Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2033 Date: August 20, 2010

Transcription

1 anual ystem Pub edicare laims Processing Department of Health & Human ervices (DHH) enters for edicare & edicaid ervices () Transmittal 2033 Date: ugust 20, 2010 hange equest 7064 UBJET: End tage enal Disease (ED) Prospective Payment ystem (PP) and onsolidated Billing for Limited Part B ervices. UY O HNGE: ection 153(b) of the edicare mprovements for Patients and Providers ct (PP) requires implementation of an End tage enal Disease (ED) bundled prospective payment system (PP) effective January 1, Once implemented, the ED PP will replace the current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ED related items and services. The ED PP will provide a single payment to ED facilities, i.e., hospital-based providers of services and renal dialysis facilities, that will cover all the resources used in providing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis in the ED facility or at a patient s home, drugs, biologicals, laboratory tests, training, and support services. EETVE DTE: January 1, 2011 PLEENTTON DTE: January 3, 2011 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

2 . HNGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Per ow. /N/D N N N N HPTE / ETON / UBETON / TTLE 8/10 General Description of ED Payment 8/10.4 Deductible and oinsurance 8/10.6 mount of payment 8/20.1 alculation of ase ix djusted omposite ate and Prospective payment ystem ate 8/30.1 Publication of omposite ate 8/40 Processing equests for omposite ate Exceptions 8/ Pediatric Payment odel for ED PP 8/ Lab ervices ncluded in the Prospective Payment ystem 8/ Drugs and Biologicals ncluded in the Prospective Payment ystem 8/50.3 required nformation for n-acility claims Paid Under the omposite ate and PP 8/50.8 Training and etraining 8/50.9 oding for dequacy of Dialysis, Vascular ccess and nfection 8/60.1 Lab ervices 8/60.2 Drugs urnished in Dialysis acilities 8/60.2 Drugs urnished in Dialysis acilities 8/ eparately Billable ED Drugs 8/ acilities Billing for ED Drugs Equivalent to njectable Drugs 8/ Drug Payment mounts for acilities 8/60.3 Blood and Blood ervices urnished in Hospital Based and ndependent Dialysis acilities 8/ Payment mount for Epoetin lfa (EPO) 8/ Payment for Epoetin lfa (EPO) in Other ettings 8/60.6 Vaccines urnished to ED Patients 8/ Payment mount for Darbepoetin lfa (ranesp) 8/ Payment for Darbepoetin lfa (ranesp) in Other ettings 8/70 Payment for Home Dialysis 8/70.1 ethod election for Home Dialysis Payment

3 . UNDNG: or iscal ntermediaries (s), egional Home Health ntermediaries (HHs) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTHENT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

4 ttachment - equirements Pub Transmittal: 2033 Date: ugust 20, 2010 hange equest: 7064 UBJET: End tage enal Disease (ED) Prospective Payment ystem (PP) and onsolidated Billing (B) for Limited Part B ervices Effective Date: January 1, 2011 mplementation Date: January 3, GENEL NOTON. Background: ection 153(b) of the edicare mprovements for Patients and Providers ct (PP) requires implementation of an End tage enal Disease (ED) bundled prospective payment system (PP) effective January 1, Once implemented, the ED PP will replace the current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ED related items and services. The ED PP will provide a single payment to ED facilities, i.e., hospital-based providers of services and renal dialysis facilities, that will cover all the resources used in providing an outpatient dialysis treatment, including supplies and equipment used to administer dialysis in the ED facility or at a patient s home, drugs, biologicals, laboratory tests, training, and support services. B. Policy: The ED PP replaces the current basic case mix adjusted composite payment system and methodologies for the reimbursement of separately billable outpatient ED services. pecifically, the ED PP combines payments for composite rate and separately billable services into a single base rate. The per dialysis treatment base rate for adult patients is subsequently adjusted to reflect differences in wage levels among the areas in which ED facilities are located, by patient-level adjustments for case-mix, an outlier adjustment (if applicable), facility-level adjustments, a training add-on (if applicable), adjustments specific to pediatric patients (dialysis patients that are under the age of 18), and a budget neutrality adjustment during the transition period. The patient-level adjustments are patient-specific case-mix adjusters that were developed from a two-equation regression analysis that encompasses composite rate and separately billable items and services. ncluded in the case-mix adjusters are those variables that are currently used in basic case-mix adjusted composite payment system, that is, age, body surface area (B), and low body mass index (B). n addition to those adjusters that are currently used, the ED PP will also incorporate adjustments for six co-morbidity categories and an adjustment for the onset of renal dialysis. ED facilities that are treating patients with unusually high resource requirements as measured through their utilization of identified services beyond a specified threshold will be entitled to outlier payments, that is, additional payment beyond the otherwise applicable case-mix adjusted prospective payment amount. ED outlier services are the following items and services that are included in the ED PP bundle: (1) EDrelated drugs and biologicals that were or would have been, prior to January 1, 2011, separately billable under edicare Part B; (2) ED-related laboratory tests that were or would have been, prior to January 1, 2011, separately billable under edicare Part B; (3) medical/surgical supplies, including syringes, used to administer ED-related drugs that were or would have been, prior to January 1, 2011, separately billable under edicare Part B; and (4) renal dialysis service drugs that were or would have been, prior to January 1, 2011, covered under edicare Part D, notwithstanding the delayed implementation of ED-related oral-only drugs effective

5 January 1, ervices not included in the PP that remain separately payable, including blood and blood processing, preventive vaccines, and telehealth services, are not considered outlier services. The facility-level adjustments include adjusters to reflect urban and rural differences in area wage levels using an area wage index developed from ore Based tatistical reas (Bs). The facility-level adjustments also include an adjuster for facilities treating a low volume of dialysis treatments. acilities that are certified to furnish training services will receive an add-on payment amount of $33.44 which is adjusted by the geographic area wage index to account for an hour of nursing time for each training treatment that is furnished. The training add-on applies to both PD and HD training treatments. The pediatric payment model applies to all dialysis patients that are under the age of 18. The per treatment base rate as it applies to pediatric patients is the same base rate used for adult patients, and is also adjusted by the area wage index. However, due to the lack of statistical robustness, the base rate for pediatric patients is not adjusted for case-mix based on specific comorbidities as for adult patients. nstead, the pediatric payment adjusters are increased by 10.5 percent to reflect higher total payments for pediatric composite rate and separately billable services, compared to adult patients. The adjusters have also been increased by an additional 6.7 percent to account for patient level adjusters to the base rate that apply for adult patients, but that are not applicable for pediatric patients. The pediatric model also incorporates separate adjusters based on two age groups (<13, 13-17) and dialysis modality (hemodialysis, peritoneal dialysis). Treatments furnished to pediatric patients can qualify for a training add-on payment, when applicable, and are eligible for an outlier adjustment. However pediatric dialysis treatments are not eligible for the low-volume adjustment. The ED PP provides ED facilities a 4-year phase-in (transition) period under which they would receive a blend of payments under the prior case-mix adjusted composite payment system and the new ED PP. or Y 2011, we must continue to update the basic case-mix composite payment system for purposes of determining the composite rate portion of the blended payment amount. We will issue a change request with updates to the composite payment rate, the drug add-on adjustment to the composite rate, the wage index adjustment, and the budget neutrality adjustment. This change request will be issued at the time the physician fee schedule is finalized. n addition, for purposes of the composite rate portion of the blended payment amount, an add-on of $0.49 will be added to the adjusted composite payment to account for ED related drugs and biologicals that are currently separately paid under Part D and are now included in the ED PP. The ED PP base rate applicable for both adult and pediatric ED patients effective January 1, 2011 is $ This base rate will be wage adjusted as mentioned above where the labor-related share of the base rate from the ED PP market basket is.41737, and the non labor-related share of the base rate is $ (( * ( ) = $133.79). During the transition, the labor-related share of the case-mix adjusted composite payment system will remain Once the base rate is wage adjusted, any applicable patientlevel adjustments, facility-level adjustments, outlier adjustments, and training add-on payments (adjusted for area wage levels) are applied to determine the payment rate for a dialysis treatment. Once the payment rate for the dialysis treatment is determined, the last item in the computation to determine the final payment rate is the application of the transition budget neutrality factor of.969, that is, a 3.1 percent reduction. The ED PE will provide the payment for existing composite rate, the new ED PP payment rate, and the outlier payment (when applicable). These reimbursement amounts must be blended during a transition period for all ED facilities except those opting out of the transition and electing to be paid 100 percent of the payment amount under the new ED PP. Providers wishing to opt out of the transition period blended rate must notify their edicare ontractor on or before November 1, Providers shall not submit claims spanning date of service in 2010 and 2011.

6 The blended rate is determined as follows: percent of the old payment methodology and 25 percent of new PP payment percent of the old payment methodology and 50 percent of the new PP payment percent of the old payment methodology and 75 percent of the new PP payment percent of the PP payment New djustments applicable to the dult ate: omorbid djustments: The new ED PP provides for 3 categories of chronic comorbid conditions and 3 categories for acute comorbid conditions. single adjustment will be made to claims containing one or more of the comorbid conditions. The highest comorbid adjustment applicable will be applied to the claim. The acute comorbid adjustment may be paid no greater than 4 consecutive months for any reported acute comorbid condition unless there is a reoccurrence of the condition. The 3 chronic comorbid categories eligible for a payment adjustment are: Hereditary hemolytic and sickle cell anemia, onoclonal gammopathy (in the absence of multiple myeloma) and yelodysplastic syndrome. The 3 acute comorbid categories eligible for a payment adjustment are: Bacterial Pneumonia, Gastrointestinal Bleeding, and Pericarditis. Onset of Dialysis djustment: n adjustment will be made for patients that have edicare ED coverage during their first 4 months of dialysis. This adjustment will be determined by the dialysis start date in the ommon Working ile as provided on the orm 2728 completed by the provider. When the onset of dialysis adjustment is provided, the claim is not entitled to a comorbid adjustment or a training adjustment. Low Volume acility djustment: Providers will receive an adjustment to their PP rate when the facility furnished less than 4,000 treatments in each of the three years preceding the payment year and has not open, closed, or received a new provider number due to a change in ownership during the 3 years preceding the payment year. The provider must notify their edicare ontractor if they believe they are eligible for the low volume adjustment. ontractors must validate the eligibility and update the provider specific file. hange in Processing Home Dialysis laims: or claims with dates of service on or after January 1, 2011, the payment of home dialysis items and services furnished under ethod, regardless of home treatment modality, are included in the ED PP payment rate. Therefore, all home dialysis claims must be submitted by a renal dialysis facility and will be processed as method claims. This instructs the DE s to stop separate payment to suppliers for ethod home dialysis items and services for claims with dates of service on or after January 1, onsolidated Billing: This provides an ED consolidated billing requirement for limited Part B services included in the ED facility bundled payment. ertain lab services and limited drugs and supplies will be subject to Part B consolidated billing and will no longer be separately payable when provided for ED beneficiaries by providers other than the renal dialysis facility. hould these lab services, and limited drugs be provided to a beneficiary, but are not related to the treatment for ED, the claim lines must be submitted with the new Y modifier to allow for separate payment outside of ED prospective payment system. ED facilities billing for any labs or drugs will be considered part of the bundled PP payment unless billed with the modifier Y.

7 . BUNE EQUEENT TBLE Use hall" to denote a mandatory requirement Number equirement esponsibility (place an in each applicable column) / D hared- ystem B E aintainers Bs O PNG HNGE (nstitutional laims Only) edicare contractors shall load the new ED PP Pricer edicare contractors shall revise the outpatient provider file layout to include the newly required / redefined fields for renal dialysis facilities as follows (these fields must not be blank and must contain one of the valid indicators provided below): ield 49: Y = ED Provider waived blended payment, pay full PP N = ED Provider did not waive blended payment ield 57: or ED acilities Y= Low Volume acility N= Not a Low Volume acility edicare contractors shall update the provider file for renal dialysis facilities to include the newly required / redefined fields for renal dialysis facilities and update any revised B codes if applicable edicare contractors shall send the newly required outpatient provider specific fields to the ED Pricer: ield 49 ield edicare contractors shall apply the blended rate applicability to the 72x bill types based on the indicator 49 received in the outpatient provider specific file PE shall apply the low volume adjustment to the PP rate when the indicator in field 57 is populated with Y edicare contractors shall send the following additional data from the 72x bill type to the ED PE in the claim file: E H H V W OTHE ED PE ED PE

8 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers total number of dialysis sessions billed on the claim for outlier calculation (total number of lines with revenue codes 0821, 0831, 0841, 0851, 0881) line item date of service for each dialysis revenue code sent to the PE (needed for onset of dialysis adjustment) edicare systems shall reject any lines reporting revenue code edicare contractors shall apply to line items reporting revenue code 0880 remittance advice remark code 81: You are required to code to the highest level of specificity edicare contractors shall assign provider liability to revenue code 0880 lines (assign group code O) PE / P PE shall remove revenue code 0880 for pricing claims with dates of service on or after January 1, edicare contractors shall continue to calculate the erythropoiesis stimulating agent (E) monitoring policy reductions or providers that did not opt into the full PP, edicare contractors shall apply the separately billable payments at the line level for non-dialysis revenue codes after the applicable blended adjustment: Note: E monitoring policy reduction should occur prior to blended adjustment being made percent percent percent percent edicare contractors shall return claims to the provider with dates of service spanning 2010 and edicare contractors shall exempt from the PP payment and continue to pay the following services based on existing payment policy (do not apply the blended rate): Telehealth services billed with HP Q3014 (see 100-4, chapter 12) Preventive vaccines covered by edicare (see E H H V W ED PE

9 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers 100-4, chapter 18 for all vaccine and administration codes billable) Blood and blood services edicare contractors shall continue to send the dialysis reimbursement amount to the ED PE for providers not paid under the existing composite rate method (current exceptions to the composite rate) edicare contractors shall continue to send current exception amounts for dialysis training to the ED PE edicare contractors shall compare the claim from date to the dialysis start date edicare contractors shall reject the claim only if the dialysis start date is within 4 months of the claim from date edicare contractors shall create a new trailer to return the dialysis start date edicare contractors shall allow this reject code to be overridden edicare contractors shall send the dialysis start date in the claim file to the ED PE when receiving the W edit trailer for dialysis start date within 4 months edicare contractors shall put the edit code in the override field when sending the start date to the PE PE shall apply the new onset of dialysis adjustment to the PP rate for dialysis revenue code lines when the date of onset is within 4 months (120 days) of the line item date of service PE shall not apply comorbid adjustments or training adjustments when the onset of dialysis adjustment is applicable PE shall not apply the comorbid adjustments, onset of dialysis adjustment, low volume provider adjustment, B, B and ge adjustments to claims for pediatric patients (under 18 yrs of age) PE shall assign the pediatric hemodialysis rate to revenue code 0881 (ultrafiltration) when reported on a pediatric claim edicare contractors shall calculate the total E H H V W ED PE ED PE ED PE ED PE

10 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers payments for services applicable to the outlier and reflect the total on the claim with the payer only value code 79. Note: ervices that remain separately payable from the PP are not to be included in this total (i.e. blood, vaccines, telehealth and services reporting modifier Y) To calculate the outlier amount for value code 79, edicare contractors shall use existing payment methodologies for the list of outlier services on attachment 3 (i.e. drugs P+6%, labs according to the 50/50 rule, etc) edicare contractors shall add any new drug not on attachment 3, when reported with revenue 0636 and a HP that is effective on or after January 1, 2011 with an associated P rate on file to the value code 79 for outlier consideration edicare contractors shall include in the outlier total (value code 79) the oral drugs reported with revenue code 0250 with an ND edicare contractors shall not pay and shall not include in the value code 79 revenue code 0250 when reported without an ND edicare contractors shall use the list of ND prices provided by for the calculation of oral drugs for reporting in the value code 79. ee attachment 3 for ND Pricing List. NOTE: The oral drugs priced by ND are for possible outlier payments only and do not receive separate payment edicare contractors shall calculate the oral equivalent drugs for outlier by multiplying the ND quantity field and the ND unit price provided by in attachment 3 of the ND drug and then add the dispensing fee of $1.73. Note: Dispensing fee only payable once per claim for each ND edicare contractors shall include the total amount for the oral drug equivalents in the value code 79 for outlier edicare contractors shall send the ED PE the total calculated payment for the outlier services under value code 79. E H H V W

11 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers edicare contractors shall not allow a provider to submit a 72x claim with the payer only value code PE shall determine the applicability of outlier payment based on the value code 79 amount and the number of dialysis sessions edicare contractors shall not make revenue code 0250 a separately payable service under the existing composite rate portion of the blended payment edicare contracts shall ensure the only supplies (rev codes 27x, 62x) receiving separate payment under the composite rate portion of the blended payment are for administration of separately billable drugs under the composite rate (4913 and 4657) edicare contractors shall ensure supplies do not receive separate payment under the PP portion of the payment even when modifier Y is present except for 4913 and 4657 which may be separately paid with modifier Y. Note: 4913 and 4657 are outlier services on attachment 3 but are not counted toward outlier if the Y modifier is present edicare contractors shall accept the following reimbursement amounts from the ED PE: omposite rate and the adjusted composite rate for the blend New PP payment and the adjusted PP rate for the blend Per treatment outlier amount and adjusted per treatment outlier amount edicare contractors shall display the PE calculated amounts on the claim record When field 49 of the outpatient provider file contains N, PE returns all 6 totals edicare contractors show the line payment amount for each dialysis session calculated as follows: djusted composite rate+adjusted PP rate+adjusted outlier amount edicare contractors shall calculate the total claim payment by totaling the following: (Total adjusted rate for all dialysis sessions + E H H V W ED PE ED PE ED PE

12 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers adjusted separately billables) x.969 (transition budget neutrality) + the full payment for any PP excluded services (i.e. non-ed services with modifier Y, telehealth, preventive vaccines and blood) When field 49 of the outpatient provider file contains Y, PE returns the PP rate and the outlier amount the remaining price fields are populated with edicare contractors show the line payment amount for each dialysis session calculated as follows: PP rate+ outlier amount edicare contractors shall calculate the total claim payment by totaling the following: Total of PP rate for all dialysis sessions x any PP excluded services (i.e. non-ed services with modifier Y, telehealth, preventive vaccines and blood) edicare contractors shall display the total outlier payment under value code 17. (total outlier payment calculated as per treatment outlier with adjustment when applicable x number of dialysis sessions) or claims paid fully under the PP, edicare contractors shall ensure that line items covered in the bundle without separate payment remain shown as covered services with remittance advice with reason codes 97 and O (contractual obligation), Bs O TKNG ND PYNG OOBD DJUTENT edicare contractors shall use the list of comorbid diagnosis codes provided by (see attachment 8) edicare contractors shall append a payer only condition code for each comorbid category present on the claim. cute comorbids: G Bleed B-Pneumonia Pericarditis hronic comorbids: D yelodysplastic syndrome E- Hereditary hemolytic and sickle cell anemia category E H H V W ED PE

13 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers - onoclonal gammopathy edicare contractors shall send the payer only condition code(s) to the PE edicare contractors shall not allow providers to submit 72x claims with the payer only conditions, B,, D, E, PE shall assign and edicare contractors shall accept the following return codes: 1x- No comorbid payment 2x Paying on the category 3x Paying on the B category 4x Paying on the category 5x Paying on the D category 6x Paying on the E category 7x Paying on the category Note: Order is from highest paying to lowest paying adjustment. Pediatric claims will always be assigned 1x edicare contractors shall establish a W beneficiary auxiliary file to track the acute comorbid categories reported (condition code, B, ), including date of onset for each category, from and through claim dates and a payment indicator (see attachment 2) edicare contractors shall update the auxiliary file with each claim that contains a condition code, B, edicare contractors shall create a new onset date on the auxiliary file when a comorbid reoccurrence is present on the claim. Note: Each category will have a reoccurrence condition code assigned. ondition codes to be defined prior to implementation. ondition code H3 reoccurrence of category ondition code H4 reoccurrence of B category ondition code H5 - reoccurrence of category edicare ontractors shall accept the new condition codes H3, H4 and H5 when reported on the 72x bill type effective January 1, (Note: These codes are limited by the NUB to the 72x bill type only). E H H V W ED PE

14 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers edicare contractors shall ensure that an acute comorbid adjustment is applied for the first month reported and 3 consecutive months even if not reported. (this applies only to the, B, categories) When the return code indicates payment for a comorbid category that is not the highest paying comorbid payable, edicare contractors shall return an edit trailer indicating the highest allowable comorbid category that qualifies for an adjustment edicare contractors shall determine if the return code indicates payment for a comorbid category that has been reported on an incoming claim for more than 4 consecutive months When the return code indicates payment for a comorbid category that exceeds 4 consecutive months, the edicare contractors shall return a edit trailer indicating (1) if no comorbid categories (condition codes, B, ) reported qualify for an adjustment (i.e. all over 4 consecutive months) (2) indicate the highest allowable comorbid category that qualifies for an adjustment if the initial category return code is not eligible edicare contractors shall send the appropriate return code to PE for the edit trailer received. (i.e. no comorbid eligible = return code 1x, category eligible = 2x, B category eligible = 3x, category eligible = 4x) edicare contractors shall update the comorbid auxiliary screen with a payment indicator to indicate which comorbid category is paid PE shall accept the return code and apply the comorbid adjustment based on the return code edicare contractors shall append B22 (This payment is adjusted based on the diagnosis) to the provider remittance when the comorbid category reported by the PE for payment is revised based on the W auxiliary file edicare contractors shall identify when claims paid out of sequence resulted in claim(s) receiving or not receiving the correct comorbid adjustment. E H H V W ED PE

15 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers edicare contractors shall create an U (informational unsolicited response) with all the required data to identify the claim(s) that need to be adjusted to correct comorbid adjustments Upon receipt of the U, edicare systems shall perform an automated adjustment to the paid 72x claim to correct the comorbid adjustment edicare systems shall allow for a edicare review override for each comorbid adjustment at onset in the event that medical documentation does not support the adjustment. B PPLBLE TO LL NEW ED B EDT edicare systems shall create a new edit for ED onsolidated Billing Edits edicare systems shall accept the new edit for ED onsolidated Billing Edits edicare contractors shall assign group code O contractual obligation (provider liability) edicare contractors shall return laims djustment eason ode () 109: laim not covered by this payer/contractor. You must send the claim to the correct payer/contractor edicare contractors shall return new emittance dvice emark ode () N538 facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents edicare contractors shall return new edicare ummary Notice (N) code 4.12 English "This service has been denied/rejected since payment was made to your End tage enal Disease (ED) dialysis facility." panish "Este servicio le ha sido denegado/rechazado porque se le hizo el pago a su centro de diálisis de ED." edicare systems shall develop an overall ED B override code that will be disclosed in the W documentation to be used at the discretion of the /B s/carriers and fiscal intermediaries in accordance with instructions E H H V W PE

16 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers edicare contractors shall accept the new modifier Y: tem or service furnished to an ED patient that is not for the treatment of ED Bs O ETHOD EVE BLLED TO THE DE s Effective for claims with dates of service (DO) of January 1, 2011 and later, contractors shall deny claims containing ethod home dialysis service HP codes, when billed separately Per , contractors shall deny claims for ethod drugs (HP codes Q4081, J0882 and J0886) Per , contractors shall deny claims for ethod supplies and equipment, as specified in ttachment 5, ED upply HP Not Payable to DE uppliers edicare systems shall continue to allow separate billing for ED supply HP codes subject to PP B (see ttachment 4) when submitted by suppliers for services not related to the beneficiary s ED dialysis treatment and billed with the modifier Y Effective for claims with dates of service (DO) of January 1, 2011 and later, edicare systems shall deny claims for ED supply HP code subject to consolidated billing (B) when billed on a or electronic equivalent when a covered 72x claim is in history with overlapping dates of service, the ordering physician is listed in the P database, and the ED supply claims do not contain modifier Y ontractors shall refer to ttachment 4 for a list of ED supply HP codes subject to ED B ontractors shall pay claims for ED supplies subject to ED B when billed on a or electronic equivalent when a covered 72x claim is in history with overlapping dates of service and the ordering physician is not listed in the P database ontractors shall pay claims for ED supplies subject to ED B when billed on a or electronic equivalent if the ED supply claims contain modifier Y. E H H V W OE

17 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers ontractors shall create an informational unsolicited response (U) when a paid claim in history has covered ED supplies, the ordering physician is listed in the P database, the claim does not contain modifier Y, and an incoming 72x claim has overlapping dates of service Upon receipt of U, contractors shall perform an automated adjustment to the paid ED supply claim and deny the ED supplies at the line level for ED B ontractors shall allow the processing of the 72x claim Upon receipt of U, contractors shall perform an automated adjustment to the paid ED supply claim and deny the ED supplies at the line level for ED B. Bs for OUTPTENT BLLNG O LB EVE UBJET TO ONOLDTED BLLNG edicare systems shall reject at the line level on incoming outpatient TOBs 13x, 14x and 85x billing for ED lab services subject to B (see attachment 6 for list of labs) that do not contain modifier Y or HP G0257 when overlapping the from and through date of a covered 72x claim is in history edicare systems shall create an U when a paid outpatient TOB 13x, 14x or 85x in history has covered lab services subject to ED B and does not contain modifier Y or HP G0257 and an incoming 72x claim has overlapping dates of service edicare systems shall allow the processing of the 72x claim Upon receipt of the U, edicare systems shall perform an automated adjustment to the paid outpatient claim TOB 13x, 14x or 85x and reject the lab services at the line level for ED consolidated billing (B) edicare systems shall consider all labs on the 72x bill type to be included in the bundled PP, paid separately only for the transition period unless the modifier Y is reported on the line. Bs O E/ POENG O E H H V W

18 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers LB ontractors shall refer to attachment 6 for a list of lab services subject to ED consolidated billing (B) Upon receipt of reject from W, contractors shall deny claims for lab services subject to ED B when billed on a or electronic equivalent when a covered 72x claim is in history with overlapping dates of service, the ordering physician is listed in the P database, and the lab services do not contain modifier Y ontractors shall return the appropriate message codes per the requirements in Bs ontractors shall deny claims for lab services subject to ED B when billed on a or electronic equivalent when a covered 72x claim is in history with overlapping dates of service, the ordering physician is listed in the P database, and the lab services do not contain modifier Y ontractors shall pay claims for lab services subject to ED B when billed on a or electronic equivalent when a covered 72x claim is in history with overlapping dates of service and the ordering physician is not listed in the P database ontractors shall pay claims for lab services subject to ED B when billed on a or electronic equivalent if the lab services contain modifier Y ontractors shall pay claims for lab services subject to ED B when billed on a or electronic equivalent when there is no covered 72x claim in history, the ordering physician is listed in the P database, and the lab services are billed without modifier Y ontractors shall create an informational unsolicited response (U) when a paid claim in history has covered lab services, the ordering physician is listed in the P database, does not contain modifier Y, and an incoming 72x claim has overlapping dates of service ontractors shall allow the processing of the 72x claim. E H H V W

19 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers Upon receipt of U, contractors shall perform an automated adjustment to the paid lab claim and deny the lab services at the line level for ED B Upon implementation of the ED B, contractors shall sunset 50/50 rule modifiers D, E and only for claims submitted on forms or the electronic equivalent. 50/50 ule modifiers shall remain valid for use on the 72x claim for the purposes of calculating the blended transition rate and outlier. Bs O OUTPTENT ND PT B DUG UBJET TO ED ONOLDTED BLLNG ontractors shall reject at the line level incoming outpatient TOBs 13x, 14x, 85x for drugs subject to ED B (see attachment 7) that do not contain modifier Y or HP G0257 when overlapping the from and through date of a covered 72x claim is in history ontractors shall reject for ED B outpatient TOBs 13x, 14x or 85x for drugs subject to the ED B at the line level ontractors shall reject incoming Part B claims for drugs subject to ED B (see attachment 7) from rendering practitioners included on the onthly apitation Payment (P) Data ile that do not contain modifier Y or HP G0257 when a covered 72x claim is in history with overlapping dates of service ontractors shall deny the claim lines rejected to them in ontractors shall return the appropriate message codes per the requirements in Bs ontractors shall allow the processing of the 72x claim ontractors shall create an U when a paid outpatient TOB 13x, 14x, or 85x in history has covered drugs subject to ED B that do not contain modifier Y or HP G0257 and an incoming 72x claim has overlapping dates of service. E H H V W Upon receipt of the U, ontractors shall perform

20 Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTHE B E aintainers an automated adjustment to the paid outpatient claim and reject the drug service(s) at the line level for ED B ontractors shall create an U when a paid Part B practitioner claim in history has covered drugs subject to ED B from a rendering practitioner included on the P Data ile that do not contain modifier Y or HP G0257 and an incoming 72x claim has overlapping dates of service Upon receipt of the U, ontractors shall perform an automated adjustment to the paid Part B practitioner claim to recoup payment ontractors shall return the appropriate message codes per the requirements in Bs ontractors shall not pay separately for any drugs on the 72x bill type except for during the transitional period, unless the modifier Y is present ontractors shall not pay for the drugs subject to the ED B on the 72x bill type regardless of whether modifier Y is present or not (see attachment 7). Bs for ETHOD 1 ND 2 ELETON edicare contractors shall no longer enter method selection forms that become effective on or after 1/1/2011 into the standard systems edicare contractors shall treat all 72x claims with condition code 74 as method 1 home dialysis claims edicare contractors shall not edit for the presence of a method selection on file for home dialysis claims (72x bill type with condition code 74) with dates of service on or after January 1, edicare systems shall send claims for beneficiaries with method 2 selection on file with dates of service on or after 1/1/2011 to the ED PE. Note: Effective 1/1/2011 ethod 2 goes away and those claims will be paid and processed the same as ethod 1. E H H V W

21 . POVDE EDUTON TBLE Number equirement esponsibility (place an in each applicable column) / D hared- ystem OTH E B E aintainers provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. E H H V W V. UPPOTNG NOTON ection : or any recommendations and supporting information associated with listed requirements, use the box below: Use "hould" to denote a recommendation. -ef equirement Number \ ecommendations or other supporting information: Part P claims shall continue to be sent to the outpatient PY sub-modules (PPYOL and PPYO) in PPY for edicare secondary payment calculations. ection B: or all other recommendations and supporting information, use this space:

22 V. ONTT Pre-mplementation ontact(s): laims Processing: nstitutional laims Practitioner laims ndependent Labs laims DE laims P : ichard.azur@cms.hhs.gov; ED PP Policy: ichelle.ruse@cms.hhs.gov Post-mplementation ontact(s): laims Processing: nstitutional laims Wendy.Tucker@cms.hhs.gov; Practitioner laims Leslie.Trazzi@cms.hhs.gov; ndependent Labs laims elicia.owe@cms.hhs.gov; DE laims usan.webster@cms.hhs.gov P : ichard.azur@cms.hhs.gov ; ED PP Policy: ichelle.ruse@cms.hhs.gov V. UNDNG ection : or iscal ntermediaries (s), arriers, and egional Home Health ntermediaries (HHs): No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: or edicare dministrative ontractors (s), use the following statement: The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. ttachments

23 ttachment 1: PE ile Layout. ****************************************************************** * Note: ll items defined as numeric should contain a number even* * if it is zero. Newly defined return codes are not used when * * bills prior to 2011 are processed. * * * * ******** POBLE ETUN ODE O TH POG ******** * * * * **** PP-T = Bill Payment nformation odes * * * * ** eturn codes effective 4/1/ /31/2010 * * 00 = ED PP payment calculated * * 01 = ED acility rate greater than zero * * ** eturn codes effective 1/1/2011 * * 02 = PP no adjustments * * 03 = PP w/outlier * * 04 = PP w/acute comorbid * * 05 = PP w/chronic comorbid * * 06 = PP w/acute comorbid and outlier * * 07 = PP w/chronic comorbid and outlier * * 08 = PP w/onset adjustment * * 09 = PP w/onset adjustment and outlier * * 10 = PP w/low volume adjustment * * 11 = PP w/training adjustment * * 12 = PP w/low volume and training *

24 * 13 = PP w/multiple adjustments * * 14 = PP pediatric * * 15 = PP pediatric w/training * * 16 = PP pediatric w/outlier * * 17 = PP pediatric w/outlier and training * * **** PP-T = Why the bill was NOT paid * * 50 = ED acility rate NOT numeric * * 52 = Provider type NOT = '40' O '41' O '05' * * 53 = pecial payment indicator NOT = '1' O blank * * 54 = Date of Birth NOT numeric O = ZEO * * 55 = Patient Weight NOT numeric O = ZEO * * 56 = Patient Height NOT numeric O = ZEO * * 57 = evenue enter ode NOT in range * * 58 = ondition ode NOT = '73' O '74' O blank * * 60 = Wage adjustment rate record NOT found * * 71 = Exceeds aximum Height allowance * * 72 = Exceeds aximum Weight allowance * * 73 = laim-num-dial-ession NOT numeric O = ZEO * * 74 = Line-tem-vc-Date NOT numeric O = ZEO * * 75 = Dial-tart-Date NOT numeric O = ZEO * * 76 = Tot-Outlier-Pmt NOT numeric * * 81 = omorbid-w-eturn-code NOT valid * * 98 = laim through date before 04/01/2005 or NOT * * numeric * ******************************************************************

25 LNKGE ETON. ****************************************************************** * This is the Line-tem ecord that comes from * * will be passed to the ELxxx program * ****************************************************************** Variable name Picture olumns ---- Notes---- BLL-NEW-DT BLL-POTON. B-OND-ODE P (02) B-EV-ODE. B-EV-ODE3 P (03) LLE P (01) B-PTENT-HGT P 9(07)V9(02) B-PTENT-WGT P 9(07)V9(02) B-THU-DTE. B-THU-YY P 9(04) B-THU- P 9(02) B-THU-DD P 9(02) B-DOB-DTE. B-DOB-YY P 9(04) B-DOB- P 9(02) B-DOB-DD P 9(02)

26 LLE P (20) POVDE-PE-LE-POTON. P-NP P (08) P-NP-LLE P (02) P-POV-O P (06) P-GEO- P (04) P-GEO-B P (05) P-PE-PYT-ND P (01) P-POV-TYPE P (02) P-PE-WGE-ND P 9(02)V9(04) P-ED-TE P 9(07)V9(02) P-POV-WVE-BLEND-PY-ND P (01) Y/N P-POV-LOW-VOLUE-ND P (01) Y/N LLE P (40) BUNDLED-BLL-POTON. B-L-NU-DLY-EON P 9(02) B-LNE-TE-DTE-EVE P 9(08) YYDD B-DLY-TT-DTE P 9(08) YYDD B-TOT-PE-B-OUTLE P 9(07)V9(02) LLE P (40)

27 OOBDTE-POTON. OOBD-DT OU 6 TE OOBD- P (02) OOBD-EUENE-OND-ODE P (02) OOBD-W-ETUN-ODE P (02) LLE P (40)

28 ************************************************************** * This is the alculated data being returned from the * * ELxxx program and then passed back to * ************************************************************** PP-DT-LL. PP-T P 9(02) PP-DT. PP- P (04) PP-B P (05) PP-WGE-DJ-TE P 9(04)V9(02) PP-NL-PY-T P 9(07)V9(02) PP-L-VE-D P (05) PP-OND-ODE P (02) PP-EV-ODE P (04) LLE P (20) PP-OTHE-DT. PP-NT-LBO-PT P 9(01)V9(05) PP-NT-NONLBO-PT P 9(01)V9(05) PP-GE-TO P 9(01)V9(03) PP-B-TO P 9(01)V9(04) PP-B-TO P 9(01)V9(04) PP-BDGT-NEUT-TE P 9(01)V9(04) LLE P (20) PP-OOBD-DT. PP-OOBD- P (02)

29 PP-OOBD-- P (02) PP-OOBD-PY P (02) LLE P (24) ULL-OP-TE P 9(04)V9(02) BLEND-OP-TE P 9(04)V9(02) ULL-PP-TE P 9(04)V9(02) BLEND-PP-TE P 9(04)V9(02) ULL-OUTLE-TE P 9(04)V9(02) BLEND-OUTLE-TE P 9(04)V9(02) LLE P (40)

30 ttachment 2: ommon Working ile creen Example ED Beneficiary cute ormobid onditions ost urrent Period : G Bleed B: Pneumonia : Pericarditis Onset Date: Onset Date: Onset Date: rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P Onset > 4 mo: DOLB: Onset > 4 mo: DOLB: Onset > 4 mo: DOLB: Prior Period 1: : G Bleed B: Pneumonia : Pericarditis Onset Date: Onset Date: Onset Date: rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P rom Thru P Onset > 4 mo: DOLB: Onset > 4 mo: DOLB: Onset > 4 mo: DOLB: etain 10 years of prior periods (this is what PE have been made to do in order to rate adjustments back as far as 10 years)

31 ttachment 3: Outlier ervices njectable Drugs ategory HP ode Description ccess management J1642 NJ HEPN ODU PE 10 U ccess management J1644 NJ HEPN ODU PE 1000U ccess management J1945 LEPDUN ccess management J2993 ETEPLE NJETON ccess management J2997 LTEPLE EOBNNT ccess management J3364 UOKNE 5000 U NJETON ccess management J3365 UOKNE 250,000 U NJ nemia management J0882 DBEPOETN nemia management J1756 ON UOE NJETON nemia management J2916 N E GLUONTE OPLE nemia management J3420 VTN B12 NJETON nemia management Q4081 EPO ntiemetic J0780 POHLOPEZNE NJETON ntiemetic J1260 DOLETON EYLTE ntiemetic J1626 GNETON HL NJETON ntiemetic J2405 ONDNETON HL NJETON ntiemetic J2550 POETHZNE HL NJETON ntiemetic J2765 ETOLOPDE HL NJETON ntiemetic J2950 POZNE HL NJETON ntiemetic J3230 HLOPOZNE HL NJETON ntiemetic J3250 TETHOBENZDE HL NJ ntiemetic J3310 PEPHENZNE NJETON nxiolytic J2060 LOZEP NJETON nxiolytic J2250 NJ DZOL HYDOHLODE nxiolytic J3360 DZEP NJETON Bone and mineral metabolism J0610 LU GLUONTE NJETON Bone and mineral metabolism J0630 LTONN LON NJETON Bone and mineral metabolism J0635 LTOL Bone and mineral metabolism J0636 NJ LTOL PE 0.1 G Bone and mineral metabolism J0895 DEEONE EYLTE NJ Bone and mineral metabolism J1270 NJETON, DOELEOL Bone and mineral metabolism J1740 BNDONTE ODU Bone and mineral metabolism J2430 PDONTE DODU /30 G Bone and mineral metabolism J2501 PLTOL ellular management J1955 NJ LEVONTNE PE 1 G Pain management J1170 HYDOOPHONE NJETON Pain management J1885 KETOOL TOETHNE NJ Pain management J2175 EPEDNE HYDOHL /100 G Pain management J2270 OPHNE ULTE NJETON Pain management J2271 OPHNE O4 NJETON 100G Pain management J2275 OPHNE ULTE NJETON Pain management J2300 NJ NLBUPHNE HYDOHLODE Pain management J2310 NJ NLOONE HYDOHLODE Pain management J3010 ENTNYL TTE NJETON Pain management J3070 PENTZONE NJETON nti-infective J0278 KN ULTE nti-infective J0285 PHOTEN B nti-infective J0290 PLLN 500 G NJ nti-infective J0295 PLLN ODU PE 1.5 G nti-infective J0456 ZTHOYN nti-infective J0530 PENLLN G BENZTHNE NJ