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J11 PART B MEDICARE ADVISORY
Latest Medicare News for J11 Part B
What’s Inside...
Administration
Medicare Participating Physicians Directory (MEDPARD) ...................................................3
CMS Quarterly Provider Update ............................................................................................4
Going Beyond Diagnosis ........................................................................................................4
Provider Contact Center Training/Holiday Closure Schedule ............................................ 5-6
Incorporation of Certain Provider Enrollment Policies in CMS-4159-F into Pub. 100-08,
Program Integrity Manual (PIM), Chapter 15................................................................. 7-8
New Timeframe for Response to Additional Documentation Requests ................................9
Receive ADRs Electronically: Go Green via our Online Provider Services Portal ..............10
Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments .........................11-14
Opting out of Medicare and/or Electing to Order and Certify Items and Services to Medicare Beneﬁciaries ............................................................................................... 15-18
Continued Use of Modiﬁer 59 after January 1, 2015 ...........................................................19
Drugs and Biologicals
Modiﬁcations to Medicare Part B Coverage of Pneumococcal Vaccinations ................ 20-21
Durable Medical Equipment Prosthetics, Orthotics, and Supplies
Registration Reminder for DMEPOS Competitive Bidding: Round 2 Recompete &
National Mail-Order Recompete ................................................................................ 22-23
2015 Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List .... 24-33
Holding of 2015 Date-of-Service Claims and DMEPOS Competitive Bidding Registration Reminder................................................................................................. 34-35
Education
Educational Events Now Available… ...................................................................................36
Continued >>
palmettogba.com/part b
The J11 Part B Medicare Advisory contains coverage, billing and other information for Jurisdiction 11 Part B. This
information is not intended to constitute legal advice. It is our ofϐicial notice to those we serve concerning their
responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily
available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information
and to follow the guidelines. The J11 Part B Medicare Advisory includes information provided by the Centers for
Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change
at any time. This bulletin should be shared with all health care practitioners and managerial members of the
provider staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/Medicare.
CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part
of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code
on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012
American Dental Association (ADA). All rights reserved.
February 2015
Volume 2015, Issue 2
Electronic Data Interchange
Remittance Advice Remark and Claims Adjustment Reason Code and Medicare Remit Easy Print and PC Print Update ............................................................................................................... 37-39
Fee Schedules and Reimbursement
Emergency Update to the Calendar Year (CY) 2015 Medicare Physician Fee Schedule Database (MPFSDB) .........40
Summary of Policies in the Calendar Year (CY) 2015 Medicare Physician Fee Schedule (MPFS) Final Rule and Telehealth Originating Site Facility Fee Payment Amount ................................................................................ 41-45
ICD-10
Results from November ICD-10 Acknowledgement Testing Week ............................................................................. 46
International Classiﬁcation of Diseases, Tenth Revision (ICD-10) Limited End to End Testing with Submitters for 2015 .............................................................................................................................................................. 47-48
FAQs – International Classiﬁcation of Diseases, 10th Edition (ICD-10) End-to-End Testing .............................. 50-53
FAQs – International Classiﬁcation of Diseases, 10th Edition (ICD-10) Acknowledgement Testing and End-to-End Testing ............................................................................................................................................. 54-56
Medicine
Preventive and Screening Services - Update - Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated with Screening Colonoscopy ................................ 57-61
Ambulatory Surgical Center
January 2015 Update of the Ambulatory Surgical Center (ASC) Payment System .............................................. 62-68
Cardiology
Transcatheter Mitral Valve Repair (TMVR)-National Coverage Determination (NCD) ...................................... 69-74
Home Health
Certifying Patients for the Medicare Home Health Beneﬁt .................................................................................. 75-87
Laboratory
New Waived Tests .................................................................................................................................................. 88-89
Calendar Year (CY) 2015 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment .......................................................................................................................... 90-94
Radiology
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors (This Change Request (CR) rescinds and fully replaces MM 8468, dated February 6, 2014.)........................................................................ 95-99
Etcetera
Medical Director’s Desk ......................................................................................................................................100-112
CMS e-News............................................................................................................................................................... 113
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2/2015
Medicare Participating Physicians Directory (MEDPARD)
The Medicare Participating Physicians Directory (MEDPARD), which contains the listing of names, addresses,
phone number and specialties of all participating providers within the Medicare Part B Program, may be
accessed through the appropriate state’s website on January 30, at:
• North Carolina:
https://www4.palmettogba.com/pgx_palmettogbacom/initMedpardSearch.do?initState=NC
• South Carolina:
https://www4.palmettogba.com/pgx_palmettogbacom/initMedpardSearch.do?initState=SC
• Virginia:
https://www4.palmettogba.com/pgx_palmettogbacom/initMedpardSearch.do?initState=VA
• West Virginia:
https://www4.palmettogba.com/pgx_palmettogbacom/initMedpardSearch.do?initState=WV
You may also visit the CMS MEDPARD listing (physicians only) Web site at
http://www.cms.gov/center/physician.asp.
MEDPARD paper requests by locality may be submitted to:
J11 MAC Palmetto GBA, AG-310
P.O. Box 100190
Columbia, SC 29202-3190
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3
2/2015
CMS Quarterly Provider Update
The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid
Services (CMS) on the ﬁrst business day of each quarter. It is a listing of all non-regulatory changes to Medicare
including program memoranda, manual changes and any other instructions that could affect providers.
Regulations and instructions published in the previous quarter are also included in the update. The purpose of
the Quarterly Provider Update is to:
•
•
•
•
•
Inform providers about new developments in the Medicare program
Assist providers in understanding CMS programs and complying with Medicare regulations and instructions
Ensure that providers have time to react and prepare for new requirements
Announce new or changing Medicare requirements on a predictable schedule
Communicate the speciﬁc days that CMS business will be published in the ‘Federal Register’
To receive notiﬁcation when regulations and program instructions are added throughout the quarter, sign up
for the Quarterly Provider Update listserv (electronic mailing list) at
https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.
We encourage you to bookmark the Quarterly Provider Update Web site at
www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. html
and visit it often for this valuable information.
Going Beyond Diagnosis: Preventing Payment Errors by Improving Provider-Payer Communication
A failure to communicate is the number one cause of Medicare claims denials. Palmetto GBA’s Going Beyond
Diagnosis (GBD) process helps reduce Medicare denials by supporting the dissemination of best practices and
process improvements. The GBD Blog was established to provide a platform for discussing the challenges and
complexities of communicating health care encounters and to provide potential solutions to identify the root
causes for speciﬁc communication errors.
The GBD Blog and Twitter ID @BeyondDx are part of Palmetto GBA’s innovative strategy for increasing the
capacity of Medicare providers to improve the quality of healthcare records and effectively decrease the claims
payment error rate. The success of this social media approach to communicating with healthcare stakeholders
depends on your active participation.
True innovation requires collaboration. Please join the on-line GBD community by visiting the GBD Blog at
http://palmgba.com/gbd/ or signing-up to follow us on Twitter @BeyondDx.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4
2/2015
Provider Contact Center Training/Holiday Closure Schedule
The Centers for Medicare & Medicaid Services (CMS) has approved
allowing Medicare provider service centers to close up to eight hours per
month for provider Customer Service Advocates (CSAs) training and/or
staff development. The goal is to help CSAs improve the consistency and
accuracy of their responses to provider questions; enhance their awareness
and understanding of Medicare policies and issues; and facilitate CSAs’
retention of the facts of their training by increasing its frequency.
Please use the tool ‘Online Provider Services’ to view beneﬁciary eligibility,
claims status, online remittances and ﬁnancial information. The Interactive
Voice Response (IVR) unit will also be available during these scheduled
training sessions for automated customer service transactions. Listed below
are training closure dates and times for the next several months:
Date
February 16, 2015
March 6, 2015
March 27, 2015
April 10, 2015
April 24, 2015
May 8, 2015
May 22, 2015
May 25, 2015
June 12, 2015
June 26, 2015
July 3, 2015
July 10, 2015
July 24, 2015
August 7, 2015
August 21, 2015
September 4, 2015
September 7, 2015
September 18, 2015
October 12, 2015
November 11, 2015
November 26-27, 2015
December 4, 2015
December 18, 2015
PCC/Ofﬁce Closed
PCC closed/ Training
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
Ofﬁce closed/ Memorial Day
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
Ofﬁce closed/Independence Day
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m..
Ofﬁce closed/ Labor Day
PCC closed 8 a.m. to 12 p.m.
PCC closed/ Training
PCC closed/ Training
Ofﬁce Closed/ Thanksgiving
PCC closed 8 a.m. to 12 p.m.
PCC closed 8 a.m. to 12 p.m.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5
2/2015
Date
December 24-25, 2015
January 1, 2016
PCC/Ofﬁce Closed
Ofﬁce closed/Christmas Eve/ Christmas Day
Ofﬁce closed/ New Year’s Day
Changes to our planned closure schedule will be communicated at least three weeks in advance via the Web
site, IVR features and automatic email notiﬁcations.
If you have not already done so, we encourage you to sign up for automatic email notices of updates to our
website. Subscribing to this listserv is the fastest way to ﬁnd out about Medicare changes that may affect you.
There is no charge for the service, and we will not share your email address with others. To register, go to Email
Updates on our website at http://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm.
If you have any questions, please contact our provider service center at our toll-free number at 855-696-0705.
For information regarding claims status or eligibility, please call the Interactive Voice Response (IVR) at 855
696-0705 or use the Palmetto GBA Online Provider Services (OPS) tool, located at
http://www.PalmettoGBA.com/OPS.
A list of current system-related claims processing issues is available
on our website. These issues were reported to the Centers for Medicare
& Medicaid Services (CMS) and/or the Multi-Carrier System (MCS).
Please check often for updates before contacting the provider contact
center. The issues are identiﬁed by stand alone articles and will be updated as needed. Be sure to sign-up to
receive updates using the “Article Update Notiﬁcation” feature.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6
2/2015
Incorporation of Certain Provider Enrollment Policies in
CMS-4159-F into Pub. 100-08, Program Integrity Manual
(PIM), Chapter 15
MLN Matters® Number: MM8901
Related Change Request (CR) #: CR 8901
Related CR Release Date: December 12, 2014
Effective Date: March 18, 2015
Related CR Transmittal #: R561PI
Implementation Date: March 18, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and eligible professionals who prescribe Medicare Part
D drugs, and for providers and suppliers that submit claims to Medicare Administrative Contractors (MACs)
for services provided to Medicare beneﬁciaries.
What You Need to Know
Change Request (CR) 8901 incorporates into Chapter 15 of the “Program Integrity Manual” (PIM) several
provider enrollment policies in the ﬁnal rule titled, “Medicare Program; Contract Year 2015 Policy and Technical
Changes to the Medicare Advantage and the Medicare Prescription Drug Beneﬁt Programs.”
Key Points of CR8901
The key points of the updated Chapter 15 of the “Medicare Program Integrity Manual” are as follows:
• If a MAC approves a provider’s or supplier’s Form CMS-855 reactivation application or Reactivation
Certiﬁcation Package (RCP) for a Part B non-certiﬁed supplier, the reactivation effective date will be the
date the MAC received the application or RCP that was processed to completion. Also, upon reactivating
billing privileges for a Part B non-certiﬁed supplier, the MAC will issue a new Provider Transaction Access
Number (PTAN).
• CMS may deny a physician’s or eligible professional’s Form CMS-855 enrollment application under §
424.530(a)(11) if:
• The physician’s or eligible professional’s Drug Enforcement Administration (DEA) Certiﬁcate of
Registration to dispense a controlled substance is currently suspended or revoked; or
• The applicable licensing or administrative body for any state in which the physician or eligible
professional practices has suspended or revoked the physician’s or eligible professional’s ability to
prescribe drugs, and such suspension or revocation is in effect on the date the physician or eligible
professional submits his or her enrollment application to the Medicare contractor.
• CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(13) if:
• The physician’s or eligible professional’s DEA Certiﬁcate of Registration is suspended or revoked; or
• The applicable licensing or administrative body for any state in which the physician or eligible
professional practices has suspended or revoked the physician’s or eligible professional’s ability to
prescribe drugs.
• CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(14) if
CMS determines that the physician or eligible professional has a pattern or practice of prescribing Part D
drugs that falls into one of the following categories:
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7
2/2015
•
•
The pattern or practice is abusive or represents a threat to the health and safety of Medicare beneﬁciaries
or both.
The pattern or practice of prescribing fails to meet Medicare requirements.
Additional Information
The ofﬁcial instruction, CR8901, issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R561PI.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8
2/2015
New Timeframe for Response to Additional Documentation Requests
MLN Matters® Number: MM8583 Revised
Related Change Request (CR) #: CR 8583
Related CR Release Date: January 7, 2015
Effective Date: April 1, 2015
Related CR Transmittal #: R566PI
Implementation Date: April 6, 2015
Note: This article was revised on January 8, 2015, to reﬂect the revised CR8583 issued on January 7. The
article was revised to include a statement that reviewers should not grant providers additional time to respond
to additional documentation requests. 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 physicians, providers and suppliers submitting claims to Medicare
Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services to
Medicare beneﬁciaries.
What You Need to Know
This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity
Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state
that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond
within 45 days of a pre-payment review ADR will result in denial of the claim(s) related to the ADR. Make
sure your billing staffs are aware of these changes.
Background
In certain circumstances, CMS review contractors (MACs, ZPICs, Recovery Auditors, the Comprehensive
Error Rate Testing contractor and the Supplemental Medical Review Contractor) may not be able to make a
determination on a claim they have chosen for review based upon the information on the claim, its attachments
or the billing history found in claims processing system (if applicable) or Medicare’s Common Working File
(CWF).
In those instances, the CMS review contractor will solicit documentation from the provider or supplier by
issuing an ADR. The requirements for additional documentation are as follows:
• The Social Security Act, Section 1833(e) - Medicare contractors are authorized to collect medical
documentation. The Act states that no payment shall be made to any provider or other person for services
unless they have furnished such information as may be necessary in order to determine the amounts due
to such provider or other person for the period with respect to which the amounts are being paid or for any
prior period.
• According to the “Medicare Program Integrity Manual,” Chapter 3, Section 3.2.3.2, (Verifying Potential
Errors and Tracking Corrective Actions),when requesting documentation for pre-payment review, the MAC
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9
2/2015
and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days
of the request. The reviewer should not grant extensions to the providers who need more time to comply
with the request. Reviewers shall deny claims for which the requested documentation was not received
by day 46.
Additional Information
The ofﬁcial instruction, CR 8583, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R566PI.pdf on the Centers
for Medicare & Medicaid Services (CMS) website.
Receive ADRs Electronically: Go Green via
our Online Provider Services Portal
J11 Part B and Railroad Medicare providers can now opt to receive Additional
Documentation Requests (ADRs) through our Online Provider Services (OPS) portal.
If your claim is selected for review, you can receive your request as it is generated
– instead of by mail (which decreases the amount of time you have to respond).
This new process is free and easy to use. Our messaging function in OPS will send
an inbox message to let users know that an ‘eLetter’ is now available. This new process delivers the electronic
document as a link within the secure message once you sign into OPS.
For more information about OPS and the many services it offers, please visit our website at
www.PalmettoGBA.com/OPS.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10
2/2015
Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments MLN Matters® Number: MM8667
Revised Related Change Request (CR) #: CR 8667
Related CR Release Date: May 16, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R1384OTN
Implementation Date: October 6, 2014
Note: This article was revised on January 15, 2015, to correct a typo on page 4. The reference should have
stated “2% EHR negative adjustment $1.90 (95 x.02).” It incorrectly stated “2% PQRS.” All other information
remains the same.
Provider Types Affected
This MLN Matters® Article is intended for Medicare eligible professionals (EPs) submitting professional
claims to Medicare Administrative Contractors (MACs) for services to Medicare beneﬁciaries.
Provider Action Needed
This article is based on Change Request (CR) 8667, whose purpose is to place the Electronic Health Record
(EHR) and Physician Quality Reporting System (PQRS) Negative Adjustment Limiting Charge amounts on
MAC websites and hard copy disclosure reports. EPs under the Medicare EHR Incentive Program include:
Doctor of medicine or osteopathy, Doctor of oral surgery or dental medicine, Doctor of podiatry, Doctor of
optometry, and Chiropractor. Be sure your billing staffs are aware of these changes.
Background Electronic Health Record (EHR) Beginning January 1, 2015, Section 1848(a)(7) of the Social Security Act as amended by Section 4101(b) of the
HITECH Act, requires that EPs that are not meaningful EHR users are subject to the EHR negative adjustment.
Speciﬁcally, Section 1848(a)(7) of the Act states that: “If the eligible professional is not a meaningful EHR user
(as determined under Subsection (o)(2)) for an EHR reporting period for the year, the fee schedule amount for
such services furnished by such professional during the year (including the fee schedule amount for purposes
of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule
amount that would otherwise apply to such services under this subsection (determined after application of
paragraph (3) but without regard to this paragraph).”
Physician Quality Reporting System (PQRS)
Beginning on January 1, 2015, Section 1848(a)(8) of the Social Security Act, as added by Section 3002(b) of
the Affordable Care Act, requires that EPs who do not satisfactorily report data on quality measures for covered
professional services for the quality reporting period of the year are subject to the PQRS negative adjustment.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11
2/2015
Speciﬁcally, Section 1848(a)(8) of the Act states that: “If the eligible professional does not satisfactorily
submit data on quality measures for covered professional services for the quality reporting period for the year
(as determined under Subsection (m)(3)(A)), the fee schedule amount for such services furnished by such
professional during the year (including the fee schedule amount for purposes of determining a payment based
on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise
apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), but
without regard to this paragraph).”
The negative payment adjustment applies to all EPs, regardless of whether the EP elects to be “participating”
or “non-participating” for purposes of Medicare payments.
Non-participating (Non-Par) EPs in the Medicare program may choose either to accept or not accept assignment
on Medicare claims on a claim-by-claim basis. If EPs choose not to accept assignment, they may not charge the
beneﬁciary more than the Medicare limiting charge for unassigned claims for Medicare services. The limiting
charge is 115 percent of the MPFS amount. The beneﬁciary is not responsible for billed amounts in excess of
the limiting charge for a covered service.
Non-participating EPs that do not accept assignment on a claim may choose to collect the entire limiting charge
amount up front from the beneﬁciary at the time of service.
Submission of a non-par, non-assigned Medicare Physician Fee Schedule (MPFS) service with a charge in
excess of the Medicare limiting charge amount constitutes a violation of the limiting charge. A physician or
supplier who violates the limiting charge is subject to a civil monetary penalty of not more than $10,000, an
assessment of not more than 3 times the amount claimed for each item or service, and possible exclusion from
the Medicare program. Therefore, it is crucial that EPs are provided with the correct limiting charge they may
bill for a MPFS service.
Your MAC will list and display the limiting charge amount after applying the EHR and PQRS negative
adjustment on their website. Speciﬁcally, they will add the following to their website:
• EHR Limiting Charge;
• PQRS Limiting Charge;
• EHR/2014 eRx Limiting Charge;
• EHR + PQRS Limiting Charge; and
• EHR/2014 eRx + PQRS Limiting Charge.
Examples Non-Par Non-Assigned Claim No EHR/PQRS Adjustment: Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
Adjustment Total $5.00
MPFS Allowed Amount $100-$5.00= $95.00
Limiting Charge Allowed= $95.00 x 115%= $109.25
Non-Par Non-Assigned Claim with EHR Adjustment:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12
2/2015
1% EHR negative adjustment $.95 (95 x.01)
Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
Limiting Charge Allowed= $94.05 x 115%= $108.16
Non-Par Non-Assigned Claim with PQRS Adjustment:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1.5% PQRS negative adjustment $1.43 (95 x.015)
Adjustment Total $ 6.43
MPFS Allowed Amount $100-$6.43= $93.57
Limiting Charge Allowed= $93.57 x 115%= $107.61
Non-Par Non-Assigned Claim with EHR + e-prescribing:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x.02)
Adjustment Total $ 6.90
MPFS Allowed Amount $100-$6.90= $93.10
Limiting Charge Allowed= $93.10 x 115%= $107.07
Non-Par Non-Assigned Claim with EHR without 2014 e-Prescribing Adjustment + PQRS:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1% EHR negative adjustment $.95 (95 x .01)
EHR Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
1.5% PQRS negative adjustment $1.41 ($94.05 x .015)
PQRS Adjustment Total $94.05-$1.41=$92.64
MPFS Allowed Amount $92.64
Limiting Charge Allowed= $92.64 x 115%= $106.54
Non-Par Non-Assigned Claim with EHR with 2014 e-Prescribing Adjustment + PQRS:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x .02)
EHR Adjustment Total $6.90
MPFS Allowed Amount $100-$6.90= $93.10
1.5% PQRS negative adjustment $1.40 (93.10 x .015)
PQRS Adjustment Total $93.10-$1.40=$91.70
MPFS Allowed Amount $91.70
Limiting Charge Allowed= $91.70 x 115%= $105.46
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
13
2/2015
Additional Information
Information about the EHR Incentive Programs is available at
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html on the Centers
for Medicare & Medicaid Services (CMS) website.
Information about “Physician Quality Reporting System (PQRS) Payment Adjustment Information” is available
at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment
Adjustment-Information.html on the CMS website.
The ofﬁcial instruction, CR 8667, issued to your MAC regarding this change, may be viewed at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1384OTN.pdf on the
CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14
2/2015
Opting out of Medicare and/or Electing to Order and Certify Items and Services to Medicare Beneﬁciaries
MLN Matters® Number: SE1311
Revised Related Change Request (CR) #: Not applicable
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Note: This article was revised on January 14, 2015, to add clarifying language, on the “opt-out” process and
requirements, especially in regards to the deﬁnition of “opt-out.” All other information is unchanged.
Provider Types Affected
This MLN Matters® Special Edition is intended for physicians and non-physician practitioners who opt out of
Medicare and/or elect to order and refer services to Medicare beneﬁciaries and who would otherwise submit
claims to Medicare contractors (carriers and Medicare Administrative Contractors (A/B MACs) for services
to Medicare beneﬁciaries.
What You Need to Know
This MLN Matters® Special Edition Article informs physicians and non-physician practitioners who wish to
opt-out of Medicare of the need to provide certain information in a written Afﬁdavit to their Medicare contractor
(Medicare Carrier or Medicare Administrative Contractor (MAC)). Make sure that your billing staffs are aware
of this information.
Background
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare.
This means that neither the physician, nor the beneﬁciary submits the bill to Medicare for services rendered.
Instead, the beneﬁciary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private
contract is signed between the physician and the beneﬁciary that states, that neither one can receive payment
from Medicare for the services that were performed. The physician or practitioner must submit an afﬁdavit
to Medicare expressing his/her decision to opt-out of the program. The following shows physicians and other
practitioners who are permitted by statute to opt-out of the Medicare program:
• Physicians who are:
• Doctors of medicine or osteopathy;
• Doctors of dental surgery or dental medicine;
• Doctors of podiatry; or
• Doctors of optometry; and
• Who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State
in which such function or action is performed.
Practitioners who are:
• Physician assistants;
• Nurse practitioners;
• Clinical nurse specialists;
• Certiﬁed registered nurse anesthetists;
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
15
2/2015
•
•
•
•
•
Certiﬁed nurse midwives;
Clinical psychologists;
Clinical social workers; or
Registered dietitians or nutrition professionals; and
Legally authorized to practice by the State and otherwise meet Medicare requirements.
Filing an Afﬁdavit to Opt-out
Physicians and non-physician practitioners who want to opt-out must ﬁle a written afﬁdavit with Medicare in
which they agree to opt-out of Medicare for a period of two years and to meet certain other criteria.
• In general, the law requires that during that 2-year period of time, physicians and non-physician practitioners
who have ﬁled afﬁdavits opting out of Medicare must sign private contracts with all Medicare beneﬁciaries
to whom they furnish services that would otherwise be covered by Medicare, except those who are in need
of emergency or urgently needed care.
• They cannot sign such contracts with beneﬁciaries in need of emergency or urgent care services.
• Moreover, physicians and non-physician practitioners who opt-out cannot choose to opt-out of Medicare
for some Medicare beneﬁciaries but not others; or for some services and not others.
• Opt out afﬁdavits are only valid for 2 years, after which the physician or practitioner may renew an opt out
without interruption by ﬁling an afﬁdavit with each Medicare contractor who has jurisdiction over claims
the physician/practitioner would otherwise ﬁle with Medicare, provided the afﬁdavits are ﬁled within 30
days after the current opt-out period expires.
The Centers for Medicare & Medicaid Services (CMS) does not have a standard afﬁdavit form, however,
many MACs have a form available on their website. To locate your MAC’s website, refer to http://www.cms.
gov/Medicare/Provider-Enrollment-and-Certiﬁcation/MedicareProviderSupEnroll/Downloads/contact_list.
pdf on the CMS website. Otherwise, those physicians and practitioners who wish to opt-out must provide the
information mentioned in writing to the MAC within their service jurisdiction. Currently there is not an option
to submit an opt-out afﬁdavit online.
• The afﬁdavit must be in writing and signed by the physician/non-physician practitioner.
• It must include various statements to which the physician/non-physician practitioner must agree; for example,
the physician/non-physician practitioner must agree not to submit claims to Medicare for any services
furnished during the opt-out period, except for emergency or urgent care services furnished to beneﬁciaries
with whom the physician/non-physician practitioner has not previously entered into a private contract.
• It must identify the physician/non-physician practitioner sufﬁciently so that the Medicare contractor can
ensure that no payment is made to the physician/non-physician practitioner during the opt-out period.
• It must be ﬁled with all Medicare contractors who have jurisdiction over the claims the physician/non
physician practitioner would have otherwise ﬁled with Medicare and must be ﬁled no later than 10 days
after entering into the ﬁrst private contract to which the afﬁdavit applies.
The following speciﬁc information must be included in the afﬁdavit:
• The physician/non-physician practitioner’s legal name;
• Medicare specialty;
• T
axpayer Identiﬁcation Number (TIN) (Social Security Number (SSN)) (required if a National Payer
Identiﬁer (NPI) has not been assigned);
• Address (If the address in the afﬁdavit is a P.O. Box, the Medicare contractor may request a different address);
• Telephone number;
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16 2/2015
• Medicare Billing ID/Provider Transaction Number (PTAN) (if the provider was previously enrolled and
one had been assigned); and
• NPI (only if one has been assigned).
Physicians/non-physician practitioners who have never enrolled in Medicare are not required to enroll in
Medicare before they can opt-out of Medicare.
A nonparticipating physician or practitioner may opt-out of Medicare at any time and the effective date of the
afﬁdavit record must comply with the following:
• The 2-year opt-out period begins the date the afﬁdavit is signed, provided the afﬁdavit is ﬁled within 10
days after he or she signs his or her ﬁrst private contract with a Medicare beneﬁciary.
• Physicians or practitioners that opt out in multiple contractor jurisdictions are required to ﬁle a separate
afﬁdavit with each contractor. If the physician or practitioner does not timely ﬁle all required afﬁdavits,
the 2-year opt-out period begins when the last such afﬁdavit is ﬁled. Any private contract entered into
before the last required afﬁdavit is ﬁled becomes effective upon the ﬁling of the last required afﬁdavit. The
furnishing of any items or services to a Medicare beneﬁciary under such contract before the last required
afﬁdavit is ﬁled is subject to standard Medicare rules.
If the physician or non-physician practitioner had been enrolled in Medicare and had signed a Part B participation
agreement and is now opting out, the participation agreement terminates at the same time the enrollment
terminates. If an enrolled physician/non-physician practitioner is opting out, the existing enrollment record
will be automatically end dated. The effective date of the opt-out afﬁdavit shall comply with the following:
• A participating physician may properly opt-out of Medicare at the beginning of any calendar quarter,
provided that the afﬁdavit is submitted to the participating physician’s Medicare contractor at least 30 days
before the beginning of the selected calendar quarter.
• A private contract entered into before the beginning of the selected calendar quarter becomes effective at
the beginning of the selected calendar quarter and the furnishing of any items or services to a Medicare
beneﬁciary under such contract before the beginning of the selected calendar quarter is subject to standard
Medicare rules.
Opt-Out Providers Who May Order and Certify Items and Services
There are differences between providers who are permitted to opt-out and providers who opt-out and elect to
order and certify items and services. The following physicians and non-physician practitioners are permitted
to order and certify:
• Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor
of podiatric medicine, doctor of optometry, optometrists may only order and certify DMEPOS products/
services and laboratory and X-Ray services payable under Medicare Part B);
• Physician Assistants;
• Clinical Nurse Specialists;
• Nurse Practitioners;
• Clinical Psychologists;
• Interns, Residents, and Fellows;
• Certiﬁed Nurse Midwives; and
• Clinical Social Workers.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17 2/2015
CMS emphasizes that generally Medicare will only reimburse for speciﬁc items or services when those items
or services are ordered or certiﬁed by providers or suppliers authorized by Medicare statute and regulation to
do so. The denial will be based on the fact that neither statute nor regulation allows coverage of certain services
when ordered or certiﬁed by the identiﬁed supplier or provider specialty.
CMS would like to highlight the following limitations: Chiropractors are not eligible to order supplies or services for Medicare beneﬁciaries. All services ordered by a chiropractor will be denied. • Home Health Agency (HHA) services may only be ordered or certiﬁed by a Doctor of Medicine (M.D.),
Doctor of Osteopathy (D.O.), or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered
by any other practitioner specialty will be denied.
• Optometrists may only order and certify DMEPOS products/services, and laboratory and X-Ray services
payable under Medicare Part B.
• Residents who have provisional licenses from the State and are permitted to enroll in Medicare are also
eligible to opt-out of Medicare. However, the opted out resident may only furnish under private contracts
the types of services that he or she is speciﬁcally authorized to furnish under State law at the direction of
his or her teaching institution. Although the opt-out option is available, CMS encourages licensed residents
to enroll via the CMS-855O since their employment arrangement could change and the opt-out status lasts
for two years and cannot be terminated within that timeframe.
If an opt-out provider elects to order and certify services, Medicare contractors must develop for the following
information through an additional information request:
• An NPI (if one is not contained on the afﬁdavit voluntarily);
• Conﬁrmation if an Ofﬁce of Inspector General (OIG) exclusion exists (if not contained on the Afﬁdavit);
• Date of Birth; and
• Social Security Number (if not contained on the Afﬁdavit).
If the above information is not obtained, the opt-out provider will not be able to order and certify services.
If the opt-out provider refuses to report the information listed immediately above, then the opt-out provider
cannot order and certify, but the failure to report this additional information does not affect the provider’s right
to opt out of Medicare.
The Medicare contractor must ask the opt-out physician or non-physician practitioner if he or she has been
excluded by the OIG and may speciﬁcally ask for a copy of the private contract he or she uses in order to
ascertain whether he or she has been excluded from the Medicare program.
Additional Information
You may want to review MLN Matters® Article MM8100, entitled “Effect of Beneﬁciary Agreements Not to
Use Medicare Coverage and When Payment May be Made to a Beneﬁciary for Service of an Opt-Out Physician/
Practitioner,” which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
MLN/MLNMattersArticles/Downloads/mm8100.pdf on the CMS website.
The ofﬁcial Medicare requirements for opting out are in the Chapter 15, Section 40, of the “Medicare Beneﬁt
Policy Manual” and that section is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf n the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18 2/2015
Continued Use of Modiﬁer 59 after January 1, 2015
MLN Matters® Number: SE1503
Related Change Request (CR) #: CR 8863
Related CR Release Date: N/A
Effective Date: January 1, 2015
Related CR Transmittal #: N/A
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) and Durable Medical Equipment (DME) MACs for services provided to
Medicare beneﬁciaries.
What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) implemented Change Request (CR) 8863 on January
5, 2015, effective January 1, 2015. This CR established four (4) new HCPCS modiﬁers (XE, XP, XS, XU)
to deﬁne speciﬁc subsets of the -59 CPT modiﬁer, a modiﬁer used to deﬁne a “Distinct Procedural Service”.
These modiﬁers are collectively referred to as –X {EPSU} HCPCS modiﬁers. Please note that providers may
continue to use the -59 CPT modiﬁer after January 1, 2015, in any instance in which it was correctly used
prior to January 1, 2015. The initial CR establishing the modiﬁers was designed to inform system developers
that healthcare systems would need to accommodate the new modiﬁers. Additional guidance and education
as to the appropriate use of the new –X {EPSU} HCPCS modiﬁers will be forthcoming as CMS continues to
introduce the modiﬁers in a gradual and controlled fashion. That guidance will include additional descriptive
information about the new modiﬁers. CMS will identify situations in which a speciﬁc –X {EPSU} HCPCS
modiﬁer will be required and will publish speciﬁc guidance before implementing edits or audits.
CR 8863 states that providers who wish to use the new modiﬁers may use them in accordance with their
published deﬁnitions, and the X modiﬁers will function within CMS systems in the same manner as the 59
modiﬁer, bypassing Procedure-to-Procedure (PTP) edits with a modiﬁer indicator of “1,” for example. A modiﬁer
indicator of “1” indicates that NCCI-associated modiﬁers may be used to bypass an edit under appropriate
circumstances.
Additional Information
CR 8863 is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf and a
related MLN Matters® article is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/MM8863.pdf on the CMS website.
Inquiries about CR 8863 (Speciﬁc Modiﬁers for Distinct Procedural Services) and any MLN Matters® article
associated with the new X Modiﬁers, should be sent to the following email address:
[email protected].
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19
2/2015
Modiﬁcations to Medicare Part B Coverage of Pneumococcal Vaccinations
MLN Matters® Number: MM9051
Related Change Request (CR) #: CR 9051
Related CR Release Date: December 31, 2014
Effective Date: September 19, 2014
Related CR Transmittal #: R202BP and Implementation Date: February 2, 2015 R3159CP
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 9051 provides an update to the Medicare pneumococcal vaccine coverage requirements,
to align with new Advisory Committee on Immunization Practices (ACIP) recommendations. Make sure your
billing staffs are aware of these updates.
Background
Medicare Part B covers certain vaccinations including pneumococcal vaccines. Speciﬁcally, Section 1861(s)
(10)(A) of the Social Security Act, which is available at
http://www.ssa.gov/OP_Home/ssact/title18/1861.htm, and regulations at 42 CFR 410.57
(http://www.ecfr.gov/cgi-bin/text-idx?SID=85dbd4cb66820b751ffe58a6c58988df&node=se42.2.410_157&
rgn=div8) authorize Medicare coverage under Part B for pneumococcal vaccine and its administration. For
services furnished on or after May 1, 1981, through September 18, 2014, the Medicare Part B program covered
pneumococcal pneumonia vaccine and its administration when furnished in compliance with any applicable
State law by any provider of services or any entity or individual with a supplier number. Coverage included an
initial vaccine administered only to persons at high risk of serious pneumococcal disease (including all people
65 and older; immunocompetent adults at increased risk of pneumococcal disease or its complications because
of chronic illness; and individuals with compromised immune systems), with revaccination administered only to
persons at highest risk of serious pneumococcal infection and those likely to have a rapid decline in pneumococcal
antibody levels, provided that at least 5 years had passed since the previous dose of pneumococcal vaccine.
However, ACIP updated its guidelines regarding pneumococcal vaccines; now recommending the administration
of two different pneumococcal vaccinations.
The Centers for Medicare & Medicaid Services (CMS) is updating the Medicare coverage requirements to
align with the updated ACIP recommendations. Effective for dates of service on or after September 19, 2014,
(and upon implementation of CR9051), Medicare will cover:
• An initial pneumococcal vaccine to all Medicare beneﬁciaries who have never received the vaccine under
Medicare Part B; and
• A different, second pneumococcal vaccine one year after the ﬁrst vaccine was administered (that is, 11
full months have passed following the month in which the last pneumococcal vaccine was administered).
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20 2/2015
Since the updated ACIP recommendations are speciﬁc to vaccine type and sequence of vaccination, prior
pneumococcal vaccination history should be taken into consideration. For example, if a beneﬁciary who is 65
years or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then
the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series
of the two recommended pneumococcal vaccinations. Receiving multiple vaccinations of the same vaccine
type is not generally recommended. Ideally, providers should readily have access to vaccination history, such
as with electronic health records, to ensure reasonable and necessary pneumococcal vaccinations.
Medicare does not require that a doctor of medicine or osteopathy order the vaccine; therefore, the beneﬁciary
may receive the vaccine upon request without a physician’s order and without physician supervision.
Note that MACs will not search for and adjust any claims for pneumococcal vaccines and their administration,
with dates of service on and after September 19, 2014. However, they may adjust such claims that you bring
to their attention.
Additional Information
The ofﬁcial instruction, CR9051 issued to your MAC includes two transmittals. The ﬁrst updates the
“Medicare Beneﬁt Policy Manual,” Chapter 15 (Covered Medical and Other Health Services), Section 50.4.4.2
(Immunizations) and “Medicare Claims Processing Manual,” Chapter 18 (Preventive and Screening Services),
Section 10.1.1 (Pneumococcal Vaccine) as attachments to that transmittal. It is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R202BP.pdf on the CMS
website. The second transmittal updates the “Medicare Claims Processing Manual” and that transmittal is
available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3159CP.pdf
on the CMS website.
The Centers for Disease Control and Prevention (CDC) recommends that providers use two pneumococcal
vaccines for adults aged =65. These vaccinations are 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and
23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23). For more information on these recommendations,
visit http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm on the CDC website.
If you have questions, please contact your DME MAC at their toll-free number. The number is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.
html under - How Does It Work?
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21
2/2015
Registration Reminder for DMEPOS Competitive Bidding: Round 2 Recompete & National Mail-Order Recompete CMS would like to remind all suppliers that registration is now open for those interested in participating in the
Round 2 Recompete and/or the national mail-order recompete of the Medicare Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. In order to submit a bid(s) for
the Round 2 Recompete and/or the national mail-order recompete, you must ﬁrst register in the Individuals
Authorized Access to CMS Computer Services (IACS) online application. Once you have registered in IACS,
you will receive a user ID and password to access the online DMEPOS Bidding System (DBidS). You must
register even if you registered during a previous round of competition (Round 1 Recompete, Round 2, or the
national mail-order competition). Only suppliers who have a user ID and password will be able to access
DBidS; suppliers that do not register will not be able to submit a bid.
If you are a supplier interested in bidding, you must designate one individual listed as an authorized ofﬁcial
(AO) on your organization’s CMS-855S enrollment application in the Provider Enrollment, Chain, and
Ownership System (PECOS) to act as your AO for registration purposes. After an AO successfully registers,
other individuals listed as an AO on the CMS-855S in PECOS may register as backup authorized ofﬁcials
(BAOs).The AO must approve a BAO’s request to register. The AO and BAOs can designate other individuals
not listed as an AO on the CMS-855S in PECOS to serve as end users (EUs).BAOs and EUs must also register
for a user ID and password in IACS in order to access DBidS. The name and Social Security number of the AO
and BAO entered in IACS must match exactly with what is recorded on the CMS-855S and on ﬁle in PECOS
to register successfully. Bidders are prohibited from sharing user IDs and passwords.
CMS strongly urges all AOs to register no later than January 6, 2015, to ensure that BAOs and EUs have time
to register. We recommend that BAOs register no later than January 20, 2015, so that they will be able to assist
AOs with approving EU registration before bidding begins on January 22, 2015.
Registration extends into the bidding period and will close on Tuesday, February 17, 2015 at 9pm prevailing
ET– no AOs, BAOs, or EUs can register after registration closes. Bidding will close on Wednesday, March
25, 2015.
To register, go to the Competitive Bidding Implementation Contractor (CBIC) website, www.dmecompetitivebid.
com, click on Round 2 & National Mail-Order Recompete, and then click on “Registration is Open” above the
Registration clock. CMS strongly recommends that you:
• Review the IACS Reference Guide at http://www.dmecompetitivebid.com/Palmetto/Cbicrd2Recompete.
Nsf/ﬁles/R2RC_IACS_Reference_Guide.pdf/$File/R2RC_IACS_Reference_Guide.pdf ,
• Watch the short and very helpful instructional video, “How to Register to Submit a Bid,”
on your computer, tablet, or phone at http://www.dmecompetitivebid.com/palmetto/
cbicrd2recompete.nsf/docsCat/Round%202%20Recompete~Bidding%20Suppliers~Instructional%20
Videos?open&expand=1&navmenu=Bidding%5eSuppliers||, and
• Use the IACS: Getting Started Registration Checklist at http://www.dmecompetitivebid.com/Palmetto/
Cbicrd2Recompete.Nsf/ﬁles/23_IACS_Getting_Started_Registration_Checklist.pdf/$File/23_IACS_
Getting_Started_Registration_Checklist.pdf.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22 2/2015
CMS would also like to remind you to:
• Review and update your enrollment records. Suppliers must maintain accurate information on their CMS
855S enrollment application with the National Supplier Clearinghouse (NSC) and in PECOS. It is important
to note that if your record is not current at the time of registration, you may experience delays and/or be
unable to register and bid. We will also validate your bid data against your enrollment record in PECOS
during bid evaluation. If it is not current or accurate, your bid(s) may be disqualiﬁed.
• Get licensed. Supplier locations must be licensed as applicable by the state in which it furnishes, or will
furnish, products and services under the DMEPOS Competitive Bidding Program.
• Get accredited. Supplier locations must be accredited by a CMS-approved accrediting organization for
the products and services it furnishes, or will furnish, under the DMEPOS Competitive Bidding Program.
The CBIC is the ofﬁcial information source for bidders. All suppliers interested in bidding are urged to sign
up for E-mail Updates on the home page of the CBIC website. For information about the Round 2 Recompete
and the national mail-order recompete, please refer to the bidder education materials located under Round 2
& National Mail-Order Recompete > Bidding Suppliers on this website. The CBIC participates in numerous
educational events to assist stakeholders in understanding the rules that govern the DMEPOS Competitive
Bidding Program. Visit the CBIC website for a listing and schedule of educational events under the Educational
Information section of the Round 2 & National Mail-Order Recompete page.
In addition to viewing the information on the CBIC website, suppliers are encouraged to call the CBIC customer
service center toll-free, at 877-577-5331, with their questions. During registration and bidding periods, the
customer service center will be open from 9 am to 9 pm ET.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23 2/2015
2015 Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List
MLN Matters® Number: MM 9018
Related Change Request (CR) #: CR 9018
Related CR Release Date: December 12, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3148CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers submitting claims to Durable Medical
Equipment Medicare Administrative Contractors (DME MACs) and Medicare Administrative Contractors
(MACs) for DMEPOS services provided to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 9018 notiﬁes suppliers that the spreadsheet containing an updated list of Healthcare
Common Procedure Coding System (HCPCS) codes for DME MAC or MAC jurisdictions is updated annually
to reﬂect codes that have been added or discontinued (deleted) each year. Changes in Chapter 23, Section 20.3
of the “Medicare Claims Processing Manual” are reﬂected in the recurring update notiﬁcation.
The spreadsheet for the 2015 DMEPOS Jurisdiction List is an Excel® spreadsheet and is available under the
Coding Category at http://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html
on the Centers for Medicare & Medicaid Services (CMS) website. The spreadsheet is also attached to CR9018.
Additional Information
The ofﬁcial instruction for CR9018 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3148CP.pdf on the CMS
website.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
24
2/2015
2015 DMEPOS Jurisdiction List
NOTE: Deleted codes are valid for dates of service on or before the date of deletion.
NOTE: Updated codes are in bold.
NOTE: The jurisdiction list includes codes that are not payable by Medicare. Please consult the Medicare contractor in whose
jurisdiction a claim would be ﬁled in order to determine coverage under Medicare.
HCPCS
A0021 - A0999
A4206 - A4209
A4210
A4211
A4212
A4213 - A4215
A4216 - A4218
A4220
DESCRIPTION
Ambulance Services
Medical, Surgical, and SelfAdministered Injection Supplies
Needle Free Injection Device
Medical, Surgical, and SelfAdministered Injection Supplies
Non Coring Needle or Stylet with or
without Catheter
Medical , Surgical, and SelfAdministered Injection Supplies
A4261
A4262 - A4263
A4264
Saline
Reﬁll Kit for Implantable Pump
Medical, Surgical, and SelfAdministered Injection Supplies
Diabetic Supplies
Cervical Cap for Contraceptive
Use
Lacrimal Duct Implants
Contraceptive Implant
A4265
A4266 - A4269
A4270
A4280
A4281 - A4286
A4290
A4300 - A4301
Parafﬁn
Contraceptives
Endoscope Sheath
Accessory for Breast Prosthesis
Accessory for Breast Pump
Sacral Nerve Stimulation Test Lead
Implantable Catheter
A4305 - A4306
Disposable Drug Delivery System
A4310 - A4358
Incontinence Supplies/ Urinary
Supplies
A4360 - A4435
Urinary Supplies
A4221 - A4250
A4252 - A4259
JURISDICTION
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
Local Carrier
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier
Local Carrier
DME MAC
DME MAC
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
If provided in the physician’s ofﬁce for a temporary condition, the
item is incident to the physician’s service & billed to the Local
Carrier. If provided in the physician’s ofﬁce or other place of
service for a permanent condition, the item is a prosthetic device &
billed to the DME MAC.
If provided in the physician’s ofﬁce for a temporary condition, the
item is incident to the physician’s service & billed to the Local
Carrier. If provided in the physician’s ofﬁce or other place of
service for a permanent condition, the item is a prosthetic device &
billed to the DME MAC.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
25
2/2015
A4450 - A4456
A4458-A4459
Tape; Adhesive Remover
Enema Bag/System
A4461-A4463
Surgical Dressing Holders
Non-elastic Binder and Elastic
Garment
Gravlee Jet Washer
Vabra Aspirator
A4465 - A4466
A4470
A4480
A4481
A4483
A4490 - A4510
A4520
A4550
A4554
A4555 - A4558
A4559
A4561 - A4562
A4565
A4570
A4575
A4580 - A4590
A4595
Tracheostomy Supply
Moisture Exchanger
Surgical Stockings
Diapers
Surgical Trays
Disposable Underpads
Electrodes; Lead Wires; Con
ductive Paste
Coupling Gel
Pessary
Sling
Splint
Topical Hyperbaric Oxygen Chamber,
Disposable
Casting Supplies & Material
A4611 - A4613
TENS Supplies
Sleeve for Intermittent Limb
Compression Device
Lithium Replacement Batteries
Tubing for Positive Airway Pressure
Device
Tracheal Suction Catheter
Oxygen Probe for Oximeter
Transtracheal Oxygen Catheter
Oxygen Equipment Batteries and
Supplies
A4614
Peak Flow Rate Meter
A4615 - A4629
A4630 - A4640
A4641 - A4642
A4648
Oxygen & Tracheostomy Supplies
DME Supplies
Imaging Agent; Contrast Material
Tissue Marker, Implanted
A4600
A4601-A4602
A4604
A4605
A4606
A4608
Local Carrier if incident to a physician’s service (not separately
payable), or if supply for implanted prosthetic device. If other,
DME MAC.
DME MAC
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier if incident to a physician’s service
(not separately payable). If other, DME MAC.
Local Carrier
Local Carrier
Local Carrier
DME MAC
Local Carrier
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable). If other, DME MAC.
DME MAC
Local Carrier
Local Carrier
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
26
2/2015
A4649
A4650
A4651 - A4932
Miscellaneous Surgical Supplies
Implantable Radiation Dosimeter
Supplies for ESRD
A5051 - A5093
Additional Ostomy Supplies
A5102 - A5200
A5500 - A5513
A6000
Additional Incontinence and Ostomy
Supplies
Therapeutic Shoes
Non-Contact Wound Warming Cover
A6010-A6024
Surgical Dressing
A6025
Silicone Gel Sheet
A6154 - A6411
Surgical Dressing
A6412
A6413
Eye Patch
Adhesive Bandage
A6441 - A6512
A6513
A6530 - A6549
Surgical Dressings
Compression Burn Mask
Compression Gradient Stockings
Supplies for Negative Pressure Wound
Therapy Electrical Pump
Accessories for Suction Pumps
Accessories for Nebulizers, Aspirators
and Ventilators
Chest Drainage Supplies
Respiratory Accessories
Vacuum Drainage Supply
Tracheostomy Supplies
Protective Helmets
Non-Prescription Drugs
A6550
A7000 - A7002
A7003 - A7039
A7040 - A7041
A7044 - A7047
A7048
A7501-A7527
A8000-A8004
A9150
Local Carrier if incident to a physician’s service (not separately
payable), or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier
DME MAC (not separately payable)
If provided in the physician’s ofﬁce for a temporary condition, the
item is incident to the physician’s service & billed to the Local
Carrier. If provided in the physician’s ofﬁce or other place of
service for a permanent condition, the item is a prosthetic device &
billed to the DME MAC.
If provided in the physician’s ofﬁce for a temporary condition, the
item is incident to the physician’s service & billed to the Local
Carrier. If provided in the physician’s ofﬁce or other place of
service for a permanent condition, the item is a prosthetic device &
billed to the DME MAC.
DME MAC
DME MAC
Local Carrier if incident to a physician’s service (not separately
payable) or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable) or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable) or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable) or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable) or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
Local Carrier if incident to a physician’s service (not separately
payable), or if supply for implanted prosthetic device or implanted
DME. If other, DME MAC.
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier
DME MAC
DME MAC
Local Carrier
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
27
2/2015
A9152 - A9153
A9155
A9180
A9270
A9272
A9273
A9274 - A9278
A9279
A9280
A9281
A9282
A9283
A9284
A9300
A9500 - A9700
A9900
A9901
A9999
B4034 - B9999
D0120 - D9999
E0100 - E0105
E0110 - E0118
E0130 - E0159
E0160 - E0175
E0181 - E0199
E0200 - E0239
E0240 - E0248
E0249
E0250 - E0304
E0305 - E0326
E0328 - E0329
E0350 - E0352
E0370
E0371 - E0373
E0424 - E0484
E0485 - E0486
E0487
E0500
E0550 - E0585
Vitamins
Artiﬁcial Saliva
Lice Infestation Treatment
Noncovered Items or Services
Disposable Wound Suction Pump
Hot Water Bottles, Ice Caps or Collars,
and Heat and/or Cold Wraps
Glucose Monitoring
Monitoring Feature/Device
Alarm Device
Reaching/Grabbing Device
Wig
Foot Off Loading Device
Non-electric Spirometer
Exercise Equipment
Supplies for Radiology Procedures
Miscellaneous DME Supply or
Accessory
Delivery
Miscellaneous DME Supply or
Accessory
Enteral and Parenteral Therapy
Dental Procedures
Canes
Crutches
Walkers
Commodes
Decubitus Care Equipment
Heat/Cold Applications
Bath and Toilet Aids
Pad for Heating Unit
Hospital Beds
Hospital Bed Accessories
Pediatric Hospital Beds
Electronic Bowel Irrigation System
Heel Pad
Decubitus Care Equipment
Oxygen and Related Respiratory
Equipment
Oral Device to Reduce Airway
Collapsibility
Electric Spirometer
IPPB Machine
Compressors/Nebulizers
Local Carrier
Local Carrier
Local Carrier
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier
Local Carrier if used with implanted DME. If other, DME MAC.
DME MAC
Local Carrier if used with implanted DME. If other, DME MAC.
DME MAC
Local Carrier
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
28
2/2015
E0600
E0601
E0602 - E0604
E0605
E0606
E0607
E0610 - E0615
E0616
E0617
E0618 - E0619
E0620
E0621 - E0636
E0637 - E0642
E0650 - E0676
E0691 - E0694
E0700
E0705
E0710
E0720 - E0745
E0746
E0747 - E0748
E0749
E0755- E0770
E0776
E0779 - E0780
E0781
E0782 - E0783
E0784
E0785 - E0786
E0791
E0830
E0840 - E0900
E0910 - E0930
E0935 - E0936
E0940
E0941
E0942 - E0945
E0946 - E0948
E0950 - E1298
E1300 - E1310
E1352 - E1392
Suction Pump
CPAP Device
Breast Pump
Vaporizer
Drainage Board
Home Blood Glucose Monitor
Pacemaker Monitor
Implantable Cardiac Event Recorder
External Deﬁbrillator
Apnea Monitor
Skin Piercing Device
Patient Lifts
Standing Devices/Lifts
Pneumatic Compressor and Appliances
Ultraviolet Light Therapy Systems
Safety Equipment
Transfer Board
Restraints
Electrical Nerve Stimulators
EMG Device
Osteogenic Stimulators
Implantable Osteogenic Stimulators
Stimulation Devices
IV Pole
External Infusion Pumps
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier
DME MAC
DME MAC
DME MAC
Billable to both the local carrier and the DME MAC. This item
may be billed to the DME MAC whenever the infusion is initiated
in the physician’s ofﬁce but the patient does not return during the
Ambulatory Infusion Pump
same business day.
Infusion Pumps, Implantable
Local Carrier
Infusion Pumps, Insulin
DME MAC
Implantable Infusion Pump Catheter
Local Carrier
Parenteral Infusion Pump
DME MAC
Ambulatory Traction Device
DME MAC
Traction Equipment
DME MAC
Trapeze/Fracture Frame
DME MAC
Passive Motion Exercise Device
DME MAC
Trapeze Equipment
DME MAC
Traction Equipment
DME MAC
Orthopedic Devices
DME MAC
Fracture Frame
DME MAC
Wheelchairs
DME MAC
Whirlpool Equipment
DME MAC
Additional Oxygen Related Equipment DME MAC
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
29
2/2015
E1399
E1405 - E1406
E2402
E2500 - E2599
E2601 - E2633
E8000 - E8002
G0008 - G0329
G0333
G0337 - G0365
G0372
G0378 - G9472
Miscellaneous DME
Additional Oxygen Equipment
Artiﬁcial Kidney Machines and
Accessories
TMJ Device and Supplies
Dynamic Flexion Devices
Communication Board
Gastric Suction Pump
Blood Glucose Monitors with Special
Features
Pulse Generator for Tympanic
Treatment of Inner Ear
Wheelchair Accessories
Negative Pressure Wound Therapy
Pump
Speech Generating Device
Wheelchair Cushions and Accessories
Gait Trainers
Misc. Professional Services
Dispensing Fee
Misc. Professional Services
Misc. Professional Services
Misc. Professional Services
J0120 - J3570
J3590
Injection
Unclassiﬁed Biologicals
J7030 - J7131
J7178
J7180 - J7195
J7196 - J7197
J7198
J7199 - J7201
J7300 - J7307
J7308 - J7309
J7310
J7311 - J7316
J7321 - J7327
J7330
J7336
Miscellaneous Drugs and Solutions
Fibrinogen
Antihemophilic Factor
Antithrombin III
Anti-inhibitor; per I.U.
Other Hemophilia Clotting Factors
Contraceptives
Aminolevulinic Acid HCL
Ganciclovir, Long-Acting Implant
Ophthalmic Drugs
Hyaluronan
Autologous Cultured Chondrocytes,
Implant
Capsaicin
J7500 - J7599
Immunosuppressive Drugs
J7604 - J7699
Inhalation Solutions
E1500 - E1699
E1700 - E1702
E1800 - E1841
E1902
E2000
E2100 - E2101
E2120
E2201 - E2397
Local Carrier if implanted DME. If other, DME MAC.
DME MAC
DME MAC (not separately payable)
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service or used in an
implanted infusion pump. If other, DME MAC.
Local Carrier
Local Carrier if incident to a physician’s service or used in an
implanted infusion pump. If other, DME MAC.
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service or used in an
implanted infusion pump. If other, DME MAC.
Local Carrier if incident to a physician’s service. If other, DME
MAC.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
30
2/2015
J7799
J8498
J8499
J8501 - J8999
J9000 - J9999
K0001 - K0108
K0195
K0455
K0462
K0552
K0601 - K0605
K0606 - K0609
K0669
K0672
K0730
K0733
K0738
K0739
K0740
K0743 - K0746
K0800 - K0899
K0900
K0901-K0902
L0112 - L4631
L5000 - L5999
L6000 - L7499
L7510 - L7520
L7600
L7900-L7902
L8000 - L8485
L8499
L8500 - L8501
L8505
L8507
L8509
L8510
NOC, Other than Inhalation Drugs
through DME
Anti-emetic Drug
Prescription Drug, Oral, Non
Chemotherapeutic
Oral Anti-Cancer Drugs
Chemotherapy Drugs
Wheelchairs
Elevating Leg Rests
Infusion Pump used for Uninterrupted
Administration of Epoprostenal
Loaner Equipment
External Infusion Pump Supplies
External Infusion Pump Batteries
Deﬁbrillator Accessories
Wheelchair Cushion
Soft Interface for Orthosis
Inhalation Drug Delivery System
Power Wheelchair Accessory
Oxygen Equipment
Repair or Nonroutine Service for DME
Repair or Nonroutine Service for
Oxygen Equipment
Suction Pump and Dressings
Power Mobility Devices
Custom DME, other than Wheelchair
Knee Orthoses
Orthotics
Lower Limb Prosthetics
Upper Limb Prosthetics
Repair of Prosthetic Device
Prosthetic Donning Sleeve
Vacuum Erection System
Prosthetics
Unlisted Procedure for Miscellaneous
Prosthetic Services
Artiﬁcial Larynx; Tracheostomy
Speaking Valve
Artiﬁcial Larynx Accessory
Voice Prosthesis, Patient Inserted
Voice Prosthesis, Inserted by a
Licensed Health Care Provider
Voice Prosthesis
Local carrier if incident to a physician’s service. If other, DME
MAC.
DME MAC
Local carrier if incident to a physician’s service. If other, DME
MAC.
DME MAC
Local Carrier if incident to a physician’s service or used in an
implanted infusion pump. If other, DME MAC.
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier if implanted DME. If other, DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
DME MAC
Local Carrier if repair of implanted prosthetic device. If other,
DME MAC.
DME MAC
DME MAC
DME MAC
Local Carrier if implanted prosthetic device. If other, DME MAC.
DME MAC
DME MAC
DME MAC
Local Carrier for dates of service on or after 10/01/2010. DME
MAC for dates of service prior to 10/01/2010
DME MAC
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
31
2/2015
L8511 - L8515
L8600 - L8699
L9900
M0075 - M0301
P2028 - P9615
Q0035
Q0081
Q0083 - Q0085
Q0091
Q0092
Q0111 - Q0115
Q0138-Q0139
Q0144
Q0161 - Q0181
Q0478 - Q0509
Q0510 - Q0514
Q0515
Q1004 - Q1005
Q2004
Q2009
Q2017
Q2026-Q2028
Q2034 - Q2039
Q2043
Q2049-Q2050
Q3001
Q3014
Q3027 - Q3028
Q3031
Q4001 - Q4051
Q4074
Q4081
Q4082
Q4100 - Q4160
Q5001 - Q5010
Q9951 - Q9954
Q9955 - Q9957
Q9958 - Q9969
Voice Prosthesis
Prosthetic Implants
Miscellaneous Orthotic or Prosthetic
Component or Accessory
Medical Services
Laboratory Tests
Inﬂuenza Vaccine; Cardio
kymography
Infusion Therapy
Chemotherapy Administration
Smear Preparation
Portable X-ray Setup
Miscellaneous Lab Services
Ferumoxytol Injection
Local Carrier if used with tracheoesophageal voice prostheses
inserted by a licensed health care provider. If other, DME MAC
Local Carrier
Local Carrier if used with implanted prosthetic device. If other,
DME MAC.
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier
Local Carrier if incident to a physician’s service. If other, DME
Azithromycin Dihydrate
MAC.
Anti-emetic
DME MAC
Ventricular Assist Devices
Local Carrier
Drug Dispensing Fees
DME MAC
Sermorelin Acetate
Local Carrier
New Technology IOL
Local Carrier
Irrigation Solution
Local Carrier
Fosphenytoin
Local Carrier
Teniposide
Local Carrier
Injectable Dermal Fillers
Local Carrier
Inﬂuenza Vaccine
Local Carrier
Sipuleucel-T
Local Carrier
Local Carrier if incident to a physician’s service or used in an
Doxorubicin
implanted infusion pump. If other, DME MAC.
Supplies for Radiology Procedures
Local Carrier
Telehealth Originating Site Facility Fee Local Carrier
Vaccines
Local Carrier
Collagen Skin Test
Local Carrier
Splints and Casts
Local Carrier
Local Carrier if incident to a physician’s service. If other, DME
Inhalation Drug
MAC.
Epoetin
Local Carrier
Drug Subject to Competitive
Acquisition Program
Local Carrier
Skin Substitutes
Local Carrier
Hospice Services
Local Carrier
Imaging Agents
Local Carrier
Microspheres
Local Carrier
Imaging Agents
Local Carrier
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
32
2/2015
R0070 - R0076
V2020 - V2025
V2100 - V2513
Diagnostic Radiology Services
Frames
Lenses
V2520 - V2523
V2530 - V2531
Hydrophilic Contact Lenses
Contact Lenses, Scleral
V2599
V2600 - V2615
V2623 - V2629
V2630 - V2632
V2700 - V2780
V2781
V2782 - V2784
V2785
V2786
V2787 - V2788
V2790
V2797
V2799
V5008 - V5299
Contact Lens, Other Type
Low Vision Aids
Prosthetic Eyes
Intraocular Lenses
Miscellaneous Vision Service
Progressive Lens
Lenses
Processing--Corneal Tissue
Lens
Intraocular Lenses
Amniotic Membrane
Vision Supply
Miscellaneous Vision Service
Hearing Services
Repair/Modiﬁcation of Augmentative
Communicative System or Device
Speech Screening
V5336
V5362 - V5364
Local Carrier
DME MAC
DME MAC
Local Carrier if incident to a physician’s service. If other, DME
MAC.
DME MAC
Local Carrier if incident to a physician’s service. If other, DME
MAC.
DME MAC
DME MAC
Local Carrier
DME MAC
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier
Local Carrier
DME MAC
DME MAC
Local Carrier
DME MAC
Local Carrier
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
33
2/2015
Holding of 2015 Date-of-Service Claims and DMEPOS Competitive Bidding Registration Reminder
Holding of 2015 Date-of-Service Claims for Services Paid Under the 2015 Medicare Physician Fee Schedule
On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) ﬁnal rule was published in
the Federal Register. In order to implement corrections to technical errors discovered after publication of the
MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015
services paid under the MPFS for the ﬁrst 14 calendar days of January 2015 (i.e., Thursday January 1 through
Wednesday January 14). The hold should have minimal impact on provider cash ﬂow as, under current law, clean
electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.
MPFS claims for services rendered on or before Wednesday Dec 31, 2014 are unaffected by the 2015 claims
hold and will be processed and paid under normal procedures and time frames.
Registration Reminder for DMEPOS Competitive Bidding: Round 2 Recompete & National Mail-Order
Recompete
CMS would like to remind all suppliers that registration is now open for those interested in participating in the
Round 2 Recompete and/or the national mail-order recompete of the Medicare Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. In order to submit a bid(s) for
the Round 2 Recompete and/or the national mail-order recompete, you must ﬁrst register in the Individuals
Authorized Access to CMS Computer Services (IACS) online application. Once you have registered in IACS,
you will receive a user ID and password to access the online DMEPOS Bidding System (DBidS). You must
register even if you registered during a previous round of competition (Round 1 Recompete, Round 2, or the
national mail-order competition). Only suppliers who have a user ID and password will be able to access
DBidS; suppliers that do not register will not be able to submit a bid.
If you are a supplier interested in bidding, you must designate one individual listed as an authorized ofﬁcial
(AO) on your organization’s CMS-855S enrollment application in the Provider Enrollment, Chain, and
Ownership System (PECOS) to act as your AO for registration purposes. After an AO successfully registers,
other individuals listed as an AO on the CMS-855S in PECOS may register as backup authorized ofﬁcials
(BAOs).The AO must approve a BAO’s request to register. The AO and BAOs can designate other individuals
not listed as an AO on the CMS-855S in PECOS to serve as end users (EUs).BAOs and EUs must also register
for a user ID and password in IACS in order to access DBidS. The name and Social Security number of the AO
and BAO entered in IACS must match exactly with what is recorded on the CMS-855S and on ﬁle in PECOS
to register successfully. Bidders are prohibited from sharing user IDs and passwords.
CMS strongly urges all AOs to register no later than January 6, 2015, to ensure that BAOs and EUs have time
to register. We recommend that BAOs register no later than January 20, 2015, so that they will be able to assist
AOs with approving EU registration before bidding begins on January 22, 2015.
Registration extends into the bidding period and will close on Tuesday, February 17, 2015 at 9pm prevailing
ET– no AOs, BAOs, or EUs can register after registration closes. Bidding will close on Wednesday, March
25, 2015.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
34
2/2015
To register, go to the Competitive Bidding Implementation Contractor (CBIC) website at
http://www.dmecompetitivebid.com, click on Round 2 & National Mail-Order Recompete, and then click on
“Registration is Open” above the Registration clock. CMS strongly recommends that you:
• Review the IACS Reference Guide: http://www.dmecompetitivebid.com/Palmetto/Cbicrd2Recompete.Nsf/
ﬁles/R2RC_IACS_Reference_Guide.pdf/$File/R2RC_IACS_Reference_Guide.pdf
• Watch the short and very helpful instructional video (http://www.dmecompetitivebid.com/palmetto/
cbicrd2recompete.nsf/docsCat/Round%202%20Recompete~Bidding%20Suppliers~Instructional%20
Videos?open&expand=1&navmenu=Bidding%5eSuppliers||), “How to Register to Submit a Bid,” on your
computer, tablet, or phone, and
• Use the IACS: Getting Started Registration Checklist: http://www.dmecompetitivebid.com/Palmetto/
Cbicrd2Recompete.Nsf/ﬁles/23_IACS_Getting_Started_Registration_Checklist.pdf/$File/23_IACS_
Getting_Started_Registration_Checklist.pdf
CMS would also like to remind you to:
• Review and update your enrollment records. Suppliers must maintain accurate information on their CMS
855S enrollment application with the National Supplier Clearinghouse (NSC) and in PECOS. It is important
to note that if your record is not current at the time of registration, you may experience delays and/or be
unable to register and bid. We will also validate your bid data against your enrollment record in PECOS
during bid evaluation. If it is not current or accurate, your bid(s) may be disqualiﬁed.
• Get licensed. Supplier locations must be licensed as applicable by the state in which it furnishes, or will
furnish, products and services under the DMEPOS Competitive Bidding Program.
• Get accredited. Supplier locations must be accredited by a CMS-approved accrediting organization for
the products and services it furnishes, or will furnish, under the DMEPOS Competitive Bidding Program.
The CBIC is the ofﬁcial information source for bidders. All suppliers interested in bidding are urged to sign
up for E-mail Updates on the home page of the CBIC website. For information about the Round 2 Recompete
and the national mail-order recompete, please refer to the bidder education materials located under Round 2
& National Mail-Order Recompete > Bidding Suppliers on this website. The CBIC participates in numerous
educational events to assist stakeholders in understanding the rules that govern the DMEPOS Competitive
Bidding Program. Visit the CBIC website for a listing and schedule of educational events under the Educational
Information section of the Round 2 & National Mail-Order Recompete page.
In addition to viewing the information on the CBIC website, suppliers are encouraged to call the CBIC customer
service center toll-free, at 877-577-5331, with their questions. During registration and bidding periods, the
customer service center will be open from 9 am to 9 pm ET.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
35 2/2015
Educational Events Now Available…Don’t Miss this
Wonderful Opportunity!
Join the Provider Outreach and Education event listed below to learn about the Medicare program.
Event Title
Date/Time
Access
J11 Part B CPT
Modiﬁer 59 and the
X{EPSU} Modiﬁers
February 12, 866-745-0425
2015, 10 a.m. Code: 13820150
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
36
2/2015
Remittance Advice Remark and Claims Adjustment Reason
Code and Medicare Remit Easy Print and PC Print Update
MLN Matters® Number: MM9004
Related Change Request (CR) #: CR 9004
Related CR Release Date: January 9, 2015
Effective Date: April 1, 2015
Related CR Transmittal #: R3161CP
Implementation Date: April 6, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 9004 updates the Claim Adjustment Reason Code (CARC) and Remittance Advice
Remark Code (RARC) lists that are effective April 1, 2015. The CR instructs Medicare system maintainers
to update Medicare Remit Easy Print (MREP) and PC Print. Make sure that your billing staffs are aware of
these changes for 2015 and that they obtain the updated MREP or PC Print software if they use that software.
Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, instructs health plans to be able to
conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states
that CARCs and appropriate RARCs that provide either supplemental explanation for a monetary adjustment
or policy information that generally applies to the monetary adjustment are required in the remittance advice
and coordination of beneﬁts transactions.
The CARC and RARC changes that affect Medicare are usually requested by the Centers for Medicare &
Medicaid Services (CMS) staff in conjunction with a policy change. Medicare contractors and Shared System
Maintainers (SSMs) are notiﬁed about these changes in the corresponding instructions from the speciﬁc
CMS component that implements the policy change, in addition to the regular code update notiﬁcation. If a
modiﬁcation has been initiated by an entity other than CMS for a code currently used by Medicare, MACs
must either use the modiﬁed code or another code if the modiﬁcation makes the modiﬁed code inappropriate
to explain the speciﬁc reason for adjustment.
SSMs have the responsibility to implement code deactivation making sure that any deactivated code is not
used in original business messages, but the deactivated code in derivative messages is allowed. SSMs must
make sure that Medicare does not report any deactivated code on or before the effective date for deactivation
as posted on the on Washington Publishing Company (WPC) website. If any new or modiﬁed code has an
effective date past the implementation date speciﬁed in CR9004, MACs will implement on the date speciﬁed
on the WPC website. The WPC website is available at http://www.wpc-edi.com/Reference on the Internet.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
37
2/2015
CR9004 lists only the changes that have been approved since the last code update CR (CR8855, Transmittal
2996, issued on July 25, 2014, with a related MLN Matters® article available at http://www.cms.gov/Outreach
and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8855.pdf), and does
not provide a complete list of codes for these two code sets.
The complete list for both CARC and RARC from the WPC website is updated three times a year – around
March 1, July 1, and November 1. The WPC website, which has four listings available for both CARC and
RARC, is available at http://www.wpc-edi.com/Reference on the Internet
Changes in CARC List since CR8855
These are changes in the CARC database since the last code update in CR8855.
New Codes – CARC:
New Code Current Narrative
262
Adjustment for delivery cost. Note: To be used for pharmaceuticals
only.
263
Adjustment for shipping cost. Note: To be used for pharmaceuticals
only.
264
Adjustment for postage cost. Note: To be used for pharmaceuticals only.
265
Adjustment for administrative cost. Note: To be used for
pharmaceuticals only.
266
Adjustment for compound preparation cost. Note: To be used for
pharmaceuticals only.
267
Claim spans multiple months. Rebill separate claim/service.
268
Claim spans 2 calendar years. Please resubmit one claim per calendar
year.
Effective Date
11/1/2014
11/1/2014
11/1/2014
11/1/2014
11/1/2014
11/1/2014
11/1/2014
Modiﬁed Codes – CARC:
Code
Modiﬁed Narrative
Effective Date
133
The disposition of the claim/service is pending further review. (Use
11/1/2014
only with Group Code OA). This change effective 11/01/2014: The
disposition of this service line is pending further review. (Use only
with Group Code OA). NOTE: Use of this code requires a reversal and
correction when the service line is ﬁnalized (use only in Loop 2110
CAS segment of the 835 or Loop 2430 of the 837).
201
Patient is responsible for amount of this claim/service through ‘set
11/1/2014
aside arrangement’ or other agreement. (Use only with Group Code
PR) At least one Remark Code must be provided (may be comprised of
either the NCPDP Reject Reason Code, or Remittance Advice Remark
Code that is not an ALERT.)
Deactivated Codes – CARC –None
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
38
2/2015
Changes in RARC List since CR8855
These are changes in the RARC database since the last code update CR 8855.
New Codes – RARC:
Code
Narrative
N729
Missing patient medical/dental record for this service.
N730
Incomplete/invalid patient medical/dental record for this service.
N731
Incomplete/Invalid mental health assessment.
N732
Services performed at an unlicensed facility are not reimbursable.
N733
Regulatory surcharges are paid directly to the state.
N734
The patient is eligible for these medical services only when unable to
work or perform normal activities due to an illness or injury.
Modiﬁed Codes – RARC:
Code
Modiﬁed Narrative
N42
Missing mental health assessment.
MA118
Alert: No Medicare payment issued for this claim for services or
supplies furnished to a Medicare-eligible veteran through a facility of
the Department of Veterans Affairs. Coinsurance and/or deductible are
applicable.
MA09
Claim submitted as unassigned but processed as assigned in accordance
with our current assignment/participation agreement.
N483
Missing Periodontal Charts
N484
Incomplete/invalid Periodontal Charts.
Deactivated Codes – RARC
Code
Modiﬁed Narrative
N483
Missing Periodontal Charts
N484
Incomplete/invalid Periodontal Charts.
Effective Date
11/1/2014
11/1/2014
11/1/2014
11/1/2014
11/1/2014
11/1/2014
Effective Date
11/1/2014
11/1/2014
11/1/2014
05/01/2015
5/1/2015
Effective Date
05/01/2015
5/1/2015
NOTE: In case of any discrepancy in the code text as posted on WPC website and as reported in any CR, the
WPC version should be implemented.
Additional Information
The ofﬁcial instruction, CR9004, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3161CP.pdf on the
CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
39
2/2015
Emergency Update to the Calendar Year (CY) 2015 Medicare Physician Fee Schedule Database (MPFSDB)
MLN Matters® Number: MM9081
Related Change Request (CR) #: CR 9081
Related CR Release Date: January 16, 2015
Effective Date: January 1, 2015
Related CR Transmittal #: R3166CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneﬁciaries.
Provider Action Needed
This article is based on Change Request (CR) 9081, to announce an emergency update to payment ﬁles issued
to contractors based on the CY 2015 MPFS Final Rule. CR9081 amends those payment ﬁles, including an
updated conversion factor of $35.7547 for services furnished between January 1, 2015, and March 31, 2015,
consistent with the Protecting Access to Medicare Act of 2014 that provides for a zero percent update from
CY 2014 rates. Make sure that your billing staffs are aware of these changes.
Background
Payment ﬁles were issued to contractors based upon the CY 2015 MPFS Final Rule, displayed on October 31,
2014 (and published in the Federal Register on November 13, 2014). CR9081 amends those payment ﬁles in
order to correct technical errors to the MPFS update ﬁles, including an updated conversion factor of $35.7547
for services furnished between January 1, 2015, and March 31, 2015, consistent with the Protecting Access to
Medicare Act of 2014 that provides for a zero percent update from the CY 2014 rate.
In preparing the CY 2015 ﬁnal rates, errors were made in work, practice expense and malpractice RVUs. In
correcting these errors and making adjustments to reﬂect the policies in the CY 2015 ﬁnal rule with comment
period, relativity adjustments were required across the fee schedule, and the conversion factor was adjusted
from that published in the ﬁnal rule. The amended payment ﬁles reﬂect all these changes and a conversion
factor of $35.7547 for services furnished on or after January 1, 2015, and on or before March 31, 2015.
Under current law, a new conversion factor will be required for services furnished on or after April 1, 2015.
These ﬁles will be provided with the April quarterly update.
Additional Information
The ofﬁcial instruction, CR9081, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3166CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
40
2/2015
Summary of Policies in the Calendar Year (CY) 2015 Medicare Physician Fee Schedule (MPFS) Final Rule and Telehealth Originating Site Facility Fee Payment Amount MLN Matters® Number: MM9034
Related Change Request (CR) #: CR 9034
Related CR Release Date: December 24, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3157CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers who submit claims to Medicare
Administrative Contractors (MACs) for services provided to
Medicare beneﬁciaries.
Provider Action Needed
This article is based on Change Request (CR) 9034 which provides a summary of the policies in the CY 2015
MPFS Final Rule and announces the Telehealth Originating
Site Facility Fee payment amount. Make sure
that your billing staff are aware of these updates for 2015.
Background
The Social Security Act (Section 1848(b)(1); (see http://www.ssa.gov/OP_Home/ssact/title18/1848.htm on
the Internet) requires the Centers for Medicare & Medicaid Services (CMS) to establish a fee schedule of
payment amounts for physicians’ services for the subsequent year. CMS issued a ﬁnal rule with comment
period on October 13, 2014 (see https://www.federalregister.gov/articles/2014/11/13 on the Internet), that
updates payment policies and Medicare payment rates for services furnished by physicians and non-physician
practitioners (NPPs) that are paid under the MPFS in CY 2015.
The ﬁnal rule also addresses public comments on Medicare payment policies that were described in the proposed
rule earlier this year: “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule,
Clinical Laboratory Fee Schedule, Access to Identiﬁable Data for the Center for Medicare & Medicaid Innovation
Models & Other Revisions to Part B for CY 2015; Proposed Rule” was published in the Federal Register on
July 11, 2014. (See http://www.gpo.gov/fdsys/pkg/FR-2014-07-11/pdf/2014-15948.pdf on the Internet).
The ﬁnal rule also addresses interim ﬁnal values established in the CY
2014 MPFS ﬁnal rule with comment period. (See
http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28737.pdf on
the Internet). The ﬁnal rule assigns interim ﬁnal values for new, revised,
and potentially misvalued codes for CY 2015 and requests comments
on these values. CMS will accept comments on those items open to
comment in the ﬁnal rule with comment period until December 30, 2014.
Sustainable Growth Rate (SGR)
The Protecting Access to Medicare Act of 2014 (see
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
41
2/2015
http://www.gpo.gov/fdsys/pkg/BILLS-113hr4302enr/pdf/BILLS-113hr4302enr.pdf on the Internet) provides
for a zero percent update from the CY 2014 rates for services furnished between January 1, 2015, and March
31, 2015. Adjusting by .06 percent to achieve required budget neutrality, the conversion factor for this period
is $35.8013.
Under current law, the conversion factor will be adjusted on April 1, 2015. In the ﬁnal rule CMS announced
a conversion factor of $28.2239 for this period, resulting in an average reduction of 21.2 percent from the CY
2014 rates. In most prior years, Congress has taken action to avert large across-the-board reductions in PFS
rates before they went into effect. The Administration supports legislation to permanently change SGR to
provide more stability for Medicare beneﬁciaries and providers while promoting efﬁcient, high quality care.
Screening and Diagnostic Digital Mammography
To ensure that the higher resources needed for 3D mammography are recognized, Medicare will pay for 3D
mammography using add-on codes that will be reported in addition to the 2D mammography codes when 3D
mammography is furnished. See MLN Matters® Article MM8874 for more information.
Primary Care and Chronic Care Management
Medicare continues to emphasize primary care by making payment for chronic care
management (CCM)
services -- non-face-to-face services to Medicare beneﬁciaries who have two or more chronic conditions
-- beginning January 1, 2015. CCM services include regular development and revision of a plan of care,
communication with other treating health professionals, and medication management. CCM can be billed once
per month per qualiﬁed beneﬁciary, provided the minimum level of services is furnished.
CMS is ﬁnalizing its proposal to allow greater ﬂexibility in the supervision of clinical staff providing CCM
services. The proposed application of the “incident to” supervision rules was widely supported by the
commenters.
Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare beneﬁciaries’ access
to primary care. Models being tested through the Innovation Center will continue to explore other primary
care innovations.
Finally, CMS will require that in order to bill CCM, a practitioner must use a certiﬁed electronic health record
(EHR) that meets the requirements for the EHR Incentive Program as of December 31 of the prior calendar year.
Application of Beneﬁciary Cost Sharing To Anesthesia Related To Screening Colonoscopies
The Medicare statute waives the Part B deductible and coinsurance applicable to screening colonoscopy. In the
CY 2015 ﬁnal rule, CMS revised the deﬁnition of a “screening colonoscopy” to include separately provided
anesthesia as part of the screening service so that the coinsurance and deductible do not apply to anesthesia for
a screening colonoscopy, reducing beneﬁciaries’ cost-sharing obligations under Part B. For more information,
review MLN Matters® Article MM8874 on the CMS website.
Enhanced Transparency in Setting PFS Rates
Since the beginning of the physician fee schedule in 1992, CMS adopted rates for new and revised codes for
the following calendar year in the ﬁnal rule on an interim basis subject to public comment. This policy was
necessary because CMS did not receive the codes in time to include in the PFS proposed rule. Until recently,
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
42
2/2015
the only services that were affected by this policy were services with new and revised codes. In recent years,
CMS began receiving new and revised codes and revaluing existing services under the misvalued codes
initiative. Establishing payment in the ﬁnal rule for misvalued codes often led to implementation of payment
reductions before the public had the opportunity to comment.CMS ﬁnalized its proposal to change the process
for valuing new, revised and potentially misvalued codes for CY 2016, so that payment for the vast majority
of these codes goes through notice and comment rulemaking prior to being adopted. After a transition in CY
2016, the process will be fully implemented in CY 2017.
Potentially Misvalued Services
Consistent with amendments to the Affordable Care Act (see
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf on the Internet), CMS has been
engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes,
and to make adjustments where appropriate.
The following are major misvalued code decisions for 2015:
• Radiation Therapy and Gastroenterology: Consistent with the ﬁnal rule policy and in response to public
comments, CMS is not adopting the CPT coding changes for CY 2015 for gastroenterology and radiation
therapy services so that CMS can propose and obtain comments on the revised coding prior to using them
for payment. As a result, CMS will not recognize some new CPT codes, and created G-codes in place of
changed and new CPT codes.
• CMS proposed to reﬁne the way it accounts for the infrastructure costs associated with radiation therapy
equipment, speciﬁcally to remove the radiation treatment vault as a direct expense when valuing radiation
therapy services. After considering public comments, CMS did not ﬁnalize this proposal.
• Radiation Treatment Vault: CMS reduced payment for these services in 2014 under the misvalued code
initiative. In response to concerns from pain physicians regarding the accuracy of the valuation, CMS
proposed to raise the values in 2015 based on their prior resource inputs before adopting further changes
after considering RUC recommendations. However, because the inputs for these services included those
related to image guidance, CMS also proposed to prohibit separate billing for image guidance for CY 2015.
CMS ﬁnalized the policy as proposed to avoid duplicate payment for image guidance. CMS has asked the
RUC to further review this issue and make recommendations to us on how to value epidural pain injections.
• Epidural Pain InjectionsFilm to Digital Substitution: CMS ﬁnalized its proposal to update the practice
expense inputs for X-ray services to reﬂect that X-rays are currently done digitally rather than with analog
ﬁlm.
Global Surgery
The U.S. Department of Health and Human Services (HHS), Ofﬁce of Inspector General (OIG) has identiﬁed
a number of surgical procedures that include more visits in the global period than are being furnished. CMS is
also concerned that post-surgical visits are valued higher than visits that were furnished and billed separately
by other physicians such as general internists or family physicians.
CMS ﬁnalized a proposal to transform all 10- day and 90-day globals to 0-day globals, beginning with 10-day
global services in CY 2017 and following with the 90-day global services in 2018. As CMS revalues these
services as 0-day global periods, CMS will actively assess whether there is a better construction of a bundled
payment for surgical services that incentivizes care coordination and care redesign across an episode of care.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
43 2/2015
Access to Telehealth Services
CMS is adding the following services to the list of services that can be furnished to Medicare beneﬁciaries
under the telehealth beneﬁt:
• Annual wellness visits,
• Psychoanalysis,
• Psychotherapy, and
• Prolonged evaluation and management services.
For the list of telehealth services, visit: http://www.cms.gov/Medicare/Medicare-General-Information/
Telehealth/index.html on the CMS website.
Telehealth Origination Site Facility Fee Payment Amount Update
The Social Security Act (Section 1834(m)(2)(B) (see http://www.ssa.gov/OP_Home/ssact/title18/1834.htm)
establishes the payment amount for the Medicare telehealth originating site facility fee for telehealth services
provided from October 1, 2001, through December 31 2002, at $20.
For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating
site facility fee is increased by the percentage increase in the Medicare Economic Index (MEI) as deﬁned in
the Social Security Act (Section 1842(i)(3) (see http://www.ssa.gov/OP_Home/ssact/title18/1842.htm on the
Internet).
The MEI increase for 2015 is 0.8 percent. Therefore, for CY 2015, the payment amount for HCPCS code
Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge, or $24.83. (The
beneﬁciary is responsible for any unmet deductible amount and Medicare coinsurance.)
Revisions to Malpractice Relative Value Units (RVUs)
As required by the Medicare law, CMS conducted a ﬁve-year review and updated the resource-based malpractice
RVUs based on updated professional liability insurance premiums, largely paralleling the methodology used
in the CY 2010 update. The ﬁnal rule indicated that anesthesia RVUs will be updated in CY 2016.
Revisions to Geographic Practice Cost Indices (GPCIs)
As required by the Medicare law, CMS adjusts payments under the PFS to reﬂect local differences in the cost
of operating a medical practice. For CY 2015, CMS is using territory-level wage data to calculate the work
GPCI and employee wage component of the PE GPCI for the Virgin Islands. The CY 2015 GPCIs also reﬂect
the application of the statutorily mandated of 1.5 work GPCI ﬂoor in Alaska, and 1.0 work GPCI ﬂoor for all
other physician fee schedule areas, and the 1.0 PE GPCI ﬂoor for frontier states (Montana, Nevada, North
Dakota, South Dakota, and Wyoming).
However, given that the statutory 1.0 work GPCI ﬂoor is scheduled to expire under current law on March 31,
2015, the GPCIs reﬂect the elimination of the 1.0 work GPCI ﬂoor from April 1, 2015, through December 31,
2015.
Services Performed in Off-campus Provider-Based Departments
CMS will collect data on services furnished in off-campus provider-based departments by requiring hospitals
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
44
2/2015
to report a modiﬁer for those services furnished in an off-campus provider-based department of the hospital
and by requiring physicians and other billing practitioners to report these services using a new place of service
code on professional claims.
Data collection will be voluntary for hospitals in 2015 and required beginning on January 1, 2016. The new place
of service codes will be used for professional claims as soon as it is available, but not before January 1, 2016.
Additional Information
The ofﬁcial instruction, CR 9034, issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3157CP.pdf on the CMS
website.
For more information about the EHR Program, go to
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html on the CMS
website.
The ﬁnal rule, published on November 13, 2014, is available at
http://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf on the Internet.
Medicare Physician Fee Lookup Tool
Use the Medicare Physician Fee Lookup Tool,
located on our home page. The new Physician Fee
Schedule tool saves our customers time and money by providing a ‘one stop shop’! Customers can locate fees
for the 2013 through 2015 throughout the United States. The tool can search up to ﬁve codes and each code
shows the allowance, all of the indicator rules such as the Global Surgery modiﬁers and Multiple Surgery rules.
This tool helps customers research more than a fee; they can determine if the wrong modiﬁer was appended
to a service, or if the service was subject to multiple surgery rules.
The fees and indicator ﬁles are downloadable and customers can easily save the data to their systems for future
use.The tool was implemented on October 6, 2014 and there were 5,761 visitors at the end of October!
Customers are saying...
• An excellent tool to ﬁnd all kinds of data relative to CPT codes without having to slog through the entire
database!
• I like the new look up tool. I liked the old look up tool on the CMS website but this one is nice and gives
everything you need to know about a code, all on one inquiry. Thanks.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
45 2/2015
Results from November ICD-10 Acknowledgement Testing Week
CMS conducted another successful acknowledgement testing week last month. Acknowledgement
testing gives providers and others the opportunity to submit claims with ICD-10 codes to the
Medicare Fee-For-service (FFS) claims systems and receive electronic acknowledgements
conﬁrming that their claims were accepted. While providers are welcome to submit acknowledgement test
claims anytime, during the November testing week, testers submitted almost 13,700 claims.
CMS conducted another successful acknowledgement testing week last month. Acknowledgement testing gives
providers and others the opportunity to submit claims with ICD-10 codes to the Medicare Fee-For-service
(FFS) claims systems and receive electronic acknowledgements conﬁrming that their claims were accepted.
While providers are welcome to submit acknowledgement test claims anytime, during the November testing
week, testers submitted almost 13,700 claims.
More than 500 providers, suppliers, billing companies, and clearinghouses participated in the testing week
last month. Testers included small and large physician practices, small and large hospitals, labs, ambulatory
surgical centers, dialysis facilities, home health providers, ambulance providers, and several other physician
specialties. Acceptance rates improved throughout the week with Friday’s acceptance rate for test claims at 87
percent. Nationally, CMS accepted 76 percent of total test claims. Testing did not identify any issues with the
Medicare FFS claims systems. This testing week allowed an opportunity for testers and CMS alike to learn
valuable lessons about ICD-10 claims processing.
To ensure a smooth transition to ICD-10, CMS veriﬁed all test claims had a valid diagnosis code that matched
the date of service, a National Provider Identiﬁer (NPI) that was valid for the submitter ID used for testing,
and an ICD-10 companion qualiﬁer code to allow for processing of claims. In many cases, testers intentionally
included errors in their claims to make sure that the claim would be rejected, a process often referred to as
“negative testing.” The majority of rejections on professional claims were common rejects related to an invalid
NPI. Some claims were rejected because they were submitted with future dates. Acknowledgement testing
cannot accept claims for future dates. Additionally, claims using ICD-10 must have an ICD-10 companion
qualiﬁer code. Claims that did not meet these requirements were rejected.
Mark your calendar for upcoming acknowledgement testing weeks on March 2-6, 2015 and June 1-5, 2015. In
addition to the special testing weeks, providers are welcome to submit acknowledgement test claims anytime
up to the October 1, 2015 implementation date. Contact your Medicare Administrative Contractor for more
information at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare
FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/index.html.
For more information:
• MLN Matters® Article MM8858, “ICD-10 Testing - Acknowledgement Testing with Providers” at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/MM8858.pdf
• MLN Matters® Special Edition Article SE1409, “Medicare FFS ICD-10 Testing Approach,” which also
includes information on opportunities for end-to-end testing with FFS Medicare at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
46 2/2015
International Classiﬁcation of Diseases, Tenth Revision (ICD-10) Limited End to End Testing with Submitters for 2015 MLN Matters® Number: MM8867
Related Change Request (CR) #: CR 8867
Related CR Release Date: January 20, 2015
Related CR Transmittal #: R1451OTN
EFFECTIVE DATES: September 12, 2014 - for MACs and CEDI (non-systems change requirements) (Note:
This is the due date of the ﬁrst MAC and CEDI requirement); January 26, 2015 - for FISS and CEDI coding
for January Testing Week; April 27, 2015 - for FISS and CEDI coding for April Testing Week; July 20, 2015
- for FISS and CEDI coding for July Testing Week.
IMPLEMENTATION DATES: January 5, 2015 - for FISS and CEDI coding for January Testing Week; February
16, 2015 - for MAC requirements for the January 15 testing. This is the due date of the last MAC deliverable.;
April 6, 2015 - for FISS and CEDI coding for April Testing Week; May 18, 2015 - for MAC requirements
for the April 15 testing. This is the due date of the last MAC deliverable.; July 6, 2015 - for FISS and CEDI
coding for July Testing Week; August 10, 2015 - for MAC requirements for the July 15 testing. This is the due
date of the last MAC deliverable.
Provider Types Affected
This MLN Matters® Article is intended for providers and clearinghouses wishing to submit test claims with
ICD-10 codes to Medicare Administrative Contractors (MACs).
What You Need to Know
Change Request (CR) 8867 directs MACs to test with a limited number of providers and clearinghouses to
ensure claims with ICD-10 codes can be processed from submission to remittance. This additional testing effort
will help ensure a successful transition to ICD-10.
The Centers for Medicare & Medicaid Services (CMS) deﬁnes successful end-to-end testing as being able to
demonstrate that:
• Testing entities are able to successfully submit ICD-10 claims to the shared systems,
• Software changes made to support ICD-10 result in appropriately adjudicated claims based on the pricing
data employed for testing purposes; and
• Remittance advices are produced.
Make sure your billing staffs are aware of this update.
Background
The International Classiﬁcation of Disease, Tenth Revision, (ICD-10) must be implemented by October 1,
2015. While system changes to implement this project have been completed and tested in previous releases,
the industry has requested the opportunity to test with CMS.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
47 2/2015
CR8867 will allow a small subset of submitters to test with MACs and the Common Electronic Data Interchanges
(CEDIs) in three testing periods to demonstrate to the industry that CMS systems are ready for the ICD-10
implementation. MACs and CEDI shall conduct three limited End-to-End testing weeks with a small subset
of submitters.
To facilitate this testing, CR8867 requires MACs to do the following:
• Conduct limited end-to-end testing with submitters in three testing periods; January 2015, April 2015 and
July 2015. Test claims will be submitted January 26 – 30, 2015, April 27 – May 1, 2015, and July 20 – 24,
2015.
• Each MAC (and CEDI with assistance from DME MACs) will select 50 submitters for each MAC Jurisdiction
supported to participate in the end-to-end testing. The Railroad Retirement Board (RRB) contractor will
also select 50 submitters. Testers will be selected randomly from a list of volunteers. At least ﬁve, but not
more than ﬁfteen of the testers will be a clearinghouse, and submitters should be a mix of provider types.
• MACs and CEDIs will post a volunteer form to their website to collect volunteer information with which
to select volunteers. o Form veriﬁes testers are ready to test, meet the requirements to test, and collect data
about the tester. (How they submit claims, what types of claims they will submit, and so forth.)
• MACs and CEDIs will post the form to their website by March 13, 2015, for the July 2015 testing.
• Volunteers must submit completed forms to the MACs and CEDIs by April 17, 2015, for the July 2015
testing.
• By May 8, 2015, for the July 2015 testing, the MACs and CEDIs (for the DME MACs) will notify the
volunteers that they have been selected to test and provide them with the information needed for the testing,
such as: o How to submit test claims (for example, what test indicators should be set);
• What dates of service may be used for testing; o How many claims may be submitted for testing (Test
claims volume is limited to a total of 50 claims for the entire testing week, submitted in no more than
three ﬁles);
• Request for National Provider Identiﬁers (NPIs) and Health Insurance Claim Numbers (HICNs) that
will be used in testing (no more than ﬁve NPIs and 10 HICNs per submitter);
• Notice that if more than 50 claims are submitted, they may not be processed;
• Notice that claims submitted with NPIs or HICNs not previously submitted for testing, likely will not
be completed; and
• Notice of potential Protected Health Information (PHI) on test remittances not submitted (and instructions
to report PHI found to the MAC).
• MACs and CEDIs (for the DME MACs) will collect information from the testers after they have been
notiﬁed of their selection, using a form provided by CMS. This form will speciﬁcally request the Health
Insurance Claim Numbers (HICNs), Provider Transaction Access Number (PTANs), and National Provider
Identiﬁers (NPIs) the tester will use during testing. Testers shall submit these forms back to the MAC/
CEDI by February 20, 2015, for the April 2015 testing, and by May 29, 2015, for the July 2015 testing.
Notiﬁcation will warn testers that if forms are not received timely, they may lose their opportunity to test.
• Testers selected in the January 2015 Testing may participate in the April 2015 testing, and may submit an
additional 50 test claims using the same HICNs and NPIs provided previously. MACs shall send a reminder
to the January 2015 testers of this option 30 days prior to the start of the April 2015 testing, using language
provided by CMS.
• Testers selected in the January 2015 and April 2015 Testing may participate in the July 2015 testing, and
may submit an additional 50 test claims using the same HICNs and NPIs provided previously. MACs shall
send a reminder to the January 2015 and April 2015 testers of this option 30 days prior to the start of the
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
48 2/2015
July 2015 testing, using language provided by CMS.
• MACs and CEDI will work with the testers selected to ensure they are prepared to test, and understand
the requirements for testing.
• MACs and CEDI will instruct the testers to submit up to a total of 50 test claims during the testing period.
This may be submitted in one to three ﬁles, but the total number of test claims cannot exceed 50.
• CEDI will instruct suppliers to submit claims with ICD-10 code with Dates of Service October 1, 2015,
through October 15, 2015. They may also submit claims with ICD-9 codes with Dates of Service before
October 1, 2015.
• MACs will instruct testers to submit test claims with ICD-10 code with Dates of Service on or after October
1, 2015. They may also submit test claims with ICD-9 codes with Dates of Service before October 1, 2015.
• MACs and CEDIs will be prepared to support increased call volume from testers during the testing window,
and up to 2 weeks following the receipt of the ERAs from testing.
• MACs and CEDIs will provide information to the testers on who to contact for testing questions. This may
be separate contacts for front end questions and remittance questions.
• MACs and CEDIs will post an announcement about the testing to their websites. The announcement will
be provided by CMS.
Additional Information
The ofﬁcial instruction, CR8867 issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1451OTN.pdf on
the CMS website.
You may also want to review MLN Matters® Article SE1409, which discusses ICD-10 testing. That
article is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/SE1409.pdf on the CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
49 2/2015
FAQs – International Classiﬁcation of Diseases,
10th Edition (ICD-10) End-to-End Testing
MLN Matters® Number: SE1435 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
Note: This article was revised on December 24, 2014, to add FAQs 6-8 on page 3 and the former FAQ 6 is
now FAQ 9. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition article is intended for all physicians, providers, suppliers, clearinghouses,
and billing agencies selected to participate in Medicare ICD-10 end-to-end testing.
Provider Action Needed
Physicians, providers, suppliers, clearinghouses, and billing agencies selected to participate in Medicare ICD
10 end-to-end testing should review the following questions and answers before preparing claims for ICD-10
end-to-end testing to gain an understanding of the guidelines and requirements for successful testing.
What to Know Prior to Testing
1. How is ICD-10 end-to-end testing different from acknowledgement testing?
The goal of acknowledgement testing is for testers to submit claims with ICD-10 codes to the Medicare Fee-ForService claims systems and receive acknowledgements to conﬁrm that their claims were accepted or rejected.
End-to-end testing takes that a step further, processing claims through all Medicare system edits to produce
and return an accurate Electronic Remittance Advice (ERA). While acknowledgement testing is open to all
electronic submitters, end-to-end testing is limited to a smaller sample of submitters who volunteer and are
selected for testing.
2. What constitutes a testing slot for this testing?
A testing slot is the ability to submit 50 claims to a particular Medicare Administrative Contractor (MAC) who
selected you for testing.
3. What data must I provide to the MAC before testing?
For each testing slot, you must provide the MAC: up to 2 submitter identiﬁers (IDs), up to 5 National Provider
Identiﬁers (NPIs)/Provider Transaction Access Numbers (PTANs), and up to 10 Health Insurance Claim
Numbers (HICNs). You may use these in any combination on the 50 claims. You will need to use the same
HICN on multiple claims. Therefore, you will need to consider this when designing a test plan, since claims
will be subject to standard utilization edits.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
50
2/2015
If you were selected to test with only one submitter ID but would like to choose a second one, you must contact
the MAC to add the second submitter ID. If the MAC is not aware of your preference to use a second submitter
ID, claims submitted with that ID may not be processed.
4. What should I consider when choosing HICNs for testing?
The MAC will copy production information into the test region for the HICNs that you provide. This includes
eligibility information, claims history, and other documentation such as Certiﬁcates of Medical Necessity
(CMNs). The HICNs you provide must be real beneﬁciaries and may not have a Date of Death on ﬁle. If you
previously submitted HICNs for beneﬁciaries who are deceased, contact the MAC as soon as possible with
replacement HICNs.
5. If I was selected for the January 2015 end-to-end testing, do I need to reapply for later testing rounds?
No, once you are selected for testing, you are automatically registered for the later rounds of testing.
6. Does this mean that no new submitters will be accepted for the April and July 2015 end-to-end testing
periods or will a new group of 850 testers be selected for both April and July?
A new group will be selected for each of the April and July 2015 testing periods, and these groups will be able
to test in addition to the already chosen testers. Therefore, the total number of potential testers will be 1,700
for April 2015 and 2,550 for July 2015.
7. Do you have information on who has been selected for the January 2015 end-to-end testing?
We will release this information as part of the public release of our January test results.
8. When do you expect to publically release results of the ﬁrst round of end-to-end testing?
We expect to publically release results of the ﬁrst round of end-to-end testing around the end of February 2015.
9. Can I submit additional NPIs, PTANs, and HICNs for the later rounds of testing?
Yes, while you do not need to re-apply for the later rounds of testing, you may choose to submit up to 2
additional submitter IDs, up to 5 additional NPIs/PTANs, and up to 10 additional HICNs. You may also still
use the information you submitted for the previous testing round. The MAC will provide the form you must
use to submit this new information, and the information must be received by the due date on the form to be
considered for the next round of testing.
What to Know During Testing
1. Is it safe to submit test claims with Protected Health Information (PHI)?
The test claims you submit are accepted into the system using the same secure method used for production
claims on a daily basis. They will be processed by the same MACs who process production claims, and all the
same security protocols will be followed. Therefore, using real data for this test does not cause any additional
risk of release of PHI.
2. What Dates of Service can be used on test claims?
Professional claims with an ICD-10 code must have a date of service on or after October 1, 2015.
Inpatient claims with an ICD-10 code must have a discharge date on or after October 1, 2015.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
51
2/2015
Supplier claims with an ICD-10 code must have a date of service between October 1, 2015, and October 15,
2015.
For professional and institutional claims, you may use dates up to December 31, 2015. You cannot use dates
in 2016 or beyond.
3. Can both ICD-9 and ICD-10 codes be submitted on the same claim?
ICD-9 and ICD-10 codes cannot be submitted on the same claim. For additional information on how to submit
claims that span the ICD-10 implementation date (when ICD-9 codes are effective for that portion of the services
rendered on September 30, 2015, and earlier, and when ICD-10 codes are effective for that portion of the
services rendered on October 1, 2015, and later), please refer to MLN Matters® Article SE1325, “Institutional
Services Split Claims Billing Instructions for Medicare Fee-For-Service (FFS) Claims that span the ICD-10
Implementation Date” located at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
MLN/MLNMattersArticles/Downloads/SE1325.pdf on the Centers for Medicare & Medicaid Services website.
4. Do Returned to Provider (RTP) claims count toward the 50 claims submitted? Can RTP’d claims be
re-submitted for testing?
Institutional claims that fail Return to Provider (RTP) editing count toward the 50 claim submission limit.
Claims that are RTP’d will not appear on the electronic remittance advice, and will not be available through
DDE. If claims accepted by the front end edits do not appear on the remittance advice, please contact the
Medicare Administrative Contractor (MAC) for further information.
Claims that are rejected by front end editing do not count toward the 50 claim submission limit; therefore, they
should be corrected and resubmitted.
5. If a Certiﬁcate of Medical Necessity (CMN) or DME Information Form (DIF) is required for a supplier
claim, do I need to submit a CMN during testing?
If the beneﬁciary has a valid CMN or DIF on ﬁle for that equipment/supply covered by the dates of service on
your test claim (after 10/1/2015), you do not need to submit a new CMN/DIF.
If the beneﬁciary’s CMN/DIF has expired for the dates of service on your test claim (after 10/1/2015), you
must submit a revised CMN/DIF to extend the end date for that CMN/DIF.
If the beneﬁciary does not have a CMN or DIF for that equipment/supply, you must submit a new CMN/DIF.
6. For Home Health claims, how should I submit the Request for Anticipated Payment (RAP) and ﬁnal
claim for testing?
Submit the RAP and ﬁnal claim in the same ﬁle and the system will allow them to process. The ﬁnal claim will
be held and recycle (as in normal processing) until the RAP ﬁnalizes. It will then be released to the Common
Working File (CWF). The RAP processing time will be short since the test beneﬁciaries are set up in advance.
To get your results more quickly, you may also want to consider billing Low Utilization Payment Adjustment
claims with four visits or less that do not require a RAP.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
52
2/2015
7. For Hospice claims, should I submit the Notice of Election (NOE) prior to testing?
You will not need to provide NOEs to the MAC prior to the start of testing. The MACs will set up NOEs for
any hospice claims received during testing.
8. For an Inpatient Rehabilitation Facility (IRF) or Skilled Nursing Facility (SNF) stay, can the CaseMix Group (CMG) or Resource Utilization Group (RUG) code be submitted on the claim even though
the date of service is in the future?
Yes, you can send the IRF claim with a valid CMG code on the claim and a SNF claim with a valid RUG
code on the claim, even though the date is in the future. For testing purposes, only a claim with a valid Health
Insurance Prospective Payment System (HIPPS) code will be required. You do not need to submit the supporting
data sheets.
Online Provider Services (OPS)
Eligibility
HETS requires you to enter beneﬁciary last name and HICN, in addition to
either the birth date or ﬁrst name. See options below:
•
•
•
HICN, Last Name, First Name, Birth Date
HICN, Last Name, Birth Date
HICN, Last Name, First Name
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
53
2/2015
FAQs – International Classiﬁcation of Diseases, 10th Edition (ICD-10) Acknowledgement Testing and End-to-End Testing MLN Matters® Number: SE1501
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
Provider Types Affected
This MLN Matters® Special Edition article is intended for all physicians, providers, suppliers, clearinghouses,
and billing agencies who participate in Medicare ICD-10 acknowledgement testing and who are selected to
participate in end-to-end testing.
Provider Action Needed
Physicians, providers, suppliers, clearinghouses, and billing agencies who participate in acknowledgement
testing and who are selected to participate in Medicare ICD-10 end-to-end testing should review the following
questions and answers before preparing claims for ICD-10 acknowledgement testing and end-to-end testing
to gain an understanding of the guidelines and requirements for successful testing. When “you” is used in this
publication, we are referring to ICD-10 acknowledgement testers or end-to-end testers.
Question
Do I need to register
for testing?
Acknowledgement Testing
No, you do not need to register for
acknowledgement testing.
End-to-End Testing
Yes, end-to-end testing volunteers
must register on their Medicare
Administrative Contractor (MAC)
website during speciﬁc time periods.
Who can participate
Acknowledgement testing is open to
End-to-end testing is open to:
in testing?
all Medicare Fee-For-Service (FFS)
 Medicare FFS direct submitters;
electronic submitters.
 Direct Data Entry (DDE) submitters
who receive an Electronic Remit
tance Advice (ERA);
 Clearinghouses; and . Billing agen
cies.
How many testers will All Medicare FFS electronic submitters 50 end-to-end testers will be selected
be selected?
can acknowledgement test.
per MAC jurisdiction for each testing
round. You must be selected by the
MAC for this testing.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
54
2/2015
Question
What will the testing
show?
Will the testing test
National Coverage
Determinations
(NCDs) and
Local Coverage
Determinations
(LCDs)?
Will the testing
conﬁrm payment and
return an ERA to the
tester?
Acknowledgement Testing
The goal of acknowledgement testing is
to demonstrate that:
 Providers and submitters can submit
claims with valid ICD-10 codes and
ICD-10 companion qualiﬁer codes;
 Providers submitted claims with
valid National Provider Identiﬁers
(NPIs)
 The claims are accepted by the
Medicare FFS claims systems; and
 Claims receive 277CA or 999 ac
knowledgement, as appropriate, to
conﬁrm that the claim was accepted
or rejected by Medicare.
No, acknowledgment testing will not
test NCDs and LCDs.
No, acknowledgement testing
will not conﬁrm payment. Test
claims will receive 277CA or 999
acknowledgement, as appropriate, to
conﬁrm that the claim was accepted or
rejected by Medicare.
How many claims can There is no limit on the number of
testers submit?
acknowledgement test claims you can
submit.
How do testers submit You submit acknowledgement
claims for testing?
test claims directly or through a
clearinghouse or billing agency with
test indicator “T” in the Interchange
Control Structure (ISA) 15 ﬁeld.
When should testers
You may submit acknowledgement
submit test claims?
test claims anytime. We encourage you
to test during the highlighted testing
weeks:
 March 2 – 6, 2015; and
 June 1 – 5, 2015.
End-to-End Testing
The goal of end-to-end testing is to
demonstrate that:
 Providers and submitters can suc
cessfully submit claims containing
ICD-10 codes to the Medicare FFS
claims systems;
 Software changes the Centers for
Medicare & Medicaid Services
(CMS) made to support ICD-10
result in appropriately adjudicated
claims; and
 Accurate Remittance Advices are
produced.
Yes, end-to-end test claims will be
subject to all NCDs and LCDs.
Yes, end-to-end testing will provide an
ERA based on current year pricing.
You may submit 50 end-to-end test
claims per test week.
You submit end-to-end test claims
directly with test indicator “T” in the
ISA15 ﬁeld or through DDE.
You must submit end-to-end test claims
during the following testing weeks:
 January 26 – 30, 2015;
 April 27 – May 1, 2015; and
 July 20 – 24, 2015.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
55
2/2015
Question
What dates of service
do testers use during
testing?
Acknowledgement Testing
You must use current dates of service
End-to-End Testing
You must use the following future dates
during acknowledgement testing. of
service during end-to-end testing:
 Professional claims – Dates of ser
vice on or after October 1, 2015;
 Inpatient claims – Discharge dates
on or after October 1, 2015;
 Supplier claims – Dates of service
between October 1, 2015, and Octo
ber 15, 2015; and
 Professional and institutional claims
– Dates up to December 31, 2015.
You cannot use dates in 2016 or beyond.
Important Note: Remember that you must be selected by the MAC in order to participate in end-to-end
testing.
Resources
The chart below provides ICD-10 resource information.
For More Information Resource
About…
ICD-10
http://www.cms.gov/Medicare/Coding/ICD10/index.html website on the CMS
ICD-10 Information
http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-For-Service
for Medicare Fee-ForProvider-Resources.html on the CMS website
Service Providers
ICD-10 Implementation http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTime.
Timelines
html on the CMS website
ICD-10 Statute and
http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html on the
Regulations
CMS website
All Available Medicare
“Medicare Learning Network® Catalog of Products” located on the CMS
Learning Network®
website at http://www.cms.gov/Outreach-and-Education/Medicare-Learning
(MLN) Products
Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf
Provider-Speciﬁc
MLN publication titled “MLN Guided Pathways: Provider Speciﬁc Medicare
Medicare Information
Resources” located at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_
Provider_Speciﬁc_Booklet.pdf on the CMS website
Medicare Information for http://www.medicare.gov on the CMS website
Patients
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
56
2/2015
Preventive and Screening Services - Update - Intensive
Behavioral Therapy for Obesity, Screening Digital
Tomosynthesis Mammography, and Anesthesia Associated
with Screening Colonoscopy
MLN Matters® Number: MM8874 Revised
Related Change Request (CR) #: CR 8874
Related CR Release Date: January 7, 2015
Effective Date: January 1, 2015
Related CR Transmittal #: R3160CP
Implementation Date: January 5, 2015
Note: This article was revised on January 8, 2015, to reﬂect the revised CR8874 issued on January 7. In the
article, the CR release date, transmittal number, and the Web address for accessing CR8874 are revised. All
other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for Medicare practitioners providing preventive and screening services
to Medicare beneﬁciaries and billing Medicare Administrative Contractors (MACs) for those services.
Provider Action Needed
Change Request (CR) 8874 is an update from the Centers for Medicare & Medicaid Services (CMS) to ensure
accurate program payment for three screening services. The coinsurance and deductible for these services are
currently waived, but due to coding changes and additions, the payments for Calendar Year (CY) 2015 would
not be accurate without updated CR8874 for intensive behavioral group therapy for obesity, digital breast
tomosynthesis, and anesthesia associated with screening colonoscopy. Make sure billing staffs are aware of
these updates.
Background
The following outlines the CMS updates:
Intensive Behavioral Therapy for Obesity
Intensive behavioral therapy for obesity
became a covered preventive service under
Medicare, effective November 29, 2011. It
is reported with HCPCS code G0447 (Face
to-face behavioral counseling for obesity, 15
minutes). Coverage requirements are in the
“Medicare National Coverage Determinations
(NCDs) Manual,” Chapter 1, Section 210.
To improve payment accuracy, in CY 2015
Physician Fee Schedule (PFS) Proposed
Rule, CMS created a new HCPCS code for
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
57
2/2015
the reporting and payment of behavioral group counseling for obesity -- HCPCS codes G0473 (Face-to-face
behavioral counseling for obesity, group (2-10), 30 minutes).
For coverage requirements of intensive behavioral therapy for obesity, see the NCD for Intensive Behavioral
Therapy for Obesity.
The same claims editing that applies to HCPCS code G0447 applies to HCPCS code G0473. Therefore, effective
for claims with dates of service on or after January 1, 2015, MACs will recognize HCPCS code G0473, but
only when billed with one of the ICD-9 codes for Body Mass Index (BMI) 30.0 and over (V85.30,-V85.39,
V85.41-V85.45). (Once ICD-10 is effective, the related ICD-10 codes are Z68.30-Z68.39 and Z68.41-Z68.45.)
When claims for HCPCS code G0473 are submitted without a required diagnosis code, they will be denied
using the following remittance codes:
• Claim Adjustment Reason Code (CARC) 167: 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.
• Remittance Advice Remarks Code (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.mcd.search.asp. If you do not have web access,
you may contact the contractor to request a copy of the NCD.
Effective for claims with dates of service on or after January 1, 2015, beneﬁciary coinsurance and deductible
do not apply to claim lines with HCPCS code G0473.
Note that Medicare pays claims with HCPCS code G0473 only when submitted by the following provider
specialty types as found on the provider’s Medicare enrollment record:
• 01 - General Practice
• 08 - Family Practice
• 11 - Internal Medicine
• 16 - Obstetrics/Gynecology
• 37 - Pediatric Medicine
• 38 - Geriatric Medicine
• 50 - Nurse Practitioner
• 89 - Certiﬁed Clinical Nurse Specialist
• 97 - Physician Assistant
Claim lines submitted with HCPCS code G0473, but without an appropriate provider specialty will be denied
with the following remittance codes:
• CARC 8: The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to
the 835 Healthcare Policy Identiﬁcation Segment (loop 2110 Service Payment Information REF), if present.
• RARC N95: This provider type/provider specialty may not bill this service.
• Group Code CO (if GZ HCPCS modiﬁer present) or PR (if HCPCS modiﬁer GA is present).
Further, effective for dates of service on or after January 1, 2015, claim lines with HCPCS code G0473 are
only payable for the following Places of Service (POS) codes:
• 11 - Physician’s Ofﬁce
• 22 - Outpatient Hospital
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
58 2/2015
• 49 - Independent Clinic
• 71 - State or local public health clinic
Claim lines for HCPCS code G0473 will be denied without an appropriate POS code using the following
remittance codes:
• CARC 5: The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835
Healthcare Policy Identiﬁcation Segment (loop 2110 Service Payment Information REF), if present.
• RARC M77: Missing/incomplete/invalid place of service.
• Group Code CO (if GZ HCPCS modiﬁer present) or PR (if HCPCS modiﬁer GA is present).
Remember that Medicare will deny claim lines billed for HCPCS codes G0447 and G0473 if billed more than
22 times in a 12-month period using the following codes:
• CARC 119: Beneﬁt maximum for this time period or occurrence has been reached.
• RARC N362: The number of days or units of service exceeds our acceptable maximum.
• Group Code CO (if GZ HCPCS modiﬁer present) or PR (if HCPCS modiﬁer GA is present).
Note: MACs will display the next eligible date for obesity counseling on all MAC provider inquiry screens.
MACs will allow both a claim for the professional service and a claim for a facility fee for HCPCS code G0473
when that code is billed on type of bill (TOB) 13X or on TOB 85X when revenue code 096X, 097X, or 098X
is on the TOB 85X. Payment on such claims is based on the following:
• TOB 13X paid based on the OPPS:
• TOB 85X in Critical Access Hospitals based on reasonable cost; except
• TOB 85X Method II hospitals based on 115 percent of the lesser of the fee schedule amount or the submitted
charge.
Institutional claims submitted on other than TOB 13X or 85X will be denied using:
• CARC 171: Payment is denied when performed by this type of provider on 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.
• Group Code CO (if GZ HCPCS modiﬁer present) or PR (if HCPCS modiﬁer GA is present).
Digital Breast Tomosynthesis
In the CY 2015 PFS Final Rule with comment period, CMS established a payment rate for the newly created
CPT code 77063 for screening digital breast tomosynthesis mammography. The same policies that are applicable
to other screening mammography codes are applicable to CPT code 77063. In addition, since this is an add-on
code it should only be paid when furnished in conjunction with a 2D digital mammography.
Effective January 1, 2015, CPT code 77063 (Screening digital breast tomosynthesis, bilateral (list separately
in addition to code for primary procedure)), must be billed in conjunction with the screening mammography
HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging
only. Effective January 1, 2015, beneﬁciary coinsurance and deductible does not apply to claim lines with CPT
code 77063 (Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary
procedure).
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
59 2/2015
Payment for CPT code 77063 is made only when billed with an ICD-9 code of V76.11 or V76.12 (and when
ICD-10 is effective with ICD-10 code Z12.31). When denying claim lines for 77063 that are submitted without
the appropriate diagnosis code, the claim lines are denied using the following messages:
• CARC 167: 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.mcd.search.asp. If you do not have web access, you may contact the contractor to
request a copy of the NCD.
• Group Code CO (if GZ HCPCS modiﬁer present) or PR (if HCPCS modiﬁer GA is present).
On institutional claims:
• MACs will pay for tomosynthesis, CPT code 77063, on TOBs 12X, 13X, 22X, 23X based on MPFS, and
TOB 85X with revenue code other than 096x, 097x, or 098x based on reasonable cost. TOB 85X claims
with revenue code 096x, 097x, or 098x are paid based on MPFS (115% of the lesser of the fee schedule
amount and submitted charge).
• MACs will pay for tomosynthesis, CPT code 77063 with revenue codes 096X, 097X, or 098X when billed
on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or submitted charge.
• MACs will return to the provider any claim submitted with tomosynthesis, CPT code 77063 when the TOB
is not 12X, 13X, 22X, 23X, or 85X.
• MACs will pay for tomosynthesis, CPT code 77063, on institutional claims TOBs 12X, 13X, 22X, 23X,
and 85X when submitted with revenue code 0403 and on professional claims TOB 85X when submitted
with revenue code 096X, 097X, or 098X.
• Effective for claims with dates of service on or after January 1, 2015, MACs will RTP claims for CPT code
77063 that are not submitted with revenue code 0403, 096X, 097X, or 098X.
Anesthesia Furnished in Conjunction with Colonoscopy
Section 4104 of the Affordable Care Act deﬁned the term “preventive services” to include “colorectal cancer
screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1)
of the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of
the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services
furnished on or after January 1, 2011.
In the CY 2015 PFS Proposed Rule, CMS proposed to revise the deﬁnition of “colorectal cancer screening
tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY
2015 PFS Final Rule with comment period, CMS ﬁnalized this proposal. The deﬁnition of “colorectal cancer
screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the
Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneﬁciary coinsurance and deductible does not
apply to anesthesia services associated with screening colonoscopies.
As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia professionals who
furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code
00810 performed in conjunction with HCPCS codes G0105 and G0121) shall include the following on the
claim for the services that qualify for the waiver of coinsurance and deductible:
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
60 2/2015
•
CPT Modiﬁer 33 – Preventive Services: when the primary purpose of the service is the delivery of an
evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services
identiﬁed in preventive services mandates (legislative or regulatory), the service may be identiﬁed by adding
CPT modiﬁer 33 to the procedure. For separately reported services speciﬁcally identiﬁed as preventive,
the modiﬁer should not be used.
Additional Information
The ofﬁcial instruction, CR8874 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3160CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
61 2/2015
January 2015 Update of the Ambulatory Surgical Center
(ASC) Payment System
MLN Matters® Number: MM9021
Related Change Request (CR) #: CR 9021
Related CR Release Date: January 9, 2015
Effective Date: January 1, 2015
Related CR Transmittal #: R3163CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for Ambulatory Surgical Centers (ASCs) submitting claims to Medicare
Administrative Contractors (MACs) for services to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 9021 informs MACs about changes to and billing instructions for various payment
policies implemented in the January 2015 ASC payment system update. As appropriate, this notiﬁcation also
includes updates to the Healthcare Common Procedure Coding System (HCPCS). Make sure that your billing
staff are aware of these changes.
Background
Included in this notiﬁcation are Calendar Year (CY) 2015 payment rates for separately payable drugs and
biologicals, including descriptors for newly created Level II HCPCS codes for drugs and biologicals (ASC
DRUG ﬁles), and covered surgical and ancillary services (ASCFS ﬁle).
Many ASC payment rates under the ASC payment system are established using payment rate information in
the Medicare Physician Fee Schedule (MPFS). The payment ﬁles associated with this transmittal reﬂect the
most recent changes to CY 2015 MPFS payment. Key updates are:
1. New Device Pass-Through Category and Device Offset for Payment
Additional payments may be made to the ASC for covered ancillary services, including certain implantable
devices with pass-through status under the outpatient prospective payment system (OPPS). Section 1833(t)
(6)(B) of the Social Security Act (the Act) requires that, under the OPPS, categories of devices be eligible for
transitional pass-through payments for at least 2, but not more than 3 years. Section 1833(t)(6)(B)(ii)(IV) of
the Act requires that we create additional categories for transitional pass-through payment of new medical
devices not described by current or expired categories of devices. This policy was implemented in the 2008
revised ASC payment system.
The Centers for Medicare & Medicaid Services (CMS) is establishing one new HCPCS device pass-through
category as of January 1, 2015 for the OPPS and the ASC payment systems. That HCPCS code is HCPCS
code C2624 (Wireless pressure sensor) is assigned ASC PI=J7 (OPPS pass-through device paid separately
when provided integral to a surgical procedure on ASC list; payment contractor-priced). Table 1 below shows
more details.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
62
2/2015
Table 1 - New Device Pass-Through Code HCPCS
HCPCS Short Descriptor
Long descriptor
C2624
Wireless pressure
sensor
Implantable wireless pulmonary artery
pressure sensor with delivery catheter,
including all system components
ASC Payment
Indicator (PI)
J7
2. New Service
The Centers for Medicare & Medicaid Services (CMS) is establishing one new HCPCS surgical procedure
code for ASC use effective January 1, 2015, as shown in table 2.
Table 2 – New Procedure Payable under the ASC Payment System Effective January 1, 2015
HCPCS Short Descriptor
Long descriptor
ASC PI
G2
C9742
Laryngoscopy with
Laryngoscopy, ﬂexible ﬁberoptic, with
injection
injection into vocal cord(s), therapeutic,
including diagnostic laryngoscopy, if
performed
3. Billing for Corneal Tissue
CMS reminds ASCs that, according to the “Medicare Claims Processing Manual,” Chapter 14, Section 40 Payment for Ambulatory Surgery
(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf), corneal tissue
is paid based on acquisition cost or invoice. To receive cost based reimbursement for corneal tissue acquisition,
ASCs must bill charges for corneal tissue using HCPCS code V2785.
4. Coding Guidance for Intraocular or Periocular Injections of Combinations of Anti-Inﬂammatory
Drugs and Antibiotics
Intraocular or periocular injections of combinations of anti-inﬂammatory drugs and antibiotics are being
used with increased frequency in ocular surgery (primarily cataract surgery). One example of combined or
compounded drugs includes triamcinolone and moxiﬂoxacin with or without vancomycin. Such combinations
may be administered as separate injections or as a single combined injection. Because such injections may
obviate the need for post-operative anti-inﬂammatory and antibiotic eye drops, some have referred to cataract
surgery with such injections as “dropless cataract surgery.”
The CY2015 National Correct Coding Initiative (NCCI) Policy Manual states (in Chapter VIII, Section D,
Item 20 in the “Downloads” Section at
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html) that injection of a drug during
a cataract extraction procedure or other ophthalmic procedure is not separately reportable. Speciﬁcally, no
separate procedure code may be reported for any type of injection during surgery or in the perioperative period.
Injections are a part of the ocular surgery and are included as a part of the ocular surgery and the HCPCS code
used to report the surgical procedure.
According to the “Medicare Claims Processing Manual, Chapter 17,”
(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf) Section 90.2,
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
63
2/2015
the compounded drug combinations described above and similar drug combinations should be reported with
HCPCS code J3490 (Unclassiﬁed drugs), regardless of the site of service of the surgery, and are packaged
as surgical supplies in both the Hospital Outpatient Department (HOPD) and the ASC. Although these drugs
are a covered part of the ocular surgery, no separate payment will be made. In addition, these drugs and drug
combinations may not be reported with HCPCS code C9399.
According to the “Medicare Claims Processing Manual,” Chapter 30, Section 40.3.6,
(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf) physicians
or facilities should not give Advance Beneﬁciary Notices (ABNs) to beneﬁciaries for either these drugs or for
injection of these drugs because they are fully covered by Medicare. Physicians or facilities are not permitted
to charge the patient an extra amount (beyond the standard copayment for the surgical procedure) for these
injections or the drugs used in these injections because they are a covered part of the surgical procedure. Also,
physicians or facilities cannot circumvent packaged payment in the HOPD or ASC for these drugs by instructing
beneﬁciaries to purchase and bring these drugs to the facility for administration.
5. Drugs, Biologicals, and Radiopharmaceuticals
a) New CY 2015 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals.
For CY 2015, several new HCPCS codes have been created for reporting drugs and biologicals in the ASC
setting, where there have not previously been speciﬁc codes available. These are displayed in Table 3.
Table 3 – New CY 2015 HCPCS Codes Effective for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2015
CY 2015 Long Descriptor
CY 2015 Payment Indicator
HCPCS Code
C9027
Injection, pembrolizumab, 1 mg
K2
C9136
Injection, factor viii, fc fusion protein, (recombinant), K2
per i.u.
C9349
FortaDerm, and FortaDerm Antimicrobial, any type,
K2
per square centimeter
C9442
Injection, belinostat, 10 mg
K2
C9443
Injection, dalbavancin, 10 mg
K2
C9444
Injection, oritavancin, 10 mg
K2
C9446
Injection, tedizolid phosphate, 1 mg
K2
C9447
Injection, phenylephrine and ketorolac, 4 ml vial
K2
J7180
Factor XIII anti-hem factor
K2
J7327
Hyaluronan or derivative, Monovisc, for intra
K2
articular injection, per dose
b) Other CY 2015 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals.
Table 4 notes those separately payable drugs, biologicals, and radiopharmaceuticals that have undergone
changes in their HCPCS codes, their long descriptors, or both. Each product’s CY 2014 HCPCS code and CY
2014 long descriptors are noted in the two left-hand columns. The CY 2015 HCPCS code and long descriptors
are noted in the adjacent right-hand columns.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Table 4 – Other CY 2015 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2014 CY 2014 Long Descriptor
CY 2015
CY 2015 Long Descriptor
HCPCS
HCPCS
Code
Code
J7195
Factor ix (antihemophilic factor,
J7195
Injection, Factor ix (antihemophilic
recombinant) per i.u.
factor, recombinant) per i.u., not
otherwise speciﬁed
C9021
Injection, obinutuzumab, 10 mg
J9301
Injection, obinutuzumab, 10 mg
C9022
Injection, elosulfase alfa, 1mg
J1322
Injection, elosulfase alfa, 1mg
C9023
Injection, testosterone undecanoate, 1
J3145
Injection, testosterone undecanoate,
mg
1 mg
C9133
Factor ix (antihemophilic factor,
J7200
Factor ix (antihemophilic factor,
recombinant), Rixubis, per i.u.
recombinant), Rixubis, per i.u.
C9134
Factor XIII (antihemophilic factor,
J7181
Factor XIII (antihemophilic factor,
recombinant), Tretten, per i.u.
recombinant), Tretten, per i.u.
C9135
Factor ix (antihemophilic factor,
J7201
Factor ix (antihemophilic factor,
recombinant), Alprolix, per i.u.
recombinant), Alprolix, per i.u.
J7335
Capsaicin 8% patch, per 10 square
J7336
Capsaicin 8% patch, per square
centimeters
centimeter
Q9970
Injection, ferric carboxymaltose, 1mg
J1439
Injection, ferric carboxymaltose, 1
mg
c. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective January 1, 2015
For CY 2015, payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals is made
at a single rate of ASP plus six percent, which provides payment for both the acquisition cost and pharmacy
overhead costs associated with the drug, biological or therapeutic radiopharmaceutical. In CY 2015, a single
payment of ASP + 6 percent for pass-through drugs, biologicals and radiopharmaceuticals is made to provide
payment for both the acquisition cost and pharmacy overhead costs of these pass-through items. Payments for
drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions
become available.
Effective January 1, 2015, payment rates for many drugs and biologicals have changed from the values published
in the CY 2015 Outpatient Payment Prospective System (OPPS)/ASC ﬁnal rule with comment period as a
result of the new ASP calculations based on sales price submissions from the third quarter of CY 2014. In
cases where adjustments to payment rates are necessary, changes to the payment rates will be incorporated in
the January 2015 ASC Drug ﬁle.
CMS is not publishing the updated payment rates in this CR implementing the January 2015 update of the
ASC Payment System. The updated payment rates effective January 1, 2015, can be found in the January 2015
ASC Addendum BB at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
on the CMS website.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
65
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d. Skin Substitute Procedure Edits
The payment for skin substitute products that do not qualify for OPPS pass-through status are packaged into
the OPPS payment for the associated skin substitute application procedure. This policy is also implemented in
the ASC payment system. The skin substitute products are divided into two groups:
1. High cost skin substitute products, and
2. Low cost skin substitute products for packaging purposes.
Table 5 lists the skin substitute products and their assignment as either a high cost or a low cost skin substitute
product, when applicable. ASCs should not separately bill for packaged skin substitutes (ASC PI=N1).
High cost skin substitute products should only be utilized in combination with the performance of one of the
skin application procedures described by CPT codes 15271-15278. Low cost skin substitute products should
only be utilized in combination with the performance of one of the skin application procedures described by
HCPCS code C5271-C5278. All OPPS pass-through skin substitute products (ASC PI=K2) should be billed
in combination with one of the skin application procedures described by CPT codes 15271-15278.
Table 5 – Skin Substitute Product Assignment to High Cost/Low Cost Status for CY 2015
CY 2015
CY 2015 Short Descriptor
ASC PI
Low/High Cost Skin Substitute
HCPCS Code
C9349
Fortaderm, fortaderm antimic
N1
High
C9358
SurgiMend, fetal
N1
Low
C9360
SurgiMend, neonatal
N1
Low
C9363
Integra Meshed Bil Wound Mat
N1
High
Q4100
Skin substitute, NOS
N1
Low
Q4101
Apligraf
N1
High
Q4102
Oasis wound matrix
N1
Low
Q4103
Oasis burn matrix
N1
Low
Q4104
Integra BMWD
N1
High
Q4105
Integra DRT
N1
High
Q4106
Dermagraft
N1
High
Q4107
Graftjacket
N1
High
Q4108
Integra Matrix
N1
High
Q4110
Primatrix
N1
High
Q4111
Gammagraft
N1
Low
Q4112
Cymetra injectable
N1
N/A
Q4113
GraftJacket Xpress
N1
N/A
Q4114
Integra Flowable Wound Matrix
N1
N/A
Q4115
Alloskin
N1
Low
Q4116
Alloderm
N1
High
Q4117
Hyalomatrix
N1
Low
Q4118
Matristem Micromatrix
N1
N/A
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2/2015
Q4119
Q4120
Q4121
Q4122
Q4123
Q4124
Q4125
Q4126
Q4127
Q4128
Q4129
Q4131
Q4132
Q4133
Q4134
Q4135
Q4136
Q4137
Q4138
Q4139
Q4140
Q4141
Q4142
Q4143
Q4145
Q4146
Q4147
Q4148
Q4149
Q4150
Q4151
Q4152*
Q4153
Q4154
Q4155
Q4156
Q4157
Q4158
Q4159
Matristem Wound Matrix
Matristem Burn Matrix
Theraskin
Dermacell
Alloskin
Oasis Tri-layer Wound Matrix
Arthroﬂex
Memoderm/derma/tranz/integup
Talymed
Flexhd/Allopatchhd/matrixhd
Unite Biomatrix
Epiﬁx
Graﬁx core
Graﬁx prime
HMatrix
Mediskin
EZder
Amnioexcel or Biodexcel, 1cm
BioDfence DryFlex, 1cm
Amniomatrix or Biodmatrix, 1cc
Biodfence 1cm
Alloskin ac, 1 cm
Xcm biologic tiss matrix 1cm
Repriza, 1cm
Epiﬁx, 1mg
Tensix, 1cm
Architect ecm px fx 1 sq cm
Neox 1k, 1cm
Excellagen, 0.1 cc
Allowrap DS or Dry 1 sq cm
AmnioBand, Guardian 1 sq cm
Dermapure 1 square cm
Dermavest 1 square cm
Biovance 1 square cm
NeoxFlo or ClarixFlo 1 mg
Neox 100 1 square cm
Revitalon 1 square cm
MariGen 1 square cm
Afﬁnity 1 square cm
N1
N1
K2
K2
N1
N1
N1
N1
K2
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
N1
Low
Low
High
High
High
Low
High
High
High
High
High
High
High
High
High
Low
Low
High
High
N/A
High
Low
Low
Low
N/A
Low
High
High
N/A
Low
Low
High
Low
High
N/A
High
Low
Low
High
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
67
2/2015
Q4160
NuShield 1 square cm
N1
High
*HCPCS code Q4152 was assigned to the low cost group in the CY 2015 OPPS/ASC ﬁnal rule with comment
period. Upon submission of updated pricing information, Q4152 is assigned to the high cost group for CY 2015.
6. Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates
Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactively.
These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected
payments rates will be accessible on the ﬁrst date of the quarter at
http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html on the CMS website.
Suppliers, who think they may have received an incorrect payment for drugs and biologicals impacted by these
corrections, may request their MAC’s adjustment of the previously processed claims.
7. CY2015 ASC Wage index
As discussed and ﬁnalized in the CY 2015 OPPS/ASC ﬁnal rule with comment (79 FR 66937), in CY2015,
CMS is using the new Core Based Statistical Area (CBSA) delineations issued by the Ofﬁce of Management and
Budget (OMB) in OMB Bulletin 13-01, dated February 28, 2013, for the IPPS hospital wage index. Therefore,
because the ASC wage indexes are the pre-ﬂoor and pre-reclassiﬁed IPPS hospital wage indexes, the CY 2015
ASC wage indexes reﬂect the new OMB delineations.
In CY2015, where the CY 2015 ASC wage index value with the CY 2015 CBSAs is lower than the CY 2014
CBSA values, CMS calculates, or blends, the CY 2015 ASC wage index adjusted payment rates such that it
will equal 50 percent of the ASC wage index based on the CY 2014 CBSA value and 50 percent of the ASC
wage index based on the new CY 2015 CBSA value. The blending of these speciﬁc wage index values will
mitigate any short-term instability to ASC payments. CY2015 CBSAs with wage index values that are higher
than the CY2014 are not transitioned or blended and reﬂect the full higher wage index value. For additional
information on this ASC wage index policy, please refer to page 66937 in the CY 2015 OPPS/ASC Final Rule
(CMS-1613-FC), which is accessible at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1613-FC.html on the CMS
website.
8. Coverage Determinations
The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the
OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or
service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other
service meets all program requirements for coverage. For example, MACs determine that it is reasonable and
necessary to treat the beneﬁciary’s condition and whether it is excluded from payment.
Additional Information
The ofﬁcial instruction, CR9021, issued to your MAC regarding this change, is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3163CP.pdf on the CMS
website
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
68
2/2015
Transcatheter Mitral Valve Repair (TMVR)-National Coverage Determination (NCD)
MLN Matters® Number: MM9002
Related Change Request (CR) #: CR 9002
Related CR Release Date: December 5, 2014
Effective Date: August 7, 2014
Related CR Transmittal #: R178NCD and R3142CP
Implementation Date: April 6, 2015
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to
Medicare Administrative Contractors (MACs) for Transcatheter Mitral Valve Repair (TMVR) services provided
to Medicare beneﬁciaries.
Provider Action Needed
Effective for claims with dates of service furnished on or after August 7, 2014, the Centers for Medicare &
Medicaid Services (CMS) will reimburse claims for TMVR for Mitral Regurgitation (MR) when furnished
under Coverage with Evidence Development (CED).
TMVR is non-covered for the treatment of MR when not furnished under CED according to the above-noted
criteria. TMVR used for the treatment of any non-MR indications are non-covered by Medicare.
Background
TMVR is a new technology for use in treating MR. MR occurs when the leaﬂets of the mitral valve do not close
properly and blood ﬂows from the left ventricle back into the left atrium, causing the heart to work harder to
pump. This, in turn, causes enlargement of the left ventricle and can lead to potential heart failure.
Abbott’s MitraClip, the only U.S. Food and Drug Administration (FDA)-approved TMVR device, involves
clipping together a portion of the mitral valve leaﬂets. This is performed under general anesthesia, with
delivery of the device typically through a percutaneous transvenous approach, via echocardiographic and
ﬂuoroscopic guidance. The procedure is performed in a cardiac catheterization laboratory or hybrid operating
room/cardiac catheterization laboratory with advanced quality imaging. TMVR is covered for uses not listed
as an FDA-approved indication when performed in approved clinical studies which meet certain study question
requirements. The TMVR procedure must be performed by an interventional cardiologist or cardiac surgeon,
or they may jointly participate in the intraoperative technical aspects, as appropriate.
On August 7, 2014, CMS issued a ﬁnal decision memorandum covering TMVR for MR under CED for the
treatment of MR when furnished for an FDA-approved indication with an FDA-approved device as follows:
• Treatment of signiﬁcant, symptomatic, degenerative MR when furnished according to an FDA-approved
indication, and all CMS coverage criteria are met; and
• TMVR for MR uses not expressly listed as FDA-approved indications but only within the context of an
FDA-approved, randomized clinical trial that meets all CMS coverage criteria.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
69 2/2015
CED requires that each patient be entered into a qualiﬁed national registry. In addition, prior to receiving TMVR,
face-to-face examinations of the patient are required by a cardiac surgeon and a cardiologist experienced in
mitral valve surgery to evaluate the patient’s suitability for TMVR and determination of prohibitive risk, with
documentation of their rationale.
The NCD lists the criteria that must be met prior to beginning a TMVR program and after a TMVR program is
established. No NCD existed for TMVR for MR prior to August 7, 2014, and TMVR is non-covered outside CED
or for non-MR indications. The Web address for accessing the NCD transmittal is available in the “Additional
Information” section at the end of this article.
CR9002 revises the “Medicare Claims Processing Manual,” Chapter 32, Section 340 (Transcatheter Mitral
Valve Repair (TMVR)), and the “National Coverage Determinations (NCD) Manual,” Chapter 20, Section
20.33 (Transcatheter Mitral Valve Repair (TMVR) which are included in CR9002.
Based on the NCD, TMVR must be furnished in a hospital with the appropriate infrastructure that includes
but is not limited to:
• On-site active valvular heart disease surgical program with >2 hospital-based cardiothoracic surgeons
experienced in valvular surgery;
• Cardiac catheterization lab or hybrid operating room/catheterization lab equipped with a ﬁxed radiographic
imaging system with ﬂat-panel ﬂuoroscopy, offering catheterization laboratory-quality imaging;
• Non-invasive imaging expertise including transthoracic/transesophageal/3D echocardiography, vascular
studies, and cardiac CT studies;
• Sufﬁcient space, in a sterile environment, to accommodate necessary equipment for cases with and without
complications;
• Post-procedure intensive care facility with personnel experienced in managing patients who have undergone
open-heart valve procedures;
• Adequate outpatient clinical care facilities; and
• Appropriate volume requirements per the applicable qualiﬁcations below.
There are institutional and operator requirements for performing TMVR. The hospital must have the following:
• A surgical program that performs =25 total mitral valve surgical procedures for severe MR per year of
which at least 10 must be mitral valve repairs;
• An interventional cardiology program that performs =1000 catheterizations per year, including =400
Percutaneous Coronary Interventions (PCIs) per year, with acceptable outcomes for conventional procedures
compared to National Cardiovascular Data Registry (NCDR) benchmarks;
• The heart team must include:
1. An interventional cardiologist(s) who:
• performs =50 structural procedures per year including Atrial Septal Defects (ASD), Patent Foramen Ovale
(PFO) and trans-septal punctures; and,
• must receive prior suitable training on the devices to be used; and,
• must be board-certiﬁed in interventional cardiology or board-certiﬁed/eligible in pediatric cardiology or
similar boards from outside the United States;
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
70 2/2015
2. Additional members of the heart team, including cardiac echocardiographers, other cardiac imaging
specialists, heart valve and heart failure specialists, electrophysiologists, cardiac anesthesiologists, intensivists,
nurses, nurse practitioners, physician assistants, data/research coordinators, and a dedicated administrator.
• All cases must be submitted to a single national database;
• Ongoing continuing medical education (or the nursing/technologist equivalent) of 10 hours per year of
relevant material; and
• The cardiothoracic surgeon(s) must be board-certiﬁed in thoracic surgery or similar foreign equivalent.
• The heart team’s interventional cardiologist or a cardiothoracic surgeon must perform the TMVR.
Interventional cardiologist(s) and cardiothoracic surgeon(s) may jointly participate in the intra-operative
technical aspects of TMVR as appropriate.
The heart team and hospital must be participating in a prospective, national, audited registry that: 1) consecutively
enrolls TMVR patients; 2) accepts all manufactured devices; 3) follows the patient for at least one year; and,
4) complies with relevant regulations relating to protecting human research subjects, including 45 Code of
Federal Regulations (CFR) Part 46 and 21 CFR Parts 50 & 56. For complete details on the outcomes that must
be tracked by the registry and the data that must be provided to the registry, see the CR9002 NCD transmittal.
The Web address for that transmittal is in the “Additional Information” section at the end of this article.
Coding Requirements/Claims Processing Requirements
Coding Requirements for TMVR for MR Claims Furnished on or After August 7, 2014
The Current Procedural Terminology (CPT) Codes for TMVR for MR Claims are:
• 0343T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when
performed; initial prosthesis. (Note: 0343T will be replaced by CPT code 33418 effective January 1, 2015.)
• 0344T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when
performed; additional prosthesis(es) during same session (List separately in addition to code for primary
procedure). (Note: 0344T will be replaced by CPT code 33419 effective January 1, 2015.)
• 0345T - Transcatheter mitral valve repair percutaneous approach via the coronary sinus
• 33418 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when
performed; initial prosthesis. (Note: CPT code 33418 is effective January 1, 2015.)
• 33419 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when
performed; additional prosthesis(es) during same session. (List separately in addition to code for primary
procedure.) (Note: CPT code 33419 is effective January 1, 2015.)
ICD-9/ICD-10 Codes for TMVR for MR Claims The ICD-9 (and upon ICD-10 implementation)/ ICD-10 codes are: • ICD-9 Procedure Code - 35.97 - Percutaneous mitral valve repair with implant - and ICD-10 procedure
code is 02UG3JZ – Supplement mitral valve with synthetic substitute, percutaneous approach
• ICD-9 Diagnosis Code for TMVR for MR Claims is - 424.0 – Mitral valve disorder and ICD-10 diagnosis
codes are I34.0 – Nonrheumatic mitral (valve) insufﬁciency or I34.8 – Other nonrheumatic mitral valve
disorders
Professional Claims Place of Service (POS) Codes for TMVR for MR Claims
Effective for claims with dates of service on and after August 7, 2014, place of service (POS) code 21 is valid
for use for TMVR for MR services. All other POS codes will be denied. MACs will supply the following
messages when MACs denying TMVR for MR claims for invalid POS:
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
71 2/2015
• Claim Adjustment Reason Code (CARC) 58: “Treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identiﬁcation
Segment (loop 2110 Service Payment Information REF), if present.”
• Group Code CO (Contractual Obligation) assigning ﬁnancial liability to the provider (if a claim is received
with a GZ HCPCS modiﬁer indicating no signed Advance Beneﬁciary Notice (ABN) is on ﬁle.)
Professional Claims Modiﬁers for TMVR for MR Claims
Effective for claims with dates of service on or after August 7, 2014, MACs will pay TMVR for MR claim
lines billed with CPT codes 0343T, 0344T, and 00345T when billed for two surgeons/co-surgeons only when
the claim includes CPT modiﬁer -62. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT
codes 0343T and 0344T, respectively.) Claim lines for two surgeons/co-surgeons billed without CPT modiﬁer
-62 shall be returned as unprocessable.
MACs will supply the following messages when returning TMVR for MR claim lines for two surgeons/co
surgeons billed without CPT modiﬁer -62 as unprocessable:
• CARC 4: “The procedure code is inconsistent with the modiﬁer used or a required modiﬁer is missing.
Note: Refer to the 835 Healthcare Policy Identiﬁcation Segment (loop 2110 Service Payment Information
REF), if present.”
• Remittance Advice Remarks Code (RARC) N517: “Resubmit a new claim with the requested information. “
• Group Code: CO
Effective for claims with dates of service on or after August 7, 2014, MACs will pay claim lines for TMVR for
MR billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial when billed with HCPCS modiﬁer -Q0.
(Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.)
TMVR for MR claim lines in a clinical trial billed without HCPCS modiﬁer -Q0 will be returned as unprocessable.
MACs will supply the following messages when returning TMVR for MR claim lines in a clinical trial billed
without HCPCS modiﬁer -Q0 as unprocessable:
• CARC 4: “The procedure code is inconsistent with the modiﬁer used or a required modiﬁer is missing.
Note: Refer to the 835 Healthcare Policy Identiﬁcation Segment (loop 2110 Service Payment Information
REF), if present.”
• RARC N517: “Resubmit a new claim with the requested information.“
• Group Code: CO
Professional Clinical Trial Diagnostic Coding for TMVR for MR Claims
Effective for claims with dates of service on or after August 7, 2014, MACs will pay claim lines for TMVR
for MR billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial when billed with ICD-9 diagnosis
code 424.0 (ICD-10 I34.0 or I34.8) and secondary ICD-9 diagnosis code V70.7 (ICD-10=Z00.6). (Effective
January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.) TMVR
for MR claim lines in a clinical trial billed without ICD-9 diagnosis code 424.0 (ICD-10 I34.0 or I34.8) and
secondary ICD-9 diagnosis code V70.7 (ICD-10=Z00.6) will be denied.
MACs will supply the following messages when denying TMVR for MR claim lines in a clinical trial billed
without secondary ICD-9 diagnosis code V70.7(ICD-10=Z00.6) as unprocessable:
• CARC 50: “These are non-covered services because this is not deemed a “medical necessity” by the payer.”
• RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
72 2/2015
a coverage determination as to whether a particular item or service is covered. A copy of this policy is
available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the
contractor to request a copy of the NCD.”
• Group Code: CO
Mandatory National Clinical Trial (NCT) Number for TMVR for MR Claims
Effective for claims with dates of service on or after August 7, 2014, contractors shall pay TMVR for MR
claim lines billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial only when billed with an 8-digit
National Clinical Trial (NCT) number. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT
codes 0343T and 0344T, respectively.) MACs shall accept the numeric, 8-digit NCT number preceded by the
two alpha characters of “CT” when placed in Field 19 of paper Form CMS-1500, or when entered WITHOUT
the “CT” preﬁx in the electronic 837P in Loop 2300 REF02 (REF01=P4). NOTE: The “CT” preﬁx is required
on a paper claim, but it is not required on an electronic claim. TMVR for MR claim lines in a clinical trial billed
without an 8-digit NCT number shall be returned as unprocessable. MACs will supply the following messages
when returning TMVR for MR claim lines as unprocessable when billed without an 8-digit NCT number:
• CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code
must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark
Code that is not an ALERT.)”
• RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved
clinical trial services.”
• Group Code: CO
Claims Processing Requirements for TMVR for MR on Inpatient Hospital Claims
Inpatient hospitals shall bill for TMVR for MR on a 11X Type of Bill (TOB) effective for discharges on or
after August 7, 2014. In addition to the ICD-9/10 procedure and diagnosis codes mentioned above, inpatient
hospital discharges for TMVR for MR shall be covered when billed with the following clinical trial coding:
• Secondary ICD-9 diagnosis code V70.7/ICD-10 diagnosis code Z00.6;
• Condition Code 30; and
• An 8-digit NCT Number assigned by the National Library of Medicine (NLM) and displayed at
• https://clinicaltrials.gov/ on the Internet.
Inpatient hospital discharges for TMVR for MR will be rejected when billed without the ICD-9/10 diagnosis
and procedure codes and clinical trial coding mentioned above. Claims that do not include these required
codes shall be rejected with the following messages:
• CARC: 50 - “These are non-covered services because this is not deemed a “medical necessity” by the payer.”
• 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 service is covered. A copy of this policy is available at service is covered. A copy of this policy
is available at
• Group Code - Contractual Obligation (CO)
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
73 2/2015
Additional Information
The ofﬁcial instruction, CR9002, issued to your MAC regarding this change consists of two transmittals. The
ﬁrst updates the “Medicare Claims Processing Manual” and it is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3142CP.pdf on the CMS
website. The second updates the NCD Manual and it is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R178NCD.pdf on the
CMS website.
Denial Resolution Tool
The Palmetto GBA Denial Resolution tool, located on the home
page under Self-Service Tools, includes resources for resolving the top
claim rejections and denial reasons. Save time and resources by looking here before
you pick up the phone.
•
•
•
Access denial reasons in plain language
Scroll through the titles to locate your procedure
Use the Palmetto GBA search engine to search by remark code
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Certifying Patients for the Medicare Home Health Beneﬁt
MLN Matters® Number: SE1436
Revised Related Change Request (CR) #: NA
Related CR Release Date: NA
Effective Date: NA
Related CR Transmittal #: NA
Implementation Date: NA
Note: This article was revised on December 31, 2014, to add clarifying language. All other information remains
unchanged.
Provider Types Affected
This MLN Matters® Special Edition (SE) 1436 is intended for Medicare-enrolled physicians who certify patient
eligibility for home health care services and submit claims to Medicare Administrative Contractors (MACs)
for those services provided to Medicare beneﬁciaries.
What You Need to Know
This MLN Matters® SE1436 article gives Medicare-enrolled providers an overview of the Medicare home
health services beneﬁt, including patient eligibility requirements and certiﬁcation/recertiﬁcation requirements
of covered Medicare home health services.
Key Points
To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per
Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):
• Be conﬁned to the home;
• Need skilled services;
• Be under the care of a physician;
• Receive services under a plan of care established and reviewed by a physician; and
• Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP).
Care must be furnished by or under arrangements made by a Medicare-participating Home Health Agency
(HHA).
Patient Eligibility—Conﬁned to Home
Section 1814(a) and Section 1835(a) of the Act specify that an individual is considered “conﬁned to the home”
(homebound) if the following two criteria are met:
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2/2015
First Criteria
One of the Following must be met:
1. Because of illness or injury, the individual needs
the aid of supportive devices such as crutches, canes,
wheelchairs, and walkers; the use of special transportation;
or the assistance of another person to leave their place of
residence.
2. Have a condition such that leaving his or her home is
medically contraindicated.
Second Criteria
Both of the following must be met:
1. There must exist a normal inability to
leave home.
2. Leaving home must require a
considerable and taxing effort.
The patient may be considered homebound (that is, conﬁned to the home) if absences from the home are:
• Infrequent;
• For periods of relatively short duration;
• For the need to receive health care treatment;
• For religious services;
• To attend adult daycare programs; or
• For other unique or infrequent events (for example, funeral, graduation, trip to the barber).
Some examples of persons conﬁned to home are:
• A patient who is blind or senile and requires the assistance of another person in leaving their place of
residence;
• A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant
weakness and pain and therefore their actions may be restricted by their physician to certain speciﬁed and
limited activities such as getting out of bed only for a speciﬁed period of time or walking stairs only once
a day; and
• A patient with a psychiatric illness that is manifested, in part, by a refusal to leave home or is of such a
nature that it would not be considered safe for the patient to leave home unattended, even if they have no
physical limitations.
Patient Eligibility—Need Skilled Services
According to Section 1814(a)(2)(C) and Section1835(a)(2)(A) of the Act, the patient must be in need of one
of the following services:
• Skilled nursing care on an intermittent basis (furnished or needed on fewer than 7 days each week or less
than 8 hours each day for periods of 21 days or less, with extensions in exceptional circumstances when
the need for additional care is ﬁnite and predictable per Section 1861(m) of the Act);
• Physical Therapy (PT);
• Speech-Language Pathology (SLP) services; or
• Continuing Occupational Therapy (OT).
Patient Eligibility—Under the Care of a Physician and Receiving Services Under a Plan of Care
Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act require that the patient must be under the care of
a Medicare-enrolled physician, deﬁned at at42 CFR 424.22(a)(1)(iii) as follows:
• Doctor of Medicine;
• Doctor of Osteopathy; or
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
76 2/2015
• Doctor of Podiatric Medicine (may perform only plan of treatment functions that are consistent with the
functions he or she is authorized to perform under State law).
According to Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act, the patient must receive home health
services under a plan of care established and periodically reviewed by a physician. Based on 42 CFR 424.22(d)
(1) a plan of care may not be established and reviewed by any physician who has a ﬁnancial relationship with
the HHA.
Certiﬁcation Requirements, Including the Required Face-to-Face Encounter are as follows:
As a condition for payment, according to the regulations at 42 CFR 424.22(a)(1):
• A physician must certify that a patient is eligible for Medicare home health services according to 42 CFR
424.22(a)(1)(i)-(v); and
• The physician who establishes the plan of care must sign and date the certiﬁcation.
The Centers for Medicare & Medicaid Services (CMS) does not require a speciﬁc form or format for the
certiﬁcation as long as a physician certiﬁes that the following ﬁve requirements, outlined in 42 CFR Section
424.22(a)(1), are met:
• The patient needs intermittent SN care, PT, and/or SLP services;
• The patient is conﬁned to the home (that is, homebound);
• A plan of care has been established and will be periodically reviewed by a physician;
• Services will be furnished while the individual was or is under the care of a physician; and
• A face-to-face encounter:
• Occurred no more than 90 days prior to the home health start of care date or within 30 days of the start
of the home health care;
• Was related to the primary reason the patient requires home health services; and
• Was performed by a physician or allowed Non-Physician Practitioner.
According to the regulations at 42 CFR 424.22(a)(2) physicians should complete the certiﬁcation when the
plan of care is established or as soon as possible thereafter. The certiﬁcation must be complete prior to when
an HHA bills Medicare for reimbursement.
Certiﬁcation Requirements: Face-to-Face Encounter
According to 42 CFR 424.22(a)(1)(v)(A), the face-to-face encounter can be performed by:
• The certifying physician;
• The physician who cared for the patient in an acute or post-acute care facility (from which the patient was
directly admitted to home health);
• A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying
physician or the acute/post-acute care physician; or
• A certiﬁed nurse midwife or physician assistant under the supervision of the certifying physician or the
acute/post-acute care physician.
According to 42 CFR 424.22(d)(2), the face-to-face encounter cannot be performed by any physician or allowed
NPP (listed above) who has a ﬁnancial relationship with the HHA.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
77 2/2015
Certiﬁcation Requirements: Management and Evaluation Narrative
According to 42 CFR 424.22(a)(1)(i) if a patient’s underlying condition or complication requires a Registered
Nurse (RN) to ensure that essential non-skilled care is achieving its purpose and a RN needs to be involved
in the development, management and evaluation of a patient’s care plan, the physician will include a brief
narrative describing the clinical justiﬁcation of this need.
If the narrative is part of the certiﬁcation form then the narrative must be located immediately prior to the
physician’s signature. If the narrative exists as an addendum to the certiﬁcation form in addition to the physician’s
signature on the certiﬁcation form, the physician must sign immediately following the narrative in the addendum.
For skilled nursing care to be reasonable and necessary for management and evaluation of the patient’s plan of
care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must
require the involvement of a registered nurse to promote the patient’s recovery and medical safety in view of
the patient’s overall condition.
For more information about SN for management and evaluation refer to Section 40.1.2.2, Chapter 7 of the
“Medicare Beneﬁt Policy Manual” at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf on the CMS
website.
Certiﬁcation Requirements: Supporting Documentation
• Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s
medical records (if the patient was directly admitted to home health) shall be used as the basis for certiﬁcation
of home health eligibility. If the documentation used as the basis for the certiﬁcation of eligibility is not
sufﬁcient to demonstrate that the patient is or was eligible to receive services under the Medicare home
health beneﬁt, payment will not be rendered for home health services provided.
• According to the regulations at 42 CFR 424.22(c), Certifying physicians and acute/post-acute care facilities
must provide, upon request, the medical record documentation that supports the certiﬁcation of patient
eligibility for the Medicare home health beneﬁt to the home health agency, review entities, and/or CMS.
Certifying physicians who show patterns of non-compliance with this requirement, including those physicians
whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as
provider-speciﬁc probe reviews.
• Information from the HHA, such as the patient’s comprehensive assessment, can be incorporated into the
certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.
• Information from the HHA must be corroborated by other medical record entries and align with the time
period in which services were rendered.
• The certifying physician must review and sign off on anything incorporated into the patient’s medical record
that is used to support the certiﬁcation of patient eligibility (that is, agree with the material by signing and
dating the entry).
• The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must
contain information that justiﬁes the referral for Medicare home health services. This includes documentation
that substantiates the patient’s:
• Need for the skilled services; and
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
78 2/2015
• Homebound status.
• The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must
contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:
• Occurred within the required timeframe;
• Was related to the primary reason the patient requires home health services; and
• Was performed by an allowed provider type.
This information can be found most often in, but is not limited to, clinical and progress notes and discharge
summaries.
Please review the following examples included at the end of this article:
• Discharge Summary;
• Progress Note;
• Progress Note and Problem List; or
• Discharge Summary and Comprehensive Assessment.
Recertiﬁcation
At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient
for a subsequent 60-day episode. According to the regulations at 424.22(b)(1) recertiﬁcation is required at
least every 60 days when there is a need for continuous home health care after an initial 60-day episode and
unless there is a:
• Patient-elected transfer; or
• Discharge with goals met and/or no expectation of a return to home health care.
(These situations trigger a new certiﬁcation, rather than a recertiﬁcation)
Medicare does not limit the number of continuous episodes of recertiﬁcation for patients who continue to be
eligible for the home health beneﬁt.
Recertiﬁcation Requirements:
• Must be signed and dated by the physician who reviews the plan of care;
• Indicate the continuing need for skilled services (the need for OT may be the basis for continuing services
that were initiated because the individual needed SN, PT or SLP services); and
• Estimate how much longer the skilled services will be required.
Physician Billing for /Certiﬁcation/Recertiﬁcation
Certifying/recertifying patient eligibility can include contacting the home health agency and reviewing of
reports of patient status required by physicians to afﬁrm the implementation of the plan of care that meets
patient’s needs.
• Healthcare Common Procedure Coding System (HCPCS) code G0180 - Physician certiﬁcation home health
patient for Medicare-covered home health service under a home health plan of care (patient not present).
• HCPCS code G0179 -Physician recertiﬁcation home health patient for Medicare-covered home health
services under a home health plan of care (patient not present)
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
79 2/2015
Physician claims for certiﬁcation/recertiﬁcation of eligibility for home health services (HCPCS codes G0180 and
G0179 respectively) are not considered to be for “Medicare-covered” home health services if the HHA claim
itself was non-covered because the certiﬁcation/recertiﬁcation of eligibility was not complete or because there
was insufﬁcient documentation to support that the patient was eligible for the Medicare home health beneﬁt.
Additional Information
If you have questions, please contact your MAC at their toll-free number. The number is available at http://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
under - How Does It Work?
More information is available at the Medicare Home Health Agency website at
http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html on the CMS website.
Attached are a number of examples that illustrate some of the key points of this article.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2/2015
Example 1
AAA HOSPITAL DISCHARGE SUMMARY
-DEPARTMENT OF SURGERYDOE, JANE
00000123
02-13-2014
02-17-2014
Patient Name
Med Rec No.
Admit Date
Discharge Date
Physician: John A. Doe, M.D.
Dictated By: John A. Doe, M.D.
Date of Encounter
Allowed Provider Type
ADMISSION DIAGNOSIS:
Right knee osteoarthritis.
DISCHARGE DIAGNOSIS:
Right knee osteoarthritis.
CONSULTATIONS:
1. Physical Therapy
2. Occupational Therapy
PROCEDURES:
02/14/2014: Total Right knee arthroplasty.
HISTORY OF PRESENT ILLNESS:
Mrs. Doe is a pleasant 60-year old female who has had a longstanding history of right knee arthritis. She has complained
of right sided knee pain since January 2013. Since then, her ambulation has been limited by pain and she has pain at night
that interrupts sleep. Pain medication, ibuprofen and hydrocodone, have been unsuccessful in relieving her pain for the
last 6 months. Workup did show reduction in the right knee joint space. She initially failed conservation treatment and
has elected to proceed with surgical treatment.
PAST MEDICAL HISTORY:
Hypertension, Gout.
PAST SURGICAL HISTORY:
Hysterectomy.
Meets the requirements for documenting: (1) the need for skilled
services; (2) the patient was/is confined to the home (homebound); and
(3) that the encounter was related to the primary reason the patient
requires home health services.
DISCHARGE MEDICATIONS:
Colace 100 mg daily, Percocet 5/325 every 4 hours as needed for pain, Lisinopril 10 mg daily, Coumadin 4 mg daily;
blood draw for INR ordered for 2/20/2014.
DISCHARGE CONDITION:
Upon discharge Mrs. Doe is stable status post right total knee replacement and has made good progress with her therapies
and rehabilitation. Mrs. Doe is to be discharged to home with home health services, physical therapy and nursing visits,
ordered. The patient is temporarily homebound secondary to status post total knee replacement and currently walker
dependent with painful ambulation. PT is needed to restore the ability to walk without support. Short-term skilled nursing
is needed to monitor for signs of decomposition or adverse events from the new Coumadin medical regimen.
PATIENT INSTRUCTION:
The patient is discharged to home in the care of her son. Diet is regular. Activity, weight bear as tolerated right lower
extremity. The patient prescribed Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.
Resume home medications. Call the office or return to the emergency room for any concerns including increased redness,
swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. Doe
in two weeks.
Transcribed by: A.M 02/17/2014
Electronically signed by: John A. Doe, M.D. 02/17/2014 17:52
Patient: Smith, Jane
DOB: 04/13/1941
Address: 1714 Main Street, Plano TX 15432
Example 2
Subjective:
CC:
HPI:
Provider: John Doe, M.D.
Date: 05/03/2013
Progress Notes
Allowed Provider Type
Date of Encounter
1. Wound on left heel.
Pt is here for evaluation of wound on left heel. Patient reports her daughter noticed the wound on patient’s
heel when she was washing her feet. Patient states she has difficulty with reaching her feet and her daughter will
sometimes clean them for her. She reports she uses a shoe horn to put on her shoes.
ROS:
General:
No weight change, no fever, no weakness, no fatigue.
Cardiology:
No chest pain, no palpitations, no dizziness, no shortness of breath.
Skin:
Wound on left lower heel, no pain.
Medical History: HTN, hyperlipidemia, hypothryroidism, DJD.
Medications: zolpidem 10 mg tablet 1 tab(s) once a day (at bedtime), Diovan HCl 12.5 mg-320 mg tablet 1 tab(s) once a
day, Lipitor 10 mg tablet 1 tab(s) once a day.
Allergies: NKDA
Objective:
Vitals: Temp 96.8, BP 156/86, HR 81, RR 19, Wt 225, Ht 5’4”
Examination: General appearance pleasant. HEENT normal. Heart rate regular rate and rhythm, lungs clear, BS present,
pulses 2+ bilaterally radial and pedal. Diminished pinprick sensation on bilateral lower extremities from toes to knees.
Left heel wound measures 3 cm by 2 cm and 0.4 cm deep. Wound bed is red, without slough. Minimal amount of yellow
drainage noted on removed bandage.
Assessment:
1. Open wound left heel
Plan:
1. OPEN WOUND Begin hydrocolloid with silver dressing changes. Minimal weight bear on left leg with a surgical boot
on left foot. Begin home health for wound care, family teaching on wound care, and patient education on signs and
symptoms of infection. The patient is now homebound due to minimal weight bearing on left foot and restrictions on
walking to promote wound healing, she is currently using a wheelchair. Short-term nursing is needed for wound care,
monitor for signs of infection, and education on wound care for family to perform dressing changes.
Follow Up: Return office visit in 2 weeks.
Provider: John Doe, M.D.
Patient: Smith, Jane DOB: 04/13/1941 Date: 05/03/2013
Electronically signed by John Doe, M.D. on 05/03/2013 at 10:15 AM
Sign off status: Completed
Meets the requirements for documenting:
(1) the need for skilled services; (2) why the
patient was/is confined to the home
(homebound); and (3) that the encounter
was related to the primary reason the
patient requires home health services.
Example 3 – Part 1 of 2
Patient: Rogers, Buck
DOB: 08/13/1925
Address: 234 Happy Lane, Teamwork, MD 12345
Provider: Jane Doe, M.D.
Date: 09/01/2014
Subjective:
CC:
HPI:
Progress Notes
Allowed provider
type
Date of Encounter
Weakness
Pt was hospitalized 2 weeks ago for pneumonia. He was treated with IV antibiotics for 5 days and discharged on
oral antibiotics for 10 days. His caregiver is present with him for the visit. The patient reports that his appetite has been
decreased since the hospitalization and he has noticed increasing weakness and difficulty walking. The patient has lost 2
lbs. since his last visit. He has stayed in bed for most of the time since his hospitalization. He used a wheelchair to move
from the front of the office building to the exam room. The patient has not needed a wheel chair previously. The patient
denies any fever, chills, cough, rhinorrhea, sore throat, ear pain, difficulty drinking liquids, nausea, vomiting or diarrhea.
ROS:
General:
2 lb weight change, positive for weakness, positive for fatigue.
Pulmonary: As per the HPI
Cardiology:
No chest pain, no palpitations, no dizziness, no shortness of breath.
Medical History: HTN; hyperlipidemia; Diabetes Mellitus
Medications: ASA 325 mg once a day, Diovan HCl 12.5 mg-320 mg tablet 1 tab(s) once a day, Lipitor 10 mg tablet 1
tab(s) once a day. Metformin 1000 mg once a day.
Allergies: NKDA
Objective:
Vitals: Temp 98.6, BP 120/80, HR 71, RR 12, Wt 200, Ht 5’9” pulse ox 99% on room air
Examination: The patient is awake and alert and in no acute distress. He is in a wheelchair. HEENT: Pupils do not react
to light. Heart rate regular rate and rhythm, lungs clear, BS present, Extremities: pulses 2+ bilaterally radial and pedal.
Diminished pinprick sensation on bilateral lower extremities from toes to knees ; Muscle Strength 3/5 in all 4
extremities(normal 5/5). The patient’s get up and to test was 35 seconds(normal <10)
Assessment:
1. Muscle Weakness secondary to deconditioning due to pneumonia
Plan:
1. Prior to the patient’s hospitalization for pneumonia, the patient could ambulate in his residence with assistance and
was able to rise from a chair without difficulty. The patient requires a home health PT program for gait training and
increasing muscle strength to restore the patient’s ability to walk in his residence.
Follow Up: Return office visit in 6 weeks.
Provider: Jane Doe, M.D.
Electronically signed by Jane Doe, M.D. on 09/02/2014 at 10:15 AM
Sign off status: Completed
Meets the requirements for documenting: (1)
the need for skilled services; and (2) that the
encounter was related to the primary reason
the patient requires home health services.
Please see problem list (Part 2 of 2) for
homebound status.
Problem List*
Example 3 – Part 2 of 2
Patient: Rogers, Buck
DOB: 08/13/1925
Address: 234 Happy Lane, Teamwork, MD 12345
401.1
272.2
250.5
369.22
HTN - 1999
Hyperlipidemia -1999
Diabetes Mellitus with ophthalmic manifestations -2000
Blindness - 2002 (requires a caregiver assistance in order to leave the home)
482.31 Pneumonia- Streptococcus- 2014
In conjunction with the progress note, this
meets the requirements for documenting
why the patient was/is confined to the
home (homebound).
*A problem list would not be acceptable by itself to demonstrate skilled need and/or homebound
status.
Example 4 – Part 1 of 2
Date of Encounter
AAA HOSPITAL DISCHARGE SUMMARY
-DEPARTMENT OF SURGERYSmith, John
00000124
04-14-2014
04-18-2014
Patient Name
Med Rec No.
Admit Date
Discharge Date
Physician: Sam Bone, M.D.
Dictated By: Sam Bone, M.D.
Allowed Provider Type
ADMISSION DIAGNOSIS:
Left knee osteoarthritis.
DISCHARGE DIAGNOSIS:
Left knee osteoarthritis.
CONSULTATIONS:
1. Physical Therapy
2. Occupational Therapy
PROCEDURES:
04/14/2014: Left knee arthroplasty.
HISTORY OF PRESENT ILLNESS:
Mr. Smith is 70 y.o. male who presents with left knee osteoarthritis for 10 years. Over the past three years the pain has
steadily increased. It was initially controlled by ibuprofen and steroid injections. In the last year he has required ibuprofen
and Percocet to ambulate and this treatment has been unsuccessful in relieving pain for the last 6 months. His ambulation
has been limited by pain and he has pain at night that interrupts sleep. Workup did show reduction in the left knee joint
space. He has failed conservative treatment and has elected to proceed with surgical treatment.
PAST MEDICAL HISTORY:
Hypertension
PAST SURGICAL HISTORY:
Inguinal hernia repair
Meets the requirements for documenting: (1) the need for
skilled services; and (2) that the encounter was related to
the primary reason the patient requires home health
services.
Please see OASIS (Part 2 of 2) for homebound status.
DISCHARGE MEDICATIONS:
Colace 100 mg daily, Percocet 5/325 every 4 hours as needed for pain, Lisinopril 10 mg daily, Lovenox 30mg sq every
12hours for 6 more days.
DISCHARGE CONDITION:
Upon discharge Mr. Smith is stable status post left total knee replacement and has made good progress with his therapies
and rehabilitation. Mr. Smith is to be discharged to home with home health services, physical therapy and nursing visits,
ordered. PT is needed to restore the ability to walk without support. Short-term skilled nursing is needed to monitor for
signs of decomposition and teaching of Lovenox injections.
PATIENT INSTRUCTION:
The patient is discharged to home in the care of his wife. Diet is regular. Activity, weight bear as tolerated left lower
extremity. Call the office or return to the emergency room for any concerns including increased redness, swelling,
drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. Bone in two
weeks.
Transcribed by: A.M 04/18/2014
Electronically signed by: Sam Bone, M.D. 04/18/2014 18:31
Example 4 – Part 2 of 2
Generic Home Health Agency
Excerpt from Comprehensive Assessment (OASIS-C)
Patient Name: John Smith
HH Record Number: 4433225
ADL/IADLs continued
(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely,
adjust clothes and/or incontinence pads before and after using toilet, commode,
bedpan, urinal. If managing ostomy, includes cleaning area around stoma,
but not managing equipment.
⃞ 0 - Able to manage toileting hygiene and clothing management without assistance.
X 1 - Able to manage toileting hygiene and clothing management without assistance
if supplies/implements are laid out for the patient.
⃞ 2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
⃞ 3 - Patient depends entirely upon another person to maintain toileting hygiene.
Comments: Patient requires clothes to be laid out on bed. He is able to dress himself from a
seated position at foot of bed.
(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn
and position self in bed if patient is bedfast.
⃞ 0 - Able to independently transfer.
X 1 - Able to transfer with minimal human assistance or with use of an assistive device.
⃞ 2 - Able to bear weight and pivot during the transfer process but unable to transfer self.
⃞ 3 - Unable to transfer self and is unable to bear weight or pivot when transferred by another person.
⃞ 4 - Bedfast, unable to transfer but is able to turn and position self in bed.
⃞ 5 - Bedfast, unable to transfer and is unable to turn and position self.
Comments: Patient requires one-arm assistance to transfer from bed to chair.
(M1860) Ambulation/Locomotion: Current ability to walk safely, once
in a standing position, or use a wheelchair, once in a seated position,
on a variety of surfaces.
⃞ 0 - Able to independently walk on even and uneven surfaces and negotiate stairs
with or without railings (i.e., needs no human assistance or assistive device).
⃞ 1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker),
able to independently walk on even and uneven surfaces and
negotiate stairs with or without railings.
X 2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone
on a level surface and/or requires human supervision or assistance
to negotiate stairs or steps or uneven surfaces.
⃞ 3 - Able to walk only with the supervision or assistance of
another person at all times.
⃞ 4 - Chairfast, unable to ambulate but is able to wheel self independently.
Pg.13
Example 4 – Part 2 of 2
⃞ 5 - Chairfast, unable to ambulate and is unable to wheel self.
⃞ 6 - Bedfast, unable to ambulate or be up in a chair.
Comments: Pt. with a shuffling gait and frequently trips while ambulating. Pt. requires a wheeled walker and requires
frequent cueing to remind him to not shuffle when he walks and to look up to avoid environmental hazards. Unable to
go up and down stairs without his daughter assisting him. Daughter states that patient needs 24/7 supervision and is
only able to leave his home for doctor appointments and only when she and her husband assist him. Patient is an
increased fall risk because of inability to safely navigate stairs, uneven sidewalks and curbs.
In conjunction with the discharge
summary, this meets the
requirements for documenting why
the patient was/is confined to the
home (homebound).
Pg.14
Sam Bone, M.D. 4/20/2014
Signed and dated by certifying
physician indicating review and
incorporation into the patient’s
medical record.
New Waived Tests MLN Matters® Number: MM8951
Related Change Request (CR) #: CR 8951
Related CR Release Date: December 12, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3149CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 8951 informs MACs about the new Clinical Laboratory Improvement Amendments of 1998 (CLIA) waived tests approved by the Food and Drug Administration (FDA). Since these tests are marketed
immediately after approval, the Centers for Medicare & Medicaid Services (CMS) must notify its MACs of the new tests so that they can accurately process claims. There are four newly added waived complexity tests. CLIA requires that for each test it performs, a laboratory facility must be appropriately certiﬁed. The CPT codes that the CMS considers to be laboratory tests under CLIA (and thus requiring certiﬁcation) change each year. If you do not have a valid, current, CLIA certiﬁcate and submit a claim to your MAC for a Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certiﬁcate, your Medicare payment may be impacted. Make sure that your billing staffs are aware of these changes. Background
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.
Listed below are the latest tests approved by the FDA as waived tests under CLIA. CPT codes for the following
new tests must have the modiﬁer QW to be recognized as a waived test. Tests with CPT codes shown on the
ﬁrst page of the attachment to CR8951 (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 listed in the following table.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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HCPCS/
CPT Code
& HCPCS
Modiﬁer
87807QW
G0434QW
87807QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
87880QW
87880QW
G0434QW
86308QW
87880QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
G0434QW
81003QW
Effective Date
Description
March 18, 2014 BD Veritor System for Rapid Detection of RSV (For use with
nasopharyngeal specimens){Includes a reader}
May 12, 2014
Native Diagnostics International, DrugSmart Dip Single/Multi-Panel
Drug Screen Dip Card Tests
May 30, 2014
Soﬁa RSV
June 9, 2014
Healgen THC One Step Marijuana Test Strip
June 9, 2014
Healgen THC One Step Marijuana Test Cassette
June 9, 2014
Healgen THC One Step Marijuana Test Cup
June 9, 2014
Healgen THC One Step Marijuana Test Dip Card
June 9, 2014
Healgen mAMP One Step Methamphetamine Test Strip
June 9, 2014
Healgen mAMP One Step Methamphetamine Test Cassette
June 9, 2014
Healgen mAMP One Step Methamphetamine Test Cup
June 9, 2014
Healgen mAMP One Step Methamphetamine Test Dip Card
June 11, 2014
Poly stat Strep A Strip Test {Specimen type (Throat Swab)}
June 25, 2014
StrepAim {Specimen type (Throat Swab)}
June 27, 2014
Wal-Mart Stores, Inc. ReliOn Home Drug Urine Cup Test
July 7, 2014
Jant Pharmacal Corp. Accutest Rapid Mono Test {Whole Blood}
July 9, 2014
Cardinal Health Strep A Dipstick – Rapid Test (Throat Swab
Specimen)
July 18, 2014
Healgen COC One Step Cocaine Test Strip
July 18, 2014
Healgen COC One Step Cocaine Test Cassette
July 18, 2014
Healgen COC One Step Cocaine Test Cup
July 18, 2014
Healgen COC One Step Cocaine Test Dip Card
July 18, 2014
Healgen MOP One Step Morphine Test Strip
July 18, 2014
Healgen MOP One Step Morphine Test Cassette
July 18, 2014
Healgen MOP One Step Morphine Test Cup
July 18, 2014
Healgen MOP One Step Morphine Test Dip Card
August 8, 2014 Medline 120 Urine Analyzer
MACs will not search their ﬁles to either retract payment or retroactively pay claims processed prior to
implementation of CR8951; however, they should adjust claims if you bring such claims to your MAC’s attention.
Additional Information
The ofﬁcial instruction, CR8951 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3149CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Calendar Year (CY) 2015 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
MLN Matters® Number: MM9028
Related Change Request (CR) #: CR 9028
Related CR Release Date: December 19, 2014
Effective Date: January 1, 2015
Related CR Transmittal #: R3152CP
Implementation Date: January 5, 2015
Provider Types Affected
This MLN Matters® article is intended for clinical diagnostic laboratories who submit claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneﬁciaries.
Provider Action Needed
Change Request (CR) 9028 provides instructions for the CY 2015 clinical laboratory fee schedule, mapping
for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge
payment. Make sure your billing staffs are aware of these updates.
Background
In accordance with Section 1833(h)(2)(A)(i) of the Social Security Act (the Act), as amended by Section 628 of
the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, and further amended
by Section 3401 of the Affordable Care Act of 2010, the annual update to the local clinical laboratory fees
for CY 2015 is (-0.25) percent. The annual update to local clinical laboratory fees for CY 2015 reﬂects an
additional multi-factor productivity adjustment and a (-1.75) percentage point reduction as described by the
Affordable Care Act.
The annual update to payments made on a reasonable charge basis for all other laboratory services for CY
2015 is 2.10 percent (See 42 CFR 405.509(b)(1)). Section 1833(a)(1)(D) of the Act provides that payment
for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the National
Limitation Amount (NLA).
For a cervical or vaginal smear test (pap smear), Section 1833(h)(7) of the Act requires payment to be the
lesser of the local fee or the NLA, but not less than a national minimum payment amount (described below).
However, for a cervical or vaginal smear test (pap smear), payment may also not exceed the actual charge. The
Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule.
Key Points of CR9028
National Minimum Payment Amounts
For a cervical or vaginal smear test (pap smear), Section 1833(h)(7) of the Act requires payment to be the
lesser of the local fee or the NLA, but not less than a national minimum payment amount. Also, payment may
not exceed the actual charge. The CY 2015 national minimum payment amount is $14.38 ($14.42 plus (-0.25)
percent update for CY 2015).
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
90
2/2015
The affected codes for the national minimum payment amount are CPT codes 88142, 88143, 88147, 88148,
88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, and HCPCS codes G0123, G0143,
G0144, G0145, G0147, G0148, and P3000. National Limitation Amounts (Maximum)
For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of
the local fees. For tests for which the NLAs are ﬁrst established on or after January 1, 2001, the NLA is 100
percent of the median of the local fees in accordance with Section 1833(h)(4)(B)(viii) of the Act.
Access to Data File
Internet access to the CY 2015 clinical laboratory fee schedule data ﬁle
is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service
Payment/ClinicalLabFeeSched/index.html on the Centers for Medicare
& Medicaid Services (CMS) website. Other interested parties, such as
the Medicaid State agencies, the Indian Health Service, the United Mine
Workers, and the Railroad Retirement Board, may use the Internet to retrieve
the CY 2015 clinical laboratory fee schedule; available in multiple formats,
including Excel, text, and comma delimited.
Public Comments
On July 14, 2014, CMS hosted a public meeting to solicit input on the
payment relationship between CY 2014 codes and new CY 2015 CPT
codes. Notice of the meeting was published in the Federal Register
on March 25, 2014, and on the CMS web site approximately April 1,
2014. Recommendations were received from many attendees, including
individuals representing laboratories, manufacturers, and medical societies.
CMS posted a summary of the meeting and the tentative payment
determinations on the web site at http://www.cms.gov/Medicare/Medicare
Fee-for-Service-Payment/ClinicalLabFeeSched/index.html?redirect=/ClinicalLabFeeSched. Additional written
comments from the public were accepted until October 30, 2014. CMS has posted a summary of the public
comments and the rationale for the ﬁnal payment determinations at http://www.cms.gov/Medicare/Medicare
Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2015-CLFS-Codes-Final-Determinations.pdf
on the CMS web site.
Pricing Information
The CY 2015 clinical laboratory fee schedule includes separately payable fees for certain specimen collection
methods (CPT code 36415 and HCPCS codes P9612, and P9615). The fees are established in accordance with
Section 1833(h)(4)(B) of the Act.
The fees for clinical laboratory travel HCPCS codes P9603 and P9604 are updated annually. The clinical
laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing
home or homebound patient. If there is a revision to the standard mileage rate for CY 2015, CMS will issue a
separate instruction on the clinical laboratory travel fees.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
91
2/2015
The CY 2015 clinical laboratory fee schedule also includes codes that have a “QW” HCPCS modiﬁer to both
identify codes and to determine payment for tests performed by a laboratory having only a certiﬁcate of waiver
under the Clinical Laboratory Improvement Amendments (CLIA).
Organ or Disease Oriented Panel Codes
As in prior years, the CY 2015 pricing amounts for certain organ or disease panel codes and evocative/
suppression test codes were derived by summing the lower of the clinical laboratory fee schedule amount or
the NLA for each individual test code included in the panel code. The NLA ﬁeld on the data ﬁle is zero-ﬁlled.
Mapping Information
Existing code 83516QW is priced at the same rate as code 83516. New code 80163 is priced at the same rate as code 80162. New code 80165 is priced at the same rate as code 80164. New codes to be gap ﬁlled are 81161, 81246, 81287, 81288, 81313, 81410, 81411, 81415, 81416, 81417, 81420, 81425, 81426, 81427, 81430, 81431, 81435, 81436, 81440, 81445, 81450, 81455, 81460, 81465, 81470, and 81471. New code 83006 is priced at the same rate as code 82777. New code 87505 is priced at the same rate as code 87631. New code 87506 is priced at the same rate as code 87632. New code 87507 is priced at the same rate as code 87633. New code 87623 is priced at the same rate as code 87621. New code 87624 is priced at the same rate as code 87621. New code 87625 is priced at the same rate as code 87621. New code 87806 is priced at the same rate as code 87389. New code G6030 is priced at the same rate as code 80152. New code G6031 is priced at the same rate as code 80154. New code G6032 is priced at the same rate as code 80160. New code G6034 is priced at the same rate as code 80166. New code G6035 is priced at the same rate as code 80172. New code G6036 is priced at the same rate as code 80174. New code G6037 is priced at the same rate as code 80182. New code G6038 is priced at the same rate as code 80196. New code G6039 is priced at the same rate as code 82003. New code G6040 is priced at the same rate as code 82055. New code G6041 is priced at the same rate as code 82101. New code G6042 is priced at the same rate as code 82145. New code G6043 is priced at the same rate as code 82205. New code G6044 is priced at the same rate as code 82520. New code G6045 is priced at the same rate as code 82646. New code G6046 is priced at the same rate as code 82649. New code G6047 is priced at the same rate as code 82651. New code G6048 is priced at the same rate as code 82654. New code G6049 is priced at the same rate as code 82666. New code G6050 is priced at the same rate as code 82690. New code G6051 is priced at the same rate as code 82742. Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
92
2/2015
New code G6052 is priced at the same rate as code 83805. New code G6053 is priced at the same rate as code 83840. New code G6054 is priced at the same rate as code 83858. New code G6055 is priced at the same rate as code 83887. New code G6056 is priced at the same rate as code 83925. New code G6057 is priced at the same rate as code 84022. New code G6058 is priced at the same rate as code 80102. New code G0464 is priced at the same rate as sum of codes 81315, 81275, and 82274. The following existing codes are to be deleted: 80440, 82000, 82055, 82055QW, 82953, 82975, 82980, 83008, 83055, 83071, 83634, 83866, 84127, 87001, 87620, 87621, 87622, 80102, 80152, 80154, 80160, 80166, 80172, 80174, 80182, 80196, 82003, 82101, 82145, 82205, 82520, 82646, 82649, 82651, 82654, 82666, 82690, 82742, 83805, 83840, 83858, 83887, 83925, and 84022. Laboratory Costs Subject to Reasonable Charge Payment in CY 2011
For outpatients, the following codes are paid under a reasonable charge basis. The reasonable charge may not
exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period
ending June 30, updated by the inﬂation-indexed update. The inﬂation-indexed update is calculated using the
change in the applicable Consumer Price Index for the 12-month period ending June 30 of each year as set
forth in 42 CFR 405.509(b)(1). The inﬂation-indexed update for CY 2015 is 2.1 percent.
Manual instructions for determining the reasonable charge payment can be found in Publication 100-4, “Medicare
Claims Processing Manual,” Chapter 23, Section 80 through 80.8, available at http://www.cms.gov/Regulations
and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf on the CMS website. If there is sufﬁcient charge
data for a code, the instructions permit considering charges for other similar services and price lists.
When services described by the Healthcare Common Procedure Coding System (HCPCS) in the following list
are performed for independent dialysis facility patients, the “Medicare Claims Processing Manual,” Chapter
8, Section 60.3, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c08.pdf, instructs that the reasonable charge basis applies. When these services are performed
for hospital-based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these
services are performed for hospital outpatients, payment is made under the hospital Outpatient Prospective
Payment System (OPPS).
Blood Product Codes
Blood Product codes are P9010, P9011, P9012, P9016, P9017, P9019, P9020, P9021, P9022, P9023, P9031,
P9032, P9033, P9034, P9035, P9036, P9037, P9038, P9039, P9040, P9044, P9050, P9051, P9052,P9053,
P9054, P9055, P9056, P9057,P9058, P9059, and P9060. Also, payment for codes P9010, 9016, P9021, P9022,
P9038, P9039, P9040, P9051, P9054, P9056, P9057, and P9058 should be applied to the blood deductible as
instructed in the “Medicare General Information, Eligibility and Entitlement Manual,” Chapter 3, Section 20.5
through 20.5.4 (available at Also, payment for codes P9010, 9016, P9021, P9022, P9038, P9039, P9040, P9051,
P9054, P9056, P9057, and P9058 should be applied to the blood deductible as instructed in the “Medicare
General Information, Eligibility and Entitlement Manual,” Chapter 3, Section 20.5 through 20.5.4 (available
at Also, payment for codes P9010, 9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9056, P9057,
and P9058 should be applied to the blood deductible as instructed in the “Medicare General Information,
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
93
2/2015
Eligibility and Entitlement Manual,” Chapter 3, Section 20.5 through 20.5.4 (available at
NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on Section 1842(o)
of the Act. The payment limits based on Section 1842(o), including the payment limits for codes P9041, P9045,
P9046, and P9047 should be obtained from the Medicare Part B drug pricing ﬁles
Transfusion Medicine Codes
Transfusion Medicine codes are 86850, 86860, 86870, 86880, 86885, 86886, 86890, 86891, 86900, 86901,
86902, 86904, 86905, 86906, 86920, 86921, 86922, 86923, 86927, 86930, 86931, 86932, 86945, 86950, 86960,
86965, 86970, 86971, 86972, 86975, 86976, 86977, 86978, and 86985.
Reproductive Medicine Procedures
Reproductive Medicine Procedure codes are 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260,
89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89342, 89343, 89344, 89346, 89352, 89353,
89354, and 89356.
MACs will not search their ﬁles to either retract payment or retroactively pay claims; however, they should
adjust claims that you bring to their attention.
Additional Information
The ofﬁcial instruction, CR9028, issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3152CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
94
2/2015
Fluorodeoxyglucose (FDG) Positron Emission Tomography
(PET) for Solid Tumors (This Change Request (CR) rescinds
and fully replaces MM 8468, dated February 6, 2014.)
MLN Matters® Number: MM8739 Revised
Related Change Request (CR) #: CR 8739
Related CR Release Date: January 8, 2015
Effective Date: June 11, 2013
Related CR Transmittal #: R3162CP, R168NCD
Implementation Dates: May 19, 2014 - MAC Non-Shared System Edits; July 7, 2014 - CWF development/
testing, FISS requirement development; October 6, 2014 - CWF, FISS, MCS Shared System Edits
Note: This article was revised on January 12, 2015, to reﬂect the revised CR8739 issued on January 8. In
the article, reference to an attachment at the bottom of page 2 has been replaced with a Web link to the list of
appropriate diagnosis codes. Note that 793.11 has been added to that list. 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 physicians, providers and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services to Medicare beneﬁciaries.
Provider Action Needed
This article is based on Change Request (CR) 8739, which advises MACs, effective for dates of service on or
after June 11, 2013, to cover three FDG PET scans when used to guide subsequent management of anti-tumor
treatment strategy after completion of initial anti-cancer therapy for the same cancer diagnosis. Coverage of
any additional FDG PET scans (that is, beyond three) used to guide subsequent management of anti-tumor
treatment strategy after completion of initial anti-cancer therapy for the same diagnosis will be determined by
your MAC. Make sure your billing staffs are aware of these changes.
Background
The Centers for Medicare & Medicaid Services (CMS) has reconsidered Section 220.6, of the “National
Coverage Determinations (NCD) Manual” to end the prospective data collection requirements across all
oncologic indications of FDG PET in the context of CR8739. The term FDG PET includes PET/computed
tomography (CT) and PET/magnetic resonance (MRI).
CMS is revising the “NCD Manual”, Section 220.6, to reﬂect that CMS has ended the coverage with evidence
development (CED) requirement for (2-[F18] ﬂuoro-2-deoxy-D-glucose) FDG PET, PET/CT, and PET/MRI
for all oncologic indications contained in Section 220.6.17 of the “NCD Manual”. This removes the current
requirement for prospective data collection by the National Oncologic PET Registry (NOPR) for oncologic
indications for FDG (Healthcare Common Procedure Coding System (HCPCS) Code A9552) only.
NOTE: For clariﬁcation purposes, as an example, each different cancer diagnosis is allowed one (1) initial
treatment strategy (-PI modiﬁer) FDG PET Scan and three (3) subsequent treatment strategy (-PS modiﬁer)
FDG PET Scans without the -KX modiﬁer. The fourth FDG PET Scan and beyond for subsequent treatment
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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strategy for the same cancer diagnosis will always require the -KX modiﬁer. If a different cancer diagnosis is
reported, whether reported with a -PI modiﬁer or a -PS modiﬁer, that cancer diagnosis will begin a new count
for subsequent treatment strategy for that beneﬁciary. A beneﬁciary’s ﬁle may or may not contain a claim for
initial treatment strategy with a -PI modiﬁer. The existence or non-existence of an initial treatment strategy
claim has no bearing on the frequency count of the subsequent treatment strategy (-PS) claims.
Providers may refer to http://cms.gov/medicare/coverage/determinationprocess/downloads/
petforsolidtumorsoncologicdxcodesattachment_NCD220_6_17.pdf for a list of appropriate diagnosis codes.
Effective for claims with dates of service on or after June 11, 2013, Medicare will accept and pay for FDG PET
oncologic claims billed to inform initial treatment strategy or subsequent treatment strategy for suspected or
biopsy proven solid tumors for all oncologic conditions Effective for claims with dates of service on or after
June 11, 2013, Medicare will accept and pay for FDG PET oncologic claims billed to inform initial treatment
strategy or subsequent treatment strategy for suspected or biopsy proven solid tumors for all oncologic conditions
Effective for claims with dates of service on or after June 11, 2013, Medicare will accept and pay for FDG PET
oncologic claims billed to inform initial treatment strategy or subsequent treatment strategy for suspected or
biopsy proven solid tumors for all oncologic conditions
• Q0 modiﬁer: Investigational clinical service provided in a clinical research study that is in an approved
clinical research study (institutional claims only);
• Q1 modiﬁer: routine clinical service provided in a clinical research study that is in an approved clinical
research study (institutional claims only);
• V70.7: Examination of participant in clinical research; or
• Condition code 30 (institutional claims only).
Effective for dates of service on or after June 11, 2013, MACs will use the following messages when denying
claims in excess of three for PET FDG scans for subsequent treatment strategy when the –KX modiﬁer is not
included, identiﬁed by CPT codes 78608, 78811, 78812, 78813, 78814, 78815, or 78816, modiﬁer –PS, HCPCS
A9552, and the same cancer diagnosis code:
• Claim Adjustment Reason Code (CARC) 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare
Policy Identiﬁcation Segment (loop 2110 Service Payment Information REF), if present.”
• Remittance Advice Remarks Code (RARC) N435: “Exceeds number/frequency approved/allowed within
time period without support documentation.”
• Group Code PR assigning ﬁnancial liability to the beneﬁciary, if a claim is received with a GA modiﬁer
indicating a signed ABN is on ﬁle.
• Group Code CO assigning ﬁnancial liability to the provider, if a claim is received with a GZ modiﬁer
indicating no signed ABN is on ﬁle.
MACs will not search their ﬁles to adjust claims processed prior to implementation of CR8739. However, if you
have such claims and bring them to the attention of your MAC, the MAC will adjust such claims if appropriate.
Synopsis of Coverage of FDG PET for Oncologic Conditions
Effective for claims with dates of service on and after June 11, 2013, the chart below summarizes national
FDG PET coverage for oncologic conditions:
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
96 2/2015
FDG PET for Cancers
Tumor Type
Initial Treatment Strategy
(formerly “diagnosis” &
“staging”
Colorectal
Esophagus
Head and Neck (not thyroid, CNS)
Lymphoma
Non-small cell lung
Ovary
Brain
Cervix
Small cell lung
Soft tissue sarcoma
Pancreas
Testes
Prostate
Thyroid
Breast (male and female)
Melanoma
All other solid tumors
Myeloma
All other cancers not listed
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover with exceptions *
Cover
Cover
Cover
Cover
Non-cover
Cover
Cover with exceptions *
Cover with exceptions *
Cover
Cover
Cover
Subsequent Treatment Strategy
(formerly “restaging” &
“monitoring response to
treatment”
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
Cover
*Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor treatment
strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered.
*Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally covered
for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast
cancer are nationally covered.
*Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial
anti-tumor treatment strategy for melanoma are nationally covered.
Additional Information
The ofﬁcial instruction, CR 8739, issued to your MAC regarding this change, is available at in two transmittals
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3162CP.pdf and
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R168NCD.pdf on the
CMS website.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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P-ACE
Palmetto GBA is excited to announce we have launched our new Palmetto GBA Advanced Clinical Editing
System (P-ACE)! P-ACE is available to all direct submitters as well as those who transmit claims via
clearinghouses/billing services. New CEM ‘Smart edits’ will appear on claim rejection reports (277CA) as
Palmetto GBA deploys P-ACE to electronic the claim submission process for professional claims.
• P-ACE returns pre-adjudicated claims information through claim acknowledgement transaction reports
sent by your clearinghouse based on the Medicare 277CA
• All direct submitters will receive the Medicare 277CA report with the new smart edits
• Claims failing the pre-adjudication editing process are not forwarded to the claims adjudication system
• P-ACE will work with your current clearinghouse/billing service workﬂow so you can modify claims before
the MCS system receives them
After you have reviewed the Smart Edit, if you choose not to change the claims, you can resubmit in its original
format and it will pass to the MCS claims adjudication system for processing. P-ACE is available to you at no
cost! No downloads or software is required. P-ACE is incorporated in your normal EDI stream.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
98 2/2015
Interactive Tools
These guides provide instruction
on how to complete or interpret the
following forms. They are available
on the home page, under Self-Service
Tools.
Remittance Advice
EDI Agreement
EDI Application
EDI Provider
Authorization
Advance Beneﬁciary Notice (ABN)
CMS 1500 Claim Form
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
99
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Medical Director’s Desk
Medical Affairs publishes Medicare Local Coverage Determination (LCDs)
and medically related articles in this special section of the Medicare Advisory.
We encourage you to help us maintain accurate LCDs. Please review LCDs and
address your comments and concerns to your Carrier Advisory Committee specialty
representative or contact the Medical Affairs Department.
Medical articles are published in the Medicare Advisory to provide education
and alert Medicare providers of billing/coding issues. Remember, physicians and
non-physician practitioners (NPPs) who bill Medicare are responsible for accurate
service coding. Errors may result in overpayment requests or Recovery Auditor
(RA) referrals. If you purchase a new device or need to submit claims for a new
procedure, please review applicable service codes and descriptions in the current
CPT and HCPCS manuals. If you question the recommended service procedures
received from other sources such as manufacturers, send your inquiry and the
device description to the Medical Affairs Department.
To contact the Medical Affairs Department:
e-mail: [email protected]
Mail: J11 Part B Medical Affairs, AG-300
Palmetto GBA
PO Box 100190
Columbia, SC 29202-3190
Continued >>
Looking for Local Coverage Determinations (LCDs) Converted to ICD-10?
A list of Local Coverage Determinations (LCDs) converted to ICD-10 is available on the LCDs by Contractor
Index (http://go.cms.gov/1tOP9VN). Use the scroll box on the index to select your Medicare Administrative
Contractor (MAC) and select the ‘Submit’ button to view a list of states that the speciﬁed MAC services. You
can then select your MAC name from the table to view the future translated LCDs.
Please view the Special Edition MLN article SE1421, at http://www.cms.gov/Outreach-and-Education/Medicare
Learning-Network-MLN/MLNMattersArticles/Downloads/SE1421.pdf, ‘How to Access Updates to ICD-10
Local Coverage Determinations in the CMS Medicare Coverage Database,’ for more information.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
100
2/2015
The table below provides a summary of the Local Coverage Determination (LCD) revisions/updates and those
that may be retired. To view date speciﬁc policy revisions/updates, select the ‘Active’ or ‘Retired’ menu for
the appropriate state from the LCDs and NCDs web page, then make your policy selection and scroll to the
‘Revision History Explanation’ section. To view a draft policy, select ‘Draft’ from the policy menu. To facilitate
comments, a contact link has been provided near the bottom of the policy.
Policy Title
Allergy Skin Testing
L31774 Rev 7
Assays for Vitamins and
Metabolic Function
L31775
Rev 5
Bladder Tumor Markers
L32118 Rev 5
Brain Natriuretic Peptide
(BNP) Level L31697
Rev 5
Chemodenervation
L31701
Rev 9
Diagnostic
Mammography
L31785
Rev 4
Infectious Disease
Molecular Diagnostic
Testing
L31747
Rev 7
Spinal Cord Stimulators
for Chronic Pain L32549
Rev. 4
Policy Title
Allergy Skin Testing
L33417
Rev 1
LCD ICD-9 Revision
Under CMS National Coverage Policy added citation 42 Code of Federal
Regulations, §410.20, Physician’s Services.
Under CMS National Coverage Policy revised “CMS Manual System” to now
read “CMS Internet-Only Manuals”. Italicized titles of manuals. Completed
title of Medicare National Coverage Determinations Manual. Under Sources of
Information and Basis for Decision revised citations to AMA format. Removed
reference to Program Memorandum Transmittal AB-02-165 as this is already cited
in CMS National Coverage Policy section. Corrected hyperlink to NCD reference.
Corrected page numbers for American College of Cardiology and American Heart
Association reference.
Under Sources of Information and Basis for Decision placed 3rd bibliography in
a hyperlinked url for the web site when clicked on the text.
Under CMS National Coverage Policy corrected citation by adding CMS InternetOnly Manuals and removing CMS Manual System. Under Sources of Information
and Basis for Decision removed the verbiage, “The development and coverage
guidelines in this policy were based on a review of pertinent medical literature,
policies from other Medicare contractors, and discussions with appropriate
specialists,” as this information is redundant since our bibliography is listed.
Under CMS National Coverage Policy revised Section of Pub 100-2 of CMS
Internet-Only Manuals to now read 50.4.1.
Effective Date
01/23/2015
01/23/2015
01/23/2015
01/15/2015
01/23/2015
Under CPT/HCPCS Codes Group 1, a descriptor change was made to HCPCS 01/01/2015
codes G0204 and G0206. These changes are due to the Annual CPT/HCPCS Update
CR 8975 dated 10/24/2014.
Under CPT HCPCS Codes the following codes had short descriptor changes: 01/01/2015
87501, 87502 and 87503. CPT code 87621 was deleted and 87624 was added.
Under ICD-9 Codes that Support Medical Necessity Group 10: Paragraph, CPT
code 87621 was deleted and CPT code 87624 was added. These revisions are due
to CR 8975 HCPCS Annual Update dated 10/24/2014.
Under CPT/HCPCS Codes removed HCPCS code L8680 as this was made not 01/08/2015
valid for Medicare per CR 8645.
LCD ICD-10 Revision
Effective Date
Under CMS National Coverage Policy added citation 42 Code of Federal 10/01/2015
Regulations, §410.20, Physician’s Services.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
101
2/2015
Assays for Vitamins and
Metabolic Function
L33418
Rev 1
Bladder Tumor Markers
L33420
Rev 1
Brain Natriuretic Peptide
(BNP) Level L33422
Rev 1
Chemodenervation
L33458
Rev 5
Diagnostic
Mammography
L33429
Rev 2
Infectious Disease
Molecular Diagnostic
Testing
L33433
Rev 2
Spinal Cord Stimulators
for Chronic Pain L34556
Rev 2
Under CMS National Coverage Policy italicized titles of manuals. Completed 10/01/2015
title of Medicare National Coverage Determinations Manual. Under Sources of
Information and Basis for Decision revised citations to AMA format. Removed
reference to Program Memorandum Transmittal AB-02-165 as this is already cited
in CMS National Coverage Policy section. Corrected hyperlink to NCD reference.
Corrected page numbers for American College of Cardiology and American Heart
Association reference.
Under Sources of Information and Basis for Decision placed 3rd bibliography in 10/01/2015
a hyperlinked url for the web site when clicked on the text.
Under CMS National Coverage Policy corrected citation by adding CMS Internet- 10/01/2015
Only Manuals and removing CMS Manual System. Under Sources of Information
and Basis for Decision removed the verbiage, “The development and coverage
guidelines in this policy were based on a review of pertinent medical literature,
policies from other Medicare contractors, and discussions with appropriate
specialists,” as this information is redundant since our bibliography is listed.
Under CMS National Coverage Policy revised Section of Pub 100-2 of CMS 10/01/2015
Internet-Only Manuals to now read 50.4.1.
Under CPT/HCPCS Codes Group 1, a descriptor change was made to HCPCS 10/01/2015
codes G0204 and G0206. These changes are due to the Annual CPT/HCPCS Update
CR 8975 dated 10/24/2014.
Under CPT HCPCS Codes the following codes had short descriptor changes: 10/01/2015
87501, 87502 and 87503. CPT code 87621 was deleted and 87624 was added.
Under ICD-9 Codes that Support Medical Necessity Group 10: Paragraph, CPT
code 87621 was deleted and CPT code 87624 was added. These revisions are due
to CR 8975 HCPCS Annual Update dated 10/24/2014.
Under CPT/HCPCS Codes removed HCPCS code L8680 as this was made not 10/01/2015
valid for Medicare per CR 8645.
CPT/HCPCS UPDATES TO ARTICLES
Coverage for High
Resolution Anoscopy
A53407/A53408
Coverage for High
Resolution Anoscopy
A53408
Under Article Text removed the statement regarding the Category III CPT codes 01/01/2015
and replaced 0266T 0267T with HCPCS codes G6027 and G6028. CPT/HCPCS 10/01/2015
Codes, paragraph section, removed the statement, “HRA with collection of
specimens (CPT Category III Code 0226T) and HRA with biopsy (CPT Category
III Code 0227T) will be covered only for patients with abnormalities on anoscopy,
abnormalities in digital rectal examination, history of HPV-related anal disease or
abnormalities in anorectal cytology”, as this statement already exists in the Article
text with the exception regarding the CPT Category III Codes. Deleted CPT codes
0226T and 0227T,” added HCPCS codes G6027 and G6028. The changes were due
to CR 8975, Annual HCPCS Update for 2015.
Under Article Text added the paragraph, “High-resolution anoscopy (HRA) is 10/01/2015
analogous to cervical colposcopy. During HRA, a lubricated anoscope is inserted
into the anal canal. A cotton swab wrapped in gauze and soaked in 3-percent acetic
acid is then inserted through the anoscope, and the anoscope is removed, leaving
the gauze in place. The acetic acid gives dysplastic epithelium a white appearance.
After two minutes, the gauze is removed and the anoscope reinserted. A highresolution colposcope (magniﬁcation of 10x to 40x) is used to view the walls of
the anus. A biopsy of suspicious tissue can be taken,” as this paragraph was in the
original article A53407.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
102
2/2015
CPT Modiﬁer 59:
Gastroenterology
A53398/A53399
Failed Colonoscopy
Screening & Diagnostic
A53410/A53412
Low Frequency, Noncontact, Non-thermal
Ultrasound (CPT 97610)
A53774/A53782
Mitraclip Investigational
Device Exemptions
(IDEs) Billing and
Coding A53388/A53389
NCD Anti-Inhibitor
Coagulant Complex
A53569/A53689
NCD Deep Brain
Stimulation for Essential
Tremor and Parkinson’s
Disease A53577/A53647
NCD Hyperbaric Oxygen
Therapy A53603/A53655
NCD Percutaneous
Transluminal Angioplasty
A53626/A53674
Sacroiliac-Bone Implant
System A53451/A53452
Percutaneous Ventricular
Assist Device
A53981
Percutaneous Ventricular
Assist Device
A53986
Under Article Text and CPT/HCPCS Codes descriptor changes were made to
45385, and 45380. The changes were due to CR 8975, Annual HCPCS Update for
2015.
Under CPT/HCPCS Code CPT code 45378 had a revised descriptor change. CR
8975 Annual HCPCS Update for 2015 was the reason for this update to the LCD.
Under Article Text removed CPT Codes 97605 and 97606 and added CPT codes
97607 and 97608 as the descriptors were changed to reﬂect which items were DME
or disposable. Under CPT/HCPCS Codes the following codes were removed from
this article as they are not applicable to this article: 97605 and 97606. Added CPT
codes 97607 and 97608, per CR 8975, Annual HCPCS Update for January 2015.
Under Article Text removed the Category III CPT codes 0343T and 0344T and the
code descriptors. Added CPT code 33418 and 33419 to area where it tells them how
to submit a claim, and removed instructions Enter ‘MITRACLIP’ in the comment/
narrative ﬁeld for the following claim ﬁeld/types: Loop 2400, NTE02 or SV101-7
for the 5010A1 837P, Box 19 for paper claim. Under CPT/HCPCS Code added
HCPCS codes 33418 and 33419, and CPT Category III Codes 0343T and 0344T
were deleted. The revisions were due to CR 8975 HCPCS Annual Update dated
10/24/2014.
Under CPT/HCPCS Codes the following HCPCS codes were added to the article:
J7181, J7182, J7200 and J7201. J7195 had a descriptor change. Under ICD-9
Codes that Support Medical Necessity added the HCPCS codes to the paragraph
section, Group 1 J7181, Group 4, J7182, Group 5 J7200 and J7201. The revisions
were due to CR 8975 HCPCS Annual Update dated 10/24/2014.
Under CPT/HCPCS Codes 95972 had a descriptor change. The revision is due to
CR 8975 HCPCS Annual Update for 2015.
Under CPT/HCPCS Codes added HCPCS code G0277. The addition of this code
is reﬂective of CR 8975 HCPCS Annual update dated 10/24/2014.
Under CPT/HCPCS Codes CPT codes 0075T, 0076T and 37215 had descriptor
changes per CR 8975, Annual HCPCS Update for 2015.
01/01/2015
10/01/2015
01/01/2015
10/01/2015
01/01/2015
10/01/2015
01/01/2015
10/01/2015
01/01/2015
10/01/2015
01/01/2015
10/01/2015
01/01/2015
10/01/2015
Under Article Text removed CPT Category III Code 0334T and replaced with CPT 01/01/2015
code 27279 and made the effective date January 1, 2015. CPT/HCPCS Codes added 10/01/2015
27279 as 0334T was deleted. The revisions were due to CR 8975 HCPCS Annual
Update dated 10/24/2014.
ICD-9 Articles
Under Coverage-Medicare Coverage -General Information-Medicare Coverage
Database enter the document number for the article in the search ﬁeld.
This Percutaneous Ventricular Assist Device article was created to assist with 01/15/2015
billing of this procedure in part B.
ICD-10 Articles
Under Coverage-Medicare Coverage -General Information-Medicare Coverage
Database enter the document number for the article in the search ﬁeld.
This Percutaneous Ventricular Assist Device article was created to assist with 10/01/2015
billing of this procedure in part B.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
103
2/2015
A/B MAC Local Coverage Determinations
Policy Title
Revisions ICD-9 LCDs
Effective
Date
Inﬂiximab
Under CMS National Coverage Policy separated Pub 100-02 Chapter 1 and Chapter 15 12/24/14
(Remicade®) L35426 into individual citations.
Rev #4
Under Coverage Indications, Limitations and/or Medical Necessity inserted coverage
criteria for chronic pulmonary sarcoidosis: “Patients with chronic pulmonary sarcoidosis
who remain symptomatic despite treatment for 3 or more months with steroids (10 mg
per day or more) and immunosuppressants (such as azathioprine, cyclophosphamide, or
methotrexate) or have a contraindication or intolerance to one immunosuppressant (such as
azathioprine, cyclophosphamide, or methotrexate) and the patient is not receiving inﬂiximab
in combination with either of the following: 1) Biologic DMARD [e.g., Enbrel (etanercept),
Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] 2) Janus kinase
inhibitor [e.g., Xeljanz (tofacitinib)]. The current and prospective roles of inﬂiximab in
the treatment of pulmonary sarcoidosis do not currently have FDA approval; therefore,
it is recommended that providers consult the literature for proper dosing of inﬂiximab.”
Under Limitations corrected the second paragraph to read “When used in combination with
other biologics such as Enbrel®(etanercept), Kineret® (anakinra), Orencia®(abatacept),
Rituxan®(rituximab), Humira®(adalimumab), Cimzia® (certolizumab), Simponi®
(golimumab), or a Janus kinase inhibitor [e.g. Xeljanz® (tofacitinib)], Remicade©
(Inﬂiximab) is considered not medically reasonable and necessary and therefore not
covered.”
Under ICD-9 Codes that Support Medical Necessity added ICD-9 code 135 for coverage
of sarcoidosis.
Total Joint
Arthroplasty L33050
Rev #4
Under Sources of Information and Basis for Decision added citations for Amin E, Closser
D, Crouser E. Therapeutic Advances in Respiratory Disease; Baughman R, Lower E.
Medical Therapy of Sarcoidosis; Judson MA, Baughman RP, et al. Efﬁcacy of inﬂiximab
in extrapulmonary sarcoidosis: results from a randomized trial; Baughman R, Drent M,
Kavuru M, et al. Inﬂiximab Therapy in Patients with Chronic Sarcoidosis and Pulmonary
Involvement; Doty J, Mazur J, Judson M. Treatment of Sarcoidosis With Inﬂiximab;
Saleh S, Ghodsian S, Yakimova V. et al. Effectiveness of inﬂiximab in treating selected
patients with sarcoidosis; and Roberts S, Wilkes D, Burgett R, et al. Refractory Sarcoidosis
Responding to Inﬂiximab. Citations were removed for package inserts 1999-2002, 2005
and 2006 and added for package insert 2013. All sources corrected to AMA formatting.
Under Sources of Information and Basis for Decision corrected web site address for 12/18/14
archived article on AHRQ for Total Knee Replacement.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
104
2/2015
Policy Title
Revisions ICD-10 LCDs
Effective
Date
Inﬂiximab
Under CMS National Coverage Policy separated Pub 100-02 Chapter 1 and Chapter 15 10/01/15
(Remicade®) L35677 into individual citations.
Rev #5
Under Coverage Indications, Limitations and/or Medical Necessity inserted coverage
criteria for chronic pulmonary sarcoidosis: “Patients with chronic pulmonary sarcoidosis
who remain symptomatic despite treatment for 3 or more months with steroids (10 mg
per day or more) and immunosuppressants (such as azathioprine, cyclophosphamide, or
methotrexate) or have a contraindication or intolerance to one immunosuppressant (such as
azathioprine, cyclophosphamide, or methotrexate) and the patient is not receiving inﬂiximab
in combination with either of the following: 1) Biologic DMARD [e.g., Enbrel (etanercept),
Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] 2) Janus kinase
inhibitor [e.g., Xeljanz (tofacitinib)]. The current and prospective roles of inﬂiximab in
the treatment of pulmonary sarcoidosis do not currently have FDA approval; therefore,
it is recommended that providers consult the literature for proper dosing of inﬂiximab.”
Under Limitations corrected the second paragraph to read “When used in combination with
other biologics such as Enbrel®(etanercept), Kineret® (anakinra), Orencia®(abatacept),
Rituxan®(rituximab), Humira®(adalimumab), Cimzia® (certolizumab), Simponi®
(golimumab), or a Janus kinase inhibitor [e.g. Xeljanz® (tofacitinib)], Remicade©
(Inﬂiximab) is considered not medically reasonable and necessary and therefore not
covered.”
Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes D86.0 and
D86.2 for coverage of pulmonary sarcoidosis.
Total Joint
Arthroplasty
L33456
Rev #3
Under Sources of Information and Basis for Decision added citations for Amin E, Closser
D, Crouser E. Therapeutic Advances in Respiratory Disease; Baughman R, Lower E.
Medical Therapy of Sarcoidosis; Judson MA, Baughman RP, et al. Efﬁcacy of inﬂiximab
in extrapulmonary sarcoidosis: results from a randomized trial; Baughman R, Drent M,
Kavuru M, et al. Inﬂiximab Therapy in Patients with Chronic Sarcoidosis and Pulmonary
Involvement; Doty J, Mazur J, Judson M. Treatment of Sarcoidosis With Inﬂiximab;
Saleh S, Ghodsian S, Yakimova V. et al. Effectiveness of inﬂiximab in treating selected
patients with sarcoidosis; and Roberts S, Wilkes D, Burgett R, et al. Refractory Sarcoidosis
Responding to Inﬂiximab. Citations were removed for package inserts 1999-2002, 2005
and 2006 and added for package insert 2013. All sources corrected to AMA formatting.
Under Sources of Information and Basis for Decision corrected web site address for 10/01/15
archived article on AHRQ for Total Knee Replacement.
ICD-9 Articles
Under Coverage-Medicare Coverage -General Information-Medicare Coverage
Database enter the document number for the article in the search ﬁeld.
Spiracur SNaP Wound This article was consolidated into an A/B MAC Article. Under Article Text removed 01/01/15
Care System
HCPCS codes G0456 and G0457 and added CPT Codes 97607 and 97608. Under CPT/
A53400
HCPCS Codes added CPT codes 97607 and 97608. Due to the 2015 Annual CPT/HCPCS
Update, HCPCS G0456 and G0457 were deleted. This revision was due to the 2015 Annual
CPT/HCPCS update.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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ICD-10 Articles
Under Coverage-Medicare Coverage -General Information-Medicare Coverage
Database enter the document number for the article in the search ﬁeld.
Spiracur SNaP Wound This article was consolidated into an A/B MAC Article. Under Article Text removed 10/01/15
Care System A53781 HCPCS codes G0456 and G0457 and added CPT Codes 97607 and 97608. Under CPT/
HCPCS Codes added CPT codes 97607 and 97608. Due to the 2015 Annual CPT/HCPCS
Update, HCPCS G0456 and G0457 were deleted. This revision was due to the 2015 Annual
CPT/HCPCS update.
Retired ICD-9 LCD
Intraoperative
Neurophysiological
Monitoring
L31748
The Intraoperative Neurophysiological Monitoring Local Coverage Determination (LCD) 12/18/14
L31748 was retired effective 12/18/2014. Coding found in the policy did not reﬂect the true
intent of the LCD.
Retired ICD-10 LCD
Intraoperative
Neurophysiological
Monitoring
L34550
The Intraoperative Neurophysiological Monitoring Local Coverage Determination (LCD) 10/1/15
L34550 was retired effective 12/18/2014. Coding found in the policy did not reﬂect the
true intent of the LCD. This ICD-10 LCD was retired because its ICD-9 LCD counterpart
L31748 was retired. Since this LCD was retired prior to its Original Effective Date, it will
never be in effect.”
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
106
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MolDX Local Coverage Determinations
Response to Comments
Molecular Diagnostic Tests (MDT) – L33599
Effective 01/08/2015
MDT (DL33599) Comments
Note: L33599 has been in effect since October, 2013. The only change to the policy was the addition of new AMA CPT codes. While
Palmetto GBA appreciates the general comments, and has responded to the comments received, there has been no beneﬁciary access
or coverage issues raised by providers in this jurisdiction pertaining to the original policy. We hope the responses will promote a
better understanding of general claims processing, the purpose of LCDs and Medicare regulations.
1. Coverage & Payment for Molecular Pathology Testing During Technology Assessments
Comment: Commenter indicates that “as written, this draft LCD continues the existing Palmetto policy of potentially stopping
payment for a test until a technical assessment is performed”: Palmetto GBA will review all new test /assay clinical information to
determine if a test meets Medicare’s reasonable and necessary requirement. The commenter then states that “during the lengthy
review process, patient access to these potentially lifesaving test could be jeopardized because of the uncertainty surrounding
coverage and payment”.
Response: The key word in the above sentence is “new test/assay”. All new services, procedures and tests must meet Medicare’s
reasonable and necessary criteria. This is standard requisite procedure for all providers to obtain coverage of any new procedure or
device, and is not new information or a new procedure for Medicare providers.
Single genes represented by AMA CPT Tier 1 codes have not required a TA by Palmetto. Rarely has Palmetto GBA requested TAs
for Tier 2 codes. “New” refers to tests with multiple genes with or without algorithmic analysis with diagnostic and/or prognostic
purposes that have not received FDA companion diagnostic status or been universally recognized by recognized authorities such as
NCCN, ASCO or other professional societies. For claims adjudication, contactors can request data when indicated. For these “new
tests/assays”, Palmetto formalized the process of obtaining coverage by requiring the provider to submit a formal technical assessment
(TA). For molecular laboratory providers who submit a complete TA, the review process is very short. The “lengthy reviews” result
from the fact that many TAs have insufﬁcient evidence of analytical and clinical validity (AV/CV), and no clinical utility (CU).
2. Content of LCDs and Associated Articles
Comment: After describing what should be in an LCD and an article, the commenter takes exception to the draft LCD where it
states the following: “Please refer to the MOLDX website www.palmettogba.com/MOLDX for covered and excluded tests’ speciﬁc
coding and billing information”. The commenters do not think the attached articles that provide coverage, along with coding and
billing guidelines comply with LCD requirements.
The commenters state that because the review of new tests results in new coverage decisions, “they (the new tests) are subject to the
LCD process before ﬁnal implementation of coverage. The LCDs would include identiﬁcation of the test covered by CPT code or
gene tested, the clinical indications, the patient selection limitations, the frequency of testing, the ICD-9 codes and reporting CPT
codes, and presentation of the medical literature considered in making the determination”. They state that the coverage articles on
the Palmetto website do not contain the above information, and, therefore do not comply with the LCD process. They also express
concern that the coverage articles are not in the Medicare Coverage Database (MCD).
Commenters also expressed concern that this policy did not provide the means for them to comment on the list of excluded assays.
Response: There has never been a CMS requirement to develop an LCD when a service is covered without restrictions. Every CPT
code would require an LCD if that were true. LCDs are required when a Medicare contractor denies or restricts/limits coverage for
a particular reason. Restriction of coverage requires an LCD to deﬁne what is or isn’t “reasonable and necessary”. So directing
providers to the MolDX website for coverage articles that include coding and billing information is correct protocol for this policy.
Per Medicare guidelines, tests that are determined to not be a Medicare beneﬁt (statutorily excluded) cannot be addressed in an LCD.
All unrestricted coverage determinations associated with this draft policy are in the MCD database. Following the CMS directed
2013 gapﬁlling of Tier 1 codes, CMS published, via the CLFS, pricing for the Tier 1 codes. Tier 1 CPT codes that were priced were
considered covered (without going through the LCD process because there were no restrictions to the coverage), and the genes that
were not priced were determined to have no Medicare beneﬁt category (statutory exclusion).
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
107
2/2015
The Medicare program applies to the disabled, and individuals over 65 years of age. As such, there is no beneﬁt category for
neonatal and perinatal testing, or testing of juveniles and adolescents; thus, these services are statutorily excluded. In the unusual
circumstance that a particular test on the statutorily denied list applies to a Medicare eligible beneﬁciary, the provider can appeal a
denial by providing supporting documentation of medical necessity. In addition, as noted above, because there is no beneﬁt category,
CMS expressly prohibits contractors from developing LCDs pertaining to statutorily excluded services.
3. Unique Test Identiﬁer Requirement
Comment: Two commenters express concern regarding:
 Requirement for a unique identiﬁer;
 Need to verify analytical/clinical validity for tests performed;
 Performing 3 or more test creates “new test” to be reviewed for medical necessity;
 Need to address “clinical utility”.
Response: A unique identiﬁer allows the payer to know what they are paying for. With roughly 600 genes represented by 9 codes,
there is absolutely no speciﬁcity. Commenters argue that levels of complexity and resources for testing for each Tier 2 code are
similar. However, neither levels of complexity or resources used establish medical necessity. Coverage for a gene is based on
medical necessity which is based on published clinical utility.
Commenters strongly feel that CLIA is adequate to assure lab quality. CLIA does, in fact establish a minimal standard that labs are
expected to comply with, but lab quality is not the issue and it does not determine medical necessity, nor does it speciﬁcally address
a particular test’s clinical validity. The commenters suggest that the AMA CPT code application process includes a review of AV/
CV to determine whether it is sufﬁcient to support its positon as part of medical practice but that again is not a Medicare beneﬁt or
speciﬁc medical necessity determination.
There is nothing in the MDT draft policy that 3 tests performed in a series (reﬂex testing – next test depends on the result of the
previous test) is considered a new test that requires AV/CV/CU. The commenters agree that MAAA tests do require AV/CV/CU to
determine medical necessity.
Commenters state that CU assessment should be done by an outside organization, go through the LCD process, present evidence to
CAC, and public comment, which they claim Palmetto is not adhering to.
Palmetto GBA’s medical necessity determinations (to include clinical utility) are performed and informed by multiple external subject
matter experts from academia and industry. If a test is determined to be not medically necessary or its coverage to be limited, an LCD
would be drafted, with presentation of evidence to the CAC, and posted for public comment for 45 days. If there is no restriction to
coverage, an LCD is not needed.
4. Unique identiﬁer and TA are two distinct processes
The unique identiﬁer allows the payer to know exactly what test is being performed. A TA is only required for “new” tests prior to coming to market. Genes listed as Tier 1 and most Tier 2 codes do not require a TA. TAs are largely restricted to MAAA assays. 5. Status of FDA Approved Tests
Comment: This LCD fails to address its application to FDA approved tests. The commenters request:
1. Does the unique identiﬁer program apply to FDA approved tests? Will there be an article accompanying this LCD with
information for billing?
2. Are FDA approved tests recognized for their approved indications?
3. Would existing coverage determinations (LCDs) apply to FDA approved tests?
4. How should a laboratory indicate on the claim that a test being billed under a speciﬁc code is done with an FDA
approved test and not one that requires a unique identiﬁer?
Response:
1-4. To bill for molecular testing, all labs must obtain a unique identiﬁer for each test. This means FDA approved tests must
obtain a unique identiﬁer also. Many manufacturers register and receive a unique identiﬁer for each of their tests. However,
regardless of whether the manufacturer has registered each of their tests, each laboratory must register the molecular assays
they perform. On the registration form, the lab designates whether or not the FDA approved test will be performed without
modiﬁcation. If the test is not modiﬁed, the lab is given the FDA approved unique identiﬁer. In other words, every lab
performing an unmodiﬁed FDA approved test has the same unique identiﬁer.
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
108 2/2015
If an FDA approved test is modiﬁed by a lab (performed as an LDT), the lab receives a unique identiﬁer. If a laboratory (ex:
LabCorp or Quest) is performing an-FDA approved test by exact methodology/reagents/etc at multiple sites, each of the sites
receives the same identiﬁer for the test.
FDA approved tests are recognized for their approved indications. A new FDA approved test would have the same coverage
if a coverage determination already existed.
A laboratory in J11 must register for and obtain a unique identiﬁer. All molecular tests must have an identiﬁer to submit
claims. McKesson assigns identiﬁers according to the information submitted on the registration. Palmetto reviews the
registration information and provides written conﬁrmation of the unique identiﬁer and correct CPT code for billing. On the
claim, the unique identiﬁer is entered into the SV101-7 ﬁeld. Any claim without a unique identiﬁer is rejected.
MolDX: Prolaris™ Prostate Cancer Genomic Assay - L35629
1.
omment:
C
Multiple comments expressed support of the draft LCD DL35629 but requested the expansion of Criteria for Coverage to
all risk categories, with some commenters specifying that expansion would be in line with NCCN Guidelines.
Response:
Palmetto GBA has received numerous comments suggesting expansion of coverage to all prostate cancer risk categories.
Many commenters indicate more than adequate clinical utility to support expanded coverage.
The cornerstone of the literature validating the Prolaris assay is from UK men, diagnosed with prostate cancer (at varied
PSA and clinical stages) and managed conservatively. The frequency or method of follow up is unknown. And, in these
patients, the 10-year mortality for prostate cancer for even the lowest CCP numbers was close to 20% (Cuzik 2011).
In multiple other studies, the Prolaris assay provides additional prognostic information beyond clinicopathological
characteristics, but no author suggests that the test can replace these factors especially since all reported outcomes were
analyzed retrospectively. Some comments extrapolate that the Prolaris assay can override the clinicopathologic stage in
patients with intermediate and high-risk disease category. This is in direct conﬂict with the NCCN 2015 v1 guidelines,
which state, “Active surveillance of intermediate and high-risk clinically localized cancers is not recommended in
patients with a life expectancy > 10 years.” (NCCN Prostate 2015.1).
The NCCN suggests, “Men with clinically localized disease could consider use of a tumor-based molecular assay to
stratify better risk of adverse pathology AT RADICAL PROSTATECTOMY or chance of biochemical recurrence or
disease-speciﬁc mortality after radical prostatectomy.“ (NCCN Prostate 2015.1 Pros-1; Capitalization added). Regarding
the Prolaris assay, NCCN comments that “clinical utility awaits evaluation by prospective, randomized clinical trials,
which are unlikely to be done. The marketplace and comparative effective research may be the only means . . .to gain
proper place for better risk stratiﬁcation for men with clinically localized prostate cancer.”
Based the literature, subject matter experts and NCCN, Palmetto GBA believes that outside of a well designed prospective clinical
trial, extension of testing to intermediate and high grade patients would likely increase morbidity and mortality and strongly
recommends a prospective “comparative effectiveness” trial before wholesale expansion into these groups.
MolDX: Decipher® Prostate Cancer Classiﬁer Assay – L35650
1. Applaud Palmetto’s prostate biomarker coverage.
Comment: A national organization applauds Palmetto’s initiative in covering prostate biomarkers (ConﬁrmMDx, Decipher,
and Prolaris) with data development.
Response: Agree. The prospective data will impact physician management of prostate cancer.
2. ASCO endorsed AUA/ASTRO guidelines on the use of adjuvant and salvage radiotherapy after prostatectomy for
clinically high-risk patients with post-surgery adverse pathologic ﬁndings
Comment: A commenter notes that the endorsement panel highlighted a qualifying statement that “not all men who are
candidates for adjuvant or salvage radiotherapy have the same risk for recurrence or disease progression, and thus, not all
men will derive the same beneﬁt from adjuvant radiotherapy.” (Freedland et al. Nov 2014, JCO). The commenter believes
this patient population is best supported by the Decipher test as it provides a biological estimate of risk to help high-risk
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
109 2/2015
patient and their physician best decide on whether to undergo radiotherapy or not.
Response:High-risk patients are the intended population for the Decipher test. 3. NCCN (2015, version 1) has added a recommendation statement in the 2015 guidelines.
Comment:NCCN has stated that “Men with clinically localized disease could consider use of a tumor-based molecular assay
to stratify better risk of adverse pathology at radical prostatectomy or chance of biochemical recurrence or disease-speciﬁc
mortality after radical prostatectomy.”
Response: Agree
Policy Title
ICD-9 Additions/Revisions/Deletions
Effective
Date
Genetic Testing for
Lynch Syndrome –
L33779
The following revisions were made to Genetic Testing for Lynch Syndrome due to CR
8975 HCPCS Annual Update published 10/24/14:
 Added CPT 81288 as limited coverage.
 The following CPT codes were added as non-covered:
o 81435
o 81436
o 81445
o 81455
 The following CPT/HCPCS codes were deleted:
o G0461 was deleted from Group 1
o G0462 was deleted from Group 1
01/01/15
Molecular
Diagnostic Tests
(MDT) –
L33599
The following revisions were made to Molecular Diagnostic Testing (MDT) due to CR
8975 HCPCS Annual Update published 10/24/14:
 Added the following codes due to CR 8975:
o 81410
o 81471
o 81246
o 81288
o 81313
o 0006M
o 0007M
o 0008M
o 81519
 For the following CPT/HCPCS codes either the short description and/or the
long description was changed. Depending on which description is used in this
LCD, there may not be any change in how the code displays in the document:
o 81245 descriptor was changed in Group 1
o 81402 descriptor was changed in Group 1
o 81405 descriptor was changed in Group 1
01/01/15
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
110
2/2015
Controlled
Substance
Monitoring and
Drugs of Abuse
Testing – L35105
Added the following HCPCS codes due to CR 8975:
 84999
 G6030
 G6031
 G6032
 G6034
 G6036
 G6037
 G6040
 G6041
 G6042
 G6043
 G6044
 G6045
 G6046
 G6048
 G6051
 G6052
 G6053
 G6054
 G6056
 G6057
 G6058
For the following CPT/HCPCS codes either the short description and/or the long description
was changed. Depending on which description is used in this LCD, there may not be any
change in how the code displays in the document:
 80159 descriptor was changed in Group 1
 80171 descriptor was changed in Group 1
The following CPT/HCPCS codes were deleted:
 80102 was deleted from Group 1
 80152 was deleted from Group 1
 80154 was deleted from Group 1
 80160 was deleted from Group 1
 80166 was deleted from Group 1
 80174 was deleted from Group 1
 80182 was deleted from Group 1
 82055 was deleted from Group 1
 82101 was deleted from Group 1
 82145 was deleted from Group 1
 82205 was deleted from Group 1
 82520 was deleted from Group 1
 82646 was deleted from Group 1
 82649 was deleted from Group 1
 83805 was deleted from Group 1
 83840 was deleted from Group 1
 83925 was deleted from Group 1
 80100 was deleted from Group 2
 80101 was deleted from Group 2
80299 and 82542 were deleted because the descriptor change made the code not applicable
to the policy.
01/01/2015
NRAS Genetic
Testing – L34627
For the following CPT/HCPCS codes either the short description and/or the long
description was changed due to CR 8975:
1/1/2015
81404 descriptor was changed in Group 1
Continued >>
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
111
2/2015
Molecular
Diagnostic Tests
(MDT) –
L33599
The comment period for the J11 Part B Molecular Diagnostic Tests (MDT) –
L33599 began on November 10, 2014 and ended on December 25, 2014. The notice
period for this LCD began on January 8, 2015. The LCD will become effective February
23, 2015.
01/08/15
MolDX: Decipher®
Prostate Cancer
Classiﬁer Assay –
L35650
The comment period for the J11 Part B MolDX: Decipher® Prostate Cancer Classiﬁer
Assay – L35650 began on November 10, 2014 and ended on December 25, 2014. The
notice period for this LCD began on January 15, 2015. The LCD will become effective
March 2, 2015.
01/15/15
MolDX: Prolaris™
Prostate Cancer
Genomic Assay
The comment period for the J11 Part B MolDX: Prolaris™ Prostate Cancer Genomic
Assay began on November 10, 2014 and ended on December 25, 2014. The notice period
for this LCD began on January 15, 2015. The LCD will become effective March 2,
2015.
01/15/15
Policy Title
ICD-10 Additions/Revisions/Deletions
Effective
Date
Genetic Testing for
Lynch Syndrome –
L35024
The following revisions were made to Genetic Testing for Lynch Syndrome due to CR
8975 HCPCS Annual Update published 10/24/14:
 Added CPT 81288 as limited coverage.
 The following CPT codes were added as non-covered:
o 81435
o 81436
o 81445
o 81455
 The following CPT/HCPCS codes were deleted:
o G0461 was deleted from Group 1
o G0462 was deleted from Group 1
10/01/2015
Molecular
Diagnostic Tests
(MDT) –
L35025
The following revisions were made to Molecular Diagnostic Testing (MDT) due to CR
8975 HCPCS Annual Update published 10/24/14:
 Added the following codes due to CR 8975:
o 81410
o 81471
o 81246
o 81288
o 81313
o 0006M
o 0007M
o 0008M
o 81519
 For the following CPT/HCPCS codes either the short description and/or the
long description was changed. Depending on which description is used in this
LCD, there may not be any change in how the code displays in the document:
o 81245 descriptor was changed in Group 1
o 81402 descriptor was changed in Group 1
o 81405 descriptor was changed in Group 1
10/01/2015
NRAS Genetic
Testing – L34073
For the following CPT/HCPCS codes either the short description and/or the long
description was changed due to CR 8975:
10/1/2015
81404 descriptor was changed in Group 1
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
112
2/2015
CMS e-News
e-News contains a week’s worth of Medicare-related messages instead
of many different messages being sent to you throughout the week.
This notiﬁcation process ensures planned, coordinated messages are
delivered timely about Medicare-related topics.
_______________________________________
MLN Connects™ Provider eNews
MLN Connects™ Provider eNews for January 8, 2015
www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-01-08-eNews.pdf
MLN Connects™ Provider eNews for January 15, 2015
www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-01-15-Enews.pdf
MLN Connects™ Provider eNews for January 22, 2015
www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2015-01-22-eNews.pdf
Holding of 2015 Date-of-Service Claims for Services Paid Under the 2015 Medicare Physician Fee Schedule
On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) ﬁnal rule was published in
the Federal Register. In order to implement corrections to technical errors discovered after publication of the
MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015
services paid under the MPFS for the ﬁrst 14 calendar days of January 2015 (i.e., Thursday January 1 through
Wednesday January 14). The hold should have minimal impact on provider cash ﬂow as, under current law, clean
electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.
MPFS claims for services rendered on or before Wednesday Dec 31, 2014 are unaffected by the 2015 claims
hold and will be processed and paid under normal procedures and time frames.
CPT codes, descriptors and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
113
2/2015
CMS Offers FREE Medicare Training for Providers
CMS Web Training
The Centers for Medicare & Medicaid Services (CMS) has launched a series of education and training
programs designed to leverage emerging Internet and satellite technologies to offer just-in-time training
to Medicare providers and suppliers throughout the United States. Many of these programs include free,
downloadable computer/Web based training courses. These courses are also available on CD-ROM.
http://www.cms.gov/MLNGenInfo
Palmetto GBA Medicare Customer Information and Outreach
Important Telephone Numbers
Training Available
Provider Contact Center
(855) 696-0705 (Toll-Free)
To request a Medicare Education meeting/seminar
at no cost to you, complete and fax the form located
on the
http://www.PalmettoGBA.com/J11B/forms.
Electronic Data Interchange (EDI)
Technical Support
(855) 696-0705
http://www.PalmettoGBA.com/Medicare
Medicare Beneﬁciary Call Center
Important Sources For You
1-800-MEDICARE (1-800-633-4227)
TTY 1-877-486-2048
•
•
•
http://www.cms.gov
http://www.cms.gov/MLNGenInfo
http://www.cms.gov/CMSforms/CMSforms/list.asp
Attention: Billing Manager
114
2/2015