1. No category

November 2014
This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.
Bulletins are available at no cost from our Website at www.CahabaGBA.com.
News From Cahaba GBA
News From CMS continued…….
Disclaimer………………….……………………....….…
2
Please Route……………………………………………..
3
General Medicare Questions for Medicare Recipients…..
3
2014 Holiday Closure Schedule………………...…….....
4
Provider Contact Center (PCC), Clerical Error
Reopenings (CER) and EDI Training Schedule……..…..
5
Provider Contact Center (PCC) Telephone Number….....
5
Using the Interactive Voice Response (IVR) System for
Claim Status and Eligibility Requests......……….........…
6
Medicare Health Insurance Claim (HIC) Number………
Sample Collection Fee Adjustment for Clinical
Laboratory Fee Schedule and Laboratory Services….…
35
Transitioning Medicare Administrative Contractor
(MAC) Workloads to the New Banking Contractor(s)...
37
Screening for Hepatitis C Virus (HCV) in Adults……..
39
October 2014 Update of the Ambulatory Surgical
Center (ASC) Payment System – Revised………….….
45
Manual Update to Clarify Claims Processing for
Laboratory Services…………………………………….
49
7
Influenza Vaccine Payment Allowances - Annual
Update for 2014-2015 Season – Revised………………
51
Cahaba GBA’s Email Notification Service.……..………
8
Annual Clotting Factor Furnishing Fee Update 2015….
54
Top EDI Claim Rejections………………………………
9
Claim Specific CERT Errors- September 2014………....
9
January 2015 Quarterly Average Sales Price (ASP)
Medicare Part B Drug Pricing Files and Revisions to
Prior Quarterly Pricing Files…………………….……..
56
Comment Period for Proposed/Draft Local Coverage
Determinations (LCDs)…………………………………
10
2014 Flu Season Allowances- Reminder……………….
11
Examining the Difference between a National Provider
Identifier (NPI) and a Provider Transaction Access
Number (PTAN) - Revised…………………………….
58
Influenza Season Is Here- Are You Billing Properly?.....
11
Provider Outreach & Education Advisory Group
Accepting Applications for Part B Providers……………
2014-2015 Influenza (Flu) Resources for Health Care
Professionals……………………………………….…..
63
12
CMS MLN Connects™ Provider eNews…………..…..
67
Two CMS Educational Resources for Medicare
Providers & Suppliers……………………………….…
68
News From CMS
Invalidation of National Coverage Determination 140.3 Transsexual Surgery……………………………………..
13
Pub 100-03, Chapter 1, Language-only Update- Revised.
22
CMS 1500 Claim Form Instructions: Revised for Form
Version 02/12 – Revised…………………….…………..
24
Flu Season Is Here!
Cardiac Rehabilitation Programs for Chronic Heart
Failure – Revised………………………………………...
27
New Waived Tests – Revised……………………………
30
New Physician Specialty Code for Interventional
Cardiology – Revised……………………………………
If you have any questions related to the influenza vaccine;
refer to pages 11, 51 and 63 in this monthly newsletter as
well as the following web link
https://apps.cahabagba.com/fees/getVaccines.do.
33
Survey
Medicare B Newsline Quality Survey………………….
69
Key For Icons
All Providers
End Stage Renal Disease (ESRD)
Claims
Radiology
Skilled Nursing Facility (SNF)
The Medicare B Newsline provides information for those providers who submit claims to Cahaba Government Benefit
Administrators®, LLC. The CPT codes, descriptors and other data only are copyright © 2013 American Medical Association. All
rights reserved. Applicable FARS/DFARS apply.
Disclaimer
This educational material was prepared as a tool to assist Medicare providers and other interested parties and is not intended to
grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information
within this module, the ultimate responsibility for the correct submission of claims lies with the provider of services. Cahaba
Government Benefit Administrators®, LLC employees, agents, and staff make no representation, warranty, or guarantee that
this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences
of the use of these materials. This publication is a general summary that explains certain aspects of the Medicare Program, but
is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
We encourage users to review the specific statues, regulations and other interpretive materials for a full and accurate statement
of their contents. Although this material is not copyrighted, CMS prohibits reproduction for profit making purposes.
American Medical Association Notice and Disclaimer
CPT codes, descriptors and other data only are Copyright 2013 American Medical Association. All rights reserved.
ICD-9 Notice
The ICD-9-CM codes and descriptors used in this material are copyright 2013 under uniform copyright convention. All rights
reserved.
Page 2
November 2014 Medicare B Newsline
News From Cahaba GBA for All Part B Providers
Please Route
Remember that this newsletter, and all other Medicare publications, serves as your official notice of
Medicare coverage and billing information. If you have any questions about the information included in this
newsletter, please call your Provider Contact Center.
This bulletin shall be shared with all health care practitioners and managerial members of your provider
staff. Bulletins are available at no cost from our website at https://www.cahabagba.com/partb/education/cahaba-gba-medicare-part-b-newsletters/.
Routing List






Provider/Supplier
Administrator
Office/Clinic Manager
Medical Personnel
Billing/Insurance Staff
Other Additional Staff
General Medicare Questions for Medicare Recipients
Do some of your patients have questions regarding their Medicare benefits and you are not sure how to
answer? Medicare recipients should call 1-800-MEDICARE (1-800-633-4227) for all questions related to
Medicare services. Questions regarding specific claims will be automatically routed to the appropriate
Medicare contractor’s call center for response. Please do not ask your patients to contact Medicare on a
claim that you accepted assignment on.
Page 3
November 2014 Medicare B Newsline
Holiday Closure Schedule-2014- UPDATE
Cahaba GBA’s Medicare offices in Birmingham, Alabama and Douglasville, Georgia are closed on the following
days in 2014. In addition, the Medicare Provider Contact Center (PCC), Clerical Error Reopenings (CER), and
the EDI Help Desk close on federal holidays for continuing education training; therefore, these representatives will
not be available on those days to receive your calls.
Please note that Cahaba GBAs Christmas holiday has changed.
Holiday / Date
Closure Schedule
New Year’s Day Observed
January 1, 2014
Wednesday
All Offices Closed
Martin Luther King Jr Day
January 20, 2014
Monday
All Offices Closed
President’s Day
February 17, 2014
Monday
PCC/CER/EDI Closed for Training
Good Friday
April 18, 2014
Friday
All Offices Closed
Memorial Day
May 26, 2014
Monday
All Offices Closed
Independence Day
July 4, 2014
Friday
All Offices Closed
Labor Day
September 1 , 2014
Monday
All Offices Closed
Columbus Day
October 13, 2014
Monday
PCC/CER/EDI Closed for Training
Veterans Day Observed
November 11, 2014
Tuesday
PCC/CER/EDI Closed for Training
Thanksgiving
November 27 & 28, 2014
Thursday/Friday
All Offices Closed
Christmas **
December 25-26, 2014
Thursday/Friday
All Offices Closed
New Year’s Day
January 1, 2015
Thursday
All Offices Closed
**- Dates changed from Wednesday/Thursday to Thursday/Friday
Page 4
November 2014 Medicare B Newsline
Provider Contact Center, Clerical Error Reopening, and EDI Training
Schedule
Medicare is a continuously changing program, and it is important that we provide correct and accurate
answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid
Services (CMS) allows the Provider Contact Center (PCC), Clerical Error Reopenings (CERs), and the
Electronic Data Interchange (EDI) Help Desk the opportunity to offer training to their representatives.
Listed below are the closed training dates and times.
PCC, CER, & EDI Training Dates
Friday, November 7, 2014
Tuesday, November 11, 2014
Friday, November 14, 2014
Friday, November 21, 2014
Time
9:30 - 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET
Closed All Day for Training - Veterans Day
9:30 - 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET
9:30 - 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET
Provider Contact Center Telephone Number

1-877-567-7271
Our Interactive Voice Response (IVR) system is designed to assist providers in obtaining answers to
numerous issues through self-service options. Options on our IVR include information regarding patient
eligibility, checks, claims, deductible and other general information. Please note that our Customer Service
Representatives (CSRs) are available to answer questions that cannot be answered by the IVR. CSRs are
physically located in Birmingham, Alabama and Douglasville, Georgia. When your call is received, it is
routed to the next available representative. CSRs are available Monday through Friday 8:00 a.m. - 4:00 p.m.
in your time zone.
Page 5
November 2014 Medicare B Newsline
Using the Interactive Voice Response (IVR) System for Claim Status and
Eligibility Requests
Some providers opt out of the Interactive Voice Response (IVR) system to speak to a Customer Service
Representative (CSR) for information that can be accessed through the IVR.
The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Chapter 6 Section
50.1 states:
“Providers shall be required to use IVRs to access claim status and beneficiary eligibility
information. CSRs shall refer providers back to the IVR if they have questions about claims status
or eligibility that can be handled by the IVR. CSRs may provide claims status and/or eligibility
information if it is clear that the provider cannot access the information through the IVR because the
IVR is not functioning.”
If you are requesting whether Cahaba has received a claim or if a claim has finalized, this is
considered a claim status request.
DDR Section 3.3 (424.05 kB) states: “If a CSR or written inquiry correspondent receives an inquiry about
information that can be found on a Remittance Advice (RA), the CSR/correspondent should take the
opportunity to educate the inquirer on how to read the RA, in an effort to encourage the use of self-service.
The CSR/correspondent should advise the inquirer that the RA is needed in order to answer any questions
for which answers are available on the RA. Providers should also be advised that any billing staff or
representatives that make inquiries on his/her behalf will need a copy of the RA.”
Cahaba GBA CSRs have visibility as to the path the provider takes in the IVR and/or whether they opt out
to speak with a representative up front. The CSR will instruct the provider to call back and utilize the IVR
if they did not attempt to use this self service option as required by CMS.
Page 6
November 2014 Medicare B Newsline
Medicare Health Insurance Claim (HIC) Number
A Medicare card is issued to every person who is eligible for Medicare benefits and may be identified by its
red, white and blue coloring. This card identifies the Medicare beneficiary and includes the following
information:




Name (exactly as it appears on the Social Security records);
Medicare Health Insurance Claim (HIC) number;
Beginning date of Medicare entitlement for hospital and/or medical insurance;
Sex and Beneficiary's signature.
Three of the top five reasons for claim rejection in any given month are for:



The last name submitted for the beneficiary does not match the last name we have on record for
the HIC number on the claim. The beneficiary's last name must include apostrophes, spaces,
hyphens, etc., if they appear in the beneficiary's last name on his or her Medicare card.
The first name submitted for the beneficiary does not match the first name we have on record for
the HIC number on the claim. The beneficiary's first name must appear as it does on the
beneficiary's Medicare card. This includes spaces, hyphens, apostrophes, etc.
The HIC number not matching the name we have on record. The Medicare Claim Number must
appear on the claim exactly as it does on the beneficiary’s card, without the dashes and with no
spaces.
It is extremely important that you submit the patient’s complete name and HIC number to Medicare or any
other health care provider you use (i.e. clinical laboratories, radiology imaging groups, or outpatient therapy
providers, etc.). This will ensure that those providers have the correct patient information to file their claims
as well.
Page 7
November 2014 Medicare B Newsline
Cahaba GBA’s Email Notification Service Subscription Process
Cahaba GBA implemented changes that simplify the process in which providers subscribe to our email
notification service (Listserv). New members simply provide their name, city, state, zip code, e-mail
address, and an optional password. In addition, they can select from two different lists to subscribe to:


J10 Part A News
J10 Part B News
Once you are a member, you can edit your profile to:





unsubscribe from all lists
subscribe to additional lists
update your e-mail address
change your name or address information
change what Cahaba GBA lists you are subscribed to.
Already a Member?
If you enrolled to Cahaba GBA’s Listserv prior to November 1, 2009, you will continue to receive
messages. However, depending on the selections you made on the subscription form when you originally
enrolled, you may receive messages from more than one Cahaba GBA list. To change the list you are
subscribed to, access the “Edit Your Email Notification Service Member Profile” Web page to review and
edit your profile.
In order to ensure that you receive your subscription emails and announcements from Cahaba GBA, please
add us to your contact lists, adjust your spam settings, or follow the instructions from your email provider
on how to prevent our emails from being marked “Spam” or “Junk Mail”.
Page 8
November 2014 Medicare B Newsline
Top Electronic Data Interchange (EDI) Claim Rejections
The Electronic Data Interchange (EDI) Department publishes information on the Top EDI Claim Rejections
for HIPAA 5010 on our website. The rejections are updated monthly and can be viewed at
https://www.cahabagba.com/part-b/claims-2/electronic-data-interchange-edi/4010a1-2/.
The information published has been extracted from the 277CA transactions created for the month indicated.
The 277CA indicates files, batch, and claim level rejections. Information about the 277CA transactions can
be found on the Washington Publishing Company's website at http://www.wpc-edi.com/. For more
information about specific edits, visit the CMS website at
http://www.cms.gov/Medicare/Billing/MFFS5010D0/Technical-Documentation.html.
Referring to these reports will allow you to correct and resubmit claims quickly, reducing delay of payment.
Claim Specific CERT Errors – September 2014
The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare &
Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like
Cahaba GBA. Contractors are then notified by CERT of the errors and findings.
We would like to remind you that should you receive an Additional Documentation Request (ADR), such as
a request for records to support services that are involved in a CERT review, you should submit the
appropriate documentation to support the services billed, including but not limited to progress note(s) to
match the DOS billed, lab results, operative reports, diagnostic tests, physician orders, etc. Medicare
requires a legible identifier for services provided/ordered. The method used shall be hand written or an
electronic signature (stamp signatures are not acceptable) to sign an order or other medical record
documentation for medical review purposes.
Providers may appeal unfavorable decisions with additional supporting documentation. For detailed
information regarding the Appeals Process, refer to the following link: http://www.cahabagba.com/partb/claims-2/appeals-2-2/.
Please contact the Provider Contact Center for individual questions concerning CERT errors at 1-877-5677271.
This summary provides examples of Cahaba GBA's errors identified by CERT. We encourage all providers
to review this listing to educate you on common errors. This information will be updated periodically. The
intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and
reduce future denials by Medicare.
Page 9
November 2014 Medicare B Newsline
Comment Period for Proposed/Draft Local Coverage Determinations
The Comment Period for the Proposed/Draft Local Coverage Determinations (LCDs) listed below is from
November 13, 2014 through December 31, 2014:


Medicine: Psychotherapy Services (DL35626)
Surgery: Fusion for Degenerative Joint Disease of the Lumbar Spine (DL35624)
The Proposed/Draft LCDs are located on the Medicare Coverage Database (MCD), which can be accessed
from the ‘Local Coverage Determinations (LCDs) & Articles’ page of the ‘Medical Review’ sections on the
Cahaba GBA website (select ‘LCDs’ for your state, and choose ‘Proposed/Draft LCDs not released to final
LCDs’).
Comments on the Proposed/Draft LCDs may be submitted via e-mail to
[email protected] or in writing to the Medical Director at the address listed below:
Cahaba Government Benefit Administrators®, LLC
Comments for Draft LCDs
Attention: Contractor Medical Director
Post Office Box 13384
Birmingham, Alabama 35202-3384
Page 10
November 2014 Medicare B Newsline
2014 Flu Season Allowances – Reminder
The 2014 Flu allowances have been released by the Centers for Medicare & Medicaid Services (CMS) and
are listed on the 2014 Fee Schedule Index, under the Drugs and Biological heading at
http://www.cahabagba.com/part-b/claims-2/fee-schedules/. They are included as part of the October 2014
Average Sales Price (ASP) files. Per CMS MLN Matters MM8890, they are retroactive to August 1, 2014.
Influenza Season Is Here! Are You Billing Properly?
The 2014-2015 Influenza Season is here. It began August 1, 2014 and ends July 31, 2015. Cahaba GBA
wants to remind providers the only administration code for influenza vaccine is G0008. The HCPCS code
G0008 is special because it bypasses deductible and coinsurance amounts for the beneficiaries, allowing
these services to be paid at 100%. A billing guide titled, “Quick Reference Information: Medicare
Immunization Billing (Seasonal Influenza Virus, Pneumococcal, and Hepatitis B)” can be found on the CMS
website and is linked below for your convenience.
We have seen providers bill CPTs 90471, 90472, and 90473 for the administration of the influenza vaccine.
These codes are incorrect for Medicare and will be denied as a billing error.
Many providers are also billing HCPCS code Q2039 and are providing a generic description, such as flu
NOS, age three years and older, or flu vaccine. Payment is based on the actual name brand product used.
You must provide the brand name and dose of the vaccine used for Q2039. If this information is missing,
Q2039 will be rejected.
Please review the helpful document titled, "Influenza Vaccine Products for the 2014-2015 Influenza Season"
to assist your billing of the influenza vaccine.
Other information, such as fee schedules for the 2014-2015 flu season, can be found on the CMS Seasonal
Influenza Vaccines Pricing website.
References



Influenza Vaccine Products for the 2014-2015 Influenza Season
Seasonal Influenza Vaccines Pricing
Quick Reference Information: Medicare Immunization Billing (Seasonal Influenza Virus,
Pneumococcal, and Hepatitis B)
Page 11
November 2014 Medicare B Newsline
Cahaba GBA Provider Outreach & Education Advisory Group Accepting
Applications for Part B Providers
The Part B Provider Outreach and Education team is currently accepting applications from providers to
participate in the Part B Advisory Group.
What does an Advisory Group Member do? An Advisory Group member assists with the creation,
implementation and review of provider education strategies and efforts. A member provides input and
feedback on training topics and educational materials, plus members also help identify provider educational
issues.
Does this sound like something that may interest you? If it does, we encourage you to complete an
application to assist us in filling vacancies we currently have in Alabama, Georgia, and Tennessee.
It’s easy, complete this application: http://www.cahabagba.com/documents/2014/10/2015-advisory-grouprecruitment-application.pdf by November 28, 2014.
Don’t delay, submit your application today!
Page 12
November 2014 Medicare B Newsline
CMS Manual System
Department of Health &
Human Services (DHHS)
Pub 100-03 Medicare National Coverage
Determinations
Centers for Medicare &
Medicaid Services (CMS)
Transmittal 169
Date: June 27, 2014
Change Request 8825
SUBJECT: Invalidation of National Coverage Determination 140.3 - Transsexual Surgery
I. SUMMARY OF CHANGES: The purpose of this change request (CR) is to implement the Departmental
Appeals Board decision consistent with 42 CFR § 426.560(b)(2) by removing section 140.3, Transsexual
Surgery, from Pub. 100-03, Medicare National Coverage Determinations Manual. Additionally, references to
transsexual surgery have been removed from Pub. 100-02, Medicare Benefit Policy Manual.
EFFECTIVE DATE: May 30, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: June 29, 2014 - (For clarification, 6/29/14 was referred to as the 'effective'
date in recent communication; 6/29/14 is the 'implementation' date)
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.
R/N/D
CHAPTER / SECTION / SUBSECTION / TITLE
D
1/140.3/Transsexual Surgery
III. FUNDING:
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in
your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not
obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized
by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the
current scope of work, the contractor shall withhold performance on the part(s) in question and immediately
notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued
performance requirements.
IV. ATTACHMENTS:
Business Requirements
Page 13
November 2014 Medicare B Newsline
Attachment - Business Requirements
Pub. 100-03
Transmittal: 169
Date: June 27, 2014
Change Request: 8825
SUBJECT: Invalidation of National Coverage Determination 140.3 - Transsexual Surgery
EFFECTIVE DATE: May 30, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: June 29, 2014 - (For clarification, 6/29/14 was referred to as the 'effective'
date in recent communication; 6/29/14 is the 'implementation' date)
I.
GENERAL INFORMATION
A. Background: The purpose of this Change Request (CR) is to inform you that the Department of Health
and Human Services Departmental Appeals Board (DAB) has invalidated National Coverage Determination
(NCD) 140.3 “Transsexual Surgery” pursuant to section 1869(f)(1)(A)(iii) of the Social Security Act (SSA).
(Docket #A-13-47, Decision #2576) dated May 30, 2014. As a consequence of this decision, NCD 140.3 is no
longer valid. Implementation of this policy shall be June 29, 2014.
B. Policy: Because the NCD is no longer valid as of the effective date, its provisions are no longer a basis
for denying claims for Medicare coverage of “transsexual surgery” under 42 CFR §405.1060. Moreover, any
local coverage determinations used to adjudicate such claims may not be based on or rely on the provisions or
reasoning from section 140.3 of Pub. 100-03, Medicare NCD Manual. In the absence of an NCD, contractors
and adjudicators should consider whether any Medicare claims for these services are reasonable and necessary
under §1862(a)(1)(A) of the SSA consistent with the existing guidance for making such decisions when there is
no NCD.
Therefore, the Centers for Medicare & Medicaid Services will implement the DAB decision with this CR
consistent with 42 CFR §426.560(b)(2). Section 140.3 will be removed from the Medicare NCD Manual.
II.
BUSINESS REQUIREMENTS TABLE
"Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.
Number
8825 - 03.1
Page 14
Requirement
Effective for claims with dates of service on and
after May 30, 2014, coverage determinations under
section 1862(a)(1)(A) of the SSA for transsexual
surgery will be made by the local Medicare
Administrative Contractors.
Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
M
H
I C M W
H A S S S F
C S
X X
November 2014 Medicare B Newsline
Other
III.
PROVIDER EDUCATION TABLE
Number
Requirement
Responsibility
A/B
MAC
8825 - 03.2
IV.
CR as Provider Education: Contractors shall post this entire instruction, or a
direct link to this instruction, on their Web sites and include information about
it in a listserv message within 1 week of the release of this instruction. In
addition, the entire instruction must be included in the contractor’s next
regularly scheduled bulletin. Contractors are free to supplement it with
localized information that would benefit their provider community in billing
and administering the Medicare program correctly.
D C
M E
E D
I
A B H
M
H
H A
C
X X
SUPPORTING INFORMATION
Section A: Recommendations and supporting information associated with listed requirements: N/A
"Should" denotes a recommendation.
X-Ref
Requirement
Number
Recommendations or other supporting information:
Section B: All other recommendations and supporting information: N/A
V.
CONTACTS
Pre-Implementation Contact(s): Pat Brocato-Simons, 410-786-0261 or [email protected]
(Coverage), Janet Brock, 410-786-2700 or [email protected] (Coverage), Lori Ashby, 410-786-6322 or
[email protected] (Coverage)
Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR).
VI.
FUNDING
Section A: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in
your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not
obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be
outside the current scope of work, the contractor shall withhold performance on the part(s) in question and
immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding
continued performance requirements.
ATTACHMENTS: 0
Page 15
November 2014 Medicare B Newsline
CMS Manual System
Department of Health &
Human Services (DHHS)
Pub 100-02 Medicare Benefit Policy
Centers for Medicare &
Medicaid Services (CMS)
Transmittal 189
Date: June 27, 2014
Change Request 8825
SUBJECT: Invalidation of National Coverage Determination 140.3 - Transsexual Surgery
I. SUMMARY OF CHANGES: The purpose of this change request (CR) is to implement the Departmental
Appeals Board decision consistent with 42 CFR §426.560(b)(2) by removing section 140.3, Transsexual
Surgery, from Pub. 100-03, Medicare National Coverage Determinations Manual. Additionally, references to
transsexual surgery have been removed from Pub. 100-02, Medicare Benefit Policy Manual.
EFFECTIVE DATE: May 30, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: June 29, 2014 - (For clarification, 6/29/14 was referred to as the 'effective'
date in recent communication; 6/29/14 is the 'implementation' date)
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.
R/N/D
CHAPTER / SECTION / SUBSECTION / TITLE
R
16/120/Services Related to and Required as a Result of Services Which Are Not Covered
Under Medicare
R
16/180/Services Related to and Required as a Result of Services Which Are Not Covered
Under Medicare
III. FUNDING:
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in
your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not
obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized
by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the
current scope of work, the contractor shall withhold performance on the part(s) in question and immediately
notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued
performance requirements.
Page 16
November 2014 Medicare B Newsline
IV. ATTACHMENTS:
Business Requirements
Manual Instruction
Page 17
November 2014 Medicare B Newsline
Attachment - Business Requirements
Pub. 100-02
Transmittal: 189
Date: June 27, 2014
Change Request: 8825
SUBJECT: Invalidation of National Coverage Determination 140.3 - Transsexual Surgery
EFFECTIVE DATE: May 30, 2014
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: June 29, 2014 - (For clarification, 6/29/14 was referred to as the 'effective'
date in recent communication; 6/29/14 is the 'implementation' date)
I.
GENERAL INFORMATION
A. Background: The purpose of this Change Request (CR) is to inform you that the Department of Health
and Human Services Departmental Appeals Board (DAB) has invalidated National Coverage Determination
(NCD) 140.3 “Transsexual Surgery” pursuant to section 1869(f)(1)(A)(iii) of the Social Security Act (SSA).
(Docket #A-13-47, Decision #2576) dated May 30, 2014. As a consequence of this decision, NCD 140.3 is no
longer valid. Implementation of this decision shall be June 29, 2014.
B. Policy: Because the NCD is no longer valid as of the effective date, its provisions are no longer a basis
for denying claims for Medicare coverage of “transsexual surgery” under 42 CFR §405.1060. Moreover, any
local coverage determinations used to adjudicate such claims may not be based on or rely on the provisions or
reasoning from section 140.3 of Pub. 100-03, Medicare NCD Manual. In the absence of an NCD, contractors
and adjudicators should consider whether any Medicare claims for these services are reasonable and necessary
under §1862(a)(1)(A) of the SSA consistent with the existing guidance for making such decisions when there is
no NCD.
Therefore, the Centers for Medicare & Medicaid Services will implement the DAB decision with this CR
consistent with 42 CFR §426.560(b)(2). Section 140.3 will be removed from the Medicare NCD Manual.
II.
BUSINESS REQUIREMENTS TABLE
"Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.
Number
8825 - 02.1
Page 18
Requirement
Effective for claims with dates of service on and
after May 30, 2014, Medicare coverage under
section 1862(a)(1)(A) of the SSA for transsexual
surgery will be determined by the local Medicare
Administrative Contractors.
Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
M
H
I C M W
H A S S S F
C S
X X
November 2014 Medicare B Newsline
Other
III.
PROVIDER EDUCATION TABLE
Number
Requirement
Responsibility
A/B
MAC
8825 - 02.2
IV.
CR as Provider Education: Contractors shall post this entire instruction, or a
direct link to this instruction, on their Web sites and include information about
it in a listserv message within 1 week of the release of this instruction. In
addition, the entire instruction must be included in the contractor’s next
regularly scheduled bulletin. Contractors are free to supplement it with
localized information that would benefit their provider community in billing
and administering the Medicare program correctly.
D C
M E
E D
I
A B H
M
H
H A
C
X X
SUPPORTING INFORMATION
Section A: Recommendations and supporting information associated with listed requirements: N/A
"Should" denotes a recommendation.
X-Ref
Requirement
Number
Recommendations or other supporting information:
Section B: All other recommendations and supporting information: N/A
V.
CONTACTS
Pre-Implementation Contact(s): Pat Brocato-Simons, 410-786-0261 or [email protected]
(Coverage), Janet Brock, 410-786-2700 or [email protected] (Coverage), Lori Ashby, 410-786-6322 or
[email protected] (Coverage)
Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR).
VI.
FUNDING
Section A: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in
your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not
obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be
outside the current scope of work, the contractor shall withhold performance on the part(s) in question and
immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding
continued performance requirements.
ATTACHMENTS: 0
Page 19
November 2014 Medicare B Newsline
Medicare Benefit Policy Manual
Chapter 1 – Inpatient Hospital Services Covered under Part A
120 - Services Related to and Required as a Result of Services Which Are Not Covered
Under Medicare
(Rev. 189, Issued: 06-27-14, Effective: 05-30-14, Implementation: 06-29-14)
Medical and hospital services are sometimes required to treat a condition that arises as a result of services that
are not covered because they are determined to be not reasonable and necessary or because they are excluded
from coverage for other reasons. Services "related to" non-covered services (e.g., cosmetic surgery, noncovered organ transplants, non-covered artificial organ implants, etc.), including services related to follow-up
care and complications of non-covered services which require treatment during a hospital stay in which the noncovered service was performed, are not covered services under Medicare. Services "not related to" non-covered
services are covered under Medicare.
Following are examples of services "related to" and "not related to" non-covered services while the beneficiary
is an inpatient:
•
A beneficiary was hospitalized for a non-covered service and broke a leg while in the hospital.
Services related to care of the broken leg during this stay is a clear example of "not related to"
services and are covered under Medicare.
•
A beneficiary was admitted to the hospital for covered services, but during the course of
hospitalization became a candidate for a non-covered transplant or implant and actually received the
transplant or implant during that hospital stay. When the original admission was entirely unrelated
to the diagnosis that led to a recommendation for a non-covered transplant or implant, the services
related to the admitting condition would be covered.
•
A beneficiary was admitted to the hospital for covered services related to a condition which
ultimately led to identification of a need for transplant and receipt of a transplant during the same
hospital stay. If, on the basis of the nature of the services and a comparison of the date they are
received with the date on which the beneficiary is identified as a transplant candidate, the services
could reasonably be attributed to preparation for the non-covered transplant, the services would be
"related to" non-covered services and would also be non-covered.
Following is an example of services received subsequent to a non-covered inpatient stay:
After a beneficiary has been discharged from the hospital stay in which the beneficiary received non-covered
services, medical and hospital services required to treat a condition or complication that arises as a result of the
prior non-covered services may be covered when they are reasonable and necessary in all other respects. Thus,
coverage could be provided for subsequent inpatient stays or outpatient treatment ordinarily covered by
Medicare, even if the need for treatment arose because of a previous non-covered procedure. Some examples of
services that may be found to be covered under this policy are the reversal of intestinal bypass surgery for
obesity, complications from cosmetic surgery, removal of a non-covered bladder stimulator, or treatment of any
infection at the surgical site of a non-covered transplant that occurred following discharge from the hospital.
However, any subsequent services that could be expected to have been incorporated into a global fee are not
covered. Thus, where a patient undergoes cosmetic surgery and the treatment regimen calls for a series of
postoperative visits to the surgeon for evaluating the patient's progress, these visits are not covered.
Page 20
November 2014 Medicare B Newsline
Medicare Benefit Policy Manual
Chapter 16 – General Exclusions from Coverage
180 - Services Related to and Required as a Result of Services Which Are Not
Covered Under Medicare
(Rev. 189, Issued: 06-27-14, Effective: 05-30-14, Implementation: 06-29-14)
Medical and hospital services are sometimes required to treat a condition that arises as a result of services that
are not covered because they are determined to be not reasonable and necessary or because they are excluded
from coverage for other reasons. Services "related to" non-covered services (e.g., cosmetic surgery, noncovered organ transplants, non-covered artificial organ implants, etc.), including services related to follow-up
care and complications of non-covered services which require treatment during a hospital stay in which the noncovered service was performed, are not covered services under Medicare. Services "not related to" non-covered
services are covered under Medicare.
Following are examples of services "related to" and "not related to" non-covered services while the beneficiary
is an inpatient:
•
A beneficiary was hospitalized for a non-covered service and broke a leg while in the hospital. Services
related to care of the broken leg during this stay is a clear example of "not related to" services and are
covered under Medicare.
•
A beneficiary was admitted to the hospital for covered services, but during the course of hospitalization
became a candidate for a non-covered transplant or implant and actually received the transplant or
implant during that hospital stay. When the original admission was entirely unrelated to the diagnosis
that led to a recommendation for a non-covered transplant or implant, the services related to the
admitting condition would be covered.
•
A beneficiary was admitted to the hospital for covered services related to a condition which ultimately
led to identification of a need for transplant and receipt of a transplant during the same hospital stay. If,
on the basis of the nature of the services and a comparison of the date they are received with the date on
which the beneficiary is identified as a transplant candidate, the services could reasonably be attributed
to preparation for the non-covered transplant, the services would be "related to" non-covered services
and would also be non-covered.
Following is an example of services received subsequent to a non-covered inpatient stay:
After a beneficiary has been discharged from the hospital stay in which the beneficiary received non-covered
services, medical and hospital services required to treat a condition or complication that arises as a result of the
prior non-covered services may be covered when they are reasonable and necessary in all other respects. Thus,
coverage could be provided for subsequent inpatient stays or outpatient treatment ordinarily covered by
Medicare, even if the need for treatment arose because of a previous non-covered procedure. Some examples of
services that may be found to be covered under this policy are the reversal of intestinal bypass surgery for
obesity, complications from cosmetic surgery, removal of a non-covered bladder stimulator, or treatment of any
infection at the surgical site of a non-covered transplant that occurred following discharge from the hospital.
However, any subsequent services that could be expected to have been incorporated into a global fee are not
covered. Thus, where a patient undergoes cosmetic surgery and the treatment regimen calls for a series of
postoperative visits to the surgeon for evaluating the patient's progress, these visits are not covered.
Page 21
November 2014 Medicare B Newsline
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
NEW product from the Medicare Learning Network® (MLN)

“Vaccine Payments Under Medicare Part D” Fact Sheet, ICN 908764, downloadable
and hard copy
MLN Matters® Number: MM8506 Revised
Related Change Request (CR) #: CR 8506
Related CR Release Date: September 4, 2014
Effective Date: Upon ICD-10 Implementation
Related CR Transmittal #: R173NCD
Implementation: Upon ICD-10 Implementation
Pub 100-03, Chapter 1, Language-only Update
Note: This article was revised on September 8, 2014, to reflect the revised CR8506 issued on
September 4. The CR release date, effective and implementation dates, transmittal number, and the
Web address for accessing the CR are revised. All other information is unchanged.
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to
A/B Medicare Administrative Contractors (A/B MACs), Hospice and Home Health (HH&H MACs), and
Durable Medical Equipment MACs (DME MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8506 as an
informational alert to providers that language-only changes—updates to the “Medicare National
Coverage Determinations (NCD) Manual”, Pub 100-03—were made.
The changes were made to comply with:
1. Conversion from ICD-9 to ICD-10;
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to
statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of
either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and
accurate statement of their contents. CPT only copyright 2012 American Medical Association.
Page 22
November 2014 Medicare B Newsline
Page 1 of 2
MLN Matters® Number: MM8506
Related Change Request Number: 8506
2. Conversion from ASC X12 Version 4010 to Version 5010;
3. Conversion of former contractor types to MACs; and,
4. Other miscellaneous editorial and formatting updates provided for better clarity, correctness,
and consistency.
NOTE: The edits made to the NCD Manual are technical/editorial only and in no way alter
existing NCD policies.
Background
These edits to Pub. 100-03 are part of a CMS-wide initiative to update its manuals and bring them in
line with recently released instructions regarding the above-noted subject matter.
Additional Information
The official instruction, CR 8506, issued to your MAC regarding this change may be viewed at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R173NCD.pdf on the
CMS website.
If you have any questions, please contact your MAC at their toll-free number, which may be found at
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/providercompliance-interactive-map/index.html on the CMS website.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2012 American Medical Association.
Page 23
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED product from the Medicare Learning Network® (MLN)
•
“Contractor Entities At A Glance: Who May Contact You About Specific
Centers for Medicare & Medicaid Services (CMS) Activities”, Educational
Tool, ICN 906983, downloadable
MLN Matters® Number: MM8509 Revised
Related Change Request (CR) #: CR 8509
Related CR Release Date: October 2, 2014
Effective Date: January 6, 2014 for CMS-1500; for ICD-10 upon implementation of ICD-10
Related CR Transmittal #: R3083CP
Implementation Date: January 6, 2014 for CMS-1500; for
ICD-10 - upon implementation of ICD-10
CMS 1500 Claim Form Instructions: Revised for Form Version 02/12
Note: This article was revised on October 6, 2014, to reflect the revised CR8509 issued on
October 2. In the article, the effective and implementation dates have changed and the CR
release date, transmittal number and the Web address for accessing the CR are changed. All
other information is the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting
claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B
MACs), and Durable Medical Equipment Medicare Administrative Contractors
(DME/MACs)) for services provided to Medicare beneficiaries.
Page 24
November 2014 Medicare B Newsline
Provider Action Needed
STOP – Impact to You
This change request (CR) 8509 revises the current CMS 1500 claim form instructions to
reflect the revised CMS 1500 claim form, version 02/12.
CAUTION – What You Need to Know
Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with
claims received on and after April 1, 2014:
•
•
•
•
Medicare will begin accepting claims on the revised form, 02/12, on January 6,
2014;
Medicare will continue to accept claims on the old form, 08/05, through March 31,
2014;
On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500
claim form, 02/12; and
On and after April 1, 2014, Medicare will no longer accept claims on the old CMS
1500 claim form, 08/05.
GO – What You Need to Do
Make sure that your billing staff are aware of these instructions for the revised form version
02/12.
Background
The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim
form. On June 10, 2013, the White House Office of Management and Budget (OMB)
approved the revised form, 02/12. The revised form has a number of changes. Those most
notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes
on a claim, and qualifiers to identify whether certain providers are being identified as having
performed an ordering, referring, or supervising role in the furnishing of the service. In
addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and
expands the number of possible diagnosis codes on a claim to 12.
The qualifiers that are appropriate for identifying an ordering, referring, or supervising role
are as follows:
Page 25
•
DN - Referring Provider
•
DK - Ordering Provider
November 2014 Medicare B Newsline
•
DQ - Supervising Provider
Providers should enter the qualifier to the left of the dotted vertical line on item 17.
The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be
sent electronically unless certain exceptions are met. Those providers meeting these
exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that
the paper format for professional and supplier paper claims be the CMS 1500 claim form.
Medicare therefore supports the implementation of the CMS 1500 claim form and its
revisions for use by its professional providers and suppliers meeting an ASCA exception.
More information about ASCA exceptions can be found in Chapter 24 of the "Medicare
Claims Processing Manual" which is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c24.pdf on the Centers for Medicare &
Medicaid Services (CMS) website.
Additional Information
The official instruction, CR 8509 issued to your MAC regarding this change may be viewed
at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3083CP.pdf on the CMS website. CR
8509 contains the instructions for completing the revised CMS 1500 claim form (02/12),
which will become part of Chapter 26 in the "Medicare Claims
Processing Manual" (Pub. 100-04).
If you have any questions, please contact your MAC at their toll-free number, which may be
found at http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
News Flash - Generally, Medicare Part B covers one flu vaccination and its administration per flu season for
beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries. Health care
providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from
spreading it to their family, co-workers, and patients. Note: The flu vaccine is not a Part D-covered drug. For
more information, visit:
•
•
•
•
MLN Matters® Article #MM8433, “Influenza Vaccine Payment Allowances - Annual Update for 2013-2014
Season”
MLN Matters® Article #SE1336, “2013-2014 Influenza (Flu) Resources for Health Care Professionals”
HealthMap Vaccine Finder - a free, online service where users can search for locations offering flu and
other adult vaccines. While some providers may offer flu vaccines, those that don’t can help their patients
locate flu vaccines within their local community.
The CDC website for Free Resources, including prescription-style tear-pads that allow you to give a
customized flu shot reminder to patients at high-risk for complications from the flu.
Page 26
November 2014 Medicare B Newsline
Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
NEW product from the Medicare Learning Network® (MLN)
•
“Drug Diversion: Do You Know Where the Drugs Are Going?” Web-based
Training (WBT)
MLN Matters® Number: MM8758 Revised
Related Change Request (CR) #: CR 8758
Related CR Release Date: August 29, 2014
Effective Date: February 18, 2014
Related CR Transmittal #: R171NCD, R3058CP,
Implementation Date: August 18, 2014
R539PI, and R193BP
Cardiac Rehabilitation Programs for Chronic Heart Failure
Note: This article was revised on September 4, 2014, to reflect changes to CR8758. In the
article, the transmittal numbers, the CR release date, and the Web addresses for accessing the
transmittals are revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting
claims to Medicare Administrative Contractors (MACs) for cardiac rehabilitation services
for Medicare beneficiaries.
What You Need to Know
STOP – Impact to You
Effective for dates of service on and after February 18, 2014, Medicare covers cardiac
rehabilitation services for beneficiaries with stable, chronic heart failure.
Page 27
November 2014 Medicare B Newsline
CAUTION – What You Need to Know
This article, based on Change Request (CR) 8758, informs you that, effective for dates of
service on and after February 18, 2014, Medicare covers cardiac rehabilitation services for
beneficiaries with 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. Stable
patients are defined as patients who have not had recent (≤6 weeks) or planned (≤6 months)
major cardiovascular hospitalizations or procedures.
GO – What You Need to Do
Make sure your billing staffs are aware of these changes.
Background
On June 4, 2013, the Centers for Medicare & Medicaid Services (CMS) initiated a National
Coverage Analysis (NCA) to expand Medicare coverage of cardiac rehabilitation for
beneficiaries diagnosed with chronic heart failure.
Items and services furnished under a Cardiac Rehabilitation (CR) program may be covered
under Medicare Part B per Section 1861(s)(2)(CC) and 1861(eee)(1) of the Social Security
Act. Among other things, Medicare regulations define key terms, address the components of
a Cardiac Rehabilitation program, establish the standards for physician supervision, and
limit the maximum number of program sessions that may be furnished. These regulations
may be viewed at 42 Code of Federal Regulations (CFR), Section 410.49, available at
http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A2.0.1.2.10 on the Internet.
CR services mean a physician-supervised program that furnishes physician prescribed
exercise, cardiac risk factor modification, including education, counseling, and behavioral
intervention; psychosocial assessment, outcomes assessment, and other items/services as
determined by the Secretary under certain conditions.
The regulations describe the cardiac conditions that would enable a beneficiary to obtain CR
services. Specifically, coverage is permitted for beneficiaries who have experienced one or
more of the following:
•
•
•
•
•
•
Page 28
An acute myocardial infarction within the preceding 12 months;
A coronary artery bypass surgery;
Current stable angina pectoris;
Heart valve repair or replacement;
Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting; or
A heart or heart-lung transplant.
November 2014 Medicare B Newsline
Effective for dates of service on or after February 18, 2014, this change request adds stable,
chronic heart failure to the list of cardiac conditions above that would enable a beneficiary
to obtain Cardiac Rehabilitation services.
CMS may add “other cardiac conditions as specified through a national coverage
determination” (42 CFR Section 410.49(b)(vii).
Any cardiac indication not specifically identified in 42 CFR 410.49(b)(l)(vii) or identified as
covered in any National Coverage Determination (NCD) is considered non-covered.
Also, note that MACs will not search for and adjust claims processed prior to the
implementation of CR8758. However, your MAC will adjust such claims that you bring to
their attention.
Additional Information
CR8758 consists of four transmittals, each of which relates to a Medicare manual. The
transmittal related to the "National Coverage Determination Manual" is available at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R171NCD.pdf on the CMS website. The
transmittal related to the "Medicare Claims Processing Manual" is at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3058CP.pdf, the transmittal related to the
"Medicare Program Integrity Manual" is at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R539PI.pdf, and the transmittal related to
the "Medicare Benefit Policy Manual" is at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R193BP.pdf on the CMS website.
You may also want to review MLN Matters® Article MM6850, which is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/mm6850.pdf for more information on cardiac
rehabilitation services.
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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 29
November 2014 Medicare B Newsline
Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED product from the Medicare Learning Network® (MLN)
•
“Medicare Enrollment Guidelines for Ordering/Referring Providers” Fact
Sheet (ICN 906223), downloadable
MLN Matters® Number: MM8805 Revised
Related Change Request (CR) #: CR 8805
Related CR Release Date: September 17, 2014
Effective Date: : October 1, 2014
Related CR Transmittal #: R3070CP
Implementation Date: October 6, 2014
New Waived Tests
Note: This article was revised on September 19, 2014, to reflect the revised CR8805 issued on
September 17. The article was revised to correct the description in bullet point 7 on page 2.
Also 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 clinical diagnostic laboratory providers
submitting clinical diagnostic laboratory claims to Medicare Administrative Contractors
(MACs) for services to Medicare beneficiaries.
Provider Action Needed
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a
facility to be appropriately certified for each test performed. To ensure that Medicare &
Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in
facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the
CLIA certificate level.
Page 30
November 2014 Medicare B Newsline
The Current Procedural Terminology (CPT) codes that the Centers for Medicare &
Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring
certification) change each year. Change Request (CR) 8805 informs the MACs about the
latest new CPT codes that are subject to CLIA edits. Make sure your billing staffs are aware
of these latest CLIA-related changes, and that you remain current with certification
requirements.
Background
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as
waived tests under CLIA. The CPT codes for the following new tests must have the
modifier QW (CLIA-waived test) to be recognized as a waived test. However, the tests
mentioned on the first page of the list attached to CR8805 (i.e., CPT codes: 81002, 81025,
82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be
recognized as a waived test.
The CPT code, effective date and description for the latest tests approved by the FDA as
waived tests under CLIA are the following:
Page 31
•
G0434QW, September 6, 2013, BTNX Inc. Rapid Response Multi-Drug Urine Test
Cup;
•
G0434QW, September 6, 2013, BTNX Inc. Rapid Response Multi-Drug Urine Test
Panel;
•
G0434QW, October 4, 2013, uVera Diagnostics, Inc. CR2 Multi-Drug Urine Test Cup;
•
G0434QW, October 4, 2013, uVera Diagnostics, Inc. CR3 Multi-Drug Urine Test Cup;
•
G0434QW, October 4, 2013, uVera Diagnostics, Inc. SMARTOX U3 Multi-Drug Urine
Test Cup;
•
G0434QW, October 24, 2013, American Institute of Toxicology, Inc., AIT Laboratories
Drug of Abuse Cup;
•
80061QW, 82962, 82465QW, 83718QW, 84478QW, November 12, 2013, Jant
Pharmacal Corp, LipidPlus Professional Lipid Profile and Glucose Measuring System
(LipidPlus Lipid Profile test strips);
•
G0434QW, December 4, 2013, Nobel Medical Inc. INSTA-SCREEN Multi-Drug Urine
Test Cup;
•
G0434QW, December 5, 2013, Micro Distributing II, LTD One Step Multi-Drug Urine
Test Panel;
•
G0434QW, February 11, 2014, Alfa Scientific Designs, Inc. Confidential Drug Test –
Multi Drugs of Abuse Urine Test (OTC);
November 2014 Medicare B Newsline
•
87880QW, February 18, 2014, BD Veritor System for Rapid Detection of Group A
Strep (direct from throat swab);
•
85018QW, February 18, 2014, Clarity HbCheck Hemoglobin Testing System;
•
87077QW, February 18, 2014, Jant Accutest Rapid Urease test (H. pylori detection);
•
G0434QW, March 13, 2014, UCP Biosciences, Inc. UCP Multi-Drug Test Key Cups;
•
83986QW, March 18, 2014, RightBio Metrics, RightSpot Infant pH Indicator;
•
83986QW, March 18, 2014, RightBio Metrics, RightSpot pH Detector;
•
83986QW, March 18, 2014, RightBio Metrics, RightSpot pH Indicator;
•
85018QW, March 21,2014, AimStrip Hb Hemoglobin (Hb) Testing System;
•
G0434QW, April 11, 2014, PTox Drug Screen Cup {Cassette Dip Card format};
•
86308QW, April 22, 2014, Polymedco Polystat Mono {whole blood};
•
82274QW, G0328QW, April 22, 2014, Rapid Response(TM) FIT-Fecal
Immunochemical Test;
•
84443QW, May 16, 2014, Germaine Laboratories, Inc. AimStep Thyroid Screen {whole
blood};
•
82055QW, May 21, 2014, Express Diagnostics International, Incorporated Saliva
Alcohol Test;
83037QW, May 22, 2014, BIO-RAD in2it (II) System Analyzer Prescription Home Use;
and
87880QW, May 23, 2014, Accustrip Strep A {Specimen type (Throat Swab)}.
•
•
You should be aware that your MAC will not search their files, to either retract payment or
retroactively pay claims; however, they should adjust such claims that you bring to their
attention.
Additional Information
The official instruction, CR8805, issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3070CP.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 32
November 2014 Medicare B Newsline
Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
NEW products from the Medicare Learning Network® (MLN)
• “Medicaid Compliance and Your Dental Practice” Fact Sheet, ICN 908668, downloadable
MLN Matters® Number: MM8812 Revised
Related Change Request (CR) #: CR 8812
Related CR Release Date: September 23, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3073CP, R238FM Implementation Date: January 5, 2015
New Physician Specialty Code for Interventional Cardiology
Note: This article was revised on September 26, 2014, to reflect the revised CR8812 that was
issued on September 23. 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 physicians, non-physician practitioners, and
suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to
Medicare beneficiaries.
What You Need to Know
CR 8812, from which this article is taken, provides notice that the Centers for Medicare &
Medicaid Services (CMS) is establishing a new physician specialty code for Interventional
Cardiology. The CR is also changing the description of specialty code 62, and updating the
names associated to specialty codes 88 and 95. Make sure your billing staffs are aware of
these changes.
Page 33
November 2014 Medicare B Newsline
Background
Physicians who enroll in the Medicare program self-designate their Medicare physician
specialty on the Medicare enrollment application (CMS-855B) or via the Internet-based
Provider Enrollment, Chain, and Ownership System (PECOS). Non-physician practitioners
who enroll with Medicare are assigned a Medicare specialty code. These Medicare
physician/non-physician practitioner specialty codes describe the specific/unique types of
medicine that physicians and non-physician practitioners (and certain other suppliers)
practice. They become associated with the claims that physician or non-physician
practitioners submit; and are used by CMS for programmatic and claims
processing purposes.
CR 8812 establishes a new physician specialty code for Interventional Cardiology (C3).
CR8812 is also removing the word “Clinical” from the description of specialty code 62
(Psychologist (Billing Independently)), and is changing the description of specialty code 88
to “Unknown Provider,” and of specialty code 95 to “Unknown Supplier”. The changes to
the descriptions for codes 88 and 95 align their names with their intended usages.
Additional Information
The official instruction, CR 8812 issued to your MAC regarding this change is available in 2
transmittals at hhttp://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3073CP.pdf and
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R238FM.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 34
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED products from the MLN
• “Medicare Learning Network® (MLN) Suite of Products & Resources for Billers
and Coders,” Educational Tool, ICN 904183, Downloadable only.
MLN Matters® Number: MM8837
Related Change Request (CR) #: CR 8837
Related CR Release Date: August 29, 2014
Effective Date: April 1, 2014
Related CR Transmittal #: R3056CP
Implementation Date: December 1, 2014
Sample Collection Fee Adjustment for Clinical Laboratory Fee Schedule and
Laboratory Services
Provider Types Affected
This MLN Matters® Article is intended for independent clinical laboratories, skilled nursing
facilities (SNFs) and home health agencies (HHAs) submitting claims to Medicare
Administrative Contractors (MACs) for services to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 8837 provides instructions to MACs for adjusting payment for a
sample collected by a laboratory from an individual in a SNF or on behalf of a HHA. Make
sure your billing staffs are aware of these changes.
Background
CR 8837 applies to Section 1833(h)(3)(A) of the Social Security Act, as amended by
Section 216 of the Protecting Access to Medicare Act (PAMA) (P.L. 113-93), and the
"Medicare Claims Processing Manual," Chapter 16, Section 60.1, which is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/
clm104c16.pdf on the Centers for Medicare & Medicaid Services (CMS) website.
Page 35
November 2014 Medicare B Newsline
When a sample is collected by a laboratory from an individual in a SNF or from an
individual on behalf of a HHA, the Healthcare Common Procedure Coding System
(HCPCS) code, G0471 “Collection of venous blood by venipuncture or urine sample by
catheterization from an individual in a SNF or by a laboratory on behalf of a HHA,” is used.
Effective April 1, 2014, the nominal fee is increased by $2, from $3 to $5, in accordance
with the Protecting Access to Medicare Act (PAMA).
The “Sample Collection Fee” is raised from $3.00 to $5.00 ONLY when the following
statements apply:
•
•
The sample is being collected by a laboratory technician that is employed by the
laboratory that is performing the test, and
The sample is from an individual in either a SNF or a HHA.
MACs will not search their files to adjust claims already processed. However, they will
adjust such claims that you bring to their attention.
Additional Information
The official instruction, CR 8837 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3056CP.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 36
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED product from the Medicare Learning Network® (MLN)
• “Medicare Learning Network® (MLN) Suite of Products & Resources for
Compliance Officers” Educational Tool, ICN 908525, Downloadable only.
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
Transitioning Medicare Administrative Contractor (MAC) Workloads to the New
Banking Contractor(s)
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 recompeted 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);
Page 37
November 2014 Medicare B Newsline
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-andGuidance/Guidance/Transmittals/Downloads/R240FM.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 38
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Revised product from the Medicare Learning Network® (MLN)

“Medicare Learning Network® (MLN) Suite of Products & Resources for
Rural Health Providers” Educational Tool, ICN 908465, downloadable.
MLN Matters® Number: MM8871
Related Change Request (CR) #: CR 8871
Related CR Release Date: September 5, 2014
Effective Date: June 2, 2014
Related CR Transmittal #: R3063CP and
R174NCD
Implementation Date: January 5, 2015
Screening for Hepatitis C Virus (HCV) in Adults
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers
submitting claims to Medicare Administrative Contractors (MACs) for Hepatitis C Virus
(HCV) screening services provided to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 8871 states, effective June 2, 2014, the Centers for Medicare &
Medicaid Services (CMS) will cover screening for hepatitis C virus (HCV) consistent with
the grade B recommendations by the United States Preventive Services Task Force
(USPSTF) for the prevention or early detection of an illness or disability and is appropriate
for individuals entitled to benefits under Medicare Part A or enrolled under Part B. Make
sure your billing staffs are aware of these changes.
Background
Hepatitis C Virus (HCV) is an infection that attacks the liver and is a major cause of chronic
liver disease. Inflammation over long periods of time (usually decades) can cause scarring,
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to
statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of
either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and
accurate statement of their contents. CPT only copyright 2013 American Medical Association.
Page 39
November 2014 Medicare B Newsline
Page 1 of 6
MLN Matters® Number: MM8871
Related Change Request Number: 8871
called cirrhosis. A cirrhotic liver fails to perform the normal functions of the liver which leads
to liver failure. Cirrhotic livers are more prone to become cancerous and liver failure leads to
serious complications, even death. HCV is reported to be the leading cause of chronic
hepatitis, cirrhosis, and liver cancer, and a primary indication for liver transplant in the
Western World.
Prior to June 2, 2014, CMS did not cover screening for HCV in adults. Pursuant to
§1861(ddd) of the Social Security Act, CMS may add coverage of "additional preventive
services" through the National Coverage Determination (NCD) process.
Effective June 2, 2014, CMS will cover screening for HCV with the appropriate U.S. Food
and Drug Administration (FDA) approved/cleared laboratory tests (used consistently with
FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act
(CLIA) regulations) when ordered by the beneficiary’s primary care physician or practitioner
within the context of a primary care setting, and performed by an eligible Medicare provider
for these services, for beneficiaries who meet either of the following conditions:
1. Adults at high risk for HCV infection. “High risk” is defined as persons with a current or
past history of illicit injection drug use, and persons who have a history of receiving a
blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually
only for persons who have had continued illicit injection drug use since the prior negative
screening test.
2. Adults who do not meet the high risk definition as defined above, but who were born from
1945 through 1965. A single, once-in-a-lifetime screening test is covered for
these individuals.
The determination of “high risk for HCV” is identified by the primary care physician or
practitioner who assesses the patient’s history, which is part of any complete medical history,
typically part of an annual wellness visit and considered in the development of a
comprehensive prevention plan. The medical record should be a reflection of the
service provided.
General Claims Processing Requirements for Claims with Dates of Service on and
After June 2, 2014:
1. New G code G0472, short descriptor - Hep screen high risk/other and long descriptorHepatitis C antibody screening for individual at high risk and other covered indication(s),
will be used.
2. Beneficiary coinsurance and deductibles do not apply to code G0472.
3. For services provided to beneficiaries born between the years 1945 and 1965 who are not
considered high risk, HCV screening is limited to once per lifetime, claims shall be
submitted with:
o HCPCS G0472
4. For those determined to be high-risk initially, claims must be submitted with:
o HCPCS G0472
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 40
November 2014 Medicare B Newsline
Page 2 of 6
MLN Matters® Number: MM8871
Related Change Request Number: 8871
o ICD-9 diagnosis code V69.8, other problems related to life style/ICD-10
diagnosis code Z72.89, other problems related to lifestyle (once ICD-10 is
implemented)
5. Screening may occur on an annual basis if appropriate, as defined in the policy. Claims
for adults at high risk who have had continued illicit injection drug use since the prior
negative screening shall be submitted with:
o HCPCS G0472,
o ICD diagnosis code V69.8/Z72.89, and
o ICD diagnosis code 304.91, unspecified drug dependence,
continuous/F19.20, other psychoactive substance abuse, uncomplicated (once
ICD-10 is implemented).
NOTE: Annual is defined as 11 full months must pass following the month of the last
negative HCV screening.
Institutional Billing Requirements
Effective for claims with dates of service on and after June 2, 2014, institutional providers
may use types of bill (TOB) 13X and 85X when submitting claims for HCV screening,
HCPCS G0472. Medicare will deny G0472 service line-items on other TOBs using the
following messages:


Claim Adjustment Reason Code (CARC) 170 -Payment denied when performed/billed
by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment
(loop 2110 Service Payment Information REF), if present.
Remittance Advice Remarks Code (RARC) N95 - This provider type/provider specialty
may not bill this service.
The service is paid on the following basis:



Outpatient hospitals – TOB 13X - based on Clinical Diagnostic Lab Fee Schedule;
Critical Access Hospitals (CAHs) - TOB 85X – based on reasonable cost; and
CAH Method II – TOB 85X - based on 115 percent of the lesser of the Medicare
Physician Fee Schedule (MPFS) amount or actual charge as applicable with revenue
codes 096X, 097X, or 098X.
Note: For outpatient hospital settings, as in any other setting, services covered under this
NCD must be provided by a primary care provider.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 41
November 2014 Medicare B Newsline
Page 3 of 6
MLN Matters® Number: MM8871
Related Change Request Number: 8871
Professional Billing Requirements
For professional claims with dates of service on or after June 2, 2014, CMS will allow
coverage for HCPCS G0472, only when services are submitted by the following provider
specialties found on the provider’s enrollment record:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric Medicine
38 - Geriatric Medicine
42 – Certified Nurse Midwife
50 - Nurse Practitioner
89 - Certified Clinical Nurse Specialist
97 - Physician Assistant
Medicare will deny claims submitted for these services by providers other than the specialty
types noted above. When denying such claims, Medicare will use the following messages:
 CARC 184 - The prescribing/ordering provider is not eligible to prescribe/order the
service. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present.
 RARC N574 - Our records indicate the ordering/referring provider is of a
type/specialty that cannot order/refer. Please verify that the claim ordering/referring
information is accurate or contact the ordering/referring provider.
 Group Code CO (contractual obligation) if claim received without GZ modifier.
For professional claims with dates of service on or after June 2, 2014, CMS will allow
coverage for HCV screening, G0472, only when submitted with one of the following place
of service (POS) codes:
11 – Physician’s Office
22 – Outpatient Hospital
49 – Independent Clinic
71 – State or Local Public Health Clinic
Medicare will deny claims submitted without one of the POS codes noted above with the
following messages:


CARC 171 - Payment denied when performed by this type of provider in this type of
facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment Information REF), if present.
RARC N428 - Not covered when performed in this place of service.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 42
November 2014 Medicare B Newsline
Page 4 of 6
MLN Matters® Number: MM8871
Related Change Request Number: 8871
Other Billing Information for Both Professional and Institutional Claims
On both institutional and professional claims, Medicare will deny claims line-items for
HCPCS G0472 with dates of service on or after June 2, 2014, where it is reported more than
once in a lifetime for beneficiaries born from 1945 through 1965 and who are not high risk.
Medicare will also line-item deny when more than one HCV screening is billed for the same
high-risk beneficiary prior to their annual eligibility criteria being met. In denying these
claims, Medicare will use:



CARC 119 - Benefit maximum for this time period or occurrence has been reached.
RARC N386 - This decision was based on a National Coverage Determination (NCD).
An NCD provides a coverage determination as to whether a particular item or service is
covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the
CMS website. If you do not have web access, you may contact the contractor to request
a copy of the NCD.
Group Code - CO if claim received without GZ modifier.
When applying the annual frequency limitation, MACs will allow both a claim for a
professional service and a claim for a facility fee.
In addition, remember that the initial HCV screening for beneficiaries at high risk must also
contain ICD-9 diagnosis code V69.8 (ICD-10 code Z72.89 once ICD-10 is implemented).
Then, for the subsequent annual screenings for high risk beneficiaries, you must include
ICD-9 code V69.8 and 304.91 (ICD-10 of Z72.89 and F19.20). Failure to include the
diagnosis code(s) for high risk beneficiaries will result in denial of the line item. In denying
these payments, Medicare will use the following:



CARC- This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
RARC N386 - This decision was based on a National Coverage Determination (NCD).
An NCD provides a coverage determination as to whether a particular item or service is
covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the
CMS website. If you do not have web access, you may contact the contractor to request
a copy of the NCD.
Group Code CO if claim received without GZ modifier.
Additional Information
The official instruction, CR 8871, was issued to your MAC regarding this change via two
transmittals. The first transmittal updates the "Medicare Claims Processing Manual" and it
is available at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R3063CP.pdf on the CMS website. The second transmittal
updates the NCD Manual and it is available at http://www.cms.hhs.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R174NCD.pdf on the CMS website.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 43
November 2014 Medicare B Newsline
Page 5 of 6
MLN Matters® Number: MM8871
Related Change Request Number: 8871
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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 44
November 2014 Medicare B Newsline
Page 6 of 6
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
NEW products from the Medicare Learning Network® (MLN)
•
“Protecting Access to Medicare Act of 2014” Podcast, ICN 909050, downloadable
only.
MLN Matters® Number: MM8880 Revised
Related Change Request (CR) #: CR 8880
Related CR Release Date: September 26, 2014
Effective Date: October 1, 2014
Related CR Transmittal #: R3078CP
Implementation Date: October 6, 2014
October 2014 Update of the Ambulatory Surgical Center (ASC) Payment System
Note: CMS revised this article on September 30, 2014, to reflect the revised CR8880 issued on
September 26. In the article, the descriptor for HCPCS code C9135 has been revised in the
table on page 2 to end with per i.u., instead of per 10 i.u. 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, providers, and suppliers submitting
claims to Medicare Administrative Contractors (MACs) for services provided to
Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8880 describes changes to and billing instructions for various
payment policies implemented in the October 2014 ASC payment system update. CR8880
also includes updates to the Healthcare Common Procedure Coding System (HCPCS). Make
sure that your billing staffs are aware of these changes.
Page 45
November 2014 Medicare B Newsline
Key Points of CR8880
New Services
There are no new services assigned for separate payment under the Ambulatory Surgical
Center (ASC) Payment System, effective October 1, 2014.
Billing for Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective
October 1, 2014
Payments for separately payable drugs and biologicals based on ASPs are 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 ASC
Drug File. The updated payment rates, effective October 1, 2014, will be included in the
October 2014 update of the ASC Addendum BB, which will be posted at http://www.cms.
gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Up
dates.html on the Center for Medicare & Medicaid Services (CMS) website.
b. New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC
Payment System Effective October 1, 2014
Four drugs and biologicals have been granted ASC payment status effective October 01,
2014. These items, along with their descriptors and ASC payment indicators (PIs) are
as follows:
New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC
Payment System, Effective October 1, 2014
HCPCS
Code
Short Descriptor
Long Descriptor
ASC PI
C9023
Inj testosterone
undecanoate
Injection, testosterone undecanoate,
1 mg
K2
C9025
Injection, ramucirumab
Injection, ramucirumab, 5 mg
K2
C9026
Injection, vedolizumab
Injection, vedolizumab, 1 mg
K2
Factor ix (Alprolix)
Factor ix (antihemophilic factor,
recombinant), Alprolix, per i.u.
K2
C9135
Note: These HCPCS codes are new codes effective October 1, 2014.
c. Revised ASC Payment Indicator for HCPCS Codes J9160 and J9300
Page 46
November 2014 Medicare B Newsline
Effective October 1, 2014, the payment indicator for HCPCS codes J9160 (Injection,
denileukin diftitox, 300 micrograms) and J9300 (Injection, gemtuzumab ozogamicin, 5 mg)
will change from K2 to Y5 because the product associated with HCPCS code J9160 is no
longer marketed. Effective October 1, 2014, the payment indicator for HCPCS code J9300
(Injection, gemtuzumab ozogamicin, 5 mg) will change from K2 to Y5 because the product
associated with HCPCS code J9300 is no longer marketed.
d. Updated Payment Rate for HCPCS Code J9171, Effective January 1, 2014 through
March 31, 2014
The payment rate for one HCPCS code was incorrect in the January 2014 ASC Drug File.
The corrected payment rate is listed in the following table, and has been installed in the
revised January 2014 ASC Drug File, effective for services furnished on January 1, 2014,
through March 31, 2014. Suppliers who think they may have received an incorrect payment
for dates of service January 1, 2014, through March 31, 2014, may request their MAC to
adjust the previously processed claims.
Updated Payment Rate for HCPCS Code J9171
Effective January 1, 2014, through March 31, 2014
HCPCS
Code
J9171
Short Descriptor
Corrected
Payment
Rate
Docetaxel injection
ASC PI
4.63
K2
e. 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 ASC Drug File.
The corrected payment rate is listed in the following table, and has been installed in the
revised April 2014 ASC Drug File, effective for services furnished on April 1, 2014,
through June 30, 2014. Suppliers who think they may have received an incorrect payment
for dates of service April 1, 2014, through June 30, 2014, may request their MAC to adjust
the previously processed claims.
Updated Payment Rates for Certain HCPCS Codes
Effective April 1, 2014, through June 30, 2014
HCPCS
Code
Page 47
Short Descriptor
J7335
Capsaicin 8% patch
J8700
Temozolomide
Corrected
Payment
Rate
ASC PI
25.49
K2
6.94
K2
November 2014 Medicare B Newsline
HCPCS
Code
J9171
Short Descriptor
Docetaxel injection
Corrected
Payment
Rate
ASC PI
4.35
K2
f. 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 ASC Drug File.
The corrected payment rates are listed in the following table, and have been installed in the
revised July 2014 ASC Drug File, effective for services furnished on July 1, 2014, through
September 30, 2014. Suppliers who think they may have received an incorrect payment for
dates of service July 1, 2014, through September 30, 2014, may request their MAC to adjust
the previously processed claims.
Updated Payment Rates for Certain HCPCS Codes
Effective July 1, 2014, through September 30, 2014
HCPCS
Code
Short Descriptor
Corrected
Payment
Rate
J9047
Injection, carfilzomib, 1 mg
29.67
K2
J9315
Romidepsin injection
270.24
K2
ASC PI
Additional Information
The official instruction, CR 8880, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3078CP.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 48
November 2014 Medicare B Newsline
Page 4 of 4
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED product from the Medicare Learning Network® (MLN)
• “Medicare Learning Network® (MLN) Suite of Products & Resources for
Educators and Students” Educational Tool, ICN 903763, Downloadable
only.
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
Manual Update to Clarify Claims Processing for Laboratory Services
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:
Page 49
November 2014 Medicare B Newsline
•
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.
Additional Information
The official instruction, CR8883 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-andGuidance/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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 50
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED product from the Medicare Learning Network® (MLN)
“Medicare Enrollment Guidelines for Ordering/Referring Providers,” Fact Sheet,
ICN 906223, Downloadable only.
MLN Matters® Number: MM8890 Revised
Related Change Request (CR) #: CR 8890
Related CR Release Date: September 3, 2014
Effective Date: August 1, 2014
Related CR Transmittal #: R3059CP
Implementation Date: No later than November 24, 2014
Influenza Vaccine Payment Allowances - Annual Update for 2014-2015 Season
Note: This article was revised on September 3, 2014, to reflect a new Change Request (CR). The
revised CR corrected the implementation date. In this article the CR release date, transmittal
number and link to the CR also changed. 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 influenza vaccine
services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 8890, which informs MACs about the
availability of payment allowances for seasonal influenza virus vaccines. These payment
allowances are updated on an annual basis effective August 1st of each year. Make sure that
your billing staffs are aware of these changes.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to
statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of
either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and
accurate statement of their contents. CPT only copyright 2013 American Medical Association.
Page 51
November 2014 Medicare B Newsline
Page 1 of 3
MLN Matters® Number: MM8890
Related Change Request Number: 8890
Background
This recurring update notification provides the payment allowances for the following
seasonal influenza virus vaccines, when payment is based on 95 percent of the Average
Wholesale Price (AWP).
CPT 90655 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90656 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90657 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90661 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90685 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90686 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90687 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90688 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2035 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2036 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2037 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2038 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
Payment for the following CPT or HCPCS codes may be made if your MAC determines its
use is reasonable and necessary for the beneficiary, during the effective dates indicated
below:
CPT 90654 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90662 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90672 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
CPT 90673 Payment allowance is pending. Effective dates: 8/1/2014 - 7/31/2015
HCPCS Q2039 Flu Vaccine Adult - Not Otherwise Classified payment allowance is to be
determined by the local claims processing contractor with effective dates of 8/1/2014 7/31/2015.
Payment allowances for codes for products that have not yet been approved will be provided
when the products have been approved and pricing information becomes available to CMS.
The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP
and are updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug
Pricing Files.
The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines
are 95 percent of the AWP as reflected in the published compendia except where the vaccine
is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally
Qualified Health Center (FQHC). Where the vaccine is furnished in the hospital outpatient
department, RHC, or FQHC, payment for the vaccine is based on reasonable cost.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 52
November 2014 Medicare B Newsline
Page 2 of 3
MLN Matters® Number: MM8890
Related Change Request Number: 8890
Annual Part B deductible and coinsurance amounts do not apply. All physicians, nonphysician practitioners, and suppliers who administer the influenza virus vaccination and the
pneumococcal vaccination must take assignment on the claim for the vaccine.
Note: MACs will not search their files either to retract payment for claims already paid or to
retroactively pay claims prior to the implementation date of CR8890. However, they will
adjust claims that you bring to their attention.
Additional Information
The official instruction, CR8890, issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3059CP.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 53
November 2014 Medicare B Newsline
Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED products from the MLN
• “Medicare Learning Network® (MLN) Suite of Products & Resources for
Educators and Students,” Educational Tool, ICN 903763, Downloadable only.
MLN Matters® Number: MM8891
Related Change Request (CR) #: CR 8891
Related CR Release Date: August 29, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3055CP
Implementation Date: January 5, 2015
Annual Clotting Factor Furnishing Fee Update 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers billing Medicare
Administrative Contractors (MACs) for services related to the administration of clotting
factors to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8891 announces that for Calendar Year 2015 the clotting factor
furnishing fee of $0.197 per unit is included in the published payment limit for clotting
factors. For dates of service of January 1, 2015, through December 31, 2015, the clotting
factor furnishing fee of $0.197 per unit is added to the payment when no payment limit for
the clotting factor is included in the Average Sales Price (ASP) or Not Otherwise Classified
(NOC) drug pricing files. Please be sure your billing staffs are aware of this fee update.
Page 54
November 2014 Medicare B Newsline
Background
The Medicare Modernization Act section 303(e)(1) added section 1842(o)(5)(C) of the Social
Security Act which requires that a furnishing fee will be paid for items and services associated
with clotting factor.
The Centers for Medicare & Medicaid Services (CMS) includes the clotting factor furnishing
fee in the published national payment limits for clotting factor billing codes. When the
national payment limit for a clotting factor is not included on the Average Sales Price (ASP)
Medicare Part B Drug Pricing File or the Not Otherwise Classified (NOC) Pricing File, your
MAC must make payment for the clotting factor as well as make payment for the furnishing
fee.
Additional Information
The official instruction, CR 8891, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R3055CP.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 55
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
NEW product from the Medicare Learning Network® (MLN)
• “Medicaid Compliance and Your Dental Practice” Fact Sheet, ICN 908668,
Downloadable only.
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
January 2015 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing
Files and Revisions to Prior Quarterly Pricing Files
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.
Page 56
November 2014 Medicare B Newsline
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.
The following table shows how the quarterly payment files will be applied:
Files
January 2015 ASP and ASP NOC
Effective Dates of Service
January 1, 2015, through March 31,
2015
October 2014 ASP and ASP NOC
October 1, 2014, through December 31,
2014
July 2014 ASP and ASP NOC
July 1, 2014, through September 30,
2014
April 2014 ASP and ASP NOC
April 1, 2014, through June 30, 2014
January 2014 ASP and ASP NOC
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-andGuidance/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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 57
November 2014 Medicare B Newsline
Page 2 of 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time
of enrollment, enrollment change request, or revalidation, providers and suppliers that
expect to receive payment from Medicare for services provided must also agree to
receive Medicare payments through Electronic Funds Transfer (EFT). Section 1104 of
the Affordable Care Act further expands Section 1862(a) of the Social Security Act by
mandating federal payments to providers and suppliers only by electronic means. As
part of CMS’s revalidation efforts, all suppliers and providers who are not currently
receiving EFT payments are required to submit the CMS-588 EFT form with the
Provider Enrollment Revalidation application, or at the time any change is being made
to the provider enrollment record by the provider or supplier, or delegated official. For
more information about provider enrollment revalidation, review the MLN Matters®
Special Edition Article SE1126, “Further Details on the Revalidation of Provider
Enrollment Information.”
MLN Matters® Number: SE1216 Revised
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Examining the Difference between a National Provider Identifier (NPI) and a
Provider Transaction Access Number (PTAN)
Note: This article was revised on September 5, 2014, to add the "Where Can I Find My
PTAN?" section on page 3. All other information is the same.
Provider Types Affected
This MLN Matters® Special Edition Article is intended for physicians, providers, and
suppliers who are enrolled in Medicare.
Page 58
November 2014 Medicare B Newsline
What You Need to Know
This article explains the difference between a National Provider Identifier (NPI) and a
Provider Transaction Access Number (PTAN). There are no policy changes in this article.
Background
New Enrollees
All providers and suppliers who provide services and bill Medicare for services
provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare
Administrative Contractor (MAC), the provider or supplier will also be issued a
Provider Transaction Access Number (PTAN). While only the NPI can be submitted
on claims, the PTAN is a critical number directly linked to the provider or
supplier’s NPI.
Revalidation
Section 6401(a) of the Affordable Care Act established a requirement for all enrolled
physicians, providers, and suppliers to revalidate their enrollment information under new
enrollment screening criteria.
Providers and suppliers receiving requests to revalidate their enrollment information have
asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences
between the NPI and the PTAN.
National Provider Identifier (NPI)
The NPI is a national standard under the Health Insurance Portability and Accountability
Act (HIPAA) Administrative Simplification provisions.
Page 59
•
The NPI is a unique identification number for covered health care providers.
•
The NPI is issued by the National Plan and Provider Enumeration System (NPPES).
•
Covered health care providers and all health plans and health care clearinghouses
must use the NPI in the administrative and financial transactions (for example,
insurance claims) adopted under HIPAA.
•
The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The
NPI does not carry information about healthcare providers, such as the state in which
they live or their medical specialty. This reduces the chances of insurance fraud.
•
Covered providers and suppliers must share their NPI with other suppliers and
providers, health plans, clearinghouses, and any entity that may need it for
billing purposes.
November 2014 Medicare B Newsline
Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy
provider identifiers, including the Unique Physician Identification Number (UPIN), as the
unique identifier for all providers, and suppliers in HIPAA standard transactions.
You should note that individual health care providers (including physicians who are sole
proprietors) may obtain only one NPI for themselves (Entity Type 1
Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1
Individual) if they are health care providers and an additional NPI(s) for their corporation(s)
(Entity Type 2 Organization). Organizations that render health care or furnish health care
supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their
subparts (if applicable).
For more information about the NPI, visit the NPPES website at
https://nppes.cms.hhs.gov/NPPES/Welcome.do on the CMS website.
Provider Transaction Access Number (PTAN)
A PTAN is a Medicare-only number issued to providers by MACs upon enrollment to
Medicare. When a MAC approves enrollment and issues an approval letter, the letter will
contain the PTAN assigned to the provider.
•
The approval letter will note that the NPI must be used to bill the Medicare program
and that the PTAN will be used to authenticate the provider when using MAC selfhelp tools such as the Interactive Voice Response (IVR) phone system, internet
portal, on-line application status, etc.
•
The PTAN's use should generally be limited to the provider’s contacts with
their MAC.
Where can I find my PTAN?
You can find your PTAN by doing any one of the following:
1. View the letter sent by your MAC when your enrollment in Medicare was approved.
2. Log into Internet-based PECOS. Click on the “My Enrollments” button and then
“View Enrollments”. Locate the applicable enrollment and click on the “View
Medicare ID Report” link which will list all of the provider or supplier’s active
PTANs in one report.
3 The provider (or, in the case of an organizational provider, an authorized or
delegated official) shall send a signed written request on company letterhead to your
MAC; include your legal name/legal business name, national provider identifier
(NPI), telephone and fax numbers.
Page 60
November 2014 Medicare B Newsline
Relationship of the NPI to the PTAN
The NPI and the PTAN are related to each other for Medicare purposes. A provider must
have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system,
representing the provider’s enrollment. If the provider has relationships with one or more
medical groups or practices or with multiple Medicare contractors, separate PTANS are
generally assigned.
Together, the NPI and PTAN identify the provider, or supplier in the Medicare program.
CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership
System (PECOS), the master provider and supplier enrollment system.
Protect Your Information in PECOS
All providers and suppliers should carefully review their PECOS records in order to protect
themselves and their practices from identity theft. PECOS should only contain active
enrollment records that reflect current practice and group affiliations. You can review and
update your PECOS records in the following ways:
•
Use internet-based PECOS: Log on to internet-based PECOS at
https://pecos.cms.hhs.gov/pecos/login.do on the CMS website.
•
Use the Paper CMS 855 enrollment application (i.e., 855A, 855B, 855I, 855O, 855R,
or 855S).
•
Note: The Medicare contractor may not release provider specific information to
anyone other than the individual provider, authorized/delegated official of the
provider organization, or the contact person. The request must be submitted in
writing on the provider’s letterhead and signed by the individual provider,
authorized/delegated official of the organization or the contact person.
The MLN fact sheet titled “How to Protect Your Identity Using the Provider Enrollment,
Chain and Ownership System (PECOS),” provides guidelines and steps you can take to
protect your identity while using Internet-based PECOS. This fact sheet is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MedEnroll_ProtID_FactSheet_ICN905103.pdf on the
CMS website.
Additional Information
MLN Matters® Special Edition Article SE1126 titled “Further Details on the Revalidation of
Provider Enrollment Information,” is available at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1126.pdf on the CMS website.
“Medicare Provider–Supplier Enrollment National Educational Products,” contains a list of
products designed to educate Medicare Fee-For-Service (FFS) providers about important
Medicare enrollment information, including how to use Internet-based PECOS to enroll in
Page 61
November 2014 Medicare B Newsline
the Medicare Program and maintain their enrollment information. This resource is available
at http://www.cms.gov/MedicareProviderSupEnroll/downloads/Medicare_ProviderSupplier_Enrollment_National_Education_Products.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-Net
work-MLN/MLNMattersArticles/index.html under - How Does It Work.
Page 62
November 2014 Medicare B Newsline
Page 5 of 5
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
REVISED products from the Medicare Learning Network® (MLN)
•
“Medicare Vision Services”, Fact Sheet, ICN 907165, downloadable
MLN Matters® Number: SE1431
Related Change Request (CR) #: NA
Related CR Release Date: NA
Effective Date: NA
Related CR Transmittal #: NA
Implementation Date: NA
2014-2015 Influenza (Flu) Resources for Health Care Professionals
Provider Types Affected
All health care professionals who order, refer, or provide flu vaccines and vaccine
administration to Medicare beneficiaries.
What You Need to Know
Page 63
•
Keep this Special Edition MLN Matters article and refer to it throughout the 2014 - 2015
flu season.
•
Take advantage of each office visit as an opportunity to encourage your patients to
protect themselves from the flu and serious complications by getting a flu shot.
•
Continue to provide the flu shot as long as you have vaccine available, even after the
new year.
•
Remember to immunize yourself and your staff.
November 2014 Medicare B Newsline
Introduction
The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals
that Medicare Part B reimburses health care providers for flu vaccines and their
administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket
costs to the Medicare patient. No deductible or copayment/coinsurance applies.)
You can help your Medicare patients reduce their risk for contracting seasonal flu and
serious complications by using every office visit as an opportunity to recommend they take
advantage of Medicare’s coverage of the annual flu shot.
As a reminder, please help prevent the spread of flu by immunizing yourself and your staff!
Know What to Do About the Flu!
Educational Products for Health Care Professionals
The Medicare Learning Network® (MLN) has developed a variety of educational
resources to help you understand Medicare guidelines for seasonal flu vaccines and
their administration.
1. MLN Influenza Related Products for Health Care Professionals
Page 64
•
MLN Matters Article MM8890: Influenza Vaccine Payment Allowances – Annual
Update for 2014-2015 Season – http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8890.pdf
•
Quick Reference Information: Medicare Part B Immunization Billing chart http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/qr_immun_bill.pdf
•
Quick Reference Information: Preventive Services charthttp://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_Q
uickReferenceChart_1.pdf
•
MLN Preventive Services Educational Products web page http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html
•
Preventive Services Educational Products PDF- http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/education_products_prevserv.pdf
November 2014 Medicare B Newsline
2. Other CMS Resources
•
Seasonal Influenza Vaccines 2014 Pricing http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-BDrugs/McrPartBDrugAvgSalesPrice/2014ASPFiles.html
•
Immunizations web page http://www.cms.gov/Medicare/Prevention/Immunizations/index.html
•
Prevention General Information http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html
•
CMS Frequently Asked Questions - http://questions.cms.gov/faq.php
•
Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf
•
Medicare Claims Processing Manual – Chapter 18, Preventive and Screening
Services http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c18.pdf
3. Other Resources
The following non-CMS resources are just a few of the many available in you may find
useful information and tools for the 2014 – 2015 flu season:
Page 65
•
Advisory Committee on Immunization Practices http://www.cdc.gov/vaccines/acip/index.html
•
Other sites with helpful information include:
•
Centers for Disease Control and Prevention - http://www.cdc.gov/flu;
•
Flu.gov - http://www.flu.gov;
•
Food and Drug Administration - http://www.fda.gov;
•
Immunization Action Coalition - http://www.immunize.org;
•
Indian Health Services - http://www.ihs.gov;
•
National Alliance for Hispanic Health - http://www.hispanichealth.org;
•
National Foundation For Infectious Diseases http://www.nfid.org/influenza;
•
National Library of Medicine and NIH Medline Plus http://www.nlm.nih.gov/medlineplus/immunization.html;
November 2014 Medicare B Newsline
•
National Network for Immunization Information http:/www.immunizationinfo.org;
•
National Vaccine Program - http://www.hhs.gov/nvpo;
•
Office of Disease Prevention and Health Promotion http://odphp.osophs.dhhs.gov;
•
Partnership for Prevention - http://www.prevent.org; and
•
World Health Organization - http://www.who.int/en
Beneficiary Information
For information to share with your Medicare patients, please visit
http://www.medicare.gov on the Internet.
Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all
Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its
administration once in a lifetime for all Medicare beneficiaries; however, Medicare may cover
additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal
vaccination status. Medicare provides coverage for these vaccines and their administration with no
co-pay or deductible.
Remember to immunize yourself and your staff. Protect yourself from the flu.
Remember – The influenza vaccine plus its administration is a covered Part B benefit. The
influenza vaccine is NOT a Part D covered drug. For more information on coverage and billing of
the flu vaccine and its administration, please visit the CMS Medicare Learning Network®
Preventive Services Educational Products and CMS Immunizations web pages.
While some health care professionals may offer the flu vaccine, others can help their patients locate
a vaccine provider within their local community. HealthMap Vaccine Finder is a free, online
service where users can search for locations offering flu vaccines.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law
or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2013 American Medical Association.
Page 66
November 2014 Medicare B Newsline
Page 4 of 4
CMS MLN Connects™ Provider eNews
The Centers for Medicare & Medicaid Services (CMS) MLN ConnectsTM Provider eNews is an
official Medicare Learning Network® (MLN) branded CMS product that contains a week’s worth
of news for Medicare Fee-for-Service (FFS) providers. It delivers planned, coordinated
messages on Medicare-related topics.
Below are the latest editions:





October 30, 2014
October 23, 2014
October 16, 2014
October 9, 2014
October 2, 2014
Archived editions are available on the CMS website.
Page 67
November 2014 Medicare B Newsline
Two CMS Educational Resources for Medicare Providers & Suppliers MLN Connects™ Provider eNews A weekly electronic publication containing: •
•
•
•
MLN Connects™ National Provider Calls and other event reminders CMS program updates and policy details Claim, pricer, and code information Medicare Learning Network® educational product announcements View past issues or subscribe to the eNews at go.cms.gov/enews. Scan the QR code to view on a mobile device. Note: Providers who are subscribed to their MAC’s listserv already receive the eNews. MLN Connects™ National Provider Calls Educational conference calls on new and changing Medicare programs & policies •
•
•
•
•
In‐depth presentations by CMS subject matter experts providing the latest information on topics specific to Medicare providers and suppliers, such as ICD‐10, PQRS, and provider enrollment Question & Answer sessions with CMS experts No cost to participate 24/7 access to call materials (e.g., presentation slides, written transcripts, audio recordings, and CMS videos on YouTube) Continuing education credit for participation awarded by many professional associations and credentialing organizations Learn more or register for upcoming calls at www.cms.hhs.gov/npc. Scan the QR code to view on a mobile device. Bookmark this webpage for quick access to upcoming calls! MLN Connects™ is part of the CMS Medicare Learning Network® – Official Information Health Care Professionals Can Trust. For more info, visit go.cms.gov/mlncatalog and www.cms.gov/MLNMattersArticles. * Please note: All links are case sensitive. Page 68
November 2014 Medicare B Newsline
Medicare B Newsline Quality Survey
Please take a moment to let us know your thoughts regarding this issue of the Medicare B Newsline.
Your Name (optional):
Telephone Number (optional):
Please rate the publication by circling the number of your choice.
(10 = Excellent, 5 = Satisfactory, 1 = Unacceptable)
1. Usefulness of the information.
1
2
3
4
5
6
7
8
9
10
7
8
9
10
8
9
10
8
9
10
2. Organization and layout of the information.
1
2
3
4
5
6
3. Design and physical appearance of the publication.
1
2
3
4
5
6
7
4. Value of Medicare B Newsline as a reference item.
1
2
3
4
5
6
7
5. Do you use the website to obtain copies of the Medicare newsletter?
Yes
No
6. What can we do to make Medicare B Newsline a more effective publication?
Thank you for your time. You can email your response by clicking Submit.
Submit
Please fax or mail your response to:
Cahaba Government Benefit Administrators, LLC
Provider Outreach and Education
PO Box 12967
Birmingham, Alabama 35202
Fax: 205-220-1531
Medicare B Newsline
Page 69
November 2014 Medicare B Newsline