Medicare Bulletin - September 2015

Medicare
Bulletin
Jurisdiction 15
Reaching Out
to the Medicare
Community
© 2015 Copyright, CGS Administrators, LLC.
KENTUCKY & OHIO PART B
SEPTEMBER 2015 • WWW.CGSMEDICARE.COM
Jurisdiction 15
KENTUCKY & OHIO
Administration
Laboratory & Pathology
MoPath: GeneSight® Assay for Refractory
Depression Claims Submission Reminders (Part B) 6
Checking Beneficiary Eligibility and Claim Status 3
Preventive Services
Use myCGS to Submit Your Responses
to Medical Review (MR) Additional
Documentation Requests (ADRs)! 6
MM9200: Screening for Hepatitis C Virus (HCV)
in Adults – Implementation of Additional Common
Working File (CWF) and Shared System
Maintainer (SSMs) Edits 10
Letter From The Home Health Contractor
Medical Directors (CMDs) 9
NEWS FLASH
Coding
Billing Update for Zoledronic Acid – J3489 3
KENTUCKY & OHIO PART B
Medicare Bulletin
News Flash Items 19
Mohs Micrographic Surgery:
Claim Submission Reminders 5
Not Otherwise Classified (NOC) Drugs:
Clarification on Required Information 6
MM9167 Revised: Quarterly Healthcare Common
Procedure Coding System (HCPCS) Drug/ Biological
Code Changes - July 2015 Update 7
SE1315 Rescinded: Pulmonary Procedures
and Evaluation & Management (E/M) Services 13
Enrollment & Credentialing
SE1425 Revised: Extension of Provider Enrollment
Moratoria for Home Health Agencies and Part B
Ambulance Suppliers 17
Fee Schedules & Reimbursement
MM9248: October 2015 Quarterly Average Sales
Price (ASP) Medicare Part B Drug Pricing Files
and Revisions to Prior Quarterly Pricing Files 12
ICD-10
SE1408 Revised: Medicare Fee-For-Service (FFS)
Claims Processing Guidance for Implementing
International Classification of Diseases,
10th Edition (ICD -10) – A Re-Issue of MM 7492 13
http://go.cms.gov/MLNGenInfo
Articles contained in this edition are current as of July 28, 2015.
Bold, italicized material is excerpted from the American Medical Association Current Procedural
Terminology CPT codes. Descriptions and other data only are copyrighted 2015 American Medical
Association. All rights reserved. Applicable FARS/DFARS apply.
MEDICARE BULLETIN • GR 2015-09
SEPTEMBER 2015
2
®
Kentucky & Ohio
KENTUCKY & OHIO PART B
Medicare Learning
Network : A Valuable
Educational Resource!
The Medicare Learning Network® (MLN), offered by the
Centers for Medicare & Medicaid Services (CMS), includes
a variety of educational resources for health care providers.
Access Web-based training courses, national provider
conference calls, materials from past conference calls,
MLN articles, and much more. To stay informed about all
of the CMS MLN products, refer to http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/MailingLists_FactSheet.pdf and
subscribe to the CMS electronic mailing lists. Learn more
about what the CMS MLN offers at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNGenInfo/index.html on the CMS website.
Billing Update for Zoledronic Acid – J3489
CGS has been made aware of a potential program vulnerability based on the coding and billing
of zoledronic acid. Prior to 2014, coding was in place for zoledronic acid marketed under the
brand names Zometa® (J3487) and Reclast® (J3488). Effective in 2014, the HCPCS code
J3489 was developed and is now used to reflect both drugs which have different dosages and
administration frequency, beginning with service date September 1, 2015.
When administering Reclast® CGS will require the KX modifier to be appended to the
claim submissions.
Kentucky & Ohio
Checking Beneficiary Eligibility and Claim Status
CGS has seen an increase in calls to the Provider Contact Center from providers asking for
Medicare beneficiary eligibility information and wanting to check the status of submitted claims.
According to the Centers for Medicare & Medicaid Services (CMS) providers are required
to use the Interactive Voice Response (IVR) system for claim status and eligibility
information. Refer to the CMS Medicare Contractor Beneficiary and Provider Communications
Manual, (Pub. 100-09), Chapter 6, section 50.1 (http://www.cms.gov/manuals/downloads/
com109c06.pdf), which states:
Providers shall be required to use IVRs to access claim status and beneficiary
eligibility information. CSRs shall refer providers back to the IVR if they have questions
about claims status or eligibility that can be handled by the IVR. CSRs may provide
claims status and/or eligibility information if it is clear that the provider cannot access
the information through the IVR because the IVR is not functioning.
Available Self-Service Tools
CGS offers the IVR for providers to check Medicare beneficiary eligibility and claim status. In
addition, the CGS Web portal, myCGS, is available. Both tools allow providers access to this
information 24 hours a day, seven days a week; however, information that can only be obtained
by accessing other systems may not be available 24/7.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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KENTUCKY & OHIO PART B
Interactive Voice Response (IVR) - 1.866.290.4036
yy“CGS Jurisdiction 15 Part B Interactive Voice Response (IVR) User Guide”
http://www.cgsmedicare.com/partb/cs/partb_ivr_user_guide.pdf
yyObtain the following information via the CGS IVR:
ƒƒPatient eligibility;
ƒƒClaim status and deductible;
ƒƒRedetermination status;
ƒƒChecks issued; and
ƒƒGeneral information.
yyTo access information via the IVR, you must provide the following information:
ƒƒNational Provider Identifier
ƒƒProvider Transaction Access Number (PTAN)
ƒƒProvider Tax Identification Number (TIN) (last 5 digits)
myCGS
yyYour Electronic Gateway to Self-Service: myCGS — The Jurisdiction 15 Web Portal
http://www.cgsmedicare.com/partb/myCGS/index.html
yyThe following information is available through myCGS:
ƒƒPatient eligibility;
ƒƒClaim status;
ƒƒView and print Remittance Advices (RAs);
ƒƒPayment information (payment floor) and recently issued check data;
ƒƒImmediate Offset (eOffset);
ƒƒSubmit Part B claims;
ƒƒSubmit Part B Reopenings;
ƒƒSubmit Redetermination requests, and check the status of submitted requests; and
ƒƒSubmit medical review additional development requests (ADRs) documentation.
Please remind your billing staff to use these resources before contacting a CGS Customer
Service Representative (CSR) for beneficiary eligibility and/or claim status information.
Kentucky & Ohio
Mohs Micrographic Surgery:
Claim Submission Reminders
Our Part B Medical Review department has noticed an increase in the number of claims
submitted for Mohs Micrographic Surgery (MMS) with CPT code 17311 - 17315 (performed
on the trunk or extremities) that do not include documentation, as noted in the “General
Information” section of the Mohs Micrographic Surgery Local Coverage Determination (LCD)
L31877 ) http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=318
77&ContrId=228&ver=25&ContrVer=2&CntrctrSelected=228*2&Cntrctr=228&name=CGS+Admi
nistrators%2c+LLC+(15102%2c+MAC+-+Part+B)&DocType=All&DocStatus=Active&s=22&bc=A
ggAAAIAAAAAAA%3d%3d&).
To ensure your claims are processed in the most efficient manner, please keep in mind
documentation identifying one or more of the qualifying terms listed under “Indications
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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Including this documentation upon initial submission will help avoid delays in processing, as
additional documentation request (ADR) letters will be sent if this information is not received.
Kentucky & Ohio
MoPath: GeneSight®Assay for Refractory
Depression Claims Submission Reminders (Part B)
The Medical Review department has noticed an increase in claim submissions for GeneSight®
with referrals from specialties other than licensed psychiatrists. As indicated in LCD L35437
MoPath: GeneSight® Assay for Refractory Depression (and its ICD-10 equivalent, L35443), this
test should only be ordered/referred by a licensed psychiatrist. If any other specialty orders/
refers this test, it will be considered not medically necessary.
To ensure your claims are processed in the most efficient manner, please enter the name of the
test (GeneSight) in the narrative/comment section on electronic claims in loop 2400 NTE02 for
Part B. For paper claims, submit the test name in Item 19 for Part B. A payable ICD-9 code, if
appropriate, is needed for payment consideration.
KENTUCKY & OHIO PART B
and Limitations of Coverage” must be included. This information may be submitted either
in the documentation field of your electronic claim, as an attachment to a myCGS
eClaim (http://www.cgsmedicare.com/partb/pubs/news/2015/0415/cope29055.html),
using the PWK segment (http://www.cgsmedicare.com/partb/pubs/news/2013/0213/cope21311.
html) process, or in Item 19 of your CMS-1500 claim form.
yyhttps://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/
overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/lcd-details.
aspx&LCDId=35437&ContrId=228&ver=3&ContrVer=2&CntrctrSelected=228*2&Cntrctr=22
8&name=CGS+Administrators%2c+LLC+(15102%2c+MAC+-+Part+B)&DocType=Active&D
ocStatus=Active&s=22&bc=AggAAAIAAAAAAA%3d%3d&
yyhttps://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/
overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/lcd-details.
aspx&LCDId=35443&ContrId=228&ver=2&ContrVer=2&CntrctrSelected=228*2&Cntrctr=22
8&name=CGS+Administrators%2c+LLC+(15102%2c+MAC+-+Part+B)&LCntrctr=228*2&Do
cType=Future&bc=AgACAAIAAAAAAA%3d%3d&
Kentucky & Ohio
Not Otherwise Classified (NOC) Drugs:
Clarification on Required Information
Claims for HCPCS codes J9999 (not otherwise classified anti-neoplastic drugs), J3490
(unclassified drugs) and/or J3590 (unclassified biological drugs) must be submitted with
additional qualifying information. These claims must include:
yyThe name of the drug
yyThe National Drug Code (NDC) number
yyThe exact dosage given
Claim Submission:
yyFor electronic claims, Loop/Element 2400 SV101-7 must be completed for Not Otherwise
Classified (NOC) codes. The required documentation (name, NDC and dosage) may be
submitted in Loop/Element 2400 SV101-7. If additional space is needed, Loop 2400 NTE 02
may be utilized in addition to SV101-7.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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New NOC Code for Compounded Drugs
As a result of Change Request (CR) 9167 (http://www.cms.gov/Regulations-and-Guidance/
Guidance/Transmittals/Downloads/R3254CP.pdf), effective for claims with dates of service
on and after July 1, 2015, claims for compounded drugs must be submitted using the new
compounded drug not otherwise classified (NOC) HCPCS code Q9977.
Using HCPCS code Q9977 is intended to distinguish compounded drugs (which may include
biologicals) from the other drug NOC codes listed above.
The same claim submission instructions noted above apply to HCPCS code Q9977.
Kentucky & Ohio
Use myCGS to Submit Your Responses
to Medical Review (MR) Additional
Documentation Requests (ADRs)!
myCGS is our free secure online Web portal where providers can now respond to medical
review (MR) additional documentation requests (ADRs). When medical records are requested
to correctly adjudicate a claim, myCGS is a convenient way to ensure an accurate and timely
response. Documentation in response to an MR ADR must be received by CGS on/before 45
calendar days of the request.
KENTUCKY & OHIO PART B
yyFor paper claims, the documentation must be in Item 19.
Why myCGS?
yymyCGS allows you to submit attachments as PDF (Portable Document Format) documents.
Save documents in a PDF format by using a scanner or various versions of commerciallyavailable software.
ƒƒAttach up to 5 PDF documents (up to 5MB each)
ƒƒSave PDF documents in a folder on your system to allow easy access
ƒƒSaved PDF documents help to identify what medical records were submitted to CGS
yymyCGS validates the patient and claim information you enter, ensuring the documentation
is matched correctly to the claim being reviewed.
yymyCGS provides a “Secure Form Received” message confirming CGS has received the
MR ADR documentation you submitted.
ƒƒmyCGS provides a second message, “Secure Form Confirmation” which assigns a
Submission ID to your MR ADR submission that can be used to track the status of your
response.
yymyCGS eliminates doubts that all the documentation you faxed was received and matched
with the appropriate claim.
yymyCGS eliminates personnel from mishandling the medical record documentation.
yymyCGS eliminates postage expense.
For detailed instructions about submitting your documentation in response to an MR ADR, refer
to “Chapter 7: Forms Tab” at http://www.cgsmedicare.com/pdf/mycgs/chapter7_partb.pdf of the
myCGS User Manual or the “myCGS MR ADR Job Aid” at http://cgsmedicare.com/partb/pubs/
news/2015/0415/cope28413.html
If you do not have access to myCGS, refer to the “Your Electronic Gateway to Self-Service:
myCGS – The Jurisdiction 15 Web Portal” Web page at http://www.cgsmedicare.com/partb/
myCGS/index.html for additional information.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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T WO VANTAGE WAY | NASHVILLE, TN 37228 -1504 | CGSMEDICARE.COM
A /B MAC JURISDICTION 15
Kentucky & Ohio
We IMPACT lives.
Dear Colleague:
Medicare has changed the physician documentation requirements for certification of home health care for dates of
service effective January 1, 2015. While clinicians still need to certify benefit eligibility and a face to face encounter
is still required, the need for extra documentation (e.g., the “narrative”) has been scaled back or eliminated. These
remaining requirements may be billed in the following manner: a face-to-face encounter with a physician or allowed
non-physician practitioner is billed with an evaluation and management (E&M) code and the certification is billed
with G0180 (G0179 for recertification). The home health agency will provide medical records from the office or
hospital setting describing the patient’s condition and supporting his/her eligibility for home care prior to your
completion of the certification document. The agency may need progress notes from you or hospital records of the
face-to-face visit if it was done in the hospital setting in order to substantiate the reason home health care is needed.
In review, to qualify for the Medicare Home Health Benefit beneficiaries must have Medicare Part A and/or Part B
and meet all of the following requirements:
• Be confined to the home;
• Need skilled services;
• Be under the care of a physician;
• Receive services under a plan of care established and periodically reviewed by a physician; and
• Have a face-to-face encounter with a physician or allowed non-physician practitioner (NPP) (reviewed and
counter-signed by the physician).
Your Home Health/Hospice Medicare contractor’s website may be accessed to obtain information regarding eligibility
and documentation requirements. Additional references are as follows:
• CMS MLN Article (MM9119 Revised) Manual Updates to Clarify Requirements for Physician Certification and
Recertification of Patient Eligibility for Home Health Services
• Certifying Patients for the Medicare Home Health Benefit
• Medicare Home Health Agency (HHA) Center
Sincerely,
Contractor Medical Directors
Home Health/Hospice Medicare Contractors
© 2015, CGS Administrators, LLC
CGS Administrators, LLC is a Medicare Part A, B, Home Health and Hospice, and DME Medicare Administrative Contractor
for the Centers for Medicare & Medicaid Services.
MM9167 Revised: Quarterly Healthcare Common
Procedure Coding System (HCPCS) Drug/
Biological Code Changes - July 2015 Update
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: MM9167 Revised
Related CR Release Date: July 10, 2015
Related CR Transmittal #: R3292CP
Related Change Request (CR) #: CR 9167
Effective Date: July 1, 2015
Implementation Date: July 6, 2015
Note: This article was revised on July 20, to reflect the revised CR9167 issued on July 10. In the article, language
has been modified to clarify the use of Q9977. Also, the CR release date, transmittal number, and the Web
address for accessing CR9167 are revised. On July 22, 2015, the article was revised further to include additional
language from the revised CR9167. This additional language is in the note box on page 3 of this article. All other
information remains the same.
KENTUCKY & OHIO PART B
Kentucky & Ohio
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 Medicare
Administrative Contractors (DME/MACs) and Home Health & Hospice (HH&H) MACs for
services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 9167 and informs Medicare providers about the
updating of specific drug and biological HCPCS codes that occur quarterly. It alerts providers
that the July file includes new HCPCS Codes.
CR9167 also updates Chapter 17, Section 20.1.2 (Average Sales Price (ASP) Payment
Methodology) in the “Claims Processing Manual” to address the use of a compounded drug not
otherwise classified (NOC) code on claims for compounded drugs. Make sure that your billing
staffs are aware of these changes.
Summary of New HCPCS Codes in CR9167
CR9167 adds the following HCPCS codes with the effective dates noted.
Table 1 - New HCPCS Codes in CR9167
Effective for Claims with
HCPCS
Dates of Service on or after: Code
Long Description
Type of
Short Description Service (TOS)
March 6, 2015
Q5101
Injection, Filgrastim (G-CSF),
Biosimilar, 1 microgram
Inj filgrastim g-csf
biosim
1, P
July 1, 2015
Q9976
Injection, Ferric Pyrophosphate Inj Ferric
Citrate Solution, 0.1 mg of iron Pyrophosphate Cit
1, L
July 1, 2015
Q9978
Netupitant 300 mg and
Palonosetron 0.5 mg, oral
Netupitant
Palonosetron oral
1
July 1, 2015
Q9977
Compounded Drug, Not
Otherwise Classified
Compounded Drug 1, P
NOC
Note: The Medicare Physician Fee Schedule Status Indicator for all four codes above is E.
CR9167 also updates Section 20.1.2 Average Sales Price (ASP) Payment Methodology in
Chapter 17 of the “Medicare Claims Processing Manual” to address the use of a compounded
drug NOC code on claims for compounded drugs.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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Additional Information
The official instruction, CR 9167 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3292CP.
pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Kentucky & Ohio
MM9200: Screening for Hepatitis C
Virus (HCV) in Adults – Implementation
of Additional Common Working File (CWF)
and Shared System Maintainer (SSMs) Edits
KENTUCKY & OHIO PART B
Please note: The new compounded drug code, Q9977 - Compounded Drug, Not Otherwise Classified, is not a
replacement for existing codes. It is intended to distinguish compounded drugs (which may include biologicals)
from other “not otherwise classified” codes such as J3490, J3590, J7799, J9999 and existing specific codes for
compounded nebulized drugs. The implementation of Q9977 as a means of identifying compounded drug claims
does not affect existing payment policy for compounded drugs as outlined in the “Medicare Claims Processing
Manual,” Chapter 17, Section 20.1.2..
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: MM9200
Related CR Release Date: June 19, 2015
Related CR Transmittal #: R3285CP
Related Change Request (CR) #: CR9200
Effective Date: June 2, 2014
Implementation Date: For FISS shared
system edits, split between October 5, 2015,
and January 4, 2016, releases; July 20, 2015, For non-shared MAC edits; October 5, 2015 For CWF shared systems edits.
Provider Types Affected
This MLN Matters ® Article is intended for physicians, other providers, and suppliers submitting
claims to Medicare Administrative Contractors (MACs) for Hepatitis C Virus (HCV) screening
services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9200 informs providers that beneficiaries born prior to 1945 or after 1965
with no risk factors for HCV are not eligible for HCV screening benefits as described in CR8871,
Transmittal 3215, dated March 11, 2015. CR9200 also removes Rural Health Clinics (RHCs),
Federally Qualified Health Centers (FQHCs) and Method II Critical Access Hospitals (CAHs) as
valid facilities for these HCV screening services. Make sure that your billing staffs are aware of
these changes.
Background
Effective June 2, 2014, the Centers for Medicare & Medicaid Services (CMS) covers screening
for HCV consistent with the grade B recommendations by the United States Preventive Services
Task Force for the prevention or early detection of an illness or disability, and is appropriate
for individuals entitled to benefits under Medicare Part A or enrolled under Part B. This
policy was implemented in CR8871. You may want to review the related MLN Matters ® article
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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As indicated in CR8871, and replicated in CR9200 for ease of reference only, CMS covers
screening for HCV with the appropriate U.S. Food and Drug Administration (FDA)- approved/
cleared laboratory tests, and point-of-care tests (such as rapid anti-body tests that are
performed in outpatient clinics and physician offices), used consistent with FDA-approved
labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when
ordered by the beneficiary’s primary care physician or practitioner within the context of a
primary care setting, and performed by an eligible Medicare provider for these services, for
beneficiaries who meet either of the following conditions:
1. A screening test is covered for adults at high risk for HCV infection. “High risk” is defined
as persons with a current or past history of illicit injection drug use; and persons who
have a history of receiving a blood transfusion prior to 1992. Repeat screening for high
risk persons is covered annually only for persons who have had continued illicit injection
drug use since the prior negative screening test.
2. A single screening test is covered for adults who do not meet the high risk definition as
defined above, but who were born from 1945 through 1965.
The determination of “high risk for HCV” is identified by the primary care physician or
practitioner who assesses the patient’s history, which is part of any complete medical history,
typically part of an annual wellness visit and considered in the development of a comprehensive
prevention plan. The medical record should be a reflection of the service provided.
KENTUCKY & OHIO PART B
MM8871 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM8871.pdf) for additional claims processing instructions.
Key Points
yyFor services provided to beneficiaries born between the years 1945 and 1965 who are
not considered high risk as defined in the policy, HCV screening is limited to once per
lifetime. New HCPCS code G0472 (short descriptor - Hep C screen high risk/other, and
long descriptor- Hepatitis C antibody screening for individual at high risk and other covered
indication(s)) will be used.
yyBeneficiaries born prior to 1945 or after 1965 with no risk factors are not eligible
for this benefit.
yyFor those beneficiaries determined to be high-risk initially as defined in the policy,
regardless of birth year, ICD-9 diagnosis code V69.8, “other problems related to life style”
(when ICD-10 is implemented ICD-10 diagnosis code Z72.89, “other problems related to
lifestyle”) is required in addition to HCPCS G0472.
yyCoverage of a sub-set of the above high risk beneficiaries may occur on an annual basis
if appropriate as defined in the policy, regardless of birth year, denoted by the presence
of HCPCS G0472, ICD diagnosis code V69.8/Z72.89, and ICD diagnosis code 304.91,
“unspecified drug dependence continuous”/F19.20, “other psychoactive substance abuse,
uncomplicated” (once ICD-10 is implemented). Annual is defined as 11 full months must
pass following the month of the last negative HCV screening.
yyHCV screening, HCPCS code G0472, is a technical service only and there is no
professional fee.
yyCR9200 also removes the following facilities as valid for HCV screening services:
ƒƒRHC, TOB 71X;
ƒƒFQHC, TOB 77X; and
ƒƒCAH Method II, professional services, TOB 85X with revenue code 096X, 097X, or 098X.
yyMACs will line-item deny claims for HCV screening, HCPCS G0472, for beneficiaries born
prior to 1945 and after 1965 who are not high risk with the following messages:
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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ƒƒRARC 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 http://www.cms.gov/mcd/search.asp. If
you do not have Web access, you may contact the contractor to request a copy of the
NCD.; and
ƒƒGroup Code CO – assigning financial liability to the provider.
Note: Only HCPCS G0472 as noted above should be reported for this new HCV screening benefit.
CPT code 86803, HCV rapid antibody test, is not appropriate for reporting screening under this policy.
Additional Information
The official instruction, CR9200 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3285CP.
pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
KENTUCKY & OHIO PART B
ƒƒCARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be
comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark
Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present;
Kentucky & Ohio
MM9248: October 2015 Quarterly Average Sales
Price (ASP) Medicare Part B Drug Pricing Files
and Revisions to Prior Quarterly Pricing Files
The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: MM9248
Related CR Release Date: July 10, 2015
Related CR Transmittal #: R3290CP
Related Change Request (CR) #: CR 9248
Effective Date: October 1, 2015
Implementation Date: October 5, 2015
Provider Types Affected
This MLN Matters ® Article is intended for physicians, other providers, and suppliers
submitting claims to Medicare Administrative Contractors (MACs) for services provided
to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9248 which instructs MACs to download and implement the October
2015 Average Sales Price (ASP) drug pricing files and, if released by CMS, the July 2015,
April 2015, January 2015, and October 2014, ASP drug pricing files for Medicare Part B drugs.
Medicare will use these files to determine the payment limit for claims for separately payable
Medicare Part B drugs processed or reprocessed on or after October 5, 2015, with dates of
service October 1, 2015, through December 31, 2015. MACs will not search and adjust claims
that have already been processed unless brought to their attention. Make sure your billing staffs
are aware of these changes.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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SEPTEMBER 2015
11
The Average Sales Price (ASP) methodology is based on quarterly data submitted to
CMS by manufacturers. CMS will supply Medicare contractors with the ASP and Not
Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly
basis. Payment allowance limits under the OPPS are incorporated into the Outpatient
Code Editor (OCE) through separate instructions that can be located in the “Medicare
Claims Processing Manual” (Chapter 4 (Part B Hospital (Including Inpatient Hospital
Part B and OPPS)), Section 50 (Outpatient PRICER) (https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c04.pdf).
The following table shows how the quarterly payment files will be applied:
Files
Effective Dates of Service
October 2015 ASP and ASP NOC
October 1, 2015, through December 31, 2015
July 2015 ASP and ASP NOC
July 1, 2015, through September 30, 2015
April 2015 ASP and ASP NOC
April 1, 2015, through June 30, 2015
January 2015 ASP and ASP NOC
January 1, 2015, through March 31, 2015
October 2014 ASP and ASP NOC
October 1, 2014, through December 31, 2014
NOTE: The absence or presence of a HCPCS code and its associated payment limit does not indicate Medicare
coverage of the drug or biological. Similarly, the inclusion of a payment limit within a specific column does not
indicate Medicare coverage of the drug in that specific category. The local MAC processing the claim shall make
these determinations.
KENTUCKY & OHIO PART B
Background
Additional Information
The official instruction, CR9248 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3290CP.
pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Kentucky & Ohio
SE1315 Rescinded: Pulmonary Procedures
and Evaluation & Management (E/M) Services
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: SE1315 Rescinded
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Related Change Request (CR) #: Not Applicable
Effective Date: N/A
Implementation Date: N/A
Note: This article was rescinded on July 27, 2015.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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SEPTEMBER 2015
12
SE1408 Revised: Medicare Fee-For-Service (FFS)
Claims Processing Guidance for Implementing
International Classification of Diseases, 10th
Edition (ICD-10) – A Re-Issue of MM7492
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: SE1408 Revised
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Related Change Request (CR) #: 7492
Effective Date: October 1, 2014
Implementation Date: N/A
Note: This article was revised on June 27, 2015, to clarify language under “Claims that Span the ICD-10
Implementation Date”. All other information remains the same.
Provider Types Affected
KENTUCKY & OHIO PART B
Kentucky & Ohio
This article is intended for all physicians, providers, and suppliers submitting claims
to Medicare Administrative Contractors (MACs), including Home Health & Hospice
MACs (HH&H MACs), and Durable Medical Equipment MACs (DME MACs)) for services
provided to Medicare beneficiaries.
Provider Action Needed
For dates of service on and after October 1, 2015, entities covered under the Health
Insurance Portability and Accountability Act (HIPAA) are required to use the ICD-10 code
sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim
transactions are among those for which ICD-10 codes must be used for dates of service on
and after October 1, 2015. As a result of CR7492 (and related MLN Matters ® Article MM7492),
guidance was provided on processing certain claims for dates of service near the original
October 1, 2013, implementation date for ICD-10. This article updates MM7492 to reflect
the October 1, 2015, implementation date. Make sure your billing and coding staffs are
aware of these changes.
Key Points of SE1408
General Reporting of ICD-10
As with ICD-9 codes today, providers and suppliers are still required to report all characters of a
valid ICD-10 code on claims. ICD-10 diagnosis codes have different rules regarding specificity
and providers/suppliers are required to submit the most specific diagnosis codes based upon
the information that is available at the time. Please refer to http://www.cms.gov/Medicare/
Coding/ICD10/index.html for more information on the format of ICD-10 codes. In addition, ICD10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is currently the
case with ICD-9 procedure codes.
General Claims Submissions Information
ICD-9 codes will no longer be accepted on claims (including electronic and paper) with FROM
dates of service (on professional and supplier claims) or dates of discharge/through dates (on
institutional claims) on or after October 1, 2015. Institutional claims containing ICD-9 codes
for services on or after October 1, 2015, will be Returned to Provider (RTP) as unprocessable.
Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or
after October 1, 2015, will also be returned as unprocessable. You will be required to re-submit
these claims with the appropriate ICD-10 code. A claim cannot contain both ICD-9 codes
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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SEPTEMBER 2015
13
KENTUCKY & OHIO PART B
and ICD-10 codes. Medicare will RTP all claims that are billed with both ICD-9 and ICD-10
diagnosis codes on the same claim. For dates of service prior to October 1, 2015, submit
claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1,
2015, submit with the appropriate ICD-10 diagnosis code. Likewise, Medicare will also RTP
all claims that are billed with both ICD-9 and ICD-10 procedure codes on the same claim.
For claims with dates of service prior to October 1, 2015, submit with the appropriate ICD9 procedure code. For claims with dates of service on or after October 1, 2015, submit with
the appropriate ICD-10 procedure code. Remember that ICD-10 codes may only be used for
services provided on or after October 1, 2015. Institutional claims containing ICD-10 codes for
services prior to October 1, 2015, will be Returned to Provider (RTP). Likewise, professional and
supplier claims containing ICD-10 codes for services prior to October 1, 2015, will be returned
as unprocessable. Please submit these claims with the appropriate ICD-9 code.
Will the Centers for Medicare & Medicaid Services (CMS) allow for dual
processing of ICD-9 and ICD-10 codes (accept and process both ICD-9
and ICD-10 codes for dates of service on and after October 1, 2015)?
No, CMS will not allow for dual processing of ICD-9 and ICD-10 codes after ICD-10
implementation on October 1, 2015. Many providers and payers, including Medicare have
already coded their systems to only allow ICD-10 codes beginning October 1, 2015. The scope
of systems changes and testing needed to allow for dual processing would require significant
resources and could not be accomplished by the October 1, 2015, implementation date. Should
CMS allow for dual processing, it would force all entities with which we share data, including our
trading partners, to also allow for dual processing. In addition, having a mix of ICD-9 and ICD-10
codes in the same year would have major ramifications for CMS quality, demonstration, and risk
adjustment programs.
Claims that Span the ICD-10 Implementation Date
There may be times when a claim spans the ICD-10 implementation date for institutional,
professional, and supplier claims. For example, the beneficiary is admitted as an inpatient in
late September, 2015 and is discharged after October 1, 2015. Another example is a DME
claim for monthly billing that spans between September and October, 2015 (that is, the monthly
billing dates are September 15, 2015 – October 14, 2015). The following tables provide further
guidance to providers for claims that span the periods where ICD-9 and ICD-10 codes may both
be applicable.
Table A – Institutional Providers
Bill
Type(s)
Facility Type/Services
Use FROM or
THROUGH Date
Claims Processing Requirement
11X
Inpatient Hospitals (incl.
If the hospital claim has a discharge and/or through date on or after 10/1/15,
TERFHA hospitals,
then the entire claim is billed using ICD-10.
Prospective Payment
System (PPS) hospitals,
Long Term Care Hospitals
(LTCHs), Critical Access
Hospitals (CAHs)
THROUGH
12X
Inpatient Part B Hospital
Services
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
13X
Outpatient Hospital
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
14X
Non-patient Laboratory
Services
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
18X
Swing Beds
If the [Swing bed or SNF] claim has a discharge and/or through date on or
after 10/1/2015, then the entire claim is billed using ICD-10.
THROUGH
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
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SEPTEMBER 2015
14
Bill
Type(s)
Use FROM or
THROUGH Date
Facility Type/Services
Claims Processing Requirement
21X
Skilled Nursing (Inpatient
Part A)
If the [Swing bed or SNF] claim has a discharge and/or through date on or
after 10/1/2015, then the entire claim is billed using ICD-10.
THROUGH
22X
Skilled Nursing Facilities
(Inpatient Part B)
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
23X
Skilled Nursing Facilities
(Outpatient)
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
32X
Home Health (Inpatient
Part B)
Allow HHAs to use the payment group code derived from ICD-9 codes on
claims which span 10/1/2015, but require those claims to be submitted using
ICD-10 codes.
THROUGH
3X2
Home Health – Request
for Anticipated Payment
(RAPs)*
* NOTE - RAPs can report either an ICD-9 code or an ICD-10 code based
*See Note
on the one (1) date reported. Since these dates will be equal to each other,
there is no requirement needed. The corresponding final claim, however, will
need to use an ICD-10 code if the HH episode spans beyond 10/1/2015.
34X
Home Health –
(Outpatient )
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
71X
Rural Health Clinics
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
72X
End Stage Renal Disease
(ESRD)
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
73X
Federally Qualified Health N/A – Always ICD-9 code set.
Clinics (prior to 4/1/10)
N/A
74X
Outpatient Therapy
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
75X
Comprehensive
Split Claims - Require providers split the claim so all ICD-9 codes remain
Outpatient Rehab facilities on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
77X
Federally Qualified Health Split Claims - Require providers split the claim so all ICD-9 codes remain
Clinics (effective 4/4/10)
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
81X
Hospice- Hospital
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
82X
Hospice – Non hospital
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
FROM
83X
Hospice – Hospital Based N/A
N/A
85X
Critical Access Hospital
FROM
Split Claims - Require providers split the claim so all ICD-9 codes remain
on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10
codes placed on the other claim with DOS beginning 10/1/2015 and later.
KENTUCKY & OHIO PART B
Table A – Institutional Providers
Table B - Special Outpatient Claims Processing Circumstances
Use FROM or
THROUGH Date
Scenario
Claims Processing Requirement
3-day/1-day
Payment Window
Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient
bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on
or after 10/1/2015, the claim must be billed with ICD-10 for those bundled outpatient services.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2015-09
THROUGH
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SEPTEMBER 2015
15
Use FROM or
THROUGH Date
Type of Claim
Claims Processing Requirement
All anesthesia
claims
Anesthesia procedures that begin on 9/30/2015 but end on 10/1/2015 are to be billed with
ICD-9 diagnosis codes and use 9/30/2015 as both the FROM and THROUGH date.
FROM
Table D –Supplier Claims
Use FROM or
THROUGH Date
Type of Claim
Claims Processing Requirement
DMEPOS
Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the
ICD-10 compliance date of 10/1/2015 (i.e., the FROM date of service occurs prior to 10/1/2015
and the TO date of service occurs after 10/1/2015).
FROM
Additional Information
You may also want to review SE1239 at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/SE1239.pdf on the CMS website.
SE1239 announces the revised ICD-10 implementation date of October 1, 2015.
You may also want to review SE1410 at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf on the
CMS website.
KENTUCKY & OHIO PART B
Table C – Professional Claims
If you have any questions, please contact your MAC at their toll-free number. That number is
available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/index.html under - How Does It Work.
Kentucky & Ohio
SE1425 Revised: Extension of Provider
Enrollment Moratoria for Home Health
Agencies and Part B Ambulance Suppliers
The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning
Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on
the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/2015-MLN-Matters-Articles.html
MLN Matters® Number: SE1425 Revised
Related CR Release Date: N/A
Related CR Transmittal #: N/A
Related Change Request (CR) #: N/A
Effective Date: N/A
Implementation Date: N/A
Note: This article was revised on July 27, 2015, to reflect an extension of the temporary moratoria for an additional
6 months, as noted in the article.
Provider Types Affected
This MLN Matters ® Article is intended for home health agencies, home health agency
sub-units, and part B ground ambulance suppliers in certain geographic areas of Florida,
Illinois, Michigan, Texas, Pennsylvania and New Jersey that provide services to Medicare,
Medicaid and CHIP beneficiaries.
Provider Action Needed
STOP – Impact to You
Effective July 29, 2015, the temporary moratoria on new home health agencies, home health
agency sub-units, and part B ground ambulance suppliers are being extended for an additional
6 months in certain geographic locations.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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During the 6-month temporary moratoria, initial provider enrollment applications and change
of information applications to add additional practice locations, received from home health
agencies, home health agency sub-units, and part B ground ambulance suppliers in the
moratoria counties will be denied. Application fees that are paid for applications that are denied
due to the temporary moratoria will be refunded.
GO – What You Need to Do
Effective July 29, 2015, home health agencies, home health agency sub-units, and part B
ground ambulance suppliers should not submit initial enrollment applications or change of
information applications to add additional practice locations until the 6-month moratoria has
expired. CMS will announce in the Federal Register when the moratorium has been lifted,
extended, or changed.
Background
In accordance with 42 CFR §424.570(c) (http://www.gpo.gov/fdsys/pkg/CFR-2012-title42-vol3/
pdf/CFR-2012-title42-vol3-sec424-570.pdf), the Centers for Medicare & Medicaid Services
(CMS) may impose a moratorium on the enrollment of new Medicare providers and suppliers of
a specific type or the establishment of new practice locations in a particular geographic area.
On July 28, 2015, CMS announced, in a Federal Register notice (http://federalregister.
gov/a/2015-18327), the extension of temporary moratoria on the enrollment of new home
health agencies, home health agency sub-units and part B ambulance suppliers in designated
geographic locations.
KENTUCKY & OHIO PART B
CAUTION – What You Need to Know
The moratoria initially became effective on July 30, 2013, and the implementation
was announced in the Federal Register which may be accessed on the internet at:
https://federalregister.gov/a/2013-18394. The moratoria were expanded on January 30, 2014,
and the expansion was announced in the Federal Register which may be accessed at:
https://federalregister.gov/a/2014-02166.
Moratoria Extension
Effective July 29, 2015, the temporary moratorium on new home health agencies and home
health agency sub-units is being extended for an additional 6 months in the areas stated in
Table 1, below.
Table 1: Home Health Agencies and Home Health Agency Sub-units under Temporary Moratorium
City and State
Counties
City and State Counties
Fort Lauderdale, FL
Broward
Dallas, TX
Collin
Dallas
Denton
Ellis
Kaufman
Rockwall
Tarrant
Miami, FL
Miami-Dade
Monroe
Houston, TX
Brazoria
Chambers
Fort Bend
Galveston
Harris
Liberty
Montgomery
Waller
Detroit, MI
Macomb
Monroe
Oakland
Chicago, IL
Cook
DuPage
Kane
Lake
McHenry
Will
Washtenaw
Wayne
In addition, the temporary moratorium on new part B ground ambulance suppliers is being
extended for an additional 6 months in the areas stated in Table 2, below.
Table 2: Part B Ambulance Suppliers Under 6-month Temporary Moratorium
City and State
Counties
Houston, TX
Harris
Brazoria
Chambers
Fort Bend
Galveston
Liberty
Montgomery
Waller
Philadelphia, PA
Bucks (PA)
Delaware (PA)
Montgomery (PA)
Philadelphia (PA)
Burlington (NJ)
Camden (NJ)
Gloucester (NJ)
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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SEPTEMBER 2015
17
Note: Home health agencies, home health agency sub-units, and Part B ground ambulance suppliers are afforded
appeal rights. However, the scope of review will be limited to whether the temporary moratorium applies to the
provider or supplier appealing the denial. CMS’ basis for imposing a temporary moratorium is not subject to review.
Additional Information
For more information regarding CMS’ use of temporary moratoria, please review MLN Matters ®
article MM7350 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7350.pdf on the CMS website.
If you have any questions, please contact your MAC at their toll-free number, which is available
at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/providercompliance-interactive-map/index.html on the CMS website.
Kentucky & Ohio
News Flash Items
KENTUCKY & OHIO PART B
Initial provider enrollment applications and change of information applications to add additional
practice locations received from home health agencies, home health agency sub-units, and Part
B ground ambulance suppliers in the above listed counties will be denied in accordance with
42 CFR §424.570(c). Application fees that are paid for applications that are denied due to the
temporary moratoria will be refunded.
yyJune is Men’s Health Month - Medicare provides coverage of a wide range of preventive
services, subject to certain eligibility and coverage requirements that are especially
meaningful to men in helping to prevent and detect disease. You can help your patients
make the most of their benefits by talking with them about their risk factors for disease
and encouraging them to take advantage of the preventive services covered by Medicare
that are most appropriate for them. Continue reading (https://www.cms.gov/Medicare/
Prevention/PrevntionGenInfo/Health-Observance-Mesages-New-Items/2015-06-11-MensHealth.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending) to learn more
about Medicare-covered preventive service.
yyNEW products from the Medicare Learning Network®
ƒƒ“The DMEPOS Competitive Bidding Program Repairs and Replacements Fact
Sheet,” Fact Sheet, ICN 905283, downloadable https://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DME_Repair_
Replacement_Factsheet_ICN905283.pdf
yyRevised product from the Medicare Learning Network® (MLN)
ƒƒICD-10-CM/PCS Billing and Payment Frequently Asked Questions, Fact Sheet (ICN
908974) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ICD-10BillingandPaymentFAQs.pdf
ƒƒ“Internet-based PECOS Contact Information” Fact Sheet, ICN 903766, downloadable
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/MedEnroll_PECOS_Contact_FactSheet_ICN903766.pdf
ƒƒ“ICD-10-CM Classification Enhancements,” (http://www.cms.gov/Medicare/Coding/
ICD10/downloads/ICD-10QuickRefer.pdf) Fact Sheet, ICN 903187, Downloadable only.
This newsletter should be shared with all health care practitioners and managerial members of
the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our
website at http://www.cgsmedicare.com. © 2015 Copyright, CGS Administrators, LLC.
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18