Billing and Coverage

This bookmark explains the benefits of adopting the system, recommended steps to be taken in order to plan and prepare for implementation of the system, and where additional information about the system may be found. [PERL 200810-19]

This article was revised on October 9, 2008, to update the Web site addresses and other information in the Additional Information section of this article. All other information remains the same. [SE0832, PERL 200810-11]

This article provides information about the 2009 annual update of Healthcare Common Procedure Coding System (HCPCS) codes for skilled nursing facility (SNF) consolidated billing. [MM6220]

For calendar year 2009, Medicare will continue to pay for splints, casts, dialysis supplies and equipment, and intraocular lenses (IOLs) on a reasonable charge basis. [MM6221]

The Center for Medicare & Medicaid Services (CMS) has developed tools to assist the renal care community in implementing the revised end-stage renal disease (ESRD) conditions. [PERL 200810-12]

The Centers for Medicare & Medicaid Services (CMS) recently announced that beginning October 1, 2008, it will publish most of the edits utilized in its Medically Unlikely Edit (MUE) program to improve the accuracy of claims payments. [PERL 200810-08]

CMS is soliciting nominations for individuals to serve on the Program Advisory and Oversight Committee (PAOC) that advises CMS on issues related to the durable medical equipment (DME) competitive bidding program. [PERL 200810-07, 200810-11]

Flu season is upon us. Begin now to take advantage of each office visit as an opportunity to encourage your patients to get a flu shot. And don’t forget, health care personnel can spread the highly contagious flu virus to patients. [PERL 200810-13]

The Centers for Medicare & Medicaid Services (CMS) has announced a list of providers that were exempt from meeting the quality standards for durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) accreditation. [PERL 200810-10]

FCSO is currently testing system changes so these claims can be released as soon as possible. At this time, it is not necessary to contact customer service.

This first in a series of national provider calls hosted by CMS will provide an overview of ICD-10-CM/PCS (International Classification of Diseases clinical modifications/procedure coding system) and how it differs from ICD-9-CM. [PERL 200810-15]

This article announces changes that will be included in the October 2008 release of the edit module for clinical diagnostic laboratory NCDs. [MM6213]

In the event of a pandemic or other national emergency, the Center for Medicare & Medicaid Services has developed certain emergency policies and procedures that may be implemented for the Medicare program in the event of a pandemic. [MM6164]

Providers receiving claims with reason code 31999 must submit a CMS-855A Enrollment Application (version 02/08) to update the provider master address file with a valid nine-digit ZIP code. [JSM 08442]

Since August 11, 2008, claims for which no reimbursement was made were not printed on remittance advice notices created on Tuesdays and Thursdays.

Reason code 38067 is being assigned incorrectly on some skilled nursing facility claims with type of bill 21X against some outpatient services billed on types of bill 13X and 14X.

Flu season is upon us. Begin now to take advantage of each office visit as an opportunity to encourage your patients to get a flu shot. It’s still their best defense against combating the flu this season. [PERL 200810-03]

This article provides clarification regarding Medicare payment of routine costs associated with clinical trials. [SE0822]

This manual update incorporates non-appeals related provisions published in the Federal Register on June 27, 2008. [MM6178]

CMS encourages Medicare providers to vaccinate their patients against the influenza virus. Providers may download the Medicare Part B Immunization Billing quick reference chart from the CMS Web site. [PERL 200809-19, 200809-43]

Effective October 1, 2008, if you owe overdue taxes to the Internal Revenue Service (IRS), your Medicare payment may be adjusted accordingly. [PERL 200808-26, 200809-34, 200809-41, 200809-43]

The new rules prohibit financial incentives that could encourage agents and brokers to maximize commissions by inappropriately moving, or churning, beneficiaries from one plan to another each year. [PERL 200809-41]

CMS has launched Ask Medicare, a new one-stop Web site to assist caregivers and beneficiaries with valuable health care information, services, and resources. [PERL 200809-41]

The RAC demonstration program has proven to be successful in returning dollars to the Medicare Trust Fund. This article provides tips to help you prepare for the RAC permanent program.

This guide provides information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines. [PERL 200809-42]

CMS is providing a link where providers may find the capped and uncapped amounts for the technical component (TC) of most imaging services and the TC of global services at the outpatient prospective payment system rate. [PERL 200809-38]

Medicare Part B reimburses providers who accept the Medicare-approved payment amount for influenza, pneumococcal, and hepatitis B vaccines and their administration. All adults 65 and older should get influenza and pneumococcal shots. [PERL 200809-40]

Laboratory codes reimbursed via the MPFS were not reimbursed at the line level for dates of service beginning July 1, 2008.

The incorrect rehabilitation rate was added to the HCPC file for codes G0237, G0238, and G0239, which caused an incorrect payment to outpatient claims.

This article was revised on September 18, 2008, to make minor clarifying changes on page 2 and to delete some unnecessary language on pages 5 and 9. All other information remains the same. [MM6183]

CMS has extended the previous instructions to fiscal intermediaries about holding hospital claims with HCPCS Q0091 for dates of service on or after April 1, 2008, until changes to the shared system are implemented on January 5, 2009. [JSM 08465]

On or after September 16, 2008, the October 2008 average sales price (ASP) and ASP NOC files will be available for contractors to download, along with revisions to prior payment files, as CMS deems necessary. [MM6175]

CMS has revised the implementation date of change request 6185 to December 1, 2008. In addition, the transmittal numbers, CR release date, and the Web addresses for accessing CR 6185 were revised. All other information remains the same. [MM6185]

This is in response to a federally qualified health clinic (FQHC) question raised on the September 3, 2008, special open door forum: DMEPOS Accreditation - MIPPA 2008 Guidance. [PERL 200809-22]

This article revises and clarifies payment of travel allowances that are based on either a per-mileage basis or flat-rate basis for calendar year 2008. The new rates are $1.035 per mile (code P9603) and $9.55 per flat-rate trip (code P9604). [MM6195]

Beginning March 1, 2009, Medicare contractors will accept only a properly executed revised advance beneficiary notice of noncoverage (CMS R-131) as a valid notification. [MM6136]

Influenza virus and pneumococcal vaccine claims submitted on roster bills do not require the reporting of the national provider identifier of the rendering provider in the 24J field of the Form CMS-1500 (08-05). [MM6079]

CMS study of possible alternative payment locality configurations is in the early stages of development. You are encouraged to submit comments on the options until October 20, 2008. [PERL 200809-06]

Providers may submit adjustments on claims that denied in error with reason code 55503 or 56000 based on the stated criteria. However, FCSO will adjust the impacted claims once the data becomes available. [CR 5818]

Article revised August 11, 2008, to reflect changes made to CR 6145. The transmittal number, release date, and Web address for accessing the NCD portion of CR 6145 were revised. All other information remains the same. [MM6145]

This article was revised on September 2, 2008, to revise the CR release date, transmittal number, and the Web address for accessing CR 6048. In addition, some language in item 3 on page 3 was clarified. [MM6048]

CMS has updated the Medicare benefits policy manual to incorporate guidance regarding the signature requirement for diagnostic tests. [MM6100]

An audio recording of this special forum will be accessible for downloading beginning September 10, 2008. [PERL 200808-34]

The Hospital Compare Web site gives consumers an insight into the quality of care provided by their local hospitals. Hospital Compare has become a popular tool for consumers and their caregivers in making health care decisions. [PERL 200808-32]

CMS was asked to reconsider the current noncoverage for fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging in the Medicare national coverage determinations for certain off-label uses. [MM6099]

All SNF claims processed on or after July 10, 2008, will suspend to status location SMSPR1 with reason code 75100 for ECPS review.

The purpose of this Special Open Door Forum (ODF), scheduled September 3, 2008, is to provide guidance to DMEPOS providers on the MIPPA. [PERL 200808-34]

This article provides an overview of the October Update to the 2008 Medicare Physician Fee Schedule Database, scheduled for implementation on October 6, 2008. [MM6180]

According to the MCPSS, providers continue to be satisfied with services provided by Medicare fee-for-service (FFS) contractors, showing a relatively smooth transition to the new Medicare administrative contractors (MACs). [PERL 200808-30]

CMS' study of possible alternative payment for localities under the MPFS is in early stages of development. CMS encourages interested parties to submit comments on the options presented in the report, and suggestions for other options. [PERL 200808-25]

This article was revised on August 21, 2008, to clarify the “Provider Types Affected.” All other information remains the same. [MM6125]

CMS will be hosting a series of end-stage renal disease stakeholder meetings to provide an opportunity for interested stakeholders to provide vital input and recommendations on the program moving forward. [PERL 200808-24]

This specific code describes claims denied based on the non-compliance with the physician self-referral prohibition legislation or payer policy due to a financial interest, and the provider fails to meet one of the available exceptions. [MM6131]

The remittance advice remark codes used in electronic and paper remittance advice, and the claim adjustment reason codes used in electronic and paper remittance advice and coordination-of-benefits claim transactions have been updated. [MM6109]

ICD-9 is now widely viewed as outdated with its limited ability to accommodate new procedures and diagnoses. ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. [PERL 200808-23]

The Centers for Medicare & Medicare Services (CMS) estimates that the average monthly premium beneficiaries will pay for standard Part D coverage in 2009 will be $28. [PERL 200808-22]

CMS reminds the Medicare providers of the requirements to correctly enroll in order to conduct mass immunization roster billing and centralized billing of Medicare for influenza and pneumococcal immunizations. [MM6121]

Effective March 1, 2009, when you contact Medicare through the IVR system, a CSR, or a written inquiry you will have to provide three data elements for authentication: 1) Your NPI; 2) Your PTAN, and 3) the last five-digits of your TIN. [MM6139]

CMS has awarded contracts for the 9th statement of work (SOW) for the 53 contractors participating in the Medicare QIO program. The 9th SOW focuses on improving the quality and safety of health care services to Medicare beneficiaries. [PERL 200808-17]

Organizations considering becoming co-sponsors for the two-day conference with CMS can access the notice in the Federal Register. All proposals must be submitted electronically. [PERL 200808-08, 200808-12]

This article is to remind the provider community that all Medicare beneficiaries must contact 1-800 Medicare (1-800-633-4227 TTY: 1-877-486-2048) for assistance.

Under this pilot in Arizona and Utah, a beneficiary may choose one of the selected commercial personal health record (PHR) tools, and Medicare will transfer up to two years of the individual’s claims data into the individual’s PHR. [PERL 200808-09]

The April 2008 version of the Rural Health Clinic Fact Sheet, which provides information about rural health clinic (RHC) services, is now available in print format. [PERL 200808-09]

These articles were recently revised to reflect current processes and provide the Web address which contains user reference guides. CMS will notify providers as internet applications become available. [SE0747, SE0753, SE0754]

Medicare helps beneficiaries with the cost of immunizations by providing coverage for pneumococcal, influenza and hepatitis B vaccines. Medicare covers the cost of these vaccines and their administration by recognized providers. [PERL 200808-03]

CR 6132 requires contractors to educate providers regarding the specific way that the CMS uses Medicare Cost Report (MCR) data. Medicare providers are statutorily required to submit cost reports annually. [MM6132]

Due to missing data, CMS had to re-process the July 2008 quarterly Provider Specific Files. Both the text, and new this quarter, Statistical Analysis Software data have been revised and are now available on the CMS Web site. [PERL 200808-02]

This article serves as a reminder that the annual International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) update will be effective for dates of service on and after October 1, 2008. [MM6107]

Due to a preliminary injunction issued in San Diego, implementation of CR 5772 has been delayed. [JSM 08347]

Beginning in 2009, and during the next four years, Medicare will provide incentive payments to eligible professionals who are successful electronic prescribers. [PERL 200807-30]

This article alerts providers that effective for claims with dates of service on and after March 19, 2008, CMS revised its NCD limits and will expand the population eligible for home coverage of PT/INR monitoring. [MM6138]

This instruction was issued to highlight that the use of stamped signatures is prohibited. CMS has taken this step to ensure accurate application of Medicare’s program requirements throughout the nation. [SE0829]

These fact sheets are now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. [PERL 200807-31]

The HHS Office of the Inspector General has issued a policy statement regarding the waiving of retroactive beneficiary cost-sharing amounts attributable due to increased payment rates. [PERL 200807-28]

Due to the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), legislation altered a number of Medicare policies. This article addresses five critical issues. [SE0826]

The special accreditation deadlines previously established for the second round of the program have been cancelled. The deadline of September 30, 2009, for which all DMEPOS suppliers must be accredited is still in effect. [PERL 200807-25]

Find out more about the Ombudsman Program, ZIP code files, and the important requirements of the "Grandfathered" supplier provision. [PERL 200806-19]

The moratorium that allows independent laboratories (ILs) to bill for the technical component (TC) of physician pathology services furnished to hospital patients has been reinstated. [JSM 08413, PERL 200807-23]

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) extends the use of the cost to charge payment methodology for brachytherapy and therapeutic radiopharmaceuticals through January 1, 2010. [JSM 08415, PERL 200807-22]

Contractors are instructed to hold all 72X claims that contain lab HCPCS 82330 with dates of service on or after July 1, 2008. [JSM 08391]

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) delays implementation of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. [PERL 200807-21]