DECEMBER 2010 MEDICARE UPDATE by huanghengdong

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									DECEMBER 2010 MEDICARE UPDATE

The 2011 inpatient deductible is $1,132.00.

The coinsurance amounts are shown below in the following table: Hospital Coinsurance
Skilled Nursing Facility Coinsurance

Days 61-90 $283.00

Days 91-150 $566.00(Lifetime Reserve Days)

Days 21-100 $141.50



Information on billing new Q-codes for influenza vaccine and roster
billing
The Centers for Medicare & Medicaid Services (CMS) has created specific HCPCS codes and payment rates
for Medicare billing purposes for the 2010-2011 influenza season. Effective for claims with dates of service on
or after January 1, 2011, CPT code 90658 will no longer be payable by Medicare.
Effective for dates of service on or after October 1, 2010, the following new influenza HCPCS Q-codes will be
payable by Medicare:
Q2035 (Afluria®)
Q2036 (Flulaval®)
Q2037 (Fluvirin®)
Q2038 (Fluzone®)
Q2039 (not otherwise specified flu vaccine).
CMS has instructed Medicare contractors to hold all claims containing the influenza HCPCS Q-codes with
dates of service on or after October 1, 2010, until their systems are able to accept them for processing. The
Medicare contractors’ systems will be ready to process claims containing the HCPCS Q-codes no later than
February 7, 2011. Medicare institutional providers also have the option to hold their claims containing the new
influenza HCPCS Q-codes until February 7, 2011.
In addition, Medicare institutional providers should not submit claims with the new Influenza HCPCS Q-
codes with dates of service on or after October 1, 2010, via roster billing. Medicare systems are unable to
hold roster claims submitted by institutional providers. Therefore, Medicare institutional providers may submit
their roster claims on an individual claim basis or hold their roster claims until February 7, 2011, and then
submit as a roster bill at that time.

For further information, please see Transmittal 815, Change Request 7234, issued on November 19, 2010      .




Important update on PECOS and ordering/referring
At this time, the Centers for Medicare & Medicaid Services (CMS) has not turned on the automated edits that
would deny claims for services that were ordered or referred by a physician or other eligible professional simply
for lack of an approved file in the provider enrollment chain and ownership system (PECOS). CMS is working
diligently to resolve backlog and other system issues and will provide ample advance notice to the provider and
beneficiary communities before CMS begins any such automatic denials. While there are some rumors that the
edits will be turned on in January, CMS wants to reiterate that no date has been announced yet (January 3 or
otherwise) as to when ordering/referring edits will be turned on.
Physicians or other eligible professionals not currently enrolled in PECOS should take the initiative to enroll
sooner rather than later. There are three ways to verify that you have an enrollment record in PECOS:
• Check the ordering referring report on the CMS website, available at
http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp            . If you are listed on that
report, you have a current enrollment record in PECOS.
• Use Internet-based PECOS to look for your PECOS enrollment record, available at
http://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp . If no record is displayed, you do
not have an enrollment record in PECOS.
• Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS.
Visit http://www.cms.gov/MedicareProviderSupEnroll/ for the "Medicare Fee-For-Service Contact Information"
list (in the "Downloads” section).
If you are not yet in PECOS, the best way to submit your application is through internet-based PECOS. For
more information, visit http://questions.cms.hhs.gov/app/answers/detail/a_id/10038/ .
Note: If you have problems accessing any hyperlink in this message, please copy and paste the URL into your
Internet browser.




Fractional mileage amounts submitted on ambulance claims
MLN Matters® Number: MM7065
Related Change Request (CR) #: 7065
Related CR Release Date: November 19, 2010
Effective Date: January 1, 2011
Related CR Transmittal #: R2103CP
Implementation Date: January 3, 2011

Provider Types Affected
This article is for providers and suppliers of ambulance services who bill Medicare contractors (carriers, fiscal
intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs)) for those services.

What You Need to Know
Change Request (CR) 7065, from which this article is taken, provides a new procedure for reporting fractional
mileage amounts on ambulance claims, effective for claims for dates of service on or after January 1, 2011. Prior to
that date, mileage is reported by rounding the total mileage up to the nearest whole mile. Be sure billing personnel
are aware of this change that requires ambulance providers and suppliers to report to the nearest tenth of a mile for
total mileage of less than 100 miles on ambulance claims as of January 1, 2011.

Background
Currently, the Medicare Claims Processing Manual, Chapter 15, Sections 30.1.2 and 30.2.1 require that ambulance
providers and suppliers submitting claims to Medicare contractors use the appropriate Healthcare Common
Procedure Coding System (HCPCS) code for ambulance mileage to report the number of miles traveled during a
Medicare-reimbursable trip for the purpose of determining payment for mileage. According to these instructions
from the Centers for Medicare & Medicaid Services (CMS), providers and suppliers are required to round the total
mileage up to the nearest whole mile, including trips of less than one whole mile. For example, if the total number of
round trip miles traveled equals 9.5 miles, the provider or supplier enters 10 units on the claim form or the
corresponding loop and segment of the ANSI X12N 837 electronic claim. For ambulance suppliers submitting
claims to the Medicare carriers or A/B MACs, the Medicare Claims Processing Manual, Chapter 26, Section10.4
additionally states that at least one (1) unit must be billed in Item 24G on the CMS-1500 claim form or the
corresponding loop and segment of the ANSI X12N 837P electronic claim. Therefore, if a supplier travels less than
one mile during a covered trip, the supplier would enter 1 unit on the claim form with the appropriate HCPCS code
for mileage.

In the CY 2011 Medicare Physician Fee Schedule (MPFS) final rule, CMS established a new procedure for
reporting fractional mileage amounts on ambulance claims to improve reporting and payment accuracy. The final
rule requires that, effective January 1, 2011, all Medicare ambulance providers and suppliers bill mileage that is
accurate to a tenth of a mile.

NOTE: Currently the hardcopy UB-04 form cannot accommodate fractional billing, therefore, hardcopy billers will
continue to use previous ambulance billing instructions provided in effect prior to January 1, 2011, that is, providers
that are permitted to file paper UB-04 claims will continue to round up to the nearest whole mile until further notice
from CMS.

Effective for claims with dates of service on and after January 1, 2011, ambulance providers and suppliers must
report mileage units rounded up to the nearest tenth of a mile for all claims (except hard copy billers that use the
UB-04) for mileage totaling less than 100 covered miles. Providers and suppliers must submit fractional mileage
using a decimal in the appropriate place (e.g., 99.9). Medicare contractors will truncate mileage units with fractional
amounts reported to greater than one decimal place (e.g., 99.99 will become 99.9 after truncating the hundredths
place).

For trips totaling 100 miles and greater, suppliers must continue to report mileage rounded up to the nearest whole
number mile (e.g., 999). Medicare contractors will truncate mileage units totaling 100 and greater that are reported
with fractional mileage; (e.g., 100.99 will become 100 after truncating the decimal places).

For mileage totaling less than 1 mile, providers and suppliers must include a “0” prior to the decimal point (e.g.,
0.9). For ambulance mileage HCPCS only, Medicare contractors will automatically default “0.1” unit when the total
mileage units are missing in Item 24G of the CMS-1500 claim form.

Additional Information
The official instruction, CR 7065, issued to your Medicare contractor regarding this change may be viewed at
http://www.cms.gov/Transmittals/downloads/R2103CP.pdf on the CMS website.

2011 annual update for clinical laboratory fee schedule and
laboratory services
Effective date: January 1, 2011

Implementation date: January 3, 2011

Summary
In accordance with the Social Security Act and Affordable Care Act, the annual update to the local clinical
laboratory fees for calendar year (CY) 2011 is -1.75 percent. The annual update to local clinical laboratory fees
for CY 2011 reflects an additional multi-factor productivity adjustment as described by the Affordable Care Act.
The annual update to payments made on a reasonable charge basis for all other laboratory services for CY
2011 is 0 percent.

This article addresses the following issues:

• Update to fees

• National minimum payment amounts

• National limitation amounts (maximum)
• Access to data file

• Public comments

• Pricing information

• Organ or disease oriented panel codes

• Mapping information

• Laboratory costs subject to reasonable charge payment in CY 2011

Here is the link to the MLN Matters article MM6991

                                                                                                 Source: MM6991


System change implementation related to critical access hospital
services
Effective Date: April 1, 2011

Implementation Date: April 4, 2011

Summary
This article is for critical access hospitals (CAHs) paid for outpatient services under the optional method and for
CAHs and entities owned and operated by CAHs that bill Medicare for ambulance services provided to
Medicare beneficiaries.

Key points of change request 7219
• Effective April 1, 2011, Medicare will pay for CAH ambulance services, including Indian Health Service (IHS)
CAHs, with a hospital-based ambulance service on type of bill (TOB) 85x with revenue code 054x (ambulance)
and condition code B2 (critical access hospital ambulance attestation) based on 101 percent of reasonable
cost.

• Effective April 1, 2011, Medicare will pay for CAH outpatient facility services under the optional method based
on 101 percent of reasonable cost.

• When the 35-mile rule for cost-based payment is not met, the CAH ambulance service or the ambulance
service furnished by the entity that is owned and operated by the CAH is paid based on the ambulance fee
schedule.

• When the 35-mile rule for cost-based payment is not met, the IHS/tribal CAH ambulance service or the
ambulance service furnished by the entity that is owned and operated by the IHS/tribal CAH is paid based on
the ambulance fee schedule.

Here is the link to the MLN Matters article MM7219      .




Commonly used provider enrollment terms and their definitions
Below is a list of terms commonly used in the Medicare enrollment process.
• Accredited provider/supplier -- means a supplier that has been accredited by a Centers for Medicare &
Medicaid Services (CMS)-designed accreditation organization.
• Advanced diagnostic imaging service -- means any of the following diagnostic services:
1. Magnetic Resonance Imaging (MRI)
2. Computed Tomography (CT)
3. Nuclear Medicine
4. Positron Emission Tomography (PET)
• Advanced Life Support, level 1 (ALS1) -- Transportation by ground ambulance vehicle, medically necessary
supplies and services, and either an ALS assessment by an ALS personnel or the provision of at least one ALS
intervention, refer to 42 CFR (Code of Federal Regulations) section 414.605.
• Advanced Life Support, level 2 (ALS2) -- Either transportation by ground ambulance vehicle, medically
necessary supplies and services, and the administration of at least three medications by intravenous or
transportation, medically necessary supplies and services and at least one of the seven ALS procedures
specified in 42 CFR 414.605.
• Air ambulance -- fixed wing and rotary wing. Air ambulance is furnished when the patient’s medical condition
is such that transport by ground ambulance is not appropriate: one patient’s condition requires rapid transport
to a treatment facility and second patient is inaccessible by ground or water vehicle.
• Applicant versus provider/supplier -- The provider is the entity furnishing the service, (e.g., the hospital,
home health agency, etc.) The applicant is the business entity that the provider is set up as. For instance,
suppose the provider is a hospital organized as a corporation. (That is, the hospital and the corporation are one
in the same, operating under the same TIN). In this case, the hospital is the provider, and the corporation is the
applicant.
• Applicant -- The individual (practitioner/supplier) or organization who is seeking enrollment into the Medicare
program.
• Approve/Approval -- Means the enrolling provider or supplier has been determined to be eligible under
Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges.
• Authorized Official -- Is an appointed official (e.g., chief executive officer, chief financial officer, general
partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to
enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare
program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of
the Medicare program.
• Bankruptcy -- When a provider/supplier files for protection in a Federal bankruptcy court, it may choose, with
the permission of the court, to cease operations (chapter 7) or reorganize (Chapter 11). When a
provider/supplier files under Chapter 7, it will liquidate its assets and cease operations and must notify the
contractor of this fact. When the assets are sold to a different entity that entity must enroll with the contractor if
it wishes to bill the Medicare program.
• Basic Life Support (BLS) -- Transportation by ground ambulance vehicle and medically necessary supplies
and services. The ambulance must be staffed by an individual who is qualified in accordance with State and
Local laws as an emergency medical technician basic (EMT Basic).
• Billing agency -- A company that the applicant contracts with to prepare, edit and/or submit claims on its
behalf.
• Change of ownership (CHOW) -- Is defined in 42 CFR 489.18 (a) and generally means, in the case of a
partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise,
as permitted by applicable State law. In the case of a corporation, the term generally means the merger of the
provider corporation into another corporation, or the consolidation of two or more corporations, resulting in the
creation of a new corporation. The transfer of corporate stock or the merger of another corporation into the
provider corporation does not constitute change of ownership.
• CMS- approved accreditation organization means an accreditation organization designated by CMS to
perform the accreditation functions specified.
• Coupon 8109 – (Internal Revenue Service) IRS document that is pre-printed with the tax identification
number and legal business name.
• CP-575 -- IRS documents confirming the tax identification number and legal business name
• Deactivate -- The provider or supplier’s billing privileges were stopped, but can be restored upon the
submission of updated information.
• Delegated official -- An individual, delegated by the “Authorized Official,” with the authority to report changes
and updates to the enrollment record. The delegated official must be an individual with an ownership or control
interest in (as that term is defined in section 1124(a)(3) of the Social Security Act), or be a W-2 managing
employee of, the provider or supplier.
• Deny/Denial -- The enrolling provider or supplier has been determined to be ineligible to receive Medicare
billing privileges for Medicare covered items or services provided to Medicare beneficiaries.
• Direct or indirect ownership -- The following example illustrates the difference between direct and indirect
ownership: The supplier listed in Section 2 of the CMS 855B is an ambulance company that is wholly (100
percent) owned by Company A. Here, Company A is considered to be a direct owner of the supplier (the
ambulance company), in that it actually owns the assets of the business. Now assume that Company B owns
100 percent of Company A. Company B is considered an indirect owner - but an owner, nevertheless - of the
supplier. In other words, a direct owner has an actual ownership interest in the supplier, whereas an indirect
owner has an ownership interest in an organization that owns the supplier.
• Divestiture -- The act of a provider/supplier selling off part or all of its assets, whether voluntarily or by court
order. Whether or not a divestiture constitutes a change of ownership (CHOW) for a provider depends on the
structure of the transaction.
• Enroll/Enrollment -- The process that Medicare uses to establish eligibility to submit claims for Medicare
covered services and supplies. The process includes:
• Identification of a provider or supplier;
• Validation of the provider or supplier’s eligibility to provide items or services to Medicare beneficiaries;
• Identification and confirmation of the provider or supplier’s practice locations and owners; and,
• Granting the provider or supplier Medicare billing privileges
• Enrollment application -- A CMS-approved enrollment application or an electronic Medicare enrollment
process approved by the Office of Management and Budget.
• CMS 855A -- Health Care Providers that will bill Medicare Administrative Contractors for Part A services -
application to be completed by a provider (e.g., hospital).
• CMS 855B -- Health Care Suppliers -application to be completed by a supplier (e.g., Ambulance Company)
that will bill Medicare Administrative Contractors for Part B medical services furnished to Medicare
beneficiaries.
• CMS 855I -- Individual Health Care Practitioners - A physician or non-physician practitioner who renders
medical services to Medicare beneficiaries must complete this application. This form is processed through the
Medicare carrier.
• CMS 855R -- Individual Reassignment of Benefits - An individual who renders services and seeks to reassign
his/her benefits to an eligible entity must complete this form for each entity eligible to receive reassigned
benefits. The person must be enrolled in the Medicare program as an individual prior to reassigning his/her
benefits. This form may be submitted concurrently with the Form CMS 855.
• CMS 855S -- DMEPOS Supplier Application - A supplier that whishes to enroll in the Medicare program and
provide Medicare beneficiaries with durable medical equipment, prosthetics, orthotics, or supplies. The National
Supplier Clearinghouse (NSC) is responsible for processing the application.
• FID -- Fraud Investigative Database
• Final adverse action -- one or more of the following actions:(i) A Medicare-imposed revocation of any
Medicare billing privileges; (ii) Suspension or revocation of a license to provide health care by any State
licensing authority; (iii) Revocation or suspension by an accreditation organization; (iv) A conviction of a
Federal or State felony offense (as defined in section 424.535(a)(3)(i)) within the last 10 years preceding
enrollment, revalidation, or re-enrollment; or (v) An exclusion or debarment from participation in a Federal or
State health care program.
• Financial control -- (a) An organization or individual is the owner of a whole or part interest in any mortgage,
deed of trust, note, or other obligation secured (in whole or in part) by the provider or any of the property or
assets of the provider, and (b) The interest is equal to or exceeds five percent of the total property and assets
of the provider.
• HCCL -- Health Care Clinic License (same as HCCR)
• HCCR license (health care services clinic) -- a business operating in a single structure or facility, or in a
group of adjacent structures or facilities operating under the same business name or management, at which
tender changes for reimbursement for such services. Section 456.0375, Florida Statutes, requires every such
clinic to register separately even though operated under the same business name or management.
• Inactivate -- The provider/supplier will be unable to use its billing number for claims processing. Upon taking
this action, notify the applicant you have done so and the reason.
• IRS Form 941 -- Employer’s Quarterly Federal Tax Return. This form can be used as IRS documentation
showing the Tax ID and Legal Business Name of the entity. This form can only be accepted if it is pre-printed
from the IRS with the Tax ID number and Legal Business Name.
• Joint venture -- A business undertaking involving a one-time grouping of two or more entities. Although a
joint venture is treated like a partnership for Federal Income tax purpose, it is different form the latter as it does
not involve a continuing relationship among the parties. Joint ventures are, in a sense, short-term partnerships.
In a joint venture where there is no transfer of legal title of assets, no change of ownership (CHOW) occurs.
• Legal Business Name -- The name of a business that is reported to the IRS.
• Managing employee -- A managing employee is defined as a general manager, business manager,
administrator, director, or other individual that exercises operational or managerial control over, or who directly
or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through
some other arrangement, whether or not the individual is a W-2 employee of the provider or supplier.
• Managing organization -- A managing organization is one that exercises operational or managerial control
over the provider, or conducts the day-to-day operations of the provider. The organization need not have an
ownership interest in the provider in order to qualify as a managing organization. For instance, the organization
could be a management services organization under contract with the provider to furnish management services
for one of the provider's practice locations.
• Medicare identification number -- The generic term for any number, other than the National Provider
Identifier, used by a provider or supplier to bill the Medicare program. Some examples of Medicare
identification numbers include:
• Unique Physician Identification Number (UPINs)
• Provider Identification Numbers (PINs)
• Online Survey Certification and Reporting (OSCAR)
• National Supplier Clearinghouse (NSC)
• Mobile facility/portable unit -- These terms apply when a service that requires medical equipment is
provided in a vehicle or the equipment for the service is transported to multiple locations within a geographic
area. The most common types of mobile facilities/portable units are:
• Mobile independent diagnostic testing facilities
• Portable X-ray units
• Portable mammography units
• Mobile clinics
Note: Physical therapists and other medical practitioners (e.g., physicians, nurse practitioners, physician
assistants) who perform services at multiple locations (e.g., house calls, assisted living facilities) are not
considered to be mobile facilities/portable units.
• National Provider Identifier -- The standard unique health identifier for health care providers (including
Medicare suppliers) and is assigned by the National Plan and Provider Enumeration System (NPPES).
• Non-participating provider -- A provider who does not wish to sign the participation agreement.
• Operational -- The provider or supplier has a qualified physical practice location, is open to the public for the
purpose of providing health care related services, is prepared to submit valid Medicare claims; and is properly
staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier
specialty, or the services or items being rendered) to furnish these items or services.
• Opt out provider -- A provider that has been approved to withdraw (opt out) from the Medicare Program.
• Ordering physician or ordering non-physician practitioner – CMS-covered physician or non-physician
practitioner who may order medical services for Medicare beneficiaries. The DVA, DOD or PHS must employ
the individual. The DVA, DOD or PHS must have an active enrollment record in PECOS. The physician or non-
physician practitioner will not be reimbursed for services rendered.
• Owner (Ownership) -- Any individual or entity that has any partnership interest in, or that has 5 percent or
more direct or indirect ownership of, the provider or supplier as defined in sections 1124 and 1124(A) of the
Social Security Act.
• Ownership or control interest -- Section 1124(a)(3) of the Social Security Act, defines an individual with an
ownership or control interest as: (1) A five percent direct or indirect owner of the provider, (2) An officer or
director of the provider, if the provider is a corporation, or (3) A partner of the provider, if the provider is a
partnership.
• Participating provider -- Must sign the participation agreement in order to be participating.
• PECOS – Provider Enrollment Chain and Organization System. A system that is used by CMS for
physician/non-physician practitioners and organizations that have been approved. This system is used to store
and update provider/supplier information.
• Physician or non-physician practitioner- CMS covered physician or non-physician practitioner who may
refer Medicare beneficiaries to other providers or suppliers. The DVA, DOD or PHS must employ the individual.
The DVA, DOD or PHS must have an active enrollment record in PECOS. The physician or non-physician
practitioner will not be reimbursed for services rendered.
• Physician or non-physician practitioner organization -- Any physician or non-physician practitioner entity
that enrolls in the Medicare program as a sole proprietorship or organization entity.
• Provider -- As defined at 42 CFR 400.202 and generally means a hospital, critical access hospital, skilled
nursing facility, comprehensive outpatient rehabilitation facility (CORF), home health agency or hospice, that
has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency
that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology
services; or community mental health center that has in effect a similar agreement but only to furnish partial
hospitalization services.
• Provider Access Transaction Number (PTAN) -- Providers/suppliers will be issued a PTAN to access their
IVR data and may also be used to identify their NPI number on the NPI crosswalk. The PTAN is what was
previously referred to as the Medicare Identification Number, Legacy Number and/or OSCAR number.
• Prospective provider -- means any entity specified in the definitions of “provider” in 42 CFR 498.2 that seek
to be approved for coverage of its services by Medicare.
• Prospective supplier -- means any entity specified in the definition of “supplier” in 42 CFR 405.802 that seek
to be approved for coverage of its services under Medicare.
• Reassignment -- An individual physician or non-physician practitioner, except physician assistants, has
granted a clinic or group practice the right to receive payment for the practitioner’s services.
• Reject/Rejected -- The provider or supplier’s enrollment application was not processed due to incomplete
information or that additional information or corrected information was not received from the provider or supplier
in a timely manner.
• Revoke/Revocation -- The provider or supplier’s billing privileges are terminated.
• Specialty Care Transport (SCT) -- Inter-facility transportation of a critically injured or ill beneficiary by a
ground ambulance vehicle including medically necessary suppliers and services at a level of service beyond
the scope of the EMT-Paramedic, SCT is necessary when a beneficiary’s condition requires ongoing care that
must be furnished by one or more health professionals in an appropriate specialty area.
• Sole-owner -- A business structure in which an individual and his/her company are considered separate
entities for tax and liability purposes. A sole ownership is a company that is registered with the state as a
limited liability company, corporation, professional association, etc. The owner pays income tax separately for
the company.
• Sole proprietor -- A business structure in which an individual and his/her company are considered a single
entity for tax and liability purposes. A sole proprietorship is a company, which is not registered with the state as
a limited liability company, corporation, etc. The owner is personally liable for all of the business debts and
reports any business profits or losses on their individual tax return.
• Supervision
• Personal Supervision -- a physician must be in attendance in the room during the performance of the
procedure.
• Direct Supervision -- the physician must be present in the office suite and immediately available to provide
assistance and direction throughout the performance of the procedure. It does not mean that the physician
must be present in the room when the procedure is performed.
• General Supervision -- the procedure is provided under the physician’s overall direction and control, but the
physician’s presence is not required during the performance of the procedure. General supervision also
includes the responsibility that the non-physician personnel who perform the tests are qualified and properly
trained and that the equipment is operated properly, maintained, calibrated and that necessary supplies are
available.
• Supplier is defined in 42 CFR 400.202 and means a physician or other practitioner, or an entity other than a
provider that furnishes health care services under Medicare.
• Tax Identification Number -- The number (either the Social Security Number (SSN) or Employer
Identification Number (EIN)) the individual or organization uses to report tax information to the IRS.




Waiver of coinsurance and deductible for preventive services for
RHCs
Effective Date: January 1, 2011

Implementation Date: April 4, 2011

Summary
Effective for dates of service on or after January 1, 2011, coinsurance and deductible are not applicable for the
initial preventive physical examination (IPPE), the annual wellness visit, and other Medicare covered preventive
services provided by rural health centers (RHCs). However, to ensure coinsurance and deductible are not
applied, you must provide detailed Healthcare Common Procedure Coding System (HCPCS) coding for
preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a
grade of A or B.
Payment for the professional component of allowable preventive services is made under the all-inclusive rate
when all of the program requirements are met. When one or more preventive service that meets the specified
criteria is provided as part of an RHC visit, charges for these services must be deducted from the total charge
for purposes of calculating beneficiary copayments and deductibles.

Although the Medicare processing system changes are not being implemented until April 4, 2011, providers
shall begin submitting detailed HCPCS code reporting for preventive services starting January 1, 2011.

Here is the link to the MLN Matters article MM7208     .




ESRD prospective payment system and consolidated billing
Effective Date: January 1, 2011

Implementation Date: January 3, 2011

Summary
The Centers for Medicare & Medicaid Services (CMS) has released MLN Matters article MM7064 to announce
the implementation of an end-stage renal disease (ESRD) bundled prospective payment system (PPS). The
ESRD PPS is effective for services on or after January 1, 2011; therefore, it is important that providers not
submit claims spanning dates of service in 2010 and 2011. However, ESRD facilities may make a one-time
election to be excluded from the transition period and have their payment based entirely on the payment
amount under the ESRD PPS. Facilities wishing to exercise this option must do so on or before November 1,
2010.

The ESRD PPS will replace the current basic case-mix adjusted composite payment system and the
methodologies for the reimbursement of separately billable outpatient ESRD related items and services. The
ESRD PPS will provide a single payment to ESRD facilities (i.e., hospital-based providers of services and renal
dialysis facilities). The payment will cover all the resources used in providing an outpatient dialysis treatment,
which includes the following:

• Supplies and equipment used to administer dialysis in the ESRD facility or at a patient’s home

• Drugs

• Biologicals

• Laboratory tests

• Training

• Support services

The ESRD PPS provides ESRD facilities a four-year transition period under which they would receive a blend
of the current payment methodology and the new ESRD PPS payment. In 2014, the payments will be based
100 percent on the ESRD PPS payment.

Here is the link to the MLN Matters article MM7064     .
Multiple procedure payment reduction for selected therapy services
Effective Date: January 1, 2011

Implementation Date: January 3, 2011

Summary
Section 3134 of The Affordable Care Act added section 1848(c)(2)(K) of the Social Security Act, which
specifies that the Secretary of Health & Human Services shall identify potentially misvalued codes by
examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a step in
implementing this provision, Medicare is applying a new multiple procedure payment reduction (MPPR) to the
practice expense component of payment of select therapy services paid under the Medicare physician fee
schedule (MPFS). The reduction will be similar to that currently applied to multiple surgical procedures and to
diagnostic imaging procedures. This policy is discussed in the calendar year (CY) 2011 MPFS final rule.

Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The
Centers for Medicare & Medicaid Services (CMS) is applying a MPPR to the practice expense payment when
more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to
multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest
practice expense payment. For subsequent units and procedures, furnished to the same patient on the same
day, full payment is made for work and malpractice, and 75 percent payment for the practice expense.

Here is the link to the MLN Matters article MM7050      .




Air ambulance services
Effective date: January 1, 2011

Implementation date: January 3, 2011

Summary
The MLN Matters article, which is based on change request (CR) 7161, updates Chapter 10, Section 10.4.6
(Special Payment Limitations) of the Medicare Benefit Policy Manual to better describe special payment
limitations for air ambulance services. The manual update may be viewed at the end of the CR 7161         .

Here is the link to the MLN Matters article MM7161
Jurisdiction 11 Part A
Urine Drug Screens: Correct Submission


When billing for urine drug screens to Medicare, please remember to use the correct HCPCS codes. There are two
HCPCS codes to choose from. The difference between the two codes is the number of drug classes in the codes.

         G0430 – Drug screen, qualitative, multiple drug classes, method other than chromatographic method, each
          procedure. This code includes the following drug classes: alcohols, amphetamines, barbiturates,
          benzodiazepines, cocaine, metabolites, methadone, methaqualone, opiates, phencyclidine, phenothiazines,
          propoxphene, tetrahydrocannabinoids and tricyclic antidepressants.
         G0431 – Drug screen, qualitative, single drug class, method (e.g., immunoassay, enzyme assay) each drug
          class

Palmetto GBA states ‘test coded/billed with HCPCS codes G0430 and G0431 for non-instrumented drug screening
assays must be billed with a quantity of one per episode of care regardless of the number of collection/testing items
used, the number of procedures, and the drug classes screened.’ For HCPCS code G0431, only one test per episode
of care will be allowed because Palmetto GBA does not consider multiple individual tests to be medically necessary
when a single testing item to screen for all drug classes is available.

In other words, do not use HCPCS code G0431 for multiple drug classes (single drugs classes on multiple lines)
when HCPCS code G0430 is available for multiple drug classes because Palmetto GBA will only pay for one unit
for HCPCS code G0431. Think of HCPCS code G0430 as a drug screening panel with multiple drug classes in it. It
has an allowable of one unit per episode.

Examples

Incorrect:

        Narrative                HCPCS Code & Modifier                             Units
Laboratory Chemistry          G0431                                4 (4 different drug classes)
Laboratory Chemistry          G0431-91                             5 (5 different drug classes)



Correct:

           Narrative              HCPCS Code                               Units
Laboratory Chemistry           G0430                  1 (this includes all 13 drug classes)

Incorrect:


Narrative       HCPCS Code & Modifier Units
Barbiturates G0431                                1
Methadones G0431-91                               1
Opiates         G0431-91                          1
Alcohol         G0431-91                          1
 Correct:
                   Narrative                                  HCPCS Code                     Units
Laboratory Chemistry                                              G0430                        1




I have a beneficiary who was part of a Medicare Advantage (MA) plan for part of their
stay. How do I bill for their services?


Answer:
Under the Medicare hospital benefit, if the provider is an inpatient acute care hospital, inpatient rehabilitation
facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient
institution, the patient’s status at admission or start of care determines liability.

If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not
responsible for payment.

For hospitals exempt from the Prospective Payment System (PPS) (i.e., children’s hospitals, cancer hospitals and
psychiatric hospitals/units) and Maryland waiver hospitals, if the MA organization has processing jurisdiction for
the MA involved portion of the bill, it will direct the provider to split the bill and send the appropriate portions to the
appropriate Fiscal Intermediary (FI) or MA organization. When forwarding a bill to an MA organization, the
provider must also submit the necessary supporting documents.

If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the
day of enrollment up through the day that disenrollment is effective.

 Update to Repetitive Billing Requirements for Institutional Claims



MLN Matters® Number: MM7163
Related Change Request (CR) #: 7163
Related CR Release Date: November 12, 2010
Effective Date: April 1, 2011
Related CR Transmittal #: R2092CP
Implementation Date: April 4, 2011

Provider Types Affected
Providers and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries
(FIs) and/or A/B Medicare Administrative Contractors (A/B MACs)) for repetitive pulmonary
rehabilitation Part B services provided to Medicare beneficiaries are affected.

What You Need to Know
This article is based on Change Request (CR) 7163 which updates the Frequency Billing
Requirements to include Pulmonary Rehabilitation Services, revenue code 0948 to the list of
repetitive Part B services billable as outpatient services by institutional providers.
Background
The Centers for Medicare & Medicaid Services (CMS) sets limits on the frequency of which
particular services may be billed to Medicare. In an effort to lower the volume of submitted
bills and to facilitate medical review, frequency limitations have been created to require
monthly bill submission of repetitive Part B services.

Repetitive Part B services furnished to a single individual by providers that bill institutional
claims will be billed monthly (or at the conclusion of treatment). Services repeated over a
span of time and billed with the following revenue codes are defined as repetitive services:

                    Type of Service                          Revenue Code(s)


DME Rental                                      0290 – 0299


Respiratory Therapy                             0410, 0412, 0419


Physical Therapy                                0420 – 0429


Occupational Therapy                            0430 – 0439


Speech-Language Pathology                       0440 – 0449


Skilled Nursing                                 0550 – 0559


Kidney Dialysis Treatments                      0820 – 0859


Cardiac Rehabilitation Services                 0482, 0943


Pulmonary Rehabilitation Services               0948 (added by CR 7163)



Additional Information
The official instruction, CR 7163, issued to your FIs and A/B MACs regarding this change
may be viewed at http://www.cms.gov/Transmittals/downloads/R2092CP.pdf on the CMS
website.




The “Physician Payment and Therapy Relief Act of 2010”
Extends 2.2 Percent Medicare Physician Fee Schedule Update
On Tuesday, November 30, 2010, President Obama signed into law, “The Physician
Payment and Therapy Relief Act of 2010.” This law extends through Friday,
December 31, 2010, the 2.2 percent update to the Medicare Physician Fee Schedule
(MPFS) that has been in effect for MPFS claims with dates of service of Tuesday,
June 1, 2010, through Tuesday, November 30, 2010. Payments for 2010 services
under the MPFS will continue without delay.

Please watch your listservs and our website for more information, should
Congressional action prevent the 2011 negative update from going into effect on
Saturday, January 1, 2011.

								
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