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J11 Part A Medicare Advisory
What’s Inside...
Latest Medicare News for J11 Part A
General Information......................................................................................................2
Provider Contact Center (PCC) Training and Holiday Closure Schedule.................2
CMS e-News...................................................................................................................3
Multiple Provider Information.....................................................................................3
Calendar Year 2015 Update: Amount in Controversy Requirements for
Administrative Law Judge (ALJ) and Federal District Court Appeals.....................3
2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus
Payments...................................................................................................................4
Transitioning Medicare Administrative Contractor (MAC) Workloads to
the New Banking Contractor(s).................................................................................5
Ambulance Inflation Factor for CY 2015 and Productivity Adjustment...................6
Manual Update to Clarify Claims Processing for Laboratory Services....................7
Intensive Cardiac Rehabilitation Program - Benson-Henry Institute
Cardiac Wellness Program........................................................................................8
January 2015 Quarterly Average Sales Price (ASP) Medicare Part B
Drug Pricing Files and Revisions to Prior Quarterly Pricing Files.........................10
Hospital Information................................................................................................... 11
Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS)
Fiscal Year (FY) 2015............................................................................................. 11
October 2014 Update of the Hospital Outpatient Prospective Payment System
(OPPS).....................................................................................................................15
Learning and Education Information........................................................................21
Quarterly Updates, Changes, and Reminders Webcast – December 9, 2014..........21
MLN Connects™ Provider eNews and National Provider Calls
(MLN Connects Calls) Flyer...................................................................................22
Medical Affairs Information.......................................................................................23
Response to Comments for the Extracorporeal Shock Wave Lithotripsy for
Musculoskeletal Conditions Local Coverage Determination (LCD)......................23
Response to Comments for the Rituximab (Rituxan®)
Local Coverage Determination (LCD)....................................................................23
J11 Part A Local Coverage Determinations (LCDs) Updates.................................23
Medical Secondary Payer (MSP) Information..........................................................29
Medicare Secondary Payer (MSP) Group Health Plan (GHP) Working Aged
Policy -- Definition of “Spouse;” Same-Sex Marriages..........................................29
palmettogba.com/part a
The J11 Part A Medicare Advisory contains coverage, billing and other information for Jurisdiction 11 Part A. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities
and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on
the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines.
The J11 Part A Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services
(CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be
shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost
from our website at http://www.PalmettoGBA.com/Medicare.
CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative
value units, conversion factors and/or related components are not assigned by the AMA, and are not part of CPT®, and
the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures
and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association
(ADA). All rights reserved.
November 2014
Volume 2014, Issue 11
Provider Enrollment Information..............................................................................31
Comply with MAC Request for Fingerprints within 30 Days................................31
Skilled Nursing Facilty (SNF) Information...............................................................31
2015 Annual Update of Healthcare Common Procedure Coding System
(HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing
(CB) Update............................................................................................................31
Helpful Information.....................................................................................................35
Contact Information for Palmetto GBA Part A.......................................................35
Don’t Forget to Register for the
Quarterly Updates, Changes, and Reminders Webcast on
December 9, 2014
The J11 Part A Quarterly Updates, Changes and Reminders Webcast will be held on
Tuesday, December 9, 2014, at 10 a.m. ET.
For more information about this Webcast and registration instructions, please go to page 21
of this issue.
GENERAL INFORMATION
Provider Contact Center Training and Holiday Closure Schedule
The Palmetto GBA Provider Contact Center (PCC) will continue to close up to eight hours per month for
customer service advocate (CSA) training and staff development. Please note that our Interactive Voice
Response (IVR) unit will be available during these scheduled training sessions for automated customer
service transactions. The 2014 training closure dates and times are listed below.
Date
November 11, 2014
November 27-28, 2014
December 5, 2014
December 19, 2014
December 24, 2014
December 25, 2014
January 1, 2015
PCC/Office Closed
PCC closed (Veteran’s Day)
Office Closed/Thanksgiving
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
Office closed/Christmas Eve
Office closed/Christmas Day
Office closed/New Year’s Day
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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CMS E-NEWS
CMS e-News will contain a week’s worth of Medicare-related messages from the Centers of Medicare &
Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely
about Medicare-related topics. Please share with appropriate staff. To view the most recent issues, please
copy and paste the following links in your Web browser:
October 23, 2014
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-10-23-eNewsfile.pdf
October 16, 2014
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-10-16-eNews.
pdf
October 9, 2014
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-10-09-eNewsfile.pdf
October 2, 2014
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-10-02-enews.
pdf
September 25, 2014
http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-09-25-eNews.
pdf
MULTIPLE PROVIDER INFORMATION
Calendar Year 2015 Update: Amount in Controversy Requirements for Administrative
Law Judge (ALJ) and Federal District Court Appeals
Section 1869(b)(1)(E) of the Social Security Act (the Act), as amended by Section 940 of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires an annual reevaluation
of the dollar amount in controversy required for an Administrative Law Judge (ALJ) hearing or Federal
District Court review. The amount in controversy is adjusted by the percentage increase in the medical care
component of the consumer price index for all urban consumers (U.S. city average) for July 2003 to the
July preceding the year involved. Any amount that is not a multiple of $10 will be rounded to the nearest
multiple of $10.
The amount that must remain in controversy for ALJ hearing requests filed before December 31, 2014 is
$140. This amount will rise to $150 for ALJ hearing requests filed on or after January 1, 2015. The amount
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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that must remain in controversy for review in Federal District Court requested before December 31, 2014 is
$1,430. This amount will increase to $1,460 for appeals to Federal District Court filed on or after January 1,
2015.
2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus
Payments
MLN Matters® Number: MM8942
Related Change Request (CR) #: CR 8942
Related CR Release Date: October 3, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3087CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8942 alerts you that the annual HPSA bonus payment file for 2015 will be made
available by the Centers for Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA
bonus payments on applicable claims with dates of service on or after January 1, 2015, through December
31, 2015. You should review Physician Bonuses webpage at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/HPSAPSAPhysicianBonuses on the CMS website each year to determine whether
you need to add modifier AQ to your claim in order to receive the bonus payment, or to see if the ZIP code
in which you rendered services will automatically receive the HPSA bonus payment. Make sure that your
billing staffs are aware of these changes.
Background
Section 413(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated
an annual update to the automated HPSA bonus payment file. CMS automated HPSA ZIP code file shall be
populated using the latest designations as close as possible to November 1 of each year. The HPSA ZIP code
file shall be made available to MACs in early December of each year. MACs shall implement the HPSA ZIP
code file and, for claims with dates of service January 1 to December 31 of the following year, shall make
automatic HPSA bonus payments to physicians providing eligible services in a ZIP code contained on the
file. Only areas designated as HPSAs prior to the end of the calendar will be eligible for a bonus payment in
the following year.
Additional Information
The official instruction, CR 8942, issued to your MAC regarding this change, is available at http://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3087CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Transitioning Medicare Administrative Contractor (MAC) Workloads to the New
Banking Contractor(s)
MLN Matters® Number: MM 8847
Related Change Request (CR) #: CR 8847
Related CR Release Date: September 19, 2014
Effective Date: September 19, 2014
Related CR Transmittal #: R240FM
Implementation Date: September 30, 2014
Provider Types Affected
This MLN Matters® Article is intended to alert all providers that your Medicare Administrative Contractor
(MAC) may be transitioning their banking to another bank.
What You Need to Know
This article is informational in nature and is intended to inform you that Medicare has re-competed its
banking contracts and has awarded two new five year contracts to US Bank (an incumbent bank) and to
Citibank (which replaces the prior contract with JP Morgan Chase). The Centers for Medicare & Medicaid
Services (CMS) awarded these new contracts on July 10, 2014. Change Request (CR) 8847 was issued to
manage the transition of the MAC workloads from JP Morgan Chase to Citibank.
Background
In 2010, CMS changed its Medicare banking policies by discontinuing the use of time accounts to pay
for banking service charges and awarded five year commercial services contracts through full and open
competition to two banks (US Bank and JP Morgan Chase); these two banks disburse MAC authorized
payments and Demonstration project payments for CMS. The two current commercial banking contracts
are terminating in Fiscal Year 2015. CMS has awarded new five year contracts through full and open
competition to US Bank (incumbent bank) and Citibank (new bank). Each selected bank shall provide both
MAC payment services and Demonstration payment services and shall be designated Financial Agents of
the U.S. Treasury.
CMS is transitioning MAC workloads from JP Morgan Chase to Citibank. The MAC workloads with US
Bank will remain with US Bank. The transition began in August 2014 and will end in January 2015.
Additional Information
The official instruction for CR8847 issued to your MAC regarding this change is available at http://www.
cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R240FM.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Ambulance Inflation Factor for CY 2015 and Productivity Adjustment
MLN Matters® Number: MM8895 Revised
Related Change Request (CR) #: CR 8895
Related CR Release Date: October 7, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3090CP
Implementation Date: January 5, 2015
Note: This article was revised on October 9, 2014, to reflect the revised CR8895 issued on October
7. The CR was revised to update the Multifactor Productivity Adjustment which then adjusts the
inflation factor. In addition, the CR release date, transmittal number, and the Web address for
accessing the CR are revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for ambulance services provided to Medicare beneficiaries
Provider Action Needed
CR8895 furnishes the CY 2015 ambulance inflation factor (AIF) for determining the payment limit for
ambulance services. Make sure that your billing staffs are aware of the change.
Background
CR8895 furnishes the CY 2015 ambulance inflation factor (AIF) for determining the payment limit for
ambulance services required by section 1834(l)(3)(B) of the Social Security Act (the Act).
Section 1834(l)(3)(B) of the Act provides the basis for an update to the payment limits for ambulance
services that is equal to the percentage increase in the consumer price index for all urban consumers (CPI-U)
for the 12-month period ending with June of the previous year. Section 3401 of the Affordable Care Act
amended Section 1834(l)(3) of the Act to apply a productivity adjustment to this update equal to the 10-year
moving average of changes in economy-wide private nonfarm business multi-factor productivity (MFP)
beginning January 1, 2011. The resulting update percentage is referred to as the AIF.
The MFP for calendar year (CY) 2015 is 0.60 percent and the CPI-U for 2015 is 2.10 percent. Under to
the Affordable Care Act, the CPI-U is reduced by the MFP, even if this reduction results in a negative AIF
update. Therefore, the AIF for CY 2015 is 1.50 percent.
Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule. The
2015 ambulance fee schedule file will be available to MACs in November 2014. It may be updated with
each quarterly Common Working File (CWF) update.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Additional Information
The official instruction, CR 8895 issued to your MAC regarding this change is available at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3090CP.pdf on the Centers for
Medicare & Medicaid Services (CMS) website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Manual Update to Clarify Claims Processing for Laboratory Services
MLN Matters® Number: MM8883
Related Change Request (CR) #: CR 8883
Related CR Release Date: September 19, 2014
Effective Date: December 22, 2014
Related CR Transmittal #: R3071CP
Implementation Date: December 22, 2014
Provider Types Affected
This MLN Matters® Article is intended for Medicare practitioners providing laboratory services to Medicare
beneficiaries and billing Medicare Administrative Contractors (MACs) or Durable Medical Equipment
Medicare (DME) MACs for those services.
Provider Action Needed
Change Request (CR) 8883 updates the “Medicare Claims Processing Manual” to clarify that the location
where the independent laboratory performed the test determines the appropriate billing jurisdiction for
specimen collection fees and travel allowance. The changes are intended to clarify the existing policies and
no system or processing changes are anticipated. Make sure your billing staffs are aware of these policies.
Key Points
The manual updates, which are attached to CR8883, are as follows:
• The location where the independent laboratory performed the test determines the appropriate billing
jurisdiction. If the sample originates in a different jurisdiction from where the sample is being tested, the
claim must be filed in the jurisdiction where the test was performed.
• Claims filing jurisdiction for the specimen collection fee and travel allowance is also determined by
the location where the test was performed. When billed by an independent laboratory, the specimen
collection fee and travel allowance must be billed in conjunction with a covered laboratory test.
• The specimen collection fee is paid based on the location of the independent laboratory where the test is
performed and is billed in conjunction with a covered laboratory test.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Additional Information
The official instruction, CR8883 issued to your MAC regarding this change is available at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3071CP.pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Intensive Cardiac Rehabilitation Program - Benson-Henry Institute Cardiac Wellness
Program
MLN Matters® Number: MM8894
Related Change Request (CR) #: CR 8894
Related CR Release Date: October 3, 2014
Effective Date: May 6, 2014
Related CR Transmittal #: R175NCD and R3084CP
Implementation November 4, 2014
Provider Types Affected
This MLN Matters® Article is intended for providers who submit claims to Medicare Administrative
Contractors (MACs) for cardiac rehabilitation services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8894 alerts providers that the Benson-Henry Institute Cardiac Wellness Program
meets the program requirements set forth by Congress and is a Medicare covered benefit as of May 6, 2014.
Make sure your billing staffs are aware of these changes.
Background
In CR8894, the Centers for Medicare & Medicaid Services (CMS) explains that on September 3, 2013, it
initiated a national coverage analysis (NCA) to consider the expansion of Medicare coverage of intensive
cardiac rehabilitation (ICR) services to include the Benson-Henry Institute Cardiac Wellness Program. As a
result, effective for dates of service on and after May 6, 2014, CMS determines that the evidence is sufficient
to expand the ICR benefit to include the Benson-Henry Institute Cardiac Wellness Program, national coverage
determination (NCD) NCD 20.31.3. The program meets the ICR program requirements set forth by Congress in
section 1861 (eee)(4)(A) of the Social Security Act and in the regulations at 42 C.F.R. section 410.49(c). This
program has been included on the list of approved ICR programs available at http://www.cms.gov/Medicare/
Medicare-General- Information/MedicareApprovedFacilitie/index.html/ on the CMS website.
The current ICR policy and program criteria remain unchanged as follows: ICR refers to a physician-supervised
program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner. An
ICR program must show, in peer-reviewed published research, that it accomplished one or more of the following
for its patients:
1. Positively affected the progression of coronary heart disease;
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2. Reduced the need for coronary bypass surgery; or
3. Reduced the need for percutaneous coronary interventions.
The ICR program must also demonstrate through peer-reviewed published research that it accomplished a
statistically significant reduction in five or more of the following measures for patients from their levels before
cardiac rehabilitation services to after cardiac rehabilitation services:
1. Low density lipoprotein;
2. Triglycerides;
3. Body mass index;
4. Systolic blood pressure;
5. Diastolic blood pressure; and
6. The need for cholesterol, blood pressure, and diabetes medications.
For claims with dates of service on or after May 6, 2014, MACs will adjust claims brought to their attention but
will not search their files for claims processed prior to implementation of CR8894.
Note: Providers should refer to CR 6850 for detailed claims processing, coverage, coding, and payment
information regarding ICR. No additional claims processing instructions are required to implement CR8894. You
may review the MLN Matters® Article related to CR6850 at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLN MattersArticles/downloads/MM6850.pdf on the CMS website.
Remember that MACs will only pay for ICR services when submitted on Types of Bill ((TOB) 13X and 85X.
When these services are submitted on other TOBs, note that the services will be denied with a new Claim
Adjustment Reason Code 171 - Payment is denied when performed by this type of provider in this type of
facility.
Additional Information
The official instruction, CR8894, consists of two transmittals. The first updates the NCD manual and is
available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R175NCD.pdf on the CMS website. The second updates the “Medicare Claims Processing Manual” and
it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R3084CP.pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
The Decision Memorandum for Intensive Cardiac Rehabilitation (ICR) Program - Benson-Henry Institute
Cardiac Wellness Program (CAG-00434N) is available at http://www.cms.gov/medicare-coveragedatabase/details/nca-decision-memo.aspx?NCAId=271 on the CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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To review the CMS booklet titled Cardiovascular Disease Services visit http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CardiovascularDisease-Services-Booklet-ICN907784.pdf on the CMS website.
January 2015 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files
and Revisions to Prior Quarterly Pricing Files
MLN Matters® Number: MM8912
Related Change Request (CR) #: CR 8912
Related CR Release Date: September 19, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3072CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8912 instructs Medicare Administrative Contractors (MACs) to download and
implement the January 2015 and, if released by the Centers for Medicare & Medicaid Services (CMS), the
revised October 2014, July 2014, April 2014, and January 2014, average sales price (ASP) drug pricing files
for Medicare Part B drugs.
Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part
B drugs processed or reprocessed on or after January 5, 2015, with dates of service January 1, 2015, through
March 31, 2015. MACs will not search and adjust claims that have already been processed unless brought to
their attention. Make sure your billing staffs are aware of these changes.
Background
The Average Sales Price (ASP) methodology is based on quarterly data submitted that manufacturers
submit to CMS. CMS will supply MACs with the ASP and not otherwise classified (NOC) drug pricing
files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient
Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through
separate instructions that are in Chapter 4, section 50, of the “Medicare Claims Processing Manual” which is
available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.
pdf on the CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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The following table shows how the quarterly payment files will be applied:
Files
January 2015 ASP and ASP NOC
October 2014 ASP and ASP NOC
July 2014 ASP and ASP NOC
April 2014 ASP and ASP NOC
January 2014 ASP and ASP NOC
Effective Dates of Service
January 1, 2015, through March 31, 2015
October 1, 2014, through December 31, 2014
July 1, 2014, through September 30, 2014
April 1, 2014, through June 30, 2014
January 1, 2014, through March 31, 2014
Additional Information
The official instruction, CR 8912 issued to your MAC regarding this change is available at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3072CP.pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
HOSPITAL INFORMATION
Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal
Year (FY) 2015
MLN Matters® Number: MM8889 Revised
Related Change Request (CR) #: CR 8889
Related CR Release Date: September 30, 2014
Effective Date: October 1, 2014
Related CR Transmittal #: R3082CP
Implementation October 6, 2014
Note: This article was revised on October 2, 2014, to reflect the revised CR8889 issued on September
30. In the article, the CR release date, transmittal number, and the Web address for accessing the CR
are revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for providers who submit claims to Medicare Administrative
Contractors (MACs) for services provided to inpatient Medicare beneficiaries and are paid under the
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS).
Provider Action Needed
Change Request (CR) 8889 identifies changes that are required as part of the annual IPF PPS update from
the Fiscal Year (FY) 2015 IPF PPS Final Rule displayed on August 1, 2014. These changes are applicable to
IPF discharges occurring during the Fiscal Year October 1, 2014, through September 30, 2015. Make sure
your billing staffs are aware of these IPF PPS changes for FY 2015.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Background
The Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register
on November 15, 2004, that established the IPF PPS under the Medicare program in accordance with
provisions of the Medicare, Medicaid and SCHIP Balance Budget Refinement Act of 1999 (BBRA; Section
124 of Public Law 106-113).
Payments to IPFs under the IPF PPS are based on a federal per diem base rate that includes both inpatient
operating and capital-related costs (including routine and ancillary services), but excludes certain passthrough costs (i.e., bad debts, and graduate medical education). CMS is required to make updates to this
prospective payment system annually.
CR8889 identifies changes that are required as part of the annual IPF PPS update from the IPF PPS Fiscal
Year (FY) 2015 Final Rule. These changes are applicable to IPF discharges occurring during the Fiscal Year
(FY) October 1, 2014, through September 30, 2015.
Inpatient Psychiatric Facilities Quality Reporting Program (IPFQR)
Section 1886(s)(4) of the Social Security Act (The Act) requires the establishment of a quality data reporting
program for the IPF PPS beginning in FY 2014. CMS finalized new requirements for quality reporting for
IPFs in the “Hospital Inpatient Prospective Payment System for Acute Care Hospitals and the Long Term
Care Hospital Prospective Payment System and Fiscal Year 2013 Rates” final rule (August 31, 2012) (77
FR 53258, 53644 through 53360). Section 1886(s)(4)(A)(i) of the Act requires that, for FY 2014 and each
subsequent fiscal year, the Secretary of Health and Human Services shall reduce any annual update to a
standard Federal rate for discharges occurring during the FY by 2 percentage points for any IPF that does
not comply with the quality data submission requirements with respect to an applicable year. Therefore,
CMS is applying a 2 percentage point reduction to the Federal per diem base rate and the Electroconvulsive
Therapy (ECT) base rate as follows:
• For IPFs that fail to submit quality reporting data under the IPF Quality Reporting program, CMS is
applying a 0.1 percent annual update (that is 2.1 percent reduced by two percentage points in accordance
with section 1886(s)(4)(A)(ii) of the Act) and the wage index budget neutrality factor of 1.0002 to the
FY 2014 Federal per diem base rate of $713.19, yielding a Federal per diem base rate of $714.05 for FY
2015.
• Similarly, CMS is applying the 0.1 percent annual update and the 1.0002 wage index budget neutrality
factor to the FY 2014 Electroconvulsive Therapy (ECT) base rate of $307.04, yielding an ECT base rate
of $307.41 for FY 2015.
Market Basket Update
For FY 2015, CMS used the FY 2008-based Rehabilitation, Psychiatric, and Long Term Care (RPL) market
basket to update the IPF PPS payment rates (that is the Federal per diem and ECT base rates).
The Social Security Act (Section 1886(s)(2)(A)(ii); see http://www.ssa.gov/OP_Home/ssact/title18/1886.
htm on the Internet), requires the application of an “Other Adjustment” that reduces any update to the IPF
PPS base rate by percentages specified in the Social Security Act (Section 1886(s)(3)) for Rate Year (RY)
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12
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beginning in 2010 through the FY beginning in 2019. For the FY beginning in 2014 (that is, FY 2015), the
Act (Section 1886(s)(3)(B)) requires the reduction to be 0.3 percentage point. CMS is implementing that
provision in the FY 2015 Final Rule.
In addition, the Act Section 1886(s)(2)(A)(i) requires the application of the Productivity Adjustment
described in the Act (Section 1886(b)(3)(B)(xi)(II)) to the IPF PPS for the RY beginning in 2012 (that is, a
RY that coincides with a FY), and each subsequent FY. For the FY beginning in 2014 (that is FY 2015), the
reduction is 0.5 percentage point. CMS is implementing that provision in the FY 2015 Final Rule.
Specifically, CMS has updated - the IPF PPS base rate for FY 2015 by applying the adjusted market basket
update of 2.1 percent (which includes the RPL market basket increase of 2.9 percent, an ACA required 0.3
percent reduction to the market basket update, and an ACA required productivity adjustment reduction of
0.5 percent) and the wage index budget neutrality factor of 1.0002 to the FY 2014 Federal per diem base
rate of $713.19 yields a Federal per diem base rate of $728.31 for FY 2015. Similarly, applying the adjusted
market basket update of 2.1 percent and the wage index budget neutrality factor of 1.0002 to the FY 2014
ECT rate of $307.04 yields an ECT rate of $313.55 for FY 2015.
Pricer Updates for FY 2015
• The Federal per diem base rate is $728.31;
• The Federal per diem base rate is $714.05 (when applying the Two Percentage Point Reduction.);
• The fixed dollar loss threshold amount is $8,755;
• The IPF PPS will use the FY 2014 unadjusted pre-floor, pre-reclassified hospital wage index;
• The labor-related share is 69.294 percent;
• The non-labor related share is 30.706 percent;
• The ECT rate is $313.55; and
• The ECT rate is $307.41 (when applying the Two Percentage Point Reduction).
Cost to Charge Ratio (CCR) for the IPF Prospective Payment System FY 2015
Cost to Charge Ratio
Median
Urban
0.4710
Rural
0.6220
Ceiling
1.6582
1.8590
CMS is applying the national CCRs to the following situations:
• New IPFs that have not yet submitted their first Medicare cost report. For new facilities, CMS is using
these national ratios until the facility’s actual CCR can be computed using the first tentatively settled or
final settled cost report, which will then be used for the subsequent cost report period.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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• The IPFs whose operating or capital CCR is in excess of 3 standard deviations above the corresponding
national geometric mean (that is, above the ceiling).
• Other IPFs for whom the MAC obtains inaccurate or incomplete data with which to calculate either an
operating or capital CCR or both.
MS-DRG Update
• The code set and adjustment factors are unchanged for IPF PPS FY 2015.
FY 2014 Pre-floor, Pre-reclassified Hospital Wage Index
• CMS is using the updated wage index and the wage index budget neutrality factor of 1.0002.
COLA Adjustment for the IPF PPS FY 2015
The Office of Personal Management (OPM) began transitioning from Cost of Living Adjustment (COLA)
factors to a locality payment rate in FY 2010. The 2009 COLA factors were frozen in order to allow this
transition. In the FY 2013 IPPS/LTCH final rule (77 FR 53700 through 53701), CMS established a new
methodology to update the COLA factors for Alaska and Hawaii. In this FY 2015 IPF PPS update, CMS
adopted this new COLA update methodology and is updating the COLA rates (as published in FY 2014
IPPS/LTCH final rule (78 FR 50986), using the new methodology). The COLAs for Alaska and Hawaii are
shown in the following tables:
Alaska
City of Anchorage and 80-kilometer
(50-mile) radius by road
City of Fairbanks and 80-kilometer
(50-mile) radius by road
City of Juneau and 80-kilometer
(50-mile) radius by road
Rest of Alaska
Hawaii
City and County of Honolulu
County of Hawaii
County of Kauai
County of Maui and County of Kalawao
Cost of Living Adjustment Factor
1.23
1.23
1.23
1.23
Cost of Living Adjustment Factor
1.25
1.19
1.25
1.25
Additional Information
The official instruction, CR8889 issued to your MAC regarding this change is available at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3082CP.pdf on the CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
October 2014 Update of the Hospital Outpatient Prospective Payment System (OPPS)
MLN Matters® Number: MM8873 Revised
Related Change Request (CR) #: CR 8873
Related CR Release Date: September 26, 2014
Effective Date: October 1, 2014
Related CR Transmittal #: R3080CP
Implementation Date: October 6, 2014
Note: This article was revised on September 30, 2014, to reflect the revised CR8873 issued on
September 26. In the article, the long descriptor for HCPCS code C9135 in Table 2 is revised and
the APC code for HCPCS code J9171 in Table 7 has been revised. The CR release date, transmittal
number, and the Web address for accessing the CR are also changed. All other information remains
the same.
Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers who submit claims to Medicare
Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs for services
provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8873 describes changes to and billing instructions for various payment policies
implemented in the October 2014 hospital Outpatient Prospective Payment System (OPPS) update. Make
sure your billing staff are aware of these changes.
Background
The October 2014 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare
Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS
Modifier, Status Indicator (SI), and Revenue Code additions, changes, and deletions identified in CR8873.
The October 2014 revisions to I/OCE data files, instructions, and specifications are provided in the October
2014 I/OCE (CR8879). The MLN Matters® Article related to CR8879 will be available at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
MM8879.pdf as soon as that CR is released.
Key changes to and billing instructions for various payment policies implemented in the October 2014
OPPS update are as follows:
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Changes to Device Edits for October 2014
The most current list of device edits can be found under “Device and Procedure Edits” at http://www.cms.
gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ on the CMS website. Failure
to pass these edits will result in the claim being returned to the provider.
New Services
The new service in Table 1 is assigned for payment under the OPPS, effective October 1, 2014.
Table 1 – New Service Effective October 1, 2014
HCPCS
C9741
Effective
date
10/01/2014
SI
T
APC
0319
Short
Descriptor
Impl
pressure
sensor w/
angio
Long
Descriptor
Payment
Right heart
$15,509.99
catheterization
with
implantation
of wireless
pressure sensor
in the pulmonary
artery, including
any type of
measurement,
angiography,
imaging
supervision,
interpretation,
and report,
includes
provision of
patient home
electronics unit
Minimum
Unadjusted
Copayment
$3,102.00
Billing for Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective October 1, 2014
In the Calendar Year (CY) 2014 OPPS/ASC final rule with comment period, the Centers for Medicare &
Medicaid Services (CMS) stated that payments for drugs and biologicals based on ASPs will be updated
on a quarterly basis as later quarter ASP submissions become available. In cases where adjustments to
payment rates are necessary based on the most recent ASP submissions, CMS will incorporate changes to
the payment rates in the October 2014 release of the OPPS Pricer. The updated payment rates, effective
October 1, 2014 will be included in the October 2014 update of the OPPS Addendum A and Addendum
B, which will be posted at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html on the CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16
11/2014
b. Drugs and Biologicals with OPPS Pass-Through Status Effective October 1, 2014
Four drugs and biologicals have been granted OPPS pass-through status effective October 1, 2014. These
items, along with their descriptors and APC assignments, are identified in Table 2.
Table 2 – Drugs and Biologicals with OPPS Pass-Through Status Effective October 1, 2014
HCPCS
Code
C9023
C9025
C9026
C9135
Long Descriptor
Injection, testosterone
undecanoate, 1 mg
Injection, ramucirumab, 5 mg
Injection, vedolizumab, 1 mg
Factor ix (antihemophilic
factor, recombinant), Alprolix,
per i.u.
APC
Status Indicator
1487
G
1488
1489
1486
G
G
G
c. New HCPCS Codes Effective October 1, 2014 for Certain Drugs and Biologicals
Two new HCPCS codes have been created for reporting certain drugs and biologicals (other than new passthrough drugs and biological listed in Table 2) in the hospital outpatient setting for October 1, 2014. These
codes are listed in Table 3, and are effective for services furnished on or after October 1, 2014.
Table 3 – New HCPCS Codes for Certain Drugs and Biologicals Effective October 1, 2014
HCPCS
Code
Q9972
Q9973
Long Descriptor
APC
Injection, Epoetin Beta, 1
microgram, (For ESRD On
Dialysis)
Injection, Epoetin Beta, 1
microgram, (Non-ESRD use)
N/A
Status Indicator
Effective 10/1/14
E
N/A
E
d. Revised Status Indicator for HCPCS Codes J9160 and J9300
Effective October 1, 2014, the status indicator for HCPCS codes J9160 (Injection, denileukin diftitox, 300
micrograms) and J9300 (Injection, gemtuzumab ozogamicin, 5 mg) will change from SI=K (Paid under
OPPS; separate APC payment) to SI=E (Not paid by Medicare when submitted on outpatient claims (any
outpatient bill type)). Table 4 includes the drugs and biologicals with revised Status Indicators.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17
11/2014
Table 4 – Drugs and Biologicals with Revised Status Indicators
HCPCS
Code
J9160
J9300
Long Descriptor
Injection, denileukin diftitox,
300 micrograms
Injection, gemtuzumab
ozogamicin, 5 mg
APC
N/A
Status
Indicator
E
Effective
Date
10/1/2014
N/A
E
10/1/2014
e. Reassignment of One Skin Substitute Product that was New for CY 2014 from the Low Cost Group
to the High Cost Group
In the CY 2014 OPPS/ASC final rule, CMS finalized a policy to package payment for skin substitute
products into the associated skin substitute application procedure. For packaging purposes, CMS created
two groups of application procedures: application procedures that use high cost skin substitute products
(billed using CPT codes 15271-15278) and application procedures that use low cost skin substitute products
(billed using HCPCS codes C5271-C5278).
Assignment of skin substitute products to the high cost or low cost groups depended upon a comparison of
the July 2013 payment rate for the skin substitute product to $32, which is the weighted average payment
per unit for all skin substitute products using the skin substitute utilization from the CY 2012 claims data
and the July 2013 payment rate for each product. Skin substitute products with a July 2013 payment rate
that was above $32 per square centimeter are paid through the high cost group and those with a July 2013
payment rate that was at or below $32 per square centimeter are paid through the low cost group for CY
2014.
CMS also finalized a policy that for any new skin substitute products approved for payment during CY
2014, and CMS will use the $32 per square centimeter threshold to determine mapping to the high or low
cost skin substitute group. Any new skin substitute products without pricing information were assigned
to the low cost category until pricing information becomes available. There is now pricing information
available for three of the new skin substitute products. Table 5 shows the new products and the low/high
cost status based on the comparison of the price per square centimeter for the products to the $32 square
centimeter threshold for CY 2014.
Table 5 – Revised Low/High Cost Status for Certain Skin Substitute Codes
HCPCS
Code
Q4137
Q4138
Q4140
Long Descriptor
Amnioexcel or Biodexcel,
Per Square Centimeter
BioDfence DryFlex, Per
Square Centimeter
BioDfence, Per Square
Centimeter
Status
Indicator
N
Low/High
Cost
Status
High
Effective
Date
07/01/2014
N
High
10/01/2014
N
High
10/01/2014
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18
11/2014
f. Updated Payment Rate for HCPCS Code J9171, Effective January 1, 2014, through March 31, 2014
The payment rate for HCPCS code J9171 was incorrect in the January 2014 OPPS Pricer. The corrected
payment rate is listed in Table 6, and has been installed in the October 2014 OPPS Pricer, effective for
services furnished on January 1, 2014, through March 31, 2014. Your MAC will not automatically adjust
claims already processed with the incorrect rate, but they will adjust such claims that you bring to the
MAC’s attention.
Table 6 – Updated Payment Rate for HCPCS Code J9171, Effective January 1, 2014, through March
31, 2014
HCPCS
Code
J9171
Status
Indicator
K
APC
0823
Short Descriptor
Docetaxel injection
Corrected
Payment Rate
$4.63
Corrected
Minimum
Unadjusted
Copayment
$0.93
g. Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2014 through June 30, 2014
The payment rate for three HCPCS codes were incorrect in the April 2014 OPPS Pricer. The corrected
payment rates are listed in Table 7, and have been installed in the October 2014 OPPS Pricer, effective for
services furnished on April 1, 2014 through June 30, 2014. Your MAC will not automatically adjust claims
already processed with the incorrect rates, but they will adjust such claims that you bring to the MAC’s
attention.
Table 7 – Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2014 through June 30,
2014
HCPCS
Code
Status
Indicator
APC
Short Descriptor
Corrected
Payment Rate
J7335
K
9268
Capsaicin 8% patch
$25.49
Corrected
Minimum
Unadjusted
Copayment
$5.10
J8700
J9171
K
K
1086
0823
Temozolomide
Docetaxel injection
$6.94
$4.35
$1.39
$0.87
h. Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2014 through September 30,
2014
The payment rate for two HCPCS codes were incorrect in the July 2014 OPPS Pricer. The corrected
payment rates are listed in Table 8, and have been installed in the October 2014 OPPS Pricer, effective for
services furnished on July 1, 2014, through September 30, 2014. Your MAC will not automatically adjust
claims already processed with the incorrect rate, but they will adjust such claims that you bring to the
MAC’s attention.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19
11/2014
Table 8 – Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2014, through
September 30, 2014
HCPCS
Code
Status
Indicator
APC
J9047
G
9295
J9315
K
9265
Short Descriptor
Injection, carfilzomib,
1 mg
Romidepsin injection
Corrected
Payment Rate
$29.67
Corrected
Minimum
Unadjusted
Copayment
$5.93
$270.24
$54.05
Incorrect National Unadjusted Copayment for APC 0066 (Level I Stereotactic Radiosurgery) in the CY
2014 OPPS Final Rule
CMS incorrectly calculated the National Unadjusted Copayment for APC 0066 (Level I Stereotactic
Radiosurgery) in the CY 2014 OPPS final rule. The National Unadjusted Copayment for APC 0066 was
set to an explicit value, but it should have been set to the Minimum Unadjusted Copayment equivalent
to a coinsurance percentage of 20 percent. CMS corrected this error in the July 2014 Pricer, and CMS is
making the change for the copayment associated with APC 0066 retroactive to January 1, 2014. The correct
copayment is included in the July 2014 update of the OPPS Addendum A and Addendum B at https://www.
cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-andAddendum-B-Updates.html on the CMS website.
Providers should refer to the recent edition of the MLN Connects Provider eNews which instructs
1. contractors to reprocess claims, and
2. providers to reimburse beneficiaries for any overpayment of beneficiary copaymen
You can subscribe to MLN Connects Provider eNews at http://www.cms.gov/Outreach-and-Education/
Outreach/FFSProvPartProg/index.html on the CMS website, and you can find archived copies of
the MLN Connects Provider eNews at http://www.cms.gov/Outreach-and-Education/Outreach/
FFSProvPartProg/Provider-Partnership-Email-Archive.html on the CMS website.
Coverage Determinations
The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the
OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or
service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other
service meets all program requirements for coverage. For example, MACs determine that it is reasonable
and necessary to treat the beneficiary’s condition and whether it is excluded from payment.
Additional Information
The official instruction, CR8873 issued to your MAC regarding this change may be viewed at http://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3080CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20
11/2014
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
LEARNING AND EDUCATION INFORMATION
Quarterly Updates, Changes, and Reminders Webcast – December 9, 2014
Palmetto GBA will host the Jurisdiction 11 Part A 2014 Quarterly Updates, Changes and Reminders
Webcast on Tuesday, December 9 2014, at 10 a.m. ET.
This 60-minute Webcast is designed to provide pertinent updates, changes and reminders to assist the
provider community in staying compliant with Medicare rules and regulations and will include:
• Any new billing regulations
• Hot topics that impact provider billing
• Top denials and rejections
• Comprehensive Error Rate Testing (CERT)
Registration is required. To register for this Webcast, please go to the Event Registration Portal under the
Learning & Education section of Palmetto GBA website at www.PalmettoGBA.com/j11a. Note: A National
Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) and are required to register. You
should only enter ‘n/a’ if you do not have an NPI or PTAN.
Audio
The audio for this presentation will be broadcasting through your computer. For best results, it is
recommended that you utilize/headphones. You should not use your telephone to dial into the conference.
Handouts
A copy of the presentation will be available through the event portal once the session begins.
Registration is required. Note: An NPI and PTAN are required to register. You should only enter ‘n/a’ if you
do not have an NPI or PTAN.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21
11/2014
MLN Connects™ Provider eNews and National Provider Calls (MLN Connects Calls) Flyer
CMS created the following flyer which includes information about and how to register for the MLN
Connects™ Provider eNews and the National Provider Calls (MLN Connects Calls). Providers can access
this flyer on the CMS website at http://www.palmettogba.com/Palmetto/Providers.Nsf/files/MLN_
Connects_Marketing_Flyer.pdf/$File/MLN_Connects_Marketing_Flyer.pdf.
Please share this information with your staff.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22
11/2014
MEDICAL AFFAIRS INFORMATION
Response to Comments for the Extracorporeal Shock Wave Lithotripsy for
Musculoskeletal Conditions Local Coverage Determination (LCD)
The comment period for the J11 Part A/B MAC Extracorporeal Shock Wave Lithotripsy for Musculoskeletal
Conditions LCD L35423 became effective on July 8, 2014. The comment period ended August 25. 2014. No
comments were received from the provider community.
The start date for the notice period was October 2, 2014. This policy becomes effective November 17, 2014.
To view this future effective LCD in the Medical Policy section of the Palmetto GBA website, go to www.
PalmettoGBA.com/j11a/lcds. Go to your state and select LCDs and NCDs Web page. Select active LCDs,
future LCDs, and then “Extracorporeal Shock Wave Lithotripsy for Musculoskeletal Conditions”. The LCDs
are listed in alphabetical order.
Response to Comments for the Rituximab (Rituxan®) Local Coverage Determination
(LCD)
The comment period for the J11 Part A/B MAC Rituximab (Rituxan®) LCD L34245 became effective on
July 8, 2014. The comment period ended August 25, 2014. No comments were received from the provider
community.
The start date for the notice period for this A/B MAC LCD was October 9, 2014. This policy becomes
effective for Part A on November 24, 2014.
To view this future effective LCD in the Medical Policy section of the Palmetto GBA website, go to www.
PalmettoGBA.com/j11a/lcds. Go to your state and select LCDs and NCDs link. Select active LCDs, future
LCDs, and then “Rituximab (Rituxan®)”. The LCDs are listed in alphabetical order.
J11 Part A Local Coverage Determinations (LCDs) Updates
Revised ICD-9 LCDs
The table below provides a summary of recent J11 Part A ICD-9 LCD revisions/updates. To view the revised
LCDs go to www.PalmettoGBA.com/j11a/lcd. Choose your state and select “Active”. Select “All LCDs”
under the “Document types to further refine your search by:” section and click on the “Submit” button. The
LCDs are listed in alphabetical order.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23
11/2014
Title
Changes/Additions/Deletions
Effective
LCD ID Number
Date
Revision Number
Cardiac Rehabilitation Under CMS National Coverage Policy added CMS Internet09/18/2014
LCD Number: L32872 Only Manual, Pub 100-08, Medicare Program Integrity
Revision Number: 6
Manual, Chapter 15, §15.4.2.8. and deleted Change Request
8758, Transmittals 191, 2989, and 530 as this information was
manualized. Under Coverage Indications, Limitations and/or
Medical Necessity the following verbiage was deleted from the
bullets listed under “CR and ICR are covered for the following
patients: Patients with a stable, chronic heart failure defined as
patients with left ventricular ejection fraction of 35% or less and
New York Heart Association (NYHA) class II to IV symptoms
despite being on optimal heart failure therapy for at least six
weeks (effective February 18, 2014)” and “Stable patients are
defined as patients who have not had recent (≤6 weeks) or
planned (≤6 months) major cardiovascular hospitalizations
or procedures.” A new sentence was added to now read, “For
Cardiac Rehabilitation Only: Stable, chronic heart failure
defined as patients with left ventricular ejection fraction of 35%
or less and New York Heart Association (NYHA) class II to IV
symptoms despite being on optimal heart failure therapy for
at least 6 weeks (Effective February 18, 2014). Stable patients
are defined as patients who have not had recent (≤6 weeks) or
planned (≤6 months) major cardiovascular hospitalizations or
procedures.” Under Coverage Indications, Limitations and/
or Medical Necessity-Limitations the following verbiage was
added to bullet #1: “...through the NCD process and must meet
certain criteria for approval. A list of approved ICR programs
will be identified through the NCD listings, the CMS Web site
and the Federal Register. MACs shall use one of these options
to verify that the ICR program has met CMS approval.” The
following verbiage was added to bullet #2: “...with their local
Medicare Administrative Contractor (MAC) as an ICR program
supplier...”
Cardiac Rehabilitation Under Bill Type Codes added bill types 013X and 085X as these 09/25/2014
LCD Number: L32872 codes were inadvertently deleted.
Revision Number: 7
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
24
11/2014
Under CMS National Coverage Policy revised “CMS Manual
System” to now read “CMS Internet-Only Manual”. Corrected
name of Medicare Benefit Policy Manual. Inserted reference
for Pub 100-04, Medicare Claims Processing Manual, Chapter
4, §250.2. Corrected section for Pub 100-04, Medicare Claims
Processing Manual, Chapter 18 to now read “§60.2”. Under
Revenue Codes added second paragraph related to revenue
codes 096X, 097X and 098X. Under Associated Information
– Documentation Requirements corrected the cited section in
paragraph 1 to now read “Coverage Indications, Limitations
and/or Medical Necessity”. Under Sources of Information and
Basis for Decision sources were listed in alphabetical order.
Added author names to number 2. Corrected author names for
“Complications of colonoscopy”.
Laparoscopic Sleeve
Under CMS National Coverage Policy revised “CMS Manual
Gastrectomy for
System” to now read “CMS Internet-Only Manuals”. The title
Severe Obesity
was corrected for the cited Decision Memo to now read, “…
LCD Number: L32975 for Bariatric Surgery for the Treatment of Morbid Obesity…”
Revision Number: 5
Under Coverage Indications, Limitations and/or Medical
Necessity corrected “LGS” to read “LSG” x2. Under Coverage
Indications, Limitations and/or Medical Necessity added “and”
to the second bullet under criteria required for coverage of
laparoscopic sleeve gastrectomy. Under Coverage Indications,
Limitations and/or Medical Necessity #3 added “the” to the
third bullet. Under Sources of Information and Basis for
Decision several URLs were updated, including the access dates,
and supplement numbers were added to the 3rd citation. This
LCD was made into an A/B MAC LCD.
A/B MAC
Under CPT/HCPCS Codes added the NOTE, “For Part A
Laparoscopic Sleeve
services only, the provider should bill the appropriate procedure
Gastrectomy for
code on the UB-04 for 11X bill type.”
Severe Obesity
LCD Numbers:
L32975/L34576
Revision Numbers:
6 (ICD-9)/2 (ICD-10)
Colonoscopy/
Sigmoidoscopy/
Proctosigmoidoscopy
LCD Number: L31549
Revision Number: 5
09/25/2014
09/18/2014
10/02/2014
(L32975)
10/01/2015
(L34576)
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
25
11/2014
Psychiatric Inpatient
Hospitalization
LCD Number: L31600
Revision Number: 3
Under CMS National Coverage Policy corrected Manual
09/18/2014
system to read Internet-Only Manual and added CMS InternetOnly Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 2, Section 130.6. Added
citations for 42 CFR 412.23 and 412.27 as well as 42 CFR
482.61.
Under Coverage Indications, Limitations and/or Medical
Necessity made some grammatical and punctuation corrections.
Under Associated Information made punctuation corrections.
Under Sources of Information and Basis for Decision
corrected sources to conform to AMA formatting.
Revised ICD-10 LCDs
The table below provides a summary of recent J11 Part A ICD-10 LCD revisions/updates. To view the
revised LCDs go to www.PalmettoGBA.com/j11a/lcd. Choose your state and select “Active”. Select
“Future LCDs/Future contract number LCDs” under the “Document types to further refine your search by:”
section and click on the “Submit” button. The LCDs are listed in alphabetical order.
Title
Changes/Additions/Deletions
LCD ID Number
Revision Number
Cardiac Rehabilitation In ICD-9 Codes that Support Medical Necessity added the
LCD Number: L34412 clarification “Claims for services provided on or after 2/18/2014
Revision Number: 2
for chronic congestive heart failure will be processed when
submitted on or after 8/18/2014.
Effective
Date
10/01/2015
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
26
11/2014
Cardiac Rehabilitation Under CMS National Coverage Policy added CMS Internet10/01/2015
LCD Number: L34412 Only Manual, Pub 100-08, Medicare Program Integrity
Revision Number: 3
Manual, Chapter 15, §15.4.2.8. and deleted Change Request
8758, Transmittals 191, 2989, and 530 as this information was
manualized. Under Coverage Indications, Limitations and/or
Medical Necessity the following verbiage was deleted from the
bullets listed under “CR and ICR are covered for the following
patients: Patients with a stable, chronic heart failure defined as
patients with left ventricular ejection fraction of 35% or less and
New York Heart Association (NYHA) class II to IV symptoms
despite being on optimal heart failure therapy for at least six
weeks (effective February 18, 2014)” and “Stable patients are
defined as patients who have not had recent (≤6 weeks) or
planned (≤6 months) major cardiovascular hospitalizations
or procedures.” A new sentence was added to now read, “For
Cardiac Rehabilitation Only: Stable, chronic heart failure
defined as patients with left ventricular ejection fraction of 35%
or less and New York Heart Association (NYHA) class II to IV
symptoms despite being on optimal heart failure therapy for
at least 6 weeks (Effective February 18, 2014). Stable patients
are defined as patients who have not had recent (≤6 weeks) or
planned (≤6 months) major cardiovascular hospitalizations or
procedures.” Under Coverage Indications, Limitations and/or
Medical Necessity-Limitations the following verbiage was added
to bullet #1: “...through the NCD process and must meet certain
criteria for approval. A list of approved ICR programs will be
identified through the NCD listings, the CMS Web site and the
Federal Register. MACs shall use one of these options to verify
that the ICR program has met CMS approval.” The following
verbiage was added to bullet #2: “...with their local Medicare
Administrative Contractor (MAC) as an ICR program supplier...”
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
27
11/2014
Under CMS National Coverage Policy deleted the following
10/01/2015
citations: Pub 100-04, Medicare Claims Processing Manual ,
Chapter 12, §§30.1.B and 20.4.6. The following manual citations
were added: Pub 100-02, Medicare Benefit Policy Manual,
Chapter 6, §§20.2, 20.3, 20.4.1, 20.4.4 and Pub 100-04, Medicare
Claims Processing Manual, Chapter 4, §250.2. Throughout LCD,
any reference to ICD-9 was changed to now read ICD-10. Under
Revenue Codes added second paragraph related to revenue
codes 096X, 097X and 098X. Under Associated Information
– Documentation Requirements corrected the cited section in
paragraph 1 to now read “Coverage Indications, Limitations
and/or Medical Necessity”. Under Sources of Information and
Basis for Decision sources were listed in alphabetical order.
Added author names to number 2. The 2003 cited reference
was deleted and updated with the 2011 reference to now read
“Fisher DA, Maple JT, Ben-Menachem T, et al. Complications
of colonoscopy. Gastrointest Endosc. 2011;74(4):745-752.” The
following reference was deleted: The role of colonoscopy in
the management of patients with inflammatory bowel disease.
American Society for Gastrointestinal Endoscopy. Gastrointest
Endosc. 1998;48:689-690.
Laparoscopic Sleeve
Under CMS National Coverage Policy the title was corrected for 10/01/2015
Gastrectomy for
the cited Decision Memo to now read, “…for Bariatric Surgery
Severe Obesity
for the Treatment of Morbid Obesity…” Under Coverage
LCD Number: L34576 Indications, Limitations and/or Medical Necessity corrected
Revision Number: 1
“LGS” to read “LSG” x2. Under Coverage Indications,
Limitations and/or Medical Necessity added “and” to the second
bullet under criteria required for coverage of laparoscopic
sleeve gastrectomy. Under Coverage Indications, Limitations
and/or Medical Necessity #3 added “the” to the third bullet.
Under ICD-10 Codes That Support Medical Necessity-Group
3 effective 06/29/2014, the following invalid code was deleted
due to the 2014 & 2015 Annual ICD-10 Code Update: M51.07.
Under Sources of Information and Basis for Decision several
URLs were updated, including the access dates and supplement
numbers were added to the 3rd citation. This LCD was made into
an A/B MAC LCD.
Colonoscopy/
Sigmoidoscopy/
Proctosigmoidoscopy
LCD Number:L34454
Revision Number: 1
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
28
11/2014
Psychiatric Inpatient
Hospitalization
LCD Number: L34570
Revision Number: 1
Under CMS National Coverage Policy added CMS InternetOnly Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 2, Section 130.6. Added
citations for 42 CFR 412.23 and 412.27 as well as 42 CFR
482.61.
10/01/2015
Under Coverage Indications, Limitations and/or Medical
Necessity made some grammatical and punctuation corrections.
Under Associated Information made punctuation corrections.
Under Sources of Information and Basis for Decision corrected
sources to conform to AMA formatting.
MEDICARE SECONDARY PAYER (MSP) INFORMATION
Medicare Secondary Payer (MSP) Group Health Plan (GHP) Working Aged Policy -Definition of “Spouse;” Same-Sex Marriages
MLN Matters® Number: MM8875
Related Change Request (CR) #: CR 8875
Related CR Release Date: October 10, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R106MSP
Implementation Date: January 1, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
Section 3 of the Defense of Marriage Act (DOMA) provided for purposes of federal law, the term “spouse”
could not include individuals in a same-sex marriage. Because the MSP Working Aged provisions only
apply to subscribers and their spouses, the Working Aged provisions did not apply on the basis of spousal
status to individuals in a same-sex marriage.
The United States Supreme Court has invalidated this DOMA provision. Thus, the Centers for Medicare
& Medicaid Services (CMS) is no longer prohibited from applying the MSP Working Aged provision to
individuals in a same-sex marriage.
CAUTION – What You Need to Know
Effective January 1, 2015, the rules below apply with respect to the term “spouse” under the MSP Working
Aged provisions. This is true for both opposite-sex and same-sex marriages.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
29
11/2014
• If an individual is entitled to Medicare as a spouse based upon the Social Security Administration’s
rules, that individual is a “spouse” for purposes of the MSP Working Aged provisions.
• If a marriage is valid in the jurisdiction in which it was performed including one of the 50 states, the
District of Columbia, or a U.S. territory, or a foreign country, so long as that marriage would also be
recognized by a U.S. jurisdiction, both parties to the marriage are “spouses” for purposes of the MSP
Working Aged provisions.
• Where an employer, insurer, third party administrator, Group Health Plan (GHP), or other plan sponsor
has a broader or more inclusive definition of spouse for purposes of its GHP arrangement, it may (but
is not required to) assume primary payment responsibility for the “spouse” in question. If such an
individual is reported as a “spouse” through the Medicare, Medicaid, and SCHIP Extension Act of 2007
(MMSEA) Section 111, Medicare will pay accordingly and pursue recovery, as applicable.
GO – What You Need to Do
Make sure your billing staffs are aware of these changes.
Background
Based on Change Request (CR) 8875, effective January 1, 2015, the definition of a spouse for purposes
of the working aged provisions means “a person who is entitled to Medicare as a spouse based upon the
Social Security Administration’s rules or a person whose marriage is valid in the jurisdiction in which it was
performed including one of the 50 states, the District of Columbia, or a U.S. territory or a foreign country,
so long as that marriage would also be recognized by a U.S. jurisdiction.”
The expanded rules for the definition of “spouse,” including proper reporting pursuant to MMSEA Section
111, must be implemented with a start date for the coverage in question no later than January 1, 2015.
To the extent an employer, insurer, third party administrator, GHP or other plan sponsor insurer has chosen
to or chooses to utilize the new definitions referenced above or a broader definition of “spouse” for MSP
purposes prior to January 1, 2015, it may do so. However, MACs may not apply the revised definition
for Medicare purposes for coverage dates prior to January 1, 2015. Nor may MACs accept a definition of
spouse broader than that quoted above. In the event, Medicare does pay for coverage prior to January 1,
2015, it will pursue recovery, as applicable.
Additional Information
The official instruction, CR8875, issued to your MAC regarding this change, is available at http://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R106MSP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
30
11/2014
PROVIDER ENROLLMENT INFORMATION
Comply with MAC Request for Fingerprints within 30 Days
CMS implemented the fingerprint-based background requirement on August 6, 2014, as discussed in the
rule (http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf) published on February 2, 2011.
Fingerprint-based background checks are required for all individuals with a 5 percent or greater ownership
interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or
has submitted an initial enrollment application. Medicare Administrative Contractors (MACs) have begun
sending letters to these providers and suppliers, listing all owners who are required to be fingerprinted.
The letters are being mailed to the provider or supplier’s correspondence address and the special payments
address on file with Medicare.
Identified individuals have 30 days from the date of the letter to be fingerprinted. Failure to comply with
the fingerprint requirements could result in denial of your Medicare enrollment application or revocation
of your Medicare billing privileges. Visit Accurate Biometrics (http://www.cmsfingerprinting.com/) for
fingerprinting procedures, to find a fingerprint collection site, and to ensure the fingerprint results are
accurately submitted to the Federal Bureau of Investigation (FBI) and properly returned to CMS. For more
information on this requirement, see MLN Matters® Special Edition Article #SE1427, “Fingerprint-based
Background Check Begins August 6, 2014” at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/SE1427.pdf. If you have any questions, contact
Accurate Biometrics at 866- 361-9944, or visit their website at www.cmsfingerprinting.com.
SKILLED NURSING FACILITY (SNF) INFORMATION
2015 Annual Update of Healthcare Common Procedure Coding System (HCPCS)
Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
MLN Matters® Number: MM8943
Related Change Request (CR) #: CR 8943
Related CR Release Date: October 3, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3088CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and
Durable Medical Equipment (DME) MACs, for services provided to Medicare beneficiaries who are in a
Part A covered Skilled Nursing Facility (SNF) stay.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
31
11/2014
Provider Action Needed
STOP – Impact to You
If you provide services to Medicare beneficiaries in a Part A covered SNF stay, information in Change
Request (CR) 8943 could impact your payments.
CAUTION – What You Need to Know
CR 8943 provides the 2015 annual update of Healthcare Common Procedure Coding System (HCPCS)
Codes for Skilled Nursing Facility Consolidated Billing (SNF CB) and explains how the updates affect edits
in Medicare claims processing systems.
By the first week in December 2014, the new code files for B MAC processing, and the new Excel and
PDF files for A MAC processing will be available at http://www.cms.gov/SNFConsolidatedBilling on the
Centers for Medicare & Medicaid Services (CMS) website; and become effective on January 1, 2015.
GO – What You Need to Do
It is important and necessary to read the “General Explanation of the Major Categories” PDF file located
at the bottom of each year’s MAC update in order to understand the Major Categories, including additional
exclusions not driven by HCPCS codes.
Background
Medicare’s claims processing systems currently have edits in place for claims received for beneficiaries
in a Part A covered SNF stay, as well as for beneficiaries in a non-covered stay. These edits allow separate
payment for only those services that are excluded from consolidated billing.
Changes to HCPCS codes and Medicare Physician Fee Schedule designations are used to revise these
edits to allow MACs to make appropriate payments in accordance with policy for SNF CB, found in the
“Medicare Claims Processing Manual,” Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated
Billing), Sections 20.6 and 110.4.1. You may view this manual at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c06.pdf on the CMS website.
Additional Information
The official instruction, CR 8943, issued to your MAC regarding this change is available at http://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3088CP.pdf on the CMS
website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
32
11/2014
If you have any questions concerning this Medicare Advisory, please contact the Provider Contact Center at
855-696-0705.
This advisory should be shared with all health care practitioners and managerial members of the
provider/supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at
www.PalmettoGBA.com/j11a.
Address Changes
Have you changed your address or other significant information recently? To update this information,
please complete and submit a CMS 855A form. The most efficient way to submit your information is by
Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your
Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the
CMS website. To obtain the hard copy form plus information on how to complete and submit it – visit the
Palmetto GBA website (www.PalmettoGBA.com/j11a).
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
33
11/2014
NOTES
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
34
11/2014
HELPFUL INFORMATION
Contact Information for Palmetto GBA Part A
Department
Appeals
Beneficiary Customer
Service Center
Claims
Contact Information
Palmetto GBA
J11 Part A Appeals
Mail Code: AG-630
P.O. Box 100238
Columbia, SC 29202-3238
Fax: (803) 699-2425
Type of Inquiry
• Request for Redeterminations • Redetermination Form For Fed Ex/UPS/Certified Mail
Palmetto GBA
J11 Part A Appeals
Mail Code: AG-630
Building One
2300 Springdale Drive
Camden, SC 29020
1-800-Medicare (1-800-633-4227)
TTY: 877-486-2048
• All questions related to the
Medicare program
Visit the Medicare website at www.medicare.
gov
Palmetto GBA
J11 Part A Claims
Mail Code: AG-600
P.O. Box 100238
Columbia, SC 29202-3238
• Request for reopenings
• Clerical Error Reopening Form
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
35
11/2014
Department
Cost Report
Contact Information
Cost Report Filing
Type of Inquiry
• Cost Reports
• Checks
Mailing Address
Palmetto GBA
Attn: Cost Report Acceptance
Mail Code: AG-330
P.O. Box 100144
Columbia, SC 29202-3144
Fed Ex/UPS/Certified Mail Address
Palmetto GBA
Attn: Cost Report Acceptance
Mail Code: AG-330
2300 Springdale Drive
Building One
Camden, SC 29020-1728
Credit Balance Reporting
for NC
Cost Report Overpayment Address
(checks only)
Palmetto GBA
Medicare Finance
Mail Code: AG-260
P.O. Box 100277
Columbia, SC 29202-3277
Regular and Certified Mail
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100278
Columbia, SC 29202-3278
• Questions or concerns regarding
credit balance reports
Fed Ex/UPS/Overnight Courier
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
Reports may be faxed to:
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277
Telephone Number: (803) 763-6418
All email inquiries may be sent to Credit.
[email protected]
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
36
11/2014
Department
Credit Balance Reporting
for VA and WV
Contact Information
Type of Inquiry
Regular and Certified Mail
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100109
Columbia, SC 29202-3278
• Questions or concerns regarding
credit balance reports
Fed Ex/UPS/Overnight Courier
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
Reports may be faxed to:
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277
Telephone Number: (803) 763-6418
Electronic Data
Interchange (EDI)
for NC and SC
All email inquiries may be sent to Credit.
[email protected]
Palmetto GBA
J11 Part A EDI
Mail Code: AG-420
P.O. Box 100145
Columbia, SC 29202-3145
Provider Contact Center:
855-696-0705
• EDI enrollment
• Administrative Simplification
and Compliance Act (ASCA)
• Electronic Remittance Advice
(ERA)
• PC-ACE Pro 32 (billing
software)
• Direct Data Entry (billing
software)
DDE Hours of Availability
• Other EDI-related issues
• Monday to Friday
6 a.m. - 9 p.m. ET
• Saturday 6 a.m. - 4 p.m. ET
• Sunday** 6 a.m. - 8 a.m. and 12
- 4 pm ET
**Not available on Quarterly
Release weekends
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
37
11/2014
Department
Electronic Data
Interchange (EDI)
for VA and WV
Contact Information
Type of Inquiry
NGS EDI Help Desk: 855-696-0705
• EDI enrollment
NGS EDI website:
www.ngsmedicare.com/ngs/portal/
ngsmedicare/welcome
• Electronic Remittance Advice
(ERA)
• PC-ACE Pro 32 (billing
software)
• Direct Data Entry (billing
software)
Freedom of Information
Act (FOIA) Requests
Medical Affairs
• Other EDI-related issues • FOIA requests
Palmetto GBA
FOIA Coordinator
Mail Code: AG-615
P.O. Box 100190
Columbia, SC 29202-3190
Palmetto GBA
J11 Part A Medical Affairs
Mail Code: AG-300
P.O. Box 100238
Columbia, SC 29202-3238
• Local coverage determinations
(LCDs)
Send emails to J11A.Policy@PalmettoGBA.
com
Medical Review
Fax: (803) 935-0199
Palmetto GBA
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238
• Responding to Additional
Documentation Requests
(ADRs)
• Responses to our requests for
medical records
Please call the Provider Contact Center (PCC) at
855-696-0705 for Medical Review questions.
Fed Ex/UPS/Overnight Courier
Palmetto GBA J11 MAC
Mail Code: AG-230
2300 Springdale Drive, Building One
Camden, SC 29020
Fax: (803) 699-2432
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Department
Contact Information
Type of Inquiry
Medicare Secondary Payer For Coordination of Benefits Contractor (COBC) • MSP questions
(MSP)
questions, call 800-999-1118 or TTY/TDD
• Questions regarding
at 800-318-8782 for the hearing and speech
beneficiary’s primary or
impaired. Customer Service Representatives are
secondary records
available to provide you with quality service
Monday through Friday from 8 a.m. to 8 p.m.
ET, except holidays.
Overpayments
Address for general written inquiries:
Medicare - Coordination of Benefits
P.O. Box 33847
Detroit, MI 48232
J11 NC Part A Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100278
Columbia, SC 29202-3277
• Overpayments
• Checks for cost report and
credit balances
J11 SC Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100277
Columbia, SC 29202-3277
J11 VA and WV Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100109
Columbia, SC 29202-3109
Provider Inquiries:
For inquiries regarding overpayments, please
call the Provider Contact Center at 855-6960705.
Fax Numbers:
• To send any financial correspondence to the
overpayment department by fax, please fax
this information to (803) 419-3275.
• To request an immediate offset, fax your
request to (803) 462-2574.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Department
Overpayments
Contact Information
Type of Inquiry
J11 NC Part A Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100278
Columbia, SC 29202-3277
• Overpayments
• Checks for cost report and
credit balances
J11 SC Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100277
Columbia, SC 29202-3277
J11 VA and WV Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100109
Columbia, SC 29202-3109
Provider Inquiries:
For inquiries regarding overpayments, please
call the Provider Contact Center at 855-6960705.
Fax Numbers:
• To send any financial correspondence to the
overpayment department by fax, please fax
this information to (803) 419-3275.
• To request an immediate offset, fax your
request to (803) 462-2574.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Department
Provider Audit
Contact Information
Type of Inquiry
Palmetto GBA
Provider Audit
Mail Code: AG-320
P.O. Box 100144
Columbia, SC 29202-3144
• Issues related to cost reports,
desk reviews, audits and
settlements
• Issues related to the filing
of cost report appeals and
reopenings
Palmetto GBA
Cost Report Appeals and Reopenings
Mail Code: AG-380
P.O. Box 100144
Columbia, SC 29202-3144
Email:
Filing of Cost Report Appeals
[email protected]
Provider Contact Center
(PCC)
Filing of Cost Report Reopenings
[email protected]
Palmetto GBA
J11 Part A PCC
Mail Code: AG-840
P.O. Box 100238
Columbia, SC 29202-3238
• General coverage and
Medicare-related questions
• Crossover questions
855-696-0705
• Questions regarding claim filing
requirements
Our PCC Representatives are ready to answer
• Explanation of denial reasons
your questions about billing problems and other
issues.
J11 Part A PCC Hours: 8 a.m. to 4:30 p.m. ET
• IVR resources
• MSP resources
• Modifier guidelines
Email
Email J11 Part A (http://www.
• Medical record documentation
palmettogba.com/palmetto/Feedback.nsf/
questions
Feedback?OpenForm&SendTo=08) to have
your inquiry answered. Please do not include any • Written Inquiries
Protected Health Information.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Department
Provider Enrollment
Contact Information
Type of Inquiry
Palmetto GBA
J11 Part A Provider Enrollment
Mail Code: AG-331
P.O. Box 100144
Columbia, SC 29202-3144
• Enrollment (credentialing)
questions
For inquiries regarding provider enrollment,
please call the PCC at 855-696-0705.
• Change address, add a location
or add a new member to a
provider group
• Request CMS-855 B, I or R
forms
• Independent Diagnostic Testing
Facility (IDTF) enrollment
• Electronic Funds Transfer
(EFT) CMS 588 form
• Medicare Participating
Physician or Supplier
Agreement (PAR) CMS 460
form
• How to obtain a National
Provider Identifier (NPI)
• Participation corrections
• IRS 1099 tax form corrections
Provider Outreach and
Education (POE)
Provider Reimbursement
• Consent forms
• Educational training requests
Palmetto GBA
J11 Part A POE
Mail Code: AG-830
P.O. Box 100238
Columbia, SC 29202-3238
• Request a speaker for
association meetings in your
state
For education, please complete the Education
Request Form. To access this document, go to
the Forms Web Page at www.PalmettoGBA.
com/j11a/forms
Palmetto GBA
Provider Reimbursement
Mail Code: AG-330
P.O. Box 100144
Columbia, SC 29202-3144
Phone Number: (803) 382-6104
• Submission of interim rate
information
• Reimbursement issues
• Reimbursement specialist
• Submission of certificates
Fax updated certificates for diabetes
education, mammography and PET scan to the
reimbursement department at (803) 935-0262.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Department
Zone Program Integrity
Contractor (ZPIC)
Contact Information
AdvancedMed, an NCI Company
520 Royal Parkway, Suite 100
Nashville, TN 37214
Phone Number: (615) 871-2361
Website: www.nciinc.com/about-us/
advancemed
Type of Inquiry
• Fraud
• Abuse
• Questionable billing practices
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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