Medicare Bulletin. Latest Medicare News for J15 Part A. Vol. 2012, Issue 9 September 2012

Transcription

1 Medicare Bulletin Latest Medicare News for J15 Part A Vol. 2012, Issue September 2012 Attention Ohio and Kentucky J15 Part A Providers Please check the Learning and Education section of this issue for information about the J15 Part A ACT sessions. There are sessions scheduled this month until Spring The J15 Part A Provider Outreach and Education (POE) department encourages providers and their staff to attend these sessions to learn about current and upcoming Medicare policy and coverage information. GENERAL INFORMATION...2 Provider Contact Center Training and Holiday Closure Schedule...2 MULTIPLE PROVIDER INFORMATION...3 CMS e-news...3 Addition of Digital Document Repository to Provider Enrollment Chain and Ownership System (PECOS)...7 Liver Transplantation for Patients with Malignancies...9 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)...10 Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Medicare Remit Easy Print (MREP) and PC Print Update...13 FEE SCHEDULE INFORMATION...17 October 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files...17 ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION...18 Claim Status Category and Claim Status Codes Update...18 HOSPITAL INFORMATION...19 Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year Payment of Global Surgical Split-Care in a Method II Critical Access Hospital (CAH) Submitted with Modifier 54 and/or 5522 National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR)...24 INPATIENT REHABILITATION FACILITY (IRF) INFORMATION...29 Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for Fiscal Year (FY) LEARNING AND EDUCATION INFORMATION...31 Ohio and Kentucky Part Ask the Contractor Teleconferences (ACTs): September 2012 January MEDICAL AFFAIRS INFORMATION...32 Category III CPT Code Covered Article A50740 Update for LCD L MEDICARE SECONDARY PAYER (MSP) INFORMATION...32 Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers Compensation (WC) Medicare Secondary Payer (MSP) Claims...32 You Are Responsible... The Medicare Bulletin contains coverage, billing, and other information for J15 Part A. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the CGS Web site. It is the responsibility of each facility to obtain this information and to follow the guidelines. The Medicare Bulletin includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our Web site at CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004

2 SKILLED NURSING FACILITY (SNF) INFORMATION...40 Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update Fiscal Year (FY) HELPFUL INFORMATION...43 Contact Information for CGS Part A...43 IVR User Guide...45 GENERAL INFORMATION Provider Contact Center Training and Holiday Closure Schedule The CGS Provider Contact Center (PCC) will continue to close up to eight hours per month for customer service representative (CSR) training and staff development. The Interactive Voice Response (IVR) unit will be available during these scheduled training sessions for automated customer service transactions. Listed below are training closure dates and times for the next several months: Date September 3, 2012 September 13, 2012 September 20, 2012 September 27, 2012 October 8, 2012 November 12, 2012 November 22-23, 2012 December 6, 2012 December 13, 2012 December 20, 2012 December 24, 2012 December 25, 2012 PCC/Office Closed Office closed/labor Day PCC closed 2:30 to 4:30 p.m. ET PCC closed 2:30 to 4:30 p.m. ET PCC closed 2:30 to 4:30 p.m. ET *PCC closed/columbus Day *PCC closed/veterans Day Office closed/thanksgiving (two days) PCC closed 2:30 to 4:30 p.m. ET PCC closed 2:30 to 4:30 p.m. ET PCC closed 2:30 to 4:30 p.m. ET Office closed/christmas Eve Office closed/christmas Day Changes to our planned closure schedule will be communicated at least three weeks in advance via the Web site, IVR features and automatic notifications. You may contact our PCC at (866)

3 It Saves Time! I love that! my Now Available!

4 MULTIPLE PROVIDER INFORMATION CMS e-news CMS is piloting e-news as a new way to communicate with you. e-news will contain a week s worth of Medicare-related messages instead of many different messages being sent to you throughout the week. This new communication will be piloted from now through the end of September, The intent of this pilot is to ensure planned, coordinated messages are delivered timely about Medicare-related topics. We hope to prove that this is a more efficient and effective way to communication with our physicians, providers and suppliers. e-news Communication 1. CMS e-news for Wednesday, August 1, 2012: 01Enews.pdf 2. Medicare Shared Savings Program Electronic Application Process through Health Plan Management System Call: August 7; 1:30-3 p.m. ET On Tuesday, August 7, CMS will host a call to discuss how to submit your electronic application for the Medicare Shared Savings Program through the Health Plan Management System (HPMS). Information about the application process is available on the Shared Savings Program Application web page ( Payment/sharedsavingsprogram/Application.html). Call participants are encouraged to review application materials and log into HPMS prior to the call. Go to the CMS Teleconferences and Events web page for further conference call information ( Payment/sharedsavingsprogram/Events.html). 3. CMS e-news for Wednesday, August 8, 2012: 08Enews.pdf 4. August 16 Special Open Door Forum for Long-Term Care Hospital Providers - Rescheduled for August 30 The Special Open Door Forum for Long-Term Care Hospital (LTCH) Providers, originally scheduled for Thursday, August 16, from 2:30-4 p.m. has been rescheduled and will take place instead, on August 30, from 2-3:30 p.m. ET. This Special ODF will provide information related to the data coding of the LTCH CARE Data Set. To best prepare, we highly recommend that you review the LTCH Quality Reporting Manual Version 1.1 found on the LTCH Quality Reporting web page ( AssessmentInstruments/LTCH-Quality-Reporting/index.html). Please continue to check the LTCH Quality Reporting web page for further details and agenda items related to the August 30 Special Open Door Forum for LTCHs

5 5. CMS e-news for Wednesday, August 15, Enews.pdf 6. Special Open Door Forum Series: IRF Quality Reporting Program - Thursday, August 16; 1-2:30 p.m. ET Please join us for the second in the 4-part series of Inpatient Rehabilitation Facility (IRF) Quality Reporting Program Special Open Door Forums. The purpose of these Open Door Forums will be to address issues related to the upcoming implementation of the IRF Quality Reporting Program. We will present various topic and guest speakers each month. We will hold a question and answer session at the end of each Open Door Forum. Please let us know about topics that you would like us address at these Open Door Forums. Please your ideas to: IRF.questions@CMS.hhs.gov. Additional IRF Special Open Door Forums will be held on the following dates and times: Thursday, September 20; 1-2:30 p.m. ET Thursday, October 18; 1-2:30 p.m. ET Special Open Door Participation Instructions: Dial: & Conference ID: Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial or A Relay Communications Assistant will help. A transcript and audio recording of this Special ODF will be posted to the Special Open Door Forum ( Web site and will be accessible for downloading. For automatic s of Open Door Forum schedule updates ( ing list subscriptions) and to view Frequently Asked Questions please visit the Open Door Forum ( Education/Outreach/OpenDoorForums/index.html?redirect=/ opendoorforums/) Web site. CMS Announces Timeline for DMEPOS Competitive Bidding Round 1 Recompete; Begins Bidder Education Program Bidding Timeline CMS has announced the bidding timeline for the Round 1 Recompete of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. To view the timeline, visit the Competitive Bidding Implementation Contractor (CBIC) Web site at Bidder Education Program CMS has also launched a comprehensive bidder education program. This program is designed to ensure that DMEPOS suppliers interested in bidding receive the information and assistance they need to submit complete bids in a timely manner. The CBIC is the official information source for bidders and the focal point for bidder education. The CBIC Web site features a comprehensive array of important information for suppliers, including bidding rules, user guides, policy fact sheets, checklists, and bidding information charts. The education program will also include Webcasts that will cover all the essential topics suppliers will need

6 to know in order to bid. These Webcasts will be posted on the CBIC Web site and will be available 24 hours a day/7 days a week. When a Webcast is posted, the CBIC will announce its availability through a CBIC update announcement. To sign up to receive Webcast announcements and other key registration and bidding information, visit the CBIC Web site and subscribe to updates. In addition to viewing the information on the CBIC Web site, DMEPOS suppliers are encouraged to call the CBIC toll-free help desk, , with their questions and concerns. 7. Registration Now Open for DMEPOS Competitive Bidding Registration is now open to all suppliers interested in participating in the Round 1 Recompete of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. In order to submit a bid for the Round 1 Recompete, you must first register in the Individuals Authorized Access to the CMS Computer Services (IACS) online application. Once you have registered in IACS, you will receive a user ID and password to access the online DMEPOS Bidding System (DBidS). You must register even if you registered during a previous round of competition (Round 1 Rebid, Round 2, or the national mail-order competition). Only suppliers who have a user ID and password will be able to access DBidS; suppliers that do not register will not be able to bid. If you are a supplier interested in bidding, register now don t wait. Designate one individual listed as an authorized official (AO) on your organization s CMS-855S enrollment form in the Provider Enrollment, Chain and Ownership System (PECOS) to act as your AO for registration purposes. The AO must be the first person in the organization to register in IACS. After an AO successfully registers, other individuals listed as authorized officials on the CMS-855S in PECOS may register as backup authorized offi cials (BAOs). The AO must approve a BAO s request to register. For the AO and BAOs to register successfully, the name and Social Security number entered in IACS must match exactly with what is recorded on the CMS-855S and on file in PECOS. Individuals not listed as authorized officials on the CMS-855S in PECOS may register to serve as end users (EUs). The AO or a BAO must approve an EU s request to register. Bidders are prohibited from sharing user IDs and passwords. We strongly urge all AOs to register no later than September 7, 2012, to ensure that BAOs and EUs have time to register before bidding begins. We recommend that BAOs register no later than September 28, 2012, so that they will be able to assist AOs with approving EU registration. Registration will close on Friday, October 19, 2012 at 9 p.m. prevailing Eastern Time no AOs, BAOs, or EUs can register after registration closes. To register, go to the Competitive Bidding Implementation Contractor (CBIC) Web site, click on Round 1 Recompete, and then click on REGISTRATION IS OPEN above the Registration clock. Before you register, we strongly recommend that you review the IACS Reference Guide with step-bystep instructions and the Getting Started Registration Checklist. If you have any questions about the registration process, please contact the CBIC Customer Service Center at between 9 a.m. and 9 p.m. prevailing ET, Monday through Friday

7 The CBIC is the official information source for bidders. All suppliers interested in bidding are urged to sign up for Updates on the home page of the CBIC Web site. For information about the Round 1 Recompete, please refer to the bidder education materials on the CBIC Web site located under Round 1 Recompete > Bidding Suppliers. 8. CMS e-news for Wednesday, August 22, 2012: News.pdf 9. National Provider Call: Stage 2 Requirements for the Medicare and Medicaid EHR Incentive Programs Save the Date Thursday; September 13, 2 p.m. - 3:30 p.m. ET On Thursday Aug 23, CMS announced the final rule for Stage 2 requirements and other changes to the EHR Incentive Programs, which is scheduled to be published on September 4. This National Provider Call will provide an overview of the final rule, so you can learn what you need to know to receive EHR incentive payments. The final rule can be found at CMS Stage 2 Final Rule ( For more information on the EHR Incentive Programs, visit the CMS EHR Incentive Programs Web site ( Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ EHRIncentivePrograms). Target Audience: Hospitals, Critical Access Hospitals (CAHs), and professionals eligible for the Medicare and/or Medicaid EHR Incentive Programs. For more details: Eligibility Requirements for Professionals: Guidance/Legislation/EHRIncentivePrograms/Eligibility.html#BOOKMARK1 Eligibility Requirements for Hospitals: Guidance/Legislation/EHRIncentivePrograms/Eligibility.html#BOOKMARK2 Agenda: Extension of Stage 1 Changes to Stage 1 Criteria for Meaningful Use Proposed Medicaid policies Stage 2 Meaningful Use Overview Stage 2 Clinical Quality Measures Medicare Payment Adjustments and Exceptions Question and Answers about the incentive programs

8 Registration Information: In order to receive the call-in information, you must register for the call. Registration will open soon on the CMS Upcoming National Provider Calls registration Web site ( Presentation: The presentation for this call will be posted at least one day before the call at National Provider Calls Web site ( Education/Outreach/NPC/index.html?redirect=/NPC/Calls/list.asp). In addition, a link to the slide presentation will be ed to all registrants on the day of the call. Continuing education credit may be awarded for participation in certain CMS National Provider Calls. Visit the Continuing Education Credit Notification Web page to learn more ( Addition of Digital Document Repository to Provider Enrollment Chain and Ownership System (PECOS) MLN Matters Number: SE 1230 Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A Provider Types Affected This MLN Matters Special Edition Article is intended for physicians, other providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. Provider Action Needed: Impact to You This article informs Medicare Contractors about the changes and enhancements to the online version of the Provider Enrollment, Chain and Ownership System (Internet-based PECOS). The changes allow physicians, other providers, and suppliers to digitally upload their PECOS supporting documents and submit them electronically with their enrollment application. A Digital Document Repository (DDR) How to Guide is available at Certification/MedicareProviderSupEnroll/Downloads/DigitalDocumentRepository-HowToGuide.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. What You Need to Do Make sure that your provider enrollment staff is aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes. Note: Providers/Suppliers are not required to utilize the Digital Document Repository (DDR) process and still have the option to mail their supporting documents to their MACs

9 Background CMS has updated Internet-based PECOS to allow all providers/suppliers the ability to submit electronic copies of supporting documentation to a DDR. Prior to this enhancement, providers/suppliers were required to mail copies of all supporting documentation to their MAC. The DDR will be accessible by providers/suppliers via Internet-based PECOS during the application submission process. The DDR will apply to any documents required to be submitted as part of the Medicare Enrollment application and requests from the MACs for additional documentation that may be essential to completely process the provider/supplier s enrollment application. Examples include, but are not limited to: Medical Licenses/Certifications Final Adverse Legal Action documentation Internal Revenue Service (IRS) tax documents Accreditation documentation Voided Check/Account Verification (for Electronic Funds Transfer (EFT)) National Provider Identifier (NPI) Confirmation Letters Pay.gov receipts Provider Agreements CMS-460 Participation Agreement Forms Internet-based PECOS users will have the ability to upload all supporting documentation for any enrollment application that can be submitted via Internet-based PECOS, including new enrollment applications, Changes of Information (COI) applications and revalidation applications. Uploaded documents must be in a PDF or TIFF file format, and be equal to or less than 10 MB per file. Documents can only be uploaded for an application that has not yet been submitted for processing, or if the application has been returned for corrections. Once the application has been submitted for processing, the provider/supplier will not be able to attach any additional documents unless the application is Denied, Rejected or Returned for Corrections by the MAC, or the application is Approved and a new application is submitted (e.g., COI). Users who wish to submit an application for the sole purpose of updating documentation would submit a COI, and update the documents associated with the enrollment record. Users will also have the ability to classify documents that are uploaded based on the document type and to upload more than one document of a particular type (e.g., uploading of multiple documents with the type W-2 for Managing Employee for multiple W-2s for managing employees). Users will have the ability to add or delete previously submitted documents as part of a COI application submission and view/print any supporting documentation that was previously submitted and is currently associated with an enrollment record. Additional Information To download the Digital Document Repository (DDR) How to Guide on how to use the new DDR functionality, please refer to Certification/MedicareProviderSupEnroll/Downloads/DigitalDocumentRepository-HowToGuide.pdf on the CMS Web site

10 Liver Transplantation for Patients with Malignancies MLN Matters Number: MM7908 Related Change Request (CR) #: CR 7908 Related CR Release Date: August 3, 2012 Effective Date: June 21, 2012 Related CR Transmittal #: R2513CP and R146NCD Implementation Date: September 4, 2012 Provider Types Affected This MLN Matters Article is intended for physicians, other providers and suppliers who submit claims to Medicare Contractors (Carriers, Fiscal Intermediaries (FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for adult liver transplantation services provided to Medicare beneficiaries. Provider Action Needed: Impact to You This article is based on Change Request (CR) 7908 which updates instructions regarding adult liver transplantation services for Medicare beneficiaries and revises relevant sections of the Medicare Claims Processing Manual and the Medicare National Coverage Determinations (NCD) Manual. What You Need to Know Effective for claims with dates of service June 21, 2012, and later, CR 7908 instructs that Medicare Contractors may, at their discretion, cover adult liver transplantation for Medicare beneficiaries with 1) extrahepatic unresectable cholangiocarcinoma (CCA); 2) liver metastases due to a neuroendocrine tumor (NET); or 3) hemangioendotheliomo (HAE) when furnished in an approved Liver Transplant Center. All other nationally non-covered malignancies continue to remain nationally non-covered. What You Need to Know See the Background and Additional Information Sections of this article for further details regarding these changes. Background Liver transplantation (in situ replacement of a recipient s liver with a donor liver) may be an accepted treatment for patients with end stage liver disease due to a variety of causes. The procedure is used in selected patients as a treatment for malignancies including primary liver tumors (and certain metastatic tumors) which are typically rare but lethal and have very limited treatment options. It has also been used in the treatment of patients with extrahepatic perihilar malignancies. Despite potential short and long-term complications, transplantation may offer the only chance of cure for selected patients while providing meaningful palliation for some others. Currently, Medicare covers liver transplantation for one malignancy, hepatocellular carcinoma (HCC), in certain circumstances. See the Medicare NCD Manual (Chapter 1, Part 4, Section (Adult Liver Transplantation)) at Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site

11 It had been approximately 10 years since CMS reviewed liver transplantation for malignancies other than Hierarchical Condition Categories (HCCs). Therefore, on October 14, 2011, CMS opened this NCD reconsideration and solicited public comment. On June 21, 2012, CMS issued a final NCD in the form of a non-decision stating that liver transplantation for patients with certain malignancies offers the potential for some clinical benefit in patients carefully selected on a case by case basis. These malignancies are: 1. Extrahepatic unresectable cholangiocarcinoma (CCA) 2. Liver metastases due to a neuroendocrine tumor (NET) 3. Hemangioendothelioma (HAE) The evidence base for these malignancies is sparse and especially limited in the Medicare population. In carefully selected patients, there appears to be a survival benefit from limited case series and reviews. Thus, CMS believes that local Medicare Contractors are in a better position to consider the clinical characteristics of individual beneficiaries and the performance of transplant centers within their jurisdictions in the best interest of Medicare beneficiaries. Therefore, CR 7908 instructs that Medicare Contractors may determine coverage for adult liver transplantation (when furnished in a facility that meets CMS institutional criteria) for patients with CCA, NET or HAE. All other nationally non-covered malignancies continue to remain nationally non-covered. Additional Information The official instruction, CR 7908 issued to your Carriers, FIs and A/B MACs, regarding this change in two transmittals. The first transmittal, R146NCD, updates the Medicare NCD Manual and it is available at on the CMS Web site. The second transmittal updates the Medicare Claims Processing Manual and it is available at on the same site. You can find more information about Medicare approval for organ transplant programs including links, applicable laws, regulations, compliance information and a listing of currently approved programs at Certification/CertificationandComplianc/Transplant.html on the CMS Web site. Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) MLN Matters Number: MM7836 Related Change Request (CR) #: CR 7836 Related CR Release Date: August 3, 2012 Effective Date: June 8, 2012 Related CR Transmittal #: R2511CP and R144NCD Implementation Date: January 7,

12 Provider Types Affected This MLN Matters Article is intended for providers and suppliers that submit claims to Medicare Contractors (Carriers, Regional Home Health Intermediaries (RHHIs) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for Transcutaneous Electrical Nerve Stimulation (TENS) services provided to Medicare beneficiaries. What You Need to Know This article is based on Change Request (CR) 7836 which informs providers and suppliers that the Centers for Medicare & Medicaid Services (CMS) is revising the coverage for TENS for Chronic Low Back Pain (CLBP) effective for claims with dates of service on or after June 8, See the Key Points section of this article for specific coverage rules and review the lists of ICD-9 and ICD-10 codes attached to the official instruction CR Background In 2010, the Therapeutic and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) published a report finding TENS ineffective for CLBP. CMS internally initiated a new national coverage determination (NCD) after the AAN published report and reviewed all the available evidence on the use of TENS for the treatment of CLBP. Medicare has four NCDs pertaining to various uses of TENS that were developed before the CMS adoption of an evidence based and publicly transparent paradigm for coverage decisions. Those four NCDs are: Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain (10.2) Assessing Patient s Suitability for Electrical Nerve Stimulation Therapy ( ) Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) (160.13) Transcutaneous Electrical Nerve Stimulators (TENS) (280.13). Please note, section has been removed from the NCD manual and incorporated into NCD The evidentiary basis is unclear for historic coverage. TENS has been historically thought to relieve chronic pain but the current evidence base refutes this assertion when applied to TENS for CLBP. Since TENS falls within the durable medical equipment (DME) benefit, Medicare coverage results in purchase after a brief initial rental period, even if the patient soon develops a subsequent tolerance to the TENS effect. Key Points Effective for claims with dates of service on or after June 8, 2012, CMS believes the evidence is inadequate to support coverage of TENS for CLBP as reasonable and necessary. Thus, effective for claims with dates of service on and after June 8, 2012, Medicare will only allow coverage of TENS for CLBP defined for this decision as pain for three months or longer and not a manifestation of a clearly defined and generally recognizable primary disease entity, when the patient is enrolled in an approved clinical study under coverage with evidence development (CED). Note: CED coverage expires three years from the effective date of this CR, June 8,

13 Examples of clearly defined and recognizable primary disease entities: neurodegenerative (e.g., multiple sclerosis) disease, malignancy or well-defined rheumatic disorders (except osteoarthritis). Medicare Contractors will accept and process line items that include an appropriate TENS HCPCS code, at least one ICD-9 diagnosis code for CLBP (see list of ICD-9 codes attached to CR 7836), and all of the following: Date of service on or after June 8, 2012 Modifiers KX and Q0 ICD-9 code V Examination of participant in clinical trial (for institutional claims only) Condition code 30 - (for institutional claims only) An acceptable ICD-9 code An acceptable ICD-10 code upon implementation (see list of ICD-10 codes attached to CR 7836) Medicare Contractors will deny TENS line items on claims when billed with a TENS code and at least one of the ICD-9 or ICD-10 codes for CLBP (see attachments to transmittal R2511CP of CR 7836 at if the conditions of requirement listed above are not met. When Medicare denies such claims for not containing the requisite ICD-9 (or later ICD-10) code, your remittance advice will reflect the following messages: Group Code CO Claim Adjustment Reason Code B5 (Coverage/program guidelines were not met or were exceeded.) Remittance Advice Remark Code 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 If you do not have Web access, you may contact the contractor to request a copy of the NCD. Medicare will pay for allowed TENS for CLBP based on the DME fee schedule. All of the following conditions must be met for coverage of TENS for CLBP: CLBP is defined as: An episode of low back pain that has persisted for three months or longer Is not the manifestation of a clearly defined and generally recognizable primary disease entity For example, there are cancers that, through metastatic spread to the spine or pelvis, may elicit pain in the lower back as a symptom. Certain systemic diseases (e.g., rheumatoid arthritis, multiple sclerosis, etc.) manifest many debilitating symptoms of which low back pain is not the primary focus. CMS believes that the appropriate management of these types of diseases is guided by a systematic strategy aimed at the underlying causes. While TENS may infrequently be used adjunctively in managing the symptoms of these diseases, it is clearly not the primary therapeutic approach. The patient is enrolled in an approved clinical study that addresses one or more aspects of the following questions in a randomized, controlled design using validated and reliable instruments. This can include randomized crossover designs when the impact of prior TENS use is appropriately accounted for in the study protocol

14 1. Does the use of TENS provide a clinically meaningful reduction in pain in Medicare beneficiaries with CLBP? 2. Does the use of TENS provide a clinically meaningful improvement of function in Medicare beneficiaries with CLBP? 3. Does the use of TENS provide a clinically meaningful reduction in other medical treatments or services used in the medical management of CLBP? These studies must be designed so that the patients in the control and comparison groups receive the same concurrent treatments and either sham (placebo) TENS or active TENS intervention. The study must also adhere to standards of scientific integrity and relevance to the Medicare population and those standards are part of Section You may read the entire set of parameters in the official instruction attached to transmittal R144NCD of CR That transmittal is available at Guidance/Guidance/Transmittals/Downloads/R144NCD.pdf on the CMS Web site. Additional Information The official instruction, CR 7836, issued to your Medicare Carrier, RHHI or DME MAC regarding this change via two transmittals. The first updates the NCD Manual and it is available at on the CMS Web site. The other transmittal updates the Medicare Claims Processing Manual and it is available at on the CMS Web site. Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Medicare Remit Easy Print (MREP) and PC Print Update MLN Matters Number: MM8029 Related Change Request (CR) #: CR 8029 Related CR Release Date: August 17, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2521CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers who submit claims to Medicare contractors (Carriers, Durable Medical Equipment Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries. Provider Action Needed This article is based on Change Request (CR) 8029 which instructs Medicare contractors and Shared System Maintainers (SSMs) to make programming changes to incorporate new, modified, and deactivated Claim

15 Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) that have been added since the last recurring code update. It also instructs Fiscal Intermediary Standard System (FISS) and VIPs Medicare System (VMS) maintainers to update PC Print and Medicare Remit Easy Print (MREP) software. Make sure that your billing staffs are aware of these changes. Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA; see on the Internet), instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states that CARCs and appropriate RARCs that provide either supplemental explanation for a monetary adjustment or global policy information that generally applies to the adjudication process are required in remittance advice (RA) and coordination of benefits (COB) transactions. For transaction 835 (Health Care Claim Payment/Advice) and standard paper remittance advice (RA), there are two code sets CARC and RARC that must be used to report payment adjustments, appeal rights, and related information. If there is any adjustment, the appropriate Group Code must be reported as well. Additionally, CARC and RARC must be used for transaction 837 COB. The CARC and RARC changes that impact Medicare are usually requested by the Centers for Medicare & Medicaid Services (CMS) staff in conjunction with a policy change. If a modification has been initiated by an entity other than CMS for a code currently used by Medicare, then Medicare contractors must either use the modified code or another code if the modification makes the modified code inappropriate to explain the specific reason for adjustment. Medicare contractors stop using codes that have been deactivated on or before the effective date specified in the comment section (as posted on the Washington Publishing Company (WPC) Web site). In order to comply with any deactivation, Medicare may have to stop using the deactivated code in original business messages before the actual Stop Date posted on the WPC Web site because the code list is updated three times a year and may not align with the Medicare release schedule. Note that a deactivated code used in derivative messages must be accepted, even after the code is deactivated, if the deactivated code was used before the deactivation date by a payer or payers who adjudicated the claim before Medicare. Medicare contractors must stop using any deactivated reason and/or remark code past the deactivation date whether the deactivation is requested by Medicare or any other entity. The regular code update CR will establish the implementation date for all modifications, deactivations, and any new code for Medicare contractors and the SSMs. If another specific CR has been issued by another CMS component with a different implementation date, the earlier of the two dates will apply for Medicare implementation. If any new or modified code has an effective date past the implementation date specified in CR 8029, Medicare contractors must implement on the date specified on the WPC Web site. The discrepancy between the dates may arise because the WPC Web site gets updated only 3 times a year and may not match the CMS release schedule. CR 8029 lists only the changes that have been approved since the last code update provided by CR 7775 (Transmittal 2442 issued on April 6, 2012; see Guidance/Guidance/Transmittals/Downloads/R2442CP.pdf on the CMS Web site)

16 CR 8029 does not provide a complete list of CARCs and RARCs, and the MACs and the SSMs must get the complete list for both CARCs and RARCs from the WPC Web site which is updated three times a year (around March 1, July 1, and November 1). The implementation date for any new or modified or deactivated code for Medicare contractors is established by this recurring code update CR published three or four times a year according to the Medicare release schedule. The WPC Web site (see ) has four listings available of Codes by Status for both CARC and RARC. 1. Show All: All codes including current, to be deactivated and deactivated codes are included in this listing. 2. Current: Only currently valid codes are included in this listing. 3. To Be Deactivated: Only codes to be deactivated at a future date are included in this listing. 4. Deactivated: Only codes with prior deactivation effective dates are included in this listing. NOTE 1: In case of any discrepancy in the code text as posted on the WPC Web site and as reported in any CR, the WPC version should be implemented. NOTE 2: CR8029 lists only the changes approved since the last recurring Code Update CR once. If any change becomes effective at a future date, Medicare contractors must make sure that they update on the quarterly release date that matches the effective date as posted on the WPC Web site. If the effective date per the WPC Web site does not match any quarterly release date, Medicare contractors may update earlier than the effective date per WPC Web site for any deactivation, and later than the effective date per WPC Web site for any modification or new code. CARCs A national code maintenance committee maintains the health care CARCs, and a new code may not be added and the indicated wording may not be modified without the approval of this committee. These codes were developed for use by all U.S. health payers. As a result, they are generic, and there are a number of codes that do not apply to Medicare. This code set is updated three times a year, and the updated list is published three times a year after the committee meets before the ANSI ASC X12 trimester meeting in the months of January/February, June, and September/October. The full list of CARCs can be found and downloaded from and to find out more about CARCs, see the "Medicare Claims Processing Manual" (Chapter 22, Sections 60.1 and at on the CMS Web site. New CARCs were approved by the Code Committee, and the following changes were made in the CARC database since the last code update provided by CR These changes must be implemented, if appropriate for Medicare, by October 1,

17 New CARCs Code Code Narrative Effective Date 240 The diagnosis is inconsistent with the patient s birth 6/3/2012 weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 241 Low Income Subsidy (LIS) Co-payment Amount. 6/3/ Services not provided by network/primary care 6/3/2012 providers. 243 Services not authorized by network/primary care providers. 6/3/2012 Modified CARCs Code Code Narrative Effective date 133 The disposition of the claim/service is pending further review. This change effective 1/1/2013: The disposition of the claim/service is pending further review. Use Group Code OA.. 6/3/2012 Deactivated CARCs Code Code Narrative Effective Date 38 Services not provided or authorized by designated 1/1/2013 (network/primary care) providers. Remittance Advice Remark Codes (RARCs) Remittance Advice Remark Codes (RARCs) are maintained by CMS and may be used by any health plan when they apply. Medicare contractors must report appropriate remark code(s) that apply in both electronic and paper remittance advice, and COB claims. RARCs are used in a remittance advice to further explain an adjustment in conjunction with an appropriate CARC or relay general information about the adjudication process.. The remark code list is updated three times a year, and the list as posted at the WPC Web site and gets updated at the same time when the reason code list is updated. Both code lists are updated on or around March 1, July 1, and November 1. Medicare contractors must use the currently valid remark codes as included in the Recurring Update Notification and/or any other CMS instruction. Medicare contractors also must get the full list of RARCs by downloading the list from the WPC Web site after each update. Contractor and shared system changes must be made, as necessary, as part of a routine release to reflect changes such as retirement of previously used codes or introduction of newly created codes that may impact Medicare. The list of Remittance Advice Remark Codes (RARCs) can be found at on the Internet

18 For more information about Remark Codes: You can find out more about CARCs in the "Medicare Claims Processing Manual" (Publication , Chapter 22, Section 60.2, and at Guidance/Guidance/Manuals/downloads/clm104c22.pdf on the CMS Web site. These following changes were made in the RARC database since the last code update provided by CR The full RARC list must be downloaded from the WPC Web site at on the Internet. FEE SCHEDULE INFORMATION October 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files MLN Matters Number: MM7885 Related Change Request (CR) #: CR 7885 Related CR Release Date: August 3, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2514CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for physicians, providers and suppliers submitting claims to Medicare Contractors (Carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries. Provider Action Needed: Impact to You Medicare will use the October 2012 quarterly Average Sales Price (ASP) Medicare Part B drug pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after October 1, 2012, with dates of service from October 1, 2012, through December 31, What You Need to Know Change Request (CR) 7885, from which this article is taken, instructs your Medicare Contractors to download and implement the October 2012 Average Sales Price (ASP) Medicare Part B drug pricing file for Medicare Part B drugs and, if released by the Centers for Medicare & Medicaid Services (CMS), to also download and implement the revised July 2012, April 2012, January 2012 and October 2011 files. What You Need to Do You should make sure that your billing staffs are aware of the release of these October 2012 ASP Medicare Part B drug files

19 Background The Average Sales Price (ASP) methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare Contractors with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in the Medicare Claims Processing Manual (Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 50 (Outpatient PRICER); see Guidance/Guidance/Manuals/downloads/clm104c04.pdf on the CMS Web site.) The following table shows how the quarterly payment files will be applied: Files Effective for Dates of Service October 2012 ASP and ASP NOC October 1, 2012, through December 31, 2012 July 2012 ASP and ASP NOC July 1, 2012, through September 30, 2012 April 2012 ASP and ASP NOC April 1, 2012, through June 30, 2012 January 2012 ASP and ASP NOC January 1, 2012, through March 31, 2012 October 2011 ASP and ASP NOC October 1, 2011, through December 31, 2011 Additional Information You can find the official instruction, Change Request (CR) 7885, issued to your FI, Carrier, A/B MAC, RHHI or DME MAC by visiting Guidance/Guidance/Transmittals/downloads/R2514CP.pdf on the CMS Web site. ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION Claim Status Category and Claim Status Codes Update MLN Matters Number: MM7905 Related Change Request (CR) #: CR 7905 Related CR Release Date: August 2, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2508CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for physicians, other providers and suppliers who submit claims to Medicare Contractors (Carriers, Durable Medical Equipment Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs) and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries

20 What You Need to Know This article is based on Change Request (CR) 7905, which explains that 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 to report the status of submitted claims. Proprietary codes may not be used in the X12 276/277 to report claim status. The code sets are available at The code lists include the date when a code was added, changed or deleted. All code changes approved during the June 2012 committee meeting should have been posted on that site on or about July 1, Background HIPAA requires all health care benefit payers to use Claim Status Category Codes and Claim Status Codes to report the status of submitted claims. Only codes approved by the National Code Maintenance Committee in the X12 276/277 Health Care Claim Status Request and Response format are to be used. 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 code sets are available at (previously The code lists include specific details, including the date when a code was added, changed or deleted. Your Medicare Contractors must complete entry of all applicable code text changes and new codes, and terminated use of deactivated codes by October 1, Additional Information The official instruction, CR 7905, issued to your Carriers, DME MACs, FIs, A/B MACs and RHHIs regarding this change may be viewed at Guidance/Guidance/Transmittals/Downloads/R2508CP.pdf on the CMS Web site. HOSPITAL INFORMATION Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year 2013 MLN Matters Number: MM8000 Related Change Request (CR) #: CR 8000 Related CR Release Date: August 17, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2520CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for providers who bill Medicare fiscal intermediaries (FI) or Part A Medicare Administrative Contractors (A MACs) for inpatient psychiatric services provided to Medicare beneficiaries and are paid under the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS)

21 Provider Action Needed CR 8000, from which this article is taken, identifies changes that are required as part of the annual Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) update from the Fiscal Year (FY) 2013 IPF PPS update notice, published August 7, These changes are applicable to IPF discharges occurring during fiscal year October 1, 2012, through September 30, Make sure that your billing staff is aware of these IPF PPS changes for FY Background Payments to IPFs under the IPF PPS are based on a Federal Per Diem base rate that includes both inpatient operating and capital-related costs (including routine and ancillary services) but excludes certain pass-through costs (i.e., bad debts and graduate medical education). The Centers for Medicare & Medicaid Services (CMS) is required to make updates to this prospective payment system annually. CR 8000 identifies the required changes as part of the annual IPF PPS update from the IPF Prospective Payment System Fiscal Year 2013 Final Rule. These changes are applicable to IPF discharges occurring during the fiscal year October 1, 2012, through September 30, Key Points of CR8000 Market Basket Update: For FY 2013, the Centers for Medicare & Medicaid Services (CMS) used the FY 2008-based Rehabilitation, Psychiatric and Long Term Care (RPL) market basket to update the IPF PPS payment rates (that is the federal per diem and Electroconvulsive Therapy (ECT) base rates). Section 1886(s)(2)(A)(ii) of the Social Security Act (or the Act), requires the application of an Other Adjustment that reduces any update to the IPF PPS base rate by percentages specified in section 1886(s)(3) of the Act for Rate Year (RY) beginning in 2010 through the RY beginning in For the RY beginning in 2012 (that is, FY 2013), section 1886(s)(3)(B) of the Act requires the reduction to be 0.1 percentage point. CMS is implementing that provision in this FY 2013 notice. In addition, section 1886(s)(2)(A)(i) of the Act requires the application of the Productivity Adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS for the RY beginning in 2012 (that is, a RY that coincides with a FY) and each subsequent RY. For the RY beginning in 2012 (that is FY 2013), the reduction is 0.7 percentage point. CMS is implementing that provision in this FY 2013 notice. Specifically, CMS reduced the update to the IPF PPS base rate for FY 2013 by applying the adjusted market basket update of 1.9 percent (which includes the RPL market basket increase of 2.7 percent, an ACA required 0.1 percent reduction to the market basket update, and an ACA required productivity adjustment of 0.7 percent) and the wage index budget neutrality factor of to the RY 2012 Federal per diem base rate of $685.01, which yields a Federal per diem base rate of $ for FY Similarly, applying the adjusted market basket update of 1.9 percent and the wage index budget neutrality factor of to the RY 2012 ECT rate of $ yields an ECT rate of $ for FY

22 PRICER Updates The Federal per diem base rate is $698.51; The fixed dollar loss threshold amount is $11,600.00; The IPF PPS will use the FY 2012 unadjusted pre-floor, pre-reclassified hospital wage index; The labor-related share is percent; The non-labor related share is percent; and The ECT rate is $ Cost to Charge Ratio for the IPF Prospective Payment System Fiscal Year 2013 Cost to Charge Median Ceiling Ratio Urban Rural CMS is applying the national median Cost-to-Charge Ratios (CCRs) to the following situations: New IPFs that have not yet submitted their first Medicare cost report. For new facilities, CMS is using these national ratios until the facility's actual CCR can be computed using the first tentatively settled or final settled cost report, which will then be used for the subsequent cost report period. The IPFs whose operating or capital CCR is in excess of 3 standard deviations above the corresponding national geometric mean (that is, above the ceiling). Other IPFs for whom the fiscal intermediary obtains inaccurate or incomplete data with which to calculate either an operating or capital CCR or both. MS-DRG Update The code set and adjustment factors are unchanged for IPF Prospective Payment System Fiscal Year FY 2010 Pre-floor, Pre-reclassified Hospital Wage Index CMS is using the updated wage index and the wage index budget neutrality factor of COLA Adjustment The Office of Personal Management (OPM) began transitioning from cost of living adjustment (COLA) factors to a locality payment rate in FY The 2009 COLA factors were frozen in order to allow this transition. In order to provide a full COLA for Alaska and Hawaii, CMS is adopting the FY 2009 COLA rates obtained from the OPM Website ( These are the same rates that were in effect for RY 2010, RY 2011 and RY The COLAs for Alaska and Hawaii are shown then as follows:

23 Alaska Cost of Living Adjustment Factor City of Anchorage and 80-kilometer 1.23 (50 mile) radius by road City of Fairbanks and 80-kilometer ( mile) radius by road City of Juneau and 80-kilometer ( mile) radius by road Rest of Alaska 1.25 Hawaii Cost of Living Adjustment Factor City and County of Honolulu 1.25 County of Hawaii 1.18 County of Kauai 1.25 County of Maui and County of 1.25 Kalawao Additional Information You can find more information about the FY 2013 update to the IPF PPS by going to CR 8000, located at on the CMS Web site. In addition, the applicable previous year update is detailed in MLN Matters article MM7367 and may be reviewed at MLN/MLNMattersArticles/downloads/MM7367.pdf on the CMS Web site. If you have any questions, please contact your contractor at their toll-free number, which may be found at on the CMS Web site. Payment of Global Surgical Split-Care in a Method II Critical Access Hospital (CAH) Submitted with Modifier 54 and/or 55 MLN Matters Number: MM7872 Related Change Request (CR) #: CR7872 Related CR Release Date: August 3, 2012 Effective Date: January 1, 2013 Related CR Transmittal #: R2510CP Implementation Date: January 7,

24 Provider Types Affected This MLN Matters Article is intended for physicians, non-physician practitioners and Method II Critical Access Hospitals (CAHs) submitting claims to Medicare Contractors (Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (A/B MACs)) for services rendered in Method II CAHs to Medicare beneficiaries. Provider Action Needed This article is based on Change Request (CR) 7872, which instructs Medicare Contractors to implement the payment methodology for global surgical split care submitted on type of bill 85X with revenue codes 96X, 97X or 98X with a modifier 54 (surgical care only) and/or a Modifier 55 (postoperative management only) for CAH Method II providers. There are no policy changes attached to CR 7872, which simply applies the logic currently used when split global surgery services are billed on professional claims to those services when billed by a Method II CAH to an FI or MAC on type of bill 85X with revenue codes of 96X, 97X or 98X. Please be sure your billing staffs are aware of this clarification. Background Physicians and non-physician practitioners billing on type of bill (TOB) 85X for professional services rendered in a Method II CAH have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to the Method II CAH, payment is made to the CAH for professional services (Revenue Code (RC) 96X, 97X or 98X) based on the Medicare Physician Fee Schedule (MPFS) supplemental file. Occasionally, when more than one physician provides services included in the global surgical package, the physician who performs the surgical procedure may not always furnish the follow-up care. When this occurs, payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies result in payment that is higher than the global allowed amount (e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care)). Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. CAH Method II providers may review the split global surgery pricing rules in Medicare Claims Processing Manual, Chapter 12, Sections , available at Guidance/Guidance/Manuals/Downloads/clm104c12.pdf on the CMS Web site. CR 7872 implements the above payment logic in the Fiscal Intermediary Shared System (FISS) for CAH Method II providers to mirror the logic historically applied to physicians and non-physician practitioners that bill their own services to the Medicare Multi-Carrier System (MCS). When payments are reduced as a result of applying this global surgery payment logic, Medicare will reflect that on the remittance advice using claim adjustment reason code 59 (Processed based on the multiple or concurrent procedure rules.) and Group Code CO to denote contractual obligation

25 Section 1834(g)(2)(B) of the Social Security Act (the Act) states that professional services included within outpatient CAH services must be paid at 115 percent of such amounts as would otherwise be paid under this part if such services were not included in the outpatient CAH services. Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule (MPFS) to determine the surgical care only and postoperative percentages for a specific Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code. The MPFS is located at on the CMS Web site. Additional Information The official instruction CR 7872, issued to your FI and A/B MAC regarding this change may be viewed at on the CMS Web site. National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR) MLN Matters Number: MM7897 Revised Related Change Request (CR) #: CR 7897 Related CR Release Date: August 3, 2012 Effective Date: May 1, 2012 Related CR Transmittal #: R2512CP and R145NCD Implementation Date: January 7, 2013 Note: This article was revised on August 15, 2012, to correct two references to the secondary diagnosis code on page 5. The correct code is V70.7. All other information remains the same. Provider Types Affected This MLN Matters Article is intended for physicians and hospitals who provide Transcatheter Aortic Valve Replacement (TAVR) services to Medicare beneficiaries. Provider Action Needed: Impact to You Effective for claims with dates of service on and after May 1, 2012, Medicare Carriers, Fiscal Intermediaries (FIs), and Medicare Administrative Contractors (A/B MACs) will reimburse for Transcatheter Aortic Valve Replacement (TAVR) under Coverage with Evidence Development (CED). What You Need to Know Change Request (CR) 7897, from which this article is taken, announces that on May 1, 2012, the Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) covering TAVR under CED and CR 7897 details requirements that must be met when claims are submitted to Medicare for these services. What You Need to Do You should make sure that your billing staffs are aware of this decision and its requirements which are summarized in the Background section below

26 Background Transcatheter Aortic Valve Replacement (TAVR - also known as TAVI or Transcatheter Aortic Valve Implantation) is a new technology for use in treating certain patients with aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. CR 7897, from which this article is taken announces that on May 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) covering TAVR under Coverage with Evidence Development (CED) and only when specific requirements are met. CED Coverage Conditions with Registry Participation CMS covers TAVR for the treatment of symptomatic aortic valve stenosis under CED with the following conditions: 1. It is furnished according to a Food and Drug Administration (FDA)-approved indication and when all of the following conditions are met: 1. It is furnished with a complete aortic valve and implantation system that has received FDA Premarket Approval (PMA) for that system s FDA-approved indication 2. Two cardiac surgeons have independently examined the patient face-to-face and evaluated the patient s suitability for open Aortic Valve Replacement (AVR) surgery; and both surgeons have documented the rationale for their clinical judgment, and this rationale is available to the heart team 3. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multidisciplinary, team of medical professionals that embodies collaboration and dedication across medical specialties to offer optimal patient-centered care 4. It is furnished in a hospital with the appropriate infrastructure that includes (but is not limited to): On-site heart valve surgery program Cardiac catheterization lab or hybrid operating room/catheterization lab equipped with a fixed radiographic imaging system with flat-panel fluoroscopy, offering quality imaging Non-invasive imaging such as echocardiography, vascular ultrasound, Computed Tomography (CT) and Magnetic Resonance (MR) Sufficient space, in a sterile environment, to accommodate necessary equipment for cases with and without complications Post-procedure intensive care facility with personnel experienced in managing patients who have undergone open-heart valve procedures Appropriate volume requirements per the applicable qualifications (specifically, for hospitals without TAVR experience and for those with experience performing the procedure), which follow 2. Required qualifications for the hospitals and heart teams performing the procedure o Hospitals without TAVR experience must have the following qualifications to begin a TAVR program: total AVRs in the previous year prior to TAVR, including 10 high-risk patients 2. Two physicians with cardiac surgery privileges

27 catheterizations per year, including 400 Percutaneous Coronary Interventions (PCIs) per year o Heart Teams without TAVR experience must include the following to begin a TAVR program: 1. A cardiovascular surgeon with: 1) 100 career AVRs including 10 high-risk patients; or, 2) 25 AVRs in one year; or, 3) 50 AVRs in two years; and which include at least 20 AVRs in the last year prior to TAVR initiation 2. An interventional cardiologist with: 1) Professional experience with 100 structural heart disease procedures lifetime; or 2) 30 left-sided structural procedures per year of which 60 percent should be Balloon Aortic Valvuloplasty (BAV). Atrial septal defect and patent foramen ovale closure are not considered left-sided procedures 3. Additional members of the heart team such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses and social workers 4. Device-specific training as required by the manufacturer o Hospital programs with TAVR experience must have the following qualifications: 1. Maintain 2 physicians with cardiac surgery privileges 2. Perform 20 AVRs per year or 40 AVRs every two years 3. Perform 1000 catheterizations per year, including 400 Percutaneous Coronary Interventions (PCIs) per year o Heart teams with TAVR experience must have the following qualifications: 1. Include a cardiovascular surgeon and an interventional cardiologist whose combined experience maintains: 1) 20 TAVR procedures in the prior year; or 2) 40 TAVR procedures in the prior two years 2. Include additional members of the heart team such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses and social workers 3. The interventional cardiologists and cardiac surgeons must jointly participate in the intra-operative technical aspects of TAVR In addition, the heart team and hospital must be participating in a prospective, national, audited registry. The complete list of requirements for a qualifying registry can be found in the NCD, which is available at on the CMS Web site. To date, CMS has approved one registry, the Transcatheter Valve Therapy Registry operated by the Society of Thoracic Surgeons and the American College of Cardiology. CED Coverage Conditions with Clinical Studies For indications that are not approved by the FDA, CMS covers TAVR under CED when patients are enrolled in qualifying clinical studies. The clinical study requirements are available in the NCD, which is available at on the CMS Web site. Approved studies are listed at Development/Transcatheter-Aortic-Valve-Replacement-TAVR-.html on the CMS Web site. Note: TAVR is not covered for patients in whom existing co-morbidities would preclude the expected benefit from correction of the aortic stenosis

28 Coding Requirements - Professional Claims For TAVR services furnished on or after May 1, 2012, you should bill with the appropriate temporary level III Current Procedural Terminology (CPT) Code: 0256T: Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach 0257T: Implantation of catheter-delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular) 0258T: Transthoracic cardiac exposure (e.g., sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; without cardiopulmonary bypass 0259T: Transthoracic cardiac exposure (e.g., sternotomy, thoracotomy, subxiphoid) for catheter-delivered aortic valve replacement; with cardiopulmonary bypass Beginning January 1, 2013, CMS anticipates permanent CPT level 1 codes will replace the above four codes for processing TAVR claims, and will issue instructions for the permanent CPT level 1 codes in a future CR. You should be aware that, on or after May 1, 2012, your Carrier or A/B MAC will only reimburse your professional claims for TAVR services (for CPT Codes 0256T, 0257T, 0258T and 0259T) when used with Place of Service (POS) code 21 (inpatient hospital). They will deny all other POS codes. Should they deny your claim because of an incorrect POS, they will use the following messages: Claim Adjustment Reason Code (CARC) 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present Remittance advice remark code (RARC) N428: Not covered when performed in this place of service Group Code: Contractual Obligation (CO) Similarly, Medicare will only pay claim lines with these TAVR CPT Codes when billed with modifier 62 (two surgeons/co-surgeons). They will return all others as unprocessable. Should they return such claims, they will use: CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present RARC N29: Missing documentation/orders/notes/summary/report/chart Group Code: Contractual Obligation (CO) Medicare will only pay claim lines for these codes in a clinical trial when billed with modifier Q0 (zero). For TAVR services, use of modifier Q0 signifies CED participation (qualified registry or qualified clinical study). They will return such claims billed without modifier Q0 as unprocessable using: CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present RACR N29: Missing documentation/orders/notes/summary/report/chart

29 Group Code: Contractual Obligation (CO) Medicare will only pay claims for these codes in a clinical trial when billed with International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) secondary diagnosis code V70.7 (routine general medical examination at a health care facility) (ICD-10 = Z encounter for examination for normal comparison and control in clinical research program). For TAVR services, use of V70.7 signifies CED participation (qualified registry or qualified clinical study). They will return claim lines billed without secondary diagnosis code V70.7 as unprocessable, using: CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT) RARC N29: Missing documentation/orders/notes/summary/report/chart Group Code Contractual Obligation (CO) Coding Requirements - Inpatient Hospital Claims Hospitals should bill for TAVR services on an 11X Type of Bill (TOB), effective for discharges on or after May 1, Your FI or A/B MAC will reimburse such claims containing ICD-9 procedure codes (Endovascular replacement of aortic valve) or (Transapical replacement of aortic valve) only when billed with secondary diagnosis code V70.7 (Examination of participant in clinical trial) and condition code 30 (qualifying clinical trial). For TAVR services, use of the latter two codes signifies CED participation (qualified registry or qualified clinical study). Claims from hospitals without those latter two codes will be rejected using: CARC: 50: These are non-covered services because this is not deemed a medical necessity by the payer 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 If you do not have Web access, you may contact the contractor to request a copy of the NCD Group Code: Contractual Obligation (CO)

30 The following are the ICD-10 procedure codes applicable for TAVR: TAVR ICD-9 Procedure Codes TAVR ICD-10 Procedure Codes 02RF37Z 02RF38Z 02RF3JZ 02RF3KZ 02RF37H 02RF38H 02RF3JH 02RF3KH Additional Information CR 7897 was issued to your Medicare Contractor in two transmittals. The first transmittal modifies the Medicare National Coverage Determinations Manual and it is available at Guidance/Guidance/Transmittals/Downloads/R145NCD.pdf on the CMS Web site. The second transmittal updates the Medicare Claims Processing Manual and it is available at Guidance/Guidance/Transmittals/Downloads/R2512CP.pdf on the CMS Web site. INPATIENT REHABILITATION FACILITY (IRF) INFORMATION Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for Fiscal Year (FY) 2013 MLN Matters Number: MM7901 Related Change Request (CR) #: CR 7901 Related CR Release Date: August 10, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2518CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for Inpatient Rehabilitation Facility (IRF) providers submitting claims to Medicare Contractors (Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries. Provider Action Needed: Impact to You This article is based on Change Request (CR) 7901, which informs Medicare Contractors about the release of new IRF PPS PRICER software and the changes that software implements that will modify payment rates for IRF PPS claims

31 What You Need to Do Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes. Background On August 7, 2001, the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register, a final rule that established the PPS for IRFs, as authorized under Section 1886(j) of the Social Security Act (the Act). In that final rule, CMS set forth per discharge Federal rates for Federal Fiscal Year (FY) These IRF PPS payment rates became effective for cost reporting periods beginning on or after January 1, Annual updates to the IRF PPS rates are required by Section 1886(j)(3)(C) of the Act. Policy The FY 2013 IRF PPS Notice issued on July 30, 2012, sets forth the prospective payment rates applicable for IRFs for FY A new IRF PRICER software package will be released prior to October 1, 2012, that will contain the updated rates that are effective for claims with discharges that fall within October 1, 2012, through September 30, The new revised IRF Pricer program shall be installed timely to ensure accurate payments for IRF PPS claims with discharges occurring on or after October 1, 2012 and on or before September 30, Key Points of CR7901 For IRF PPS FY 2013 (October 1, 2012, through September 30, 2013) The standard Federal rate is $14,343 The fixed loss amount is $10,466 The labor-related share is The non-labor related share is Urban national average Cost-to-Charge (CCR) is Rural national average CCR is The Low Income Patient (LIP) Adjustment is The Teaching Adjustment is The Rural Adjustment is Note: It is very important that IRFs report the correct Patient Assessment Instrument (PAI) transmission date on their claims, as discussed in Chapter 3, Section of the Medicare Claims Processing Manual at on the CMS Web site. Additional Information The official instruction, CR 7901, issued to your FI and A/B MAC, regarding this change may be viewed at on the CMS Web site

32 LEARNING AND EDUCATION INFORMATION Ohio and Kentucky Part Ask the Contractor Teleconferences (ACTs): September 2012 January 2013 Ask the Contractor Teleconferences (ACTs) are intended to open the communication channels between providers and CGS. This allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference. To help ensure your access to this conference call, we ask that you dial in five to 10 minutes prior to the scheduled start time. Date Specialty Topic Time Call-in Number and Pass Code September 13, 2012 October 29, 2012 January 28, 2013 Provider Enrollment/ Revalidation Critical Access Hospitals Quarterly Call Critical Access Hospitals Quarterly Call 2 p.m. ET (800) p.m. ET (800) p.m. ET (800) Encore Call-in Number and Pass Code (855) (855) (855) Submit Your Questions We encourage you to submit questions prior to the call. Just fill out the ACT Request for Inquiry Items Form and fax it to (803) , attention: J15 Part A Ask the Contractor Teleconference. To access this form from the CGS Web page: 1. Go to 2. Select Resources 3. Click on Forms 4. Select the Part A Ask the Contractor Teleconference (ACT) Request for Inquiry Items Form Missed the Teleconference? An encore digital recording of these conferences will be available for replay beginning two hours after the call has ended and continuing for seven days

33 MEDICAL AFFAIRS INFORMATION Category III CPT Code Covered Article A50740 Update for LCD L31832 Effective August 1, 2012 CPT codes 0245T, 0246T, 0247T, and 0248T are covered for the open treatment and internal fixation of fractured ribs and or flail chest when medically necessary. The ICD-9-CM diagnosis codes supporting medical necessity for 0245T, 0246T, 0247T, and 0248T are: MEDICARE SECONDARY PAYER (MSP) INFORMATION Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers Compensation (WC) Medicare Secondary Payer (MSP) Claims MLN Matters Number: MM7355 Revised Related Change Request (CR) #: 7355 Related CR Release Date: August 3, 2012 Effective Date: January 1, 2013 Related CR Transmittal #: R87MSP Implementation Date: January 7, 2013 Note: This article was revised on August 3, 2012, to reflect the revised Change Request (CR) 7355 issued on August 3. In the article, the CR release date, transmittal number, effective and implementation dates (see above), and the Web address for accessing CR 7355 were revised. In addition, a reference to remittance advice remark code M32 was deleted. All other information is the same. Provider Types Affected This MLN Matters article is intended for physicians, hospitals, Home Health Agencies and other providers who bill Medicare Carriers, Fiscal Intermediaries (FIs) or Medicare Administrative Contractors (A/B/MACs), and suppliers who bill Durable Medical Equipment MACs (DME MACs) for Medicare beneficiary liability insurance (including self insurance), no-fault insurance and Workers Compensation (WC) Medicare Second Payer (MSP) claims

34 Provider Action Needed This article provides clarifications in the procedures for processing liability insurance (including selfinsurance), no-fault insurance and WC MSP claims. Not following the procedures identified in this article may impact your reimbursement. Change Request (CR) 7355, from which this article is taken, clarifies the procedures you are to follow when billing Medicare for liability insurance (including self-insurance), no-fault insurance or WC claims, when the liability insurance (including self-insurance), no-fault insurance or WC Carrier does not make prompt payment. It also includes definitions of the promptly payment rules and how contractors will identify conditional payment requests on MSP claims received from you. You should make sure that your billing staffs are aware of these Medicare instructions. Background CR 7355, from which this article is taken: 1) Clarifies the procedures to follow when submitting liability insurance (including self-insurance), no-fault insurance and WC claims when the liability insurer (including self-insurance), no-fault insurer and WC Carrier does not make prompt payment or cannot reasonably be expected to make prompt payment; 2) Defines the promptly payment rules; and 3) Instructs you how to submit liability insurance (including self-insurance), no-fault insurance and WC claims to your Medicare Contractors when requesting Medicare conditional payments on these types of MSP claims. The term Group Health Plan (GHP), as related to this MLN article, means health insurance coverage that is provided by an employer to a Medicare beneficiary based on a beneficiary s own, or family member s, current employment status. The term Non-GHP means coverage provided by a liability insurer (including selfinsurance), no-fault insurer and WC Carrier where the insurer covers for services related to the applicable accident or injury. Key Points: Conditional Medicare Payment Procedures Medicare may not make payment on a MSP claim where payment has been made or can reasonably be expected to be made by GHPs, a WC law or plan, liability insurance (including self-insurance) or no-fault insurance. Medicare can make conditional payments for both Part A and Part B WC, or no-fault or liability insurance (including self insurance) claims if payment has not been made or cannot be reasonably expected to be made by the WC, or no-fault or liability insurance claims (including self insurance) and the promptly period has expired. Note: If there is a primary GHP, Medicare may not pay conditionally on the liability, no-fault, or WC claim if the claim is not billed to the GHP first. The GHP insurer must be billed first and the primary payer payment information must appear on the claim submitted to Medicare. These payments are made on condition that the trust fund will be reimbursed if it is demonstrated that WC, no-fault or liability insurance is (or was) responsible for making primary payment (as demonstrated by a judgment; a payment conditioned upon the recipient s compromise, waiver or release (whether or not there is a determination or admission of liability for payment for items or services included in a claim against the primary payer or the primary payer s insured), or by other means). Promptly Definition: No-fault Insurance and WC Promptly Definition For no-fault insurance and WC, promptly means payment within 120 days after receipt of the claim (for specific items and services) by the no-fault insurance or WC Carrier. In the absence of evidence to the contrary, the date of service for specific items and service must be treated as the claim date when determining the promptly period. Further with respect to inpatient services, in the absence of evidence to the contrary, the date of discharge must be treated as the date of service when determining the promptly period

35 Liability Insurance Promptly Definition For liability insurance (including self-insurance), promptly means payment within 120 days after the earlier of the following: The date a general liability claim is filed with an insurer or a lien is filed against a potential liability settlement The date the service was furnished or, in the case of inpatient hospital services, the date of discharge The Medicare Secondary Payer (MSP) Manual ( Chapter 1 (Background and Overview), Section 20 (Definitions), provides the definition of promptly (with respect to liability, no-fault and WC) which all Medicare Contractors must follow. Note: For the liability situation, the MSP auxiliary record is usually posted to the Medicare s Common Working File (CWF) after the beneficiary files a claim against the alleged tortfeasor (the one who committed the tort (civil wrong)) and the associated liability insurance (including self-insurance). In the absence of evidence to the contrary, the date the general liability claim is filed against the liability insurance (including self-insurance) is no later than the date that the record was posted on Medicare s CWF. Therefore, for the purposes of determining the promptly period, Medicare Contractors consider the date the Liability record was created on Medicare s CWF to be the date the general liability claim was filed. How to Request a Conditional Payment The following summarizes the technical procedures that Part A, Part B and supplier contractors will use to identify providers conditional payment requests on MSP claims. Part A Conditional Payment Requests Providers of Part A services can request conditional non-ghp payments from Part A contractors on the hardcopy Form CMS-1450, if you have permission from Medicare to bill hardcopy claims or the 837 Institutional Electronic Claim, using the appropriate insurance value code (e.g., value code 14, 15 or 47) and zero as the value amount. Again, you must bill the non-ghp insurer, and the GHP insurer, if the beneficiary belongs to an employer group health plan, first before billing Medicare. For hardcopy (CMS-1450) claims, Providers must identify the other payer s identity on line A of Form Locator (FL) 50, the identifying information about the insured is shown on line A of FL 58-65, and the address of the insured is shown in FL 38 or Remarks (FL 80). All primary payer amounts and appropriate codes must appear on your claim submitted to Medicare. For 837 Institutional Claims, Providers must provide the primary payer s zero value code paid amount and occurrence code in the 2300 HI. (The appropriate Occurrence code (2300 HI), coupled with the zeroed paid amount and MSP value code (2300 HI), must be used in billing situations where you attempted to bill a primary payer in non-ghp (e.g., Liability, no-fault and WC) situations, but the primary payer did not make a payment in the promptly period). Note: Beginning July 1, 2012, Medicare Contractors will no longer be accepting 4010 claims. Providers must submit claims in the 5010 format beginning on this date

36 Table 1 displays the required information of the electronic claim in which a Part A provider is requesting conditional payments. Table 1: Data Requirements for Conditional Payment for Part A Electronic Claims Type of Insurance No- Fault/Liability WC CAS valid information why NGHP or GHP did not make a payment valid information why NGHP or GHP did not make payment Part A Value Code (2300 HI) 14 or 47 Value Amount (2300 HI) Occurrence Code (2300 HI) $ Auto Accident & Date 02 - No-fault Insurance Involved & Date 24 - Date Insurance Denied 15 $ Accident/Tort Liability & Date 24 - Date Insurance Denied Condition Code (2300 HI) 02 - Condition is Employment Related Part B Conditional Payment Requests (Table 2) Since the electronic Part B claim ( professional claim) does not contain Value Codes or Condition Codes, the physician or supplier must complete the: 1) 2320AMT02 = $0 if the entire claim is a non-ghp claim and conditional payment is being requested for the entire claim; or 2) 2430 SVD02 for line level conditional payment requests if the claim also contains other service line activity not related to the accident or injury, so that the contractor can determine if conditional payment should be granted for Part B services related to the accident or injury. For Version 4010, physicians and other suppliers may include CP - Medicare Conditionally Primary, AP -auto insurance policy, or OT - other in the 2320 SBR05 field. The 2320 SBR09 may contain the claim filing indicator code of AM - automobile medical, LI - Liability, LM - Liability Medical or WC - Workers Compensation Health Claim. Any one of these claim filing indicators are acceptable for the non-ghp MSP claim types. The 2300 DTP identifies the date of the accident with appropriate value. The accident related causes code is found in 2300 CLM 11-1 through CLM Note: Beginning July 1, 2012 Medicare Contractors will no longer accept 4010 claims. Providers must submit claims in the 5010 format beginning on this date

37 Table 2 displays the required information for a MSP 4010 Professional in which a physician/supplier is requesting conditional payments. Table 2: Data Requirements for Conditional Payments for MSP 4010 Professional Claims Type of Insurance No- Fault/Liability WC CAS 2320 or 2430 valid information why NGHP or GHP did not make payment 2320 or 2430 valid information why NGHP or GHP did not make payment Insurance Type Code (2320 SBR05) Claim Filing Indicator (2320 SBR09) AP or CP AM, LI or LM Paid Amount (2320 AMT or 2430 SVD02) Insurance Type Code (2000B SBR05) Date of Accident $ DTP 01 through 03 and 2300 CLM 11-1 through 11-3 with value AA, AP or OA OT WC $ DTP 01 through 03 and 2300 CLM 11-1 through 11-3 with value EM

38 Please note that for Professional claims, the insurance codes changed and the acceptable information for Medicare conditional payment request is modified as displayed in Table 3. Table 3: Data Requirements for Conditional Payment for Professional Claims Type of Insurance No- Fault/Liability WC CAS 2320 or valid information why NGHP or GHP did not make payment 2320 or valid information why NGHP or GHP did not make payment Insurance Type Code 2320 SBR05 from previous payer(s) Claim Filing Indicator (2320 SBR09) 14/47 AM or LM Paid Amount (2320 AMT or 2430 SVD02) Condition Code (2300 HI) Date of Accident $ DTP 01 through 03 and 2300 CLM 11-1 through 11-3 with value AA or OA 15 WC $ Condition is Employment Related 2300 DTP 01 through 03 and 2300 CLM 11-1 through 11-3 with value EM Note: Medicare beneficiaries are not required to file a claim with a liability insurer or required to cooperate with a provider in filing such a claim, but they are required to cooperate in the filing of no-fault claims. If the beneficiary refuses to cooperate in filing of no-fault claims Medicare does not pay

39 Situations Where a Conditional Payment Can be Made for No-Fault and WC Claims Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met: There is information on the claim or information on Medicare s CWF that indicates the no-fault insurance or WC is involved for that specific item or service There is/was no open GHP record on the Medicare CWF MSP file as of the date of service There is information on the claim that indicates the physician, provider or other supplier sent the claim to the no-fault insurer or WC entity first There is information on the claim that indicates the no-fault insurer or WC entity did not pay the claim during the promptly period Situations Where a Conditional Payment Can be Made for Liability (including Self Insurance) Claims Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met: There is information on the claim or information on Medicare s CWF that indicates liability insurance (including self-insurance) is involved for that specific item or service There is/was no open GHP record on the Medicare s CWF MSP file as of the date of service There is information on the claim that indicates the physician, provider or other supplier sent the claim to the liability insurer (including the self-insurer) first There is information on the claim that indicates the liability insurer (including the self insurer) did not make payment on the claim during the promptly period Conditional Primary Medicare Benefits Paid When a GHP is a Primary Payer to Medicare Conditional primary Medicare benefits may be paid if the beneficiary has GHP coverage primary to Medicare and the following conditions are not present: It is alleged that the GHP is secondary to Medicare The GHP limits its payment when the individual is entitled to Medicare The services are covered by the GHP for younger employees and spouses but not for employees and spouses age 65 or over If the GHP asserts it is secondary to the liability (including self insurance), no-fault or workers compensation insurer

40 Situations Where Conditional Payment is Denied Liability, No-Fault or WC Claims Denied 1. Medicare will deny claims when: o There is an employer GHP that is primary to Medicare o You did not send the claim to the employer GHP first o You sent the claim to the liability insurer (including the self-insurer), no-fault or WC entity, but the insurer entity did not pay the claim 2. Medicare will deny claims when: o There is an employer GHP that is primary to Medicare o The employer GHP denied the claim because the GHP asserted that the liability insurer (including the self-insurer), no-fault insurer or WC entity should pay first o You sent the claim to the liability insurer (including the self-insurer), no-fault, insurer or WC entity, but the insurer entity did not pay the claim Denial Codes To indicate that claims were denied by Medicare because the claim was not submitted to the appropriate primary GHP for payment, Medicare Contractors will use the following codes on the remittance advice sent to you: Claim Adjustment Reason Code 22 - This care may be covered by another payer per coordination of benefits Remittance Advice Remark Code MA04 - Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible Additional Information You can find official instruction, CR 7355, issued to your Carrier, FI, RHHI, A/B MAC or DME MAC by visiting on the CMS Web site. You will find the following revised Chapters of the Medicare Secondary Payer Manual, as an attachment to that CR: Chapter 1 (Background and Overview): Section 10.7 (Conditional Primary Medicare Benefits) Section (When Conditional Primary Medicare Benefits May Be Paid When a GHP is a Primary Payer to Medicare) Section (When Conditional Primary Medicare Benefits May Not Be Paid When a GHP is a Primary Payer to Medicare)

41 Chapter 3 (MSP Provider, Physician and Other Supplier Billing Requirements): Section (No-Fault Insurance Does Not Pay) Section (Responsibility of Provider Where Benefits May Be Payable Under Workers Compensation) Chapter 5 (Contractor Prepayment Processing Requirements): Section 40.6 (Conditional Primary Medicare Benefits) Section (Conditional Medicare Payment) Section (When Primary Benefits and Conditional Primary Medicare Benefits Are Not Payable) SKILLED NURSING FACILITY (SNF) INFORMATION Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update Fiscal Year (FY) 2013 MLN Matters Number: MM7907 Related Change Request (CR) #: CR 7907 Related CR Release Date: August 2, 2012 Effective Date: October 1, 2012 Related CR Transmittal #: R2507CP Implementation Date: October 1, 2012 Provider Types Affected This MLN Matters Article is intended for SNFs submitting claims to Medicare Contractors (Fiscal Intermediaries (FIs) and/or Part A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries paid under the SNF PPS. Provider Action Needed This article is based on Change Request (CR) 7907 which describes the updates to the payment rates used under the Prospective Payment System (PPS) for Skilled Nursing Facilities (SNFs), for FY 2013, as required by statute. Be sure your billing staff is aware of these changes. Background Annual updates to the PPS rates are required by Section 1888 (e) of the Social Security Act (The Act), as amended by the Medicare, Medicaid and Child Health Insurance Program (CHIP) Balanced Budget Refinement Act of 1999 (the BBRA), the Medicare, Medicaid and CHIP Benefits Improvement and Protection Act of 2000 (the BIPA), and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (the MMA), relating to Medicare payments and consolidated billing for SNFs

42 The Centers for Medicare & Medicaid Services (CMS) published the SNF payment rates for FY 2013 (that is, beginning October 1, 2012, through September 30, 2013), in the Federal Register, available online at Regulations.html on the CMS Web site. The updated methodology is identical to that used in the previous year and will include the MMA reimbursement for beneficiaries with Acquired Immunodeficiency Syndrome (AIDS). This update includes new case-mix indexes using the recalculated case-mix adjustments based on actual data. The statute mandates an update to the Federal rates using the latest SNF full market basket. The update can be found in Chapter 6, Section 30.7 of the Claims Processing Manual at on the CMS Web site. Additional Information The official instruction, CR 7907 issued to your Medicare FI or A/B MAC regarding this change may be viewed at on the CMS Web site. If you have any questions concerning this Medicare Bulletin, please contact the Provider Contact Center at (866) This advisory should be shared with all health care practitioners and managerial members of the provider/supplier staff. Medicare Bulletins are available at no cost from the CGS Web site at Address Changes Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. To obtain the form plus information on how to complete and submit it visit the CGS Web site (

43 NOTES

44 HELPFUL INFORMATION Contact Information for CGS Part A Department Appeals CGS J15 Part A Appeals Mail Code: AG-630 P.O. Box Columbia, SC Fax: (803) Telephone Number Please call the J15 Part A Provider Contact Center at (866) For Fed Ex/UPS/Certified Mail CGS J15 Part A Appeals Mail Code: AG-630 Building One 2300 Springdale Drive Camden, SC Appeals related to Overpayments CGS J15 Part A Overpayments Appeals PO Box Columbia, SC Beneficiary Customer Service Center Visit the Medicare Web site at Claims CGS J15 Part A Claims Mail Code: AG-600 P.O. Box Columbia, SC General Correspondence CGS J15 Part A Mail Code: AG-670 P.O. Box Columbia, SC MEDICARE ( ) TTY: (877) Please call the J15 Part A Provider Contact Center at (866) Please call the J15 Part A Provider Contact Center at (866)

45 Department Electronic Data Interchange (EDI) CGS J15 Part A EDI P.O. Box Nashville, TN Medicare Provider Enrollment CGS J15 Part A Provider Enrollment Mail Code: AG-331 P.O. Box Columbia, SC Provider Audit CGS J15 Provider Audit: (mailing and FedEx, UPS...) 3021 Montvale Drive, Suite C Springfield, IL Provider Reimbursement CGS J15 Provider Reimbursement P.O. Box Columbia, SC Telephone Number Please call the EDI Help Desk: (866) For inquiries regarding provider enrollment, please call the J15 Part A Provider Contact Center at (866) Please call the J15 Part A Provider Contact Center at (866) Please call the J15 Part A Provider Contact Center at (866)

46 IVR User Guide

47 IVR User Guide

48 IVR User Guide

49 IVR User Guide

50 IVR User Guide

51 It s Convenient! I love that! my Now Available!