Medicare Bulletin - July 2014 Edition

Medicare Bulletin - July 2014 Edition
Medicare
Bulletin
Jurisdiction 15
Reaching Out
to the Medicare
Community
© 2014 Copyright, CGS Administrators, LLC.
KENTUCKY & OHIO PART A
J U LY 2 0 1 4 • W W W.C G S M E D I C A R E .C O M
Jurisdiction 15
ADMINISTRATION
CLAIMS
2014 Provider Contact Center (PCC) Training 3
MM8401 (Revised): Mandatory Reporting
of an 8-Digit Clinical Trial Number on Claims 13
Contact Information for CGS Medicare Part A 3
eOffset Using myCGS:
Clarification of Valid Requests 3
COVERAGE
Medicare Learning Network®:
A Valuable Educational Resource! 4
MM8739 (Revised): Fluorodeoxyglucose (FDG)
Positron Emission Tomography (PET) for Solid
Tumors (This Change Request (CR) rescinds and
fully replaces MM 8468, dated February 6, 2014.) 15
MLN Connects™ Provider e-News 4
MM8456 (Rescinded): Modifying the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 5
MM8684: Claim Status Category and
Claim Status Codes Update 5
MM8764: July 2014 Integrated Outpatient
Code Editor (I/OCE) Specifications Version 15.2 6
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS) 7
Provider Contact Center Reminders 8
Quarterly Provider Update 9
Stay Informed and Join the CGS
ListServ Notification Service 9
Submit Your Redetermination Requests
through the myCGS Web Portal! 10
MM8757: Percutaneous Image-guided
Lumbar Decompression (PILD) for Lumbar
Spinal Stenosis (LSS) 18
KENTUCKY & OHIO PART A
Medicare Bulletin
FEE SCHEDULE
MM8664 (Revised): April Update to the Calendar
Year (CY) 2014 Medicare Physician Fee Schedule
Database (MPFSDB) 20
MM8773: July Update to the Calendar
Year (CY) 2014 Medicare Physician Fee
Schedule Database (MPFSDB) 24
FQHC/RHC
MM8743: Implementation of a Prospective
Payment System (PPS) for Federally Qualified
Health Centers (FQHCs) 26
SE1039 (Revised): Rural Health Clinics (RHCs)
and Federally Qualified Health Centers (FQHCs)
Billing Guide 30
HOSPITAL
MM8776: July 2014 Update of the Hospital
Outpatient Prospective Payment System (OPPS) 36
ICD-10
http://www.cms.gov/MLNGenInfo
MM8691: ICD-10 Conversion/Coding Infrastructure
Revisions/ICD-9 Updates to National Coverage
Determinations (NCDs) - Maintenance CR 42
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
KENTUCKY & OHIO PART A
Administration
2014 Provider Contact Center (PCC) Training
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 CGS
Part A PCC (1.866.590.703) will be closed for CSR training and staff development as
indicated below. The Interactive Voice Response (IVR) unit will be available during these
scheduled training sessions for automated customer service transactions.
Listed below are the training closure dates and time for July.
Date
Friday, July 4, 2014
Thursday, July 10, 2014
Thursday, July 24, 2014
PCC/Office Closed
Holiday – CGS office closed
PCC Closed 9:00 a.m. – 11:00 a.m. ET
PCC Closed 9:00 a.m. – 11:00 a.m. ET
For your reference, access the “Kentucky/Ohio Part A 2014 Holiday/Training Closure
Schedule” at http://www.cgsmedicare.com/parta/cs/holiday_schedule.pdf for a complete
list of PCC closures.
Administration
Contact Information for CGS Medicare Part A
To contact a CGS Customer Service Representative, call the CGS Provider Contact
Center at 1.866.590.6703 and choose Option 1. For additional contact information,
please access the Kentucky & Ohio Part A “Contact Information” Web page at
http://www.cgsmedicare.com/parta/cs/index.html for information about the myCGS Web
portal, the Interactive Voice Response (IVR) system, as well as telephone numbers, fax
numbers, and mailing addresses for other CGS departments.
Administration
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.
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.
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KENTUCKY & OHIO PART A
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 webpage,
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.
Administration
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.
Administration
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 listserv directly from CMS, please contact
CMS at [email protected]
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
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.
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JULY 2014
4
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
KENTUCKY & OHIO PART A
Administration
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.
Administration
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.
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
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.
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KENTUCKY & OHIO PART A
(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 1.866.590.6703 and choose Option 1.
Administration
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.
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
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.
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6
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
7/1/2014
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.
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).
KENTUCKY & OHIO PART A
or to a hospice patient for the treatment of a non-terminal illness. Make sure your billing
staffs are aware of these changes.
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 1.866.590.6703 and choose Option 1.
Administration
News Flash Messages from the Centers
for Medicare & Medicaid Services (CMS)
yyProducts from the Medicare Learning Network® (MLN)
ƒƒ
REVISED “Telehealth Services”, Fact sheet (ICN 901705) available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
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/
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.
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KENTUCKY & OHIO PART A
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLNMultimedia-Items/ICN908961-Podcast.html
ƒƒ
REVISED “Improving Quality of Care for Medicare Patients: Accountable Care
Organizations”, Fact Sheet, ICN 907407, downloadable at http://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/
ACO_Quality_Factsheet_ICN907407.pdf
ƒƒ
REVISED “Screening and Behavioral Counseling Interventions in Primary Care
to Reduce Alcohol Misuse”, Booklet (ICN 907798) EPUB, QR at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/Reduce-Alcohol-Misuse-ICN907798.pdf
ƒƒ
NEW “Medicare Enrollment Guidelines for Ordering/Referring Providers”, Fact
Sheet, ICN 906223, Downloadable, EPUB, QR at http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/
MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf
yyMLN Matters® Articles Index: Have you ever tried to search MLN Matters® articles
for information regarding a certain issue, but you did not know what year it was
published? To assist you next time in your search, try the CMS article indexes that
are published at http://www.cms.gov/outreach-and-education/medicare-learningnetwork-mln/MLNMattersArticles/ on the CMS website. These indexes resemble
the index in the back of a book and contain keywords found in the articles, including
HCPCS codes and modifiers. These are published every month. Just search on a
keyword(s) and you will find articles that contained those word(s). Then just click on
one of the related article numbers and it will open that document. Give it a try.
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.
Administration
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).
As a reminder, CGS offers the Interactive Voice Response (IVR) Unit and the myCGS
Web portal for eligibility/claim status information.
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.
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KENTUCKY & OHIO PART A
yyIVR User Guide - http://www.cgsmedicare.com/parta/cs/cgs_j15_parta_ivr_user_
guide.pdf
yymyCGS - http://www.cgsmedicare.com/parta/myCGS/index.html
Administration
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 1.866.590.6703 and choose Option 1.
Administration
Stay Informed and Join the
CGS ListServ Notification Service
The CGS ListServ Notification Service is the primary means used by CGS to
communicate with Kentucky and Ohio Medicare Part A 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.
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KENTUCKY & OHIO PART A
yyMultiple people/e-mail addresses from your facility can subscribe. We recommend
that all staff (clinical, billing, and administrative) who interacts 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.
Administration
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.”
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.
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Step 3:
Is the redetermination
request timely?
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.
KENTUCKY & OHIO PART A
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.
5. Click on the “Redetermination: 1st Level Appeal” link to access the online
Redetermination Form.
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.
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KENTUCKY & OHIO PART A
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.
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of the provider/supplier staff. Newsletters are available at no cost from our website at
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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.
KENTUCKY & OHIO PART A
If any information needs to be corrected, or if any attachments need to be added or
deleted, click ‘Cancel’ to return to the form.
Claims
MM8401 (Revised): Mandatory Reporting
of an 8-Digit Clinical Trial Number on Claims
The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning
Network® (MLN) Matters article on May 15, 2014. The article was revised again on June 9, 2014. 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-MattersArticles.html
MLN Matters® Number: MM8401 Revised
Related CR Release Date: May 13, 2014
Related CR Transmittal #: R2955CP
Related Change Request (CR) #: CR 8401
Effective Date: January 1, 2014
Implementation Date: January 6, 2014
Note: This article was revised on May 15, 2014, to reflect the revised CR 8401 issued on May 13. The
article has been revised to delete information regarding entry of the clinical trial number on institutional
paper or Direct Data Entry (DDE) claim UB-04. Also, the transmittal number, the CR release date, and
the Web address for accessing the CR are revised. All other information remains the same.
Note: This article was revised on June 9, 2104, to emphasize that coding “CT” in front of the clinical
trial number applies ONLY to paper claims. The “CT” is not to be coded on electronic claims. All other
information remains the same.
Provider Types Affected
This MLN Matters® article is intended for physicians, providers, and suppliers submitting
claims to Medicare contractors (fiscal intermediaries (FIs), carriers, durable medical
equipment (DME) Medicare administrative contractors (MACs) and A/B MACs) for items
and services provided in clinical trials to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8401, which informs you that, effective January 1, 2014, it will
be mandatory to report a clinical trial number on claims for items and services provided
in clinical trials that are qualified for coverage as specified in the “Medicare National
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KENTUCKY & OHIO PART A
Coverage Determination (NCD) Manual,” Section 310.1.
The clinical trial number to be reported is the same number that has been reported
voluntarily since the implementation of CR 5790, dated January 18, 2008. That is the
number assigned by the National Library of Medicine (NLM) http://clinicaltrials.gov/
website when a new study appears in the NLM Clinical Trials data base.
Make sure that your billing staffs are aware of this requirement.
Background
CR 5790, Transmittal 310, dated January 18, 2008, titled “Requirements for Including an
8-Digit Clinical Trial Number on Claims” is available at http://www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/Downloads/R310OTN.pdf on the CMS website.
The MLN Matters® Article for CR 5790 is available at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5790.
pdf on the CMS website.
This number is listed prominently on each specific study’s page and is always preceded
by the letters ‘NCT.’
CMS uses this number to identify all items and services provided to beneficiaries during
their participation in a clinical trial, clinical study, or registry. Furthermore, this identifier
permits CMS to better track Medicare payments, ensure that the information gained from
the research is used to inform coverage decisions, and make certain that the research
focuses on issues of importance to the Medicare population.
Suppliers may verify the validity of a trial/study/registry by consulting CMS’s clinical
trials/registry website at http://www.cms.gov/Medicare/Medicare-General-Information/
MedicareApprovedFacilitie/index.html on the CMS website.
For institutional claims that are submitted on the electronic claim 837I, the 8-digit number
should be placed in Loop 2300 REF02 (REF01=P4) when a clinical trial claim includes:
yyCondition code 30;
yyICD-9 code of V70.7/ICD-10 code Z00.6 (in either the primary or secondary
positions) and
yyModifier Q0 and/or Q1, as appropriate (outpatient claims only).
For professional claims, the 8-digit clinical trial number preceded by the 2 alpha
characters of CT (use CT only on paper claims) must be placed in Field 19 of the paper
claim Form CMS-1500 (e.g., CT12345678) or the electronic equivalent 837P in Loop
2300 REF02(REF01=P4) (do not use CT on the electronic claim, e.g., 12345678)
when a clinical trial claim includes:
yyICD-9 code of V70.7/ICD-10 code Z00.6 (in either the primary or secondary
positions) and
yyModifier Q0 and/or Q1, as appropriate (outpatient claims only).
Medicare Part B clinical trial/registry/study claims with dates of service on and after
January 1, 2014, not containing an 8-digit clinical trial number will be returned as
unprocessable to the provider for inclusion of the trial number using the messages
listed below.
yyClaim Adjustment Reason Code (CARC) 16: “Claim/service lacks information which
is needed for adjudication. At least one Remark Code must be provided (may be
comprised of either National Council for Prescription Drug Programs (NCPDP)
Reject Reason Code, or Remittance Advice Remark Code (RARC) that is not
an ALERT.)”
yyRARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number
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KENTUCKY & OHIO PART A
for FDA-approved clinical trial services.”
yyRARC MA130: “Your claim contains incomplete and/or invalid information, and no
appeal rights are afforded because the claim is unprocessable. Please submit a new
claim with the complete/correct information.”
yyGroup Code-Contractual Obligation (CO).
Note: This is a reminder/clarification that clinical trials that are also investigational device
exemption (IDE) trials must continue to report the associated IDE number on the claim form as well.
Additional Information
The official instruction, CR 8401, issued to your Medicare contractor regarding this
change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R2955CP.pdf on the CMS website.
See MLN Matters® Article SE1344 (http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1344.pdf) for
information on an interim alternative method of satisfying the requirement in CR 8401
for providers who do not have the ability to submit the clinical trial number for trial
related claims.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.866.590.6703 and choose Option 1.
Coverage
MM8739 (Revised): Fluorodeoxyglucose (FDG)
Positron Emission Tomography (PET) for Solid
Tumors (This Change Request (CR) rescinds and
fully replaces MM 8468, dated February 6, 2014.)
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: MM8739 Revised
Related CR Release Date: May 28, 2014
Related CR Transmittal #: R2932CP, R168NCD
Related Change Request (CR) #: CR 8739
Effective Date: June 11, 2013
Implementation Date: May 19, 2014 - MAC
Non-Shared System Edits; July 7, 2014 CWF development/testing, FISS requirement
development; October 6, 2014 - CWF, FISS,
MCS Shared System Edits
Note: This article was revised on May 30, 2014, to reflect the revised CR8739 issued on May 28. In the
article, the CR release date, transmittal number, and the Web address for accessing the CR are revised.
All other information remains the same.
Provider Types Affected
This MLN Matters® article is intended for physicians, providers and suppliers
submitting claims to Medicare administrative contractors (MACs) for services
to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8739, which advises MACs, effective for dates of service on
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
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KENTUCKY & OHIO PART A
or after June 11, 2013, to cover three FDG PET scans when used to guide subsequent
management of anti-tumor treatment strategy after completion of initial anti-cancer
therapy for the same cancer diagnosis. Coverage of any additional FDG PET scans (that
is, beyond three) used to guide subsequent management of anti-tumor treatment strategy
after completion of initial anti-cancer therapy for the same diagnosis will be determined
by your MAC. Make sure your billing staffs are aware of these changes.
Background
CMS has reconsidered Section 220.6, of the “National Coverage Determinations (NCD)
Manual” to end the prospective data collection requirements across all oncologic
indications of FDG PET in the context of CR8739. The term FDG PET includes PET/
computed tomography (CT) and PET/magnetic resonance (MRI).
CMS is revising the “NCD Manual”, Section 220.6, to reflect that CMS has ended the
coverage with evidence development (CED) requirement for (2-[F18] fluoro-2-deoxyD-glucose) FDG PET, PET/CT, and PET/MRI for all oncologic indications contained
in Section 220.6.17 of the “NCD Manual.” This removes the current requirement
for prospective data collection by the National Oncologic PET Registry (NOPR) for
oncologic indications for FDG (Healthcare Common Procedure Coding System (HCPCS)
Code A9552) only.
Note: For clarification purposes, as an example, each different cancer diagnosis is allowed one (1)
initial treatment strategy (-PI modifier) FDG PET Scan and three (3) subsequent treatment strategy
(-PS modifier) FDG PET Scans without the -KX modifier. The fourth FDG PET Scan and beyond for
subsequent treatment strategy for the same cancer diagnosis will always require the -KX modifier. If
a different cancer diagnosis is reported, whether reported with a -PI modifier or a -PS modifier, that
cancer diagnosis will begin a new count for subsequent treatment strategy for that beneficiary. A
beneficiary’s file may or may not contain a claim for initial treatment strategy with a -PI modifier. The
existence or non-existence of an initial treatment strategy claim has no bearing on the frequency count
of the subsequent treatment strategy (-PS) claims.
Providers may refer to Attachment 1 of CR 8739 for a list of appropriate diagnosis codes.
Effective for claims with dates of service on or after June 11, 2013, Medicare will
accept and pay for FDG PET oncologic claims billed to inform initial treatment strategy
or subsequent treatment strategy for suspected or biopsy proven solid tumors for all
oncologic conditions without requiring the following:
yyQ0 modifier: Investigational clinical service provided in a clinical research study that
is in an approved clinical research study (institutional claims only);
yyQ1 modifier: routine clinical service provided in a clinical research study that is in an
approved clinical research study (institutional claims only);
yyV70.7: Examination of participant in clinical research; or
yyCondition code 30 (institutional claims only).
Effective for dates of service on or after June 11, 2013, MACs will use the following
messages when denying claims in excess of three for PET FDG scans for subsequent
treatment strategy when the –KX modifier is not included, identified by CPT codes
78608, 78811, 78812, 78813, 78814, 78815, or 78816, modifier –PS, HCPCS A9552, and
the same cancer diagnosis code:
yyClaim Adjustment Reason Code (CARC) 96: “Non-Covered Charge(s). Note: Refer
to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present.”
yyRemittance Advice Remarks Code (RARC) N435: “Exceeds number/frequency
approved/allowed within time period without support documentation.”
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
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KENTUCKY & OHIO PART A
yyGroup Code PR assigning financial liability to the beneficiary, if a claim is received
with a GA modifier indicating a signed ABN is on file.
yyGroup Code CO assigning financial liability to the provider, if a claim is received with
a GZ modifier indicating no signed ABN is on file.
MACs will not search their files to adjust claims processed prior to implementation of CR
8739. However, if you have such claims and bring them to the attention of your MAC, the
MAC will adjust such claims if appropriate.
Synopsis of Coverage of FDG PET for Oncologic Conditions
Effective for claims with dates of service on and after June 11, 2013, the chart below
summarizes national FDG PET coverage for oncologic conditions:
FDG PET for Cancers
Tumor Type
Initial Treatment Strategy
(formerly “diagnosis” &
“staging”)
Subsequent Treatment Strategy
(formerly “restaging” & “monitoring
response to treatment”)
Colorectal
Cover
Cover
Esophagus
Cover
Cover
Head and Neck
(not thyroid, CNS)
Cover
Cover
Lymphoma
Cover
Cover
Non-small cell lung
Cover
Cover
Ovary
Cover
Cover
Brain
Cover
Cover
Cervix
Cover with exceptions *
Cover
Small cell lung
Cover
Cover
Soft tissue sarcoma
Cover
Cover
Pancreas
Cover
Cover
Testes
Cover
Cover
Prostate
Non-cover
Cover
Thyroid
Cover
Cover
Breast
(male and female)
Cover with exceptions *
Cover
Melanoma
Cover with exceptions *
Cover
All other solid tumors
Cover
Cover
Myeloma
Cover
Cover
All other cancers not
listed
Cover
Cover
* Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor
treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are
nationally covered.
* Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally
covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment
strategy for breast cancer are nationally covered.
* Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for
initial anti-tumor treatment strategy for melanoma are nationally covered.
Additional Information
The official instruction, CR 8739, issued to your MAC regarding this change, is available
at in two transmittals at http://www.cms.gov/Regulations-and-Guidance/Guidance/
Transmittals/Downloads/R2932CP.pdf and http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R168NCD.pdf on the CMS website.
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
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MM8757: Percutaneous Image-guided
Lumbar Decompression (PILD) for
Lumbar Spinal Stenosis (LSS)
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: MM8757
Related CR Release Date: May 16, 2014
Related CR Transmittal #: R167NCD and R2959CP
Related Change Request (CR) #: CR 8757
Effective Date: January 9, 2014
Implementation Date: October 6, 2014
Provider Types Affected
This MLN Matters® article is intended for providers submitting claims to Medicare
administrative contractors (MACs) for services furnished to Medicare beneficiaries.
Provider Action Needed
KENTUCKY & OHIO PART A
Coverage
Effective for claims with dates of service on and after January 9, 2014, Medicare will only
allow coverage with evidence development (CED) for percutaneous image-guided lumbar
decompression (PILD) for lumbar spinal stenosis (LSS) for beneficiaries enrolled in an
approved clinical trial.
Background
PILD is a procedure that was proposed as a treatment for symptomatic LSS
unresponsive to conservative therapy. PILD is a posterior decompression of the lumbar
spine performed under indirect image guidance without any direct visualization of the
surgical area. It is generally described as a non-invasive procedure using specially
designed instruments to percutaneously remove a portion of the lamina and debulk the
ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic,
CT) with the assistance of contrast media to identify and monitor the compressed area
via epiduragram.
CMS currently does not cover PILD; and moreover, after careful consideration,
determines that PILD for lumbar spinal stenosis LSS is not reasonable and necessary
under section 1862(a)(1)(A) of the Social Security Act (the Act).
However, CMS has determined that effective for claims with dates of service on or after
January 9, 2014, Medicare will cover PILD only when it is provided in a clinical study
under section 1862(a)(1)(E) of the Act, through CED, for beneficiaries with LSS who are
enrolled in an approved clinical study that meets the criteria described in the National
Coverage Determinations (NCD) Manual at NCD150.13.
Specific Payment Actions
yyOn or after January 9, 2014, effective for hospital outpatient procedures on type
of bill (TOB) 13X or 85X, and for professional claims billed with a place of service
(POS) 22 (outpatient) or 24 (ambulatory surgical center), Medicare will allow CED
for PILD (procedure code 0275T) for LSS, ICD-9 diagnosis range 724.01-724.03, or
ICD-10 diagnosis range M48.05-M48.07, only when billed with:
a. Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) and condition code 30 either in the
primary or secondary positions; and
b. Modifier Q0; and
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KENTUCKY & OHIO PART A
c. An 8-digit clinical trial number listed at http://www.cms.gov/Medicare/Coverage/
Coverage-with-Evidence-Development/PILD.html on the CMS CED website.
yyOn or after January 9, 2014, effective for hospital outpatient procedures on type
of bill (TOB) 13X or 85X, your MAC will reject claims for PILD, procedure code
0275T for LSS, ICD-9 diagnosis range 724.01-724.03, or ICD-10 diagnosis range
M48.05-M48.07, when billed without:
a. Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) in either the
primary/secondary positions;
b. Modifier Q0, condition code 30 (institutional claims only); and,
c. An 8-digit clinical trial number listed on the CMS website.
When rejecting these claims, they will use:
a. Claims Adjustment Reason Code (CARC): 50 -These are non-covered services
because this is not deemed a “medical necessity” by the payer;
b. Remittance Advice Remarks Code (RARC) N386 - This decision was based
on a National Coverage Determination (NCD). An NCD provides a coverage
determination as to whether a particular item or service is covered. A copy of this
policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have
Web access, you may contact the contractor to request a copy of the NCD; and
c. Group Code – Contractual Obligation (CO).
yyMACs will return the professional PILD claim as unprocessable when billed with a
diagnosis code other than 724.01-724.03 (ICD-9) or M48.05-M48.07 (ICD-10), using:
a. CARC B22: “This payment is adjusted based on the diagnosis;”
b. RARC N704: “Alert: You may not appeal this decision but can resubmit this
claim/service with corrected information if warranted.;” and
c. Group Code-Contractual Obligation (CO).
yyMACs will return the professional PILD claim as unprocessable when billed in a
place of service other than 22 (outpatient) or 24 (ambulatory surgical center), using:
a. CARC 58: “Treatment was deemed by the payer to have been rendered in an
inappropriate or invalid place of service;”
b. RARC N704: “Alert: You may not appeal this decision but can resubmit this
claim/service with corrected information if warranted.;” and
c. Group Code-Contractual Obligation (CO).
yyMACs will return the professional PILD claim as unprocessable if it does not contain
the required clinical trial diagnosis code V70.7 (ICD-9) or Z00.6 (ICD-10) in either the
primary/secondary positions, using:
a. CARC B22: “This payment is adjusted based on the diagnosis;”
b. RARC M76: “Missing/incomplete/invalid diagnosis or condition;”
c. RARC N704: “Alert: You may not appeal this decision but can resubmit this
claim/service with corrected information if warranted.;” and
d. Group Code-Contractual Obligation (CO).
yyMACs will return the professional PILD claim as unprocessable when billed without
Modifier Q0, using:
a. CARC 4: “The procedure code is inconsistent with the modifier used
or a required modifier is missing;”
b. RARC N657: “This should be billed with the appropriate code for
these services.;”
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
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KENTUCKY & OHIO PART A
c. RARC N704: “Your claim contains incomplete and/or invalid information, and no
appeal rights are afforded because the claim is unprocessable. Please submit a
new claim with the complete/correct information;” and
d. Group Code-Contractual Obligation (CO).
yyMACs will accept the numeric, 8-digit clinical trial identifier number preceded by the
two alpha characters of “CT” when placed in Field 19 of paper Form CMS-1500, or
when entered WITHOUT the “CT” prefix in the electronic 837P in Loop 2300 REF02
(REF01=P4). NOTE: The “CT” prefix is required on a paper claim, but it is not
required on an electronic claim.
yyFor PILD claims submitted without a clinical trial identifier number, they will follow the
requirements outlined in CR8401, Mandatory Reporting of an 8-Digit Clinical Trial
Number on Claims, released on October 30, 2013. You can find the associated MLN
Matters® article at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8401.pdf on the CMS website.
MACs will not search their files to adjust claims already processed, but will adjust claims
that you bring to their attention.
Finally, you should note that endoscopically assisted laminotomy/laminectomy, which
requires open and direct visualization, as well as other open lumbar decompression
procedures for LSS, are not within the scope of this NCD.
Additional Information
The official instruction, CR 8757, issued to your MAC, consists of two transmittals. The
first updates the “Medicare National Coverage Determinations Manual” and it is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R167NCD.pdf on the CMS website. The second transmittal updates the “Medicare
Claims Processing Manual” and it is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R2959CP.pdf on the same site.
Fee Schedule
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.
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
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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
HCPCS Code
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
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KENTUCKY & OHIO PART A
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
Type of Service
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.
Physician Supervision of
Diagnostic Procedures
Effective
(Phys Diag Supv)
Date
HCPCS
Code
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
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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
Mri neck spine w/o dye - Phys Diag Supv
Correction (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
Mri chest spine w/dye - Phys Diag Supv
Correction (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
72157-TC
Mri chest spine w/o & w/dye - Phys Diag
Supv
Correction (TC)
02
01/01/2014
02
01/01/2014
Mri lumbar spine w/o & w/dye - Phys Diag
72158-TC Supv
Correction (TC)
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
02
Supv Correction (TC)
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
KENTUCKY & OHIO PART A
Physician Supervision of
Diagnostic Procedures
Effective
(Phys Diag Supv)
Date
HCPCS
Code
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 1.866.590.6703 and choose Option 1.
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of the provider/supplier staff. Newsletters are available at no cost from our website at
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KENTUCKY & OHIO PART A
Fee Schedule
MM8773: July Update to the Calendar
Year (CY) 2014 Medicare Physician Fee
Schedule Database (MPFSDB)
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
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
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Short Descriptor
Procedure Status
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
KENTUCKY & OHIO PART A
HCPCS
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.
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
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KENTUCKY & OHIO PART A
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 1.866.590.6703 and choose Option 1.
FQHC/RHC
MM8743: Implementation of a Prospective
Payment System (PPS) for Federally Qualified
Health Centers (FQHCs)
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: MM8743
Related CR Release Date: May 9, 2014
Related CR Transmittal #: R1383OTN
Related Change Request (CR) #: CR 8743
Effective Date: October 1, 2014
Implementation Date: October 6, 2014
Provider Types Affected
This MLN Matters® article is intended for federally qualified health centers (FQHCs)
submitting claims to Part A Medicare administrative contractors (A MACs) for services
furnished to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
CMS is establishing a Federally Qualified Health Center (FQHC) Prospective
Payment System (PPS) with specific payment codes that FQHCs must use in
order to ensure payment.
CAUTION – What You Need to Know
CR 8743, from which this article is taken, implements the FQHC PPS, effective for cost
reporting periods beginning on or after October 1, 2014. This article does not apply to
any FQHC claims that are not subject to the PPS. FQHCs will remain under the allinclusive rate (AIR) system until their first cost reporting period beginning on or after
October 1, 2014.
GO – What You Need to Do
Make sure your billing staffs are aware of these new coding requirements.
Background
Except for services that are paid at 100 percent of costs, Medicare currently pays
FQHCs 80 percent of their AIR. MACs reconcile costs and visits at year-end through cost
report settlement.
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of the provider/supplier staff. Newsletters are available at no cost from our website at
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KENTUCKY & OHIO PART A
In compliance with the statutory requirements of the Affordable Care Act, CMS
established a national encounter-based prospective payment rate for all FQHCs,
determined based on an average of the reasonable costs of all FQHCs.
FQHCs will transition to the FQHC PPS based on their cost reporting periods. For
FQHCs with cost reporting periods beginning before October 1, 2014, MACs shall
continue to pay the FQHCs using the current AIR system. For FQHCs with cost reporting
periods beginning on or after October 1, 2014, MACs shall pay the FQHCs using the
FQHC PPS.
Under the FQHC PPS, Medicare will pay FQHCs based on the lesser of their actual
charges or the PPS rate for all FQHC services furnished to a beneficiary on the same
day when a medically-necessary, face-to-face FQHC visit is furnished to a Medicare
beneficiary. Medicare will allow for an additional payment when an illness or injury occurs
subsequent to the initial visit, or when a mental health visit is furnished on the same day
as a medical visit.
The PPS rate will be adjusted when a FQHC furnishes care to a patient who is new to
the FQHC or to a beneficiary receiving an initial preventive physical examination (IPPE)
or an annual wellness visit (AWV). CMS is establishing specific payment codes to be
used under the FQHC PPS based on descriptions of services that will correspond to the
appropriate PPS rates.
The PPS rates will also be adjusted to account for geographic differences in the cost of
inputs by applying FQHC geographic adjustment factors (FQHC GAFs). In calculating the
total payment amount, the FQHC GAF will be based on the locality of the site where the
services are furnished. For FQHC organizations with multiple sites, the FQHC GAF may
vary depending on the location of the FQHC delivery site.
From October 1, 2014, through December 31, 2015, the FQHC PPS base payment rate is
$158.85. Updates to the FQHC PPS base payment rate and the FQHC GAF will be made
available through program instruction.
The FQHC PPS rates will be calculated as follows:
Base payment rate x FQHC GAF = PPS rate
If the patient is new to the FQHC, or the FQHC is furnishing an IPPE, initial AWV,
or subsequent AWV, the PPS rate will be adjusted by 1.3416. This is a composite
adjustment factor and would only be applied once per day. The PPS rate in this case
would be calculated as follows:
Base payment rate x FQHC GAF x 1.3416 = PPS rate
To qualify for an encounter-based payment, a FQHC visit must meet all applicable
coverage requirements. Additional information on the coverage requirements for FQHC
visits can be found in the “Medicare Benefit Policy Manual”, Pub 100-02, Chapter 13,
which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/bp102c13.pdf on the CMS website.
FQHC Specific Payment Codes
CMS is establishing five specific payment codes to be used by FQHCs submitting claims
under the PPS:
1. G0466 – FQHC visit, new patient
A medically-necessary, face-to-face encounter (one-on-one) between a new
patient and a FQHC practitioner during which time one or more FQHC services are
rendered and includes a typical bundle of Medicare-covered services that would
be furnished per diem to a patient receiving a FQHC visit.
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KENTUCKY & OHIO PART A
2. G0467 – FQHC visit, established patient
A medically-necessary, face-to-face encounter (one-on-one) between an
established patient and a FQHC practitioner during which time one or more FQHC
services are rendered and includes a typical bundle of Medicare-covered services
that would be furnished per diem to a patient receiving a FQHC visit.
3. G0468 – FQHC visit, IPPE or AWV
A FQHC visit that includes an IPPE or AWV and includes a typical bundle of
Medicare-covered services that would be furnished per diem to a patient receiving
an IPPE or AWV.
4. G0469– FQHC visit, mental health, new patient
A medically-necessary, face-to-face mental health encounter (one-on-one)
between a new patient and a FQHC practitioner during which time one or more
FQHC services are rendered and includes a typical bundle of Medicare-covered
services that would be furnished per diem to a patient receiving a mental
health visit.
5. G0470 – FQHC visit, mental health, established patient
A medically-necessary, face-to-face mental health encounter (one-on-one)
between an established patient and a FQHC practitioner during which time one
or more FQHC services are rendered and includes a typical bundle of Medicarecovered services that would be furnished per diem to a patient receiving a mental
health visit.
FQHCs shall use the specific payment code that corresponds to the type of visit that
qualifies the encounter for Medicare payment, and these codes will correspond to the
appropriate PPS rates. Each FQHC shall report a charge for the FQHC visit code that
would reflect the sum of regular rates charged to both beneficiaries and other paying
patients for a typical bundle of services that would be furnished per diem to a Medicare
beneficiary.
Basic Billing Requirements
When reporting an encounter/visit for payment, the claim (77X TOB) must contain
a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that
corresponds to the type of visit.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported
under revenue code 052X or under revenue code 0519. NOTE: Revenue code 0519 is
only used for Medicare Advantage (MA) Supplemental claims.
FQHC specific payment codes G0469 and G0470 must be reported under revenue code
0900 or 0519.
FQHCs must continue to report detailed HCPCS coding on the claim to describe all
services that occurred during the encounter. All service lines must be reported with their
associated charges.
Payment for a FQHC encounter requires a medically necessary face-to-face visit. Each
FQHC specific payment code (G0466-G0470) must have a corresponding service line
with a HCPCS code that describes the qualifying visit. See Attachment A of CR 8743 for
a list of qualifying visits that correspond to the specific payment codes. (NOTE: A link to
CR 8743 is available in the “Additional Information” section at the end of this article.)
When submitting a claim for a mental health visit furnished on the same day as a medical
visit, FQHCs must report a specific payment code for a medical visit (G0466, G0467, or
G0468) and a specific payment code for a mental health visit (G0470), and each specific
payment code must be accompanied by a service line with a qualifying visit.
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of the provider/supplier staff. Newsletters are available at no cost from our website at
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KENTUCKY & OHIO PART A
When submitting a claim for a subsequent illness or injury, FQHCs must report the
appropriate specific payment code (G0467 for a medical visit or G0470 for a mental
health visit) with modifier 59. Modifier 59 is the FQHC’s attestation that the patient,
subsequent to the first visit, suffers an illness or injury that requires additional diagnosis
or treatment on the same day. Modifier 59 should only be used when reporting unrelated
services that occurred at separate times during the day (e.g., the patient had left the
FQHC and returned later in the day for an unscheduled visit for a condition that was not
present during the first visit). NOTE: A qualifying visit is still required when reporting
modifier 59 with G0467 or G0470.
FQHCs must report all services that occurred on the same day on one claim.
FQHC may submit claims that span multiple days of service. However, FQHCs
transitioning to the PPS must submit separate claims for services subject to the PPS
and services paid based on the AIR. MACs shall reject claims with multiple dates of
service that include both PPS and non-PPS dates, as determined based on the individual
FQHC’s cost reporting period.
Durable Medical Equipment (DME), laboratory services (excluding 36415), ambulance
services, hospital-based services, group services, and non-face-to-face services will be
rejected.
Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (MNT)
services are subject to the frequency edits described in Pub 100-04, Chapter 18, and
should not be reported on the same day.
FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and
their administration on a FQHC claim, and these HCPCS codes will be considered
informational only. MACs shall continue to pay for the influenza and pneumococcal
vaccines through the cost report.
Please refer to the examples in Attachment B of CR8743 for additional billing guidance.
Medicare Payment
The total payment amount for a FQHC visit shall be the lesser of the FQHC’s reported
charge for the FQHC payment code or the fully adjusted FQHC PPS rate for the specific
payment code. Under the FQHC PPS, MACs shall generally pay 80 percent of the lesser
of the FQHC’s charge for the FQHC payment code or the corresponding FQHC PPS
rate. Coinsurance will generally be 20 percent of the lesser of the actual charge or the
FQHC PPS rate.
Medicare waives coinsurance for certain preventive services. For FQHC claims that
consist solely of preventive services that are exempt from beneficiary coinsurance,
MACs shall pay 100 percent of the lesser of the provider’s charge for the FQHC payment
code or the FQHC PPS rate, and no beneficiary coinsurance would be assessed.
For FQHC claims that include a mix of preventive and non-preventive services, MACs
shall use the lesser of the provider’s charge for the specific FQHC payment code or the
corresponding FQHC PPS rate to determine the total payment amount. To determine
the amount of Medicare payment and the amount of coinsurance that should be
waived, MACs shall use the FQHC’s reported line-item charges and subtract the dollar
value of the FQHC’s reported line-item charge for the preventive services from the full
payment amount. (See the “Medicare Claims Processing Manual,” Pub. 100-04, chapter
18, section 1.2, for a table of preventive services that are exempt from beneficiary
coinsurance. That manual chapter is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c18.pdf on the CMS website.)
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
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KENTUCKY & OHIO PART A
Claims for Medicare Advantage (MA) Supplemental Payments
FQHCs that have a written contract with a MA organization that furnishes care to
beneficiaries covered by the MA plan are paid by the MA organization at the rate that
is specified in their contract. If the MA contract rate is less than the Medicare PPS rate,
Medicare will pay the FQHC the difference, less any cost sharing amounts owed by the
beneficiary. The supplemental payment is only paid if the contracted rate is less than
the fully adjusted PPS rate. To facilitate accurate payment, claims for MA supplemental
payments under the FQHC PPS must include the specific payment codes that
correspond to the appropriate PPS rates and the detailed HCPCS coding required for all
FQHC PPS claims.
Additional Information
The official instruction, CR 8743, issued to your MAC regarding this change is available
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R1383OTN.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 1.866.590.6703 and choose Option 1.
FQHC/RHC
SE1039 (Revised): Rural Health Clinics (RHCs)
and Federally Qualified Health Centers (FQHCs)
Billing Guide
The Centers for Medicare & Medicaid Services (CMS) has revised the following Special Edition
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/MedicareLearning-Network-MLN/MLNMattersArticles/2010-MLN-Matters-Articles.html
MLN Matters® Number: SE1039
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: At the time this article was first published in 2010, the information reflected Medicare policy
correctly at that time. Since then, more current information is available and new articles have been
released. This article was updated on June 5, 2014, to refer to some of the key new articles.
Provider Types Affected
This article is for Rural Health Clinics (RHCs) and Federally Qualified Health
Centers (FQHCs) submitting claims to Medicare contractors (fiscal intermediaries (FIs)
and/or A/B Medicare administrative contractors (A/B MACs)) for services provided to
Medicare beneficiaries.
What You Need to Know
This Special Edition article is based on CR 7038, CR 7208, and CR 8743; and it provides
a billing guide for FQHCs and RHCs. It describes the information FQHCs are required
to submit in order for CMS to develop and implement a Prospective Payment System
(PPS) for Medicare FQHCs. It also explains how RHCs should bill for certain preventive
services under the Affordable Care Act. Effective for dates of service on or after January
1, 2011, coinsurance and deductible are not applicable for the Initial Preventive Physical
Examination (IPPE) provided by RHCs. However, to ensure coinsurance and deductible
are not applied, detailed Healthcare Common Procedure Coding System (HCPCS)
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KENTUCKY & OHIO PART A
coding must be provided for preventive services recommended by the United States
Preventive Services Task Force (USPSTF) with a grade of A or B. The Affordable
Care Act also waives the deductible for planned colorectal cancer screening tests
that become diagnostic.
Background
Historically, RHCs and FQHCs billing instructions have been the same. However,
effective January 1, 2011, the billing requirements will be different for each of these
facilities’ types.
As outlined in CR 7208, transmittal 2122, RHCs are only required to submit detailed
HCPCS codes for preventive services with a United States Preventive Services Task
Force (USPSTF) grade of A or B in order to waive coinsurance and deductible. As
outlined in CR 7038 (see the related MLN Matters® article, MM7038 at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
downloads/MM7038.pdf on the CMS website), FQHCs are required to submit detailed
HCPCS code(s) for all services rendered during the encounter. As outlined in CR 8743
(see the related MLN Matters® article, MM8743 at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8743.
pdf on the CMS website) and effective for cost reporting periods beginning on or after
October 1, 2014, FQHCs are required to implement a prospective payment system
(PPS). FQHCs will remain under the all-inclusive rate (AIR) system until their first cost
reporting period beginning on or after October 1, 2014. Listed below is a summary of the
billing requirements for each facility that you need to know when submitting claims for
either RHCs or FQHCs.
RHCs (71X Types of Bills (TOBs):
The professional components of preventive services are part of the overall encounter,
and for TOB 71x, these services have always been billed on revenue lines with the
appropriate site of service revenue code in the 052x series. In previous requirements,
HCPCS codes have only been required to report certain preventive services subject to
frequency limits.
Effective for dates of service on or after January 1, 2011, coinsurance and deductible
are waived for the IPPE, the annual wellness visit, and other Medicare covered
preventive services recommended by the USPSTF with a grade of A or B. Detailed
HCPCS coding is required to ensure that coinsurance and deductible are not applied
to these preventive services.
Payment for the professional component of allowable preventive services is made under
the all-inclusive rate when all of the program requirements are met. Lab and technical
components should continue to be billed as non RHC services.
Basic RHC Billing for Preventive Services:
When one or more preventive service that meets the specified criteria is provided as
part of an RHC visit, charges for these services must be deducted from the total charge
for purposes of calculating beneficiary coinsurance and deductible. For example, if the
total charge for the visit is $150, and $50 of that is for a qualified preventive service, the
beneficiary coinsurance and deductible is based on $100 of the total charge.
To ensure coinsurance and deductible are waived for qualified preventive services,
RHCs must report an additional revenue line with the appropriate site of service revenue
code in the 052X series with the approved preventive service HCPCS code and the
associated charges. For example, the service lines should be reported as follows:
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Revenue Code
1
052X
2
052X
HCPCS Code
Preventive Service Code
Date of Service
Charges
01/01/2011
100.00
01/01/2011
0.00
KENTUCKY & OHIO PART A
Line
The services reported without the HCPCS code will receive an encounter/visit payment.
Payment will be based on the all-inclusive rate, and the coinsurance and deductible will
be applied. The qualified preventive service will not receive payment, as payment is
made under the all-inclusive rate for the services reported on the first revenue
line. Coinsurance and deductible are not applicable to the service line with the
preventive service.
Exceptions
If the only service provided is a preventive service (such as the IPPE or Annual Wellness
Visit (AWV)), report only one line with the appropriate site of service revenue code
(052X) and the preventive service HCPCS code. The services will be paid based on the
all inclusive rate. Coinsurance and deductible are not applicable.
NOTE: An additional visit may be paid for IPPE when billed with another qualified encounter/visit,
as outlined with CR 6445 (see the related MLN Matters® article, MM6445, at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6445.
pdf on the CMS website).
RHCs are not required to report separate revenue lines for influenza virus or
pneumococcal pneumonia vaccines on the 71x claims as the cost for these services are
not included in the encounter. Costs for the influenza virus or pneumococcal pneumonia
vaccines are included in the cost report and no line items are billed. Coinsurance and
deductible do not apply to either of these vaccines.
The hepatitis B vaccine is included in the encounter rate. The charges of the vaccine and
its administration shall be carved out of the office visit and reported on a separate line as
outlined in the above example. An encounter cannot be billed if vaccine administration
is the only service the RHC provides. For additional information on incident to services,
please see the “Medicare Benefit Policy Manual” (Chapter 13, Section 60) at http://www.
cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf on the
CMS website.
RHCs do not receive any reimbursement on TOBs 71x for the technical component
of services provided by clinics. This is because the technical component of services
are not within the scope of Medicare-covered RHC services. The associated technical
component of services furnished by the clinic/center are billed on other types of claims
that are subject to strict editing to enforce statutory frequency limits.
FQHCs (77X TOBs)
The Affordable Care Act (Section 10501(i)(3)(A) amended the Social Security Act
(Section 1834; see http://www.ssa.gov/OP_Home/ssact/title18/1834.htm) by adding a
new subsection (o) titled “Development and Implementation of Prospective Payment
System.”
This subsection provides the statutory framework for development and implementation
of a Prospective Payment System (PPS) for Medicare FQHCs. The Social Security Act
(Section 1834(o)(1)(B)) as amended by the Affordable Care Act, addresses collection of
data necessary to develop and implement the new Medicare FQHC PPS. Specifically,
the Affordable Care Act grants the Secretary of Health and Human Services the authority
to require FQHCs to submit such information as may be required in order to develop and
implement the Medicare FQHC PPS, including the reporting of services using HCPCS
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codes. The Affordable Care Act requires that the Secretary impose this data collection
submission requirement no later than January 1, 2011.
Beginning with dates of service on or after January 1, 2011, when billing Medicare,
FQHCs must report all services provided during the encounter/visit by listing the
appropriate HCPCS code. The additional revenue lines with detailed HCPCS code(s)
are for information and data gathering purposes in order to develop the FQHC PPS set
to be implemented in 2014. The additional data will not be utilized to determine current
Medicare payment to FQHCs. The Medicare claims processing system will continue to
make payments under the current FQHC interim per-visit payment rate methodology.
Basic FQHC Billing Requirements:
For dates of service on or after January 1, 2011, all valid UB04 revenue codes except
the following may be used to report the additional services that are needed for data
collection and analysis purposes only:
yy002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or
096x-310x.
Medicare will make one payment at the all-inclusive rate for each date of service that
contains a valid HCPCS code for professional services when one of the following
revenue codes is present:
Revenue Code Definition
0521
Clinic visit by member to RHC/FQHC
0522
Home visit by RHC/FQHC practitioner
0524
Visit by RHC/FQHC practitioner to a member in a covered Part A stay at a Skilled
Nursing Facility (SNF)
0525
Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay)
or NF or ICF MR or other residential facility
0527
RHC/FQHC Visiting Nurse Service(s) to a member’s home when in a Home Health
Shortage Area
0528
Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)
Payments for Encounter/Visits
Medicare will make an additional encounter payment at the all-inclusive rate on the same
claim when:
yyEffective January 1, 2011, two services lines are submitted with a 052X revenue
code and one line contains modifier 59. Modifier 59 signifies that the conditions
being treated are totally unrelated and services are provided at separate times of
the day, e.g., treatment for an ear infection in the morning and treatment for injury
to a limb in the afternoon;
yyServices subject to the Medicare outpatient mental health treatment limitation are
billed under revenue code 0900;
yyDiabetes Self Management Training (DSMT) is billed under revenue code 052x and
HCPCS code G0108 and Medical Nutrition Therapy (MNT) is billed under revenue
code 052x and HCPCS code 97802, 97803, or G0270; and
yyThe Initial Preventive Physical Examination (IPPE) billed under revenue code
052X and HCPCS code G0402. This is a once in a lifetime benefit. HCPCS
coding is required.
Note: Modifier 59 is not required for DSMT, MNT, or IPPE in order to receive an additional
encounter payment.
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Example A
Line
Rev Code
HCPCS code
Date of Service
Charges
1
0521
Office Visit
01/01
300.00
2
0636
Penicillin Injection
01/01
125.00
3
0271
Wound Cleaning
01/01
125.00
4
0771
Preventive Service Code
01/01
50.00
KENTUCKY & OHIO PART A
When reporting multiple services on FQHC claims, the 052X revenue line should include
the total charges for all of the services provided during the encounter. For preventive
services with a grade of A or B from the USPSTF, the charges for these services must
be deducted from the total charge for purposes of calculating beneficiary coinsurance
correctly. For example, if the total charge for the visit is $350.00, and $50.00 of that is for
a qualified preventive service, the beneficiary coinsurance and deductible is based on
$300.00 of the total charge.
When reporting multiple services on the same day that are unrelated, modifier 59 must
be used to report these services, e.g., treatment for an ear infection in the morning and
treatment for injury to a limb in the afternoon.
Example B
Line
Rev Code
HCPCS code
Modifier
Date of Service
1
0521
Office Visit
01/01
150.00
2
0479
Removal of Wax From Ear
01/01
100.00
3
0521
Office Visit
59
01/01
4
0271
Wound Cleaning
01/01
150.00
5
0279
Bone Setting With Casting
01/01
300.00
Charges
450.00
When reporting an additional encounter for IPPE, the revenue lines should be reflected
as follows:
Example C
Line
Rev Code
HCPCS code
Date of Service
Charges
1
0521
Office Visit
01/01
75.00
2
0419
Breathing Treatment
01/01
75.00
3
0521
IPPE (G0402)
01/01
150.00
As of January 01, 2011, for data collection and analysis for the PPS, FQHCs are required
to report separate revenue lines for influenza virus or pneumococcal pneumonia
vaccines (PPV) on the 77x claims. The charges of these vaccines and the administration
shall be carved out of the office visit and reported on a separate line as outlined in
example A. The cost for these services will continue to be reimbursed through cost
reporting. Coinsurance and deductible do not apply to either of these vaccines.
Hepatitis B vaccine is included in the encounter rate. The charges for the vaccine and
its administration will be carved out of the office visit and reported on a separate line as
outlined in example A. An encounter cannot be billed if vaccine administration is the only
service the FQHC provides. For additional information on incident to services, please
see Chapter 13, Section 60 of the “Medicare Benefit Policy Manual” at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf on the
CMS website.
Laboratory and technical components should continue to be billed as non
FQHC services.
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The chart below displays a list of elements and notes the differences between RHCs and
FQHCs:
Element
RHCs
FQHCs
Revenue Codes
052X series
All except: 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x,
067x-072x, 080x-088x, 093x, or 096-310x
HCPCS code
Required for Preventive Services
Required for all services rendered during encounter/visit
only excluding Flu and PPV
Modifier 59
Not applicable at this time
Should be used to report two distinct unrelated visits on the same
day
DSMT and MNT
Not separately payable
All inclusive payment rate
November 2013 Manual Updates
In November 2013, CR 8504 updated Chapter 13 of the “Medicare Benefit Policy Manual”
to reflect numerous updates that were effective on January 1, 2014. The MLN Matters®
article MM8504, which relates to CR 8504 is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
MM8504.pdf on the CMS website.
KENTUCKY & OHIO PART A
Summary of Differences
The FQHC PPS
FQHCs will transition to the FQHC PPS based on their cost reporting periods. For
FQHCs with cost reporting periods beginning before October 1, 2014, MACs shall
continue to pay the FQHCs using the current AIR system. For FQHCs with cost reporting
periods beginning on or after October 1, 2014, MACs shall pay the FQHCs using the
FQHC PPS.
Under the FQHC PPS, Medicare will pay FQHCs based on the lesser of their actual
charges or the PPS rate for all FQHC services furnished to a beneficiary on the same
day when a medically-necessary, face-to-face FQHC visit is furnished to a Medicare
beneficiary. Medicare will allow for an additional payment when an illness or injury occurs
subsequent to the initial visit, or when a mental health visit is furnished on the same day
as a medical visit.
The PPS rate will be adjusted when a FQHC furnishes care to a patient who is new to
the FQHC or to a beneficiary receiving an initial preventive physical examination (IPPE)
or an annual wellness visit (AWV). CMS is establishing specific payment codes to be
used under the FQHC PPS based on descriptions of services that will correspond to the
appropriate PPS rates.
The PPS rates will also be adjusted to account for geographic differences in the cost of
inputs by applying FQHC geographic adjustment factors (FQHC GAFs). In calculating the
total payment amount, the FQHC GAF will be based on the locality of the site where the
services are furnished. For FQHC organizations with multiple sites, the FQHC GAF may
vary depending on the location of the FQHC delivery site.
Complete details of the FQHC PPS are available in MLN Matters® article MM8743,
which is available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/mm8743.pdf on the CMS website.
Additional Information
Additional information on vaccines can be found in the “Medicare Claims Processing
Manual” (Chapter 1, section 10) at http://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/downloads/clm104c01.pdf on the CMS website, and additional
coverage requirements for the pneumococcal vaccine, hepatitis B vaccine, and influenza
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KENTUCKY & OHIO PART A
virus vaccine can be found in the “Medicare Benefit Policy Manual” (Chapter 15) at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.
pdf on the CMS website.
Hospital
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,
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
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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
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
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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.
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37
July 2014 OPPS
Status Indicator
July 2014
OPPS APC
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
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 patient
present)
S
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
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Table 2 – 27 Category III CPT Codes Implemented as of July 1, 2014
CY 2014
CPT Code CY 2014 Long Descriptor
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38
July 2014 OPPS
Status Indicator
July 2014
OPPS APC
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
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.
KENTUCKY & OHIO PART A
Table 2 – 27 Category III CPT Codes Implemented as of July 1, 2014
CY 2014
CPT Code CY 2014 Long Descriptor
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.
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.
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.
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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:
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.
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
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
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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.
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.
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 1.866.590.6703 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.
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KENTUCKY & OHIO PART A
ICD-10
MM8691: ICD-10 Conversion/Coding Infrastructure
Revisions/ICD-9 Updates to National Coverage
Determinations (NCDs) - Maintenance CR
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: MM8691
Related CR Transmittal #: R1388OTN
Related CR Release Date: May 23, 2014 Related Change Request (CR) #: CR 8691
Effective Date: July 1, 2014 (ICD-9 updates, local system edits), October 1, 2014
(designated ICD-9 shared system edits), October 1, 2015 (or whenever ICD-10 is
implemented) (ICD-10 updates)determined for ICD-10
Implementation Date: July 7, 2014 (designated ICD-9 updates, local system edits,
October 6, 2014 (or whenever ICD-10 is implemented (ICD-10 updates)to be determined
for ICD-10
Provider Types Affected
This MLN Matters® article is intended for physicians, other providers, and suppliers
submitting claims to Medicare administrative contractors (MACs), including home health
and hospice MACs (HH&H MACs) and durable medical equipment MACs (DME MACs),
for services to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 8691 which is the first maintenance update of ICD-10
conversions and coding updates specific to National Coverage Determinations (NCDs).
The majority of the NCDs included are a result of feedback received from previous
ICD-10 NCD CRs, specifically CR 7818, CR 8109, and CR 8197. Links to related MLN
Matters® Articles MM7818, MM8109, and MM8197 are available in the additional
information section of this article. Some are the result of revisions required to other NCDrelated CRs released separately that also included ICD-10.
Edits to ICD-10 coding specific to NCDs will be included in subsequent, quarterly
recurring updates. No policy-related changes are included with these recurring updates.
Any policy-related changes to NCDs continue to be implemented via the current, longstanding NCD process. Make sure that your billing staffs are aware of these changes to
the following 29 NCDs:
20.5 ECU Using Protein A Columns, 20.7 PTA, 20.20 ECP Therapy, 20.29 HBO Therapy,
50.3 Cochlear Implants, 70.2.1 Diabetic Peripheral Neuropathy, 80.2 Photodynamic
Therapy, 80.2.1 OPT, 80.3 Photosensitive Drugs, 80.3.1 Verteporfin, 100.1 Bariatric
Surgery, 110.8.1 Stem Cell Transplants, 110.4 Extracorpreal Photopheresis, 110.10 IV
Iron Therapy, 150.3 Bone Mineral Density, 160.18 VNS, 160.24 Deep Brain Stimulation,
160.27 TENS for CLBP, 180.1 MNT, 190.1 Histocompatibility Testing, 190.8 Lymphocyte
Mitogen Response Assay, 190.11 Home PT/INR, 210.1 PSA Screening Tests, 210.2
Screening Pap/Pelvic Exams, 210.3 Colorectal Cancer Screens, 210.10 Screening for
STIs, 250.4 Treatment for AKs, 250.3 IVIG for Autoimmune Blistering Disease, 250.5
Dermal Injections for Facial LDS
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
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Background
The purpose of CR 8691 is to both create and update NCD editing, both hard-coded
shared system edits as well as local MAC edits, that contain either ICD-9 diagnosis/
procedure codes or ICD-10 diagnosis/procedure codes, or both, plus all associated
coding infrastructure such as HCPCS/CPT codes, reason/remark codes, frequency edits,
Place of Service (POS)/Type of Bill (TOB)/provider specialties, etc. The requirements
described in CR 8691 reflect the operational changes that are necessary to implement
the conversion of the Medicare systems from ICD-9 to ICD-10 specific to the 29 NCD
spreadsheets attached to CR8691.
Additional Information
The official instruction, CR 8691 issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R1388OTN.pdf on the CMS website. Note that there are 29 spreadsheets attached
to CR 8691 and those spreadsheets relate to 9 NCDs and provide pertinent policy/
coding information necessary to implement ICD-10.
If you have any questions, please contact a CGS Customer Service Representative by
calling the CGS Provider Contact Center at 1.866.590.6703 and choose Option 1.
MM7818 is available for review at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7818.pdf
on the CMS website.
MM8109 is available for review at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8109.pdf
on the CMS website.
MM8197 is available for review at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8197.pdf
on the CMS website.
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
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