Effective Date: December 8, 2003
Implementation Date: August 16, 2004

Hospitals are no longer required to collect Medicare Secondary Payer (MSP) information where there is no face-to-face encounter with a beneficiary.

Reference:  Medlearn Matters  MM3267.   Related CR:  3267, Transmittal 17.

Effective Date: October 1, 2004

CMS asks providers to discontinue the practice of routinely resubmitting duplicate claims. If you submit more than once for the same service on the same date of service, your claim will be denied as a duplicate. In addition, duplicate claims:

1) may delay payment;
2) could cause you to be identified as an abusive biller;
3) if a pattern of duplicate billing is identified, may generate      an investigation for fraud.

Reference:  MMSE0415.

Effective Date: January 01, 2004 (Retroactive)

This is the 2^nd update to the 2004 Medicare Physician Fee Schedule Database, and includes the following changes:

Reference:  MM3286, CR: 3286; Transmittal:  173

Effective Date: October 1, 2004
Implementation Date: October 4, 2004

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires a process for physicians, providers, and suppliers to correct minor errors and omissions on claims without pursuing the formal appeals process.

Reference:  Medlearn Matters  SE0420.

Publication Date August 05, 2004

An article published in Medicare B Resource for June 2003 (page 21) announced that Medicare considered High sensitivity C-reactive protein to be used as a screening test only and therefore not reimbursable. This policy is being revised based on updated information. High sensitivity C-reactive protein (hsCRP) (CPT code 86141) has been found to be related to or somewhat predictive of atherogenic risk for cardiovascular disease or stroke. Recent literature supports this as the principal use of hsCRP. Effective immediately, NHIC-California will consider hsCRP (CPT 86141) for payment as part of the overall evaluation and treatment plan indicated for the signs or symptoms of disease. In the absence of signs or symptoms of disease, use of hsCRP as a screening test remains non covered by Medicare. In addition, where appropriate, the less costly standard CRP test (CPT 86140) should be considered.

Reference:  California Providers, Updates.

Effective Date October 01, 2004

Trailblazer – Virginia has published their Local Medical Review Policies (LMRPs) in their August News letter.

Reference:  Part B Medicare, Newsletter.

Electronic Submission of Laboratory Services with Medical Justification

Effective for dates of service on or after September 1, 2004, providers may electronically bill for laboratory services (CPT-4 80000 series codes and HCPCS Level III codes) that require medical justification by entering the medical justification in the electronic filing Remarks area of the transaction. Medical justification statements entered in the electronic filing Remarks area must not exceed 1,500 characters. If the statement exceeds the character limit, providers must submit a paper claim with the appropriate medical justification documents accompanying the claim. Claims and "By Report" attachments for the following CPT-4 and HCPCS codes may not be submitted electronically:

No Implementation Grace Period

Effective Date: October 1, 2004

The HIPAA Transaction and Code Set Rule requires the use of national/medical code sets (such as ICD-9s) that are valid at the time the service is rendered. All claims for services on or after October 1, 2004 must adhere to the 2005 diagnosis code changes.

In past years, ICD-9 codes became effective for Medi-Cal in January or February. Though code updates were released in October, Medi-Cal implementation was delayed to coincide with Medicare implementation. Medi-Cal allowed a 90-day grace period to allow you to become familiar with the new codes and learn about discontinued codes.

This year there is no grace period for use of the codes on claim submissions.

Refer to the 2005 International Classification of Diseases, 9th Revision, Clinical Modification, 6th Edition (ICD-9-CM book) for code descriptions.