MLN Matters Articles from CMS

New:

SE0826 – Important Information on the New Medicare Law – The Medicare Improvements for Patients and Providers Act of 2008 

MM6061 – Clarifications to Audiology Update Transmittal 1470 

SE0815 – Reminder that Exceptions to Therapy Caps are Restricted as of July 1, 2008 

MM6088 – Pathology Services: Notification of the Sunset for the Payment of Physician Pathology Services for Independent Laboratories 

CANCELLED - ACCREDITATION Deadlines FOR DMEPOS Competitive Bidding

The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. This new law has delayed the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program.

As a result of this delay, the special accreditation deadlines previously established for the second round of the program have been cancelled. Specifically, prior to enactment of this new law, suppliers must have been accredited or have applied for accreditation by July 21, 2008 to be eligible to submit a bid for the second round of competitive bidding and must have obtained accreditation by January 14, 2009 to be eligible for a second round contract. Both of these deadlines have been cancelled and no longer apply.

The deadline of September 30, 2009, that was previously established by which all DMEPOS suppliers must be accredited is still in effect.

Extension of Payment Rule for Brachytherapy and Therapeutic Radiopharmaceuticals

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), enacted on July 15, 2008, extends the use of the cost to charge payment methodology for Brachytherapy and Therapeutic Radiopharmaceuticals through January 1, 2010.

This change is retroactive to July 1, 2008. Some claims have already been processed, however, using the Outpatient Prospective Payment System (OPPS) rates that were in effect until MIPAA enactment. To avoid a disruption in payment while the cost to charge payment methodology is re-implemented, impacted claims will continue to be paid based on the OPPS rates. Contractors will mass adjust all impacted OPPS claims with dates of service beginning July 1, 2008, as soon as the cost to charge payment methodology has been implemented. Reprocessing will be complete by September 30, 2008.

Reinstatement of the Moratorium That Allows Independent Laboratories to Bill for the TC of Physician Pathology Services Furnished to Hospital Patients

In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, the Centers for Medicare & Medicaid Services (CMS) stated that it would implement a policy to pay only the hospital for the technical component (TC) of physician pathology services furnished to hospital patients.

Prior to this proposal, any independent laboratory could bill the carrier under the physician fee schedule for the TC of physician pathology services for hospital patients. At the request of the industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed. Subsequent legislation formalized a moratorium on the implementation of the rule. As such, during this time, the carriers and, more recently, Medicare Administrative Contractors (MAC) have continued to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital.

The most recent extension of the moratorium, established by the Medicare, Medicaid, and SCHIP Extension Act (MMSEA), Section 104, expired on June 30, 2008. A new extension of the moratorium has been established by the Medicare Improvements for Patients and Providers Act of 2008, Section 136, retroactive to July 1, 2008.

A previous communication indicated that the moratorium had ended and that independent laboratories may no longer bill Medicare for the TC of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed. This prohibition is rescinded and the moratorium will continue effective for claims with dates of service on and after July 1, 2008, but prior to January 1, 2010.

Delay of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. This new law has delayed the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. Items that had been included in the first round of the DMEPOS Competitive Bidding Program can be furnished by any enrolled DMEPOS supplier in accordance with existing Medicare rules. Payment for these items will be made under the fee schedule. Additional guidance regarding this new law will be forthcoming.

MLN Matters Articles from CMS

New:

MM6048 – Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) 

MM6137 – Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting 

Revised:

MM5993 – Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) 

MM6007 – Manual Revisions to Reflect Special Billing Instructions for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items as a Result of the DMEPOS Competitive Bidding Program 

Attention Part B MD/DCMA/DE EDI Customers: The J12 EDI Transition Line Will Be Discontinued

Highmark Medicare Services offers a dedicated, toll-free telephone number for Part B EDI assistance and support. Starting on July 21, 2008, you must call Highmark Medicare Services at 1-866-488-0546, option 1, for all Part B EDI assistance and support.

Effective July 21, 2008, the J12 EDI transition line (1-866-488-0546, option 3) will no longer be available to you. Callers who select option 3 will be instructed to hang-up and call 1-866-488-0546, option 1. Please update your telephone book accordingly.

Small Provider Groups Workshop

Attention Pennsylvania Providers located in the following counties:  Westmoreland, Fayette, Greene, Adams, Perry, Huntingdon, Fulton and York

Highmark Medicare Services is coming to a location close to you.  We will be presenting topics on the Comprehensive Error Rate Testing Program, PQRI, Tips for a Successful Claim Submission and much more. This program meets the American Academy of Professional Coders’ guidelines for 3.0 continuing education units.

Click the link above to register.

Reinstatement of the Moratorium That Allows Independent Laboratories to Bill for the TC of Physician Pathology Services Furnished to Hospital Patients

The moratorium that allows independent laboratories to bill the carrier or A/B MAC for the TC of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary's hospitalization status has been reinstated by the Medicare Improvements for Patients and Providers Act of 2008.

Attention Appeals Part B MD/DCMA/DE Customers Regarding Claim Adjustments

Claims finalized prior to July 11, 2008, will display a denial message specific to the determination made by TrailBlazer.

On appeal, denied services which are not in question will continue to deny. Due to system limitations, however, a new denial message will appear on the adjustment claim replacing the original determination message from Trailblazer. The verbiage for this new message is:

STD 136 - Failure to follow prior payer's coverage rules

When you receive "STD 136 - Failure to follow prior payer's coverage rules," please refer to the initial claim determination Remittance Advice you received from TrailBlazer for the specific denial reason.

Extension of Therapy Cap Exceptions

The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008.

New 2008 Medicare Physician Fee Schedule Payment Rates Effective for Dates of Service July 1, 2008 through December 31, 2008

The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008.  As a result, the mid-year 2008 Medicare Physician Fee Schedule (MPFS) rate of -10.6 percent has been replaced with the January-June 2008 0.5 percent update, retroactive to July 1, 2008.

Medicare Part B Reference Manual - Revision 77

Revision 77 of the Medicare Part B Reference Manual has been posted.

Medicare Quality Reporting Initiative Pays Over $36 Million To Participating Physicians From the 2007 PQRI Reporting Period

Physicians, physician group practices, and other PQRI eligible professionals should receive their payments by August 2008. The average incentive amount for individual professionals is over $600 and average incentive payment for a physician group practice is over $4,700, with the largest payment to a physician group practice totaling over $205,700. Click here to read the entire CMS Press release issued today. For more information about the PQRI program visit the PQRI page on the CMS website.

LCD/Article Updates

The August monthly Local Coverage Determination (LCD) release is being changed from August 13, 2008 to August 21, 2008.  

The following Part B Local Coverage Determinations (LCDs) have been revised: 

• M-38R  -  Transthoracic Echocardiography (TTE)
• M-49Q  -  Cardiovascular Stress Testing
• M-51M  -  Transesophageal Echocardiography (TEE)
• X-45D  -  Computed Tomographic Angiography of the Chest 

The following Part B Billing and Coding Articles have been revised: 

• M-38R  -  Transthoracic Echocardiography (TTE)
• M-49Q  -  Cardiovascular Stress Testing
• M-51M  -  Transesophageal Echocardiography (TEE) 

The following Part B Billing and Coding Articles are retiring effective July 17, 2008: 

• I-4J  -  Coding Article for Hemophilia Clotting Factors (National Benefit)
• V-26H  -  Clinical Social Worker
• X-45C  -  Computed Tomographic Angiography of the Chest
• A24634  -  Unlabeled Use for Anti-cancer Drugs

NEW REPORT SHOWS CMS PILOT PROGRAM SAVING NEARLY $700 MILLION IN IMPROPER MEDICARE PAYMENTS

The Centers for Medicare & Medicaid Services (CMS) today released a new report offering fresh evidence that the recovery audit contractors (RACs) pilot program is successfully identifying improper payments. The findings will also help the agency improve the program as it is expanded nationwide within two years, officials say.

The evaluation report shows that $693.6 million in improper Medicare payments was returned to the Medicare Trust Funds between 2005 and March 2008. The funds returned to the Medicare Trust Funds occurred after taking into account the dollars repaid to health care providers, the money overturned on appeal and the costs of operating the RAC demonstration program.

Click here to view the entire Press Release. Click here to view the RAC Evaluation Report.

2008 PQRI Reporting Options Quick Reference Chart is now available

This two-sided laminated reference chart gives Eligible Professionals and practice staff a quick reference to the new reporting options available for 2008 PQRI with their corresponding alternative reporting periods.

To order this product, visit the CMS website and click on the 2008 Physician Quality Reporting Initiative (PQRI) Reporting Quick Option Reference Chart (ICN# 900843) (May 2008) link.

Telephone Reopening Line

The Telephone Reopening Line will be closed on Tuesday, July 15, 2008, from 9:00 a.m. - 1:00 p.m. Eastern Time for training purposes. The lines will reopen at 1:00 p.m. Eastern Time. Thank you for your patience.

ATTENTION Part B MD/DCMA/DE PC-ACE Pro32 Users Only: NEW Utility Is Now Available to Enter Your New Contractor Identification Number

Expiration of Moratorium That Allowed Independent Laboratories to Bill for the TC of Physician Pathology Services Furnished to Hospital Patients

Effective for claims with dates of service on and after July 1, 2008, independent laboratories may no longer bill Medicare for the TC of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed.

In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, the Centers for Medicare & Medicaid Services (CMS) stated that it would implement a policy to pay only the hospital for the technical component (TC) of physician pathology services furnished to hospital patients.  Prior to this proposal, any independent laboratory could bill the carrier under the physician fee schedule for the TC of physician pathology services for hospital patients.  At the request of the industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed.  Subsequent legislation formalized a moratorium on the implementation of the rule.  As such, during this time, the carriers and, more recently, Medicare Administrative Contractors (MAC) have continued to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. 

The most recent extension of the moratorium was established by the Medicare, Medicaid, and SCHIP Extension Act (MMSEA).  Section 104 of the MMSEA expired on June 30, 2008, thus ending the moratorium.  Therefore, independent laboratories may no longer bill Medicare for the TC of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed.  This prohibition is effective for claims with dates of service on and after July 1, 2008.