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5-06-09 Medicare Mtg Agenda _ Mtg Notes

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5-06-09 Medicare Mtg Agenda _ Mtg Notes Powered By Docstoc
					                             Welcome to the HomeTown Health CAHABA UPDATE
                                                        6-May-09
                                         Press 6 to mute and 6 to unmute your line

10:00 AM - Welcome - Webinar Rules - Donna Meeks

10:05 AM - OPENING COMMENTS

10:15 AM - CAHABA Cutover Updates - Dale Gibson / Kathy Whitmire

ANY PROBLEMS?
              With electronic submission of claims, via clearinghouse
        With direct data entry to Cahaba's Secure FTP server?
        With Active or pending claims transitioning from BCBS GA to CAHABA?
        Tracking of claims in appeals process w/ BCBS?

LCD's - BCBS - 22 active as of 5/1/09 - See worksheet for more information
        CAHABA - 31 effective 5/4/09
         SAD List - the Same
         NCD's Listed with link
         Who is maintaining the updates and ensuring staff education on new policies?
         Important: Claims with DOS prior to 5/1/09 - BCBS LCD policy will be honored

ADR's - Additional Documentation (Development) Request - Prepayment Claims Review
        - Wide Spread Probe of Back Pain and UTI
          Flow Chart of Process - pdf file attachment

ADDRESSES for credit balance reporting & other required reporting

Newsline posted 4/28/09 - Audit Trail Descriptions

         NEW PECOS Online Mgmt of 855A Applications - CR#6231
         http://www.cms.hhs.gov/MedicareProviderSupEnroll/01_Overview.asp#TopOfPage
         https://nppes.cms.hhs.gov/NPPES/Welcome.do

           OTHER KEY UPDATES - REMINDERS
              NEW COMMUNITY BENEFIT FORM 990 with FYending in 2009
               SECTION 1011 Provider enrollment deadline: May 30, 2009.

MAC/RACS HELP Program begins May 20th - Let us know if you plan to participate
www.RACSHELP.com

10:40 AM Question & Answer Session

11:00 AM Adjourn

                                      Notes from today's meeting can be found at
                                         www.hometownhealth.wikispaces.com

To learn more about HomeTown Health visit our website at www.hometownhealthonline.com
                                         Thanks for participating in today's meeting!
Total Active LCDs: 22



          LCD ID                     LCD Title



 L912                   Cardiac Event Recorders

 L934                   Computerized Axial
                        Tomography of the Abdomen

 L986                   Erythropoietin Use in non-ESRD
                        patients (non-dialysis)

 L998                   Eyelid and Brow Surgical
                        Procedures
 L1004                  Filgrastim (G-CSF), (Neupogen)

 L18887                 Inpatient Rehabilitation

 L1063                  Intravenous Immune Globulin (IVIG)


 L19503                 Intravenous Nesiritide (BNP)
                        Infusion Therapy
 L897                   Leuprolide Acetate and Goserelin
                        Acetate
 L1329                  Magnesium
 L1005                  Myocardial Perfusion Imaging

 L26219                 Outpatient Pulmonary
                        Rehabilitation
 L23526                 Oxaliplatin
 L989                   Parathormone
 L1457                  Partial Psychiatric Hospitalization
                        Program
 L19783                 Psychiatric Inpatient
                        Hospitalization
 L1468                  Qualitative Drug Screen
L1508   Removal of Benign or
        Premalignant Skin Lesions

L1506   Respiratory Therapy
L1518   Sedimentation Rate, Erythrocyte

L1483   Syphilis Testing
L1471   Transthoracic Echocardiography
                       Revision                       Last Approval /
Effective Date                        End Date
                   Effective Date                     Revision Date


       5/28/1997          5/15/2006        5/3/2009          2/9/2009

     2/15/2000          10/1/2008        5/3/2009         2/12/2009



        6/1/1999          10/1/2008        5/3/2009         2/17/2009



     8/15/2001          7/17/2007        5/3/2009         2/12/2009


        6/1/1999          7/14/2008        5/3/2009         2/12/2009

      1/1/2005          7/17/2007        5/3/2009         2/12/2009

       8/15/2001          7/17/2007        5/3/2009         2/12/2009


      9/1/2005          7/17/2007        5/3/2009         2/12/2009


       8/10/1997          10/1/2008        5/3/2009          2/9/2009


      5/1/1999          10/1/2008        5/3/2009         2/17/2009
      8/10/1997          10/1/2007        5/3/2009           2/9/2009

      2/1/2008           2/1/2008        5/3/2009         2/12/2009


       11/1/2006         2/15/2009        5/3/2009          2/12/2009
     5/28/1997          10/1/2008        5/3/2009         2/12/2009
       8/21/1991         7/17/2007        5/3/2009          2/12/2009


      9/1/2005          7/17/2007        5/3/2009         2/12/2009


       2/15/2000          7/17/2007        5/3/2009         2/12/2009
5/28/1997    7/17/2007    5/3/2009    2/12/2009



 4/15/1999    10/1/2008    5/3/2009     2/12/2009
 6/1/1999    10/1/2008    5/3/2009    2/12/2009

 5/28/1997    10/1/2007    5/3/2009     2/12/2009
11/1/1997    10/1/2008    5/3/2009    2/12/2009
Total Active LCDs: 31
There are 31 items in this list.
  L29992                           Drugs and Biologicals: Bevacizumab (AVASTIN TM)
  L29993                           Drugs and Biologicals: Colony Stimulating
                                   Factors
  L30069                           Drugs and Biologicals: Erythropoietin Analogues
  L29995                           Drugs and Biologicals: Gemcitabine
                                   Hydrochloride (Gemzar ®)
  L29996                           Drugs and Biologicals: Immune Globulin Intravenous
                                   (IVIg)
  L29997                           Drugs and Biologicals: Infliximab (REMICADE ®)
  L29998                           Drugs and Biologicals: Octreotide Acetate for Injectable
                                   Suspension (Sandostatin® LAR Depot)
  L29999                           Drugs and Biologicals: Oxaliplatin (Eloxatin™)
  L30000                           Drugs and Biologicals: Palonosetron HCL Injection
                                   (Aloxi™)
  L30001                           Drugs and Biologicals: Pamidronate Disodium
                                   (Aredia ®)
  L30002                           Drugs and Biologicals: Rituximab (Rituxan ®)
  L30003                           Drugs and Biologicals: Zoledronic Acid
  L30004                           Medicine: Debridement Services
  L30005                           Medicine: Dysphagia/Swallowing Therapy
  L30006                           Medicine: Inpatient Rehabilitation
  L30007                           Medicine: Occupational Therapy - Outpatient
  L30008                           Medicine: Partial Hospitalization Programs
  L30009                           Medicine: Physical Therapy - Outpatient
  L30010                           Medicine: Speech Language Pathology - Outpatient
  L30011                           Medicine: Wireless Capsule Imaging
  L30012                           Pathology and Laboratory: B-type Natriuretic Peptide
                                   (BNP) Testing
  L30013                           Pathology and Laboratory: Syphilis Testing
  L30014                           Radiology: Computed Tomographic Angiography of the
                                   Heart and Coronary Vessels
  L30015                           Radiology: Computed Tomography of the
                                   Abdomen and Pelvis
  L30016                           Radiology: Computed Tomography of the Head or Brain

  L30017                           Radiology: Computed Tomography of the Thorax

  L30018                           Radiology: Magnetic Resonance Imaging of the Brain
  L30019                           Radiology: Magnetic Resonance Imaging of the
                                   Spine
  L30020                           Surgery: Colonoscopy (Diagnostic)
  L30021                           Surgery: Upper Gastrointestinal Endoscopy
  L30022                           Transportation Services: Ambulance
For services performed on or after 05/18/2009

CAHABA LCD L30004
LCD Title back to top
Medicine: Debridement Services

Indications and Limitations of Coverage and/or Medical Necessity back to top
Indications
Active wound care procedures involve selective and nonselective debridement techniques
and are performed to remove necrotic/devitalized tissue, thus promoting healing.


 1. Selective Techniques

 CPT 97597 and 97598 - Debridement is indicated whenever necrotic/devitalized tissue is
 present on an open wound. Debridement may also be indicated in cases of abnormal
 wound healing or repair. Debridement techniques usually progress from non-selective to
 selective but can be combined. Debridement will not be considered a reasonable and
 necessary procedure for a wound that is clean and free of necrotic/devitalized
 tissue.Coverage includes:



   a. Conservative Sharp Debridement is a minor procedure that requires no anesthesia
   and is performed on an outpatient basis. Scalpel, scissors and tweezers/forceps may
   be used and only clearly identified necrotic/devitalized tissue is removed. Generally,
   there is no bleeding associated with this procedure.

   b. High Pressure Water Jet

   c. Pulsed lavage-(nonimmersion hydrotherapy) is an irrigation device, with or without
   pulsation, used to provide a water jet to administer a shearing effect to loosen debris
   within a wound. Some electric pulsatile irrigation devices include suction to remove
   debris from the wound after it is irrigated.

   d. Because coverage under these CPT codes is dependent upon total surface area (in
   square centimeters), documentation should include this measurement. See
   'Documentation' section for details.
 2. Non-Selective Techniques


   a. CPT 97602 - See Limitations
   b. CPT 97022 and 97036 - Immersion hydrotherapy is only covered as a SOLE method
   of debridement for Stage 3 or 4 decubiti.
 3. Negative Pressure Wound Therapy (NPWT)
   CPT 97605 and 97606 - NPWT uses negative pressure to enhance closure of
   recalcitrant wounds. The process enhances wound healing by cleansing the wound
   and stimulating the wound bed, reducing localized edema, and improving local oxygen
   supply. Examples of wounds that would typically benefit from NPWT include, but are
   not limited to, Stage III and IV decubiti, traumatic wounds, dehisced incisions, flaps.




Limitations

 1. Unna Boot


   a. CPT 29580 - (Strapping, Unna Boot) is to be used for fractures and dislocations;
   therefore not with wound care.

   b. An unna boot as well as other dressings such as Kling, Profore, etc. may be used as
   a dressing for wound care and will be covered as a supply; however should not be
   billed with CPT 29580.

   c. The method of application (primary or secondary dressing) will be left to the
   discretion of the provider.
 2. CPT 97597, 97598, 97602, 97605, and 97606 are untimed and are only covered as 1
 unit per date of service.
 3. CPT 97597 and 97598
 4. Immersion Hydrotherapy (CPT 97022 and 97036) is considered nonselective
 debridement, but may be used as an adjunct to selective debridement. In such cases,
 immersion hydrotherapy is considered covered as part of CPT 97597 and 97598 and is
 not separately covered (i.e. CPT 97022 and 97036 may not be billed).
 5. Immersion hydrotherapy for the sole purpose of dressing removal is noncovered.
 6. With the exception of the initial patient evaluation, use of an E/M encounter in addition
 to CPT 97597 and 97598 is noncovered, unless a separate and distinct service is
 performed.
 7. Should not be billed on the same date of service as 97605 and 97606, unless a
 separate wound is documented.
 8. CPT 97602 is not routinely a skilled service therefore not routinely covered. Although
 when a caregiver is not available there may be exceptions for coverage (i.e. reasonable
 and necessary). Such exceptions include, but are not limited to, significant vision
 impairment; loss of peripheral sensation; morbid obesity; and physical impairment
 hindering access to wound. Other exceptions may include sterile management of a
 wound as prescribed by referring/supervising physician. When reasonable and
 necessary as outlined above, CPT 97602 may be covered for non therapy providers (i.e.
 Revenue Code 51X). Therapy providers may not bill services under 51X Revenue Code.
 No additional E/M code is covered in conjunction with CPT 97602 unless a separate and
 distinct service is provided. There is no coverage when active debridement is not
 occurring (i.e. lack of devitalized tissue, no progress in removing devitalized tissue; or
 dressing changes). Coverage under CPT 97602 includes:
 a. Blunt debridement - This type of debridement is defined as the removal of necrotic
 tissue by cleansing, scraping, chemical application or wet to dry dressing technique. It
 may also involve the cleaning and dressing of small or superficial lesions.

 b. Enzymatic Debridement - Debridement with topical enzymes is used when the
 necrotic substances to be removed from a wound are protein, fiber and collagen. The
 manufacturers’ product insert contains indications, contraindications, precautions,
 dosage and administration guidelines; it would be the clinician’s responsibility to comply
 with those guidelines.
 c. Autolytic Debridment - This type of debridement is indicated where manageable
 amounts of necrotic tissue are present, and there is no infection. Autolytic debridement
 occurs when the enzymes that are naturally found in wound fluids are sequestered
 under synthetic dressings; it is contraindicated for infected wounds.

  d. Mechanical Debridement - Wet-to-moist dressings may be used with wounds that
  have a high percentage of necrotic tissue. Wet-to-moist dressings should be used
  cautiously as maceration of surrounding tissue may hinder healing.
9. CPT 99211 for wound management is not routinely a skilled service therefore not
routinely covered. Although when a caregiver is not available there may be exceptions for
coverage (i.e. reasonable and necessary). Such exceptions include, but are not limited
to, significant vision impairment; loss of peripheral sensation; morbid obesity; and
physical impairment hindering access to wound. Other exceptions may include sterile
management of a wound as prescribed by referring/supervising physician.

10. Clinic visits for the sole purpose of routine dressing changes are noncovered.
11. The following services are not considered reasonable and necessary for debridement
services:

  a. trimming of callous with no associated wound debridement
  b. removing coagulation serum from normal skin surrounding an ulcer
  c. cleansing and dressing changes to promote wound healing
12. If a complete evaluation and specific plan of care are done by a physician or other
'qualified professional' (physician assistant, nurse practitioner, clinical nurse specialist)
within the same facility, an additional therapy evaluation (i.e. CPT 97001 or 97003) is not
covered.
13. CPT Codes 11040-11044 and 16000-16036 are physician services only and are not
covered for use by non-physicians. However should such services be performed by a
physician, the facility portion of the respective service is covered as long as the service is
reasonable and necessary.
14. With the exception of the initial patient evaluation, use of an E/M encounter in
addition to CPT 11040-11044 and 16000-16036 is noncovered, unless a separate and
distinct service is performed.
15. The use of the ‘Splinting, Strapping, and Casting’ codes (CPT 29065-29580) is not
covered for application of dressings or bandages. Unnaboot is considered a supply.
FUTURE

CPT/HCPCS Codes back to top
                 97022   Whirlpool therapy
                 97036   Hydrotherapy
                 97597   Active wound care/20 cm or <
                 97598   Active wound care > 20 cm
                 97602   Wound(s) care non-selective
                 97605   Neg press wound tx, < 50 cm


                 97606 Neg press wound tx, > 50 cm
  CPT/HCPCS                                        Descriptor
                  Descriptor Generic Name
    Codes                                          Brand Name



J0135         INJECTION, ADALIMUMAB, 20 MG       HUMIRA™


              INJECTION, ALPROSTADIL, 1.25 MCG
              (CODE MAY BE USED FOR MEDICARE
              WHEN DRUG ADMINISTERED UNDER
              THE DIRECT SUPERVISION OF A
              PHYSICIAN, NOT FOR USE WHEN        Caverject®
J0270         DRUG IS SELF ADMINISTERED)         Edex®




              INJECTION, CALCITONIN SALMON, UP Calcimar®
J0630         TO 400 UNITS                     Miacalcin®

              INJECTION, ETANERCEPT, 25 MG
              (CODE MAY BE USED FOR MEDICARE
              WHEN DRUG ADMINISTERED UNDER
              THE DIRECT SUPERVISION OF A
              PHYSICIAN, NOT FOR USE WHEN
J1438         DRUG IS SELF ADMINISTERED)         Enbrel®

              INJECTION, IMMUNE GLOBULIN
J1562         (VIVAGLOBIN), 100 MG               Vivaglobin®

              INJECTION, GLATIRAMER ACETATE,
J1595         20 MG                              Copaxone®

              INJECTION, HISTRELIN ACETATE, 10
J1675         MICROGRAMS                         Supprelin


                                                 Humulin,
                                                 Regular, NPH,
                                                 Lente,
J1815         INJECTION, INSULIN, PER 5 UNITS    Ultralente
              INSULIN FOR ADMINISTRATION
              THROUGH DME (I.E., INSULIN PUMP)
J1817         PER 50 UNITS                       Humalog®
        INJECTION INTERFERON BETA-1B,
        0.25 MG (CODE MAY BE USED FOR
        MEDICARE WHEN DRUG
        ADMINISTERED UNDER THE DIRECT
        SUPERVISION OF A PHYSICIAN, NOT
        FOR USE WHEN DRUG IS SELF
J1830   ADMINISTERED)                     Betaseron®
        INJECTION, OCTREOTIDE, NON-
        DEPOT FORM FOR SUBCUTANEOUS
        OR INTRAVENOUS INJECTION, 25      Sandostatin®
J2354   MCG                               Injection




J2940   INJECTION, SOMATREM, 1 MG         Protropin®




                                          Humatrope®
                                          Genotropin®
J2941   INJECTION, SOMATROPIN, 1 MG       Nutropin®
        INJECTION, SUMATRIPTAN
        SUCCINATE, 6 MG (CODE MAY BE
        USED FOR MEDICARE WHEN DRUG
        ADMINISTERED UNDER THE DIRECT
        SUPERVISION OF A PHYSICIAN, NOT
        FOR USE WHEN DRUG IS SELF
J3030   ADMINISTERED)                     Imitrex®


J3110   INJECTION, TERIPARATIDE, 10 MCG   Forteo™


J3490   UNCLASSIFIED DRUGS                Kineret®
                                          BYETTA®
                                          (Exenatide
J3490   UNCLASSIFIED DRUGS                Injection)

                                          SYMLIN®
                                          (Pramlintide
J3490   UNCLASSIFIED DRUGS                Acetate Injection)


J3590   UNCLASSIFIED BIOLOGICS            RAPTIVA™

                                          Pegasys®
                                          (injection,
                                          pegylated
J3590   UNCLASSIFIED BIOLOGICS            interferon alfa-2a)
                                                                   Pegintron®
                                                                   (injection,
                                                                   pegylated
J3590                  UNCLASSIFIED BIOLOGICS                      interferon alfa-2b)


                       INJECTION, INTERFERON ALFACON-1,
J9212                  RECOMBINANT, 1 MICROGRAM         Infergen®


                       INJECTION, INTERFERON, ALFA-2A,
J9213                  RECOMBINANT, 3 MILLION UNITS                Roferon-A®


                       INJECTION, INTERFERON, GAMMA 1-
J9216                  B, 3 MILLION UNITS                          Actimmune®


J9218                  LEUPROLIDE ACETATE, PER 1 MG                Lupron®
                       IMMUNE GLOBULIN (SCIG), HUMAN,
                       FOR USE IN SUBCUTANEOUS                     Immune Globulin
90284                  INFUSIONS, 100 MG, EACH                     (SCIg)


The Cahaba Government Benefit Administrators®, LLC (Cahaba GBA) Self Administered Drug (SAD) List includes those drug
and, therefore, not covered by Medicare. These determinations are based upon instructions provided in the Medicare Benefit P
  Exclusion       Exclusion End
                                                Comments
Effective Date         Date
                                  Rationale: Apparent on its face. SC
                                  injection administered by patient
                                  every 1-2 weeks for a chronic
       5/4/2009                   condition.




                                  Rationale: Apparent on its face.
                                  Intracavernosal injection administered
       5/4/2009                   by patient on an as needed basis.




                                  Rationale: Apparent on its face.
                                  Predominantly a SC injection used on
       5/4/2009                   a chronic basis for a chronic condition.




                                  Rationale: Apparent on its face. SC
                                  injection administered by patient two
       5/4/2009                   times per week for a chronic condition.
                                  Rationale: Apparent on its face. SC
                                  injection administered weekly by
       5/4/2009                   patient for a chronic condition.
                                  Rationale: Apparent on its face. SC
                                  injection administered by patient daily
       5/4/2009                   for a chronic condition.
                                  Rationale: Apparent on its face. SC
                                  injection administered daily by patient
       5/4/2009                   for a chronic condition.




                                  Rationale: Apparent on its face. SC
                                  injection administered on a chronic
       5/4/2009                   basis for a chronic condition.
                                  Rationale: Apparent on its face. For
                                  use in insulin pump, administered
       5/4/2009                   through DME.
           Rationale: Apparent on its face. SC
           injection administered by patient QOD
5/4/2009   for a chronic condition.
           Rationale: Apparent on its face. SC
           injection administered by patient
           usually on a daily basis for a chronic
5/4/2009   condition.
           Rationale: Apparent on its face. SC
           injection administered by patient
           several times a week for a chronic
5/4/2009   condition.




           Rationale: Apparent on its face. SC
           injection administered by patient
           several times a week for a chronic
5/4/2009   condition.



           Rationale: Apparent on its face. SC
           injection administered by patient on
           an as needed basis for a chronic
5/4/2009   condition.
           Rationale: Apparent on its face. SC
           injection administered daily by patient
5/4/2009   for a chronic condition.
           Rationale: Apparent on its face. SC
           injection administered daily by patient
5/4/2009   for a chronic condition.
           Rationale: Apparent on its face. SC
           injection administered on a chronic
5/4/2009   basis for a chronic condition.

           Rationale: Apparent on its face. SC
           injection administered on a chronic
5/4/2009   basis for a chronic condition.
           Rationale: Apparent on its face. SC
           injection administered weekly by
5/4/2009   patient for a chronic condition.


           Rationale: Apparent on its face. SC
           injection administered by patient
5/4/2009   weekly for a chronic condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered by patient
                           5/4/2009                            weekly for a chronic condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered by patient
                                                               three times a week for a chronic
                           5/4/2009                            condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered by patient daily
                                                               to three times a week for a chronic
                           5/4/2009                            condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered by patient
                                                               three times a week for a chronic
                           5/4/2009                            condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered daily by patient
                           5/4/2009                            for a chronic condition.
                                                               Rationale: Apparent on its face. SC
                                                               injection administered weekly by
                           5/4/2009                            patient for a chronic condition.


 ministered Drug (SAD) List includes those drugs that are determined by this contractor to be 'usually self-administered by the patient',
n instructions provided in the Medicare Benefit Policy Manual, Chapter 15, Section 50.2, which may be viewed at the following link:
administered by the patient',
wed at the following link:
NCD List -
http://coveragetest.fu.com/mcd/index_chapter_list.asp

0001 : 0001
 10 : Anesthesia and Pain Manageme
10.1 : Use of Visual Tests Prior to and General Anesthesia during Cataract Surgery
10.2 : Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain
10.3 : Inpatient Hospital Pain Rehabilitation Programs
10.4 : Outpatient Hospital Pain Rehabilitation Programs
10.5 : Autogenous Epidural Blood Graft

 20 : Cardiovascular System
20.1 : Vertebral Artery Surgery
20.2 : Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery
20.3 : Thoracic Duct Drainage (TDD) in Renal Transplants
20.4 : Implantable Automatic Defibrillators
20.5 : Extracorporeal Immunoadsorption (ECI) Using Protein A Columns
20.6 : Transmyocardial Revascularization (TMR)
20.7 : Percutaneous Transluminal Angioplasty (PTA)
20.8 : Cardiac Pacemakers
20.8.1 : Cardiac Pacemaker Evaluation Services
20.8.2 : Self-Contained Pacemaker Monitors
20.8.3 : Anesthesia in Cardiac Pacemaker Surgery
20.9 : Artificial Hearts and Related Devices
20.10 : Cardiac Rehabilitation Programs
20.11 : Intraoperative Ventricular Mapping
20.12 : Diagnostic Endocardial Electrical Stimulation (Pacing)
20.13 : HIS Bundle Study
20.14 : Plethysmography
20.15 : Electrocardiographic (EKG) Services
20.16 : Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB)
20.17 : Noninvasive Tests of Carotid Function
20.18 : Carotid Body Resection/Carotid Body Denervation
20.19 : Ambulatory Blood Pressure Monitoring
20.20 : External Counterpulsation (ECP) for Severe Angina
20.21 : Chelation Therapy for Treatment of Atherosclerosis
20.22 : Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis
20.23 : Fabric Wrapping of Abdominal Aneurysms
20.24 : Displacement Cardiography
20.25 : Cardiac Catheterization Performed in Other than a Hospital Setting
20.26 : Partial Ventriculectomy
20.27 : Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test
20.28 : Therapeutic Embolization
20.29 : Hyperbaric Oxygen Therapy
20.30 : Microvolt T-Wave Alternans (MTWA)

 30 : Complementary and Alternative Medicine
30.1 : Biofeedback Therapy
30.1.1 : Biofeedback Therapy for the Treatment of Urinary Incontinence
30.2 : Thermogenic Therapy
30.3 : Acupuncture
30.3.1 : Acupuncture for Fibromyalgia
30.3.2 : Acupuncture for Osteoarthritis
30.4 : Electrosleep Therapy
30.5 : Transcendental Meditation (TM)
30.6 : Intravenous Histamine Therapy
30.7 : Laetrile and Related Substances
30.8 : Cellular Therapy
30.9 : Transillumination Light Scanning or Diaphanography

 40 : Endocrine System and Metabolism
40.1 : Diabetes Outpatient Self-Management Training
40.2 : Home Blood Glucose Monitors
40.3 : Closed-Loop Blood Glucose Control Device (CBGCD)
40.4 : Insulin Syringe
40.5 : Treatment of Obesity

 50 : Ear, Nose and Throat (ENT)
50.1 : Speech Generating Devices
50.2 : Electronic Speech Aids
50.3 : Cochlear Implantation
50.4 : Tracheostomy Speaking Valve
50.5 : Oxygen Treatment of Inner Ear/Carbon Therapy
50.6 : Tinnitus Masking
50.7 : Cochleostomy with Neurovascular Transplant for Meniere's Disease
50.8 : Ultrasonic Surgery

60 : Emergency Medicine

 70 : Evaluation and Management of Patients - Office/hospital/home
70.1 : Consultations with a Beneficiary's Family and Associates
70.2 : Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility
70.2.1 : Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation
70.3 : Physician's Office Within an Institution--Coverage of Services and Supplies Incident to a Physician's Services
70.4 : Pronouncement of Death
70.5 : Hospital and Skilled Nursing Facility Admission Diagnostic Procedures

 80 : Eye
80.1 : Hydrophilic Contact Lens For Corneal Bandage
80.2 : Ocular Photodynamic Therapy (OPT)
80.3 : Verteporfin
80.4 : Hydrophilic Contact Lenses
80.5 : Scleral Shell
80.6 : Intraocular Photography
80.7 : Refractive Keratoplasty
80.8 : Endothelial Cell Photography
80.9 : Computer Enhanced Perimetry
80.10 : Phaco-Emulsification Procedure - Cataract Extraction
80.11 : Vitrectomy
80.12 : Intraocular Lenses (IOLs)

90 : Genetics

100 : Gastrointestinal System
100.1 : Bariatric Surgery for Treatment of Morbid Obesity
100.2 : Endoscopy
100.3 : 24-Hour Ambulatory Esophageal pH Monitoring
100.4 : Esophageal Manometry
100.5 : Diagnostic Breath Analyses
100.6 : Gastric Freezing
100.7 : Colonic Irrigation
100.8 : Intestinal Bypass Surgery
100.9 : Implantation of Anti-Gastroesophageal Reflux Device
100.10 : Injection Sclerotherapy for Esophageal Variceal Bleeding
100.11 : Gastric Balloon for Treatment of Obesity
100.12 : Gastrophotography
100.13 : Laparoscopic Cholecystectomy

 110 : Hematology/Immunology/Oncology
110.1 : Hyperthermia for Treatment of Cancer
110.2 : Certain Drugs Distributed by the National Cancer Institute
110.3 : Anti-Inhibitor Coagulant Complex (AICC)
110.4 : Extracorporeal Photopheresis
110.5 : Granulocyte Transfusions
110.6 : Scalp Hypothermia During Chemotherapy to Prevent Hair Loss
110.7 : Blood Transfusions
110.8 : Blood Platelet Transfusions
110.8.1 : Stem Cell Transplantation
110.9 : Antigens Prepared for Sublingual Administration
110.10 : Intravenous Iron Therapy
110.11 : Food Allergy Testing and Treatment
110.12 : Challenge Ingestion Food Testing
110.13 : Cytotoxic Food Tests
110.14 : Apheresis (Therapeutic Pheresis)
110.15 : Ultrafiltration, Hemoperfusion and Hemofiltration
110.16 : Nonselective (Random) Transfusions and Living Related Donor Specific Transfusions (DST) in Kidney Transplantation
110.17 : Anti-Cancer Chemotherapy for Colorectal Cancer
110.18 : Aprepitant for Chemotherapy-Induced Emesis
110.19 : Abarelix for the Treatment of Prostate Cancer
110.20 : Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors (Effective March 20, 2007)
110.21 : Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions

120 : Infectious Diseases

 130 : Mental Health
130.1 : Inpatient Hospital Stays for Treatment of Alcoholism
130.2 : Outpatient Hospital Services for Treatment of Alcoholism
130.3 : Chemical AversionTherapy for Treatment of Alcoholism
130.4 : Electrical Aversion Therapy for Treatment of Alcoholism
130.5 : Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic
130.6 : Treatment of Drug Abuse (Chemical Dependency)
130.7 : Withdrawal Treatments for Narcotic Addictions
130.8 : Hemodialysis for Treatment of Schizophrenia

 140 : Miscellaneous Surgical Procedures
140.1 : Abortion
140.2 : Breast Reconstruction Following Mastectomy
140.3 : Transsexual Surgery
140.4 : Plastic Surgery to Correct Moon Face
140.5 : Laser Procedures

 150 : Musculoskeletal System
150.1 : Manipulation
150.2 : Osteogenic Stimulators
150.3 : Bone (Mineral) Density Studies
150.5 : Diathermy Treatment
150.6 : Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot
150.7 : Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents
150.8 : Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders
150.9 : Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee
150.10 : Lumbar Artificial Disc Replacement(LADR)
150.11 : Thermal Intradiscal Procedures (TIPs)

 160 : Nervous System
160.1 : Induced Lesions of Nerve Tracts
160.2 : Treatment of Motor Function Disorders with Electric Nerve Stimulation
160.4 : Stereotactic Cingulotomy as a Means of Psychosurgery
160.5 : Stereotaxic Depth Electrode Implantation
160.6 : Carotid Sinus Nerve Stimulator
160.7 : Electrical Nerve Stimulators
160.7.1 : Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy
160.8 : Electroencephalographic (EEG) Monitoring During Surgical Procedures Involving the Cerebral Vasculature
160.9 : Electronecephalographic (EEG) Monitoring During Open-Heart Surgery
160.10 : Evoked Response Tests
160.12 : Neuromuscular Electrical Stimulaton (NMES)
160.13 : Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical S
160.14 : Invasive Intracranial Pressure Monitoring
160.15 : Electrotherapy for Treatment of Facial Nerve Paralysis (Bell's Palsy)
160.16 : Vertebral Axial Decompression (VAX-D)
160.17 : L-Dopa
160.18 : Vagus Nerve Stimulation for Treatment of Seizures
160.19 : Phrenic Nerve Stimulator
160.20 : Transfer Factor for Treatment of Multiple Sclerosis
160.21 : Telephone Transmission of Electroencephalograms (EEGs)
160.22 : Ambulatory EEG Monitoring
160.23 : Sensory Nerve Conduction Threshold Tests (sNCTs)
160.24 : Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease
160.25 : Multiple Electroconvulsive Therapy (MECT)
160.26 : Cavernous Nerves by Electrical Stimulation with Penile Plethsmography

 170 : Nonphysician Practitioner Services (PT/OT/SLP/Audiologists/CRNA
170.1 : Institutional and Home Care Patient Education Programs
170.2 : Melodic Intonation Therapy
170.3 : Speech-Language Pathology Services for the Treatment of Dysphagia

 180 : Nutrition
180.1 : Medical Nutrition Therapy
180.2 : Enteral and Parenteral Nutritional Therapy
 190 : Pathology and Laboratory
190.1 : Histocompatibility Testing
190.2 : Diagnostic Pap Smears
190.3 : Cytogenetic Studies
190.4 : Electron Microscope
190.5 : Sweat Test
190.6 : Hair Analysis
190.7 : Human Tumor Stem Cell Drug Sensitivity Assays
190.8 : Lymphocyte Mitogen Response Assays
190.9 : Serologic Testing for Acquired Immunodeficiency Syndrome (AIDS)
190.10 : Laboratory Tests - CRD Patients
190.11 : Home Prothrombin Time INR Monitoring for Anticoagulation Management
190.12 : Urine Culture, Bacterial
190.13 : Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
190.14 : Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
190.15 : Blood Counts
190.16 : Partial ThromboplastinTime (PTT)
190.17 : Prothrombin Time (PT)
190.18 : Serum Iron Studies
190.19 : Collagen Crosslinks, any Method
190.20 : Blood Glucose Testing
190.21 : Glycated Hemoglobin/Glycated Protein
190.22 : Thyroid Testing
190.23 : Lipid Testing
190.24 : Digoxin Therapeutic Drug Assay
190.25 : Alpha-fetoprotein (AFP)
190.26 : Carcinoembryonic Antigen (CEA)
190.27 : Human Chorionic Gonadotropin (hCG)
190.28 : Tumor Antigen by Immunoassay - CA 125
190.29 : Tumor Antigen by Immunoassay - CA 15-3/CA 27.29
190.30 : Tumor Antigen by Immunoassay - CA 19-9
190.31 : Prostate Specific Antigen (PSA)
190.32 : Gamma Glutamyl Transferase (GGT)
190.33 : Hepatitis Panel/Acute Hepatitis Panel
190.34 : Fecal Occult Blood Test (FOBT)

 200 : Pharmacology
200.1 : Nesiritide for Treatment of Heart Failure Patients
200.2 : Nebulized Beta Adrenergic Agonist Therapy for Lung Diseases

 210 : Prevention
210.1 : Prostate Cancer Screening Tests
210.2 : Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
210.3 : Colorectal Cancer Screening Tests
210.4 : Smoking and Tobacco-Use Cessation Counseling

 220 : Radiology
220.1 : Computed Tomography
220.2 : Magnetic Resonance Imaging (MRI)
220.2.1 : Magnetic Resonance Spectroscopy (MRS)
220.3 : Magnetic Resonance Angiography (MRA)
220.4 : Mammograms
220.5 : Ultrasound Diagnostic Procedures
220.6 : PET Scans
220.6.10 : PET (FDG) for Breast Cancer
220.6.1 : PET for Perfusion of the Heart
220.6.11 : PET (FDG) for Thyroid Cancer
220.6.12 : PET (FDG) for Soft Tissue Sarcoma
220.6.13 : PET (FDG) for Dementia and Neurodegenerative Diseases
220.6.14 : PET (FDG) for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and Testicular Cancers
220.6.15 : PET (FDG) for All Other Cancer Indications Not Previously Specified
220.6.16 : PET for Infection and Inflammation
220.6.2 : PET (FDG) for Lung Cancer
220.6.3 : PET (FDG) for Esophageal Cancer
220.6.4 : PET (FDG) for Colorectal Cancer
220.6.5 : PET (FDG) for Lymphoma
220.6.6 : PET (FDG) for Melanoma
220.6.7 : PET (FDG) for Head and Neck Cancers
220.6.8 : PET (FDG) for Myocardial Viability
220.6.9 : PET (FDG) for Refractory Seizures
220.7 : Xenon Scan
220.8 : Nuclear Radiology Procedure
220.9 : Digital Subtraction Angiography
220.10 : Portable Hand-Held X-Ray Instrument
220.11 : Thermography
220.12 : Single Photon Emission Computed Tomography (SPECT)
220.13 : Percutaneous Image-Guided Breast Biopsy

 230 : Renal and Genitourinary System - ESRD Services
230.1 : Treatment of Kidney Stones
230.2 : Uroflowmetric Evaluations
230.3 : Sterilization
230.4 : Diagnosis and Treatment of Impotence
230.5 : Gravlee Jet Washer
230.6 : Vabra Aspirator
230.7 : Water Purification and Softening Systems Used in Conjunction with Home Dialysis
230.8 : Non-Implantable Pelvic Floor Electrical Stimulator
230.9 : Cryosurgery of Prostate
230.10 : Incontinence Control Devices
230.12 : Dimethyl Sulfoxide (DMSO)
230.13 : Peridex CAPD Filter Set
230.14 : Ultrafiltration Monitor
230.15 : Electrical Continence Aid
230.16 : Bladder Stimulators (Pacemakers)
230.17 : Urinary Drainage Bags
230.18 : Sacral Nerve Stimulation For Urinary Incontinence
230.19 : Levocarnitine for use in the Treatment of Carnitine Deficiency in ESRD Patients

 240 : Respiratory System
240.1 : Lung Volume Reduction Surgery (Reduction Pneumoplasty)
240.2 : Home Use of Oxygen
240.2.1 : Home Use of Oxygen in Approved Clinical Trials
240.3 : Heat Treatment, including the Use of Diathermy and Ultrasound for Pulmonary Conditions
240.4 : Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA)
240.5 : Intrapulmonary Percussive Ventilator (IPV)
240.6 : Transvenous (Catheter) Pulmonary Embolectomy
240.7 : Postural Drainage Procedures and Pulmonary Exercises
240.8 : Pulmonary Rehabilitation Services

 250 : Skin
250.1 : Treatment of Psoriasis
250.2 : Hemorheograph
250.3 : Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases
250.4 : Treatment of Actinic Keratosis (AKs)

 260 : Transplantation - Solid Organ Transplants
260.1 : Adult Liver Transplantation
260.2 : Pediatric Liver Transplantation
260.3 : Pancreas Transplants
260.3.1 : Islet Cell Transplantation in the Context of a Clinical Trial
260.5 : Intestinal and Multi-Visceral Transplantation
260.6 : Dental Examination Prior to Kidney Transplantation
260.7 : Lymphocyte Immune Globulin, Anti-Thymocyte Globulin (Equine)
260.9 : Heart Transplants
260.10 : Heartsbreath Test for Heart Transplant Rejection

 270 : Wound Treatment
270.1 : Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds
270.2 : Noncontact Normothermic Wound Therapy (NNWT)
270.3 : Blood-Derived Products for Chronic Non-Healing Wounds
270.4 : Treatment of Decubitus Ulcers
270.5 : Porcine Skin and Gradient Pressure Dressings
270.6 : Infrared Therapy Devices

 280 : Medical and Surgical Supplies
280.1 : Durable Medical Equipment Reference List
280.2 : White Cane for Use by a Blind Person
280.3 : Mobility Assistive Equipment (MAE)
280.4 : Seat Lift
280.5 : Safety Roller
280.6 : Pneumatic Compression Devices
280.7 : Hospital Beds
280.8 : Air-Fluidized Bed
280.10 : Prosthetic Shoe
280.11 : Corset Used as Hernia Support
280.12 : Sykes Hernia Control
280.13 : Transcutaneous Electrical Nerve Stimulators (TENS)
280.14 : Infusion Pumps
280.15 : INDEPENDENCE iBOT 4000 Mobility System

 290 : Nursing Services
290.1 : Home Health Visits to a Blind Diabetic
290.2 : Home Health Nurses' Visits to Patients Requiring Heparin Injection

300 : Diagnostic Tests Not Otherwise Classified
300.1 : Obsolete or Unreliable Diagnostic Tests

 310 : Clinical Trials
310.1 : Routine Costs in Clinical Trials
h Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)
 hysician's Services
DST) in Kidney Transplantation
ebral Vasculature



nd Neuromuscular Electrical Stimulation (NMES)
In July 2006, CMS began implementing its plan to modernize fee-for-service (FFS) claims processing. The vision
a premier health plan that includes comprehensive quality care and first-class service. To realize that vision,
contractor (MAC) jurisdictions and to award a contract to a single contractor
in each jurisdiction to take responsibility for processing both Part A and Part B claims. CMS plans also
include the establishment of 4 MACs to process claims for durable medical equipment and 4 MACs to
process home health and hospice (HH) claims. As of August 2007, CMS has awarded 2 contracts for Part
A describes the jurisdictions and the transition schedule, and Appendix B defines key terms related to FFS

J10 Contract award by 9/08 - Cutover by 5/4/09

3/25/2009 WEBINAR CAHABA NOTES

EFT Form 588 to be received at CAHABA no later than April 20th

How will the provider know that their Form 588 Form has been received?
All the providers will be contacted if their Form 588 has not been received within 2 weeks of April 20

Form 588 requires 855A Medicare Authorized Signature on file

Angela Hunnicut - Contact BCBS to confirm the Authorized signature on file
If authorized person is no longer there, then 855A should be updated.

855A Enrollment Application Updates should be sent to BCBS - Business as usual

CHECK NPPES website to confirm your authorized signature

Joy Fowler - Policy Coordinator for Part A - LCD's have been posted and will go into effect 5/4/09

Julia McKinley, Clinical education

CMS Medicare pilot DRG Admissions Reviews - Transition from the QIO

Jan 1 -2008 Review of
Chest Pains
UTI's
Back Pain
Results will be published in an article soon

Using Interqual review criteria

Resulting in high error rates -
Plans are to Conduct a wide spread probe on Back pain and UTI

FINDINGS
Denied - did not meet I/P criteria
Patient could have been admitted to lower level of care - Should have been admitted to OBS isntead of I/P
Services could have been performed at lower level
Poor documention
Coding errors

CORRECTIVE ACTIONS
Go to the FISS Remarks screen - review documentation to make correction actions

Looking for documentation to support services that has been provided and coded on claim

APPEALS PROCESS
5 Step Process
Important Due Dates and Deadlines

Third Quarter Fiscal Year 2008: April 1, 2008 through June 30, 2008

 Third-quarter payment date: Wednesday, February 25, 2009.

Fourth Quarter Fiscal Year 2008: July 1, 2008 through September 30, 2008

 Provider enrollment deadline: March 1, 2009.
 Payment Requests and On-Call Payment forms due date: March 30, 2009.
 Fourth-quarter payment date: Monday, May 28, 2009.

First Quarter Fiscal Year 2009: October 1, 2008 through December 31, 2008

 Provider enrollment deadline: May 30, 2009.
 Payment Requests and On-Call Payment forms due date: June 29, 2009.
 First-quarter payment date: Friday, August 28, 2009.

Second Quarter Fiscal Year 2009: January 1, 2009 through March 31, 2009

 Provider enrollment deadline: August 28, 2009.
 Payment Requests and On-Call Payment forms due date: TBD.
 Second-quarter payment date: Thursday, TBD.

 To find out if you have a payment and the amount
 01 Inquiries
 FI - for checks
   Provider Number
NEW 2008 MEDICARE TERMS:

RAC’s – Recovery Audit Contractors

POA’s – Present on Admission Indicators

MSPRC – MSP Recovery Contractors

MAC’s – CMS is replacing its current claims payment contractors - fiscal intermediaries and carriers - with
new contract entities called Medicare Administrative Contractors (MACs). CMS plans to award a total of 19
MAC contracts through three procurement cycles. Fifteen of these contracts will be with entities that will cover
the majority of Part A and Part B services, i.e., A/B MACs GA, AL & TN are in J10 to be awarded by year
end.

MCR - Medicare Contracting Reform (MCR).

MUEs - Medically Unbelievable/Unlikely Edits. Last year, CMS started a new initiative under its
Comprehensive Error Rate Testing (CERT) program, which it originally titled the Medically Unbelievable Edit
program (MUE). CMS staff said the program would establish a set of edits for coding situations which should
never legitimately be billed. Effective Jan 2007

VBP - Value-Based Purchasing -
Value-based purchasing (VBP), which links payment to performance, is a key policy mechanism that CMS is
proposing to transform Medicare from a passive payer of claims to an active purchaser of care.

HAC’s – 8 Hospital Acquired Conditions (Effective 10-1-08)
Under the proposal, hospitals still would be paid for hospitalizations but would not be allowed to code and
charge for the following as "complicating conditions" if they develop during a patient's stay:
Surgical-site infections after total knee replacement, laparoscopic gastric bypass and gastroenterostomy, or
ligation and stripping of varicose veins.
Legionnaires' disease.
Diabetic ketoacidosis, nonketotic hyperosmolar coma, diabetic coma or hypoglycemic coma.
Iatrogenic pneumothorax.
Delirium.
Ventilator-associated pneumonia.
Deep-vein thrombosis or pulmonary embolism.
Staphylococcus aureus septicemia.
Clostridium difficile -associated disease. CDAD

PEPPER - Program for Evaluating Payment Patterns Electronic Report

CERT - Comprehensive Error Rate Testing

NEVER EVENTS - HAC's
MIPPA
Medicare Improvements for Patients and Providers Act of 2008

Qualified Independent Contractors (QICs) are companies that perform the second level of appeal
for Medicare fee-for-service claims.

NEW 2009 MEDICARE TERMS:

PCA - Progressive Corrective Action

EP - Eligible Professional

HRA - Health Reimbursement Arrangement

HDHP - High deductable Health Plan

ACE - ACUTE CARE EPISODE

				
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