July 2014

Medicare
Bulletin
Jurisdiction 15
Reaching Out
to the Medicare
Community
© 2014 Copyright, CGS Administrators, LLC.
HOME HEALTH & HOSPICE
JULY 2014 • WWW.CGSMEDICARE.COM
Jurisdiction 15
HOME HEALTH PROVIDERS
Submit the Correct Document Control
Number (DCN) When Requesting an
Ordering/Referring Denial Reopening 3
MM8773: July Update to the Calendar Year (CY)
2014 Medicare Physician Fee Schedule
Database (MPFSDB) 15
MM8776: July 2014 Update of the Hospital
Outpatient Prospective Payment System (OPPS) 17
Widespread Home Health Probe Results:
Utah Home Health Providers 3
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS) 23
HOSPICE PROVIDERS
Provider Contact Center (PCC) Availability
and the July 4th Holiday 24
New Hospice Denial Fact Sheet Quick Resource Tool 5
Reason Code 34952: Service Facility NPI is Required 5
HOME HEALTH &
HOSPICE PROVIDERS
Provider Contact Center Reminders 24
Quarterly Provider Update 25
HOME HEALTH & HOSPICE
Medicare Bulletin
Stay Informed and Join the CGS ListServ
Notification Service 25
Submit Your Redetermination Requests
through the myCGS Web Portal! 26
CGS Website Updates 6
eOffset Using myCGS:
Clarification of Valid Requests 7
Medicare Credit Balance Quarterly Reminder 7
Medicare Learning Network®:
A Valuable Educational Resource! 9
MLN Connects™ Provider e-News 9
MM8456 (Rescinded): Modifying the Daily
Common Working File (CWF) to Medicare
Beneficiary Database (MBD) File to Include
Diagnosis Codes on the Health Insurance
Portability and Accountability Act Eligibility
Transaction System (HETS) 270/271 Transactions 9
MM8664 (Revised): April Update to the Calendar
Year (CY) 2014 Medicare Physician Fee Schedule
Database (MPFSDB) 10
MM8684: Claim Status Category and Claim
Status Codes Update 13
http://www.cms.gov/MLNGenInfo
MM8764: July 2014 Integrated Outpatient Code
Editor (I/OCE) Specifications Version 15.2 14
Bold, italicized material is excerpted from the American Medical Association Current Procedural
Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical
Association. All rights reserved. Applicable FARS/DFARS apply.
MEDICARE BULLETIN • GR 2014-07
JULY 2014
2
HOME HEALTH & HOSPICE
For Home Health Providers
Submit the Correct Document Control
Number (DCN) When Requesting an
Ordering/Referring Denial Reopening
CGS has seen an increase in provider telephone inquiries regarding ordering/referring
denial reopening adjustments that have gone to the Return to Provider (RTP) file
because the incorrect DCN was submitted on the hardcopy adjustment UB-04 claim
(XX7). These reopening adjustments are being submitted for claims that originally denied
in the Fiscal Intermediary Standard System (FISS) with reason code 37236 or 37237. To
determine the correct DCN to report on the hardcopy UB-04 claim:
yyFrom the FISS Main Menu, select 01 “Inquiries”
yyFrom the Inquiry Menu, select 12 “Claim Summary”
yyFrom the Claim Summary Inquiry screen, enter your National Provider
Identifier (NPI) in the NPI field, and the beneficiary’s Medicare number
in the HIC field.
yyEnter ‘329’ in the TOB (type of bill) field.
yyEnter the dates of service (From Date and To Date) of the denied claim.
yySelect the denied claim.
yyGo to Page 02 and press F2 to access MAP171D.
yyThe DCN of the denied claim will appear in the upper left corner of MAP171D,
in the “DCN” field. This is the number that must be entered into ‘Document Control
Number (DCN)’ field on the ‘Medicare HHH Reopening Adjustment Request Form.’
For additional information, refer to the “Reopenings” Web page at
http://www.cgsmedicare.com/hhh/appeals/Reopenings.html on the CGS website.
For Home Health Providers
Widespread Home Health Probe
Results: Utah Home Health Providers
In the October 2013 CGS Home Health & Hospice Medicare Bulletin, available at
http://www.cgsmedicare.com/hhh/pubs/mb_hhh/2013/10_2013/PDFs/HHH_Bulletin_
Oct13.pdf, CGS published the article “Widespread Home Health Probe – Utah Home
Health Providers” (page 12), which notified home health agencies in Utah about a new
statewide service specific probe. The edit, 5012W, selected 100 claims billed with 10
or more therapy visits from October to November 2013. This probe was initiated based
on analysis of billing data which identified greater aberrancies among home health
providers in the state of Utah in comparison to the universe of CGS providers in the
following areas:
yyAverage reimbursement per claim;
yyAverage total visits;
yyAverage total therapy visits;
yyPercent of claims with therapy services; and
yyPercent of claims with 20+ therapy visits.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
3
HOME HEALTH & HOSPICE
In addition, an OIG report titled “Inappropriate and Questionable Billing by Medicare
Home Health Agencies” (http://oig.hhs.gov/oei/reports/oei-04-11-00240.pdf) identified
the state of Utah as one of eight states that had high percentages of agencies with
questionable billing practices.
CGS has completed its analysis of this probe, which resulted in a 79% error rate, based
on the dollar amount denied. Below is a table showing the denial reasons, and volume of
claims denied for each reason.
Denial Reason Code
5FFTF
5HMED
5HORD
56900
5HNOA
5HPLN
5HHBD
5HRHC, 5HRHD,
5HRHF, or 5HSUP
5HDOC
Denial Reason
Missing/incomplete/untimely face-to-face encounter
Medical necessity not supported in medical record
Missing/incomplete/untimely orders
No timely response to ADR
No OASIS assessment submitted to the state
Missing/incomplete/untimely plan of care
Homebound status not supported in the record
HIPPS code reduced – clinical domain. Incorrect
diagnosis, functional domain or non-routine supplies
Services were not documented
# of Claims Denied
37
23
8
5
4
3
3
2
1
As a result of the high error rate, CGS will be implementing a service specific edit for
home health providers in Utah that selects claims with at least 10 therapy visits.
Provider Action to Prepare and Reduce Risk of Future Denials
Home health agencies (HHAs) should take action now to ensure that they have
procedures and processes in place to appropriately identify and respond to claims
that are selected for Medical Review by this edit. Providers may access the following
resources to ensure they are prepared in the event that a claim is selected for an
additional development request (ADR).
yy“Additional Development Request (ADR) Process” Web page,
http://www.cgsmedicare.com/hhh/medreview/adr_process.html
yy“Additional Development Request (ADR) Quick Resource Tool,”
http://www.cgsmedicare.com/hhh/education/materials/pdf/ADR_QRT.pdf
To educate home health agencies on the top denials by medical review, and to prevent
future denials, CGS has developed several Home Health Denial Fact Sheets. Below is a
list of those currently available, along with the link to access these critical resources.
yy5FFTF – Missing/Incomplete/Untimely Face-to-Face Encounter,
http://www.cgsmedicare.com/hhh/education/materials/pdf/HH_5FFTF_FactSheet.pdf
yy5HHBD – Homebound Status, http://www.cgsmedicare.com/hhh/education/
materials/pdf/hh_5hhbd_factsheet.pdf
yy5HMED – Medical necessity, http://www.cgsmedicare.com/hhh/education/materials/
pdf/HH_5HMED_FactSheet.pdf
yy5HNOA – No OASIS, http://www.cgsmedicare.com/hhh/education/materials/pdf/
hh_5hnoa_factsheet.pdf
yy5HPLN/5HORD – Missing plan of care or orders, http://www.cgsmedicare.com/hhh/
education/materials/pdf/HH_5HPLN-5HORD_FactSheet.pdf
Please share this information with your staff. If you have any questions, contact the CGS
Provider Contact Center, at 1.877.299.4500 (Option 1).
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
4
HOME HEALTH & HOSPICE
For Hospice Providers
New Hospice Denial Fact
Sheet Quick Resource Tool
CGS has developed a new hospice fact sheet to assist hospice clinical staff in
avoiding medical review denials. The fact sheet, “5PPOC: Plan of Care” is available
at http://cgsmedicare.com/hhh/education/materials/hospice_qrt.html on the “Hospice
Quick Resource Tools” Web page. In addition, the fact sheet is also accessible from the
Hospice Denial Reason Codes Web page at http://cgsmedicare.com/hhh/medreview/
HOS_DRC.html on the CGS website.
yy5PPOC: Plan of Care - http://cgsmedicare.com/hhh/education/materials/pdf/
hospice_5PPOC_factsheet.pdf
For Hospice Providers
Reason Code 34952:
Service Facility NPI is Required
CGS has identified a new reason code in our Claim Submission Error (CSE) data for
May 2014. The reason code 34952 indicates that a service facility National Provider
Identifier (NPI) is required on the claim, but was not reported.
As a reminder, per Change Request 8358, effective for dates of service on/after April 1,
2014, hospice providers are now required to report a service facility NPI when billing any
of the following place of service HCPCS codes:
yyQ5003 – hospice care provided in nursing long term care facility (LTC) or non-skilled
nursing facility (NF)
yyQ5004 – hospice care provided in skilled nursing facility (SNF)
yyQ5005 – hospice care provided in inpatient hospital
yyQ5007 – hospice care provided in long term care hospital (LTCH)
yyQ5008 – hospice care provided in inpatient psychiatric facility
The service facility NPI must be reported in Loop 2310E (when billing in the 5010
electronic claim format) or the SERV FAC NPI field in the Fiscal Intermediary Standard
System (FISS) on Claim Page 03.
MAP1713PAGE 03CGS J15 MAC - HHH REGIONACPFA052MM/DD/YY
AXB1234SCINST CLAIM ENTRYC201423PHH:MM:SS
HICTOB 811S/LOC
S
B0100PROVIDER
NDCCODEOFFSITE ZIPCD:
CD
IDPAYEROSCARRI ABEST AMT DUE
A
B
C
DUE FROM PATIENTSERV FAC NPI
MEDICAL RECORD NBRCOST RPT DAYSNON COST RPT DAYS
DIAG CODES 0102030405
06070809END OF POA IND
ADMITTING DIAGNOSISE CODEHOSPICE TERM ILL IND
IDE
PROCEDURE CODES AND DATES0102
03040506
ESRD HOURS ADJUSTMENT REASON CODE
REJECT CODE
NONPAY CODE
ATT PHYSNPILFMSC
OPR PHYSNPILFMSC
OTH OPRNPILFMSC
REN PHYSNPILFMSC
REF PHYSNPILFMSC
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
5
HOME HEALTH & HOSPICE
Claims that do not include an NPI in the SERV FAC NPI field when required will be
sent to the returned to the provider (RTP) file (status/location T B9997) for correction.
Providers can reduce claims processing times and avoid payment delays by ensuring
this information is reported on the claim when required.
For additional information about billing hospice claims, refer to the “Hospice Claims
Filing” Web page at http://www.cgsmedicare.com/hhh/education/materials/Hospice_
CF.html on the CGS website.
For Home Health and Hospice Providers
CGS Website Updates
CGS has recently made updates to their website, giving providers additional resources to
assist with billing Medicare-covered services appropriately.
Please review the following updates:
yyThe “Ordering/Referring Denial Reopenings” section of the “Reopenings” Web
page at http://www.cgsmedicare.com/hhh/appeals/Reopenings.html was updated
to include information to ensure the correct Document Control Number (DCN) is
submitted on the “HHH Reopening Adjustment Request Form.”
yyThe “ICD-10-CM/PCS” Web page at http://www.cgsmedicare.com/hhh/claims/5010.
html was updated to include information about the new ICD-10 compliance date
of September 30, 2015, and the cancellation of the July ICD-10 end-to-end testing
during the week of July 21 through July 25, 2014. The “ICD-10-CM/PCS Frequently
Asked Questions” at http://www.cgsmedicare.com/hhh/education/faqs/ICD-10.html
were also updated to reflect this information.
yyThe “Home Health & Hospice 2014 Holiday/Training Closure Schedule” at
http://www.cgsmedicare.com/hhh/help/pdf/Holiday_Schedule.pdf was updated to
show the Provider Contact Center (PCC) training day change from Tuesday
to Thursday.
yyThe “Hospice Quick Resource Tools” Web page at http://cgsmedicare.com/
hhh/education/materials/hospice_qrt.html was updated to include a link to the new
“5PPOC: Plan of Care” denial fact sheet (http://cgsmedicare.com/hhh/education/
materials/pdf/hospice_5PPOC_factsheet.pdf)
yyThe Fiscal Intermediary Standard System (FISS) Guide, “Chapter Three: Inquiry
Menu” which is available at http://www.cgsmedicare.com/hhh/education/materials/
pdf/Chapter3_Inquiry_Menu.pdf was updated. The updated information shows in
red font.
yyThe “Centers for Medicare & Medicaid Services (CMS) Educational Resources”
Web page at http://www.cgsmedicare.com/hhh/education/CMS_Resources.html
has been updated to include links that allow providers to subscribe to CMS
electronic mailing lists.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
6
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
eOffset Using myCGS:
Clarification of Valid Requests
In May, CGS announced a new feature in the myCGS Web Portal - eOffset. This
feature allows registered users to submit electronic authorizations to offset from
pending overpayments that are owed to CGS. This option allows providers to request
an immediate offset each time a demanded overpayment is received, or authorize a
permanent request for all future demanded overpayments.
To use the eOffset function for an immediate offset, the provider must have received an
overpayment demand letter from CGS. The letter will include a number in the upper-right
corner of the letter. An eOffset may be requested by using this number or the account
receivable (AR) number located on the attachment to the demand letter.
CGS is aware that some providers are attempting to use the eOffset feature to submit a
voluntary refund. However, the eOffset function does not support voluntary refunds. To
make a voluntary refund, follow the instructions provided on the Overpayment Web page,
and use the appropriate Voluntary Refund form, available on the CGS website:
yyPart A, http://www.cgsmedicare.com/parta/overpay/index.html
yyPart B - Ohio, http://www.cgsmedicare.com/ohb/forms/overpayment.html
yyPart B – Kentucky, http://www.cgsmedicare.com/kyb/forms/overpayment.html
yyHome Health & Hospice, http://www.cgsmedicare.com/hhh/financial/Overpay.html
Note: Part A providers, including home health and hospices, are strongly encouraged to
electronically adjust claims to correct overpayments, rather than submit a refund via the
Voluntary Refund Request form.
If you have additional questions about using the eOffset feature, please contact the CGS
EDI Department using the appropriate number below:
yyPart A: 1.866.590.6703 (Option 2)
yyPart B – Kentucky and Ohio: 1.866.276.9558 (Option 2)
yyHome Health & Hospice: 1.877.299.4500 (Option 2)
You may also refer to the eOffset Job Aid located at http://www.cgsmedicare.com/pdf/
eOffsetsJobAid.pdf.
For Home Health and Hospice Providers
Medicare Credit Balance Quarterly Reminder
This article is a reminder submit the Quarterly Medicare Credit Balance Report. The
next report is due in our office postmarked by July 30, 2014, for the quarter ending June
30, 2014. A Medicare credit balance is an amount determined to be refundable to the
Medicare program for an improper or excess payment made to a provider because of
patient billing or claims processing errors.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
7
HOME HEALTH & HOSPICE
Each provider must submit a quarterly Medicare Credit Balance Report (CMS-838) and
certification for each individual PTAN, which is available at http://www.cms.gov/Medicare/
CMS-Forms/CMS-Forms/downloads/CMS838.pdf. The report must be postmarked by
the date indicated above. If the report is received with a postmark date later than the
date indicated above, we are required to withhold 100 percent of all payments being sent
to your facility. This withholding will remain in effect until the reporting requirements are
met. If no credit balance exists for your facility during a quarter, a signed Medicare Credit
Balance Report certification is still required. Please include your Medicare provider
number on the certification form.
Refer to the Medicare Credit Balance Report (CMS-838) form for complete instructions.
However, for additional assistance in completing the form, refer to the “Tips on
Completing a Credit Balance Report (Form CMS-838)” Web page at https://www.
cgsmedicare.com/hhh/financial/838_form_tips.html on the CGS website.
To ensure timely receipt and processing, please send to the appropriate address listed
below:
Credit Balance Reports (CMS-838)/Certification with Checks
yyIf you are sending a check with the CMS-838 to repay the credit balance amount,
please send the check, payable to “Medicare Fund,” with either a copy of the CMS838, or a letter indicating that the check is associated with the CMS-838, to the
following address:
CGS – J15 Home Health and Hospice
PO Box 957124
St. Louis, MO 63195-7124
In addition, send the original CMS-838/Certification, with a copy of the check
to the following address:
J15—HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202
Credit Balance Reports/Certification – Adjustment Submitted
yyIf you have or will be submitting an adjustment, please send the CMS-838 to the
following address:
J15—HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202
If you have any Credit Balance related questions, or are unable to access our website
at http://www.cgsmedicare.com/hhh/financial/CMS-588.html to obtain a paper copy
of the CMS-838 form, please contact the Medicare Credit Balance telephone line at
1.866.590.6703.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
8
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
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-andEducation/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/MedicareLearning-Network-MLN/MLNGenInfo/index.html on the CMS website.
For Home Health and Hospice Providers
MLN Connects™ Provider e-News
The MLN Connects™ Provider e-News contains a weeks worth of Medicare-related
messages issued by the Centers of Medicare & Medicaid Services (CMS). These
messages ensure planned, coordinated messages are delivered timely about Medicarerelated topics. The following provides access to the weekly messages. Please share with
appropriate staff. If you wish to receive the ListServv directly from CMS, please contact
CMS at LearnResource-L@cms.hhs.gov.
yyMay 22, 2014 - http://go.cms.gov/1jVHzTn
yyMay 29, 2014 - http://go.usa.gov/8PgC
yyJune 5, 2014 - http://go.cms.gov/S8OnGR
yyJune 12, 2014 - http://go.usa.gov/8ugz
For Home Health and Hospice Providers
MM8456 (Rescinded): Modifying the Daily
Common Working File (CWF) to Medicare
Beneficiary Database (MBD) File to Include
Diagnosis Codes on the Health Insurance
Portability and Accountability Act Eligibility
Transaction System (HETS) 270/271 Transactions
The Centers for Medicare & Medicaid Services (CMS) has rescinded 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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8456 Rescinded Related Change Request (CR) #: CR 8456
Related CR Release Date: May 16, 2014
Effective Date: October 1, 2014
Related CR Transmittal #: R1386OTN
Implementation Date: October 6, 2014
Note: This article was rescinded on May 20, 2014, as a result of a revision to CR 8456, issued on May
16. The CR revision eliminated the need for provider education. As a result, this article is rescinded.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
9
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
MM8664 (Revised): April Update to the Calendar
Year (CY) 2014 Medicare Physician Fee Schedule
Database (MPFSDB)
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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8664 Revised Related Change Request (CR) #: CR 8664
Related CR Release Date: April 4, 2014
Effective Date: January 1, 2014
Related CR Transmittal #: R2923CP
Implementation Date: April 7, 2014
Note: This article was revised on April 8, 2014, to reflect the revised CR 8664 issued on April 4. The CR
was revised to reflect the President signing into law the “Protecting Access to Medicare Act of 2014” on
April 1, 2014, thus averting the expiration of the 0.5% update to the physician fee schedule conversion
factor and the 1.0 work floor GPCI, which will now remain in effect until December 31, 2014. Similar
changes were made to this article. The CR release date and the Web address for accessing the CR are
revised. All other information remains the same.
Provider Types Affected
This MLN Matters® article is intended for physicians, other providers, and suppliers
who submit claims to Medicare claims administration contractors (carriers, fiscal
intermediaries (FIs), A/B Medicare administrative contractors (MACs), home health
and hospices (HH&Hs) MACs, and/or regional HH intermediaries (RHHIs)) for services
provided to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8664 which amends the payment files that were issued to
Medicare contractors based upon the CY 2014 MPFS, Final Rule and passage of the
“Protecting Access to Medicare Act of 2014,” which the President signed on April 1, 2014.
Make sure that your billing staffs are aware of these changes.
Background
The Social Security Act (Section 1848(c)(4); see http://www.ssa.gov/OP_Home/ssact/
title18/1848.htm on the Internet) authorizes CMS to establish ancillary policies necessary
to implement relative values for physicians’ services.
In order to reflect appropriate payment policy as included in the CY 2014 MPFS Final
Rule, the MPFSDB has been updated with April changes, and those necessitated by
“Protecting Access to Medicare Act of 2014,” which the President signed on April 1, 2014.
This law extends the 0.5% update through December 31, 2014. Since the Act extends the
MPFSDB policies to all of CY 2014, the April update payment files that were previously
created to be effective from January 1, 2014, to March 31, 2014, can now be used by
MACs to be effective from January 1, 2014, to December 31, 2014.
Note: Medicare contractors will not search their files to either retract payment for claims already paid or
to retroactively pay claims. However, contractors will adjust claims brought to their attention.
CR 8664 Summary of Changes
The summary of changes for the April 2014 update consists of the following:
1. Short Description Corrections for HCPCS codes G0416 - G0419
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
10
Old Short Description
Revised 2014 Short Description
G0416
Sat biopsy prostate 1-20 spc
Biopsy prostate 10-20 spc
G0417
Sat biopsy prostate 21-40
Biopsy prostate 21-40
G0418
Sat biopsy prostate 41-60
Biopsy prostate 41-60
G0419
Sat biopsy prostate: >60
Biopsy prostate: >60
2. Adjust the Facility and Non-Facility PE RVUs for HCPCS code 77293-Global
and 77293-TC via CMS update files.
HCPCS Mod
Status
Description
Non- Facility Facility
PE RVUs
PE RVUs
Global
77293
A
Respirator motion
mgmt simul
9.96
NA
ZZZ
Jan 1 to March 31, 2014
A
Respirator motion
mgmt simul
9.16
NA
ZZZ
Jan 1 to March 31, 2014
A
Respirator motion
mgmt simul
10.72
NA
ZZZ
Correction April 1, 2014, RVU
change effective January 1 to
December 31, 2014
A
Respirator motion
mgmt simul
9.92
NA
ZZZ
Correction April 1, 2014, RVU
change effective January 1 to
December 31, 2014
77293
TC
77293
77293
TC
HOME HEALTH & HOSPICE
HCPCS Code
3. HCPCS code G9361 will be added to your Medicare contractor’s systems.
HCPCS Code
G9361
Procedure Status
M
Short Descriptor
Doc comm risk calc
Effective Date
01/01/2014
Work RVU
0
Full Non-Facility PE RVU
0
Full Non-Facility NA Indicator
(blank)
Full Facility PE RVU
0
Full Facility NA Indicator
(blank)
Malpractice RVU
0
Multiple Procedure Indicator
9
Bilateral Surgery Indicator
9
Assistant Surgery Indicator
9
Co-Surgery Indicator
9
Team Surgery Indicator
9
PC/TC
9
Site of Service
9
Global Surgery
XXX
Pre
0.00
Intra
0.00
Post
0.00
Physician Supervision Diagnostic Indicator
09
Diagnostic Family Imaging Indicator
99
Non-Facility PE used for OPPS Payment Amount
0.00
Facility PE used for OPPS Payment Amount
0.00
MP Used for OPPS Payment Amount
0.00
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
11
9
Long Descriptor
Medical indication for induction [Documentation of reason(s)
for elective delivery or early induction (e.g., hemorrhage and
placental complications, hypertension, preeclampsia and
eclampsia, rupture of membranes-premature, prolonged
maternal conditions complicating pregnancy/delivery, fetal
conditions complicating pregnancy/delivery, malposition
and malpresentation of fetus, late pregnancy, prior uterine
surgery, or participation in clinical trial)]
4. Correct the Physician Supervision of Diagnostic Procedures indicator for
the TC’s of the following codes, effective January 1, 2014.
HCPCS
Code
Physician Supervision of
Diagnostic Procedures
Effective
(Phys Diag Supv)
Date
70450-TC Ct head/brain w/o dye - Phys Diag Supv Correction (TC)
01
01/01/2014
70460-TC Ct head/brain w/dye - Phys Diag Supv Correction (TC)
02
01/01/2014
70551-TC Mri brain stem w/o dye - Phys Diag Supv Correction (TC)
01
01/01/2014
70552-TC Mri brain stem w/dye - Phys Diag Supv Correction (TC)
02
01/01/2014
70553-TC Mri brain stem w/o & w/dye - Phys Diag Supv Correction (TC)
02
01/01/2014
72141-TC
01
01/01/2014
72142-TC Mri neck spine w/dye - Phys Diag Supv Correction (TC)
02
01/01/2014
72146-TC Mri chest spine w/o dye - Phys Diag Supv Correction (TC)
01
01/01/2014
72147-TC
02
01/01/2014
72148-TC Mri lumbar spine w/o dye - Phys Diag Supv Correction (TC)
01
01/01/2014
72149-TC Mri lumbar spine w/dye - Phys Diag Supv Correction (TC)
02
01/01/2014
72156-TC Mri neck spine w/o & w/dye - Phys Diag Supv Correction (TC) 02
01/01/2014
Mri neck spine w/o dye - Phys Diag Supv Correction (TC)
Mri chest spine w/dye - Phys Diag Supv Correction (TC)
72157-TC
Mri chest spine w/o & w/dye - Phys Diag Supv
Correction (TC)
02
01/01/2014
72158-TC
Mri lumbar spine w/o & w/dye - Phys Diag Supv
Correction (TC)
02
01/01/2014
72191-TC
Ct angiograph pelv w/o&w/dye - Phys Diag Supv
Correction (TC)
02
01/01/2014
74174-TC
Ct angio abd&pelv w/o&w/dye - Phys Diag Supv
Correction (TC)
02
01/01/2014
74175-TC
Ct angio abdom w/o & w/dye - Phys Diag Supv
Correction (TC)
02
01/01/2014
93880-TC Extracranial bilat study - Phys Diag Supv Correction (TC)
01
01/01/2014
93882-TC Extracranial uni/ltd study - Phys Diag Supv Correction (TC)
01
01/01/2014
77001-TC Fluoroguide for vein device - Phys Diag Supv Correction (TC)
03
01/01/2014
77002-TC Needle localization by xray - Phys Diag Supv Correction (TC)
03
01/01/2014
77003-TC Fluoroguide for spine inject - Phys Diag Supv Correction (TC)
03
01/01/2014
HOME HEALTH & HOSPICE
Type of Service
Additional Information
The official instruction, CR 8664, issued to your MAC regarding this change may be
viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R2923CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
12
MM8684: Claim Status Category
and Claim Status Codes Update
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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8684 Related CR Release Date: May 23, 2014
Related CR Transmittal #: R2967CP
Related Change Request (CR) #: CR 8684
Effective Date: October 1, 2014
Implementation Date: October 6, 2014
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
MACs (HH&H MACs), for services to Medicare beneficiaries.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Provider Action Needed
This article is based on CR 8684 which informs the MACs of the changes to Claim
Status Category Codes and Claim Status Codes. Make sure that your billing personnel
are aware of these changes.
Background
The Health Insurance Portability and Accountability Act (HIPAA) requires all health
care benefit payers to use only Claim Status Category Codes and Claim Status Codes
approved by the national Code Maintenance Committee in the X12 276/277 Health Care
Claim Status Request and Response format adopted as the standard for national use
(e.g. previous HIPAA named versions included 004010X093A1, more recent HIPAA
named versions). These codes explain the status of submitted claim(s). Proprietary
codes may not be used in the X12 276/277 to report claim status. The National Code
Maintenance Committee meets at the beginning of each X12 trimester meeting
(February, June, and October) and makes decisions about additions, modifications, and
retirement of existing codes. The codes sets are available at http://www.wpc-edi.com/
reference/codelists/healthcare/claim-status-category-codes/ and http://www.wpc-edi.
com/reference/codelists/healthcare/claim-status-codes/ on the Internet.
All code changes approved during the June 2014 committee meeting will be posted
on these sites on or about July 1, 2014. Included in the code lists are specific details,
including the date when a code was added, changed, or deleted.
These code changes will be used in the editing of all X12 276 transactions processed on
or after the date of implementation and are to be reflected in X12 277 transactions issued
on and after the date of implementation of CR 8684.
Additional Information
The official instruction, CR 8684 issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R2967CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
13
MM8764: July 2014 Integrated Outpatient Code
Editor (I/OCE) Specifications Version 15.2
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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8764
Related CR Release Date: May 16, 2014
Related CR Transmittal #: R2957CP
Related Change Request (CR) #: CR 8764
Effective Date: July 1, 2014
Implementation Date: July 7, 2014
Provider Types Affected
This MLN Matters® article is intended for physicians, other providers, and suppliers
submitting claims to Medicare administrative contractors (MACs), including the home
health and hospice MACs, for outpatient services provided to Medicare beneficiaries
and paid under the Outpatient Prospective Payment System (OPPS) and for outpatient
claims from any non-OPPS provider not paid under the OPPS, and for claims for limited
services when provided in a home health agency (HHA) not under the Home Health
Prospective Payment System (HH PPS) or claims for services to a hospice patient for the
treatment of a non-terminal illness.
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Provider Action Needed
This article is based on CR 8764 which informs MACs about the changes to the I/OCE
instructions and specifications for the I/OCE that is used under the OPPS and NonOPPS for hospital outpatient departments, community mental health centers, all nonOPPS providers, and for limited services when provided in a HHA not under the HH PPS
or to a hospice patient for the treatment of a non-terminal illness. Make sure your billing
staffs are aware of these changes.
Background
This instruction informs the MACs that the I/OCE is being updated for July 1, 2014.
The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital
claims) through a single integrated OCE, which eliminates the need to update, install, and
maintain two separate OCE software packages on a quarterly basis. The full list of I/OCE
specifications is available at http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/
index.html on the CMS website. The summary of key changes for providers is in the
following table:
Effective Date
10/1/2014
1/1/2014
7/1/2014
7/1/2014
1/1/2014
7/1/2014
1/1/2014
Modification
Modify the effective begin date for edit 86 from 10/1/2013 to 10/1/2014, to be applied for claims with
hospice bill types, 81X and 82X.
Modify the logic for packaged laboratory services. If packaged laboratory services are submitted on a
13X bill type with modifier L1, change the Status Indicator (SI) from N to A.
Make Healthcare Common Procedure Coding System (HCPCS)/Ambulatory Payment Classification
(APC)/SI changes as specified by CMS (data change files).
Implement version 20.2 of the NCCI (as modified for applicable institutional providers).
Add new modifier L1 (Separately payable lab test) to the valid modifier list.
Add new modifier SZ (Habilitative services) to the valid modifier list.
Updated documentation in Appendix F(a) and Appendix L to include bill type 13x for laboratory services
reported with modifier L1.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
14
7/1/2014
Modification
Documentation change only: modified Appendix N, List B (PHP Services) to note the add-on codes
in a separate list as part of “PHP List C”, referred to in Appendix C-a (Partial Hospitalization Logic
effective v10.0).
Additional Information
The official instruction, CR 8764 issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R2957CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
MM8773: July Update to the Calendar
Year (CY) 2014 Medicare Physician Fee
Schedule Database (MPFSDB)
HOME HEALTH & HOSPICE
Effective Date
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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8773
Related CR Release Date: June 6, 2014
Related CR Transmittal #: R2974CP
Related Change Request (CR) #: CR 8773
Effective Date: July 1, 2014
Implementation Date: July 7, 2014
Provider Types Affected
This MLN Matters® article is intended for physicians, other providers, and suppliers who
submit claims to Medicare administrative contractors (MACs), including home health and
hospice (HHH) MACs, for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8773 which amends the payment files that were issued to
MACs based upon the CY 2014 MPFS, Final Rule as modified by the “Pathway for SGR
Reform Act of 2013” (Section 101) passed on December 18, 2013, and further modified
by section 101 of the “Protecting Access to Medicare Act of 2014” on April 1, 2014. Make
sure your billing staffs are aware of these changes.
Background
The Social Security Act (Section 1848 (c)(4) (available at http://www.socialsecurity.
gov/OP_Home/ssact/title18/1848.htm) authorizes CMS to establish ancillary policies
necessary to implement relative values for physicians’ services.
In order to reflect appropriate payment policy based on current law and the Calendar
Year (CY) 2014 Medicare Physician Fee Schedule (MPFS) Final Rule, the MPFS
Database (MPFSDB) has been updated using the 0.5 percent update conversion factor,
effective January 1, 2014, to December 31, 2014.
Payment files were issued to MACs based upon the CY 2014 MPFS Final Rule,
published in the Federal Register on December 10, 2013, which is available at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/
PFS-Federal-Regulation-Notices-Items/CMS-1600-FC.html, and as modified by section
101 of the “Pathway for SGR Reform Act of 2013” passed on December 18, 2013, and
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
15
HOME HEALTH & HOSPICE
further modified by section 101 of the “Protecting Access to Medicare Act of 2014” on
April 1, 2014, for MPFS rates to be effective January 1, 2014, to December 31, 2014.
The summary of Healthcare Common Procedure Coding System (HCPCS) Code
additions for the July 2014 update are shown in the following table:
HCPCS
Short Descriptor
Procedure Status
Q9970
Inj Ferric Carboxymaltos 1mg
E
Q9974
Morphine epidural/intratheca
E
S0144
Inj, Propofol, 10mg
I
S1034
Art pancreas system
I
S1035
Art pancreas inv disp sensor
I
S1036
Art pancreas ext transmitter
I
S1037
Art pancreas ext receiver
I
0347T
Ins bone device for rsa
C
0348T
Rsa spine exam
C
0349T
Rsa upper extr exam
C
0350T
Rsa lower extr exam
C
0351T
Intraop oct brst/node spec
C
0352T
Oct brst/node i&r per spec
C
0353T
Intraop oct breast cavity
C
0354T
Oct breast surg cavity i&r
C
0355T
Gi tract capsule endoscopy
C
0356T
Insrt drug device for iop
C
0358T
Bia whole body
C
0359T
Behavioral id assessment
C
0360T
Observ behav assessment
C
0361T
Observ behav assess addl
C
0362T
Expose behav assessment
C
0363T
Expose behav assess addl
C
0364T
Behavior treatment
C
0365T
Behavior treatment addl
C
0366T
Group behavior treatment
C
0367T
Group behav treatment addl
C
0368T
Behavior treatment modified
C
0369T
Behav treatment modify addl
C
0370T
Fam behav treatment guidance
C
0371T
Mult fam behav treat guide
C
0372T
Social skills training group
C
0373T
Exposure behavior treatment
C
0374T
Expose behav treatment addl
C
All the additional codes listed in the above table are effective as of July 1, 2014. For full
details on the above codes, including on descriptors, place of service codes, co-surgery
indicators, etc. see the tables in CR 8773. The Web address for CR 8773 is in the
“Additional Information” section below.
In addition to the codes that were added, codes J2271 (Morphine SO4 injection 100mg)
and J2275 (Morphine sulfate injection) have a change in their procedure status code from
E to I, effective July 1, 2014.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
16
HOME HEALTH & HOSPICE
Also, Section 651 of Medicare Modernization Act (MMA) required the Secretary of
Health and Human Services to conduct a demonstration for up to 2 years to evaluate
the feasibility and advisability of expanding coverage for chiropractic services under
Medicare. The demonstration expanded Medicare coverage to include: “(A) care for
neuromusculoskeletal conditions typical among eligible beneficiaries; and (B) diagnostic
and other services that a chiropractor is legally authorized to perform by the state or
jurisdiction in which such treatment is provided.” The demonstration, which ended
on March 31, 2007, was required to be budget neutral as section 651(f)(1)(B) of MMA
mandates the Secretary to ensure that “the aggregate payments made by the Secretary
under the Medicare program do not exceed the amount which the Secretary would
have paid under the Medicare program if the demonstration projects under this section
were not implemented.” The costs of this demonstration were higher than expected and
CMS has been recovering costs by deducting 2 percent from payments for chiropractic
services. Since CMS has determined that the costs are fully recovered, the July update
eliminates the 2 percent reduction for CPT codes 98940, 98941, and 98942 that was
utilized for the first half of CY 2014, effective July 1, 2014.
Additional Information
The official instruction, CR 8773 issued to your MAC regarding this change may be
viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R2974CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
MM8776: July 2014 Update of the Hospital
Outpatient Prospective Payment System (OPPS)
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/2014-MLN-Matters-Articles.html
MLN Matters® Number: MM8776
Related Change Request (CR) #: CR 8776
Related CR Release Date: May 23, 2014 Effective Date: July 1, 2014
Related CR Transmittal #: R2971CP
Implementation Date: July 7, 2014
Provider Types Affected
This MLN Matters® article is intended for providers and suppliers who submit claims to
Medicare administrative contractors (MACs), including home health and hospice MACs
for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8776 which describes changes to and billing instructions for
various payment policies implemented in the July 2014 Outpatient Prospective Payment
System (OPPS) update. Make sure your billing staffs are aware of these changes.
Background
CR 8776 describes changes to and billing instructions for various payment policies
implemented in the July 2014 OPPS update. The July 2014 Integrated Outpatient
Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure
Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier,
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
17
HOME HEALTH & HOSPICE
Status Indicator (SI), and Revenue Code additions, changes, and deletions identified
in CR 8776.
The July 2014 revisions to I/OCE data files, instructions, and specifications are provided
in the forthcoming CR 8764. The MLN Matters® article related to CR 8764 is available
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/MM8764.pdf on the CMS website.
Key changes to and billing instructions for various payment policies implemented in the
July 2014 OPPS update are as follows:
Changes to Device Edits for July 2014
The most current list of device edits is available under “Device and Procedure
Edits” at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalOutpatientPPS/ on the CMS website. Failure to pass these edits will result in the
claim being returned to the provider.
New Brachytherapy Source Payment
The Social Security Act (Section 1833(t)(2)(H); see http://www.socialsecurity.gov/
OP_Home/ssact/title18/1833.htm) mandates the creation of additional groups of covered
outpatient department (OPD) services that classify devices of brachytherapy consisting
of a seed or seeds (or radioactive source) (“brachytherapy sources”) separately from
other services or groups of services. The additional groups must reflect the number,
isotope, and radioactive intensity of the brachytherapy sources furnished. Cesium-131
chloride solution is a new brachytherapy source.
The HCPCS code assigned to this source as well as payment rate under OPPS are listed
in Table 1 below.
Table 1—New Brachytherapy Source Code Effective July 1, 2014
Effective
HCPCS date
SI APC Short Descriptor
Long descriptor
C2644
7/01/2014 U
2644
Brachytherapy source,
Brachytx
cesium-131 chloride solution,
cesium-131 chloride
per millicurie
Payment
Minimum Unadjusted
Copayment
$18.97
$3.80
Category III Current Procedural Terminology (CPT) Codes
The American Medical Association (AMA) releases Category III CPT codes twice per
year: 1.) in January, for implementation beginning the following July, and 2.) in July, for
implementation beginning the following January.
For the July 2014 update, CMS is implementing in the OPPS 27 Category III CPT codes
that the AMA released in January 2014 for implementation on July 1, 2014. Of the 27
Category III CPT codes shown in Table 2 below, 17 of the Category III CPT codes are
separately payable under the hospital OPPS. The SIs and APCs for these codes are
shown in Table 2 below. Payment rates for these services can be found in Addendum B
of the July 2014 OPPS Update that is posted at http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-BUpdates.html on the CMS website.
Table 2 – 27 Category III CPT Codes Implemented as of July 1, 2014
CY 2014
CPT Code CY 2014 Long Descriptor
July 2014 OPPS
Status Indicator
July 2014
OPPS APC
0347T
Placement of interstitial device(s) in bone for radiostereometric
analysis (RSA)
Q2
0420
0348T
Radiologic examination, radiostereometric analysis (RSA); spine, (includes,
cervical, thoracic and lumbosacral, when performed)
X
0261
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
18
July 2014 OPPS
Status Indicator
July 2014
OPPS APC
0349T
Radiologic examination, radiostereometric analysis (RSA); upper
extremity(ies), (includes shoulder, elbow and wrist, when performed)
X
0261
0350T
Radiologic examination, radiostereometric analysis (RSA); lower
extremity(ies), (includes hip, proximal femur, knee and ankle, when
performed)
X
0261
0351T
Optical coherence tomography of breast or axillary lymph node, excised
tissue, each specimen; real time intraoperative
N
N/A
0352T
Optical coherence tomography of breast or axillary lymph node, excised
tissue, each specimen; interpretation and report, real time or referred
B
N/A
0353T
Optical coherence tomography of breast, surgical cavity; real time
intraoperative
N
N/A
0354T
Optical coherence tomography of breast, surgical cavity; interpretation and
report, real time or referred
B
N/A
0355T
Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon,
with interpretation and report
T
0142
0356T
Insertion of drug-eluting implant (including punctal dilation and implant
removal when performed) into lacrimal canaliculus, each
S
0698
0358T
Bioelectrical impedance analysis whole body composition assessment,
supine position, with interpretation and report
Q1
0340
0359T
Behavior identification assessment, by the physician or other qualified
health care professional, face-to-face with patient and caregiver(s), includes
administration of standardized and non-standardized tests, detailed
V
behavioral history, patient observation and caregiver interview, interpretation
of test results, discussion of findings and recommendations with the primary
guardian(s)/caregiver(s), and preparation of report
0632
0360T
Observational behavioral follow-up assessment, includes physician or other
qualified health care professional direction with interpretation and report,
administered by one technician; first 30 minutes of technician time, face-toface with the patient
V
0632
0361T
Observational behavioral follow-up assessment, includes physician or other
qualified health care professional direction with interpretation and report,
administered by one technician; each additional 30 minutes of technician
time, face-to-face with the patient (List separately in addition to code for
primary service)
N
N/A
0362T
Exposure behavioral follow-up assessment, includes physician or other
qualified health care professional direction with interpretation and report,
administered by physician or other qualified health care professional with the V
assistance of one or more technicians; first 30 minutes of technician(s) time,
face-to-face with the patient
0632
0363T
Exposure behavioral follow-up assessment, includes physician or other
qualified health care professional direction with interpretation and report,
administered by physician or other qualified health care professional with
the assistance of one or more technicians; each additional 30 minutes of
technician(s) time, face-to-face with the patient (List separately in addition to
code for primary procedure)
N
N/A
0364T
Adaptive behavior treatment by protocol, administered by technician, faceto-face with one patient; first 30 minutes of technician time
S
0322
0365T
Adaptive behavior treatment by protocol, administered by technician, faceto-face with one patient; each additional 30 minutes of technician time (List
separately in addition to code for primary procedure)
N
N/A
0366T
Group adaptive behavior treatment by protocol, administered by technician,
face-to-face with two or more patients; first 30 minutes of technician time
S
0325
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
HOME HEALTH & HOSPICE
Table 2 – 27 Category III CPT Codes Implemented as of July 1, 2014
CY 2014
CPT Code CY 2014 Long Descriptor
RETURN TO
TABLE OF CONTENTS
JULY 2014
19
July 2014 OPPS
Status Indicator
July 2014
OPPS APC
0367T
Group adaptive behavior treatment by protocol, administered by technician,
face-to-face with two or more patients; each additional 30 minutes of
technician time (List separately in addition to code for primary procedure)
N
N/A
0368T
Adaptive behavior treatment with protocol modification administered by
physician or other qualified health care professional with one patient; first 30
minutes of patient face-to-face time
S
0322
0369T
Adaptive behavior treatment with protocol modification administered by
physician or other qualified health care professional with one patient; each
additional 30 minutes of patient face-to-face time (List separately in addition
to code for primary procedure)
N
N/A
0370T
Family adaptive behavior treatment guidance, administered by physician or
other qualified health care professional (without the patient present)
S
0324
0371T
Multiple-family group adaptive behavior treatment guidance, administered by
physician or other qualified health care professional (without the
S
patient present)
0324
0372T
Adaptive behavior treatment social skills group, administered by physician or
S
other qualified health care professional face-to-face with multiple patients
0325
0373T
Exposure adaptive behavior treatment with protocol modification requiring
two or more technicians for severe maladaptive behavior(s); first 60 minutes
of technicians' time, face-to-face with patient
S
0323
0374T
Exposure adaptive behavior treatment with protocol modification requiring
two or more technicians for severe maladaptive behavior(s); each additional
30 minutes of technicians' time face-to-face with patient (List separately in
addition to code for primary procedure)
N
N/A
HOME HEALTH & HOSPICE
Table 2 – 27 Category III CPT Codes Implemented as of July 1, 2014
CY 2014
CPT Code CY 2014 Long Descriptor
Billing for Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs and Biologicals with Payments Based on Average Sales Price (ASP)
Effective July 1, 2014
In the CY 2014 OPPS/ASC final rule with comment period, CMS stated that
payments for drugs and biologicals based on ASPs will be updated on a quarterly
basis as later quarter ASP submissions become available. In cases where
adjustments to payment rates are necessary based on the most recent ASP
submissions, CMS will incorporate changes to the payment rates in the July 2014
release of the OPPS Pricer. The updated payment rates, effective July 1, 2014, will
be included in the July 2014 update of the OPPS Addendum A and Addendum B,
which will be posted at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
on the CMS website.
b. Drugs and Biologicals with OPPS Pass-Through Status Effective July 1, 2014
Three drugs and biologicals have been granted OPPS pass-through status effective
July 1, 2014. These items, along with their descriptors and APC assignments, are
identified below in Table 3.
Table 3 – Drugs and Biologicals with OPPS Pass-Through Status Effective July 1, 2014
HCPCS Code Long Descriptor
APC
C9022*
Injection, elosulfase alfa, 1mg
1480
C9134*
Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 i.u.
1481
J1446
Injection, tbo-filgrastim, 5 micrograms
1447
Status Indicator
G
G
G
Note: The HCPCS codes identified with an “*” indicate that these are new codes effective July 1, 2014.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
20
Table 4 – New HCPCS Codes for Certain Drugs and Biologicals Effective July 1, 2014
HCPCS Code Long Descriptor
APC
Status Indicator Effective 7/1/14
Q9970*
Injection, ferric carboxymaltose, 1 mg
9441
G
Q9974**
Injection, Morphine Sulfate, Preservative-Free For
N/A
N
Epidural Or Intrathecal Use, 10 mg
* HCPCS code C9441 (Injection, ferric carboxymaltose, 1 mg) will be deleted and replaced with
HCPCS code Q9970 effective July 1, 2014.
**HCPCS code J2275 (Injection, morphine sulfate (preservative-free sterile solution), per 10 mg) and
will be replaced with HCPCS code Q9974 effective July 1, 2014. The SI for HCPCS code J2275 will
change to E, “Not Payable by Medicare,” effective July 1, 2014.
d. Revised SIs for HCPCS Codes J2271 and Q2052
Effective July 1, 2014, the SI for HCPCS code J2271 (Injection, morphine sulfate,
100mg) will change:
HOME HEALTH & HOSPICE
c. New HCPCS Codes Effective July 1, 2014, for Certain Drugs and Biologicals
Two new HCPCS codes have been created for reporting certain drugs and
biologicals (other than new pass-through drugs and biological listed in Table 4) in the
hospital outpatient setting for July 1, 2014. These codes are listed below in Table 4,
and they are effective for services furnished on or after July 1, 2014.
1. From SI=N (Paid under OPPS; payment is packaged into payment for other
services. Therefore, there is no separate APC payment.),
2. To SI=E (Not paid by Medicare when submitted on outpatient claims (any
outpatient bill type)).
Effective April 1, 2014, the SI for HCPCS code Q2052 (Services, supplies,
and accessories used in the home under the Medicare intravenous immune
globulin (IVIG) demonstration) will change:
1. From SI=N (Paid under OPPS; payment is packaged into payment for other
services. Therefore, there is no separate APC payment.)
2. To SI=E (Not paid by Medicare when submitted on outpatient claims (any
outpatient bill type)).
e. Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2013,
through December 31, 2013
The payment rate for one HCPCS code was incorrect in the October 2013 OPPS
Pricer. The corrected payment rate is listed in Table 5 below, and it has been
installed in the July 2014 OPPS Pricer, effective for services furnished on October
1, 2013, through December 31, 2013. Your MAC will adjust any claims incorrectly
processed if you bring those claims to the attention of your MAC.
Table 5– Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2013 through
December 31, 2013
Corrected
Corrected Minimum
HCPCS Code Status Indicator APC Short Descriptor
Payment Rate Unadjusted Copayment
J2788
K
9023 Rho d immune globulin 50 mcg $25.15
$5.03
f. Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2014,
through March 31, 2014
The payment rate for one HCPCS code was incorrect in the January 2014 OPPS
Pricer. The corrected payment rate is listed below in Table 6, and it has been
installed in the July 2014 OPPS Pricer, effective for services furnished on January 1,
2014, through March 31, 2014. Your MAC will adjust any claims incorrectly processed
if you bring those claims to the attention of your MAC.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
21
Operational Change to Billing Lab Tests for Separate Payment
As delineated in MLN Matters Special Edition Article (SE)1412, issued on March 5, 2014,
(see http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/SE1412.pdf), effective July 1, 2014, OPPS hospitals
should begin using modifier L1 on type of bill (TOB) 13X when seeking separate payment
for outpatient lab tests under the Clinical Laboratory Fee Schedule (CLFS) in the
following circumstances:
1. A hospital collects specimen and furnishes only the outpatient labs on a given date
of service; or
2. A hospital conducts outpatient lab tests that are clinically unrelated to other
hospital outpatient services furnished the same day.
“Unrelated” means the laboratory test is ordered by a different practitioner than the
practitioner who ordered the other hospital outpatient services, for a different diagnosis.
Hospitals should no longer use TOB 14X in these circumstances.
HOME HEALTH & HOSPICE
Table 6 – Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2014, through March 31, 2014
Corrected
Corrected Minimum
HCPCS Code Status Indicator APC Short Descriptor
Payment Rate Unadjusted Copayment
J0775
K
1340 Collagenase, clost hist inj
$38.49
$7.70
CMS is providing related updates to the “Medicare Claims Processing Manual”
(Publication 100-04; Chapter 2, Section 90; and Chapter 16, Sections 30.3, 40.3,
and 40.3.1) which are included as an attachment to CR 8766.
Clarification of Payment for Certain Hospital Part B Inpatient Labs
As recently provided in CR 8445, Transmittal 2877, published on February 7, 2014
(see http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/MM8445.pdf on the CMS website), and CR 8666,
Transmittal 182, published on March 21, 2014 (see http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8666.
pdf on the CMS website), hospitals may only bill for a limited set of Part B inpatient
services when beneficiaries who have Part B coverage are treated as hospital
inpatients, and:
1. They are not eligible for or entitled to coverage under Part A, or
2. They are entitled to Part A but have exhausted their Part A benefits.
CMS is clarifying its general payment policy that, for hospitals paid under the OPPS,
these Part B inpatient services are separately payable under Part B, and are excluded
from OPPS packaging, if the primary service with which the service would otherwise be
bundled is not a payable Part B inpatient service.
CMS has adjusted its claims processing logic to make separate payment for Laboratory
services paid under the CLFS pursuant to this policy that would otherwise be OPPSpackaged beginning in 2014. Hospitals should consult their MAC for reprocessing of any
12X TOB claims with dates of service on or after January 1, 2014 that were denied and
should be paid under this policy.
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.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
22
HOME HEALTH & HOSPICE
MACs determine whether a drug, device, procedure, or other service meets all program
requirements for coverage. For example, Medicare contractors 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, CR 8776 issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R2971CP.pdf on the CMS website.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS)
yyProducts from the Medicare Learning Network® (MLN)
ƒƒ
REVISED “Advance Payment Accountable Care Organization” Fact Sheet, ICN
907403, downloadable at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Downloads/ACO_Advance_Payment_Factsheet_
ICN907403.pdf
ƒƒ
NEW “Information on the National Physician Payment Transparency Program:
Open Payments,” Podcast, ICN 908961, downloadable only at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLNMultimedia-Items/ICN908961-Podcast.html
yyWant to stay connected about the latest new and revised Medicare Learning
Network® (MLN) products and services? Subscribe to the MLN Educational
Products electronic mailing list! For more information about the MLN and how to
register for this service, visit http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/downloads/MLNProducts_ListServ.pdf and
start receiving updates immediately!
yy2015 GEMs, Reimbursement Mappings, and ICD-10 Files Now Available -The 2015
General Equivalence Mappings (GEMs), Reimbursement Mappings, ICD-10-CM
files, and ICD-10-PCS files are now available on the 2015 ICD-10-CM and GEMs
Web page at http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-andGEMs.html and 2015 ICD-10-PCS and GEMs Web page at http://www.cms.gov/
Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html. The mappings can be
used to convert policies from ICD-9-CM to ICD-10 codes. The GEMs provide both
forward (ICD-9-CM to ICD-10) and backward (ICD-10 to ICD-9-CM) mappings.
There are no new, revised, or deleted ICD-10-CM or ICD-10-PCS codes.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
23
HOME HEALTH & HOSPICE
For Home Health and Hospice Providers
Provider Contact Center (PCC)
Availability and the July 4th Holiday
Medicare is a continuously changing program, and it is important that we provide correct
and accurate answers to your questions. To better serve the provider community, the
Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers
the opportunity to offer training to our customer service representatives (CSRs). The
list below indicates when the home health and hospice PCC at 1.877.299.4500 will be
closed for training.
Date
Thursday, July 10, 2014
Thursday, July 24, 2014
PCC Closed
PCC Closed 8:00 a.m. – 10:00 a.m. ET
PCC Closed 8:00 a.m. – 10:00 a.m. ET
The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in
obtaining patient eligibility information, claim and deductible information, and general
information. For information about the IVR, access the IVR User Guide at http://www.
cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition,
CGS’ Internet portal, myCGS, is available to access eligibility information through the
Internet. For additional information, go to http://www.cgsmedicare.com/hhh/index.html
and click the “myCGS” button on the left side of the Web page.
July 4th Holiday
The CGS office will be closed on Friday, July 4, 2014. Our data center has informed us
that the Fiscal Intermediary Standard System (FISS) and access to the eligibility screens,
ELGA/ELGH will not be available on July 4th. In addition, the system will not cycle that
night, which means that claims will not be sent to the Common Working File (CWF) on
July 4, 2014. Medicare Remittance Advices, Electronic Remittance Advices (ERAs),
Medicare paper checks, and Electronic Funds Transfer (EFTs) will no be produced
July 4, 2014.
For your reference, access the “Home Health & Hospice 2014 Holiday/Training
Closure Schedule” at http://www.cgsmedicare.com/hhh/help/pdf/Holiday_Schedule.pdf
for a complete list of PCC closures.
For Home Health and Hospice Providers
Provider Contact Center Reminders
Your questions are important to us, and CGS’s Provider Contact Centers (PCCs) strive to
provide the most accurate and consistent information to our provider community. There
may be times when we receive a question that requires additional research before an
accurate response can be provided by the Customer Service Representative.
Please be advised that every effort is taken to research your questions and to return
your call as soon as possible. However, the Centers for Medicare & Medicaid Services
(CMS) does allow PCCs up to 10 business days to research and return your call. This
information can be found in the CMS Medicare Contractor Beneficiary and Provider
Communications Manual (Pub. 100-09) Chapter 6, Section 60.2.5 (http://www.cms.gov/
Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf).
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
24
HOME HEALTH & HOSPICE
As a reminder, CGS offers the Interactive Voice Response (IVR) Unit and the myCGS
Web portal for eligibility/claim status information.
yyIVR User Guide - http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf
yymyCGS - http://www.cgsmedicare.com/hhh/myCGS/index.html
For Home Health and Hospice Providers
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 nonregulatory changes to Medicare including transmittals, 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:
yyInform providers about new developments in the Medicare program;
yyAssist providers in understanding CMS programs and complying with Medicare
regulations and instructions;
yyEnsure that providers have time to react and prepare for new requirements;
yyAnnounce new or changing Medicare requirements on a predictable schedule; and
yyCommunicate 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, go to https://www.cms.gov/Regulations-and-Guidance/Regulations-andPolicies/QuarterlyProviderUpdates/CMS-Quarterly-Provider-Updates-Email-Updates.
html to sign up for the Quarterly Provider Update (electronic mailing list).
We encourage you to bookmark the Quarterly Provider Update website at
https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/
QuarterlyProviderUpdates/index.html and visit it often for this valuable information.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
For Home Health and Hospice Providers
Stay Informed and Join the
CGS ListServ Notification Service
The CGS ListServ Notification Service is the primary means used by CGS to
communicate with home health and hospice Medicare providers. This is a free email
notification service that provides you with prompt notification of Medicare news
including policy, benefits, claims submission, claims processing and educational
events. Subscribing for this service means that you will receive information as soon as
it is available, and plays a critical role in ensuring you are up-do-date on all Medicare
information.
Consider the following benefits to joining the CGS ListServ Notification Service:
yyIt’s free! There is no cost to subscribe or to receive information.
yyYou only need a valid e-mail address to subscribe.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
25
HOME HEALTH & HOSPICE
yyMultiple people/e-mail addresses from your facility can subscribe. We recommend
that all staff (clinical, billing, and administrative) who interact with Medicare topics
register individually. This will help to facilitate the internal distribution of critical
information and eliminates delay in getting the necessary information to the proper
staff members.
To subscribe to the CGS ListServ Notification Service, go to http://www.cgsmedicare.
com/medicare_dynamic/ls/001.asp and complete the required information.
For Home Health and Hospice Providers
Submit Your Redetermination
Requests through the myCGS Web Portal!
It’s fast, easy and cost effective! Redeterminations, the first level of appeal, and
supporting medical records can be submitted through the myCGS Web portal. This
allows providers to save the cost of printing and mailing paper documents. Once
submitted, providers have the ability to monitor the status of these redeterminations
within myCGS.
Redetermination requests are submitted through the ‘Forms’ tab. If you do not have
access to the ‘Forms’ tab, but believe you should, talk with your myCGS Provider
Administrator for your agency/organization, and they can update your security. If your
agency/organization has not yet registered for myCGS, visit the myCGS registration Web
page at http://cgsmedicare.com/mycgs/index.html today!
Submitting a Redetermination Request using myCGS
1. Select the ‘Forms’ tab.
Step 1:
Click ‘Forms’
2. From the “Go To page” field drop-down box, select ‘Secure Forms.’ The ‘Secure
Forms’ page will display.
Step 2:
Select ‘Secure Forms’
NOTE: The Select a Topic field on the ‘Secure Forms’ page defaults to “Appeals.” The Select a
Type field defaults to “First level appeal on a Medicare Claim.”
3. Redetermination requests must be submitted within 120 days of the initial
determination (i.e., date on the Medicare remittance advice). If you need to verify
that the redetermination request is timely, click on the ‘Appeals Calculator’ link.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
26
Step 4:
Select “Yes” if the
redetermination request is
timely.
4. Once you have determined that your request is timely, select “Yes” from the dropdown menu. If your appeal is untimely, you cannot submit your redetermination
request via the myCGS portal.
5. Click on the “Redetermination: 1st Level Appeal” link to access the online
Redetermination Form.
HOME HEALTH & HOSPICE
Step 3:
Is the redetermination
request timely?
Step 5:
Click to access the online
Redetermination Form.
6. The myCGS ‘Redetermination 1st Level Appeal’ form will appear. There are four
sections; 1) Beneficiary Information; 2) Provider Information; 3) Claims Information;
and 4) Attachments. Complete the required fields, which are marked with a red
asterisk (*).
Refer to the ‘Forms’ Tab instructions found on the myCGS User Manual Web page
at http://www.cgsmedicare.com/mycgs/manual.html for additional information.
7. Once all the information is entered, click ‘Validate.’ myCGS will validate the
information entered. If information is missing or invalid, a message will display
indicating the information that must be corrected. If information entered is complete
and correct, the message “Your entries have been validated. Please attached the
required documents, input your name, and click Submit” will display.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
27
HOME HEALTH & HOSPICE
Step 7:
Click to validate the
information entered.
NOTE: The ‘Attachments’ section of the Redetermination form allows you to attach
documentation (e.g., medical records, notes, orders, etc.) you would like CGS to consider when
processing your redetermination request. You can attach up to 5 documents (up to 5 MB each).
At least one document is required. The documents must be in a PDF format.
8. To add an attachment, select the “Browse” button, and a window will open allowing
you to locate the document on your computer that you wish to attach. Repeat this
process to attach each additional document.
Step 8:
Click on ‘Browse’ to locate and select
the document that you wish to attach.
Step 9:
Type the name of the person
completing the form.
Step 10:
And click the ‘Submit’ button.
9. Below the attachments section, complete the ‘Name’ field by typing the name of
the person who completed the form.
10. Click the “Submit” button to submit your redetermination requests to CGS. You will
receive a message in your myCGS inbox. You can access the message by either
clicking on the Messages tab, or clicking the link displayed in the Message bar.
11. An ‘e-signature’ box will appear, asking you to verify that the information entered
and attachments are correct. This ensures the signature requirement for all
redetermination requests has been met.
If the information was entered correctly, and all desired attachments were included,
click ‘OK’ to submit the Redetermination form and all attachments.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
RETURN TO
TABLE OF CONTENTS
JULY 2014
28
Step 11:
Click ‘OK’ to submit.
Step 11:
Click ‘Cancel’ to correct
information or add or remove
attachments.
12. Once submitted, a message will display in your myCGS inbox with the Subject
indicating “Secure Form Received.”
Refer to the ‘Messages’ Tab instructions found on the myCGS User Manual Web page
at http://www.cgsmedicare.com/mycgs/manual.html for additional information about the
messages received in myCGS.
This newsletter should be shared with all health care practitioners and managerial members
of the provider/supplier staff. Newsletters are available at no cost from our website at
http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.
MEDICARE BULLETIN • GR 2014-07
HOME HEALTH & HOSPICE
If any information needs to be corrected, or if any attachments need to be added or
deleted, click ‘Cancel’ to return to the form.
RETURN TO
TABLE OF CONTENTS
JULY 2014
29