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                          Volume 5 Issue 6
                                                                    Directly from CMS:

                                                                    The Centers for Medicare
                                                                    & Medicaid Services (CMS)
                                         Third Party Newsletter
                                                                    has announced the avail-
                                                                    ability of a new identifier
                                                                    for use in the standard elec-
                                                                    tronic health care transac-
                                                                    tions. The National Pro-

                                                                    vider Identifier (NPI) will
                                                                    be the single provider iden-
                                                                    tifier, replacing the differ-
                                                                    ent provider identifiers you
                                                                    currently use for each
                                                                    health plan with which you
                                                                    do business. This identifier,
                                                                    which implements a re-
                                                                    quirement of the Health                                       NPI—APPLY NOW!
                                                                    Insurance Portability and
                                                                    Accountability Act of 1996
                                                                    (HIPAA), must be used by most H       I-                  is taking to improve electronic transac-
                                                                    PAA covered entities, which are health                    tions for health care. National stan-
                                                                    plans, health care clearinghouses, and                    dards for electronic health care transac-
                                                                    health care providers that conduct elec-                  tions encourage electronic commerce
                                                                    tronic transactions for which the Secre-                  in the health care industry and simplify
                                                                    tary has adopted a standard (i.e., stan-                  the processes involved to reduce the
                                                                    dard transactions). Health care provid-                   administrative burdens on health care
                                                                    ers include individuals, such as physi-                   providers. With national standards and
                                                                    cians [includes optometrists], dentists,                  identifiers in place for electronic claims
                                                                    and pharmacists, and organizations,                       and other transactions, health care pro-
                                                                    such as hospitals, nursing homes, phar-                   viders will be able to submit transac-
                                                                    macies, and group practices.                              tions to any health plan in the United
                                                                    The NPI is one of the steps that CMS                                               (Continued to send
                                                                                                                              States. Health plans will be ableon page 4)

                                                                    Inside this issue:

                                                                  Correct Provider Identification: Boxes 17, 17a, 24k & 33    2
                                                                                                                                       Note: Abstracts of all
                                                                  Unprocessable Medicare Claims                               3      articles in this newsletter
                                                                                                                                      are found at the top of
                                                                  Medicare Does Not Accept S-Codes                            5
                                                                                                                                               page six.
                                                                  Medicare: Low Vision Assistants must be OT, PT, or Speech   5

                                                                  Abstracts of Articles and Quack Humor                       6

                                                                                                       June 2005
Medicare Reminder
Correct Provider Identification Information
Claim Boxes 17, 17a, 24k, and 33

Despite the upcoming National Provider Identifier
(NPI) discussed on page one, the Centers for Medicare
& Medicaid Services (CMS) would currently like to
remind providers and their billing staffs of the impor-
tance of reporting the correct provider identification
information in items 17, 17a, 24K, and 33 of the Form
CMS-1500, or the electronic equivalent. This informa-
tion is critical for accurate and timely processing and
payment of your claims at this time.

Items 17 and 17a
On the Form CMS-1500, or electronic equivalent, the
provider must submit the appropriate referring or order-
ing physician name in item 17, and the Unique Phys i-
cian Identification Number (UPIN) of that referring/
ordering physician in item 17a. These are required
fields when a service was ordered or referred by a phy-
sician. When a claim involves multiple referring and/or          in the preceding list shall also show the ordering/referring
ordering physicians, you must prepare a separate claim           physician's name and UPIN. For example, a surgeon shall
submission for each ordering/referring physician.                complete items 17 and 17a when a physician refers the
   Item 17: Enter the name of the referring or ordering          patient. When the ordering physician is also the perform-
   physician if the service or item was ordered or r     e-      ing physician (as often is the case with in-office clinical
   ferred by a physician.                                        laboratory tests), the performing physician's name and
   Item 17a: Enter the UPIN of the referring/ordering            assigned UPIN appear in items 17 and 17a. When a ser-
   physician listed in item 17.                                  vice is incident to the service of a physician or non-
? Referring physician - is a physician who requests              physician practitioner, the name and assigned UPIN of
an item or service for the beneficiary for which pay-            the physician or non-physician practitioner who performs
ment may be made under the Medicare program.                     the initial service and orders the non-physician service
? Ordering physician - is a physician or, when appro-            must appear in items 17 and 17a.
priate, a non-physician practitioner who orders non-             All physicians who order or refer Medicare beneficiaries
physician services for the patient. Examples of services         or services must obtain a UPIN even though they may
that might be ordered include diagnostic laboratory              never bill Medicare directly. A physician who has not
tests, clinical laboratory tests, pharmaceutical services,       been assigned a UPIN must contact the local Medicare
durable medical equipment, and services incident to              carrier to obtain the UPIN. A list of toll free numbers of
that physician's or non-physician practitioner's service.        the Medicare carriers is available at:
All claims for Medicare covered services and items that     
are the result of a physician's order or referral shall in-
clude the ordering/referring physician's name and                When a physician extender or other limited licensed prac-
UPIN. This includes...the following:                             titioner [Editor’s note: Medicare considers an OD a phy-
   ♦ Diagnostic laboratory services,                             sician] refers a patient for consultative service, the name
   ♦ Diagnostic radiology services,                              and UPIN of the physician supervising the limited li-
   ♦ Portable x-ray services,                                    censed practitioner must appear in items 17 and 17a.
   ♦ Consultative services, and                                  When a patient is referred to a physician who also orders
   ♦ Durable medical equipment.                                  and performs a diagnostic service, a separate claim form
Claims for other ordered/referred services not included                                                    (Continued on page 3)

         PAGE   22                                            June 2005                         THIRD PARTY NEWSLETTER
     Remark Code MA-130 Must Be Resubmitted

                     Unprocessable Medicare Claims
     Medicare Part B no longer accepts correc-                  rected claim be filed to Medicare.
     tions of claims denied with remittance ad-                 Any unprocessable claims received in writ-
     vice remark code MA 130 ( Your claim con-                  ing, by fax or by telephone requesting cor-
     tains incomplete and/or invalid information,               rections, will be returned to you with instruc-
     and no appeal rights are afforded because                  tions to resubmit as a new claim. If you have
     the claim is unprocessable Please submit a                 questions or concerns concerning this proc-
     new claim with the complete/correct infor-                 ess, contact our Provider Call Center at 1-
     mation) through the telephone, fax or in writ-             866-839-2438.
     ing. All MA 130 denials require a new cor-

                                   Correct Provider Identification continued

(Continued from page 2)
is required for the diagnostic service. Enter the original      be entered on the left side, next to the PIN# field. If a
ordering/referring physician's name and UPIN in items           group practice is billing, then the group PIN is to be
17 and 17a of the first claim form. Enter the ordering          placed in item 33 for paper claims. Enter the group PIN
(performing) physician's name and UPIN in items 17              at the bottom of item 33 on the right side, next to the
and 17a of the second claim form (the claim for reim-           GRP# field. Enter the PIN for the performing provider of
bursement for the diagnostic service).                          service/supplier who is a member of that group practice
                                                                in item 24K. Suppliers billing a DMERC will use the
Item 24K                                                        National Supplier Clearinghouse (NSC) number in
Enter the provider identification number (PIN) of the           this item.
performing provider of service/supplier in item 24K if
the provider is a member of a group practice. When sev-         NOTE: When implemented, the National Provider Iden-
eral different providers of service or suppliers within a       tification (NPI) number will replace the PIN and UPIN.
group are billing on the same Form CMS-1500, or elec-           At that time, you will use the NPI number in items 17a,
tronic equivalent, show the individual PIN of each per-         24K, and 33. The above instructions are included Chap-
forming provider in the corresponding line item. In the         ter 26 of the Medicare Claims Processing Manual. That
case of a service provided incident to the service of a         manual is available at:
physician or non-physician practitioner, when the person           HTTP ://WWW .CMS.HHS.GOV/MANUALS/104_CLAIMS/CLM104 INDEX.ASP

who ordered the service is not supervising, enter the PIN       The Medicare Benefit Policy Manual may be found at:
of the supervisor in item 24K. UPINs are not appropri-             HTTP ://WWW .CMS.HHS.GOV/MANUALS/102_POLICY /BP102INDEX.ASP
ate identifiers for item 24K.
                                                                And, if you have questions, please contact your carrier/
                                                                DMERC at their toll free number, available at:
Item 33
                                                                         HTTP ://WWW .CMS.HHS.GOV/MEDLEARN /TOLLNUMS.ASP
Enter the provider of service/supplier's billing name, ad-
dress, ZIP code, and telephone number. This is a re-
                                                                            Source,: Med Learn Matters Number: SE0529
quired field. For a provider who is not a member of a
group practice (e.g., private practice), enter the PIN at
the bottom of i em 33 for paper claims. The PIN should

 VOLUME 5       ISSUE 6                                      June 2005                                                      PAGE 3
NATIONAL PROVIDER IDENTIFIER                                                                 CONTINUED FROM PAGE ONE

(Continued from page 1)                                                tion collected in the application.
standard transactions such as remittance advices and refer-            You may receive notices about the NPI from many of the
ral authorizations to health care providers. These national            health plans with which you do business. Remember that
standards will make electronic data interchange a viable and           you need apply only once for an NPI. The same NPI is
preferable alternative to paper processing for health care             used for every health plan.
providers and health plans alike.
                                                                       The transition from existing health care provider identifiers
Health care providers who transmit health information                  to NPIs in standard transactions will occur over the next
electronically in connection with any of the standard trans-           couple of years. CMS urges health care providers to apply
actions are required by the NPI Final Rule to obtain NPIs,             for an NPI beginning on May 23, 2005. While the NPI
even if they use business associates, such as billing agencies,        must be used on standard transactions with health plans,
to prepare the transactions. The NPI will replace health               other than small health plans, no later than May 23, 2007,
care provider identifiers that are in use today in standard            health care providers should not begin using the NPI
transactions. Implementation of the NPI will eliminate the             in standard transactions on or before the compliance
need for health care providers to use different identification         dates until health plans have issued specific instruc-
numbers to identify themselves when conducting standard                tions on accepting the NPI. Health plans will notify
transactions with multiple health plans. Many health plans,            you when you can begin using NPIs in standard trans-
including Medicare, Medicaid, and private health insurance             actions. You should be aware that health plans might
issuers, and all health care clearinghouses must accept and            request that you begin using your NPI prior to the
use NPIs in standard transactions by May 23, 2007. Small               compliance dates. Applying for an NPI does not replace
health plans have until May 23, 2008. After those compli-              any enrollment or credentialing processes with any health
ance dates, health care providers may use only their NPIs              plan, including Medicare. You may obtain information
to identify themselves in standard transactions, where the             about the NPI at This site
NPI is called for.                                                     contains Frequently Asked Questions and other informa-
You will be able to apply for your NPI in one of three                 tion related to the NPI and other HIPAA standards. Begin-
ways:                                                                  ning May 23, 2005, we will also provide up -to-date informa-
♦ You may apply through an easy web-based application                  tion about the NPI, such as when and how to apply on the
     process, beginning May 23, 2005. The web address is               NPPES web site at, or you may                                        call the Enumerator at 1-800-465-3203 or TTY 1-800-692-
♦ You may prepare a paper application and send it to the               2326.
     entity that will be assigning the NPI (the Enumerator)
     on behalf of the Secretary, beginning July 1, 2005. A             This article is edited from a letter posted on the CMS web site from
     copy of the application, including the Enumerator’s               Mark B. McClellan, M.D., Ph.D. The CMS URL for this infor-
     mailing address, will be available on https://nppes.cms.          mation is                                                                   HTTP ://WWW .CMS.HHS.GOV/HIPAA /HIPAA2/NPI-PROVIDER.PDF

♦ You may also call the Enumerator for a copy. The
     phone number is 1-800-465-3203 or TTY 1-800-692-
With your permission, an organization may submit your
application in an electronic file. This could mean that a pro-
fessional association or perhaps a health care provider who
is your employer could submit an electronic file containing
your information and the information of other health care
providers. This process will be available in the fall 2005.
Remember, you may apply for an NPI using only one of the ways de-
scribed above. When gathering information for your applica-
tion, be sure that all of your information, such as your so-
cial security number and Federal employer identification
number, are correct. Once you receive your NPI, safeguard
its use. The application form contains a Privacy Act State-
ment, which explains how we may disseminate the informa-
             PAGE 4                                                 June 2005                                  THIRD PARTY NEWSLETTER
   Dr. Quentin Quack’s Queries and Questionable Quotes
                             Third Party Questions from NOA Doctors and Staff
                                                                                                                           Dr. Quentin Quack
S-Codes Not Accepted by Medicare
Dear Dr. Quack,                                  codes are not accepted by Medicare.              So, you would use both the GY and GA
We have tried using the S     -codes for         This can be confirmed by looking at the          modifiers on the retinal photography
screening retinal photography, and the           approved HCPCS II codes listed in our            92250 claim line.
codes are not recognized by Medicare.            Medicare Carriers Physician’s Manual.            Generally speaking, the 92250 retinal
A number of folks at Medicare have               So, at least at this time, there is no           photography code involves multiple
tried their best to help us, but we con-         point in filing any S-code with Medi-            photos as opposed to a single screening
tinue to have our claims rejected. Any           care.                                            photo. So you might consider adding
thoughts?                                        What code should you use instead?                the 52 (reduced services) modifier as
Dr Quack’s Quote:                                Well, 92250 is the code for retinal pho-         well when doing screening photogra-
We had the same problem at our office,           tography. And use of the GY modifier             phy. However, that would require the
and our insurance staff was equally              on this claim line indicates the service         use of three modifiers (GY GA 52).
perplexed. However, they finally found           is not covered (in this case because it is       Our Medicare Carrier has told us their
the solution.                                    a screening). An ABN (Advance Bene-              software may drop the third modifier
                                                 ficiary Notice) should be signed by the          on some occasions.
The S-codes are part of CMS’s (Center            patient. The ABN informs the patient
for Medicare and Medicaid Services)                                                                                                   e
                                                                                                   And, to further confuse matters, r -
                                                 this service will not be covered in their        member that Medicare considers retinal
HCPCS II codes; HCPCS II codes are               particular circumstance (screening), but
generally accepted by Medicare, Medi-                                                             photography to be a bilateral proce-
                                                 could be covered under other circum-             dure, whereas CPT considers it unilat-
caid plus private insurers. However,             stances (retinal lesion, GLC, et cetera).
although the S-codes are part of these                                                            eral.
                                                 Use of the GA modifier indicates that
HCPCS II codes and are accepted by               the patient signed an ABN.
private insurers and Medicaid, the S-

Medicare recently revised the Medicare           service must be provided by:                     Services may not be billed as therapy ser-
Benefit Policy Manual (Pub 100-02), Chap-            A person trained in only physical therapy,   vices incident to a physician’s service if the
ter 15, Sections 230.5, to incorporate the       occupational therapy, or speech language         service is provided by a person trained in
information in the Final Rule of November        pathology; or                                    any other profession, or licensed or certi-
15, 2004 concerning the definition of ther-           A person licensed as only a physical        fied in any other profession including physi-
apy services, the qualifications of thera-       therapist, occupational therapist, or speech-    cal therapist assistant and occupational
pists, and therapy services provided inci-       language pathologist,                            therapy assistant, athletic trainer or low
dent to a physician. Section 230.5 specifi-      except:                                          vision specialist.
cally discusses therapy services provided             When provided by physicians, physician
incident to a physician or non-physician         assistants, clinical nurse specialists, and
                                                                                                  HTTP://WWW . NORIDIANMEDICARE .C O M/ PROVIDER /UPDATES DOCS/
                                                                                                  SE0533_CLARIFICATION_ CR3648. PDF
practitioner. For example, when a therapy        nurse practitioners, and then only when
service is billed incident to the service of a   state and local law permits.
physician or non-physician practitioner, the

VOLUME 5      ISSUE 6                                                June 2005                                                                         PAGE 5
                              NEBRASKA OPTOMETRIC ASSOCIATION

                              201 N. 8TH Street, Suite 400     P.O. Box 81706      Lincoln, NE 68501

                                                 ABSTRACTS OF THIS MONTH’S ISSUE

                NATIONAL PROVIDER IDENTIFIER                                 remittance advice remark code MA 130 “Your claim contains incom-
CMS urges health care providers to apply for an NPI beginning on             plete and/or invalid information, and no appeal rights are afforded
May 23, 2005. The National Provider Identifier (NPI) will be the             because the claim is unprocessable Please submit a new claim with
single provider identifier, replacing the different provider identifiers     the complete/correct information”) through the telephone, fax or in
you currently use for each health plan with which you do business.           writing. All MA 130 denials require a new corrected claim be filed
Health care providers who transmit health information electronically         to Medicare.
in connection with any of the standard transactions are required by the
NPI Final Rule to obtain NPIs, even if they use business associates,                     S-CODES NOT ACCEPTED BY MEDICARE
such as billing agencies, to prepare the transactions.                       The S-codes are part of CMS’s (Center for Medicare and Medicaid
                                                                             Services) HCPCS II codes; HCPCS II codes are generally accepted
 USING CORRECT PROVIDER IDENTIFICATION INFORMATION                           by Medicare, Medicaid plus private insurers. However, although the
           CLAIM BOXES 17, 17A, 24K, AND 33                                  S-codes are part of these HCPCS II codes and are accepted by private
The Centers for Medicare & Medicaid Services (CMS) would like to             insurers and Medicaid, the S-codes are not accepted by Medicare.
remind providers and their billing staffs of the importance of report-
ing the correct provider identification information in items 17, 17a,         LOW VISION ASSISTANT MUST BE OT, PT OR SPEECH PATHOLOGIST
24K, and 33 of the Form CMS-1500, or the electronic equivalent.              Medicare states that when a therapy service is billed incident to the
This information is critical for accurate and timely processing and          service of a physician or non-physician practitioner, the service must
payment of your claims.                                                      be provided by: a person trained in physical therapy, occupational
                                                                             therapy, or speech language pathology; or a person licensed as a
             UNPROCESSABLE MEDICARE CLAIMS                                   physical therapist, occupational therapist, or speech-language patholo-
Medicare Part B no longer accepts corrections of claims denied with          gist.

           NOA 3rd PARTY NEWSLETTER ONLINE                                                         AUDIT SIGN UP
Does everyone in your office get a chance to read this newsletter,
or is it sometimes lost in the shuffle? Now our 3rd party newslet-              Dr. Quack already has a number of NOA self-audits
  ter is even easier to access on our NOA website. Just click on             scheduled. Be sure to get your name in the queue if your
       For Members Only, and “poof” the current 3rd Party                     office is interested in an audit! Contact information can
                    Newsletter icon is right there!                                           be found in the box below.

 Dr. Quentin Quack’s Queries...continued

    O           ccasionally Dr. Quack’s
       fax machine or email contains a
      question or story that is interesting,
                                                                                                        "Hey! Good idea! O.K. and thanks,"
                                                                                                        said the lads.
                                                                                                        After about five minutes Dr. Quack
                                                                                                        said to his brother, "Boy, dragging by
     but may not pertain directly to third                                                              the horns is sure a lot easier, eh?"
     party care. Dr. Quack feels that he
     should share some of these humor-                                                                  "Aye, you're right," said his brother,
                ous thoughts.                                                                           "but have you noticed that we are
                                                                                                        getting further away from the pickup?"

 In his younger days Dr. Quack was an               On the way they were stopped by a
 occasional hunter. Every fall he and his           game warden. "Let me see your                    The NOA Third Party Newsletter is published monthly by the
 brother would spend at least one                   hunting licenses and moose permit,               Nebraska Optometric Association with the assistance of
 weekend out in the wild, enjoying                  boys" he said. When he saw that                  Ed Schneider, O.D., Third Party Consultant.

 nature. For the most part the game in              everything was in order he asked if he           To reach Ed (aka Dr. Quack):
                                                                                                     > Email (BEST): (HIPAA Compliant)
 the area was unthreatened...neither Dr.            could give them some advice.                     > Fax & Voicemail: 402-466-7470 (HIPAA compliant)
 Quack nor his brother were                         "Sure!" the inexperienced hunters                > Please do not fax material to either of Ed's optometry offices
 accomplished marksmen.                                                                                  as that may not be HIPAA compliant
                                                                                                     To reach the NOA:
 On one rare occasion, having shot a                "Well boys, I think that you would find            Nebraska Optometric Association
 moose, Dr. Quack and his brother                   it a lot easier to drag that moose by the          201 North Eighth Street, Suite 400
 began dragging it by the tail to their                                                                P.O. Box 81706 (68501)
                                                    horns and not the tail."                           Lincoln, Nebraska 68508
 pickup.                                                                                               Phone: 402-474-7716 Fax: 402-476-6547

 VOLUME 5       ISSUE 6                                                    June 2005                                                                          PAGE 6

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