubmit data on behalf of their eligibleprofessionals in 2008 are not required to selfnominateagain for 2009 unless they areunsuccessful at submitting 2008 data byMarch 31, 2009. The list of qualified registriesfor the 2009 PQRI will be available on theCMS PQRI Web site athttp://www.cms.hhs.gov/PQRI on the CMSWeb site in the summer of 2009.3. Reporting PeriodsThere are no changes to the PQRI reportingperiod or the alternative reporting periods formeasures group reporting or for registrybasedreporting for 2009. In other words, the2009 PQRI reporting period continues to bethe entire calendar year. There also continuesto be two alternative reporting periods formeasures group reporting and for registrybasedreporting (i.e., the entire calendar yearand a six‐month reporting period beginningJuly 1, 2009).4. Payment for ReportingParticipating eligible professionals whosatisfactorily report as prescribed by the 2009MPFS final rule with comment period (and assummarized below in the Determination ofSatisfactory Reporting section) may earn a 2.0percent incentive payment. Because claimsprocessing times may vary, participatingeligible professionals should submit claimsfrom the end of 2009 promptly, so that thoseclaims will reach the Medicare’s NationalCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 38 MMR 2009‐5, May 2009

Claims History (NCH) file by February 28,2010. PQRI incentive payments will be paid asa lump sum in mid‐2010.The PQRI incentive payment will apply toallowed charges for all covered professionalservices, under the MPFS not just thosecharges associated with reported qualitymeasures. The term “allowed charges” refersto total charges, including the beneficiarydeductible and copayment, not just the 80percent paid by Medicare or the portioncovered by Medicare where Medicare is thesecondary payer. Other Part B services anditems that may be billed by eligibleprofessionals but are not paid under or basedupon the MPFS do not apply to the PQRIincentive payment.For 2009, the analysis of satisfactory reportingwill continue to be performed at theindividual eligible professional level usingindividual‐level National Provider Identifier(NPI) data. CMS, however, will continue touse the Taxpayer Identification Number (TIN)as the billing unit, so any PQRI incentivepayments earned will be paid to the TINholder of record. PQRI incentive paymentswill be paid to the holder of the TIN,aggregating individual incentive paymentsfor groups that bill under one TIN. Foreligible professionals who submit claimsunder multiple TINs, CMS will continue togroup claims by TIN for payment purposes.As a result, a provider with multiple TINswho qualifies for the PQRI incentive paymentunder more than one TIN will receive aseparate PQRI incentive payment associatedwith each TIN.In situations where eligible professionals whoare employees or contractors have assignedtheir payments to their employers or facilities,Section 1848(m)(1)(A)(ii) of the Act specifiesthat any PQRI incentive payment earned willbe paid to the employers or facilities.5. Individual Quality MeasuresThe 2009 PQRI includes a total of 153 qualitymeasures. This total includes 52 newmeasures. In addition, whereas all of the 2008PQRI quality measures were reportable eitherthrough claims‐based submission or registrybasedreporting, 18 of the 153 PQRI qualitymeasures for 2009 are reportable onlythrough registries. A complete list of the 2009PQRI individual quality measures can befound in the 2009 PQRI Quality Measures List,which is available as a downloadabledocument in the Measures/Codes section ofthe CMS PQRI Web site athttp://www.cms.hhs.gov/PQRI on the CMSWeb site.6. Measures GroupsThere are seven measures groups for the 2009PQRI. More detailed information on thesemeasures groups is available in the fact sheet athttp://www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf on the CMS Web site.7. Determination of Satisfactory ReportingIn order to qualify to earn an incentivepayment, eligible professionals must meet thecriteria for satisfactorily reporting data onPQRI quality measures. For the 2009 PQRI,there are a total of nine reporting options, orways in which an eligible professional canattempt to satisfactorily report. Althoughthere are multiple reporting options forsatisfactory reporting, an eligible professionalonly needs to satisfactorily report under oneoption to qualify for the 2.0 percent incentivepayment for the applicable reporting period.An eligible professional who qualifies formore than one reporting period will receivethe incentive payment for the longestreporting period for which the professionalqualifies. Only one incentive payment may beobtained regardless of how many reportingoptions the eligible professional chooses.While the number of reporting options remainsthe same as in 2008, there are some differencesbetween the 2008 PQRI reporting options andthe 2009 PQRI reporting options. The 2009 PQRIreporting options, including any changes, arealso detailed in the fact sheet athttp://www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf on the CMS Web siteCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 39 MMR 2009‐5, May 2009

and are included in CR6394 athttp://www.cms.hhs.gov/transmittals/downloads/R459OTN.pdf on the CMS Web site.As stated in the Payment for Reportingsection, the analysis of whether an eligibleprofessional has satisfactorily reported willcontinue to be performed at the individualeligible professional level using theindividual‐level NPI. The eligibleprofessional’s individual NPI must be listedalong with the HCPCS codes for services,procedures, and quality data on the claim.Thus, to participate in the 2009 PQRI, eligibleprofessionals must have their individual‐levelNPIs and must consistently use theirindividual NPIs to correctly identify theirservices, procedures, and quality‐data codesfor an accurate determination of satisfactoryreporting.Eligible professionals select the qualitymeasures and/or measures groups that areapplicable to their practices. If an eligibleprofessional submits data for a qualitymeasure or a measures group, then thatmeasure or measures group is presumed to beapplicable for the purposes of determiningsatisfactory reporting. For eligibleprofessionals choosing to report on individualquality measures, CMS recommends thateligible professionals report on every qualitymeasure that is applicable to their patientpopulations to increase the likelihood thatthey will reach the 80 percent satisfactorilyreporting requirement for the requisitenumber of measures.As detailed information, education, and toolsto support satisfactory claims‐based reportingof individual quality measures and/ormeasures groups become available, they willbe posted on the CMS PQRI Web site athttp://www.cms.hhs.gov/PQRI on the CMSWeb site.8. ValidationSection 1848(m)(5)(D)(ii) of the Social SecurityAct (the Act) permits CMS to validate, usingsampling or other means, whether qualitymeasures applicable to the services furnishedby a participating eligible professional havebeen reported. Under the claims‐basedreporting method of individual measure(s),the determination of satisfactory reporting, asdefined by statute, will itself serve as ageneral validation because the analysis willassess whether quality‐data codes areappropriately submitted by an eligibleprofessional in a sufficient proportion of theinstances when a reporting opportunityexists. In addition, for those eligibleprofessionals who satisfactorily submitquality‐data codes for fewer than three (3)PQRI measures, a two‐step measureapplicabilityvalidation (MAV) process willdetermine whether they should havesubmitted quality‐data codes for additionalmeasures. If CMS finds that eligibleprofessionals who have reported fewer thanthree quality measures have not reportedadditional measures that are also applicableto the services they furnished during thereporting period, then CMS cannot pay thoseeligible professionals the incentive payment.More information on the MAV process for the2009 PQRI is available in the Analysis andPayment section of the CMS PQRI Web site athttp://www.cms.hhs.gov/PQRI on the CMSWeb site.9. AppealsFor the 2009 PQRI, the statute specificallystates that there will be no administrative orjudicial review of the determination of: (1)quality measures applicable to servicesfurnished by eligible professionals, (2)satisfactory reporting, or (3) the incentivepayment. However, CMS will establish aprocess for eligible professionals to inquireabout these matters.10. Confidential Feedback ReportsCMS will provide confidential feedbackreports on 2009 PQRI reporting toparticipating eligible professionals at or nearthe time that the lump sum incentivepayments are made in 2010. Access toconfidential feedback reports may requireeligible professionals to complete an identity‐CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 40 MMR 2009‐5, May 2009

verification process to obtain a loginidentification and password for a secureinterface. However, this process is notrequired to participate in the 2009 PQRI or toreceive an incentive payment.In addition, Section 1848(m)(5)(G) of the Actrequires CMS to post on the CMS Web site, inan easily understandable format, a list of thenames of the eligible professionals whosatisfactorily submitted data on qualitymeasures under PQRI. Therefore, the namesof eligible professionals who satisfactorilysubmitted data on quality measures for the2009 PQRI will be posted athttp://www.medicare.gov on the Internetafter the lump sum incentive payments aremade in 2010.E‐Prescribing Incentive Program Overview1. Eligible ProfessionalsFor the 2009 E‐Prescribing Incentive Program,“eligible professional” includes the same listof professionals as previously shown aseligible for the PQRI program.However, in order to participate in thisincentive program, a professional in one ofcategories of eligible professionals must beauthorized by his or her respective state lawsto prescribe medication and prescribingmedications must fall within the individualeligible professional’s scope of practice.All Medicare‐enrolled professionals in thesecategories are eligible to participate in the2009 E‐Prescribing Incentive Program,regardless of whether the professional hassigned a Medicare participation agreement toaccept assignment on all claims. However,some professionals are eligible to participatebut are not able to participate for one or morereasons and the reasons are the same as thosewhich preclude professionals fromparticipating in PQRI as mentioned earlier inthis article.Professionals not eligible to participate in theE‐Prescribing Incentive Program and not ableto qualify to earn an incentive payment arethose that are not defined as eligibleprofessionals in the Medicare Improvementsfor Patients and Providers Act of 2008.Services payable under fee schedules ormethodologies other than the MPFS are notincluded in E‐Prescribing Incentive Program(for example, services provided in federallyqualified health centers, independentdiagnostic testing facilities, independentlaboratories, hospitals [including method Icritical access hospitals], rural health clinics,ambulance providers, and ambulatorysurgery center facilities).The E‐Prescribing Incentive Program FactSheet athttp://www.cms.hhs.gov/ERxIncentive/Downloads/erx_incentive_program_simple_factsheet.pdf on the CMS Web site provides anexcellent guide for participation in theprogram.2. Form and Manner of ReportingFor 2009, participation in the E‐PrescribingIncentive Program is limited to thesubmission of quality data codes for the e‐prescribing measure through Medicare’sclaims processing system, as described in the2009 MPFS final rule with comment period.There is no need to enroll or register to beginclaims‐based reporting for the 2009 E‐Prescribing Incentive Program.Participating eligible professionals who billfor the services or procedures included in thedenominator of the 2009 e‐prescribingmeasure will report the correspondingappropriate numerator G‐code on their claim.Claims‐based reporting may be via: (1) thepaper‐based CMS‐1500 Claim form or (2) theequivalent electronic transaction claim, the837‐P. The specifications for the 2009 e‐prescribing measure are available on the CMSE‐Prescribing Incentive Program Web site athttp://www.cms.hhs.gov/ERXIncentive on theCMS Web site.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 41 MMR 2009‐5, May 2009

The applicable CPT Category II code or G‐code quality data must be reported on thesame claim as the billable service orprocedure to which the quality‐data codeapplies. The 2009 e‐prescribing measure doesnot require a diagnosis code to helpdetermine the denominator.3. Reporting PeriodsFor 2009, the reporting period for the E‐Prescribing Incentive Program is the entirecalendar year, or January 1, 2009 – December31, 2009.4. Payment for ReportingFor 2009, eligible professionals, who aredetermined to be “successful e‐prescribers”(as discussed below), may earn an incentivepayment equal to 2.0 percent of the totalestimated allowed charges for all such MPFScovered professional services: (1) furnished bythe eligible professional during the reportingperiod of January 1 through December 31,2009, (2) received into the CMS NCH file byFebruary 28, 2010, and (3) paid under orbased upon the MPFS. Because claimsprocessing times may vary, participatingeligible professionals should submit claimsservice dates late in 2009 promptly, so thatthose claims will reach Medicare’s NCH fileby February 28, 2010. CMS anticipates that thee‐prescribing incentive payments will be paidas a lump sum in mid‐2010. There is nobeneficiary co‐payment or notice to thebeneficiary regarding the e‐prescribingincentive payments.According to the statute, however, there is alimitation with regard to the application ofthe incentive. For 2009, the incentive does notapply to eligible professionals, for thereporting period, if the Medicare allowedcharges for all covered professional servicesfor the codes to which the e‐prescribingmeasure applies are less than 10 percent of thetotal of the allowed charges under MedicarePart B for all such covered professionalservices furnished by the eligible professional.Under the E‐Prescribing Incentive Program,covered professional services are those paidunder or based upon the MPFS.The e‐prescribing incentive payment willapply to allowed charges for all coveredprofessional services, not just those chargesassociated with the e‐prescribing measure.The term “allowed charges” refers to totalcharges, including the beneficiary deductibleand copayment, not just the 80 percent paidby Medicare or the portion covered byMedicare where Medicare is the secondarypayer. Note that the amounts billed above theMPFS amounts for assigned and non‐assignedclaims will not apply to the incentive. Thestatute defines e‐prescribing covered servicesas those paid under or based upon the MPFSonly, which includes technical components ofdiagnostic services and anesthesia services, asanesthesia services are considered feeschedule services though based on a uniquemethodology.For 2009, the analysis of determiningsuccessful e‐prescribers will be performed atthe individual eligible professional level usingindividual‐level NPI data. CMS, however,will use the TIN as the billing unit, so any e‐prescribing incentive payments earned will bepaid to the TIN holder of record. E‐prescribing incentive payments will be paid tothe holder of the TIN, aggregating individualincentive payments for groups that bill underone TIN. For eligible professionals whosubmit claims under multiple TINs, CMS willgroup claims by TIN for payment purposes.As a result, a provider with multiple TINswho qualifies for the e‐prescribing incentivepayment under more than one TIN willreceive a separate e‐prescribing incentivepayment associated with each TIN. Insituations where eligible professionals whoare employees or contractors have assignedtheir payments to their employers or facilities,section 1848(m)(2)(A) of the Act specifies thatany e‐prescribing incentive payment earnedwill be paid to the employers or facilities.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 42 MMR 2009‐5, May 2009

5. Determination of a Successful E‐PrescriberFor purposes of qualifying for the e‐prescribing incentive payment for 2009, aneligible professional will be considered asuccessful e‐prescriber if he/she reported theapplicable e‐prescribing quality measure in atleast 50 percent of the cases in which suchmeasure is reportable by the eligibleprofessional during the reporting period.6. Confidential Feedback ReportsCMS will provide confidential feedbackreports to participating eligible professionalsat or near the time that the lump sumincentive payments are made in 2010. As withPQRI, access to confidential feedback reportsmay require eligible professionals to completean identity‐verification process to obtain alogin identification and password for a secureinterface. However, this process is notrequired to participate in the 2009 E‐Prescribing Incentive Program or to receive anincentive payment.In addition, section 1848(m)(5)(G) of the Actrequires CMS to post on the CMS website, inan easily understandable format, a list of thenames of the eligible professionals who aresuccessful e‐prescribers. Therefore, the namesof eligible professionals who are determinedto be successful e‐prescribers for the 2009 E‐Prescribing Incentive Program will be postedat http://www.medicare.gov on the Internetafter the lump sum incentive payments aremade in 2010.Additional InformationThe official instruction (CR 6394) issued to yourcarrier and/or A/B MAC, regarding this changemay be viewed athttp://www.cms.hhs.gov/transmittals/downloads/R459OTN.pdf on the CMS Web site.Once again, there are fact sheets available for the2009 PQRI and E‐Prescribing programs athttp://www.cms.hhs.gov/PQRI/downloads/PQRIWhatsNew2009Final.pdf andhttp://www.cms.hhs.gov/ERxIncentive/Downloads/erx_incentive_program_simple_factsheet.pdf,respectively.If you have any questions, please contact yourcarrier or A/B MAC at their toll‐free number,which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.Part B InformationInstructions for Utilizing 837Professional Claim AdjustmentSegments (CAS) for MedicareSecondary Payer (MSP) Part BClaims (This CR rescinds and fullyreplaces CR6211)MLN Matters Number: MM6427Related Change Request (CR) #: 6427Related CR Release Date: March 27, 2009Effective Date: July 1, 2009Related CR Transmittal #: R67MSPImplementation Date: July 6, 2009Provider Types AffectedPhysicians, providers, and suppliers submittingclaims to Medicare contractors (carriers, DMEMedicare administrative contractors (DMEMACs), and/or Medicare administrativecontractors (MACs)) for services provided toMedicare beneficiariesProvider Action NeededImpact to YouThis article is based on Change Request (CR) 6427which informs Medicare contractors about thechanges necessary to derive Medicare SecondaryPayer (MSP) payment calculations from incoming837 4010‐A1 claims transactions.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 43 MMR 2009‐5, May 2009

What You Need to KnowCR 6427 is limited to providers billing Part Bcontractors (carriers and MACs) and DME MACs.What You Need to DoInclude your CAS segment related group codes,claim adjustment reason codes and associatedadjustment amounts on your MSP 837 claims yousend to your Medicare contractor. Medicarecontractors need these adjustments to properlyprocess your MSP claims and for Medicare tomake a correct payment. This includes alladjustments made by the primary payer, whichexplains why the claim’s billed amount was notfully paid.BackgroundThe Health Insurance Portability andAccountability Act (HIPAA) requires thatMedicare, and all other health insurance payers inthe United States, comply with the Electronic DataInterchange (EDI) standards for health care asestablished by the Secretary of Health and HumanServices. The X12N 837 implementation guideshave been established as the standards ofcompliance for claim transactions, and theimplementation guides for each transaction areavailable at http://www.wpc‐edi.com on theInternet.This article is to remind you to include CASsegment related group codes, claim adjustmentreason codes and associated adjustment amountson your MSP 837 claims you send to yourMedicare contractor. Medicare contractors needthese adjustments to properly process your MSPclaims and for Medicare to make a correctpayment. This includes all adjustments made bythe primary payer, which, for example, explainswhy the claim’s billed amount was not fully paid.The instructions detailed by CR 6427 arenecessary to ensure:• Medicare complies with HIPAA transactionand code set requirements,• Physician and suppliers code for the CASsegments claims to reflect any adjustmentsmade by primary payers; and• MSP claims are properly calculated byMedicare contractors (and their associatedshared systems) using payment informationderived from the incoming 837 professionalclaim.Adjustments made by the payer are reported inthe CAS on the 835 electronic remittance advice(ERA) or on hardcopy remittance advices.Providers must take the CAS segmentadjustments (as found on the 835 ERA) and reportthese adjustments on the 837 (unchanged) whensending the claim to Medicare for secondarypayment.Note: If you are obligated to accept, or voluntarilyaccept, an amount as payment in full from theprimary payer, you must use the group codeContractual Obligation (CO) to identify yourcontractual adjustment amount, also known as theObligated to accept as payment in full adjustment(OTAF). Details of the MSP provisions may befound in the CMS Internet Only Manuals 100‐05and in the federal regulations at 42 CFR 411.32and 411.33. Physician and suppliers should nolonger identify the OTAF in the CN1 segment ofthe 837.Additional InformationIf you have questions, please contact yourMedicare contractor at their toll‐free number,which may be found athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMSWeb site.The official instruction (CR6427) issued to yourMedicare contractor is available athttp://www.cms.hhs.gov/transmittals/downloads/R67MSP.pdf on the CMS Web site.DisclaimerThis article was prepared as a service to the public and is not intended togrant rights or impose obligations. This article may contain references orlinks to statutes, regulations, or other policy materials. The informationprovided is only intended to be a general summary. It is not intended to takethe place of either the written law or regulations. We encourage readers toreview the specific statutes, regulations and other interpretive materials for afull and accurate statement of their contents. CPT only copyright 2008American Medical Association.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 44 MMR 2009‐5, May 2009

National Government ServicesTraining and Seminar InformationforPart A and Part B ProvidersCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 45 MMR 2009‐5, May 2009

Medicare Part A & RHHI FY 2009 Education SessionsDon’t Miss Out on Upcoming Medicare Training… Save These Dates!!!The following dates have been scheduled for Medicare Part A and Regional Home Health Intermediary(RHHI) providers. Training events will be made available for registration on our Web site:www.NGSMedicare.com.Training dates and topics are subject to change. Visit our Web site often to stay aware of additions to ourtraining schedule.DateTuesday, May 5, 2009Thursday, May 7, 2009Thursday, May 7, 2009Wednesday, May 13, 2009Thursday, May 14, 2009Thursday, May 14, 2009Tuesday, May 19, 2009Tuesday, May 26, 2009Tuesday, June 16, 2009Wednesday, June 17, 2009Thursday, June 18, 2009Thursday, June 18, 2009Tuesday, June 23, 2009Wednesday, June 24, 2009Thursday, June 25, 2009Monday, July 6, 2009Tuesday, July 7, 2009Thursday, July 9, 2009Tuesday, July 14, 2009Thursday, July 16, 2009Thursday, July 16, 2009Tuesday, July 21, 2009Tuesday, July 28, 2009Wednesday, July 29, 2009TopicMedicare Preventive Services – Glaucoma Screeningand Medical Nutrition TherapyHome Health BillingInpatient Psychiatric Facility (IPF) BillingSkilled Nursing Facility (SNF)Hospice BillingCredit Balance Reporting WebinarInpatient Psychiatric Facility (IPF) CoverageMedicare Secondary Payer (MSP) – Non‐Group HealthPlan (GHP)Medicare Secondary Payer (MSP) – CodingSkilled Nursing Facility (SNF)Federally Qualified Health Center (FQHC) BillingTeleconferenceThe Fundamentals of Medicare Secondary Payer (MSP)Critical Access Hospital (CAH) BillingThird Quarter FY 2009 Provider Open Forum Ask‐the‐Contractor TeleconferenceInformation and resources available will largely apply toproviders in CT, MA, ME, VT, NH, NY, DE, and RIPreventive Services – Prostate Cancer Screening andSmoking Cessation TeleconferenceComprehensive Error Rate Testing (CERT)Comprehensive Error Rate Testing (CERT)Fiscal Intermediary Standard System (FISS) QuarterlyUpdatesInpatient Rehabilitation Facility (IRF) – InterruptedStaySkilled Nursing Facility (SNF) BillingRural Health Clinic (RHC) Billing WebinarAcute Care – Outpatient ModifiersPreventive Services – Prostate Cancer ScreeningMedicare Secondary Payer (MSP) – BillingCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 46 MMR 2009‐5, May 2009

Upcoming Medicare Part B Provider Outreach & Education SeminarsSave the date!Make sure to keep checking our Events Calendar on the Education and Support page of our Web site atwww.NGSMedicare.com for more upcoming events as they are added throughout the year!Date Time Event Information05/07/09 11:30 a.m. –1:30 p.m.05/21/09 11:30 a.m. –1:00 p.m.05/27/09 11:30 a.m. –1:00 p.m.06/04/09 10:00 a.m. –11:30 a.m.06/09/09 11:30 a.m. –1:00 p.m.06/18/09 11:30 a.m. –1:00 p.m.Medicare Secondary Payer (MSP) Teleconference ‐ FreeNo registration required.This teleconference provides an overview of Medicare Secondary Payer from aPart B standpoint. Attendees will learn about the different MSP categories, howto determine whether Medicare is primary or secondary, and how to properlycomplete an MSP claim (on paper or electronically). In addition, theCoordination of Benefits Contractor (COBC), the MSP Questionnaire and MSPpayment calculations will be discussed.J13 Part B News Flash Teleconference ‐ FreeNo registration required.This teleconference provides the latest information and updates regardingJurisdiction 13 (J13) system issues and news, changes to the Medicare program,new/revised Local Coverage Determinations (LCDs), Electronic DataInterchange (EDI) information and tips on how to avoid top claim denials andComprehensive Error Rate Testing (CERT) errors.NGS Medicare Part B Outpatient Psychiatric and Psychology BillingGuidelines – FreeRegistration is required via Events Calendar on Web site.This teleconference will discuss Local Coverage Determination (LCD) L26895,Outpatient Psychiatry and Psychology Services and provide billing guidelines toimprove the accuracy of your Medicare Part B Mental Health Services billing.Global Surgery Teleconference ‐ FreeNo registration required.This teleconference will define how to apply the global surgery concept and howto utilize the payment policy indicators to identify and apply billing andreimbursement methods and correct modifiers applicable to the global surgeryrules.NGS Medicare Part B Outpatient Psychiatric and Psychology BillingGuidelines – FreeRegistration is required via Events Calendar on Web site.This teleconference will discuss Local Coverage Determination (LCD) L26895,Outpatient Psychiatry and Psychology Services and provide billing guidelines toimprove the accuracy of your Medicare Part B Mental Health Services billing.J13 Part B News Flash Teleconference ‐ FreeNo registration required.This teleconference provides the latest information and updates regardingJurisdiction 13 (J13) system issues and news, changes to the Medicare program,new/revised Local Coverage Determinations (LCDs), Electronic DataInterchange (EDI) information and tips on how to avoid top claim denials andComprehensive Error Rate Testing (CERT) errors.CPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 47 MMR 2009‐5, May 2009

National Government Services, IncP.O. Box 4837, Syracuse, NY 13221‐4837A CMS Contracted Agent MedicareCPT codes and descriptors are only copyright 2008 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 48 MMR 2009‐5, May 2009