CMS
Publication Date: November 05, 2004
Effective Date: January 01, 2005

Internet access to the 2005 clinical laboratory fee schedule data file will be available after November 18, 2004, at:  Payment Systems. Medicaid State agencies, the Indian Health Service, the United Mine Workers, Railroad Retirement Board, and other interested parties should use the Internet to retrieve the 2005 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text and comma delimited.

Pricing Information for the Travel Fee
For dates of service January 01, 2005 through December 31, 2005, the standard mileage rate for transportation costs is $0.385. The 2005 payment for code P9603 is $.835 and for code P9604 is $8.35.

For 2005, the clinical laboratory fee schedule will not include code G0001 and will include code 36415 Collection of venous blood by venipuncture. Code 36415 was released as not payable by Medicare in the 2005 HCPCS update file. However, code 36415 has now been activated to be payable by Medicare effective January 01, 2005. CPT code 36416 relating to a capillary specimen collection remains not payable by Medicare as a separate service.

Mapping Information for New and Revised Codes

• New code 82045 is priced at the same rate as code 83880.
• New code 82656 is priced at the same rate as code 83516.
• New code 83009 is priced at the same rate as code 83013.
• New code 83630 is priced at the same rate as code 83516.
• New code 84163 is priced at the same rate as code 84702.
• New code 84166 is priced at the sum of the rates of codes 84165 and 87015.
• New code 84450QW is priced at the same rate as code 84450.
• New code 86064 is priced at the same rate as code 86359.
• New code 86335 is priced at the sum of the rates of codes 86334 and 87015.
• New code 86379 is priced at the same rate as code 86359.
• New code 86587 is priced at the same rate as code 86359.
• New code 87807 is priced at the same rate as code 87804.

Reference: Medicare Transmittal 363  CR 3526.

CMS

Beneficiary signatures are required on submitted claims in item 12 of the CMS-1500 claim form.

In lieu of signing the claim, the patient may sign a statement or authorization form to be retained in the provider's file indefinitely, unless revoked by the patient. The provider can then submit "signature on file" in item 12.

For electronic claims submitted in ANSI 4010A1 format, submitters/providers must enter one of the following values in Loop 2300 2-130- CLM10:

B - Signed signature authorization form or forms for both CMS-1500 Claim Form item 12 and item 13 are on file

C - Signed CMS-1500 Claim Form on file

M - Signed signature authorization form for CMS-1500 Claim Form item 13 on file

P - Signature generated by provider because the patient was not physically present for services

S - Signed signature authorization form for CMS-1500 Claim Form item 12 on file

For more information on signature requirements, refer to Claim Form CMS-1500  Instructions.

CMS
Publication Date: October 22, 2004
Effective Date: January 01, 2005

The latest package of Correct Coding Initiative (CCI) edits, Version 11.0, effective January 01, 2005, will be available via the CMS Data Center (CDC). A test file will be available on or about November 01, 2004, and the final file will be available on or about November 16, 2004.

Version 11.0 will include all previous versions and updates from January 01, 1996, to the present and will be organized in two tables: Column 1/ Column 2 Correct Coding Edits and Mutually Exclusive Code (MEC) Edits.

Reference: Medicare Transmittal 324  CR 3491.

CMS
Publication Date: October 04, 2004
Effective Date: January 01, 2005

All chemistries ordered for ESRD patients must be billed individually with the following modifiers:

CD - AMCC test that has been ordered by an ESRD facility that is part of the composite rate

CE - AMCC test that has been ordered by an ESRD facility that is a composite rate test, but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity

CF - AMCC test that is not part of the composite rate and is a separately billable test that has been ordered by an ESRD facility

Medicare will calculate the number of AMCC services provided for any given date of service and divide the number of services with a CD modifier by the total number of services. If the calculation is 50% or greater, the carrier will not pay for the test. If the result is less than 50%, the carrier will pay for all the services.

For further detail refer to:  Transmittal 198  CR 2813.

CMS
Publication Date: August 01, 2004
Effective Date: January 01, 2005

The Remittance Advice Remark Codes are maintained by CMS and updated three times per year. The June 2004 updates for the X12N 835 Health Care Remittance Advice Remark Codes and the X12N835 Health Care Claim Adjustment have been posted and are available on line at: http://www.wpc-edi.com/codes/Codes.asp

The new codes will become effective on January 01, 2005. The following codes have been added: 
  

NHIC – California and New England
Publication Date: November 04, 2004

NHIC often receives requests to correct a claim as a result of a billing error.

Claim corrections are generally simple corrections. For example:

• Dates of service entered incorrectly (i.e., 09152003 instead of 09152004)
• Units entered as 0001 instead of 0010
• Dollars entered as 2.00 instead of 200.00

To request corrections as a result of these issues, providers may do one of two things:

• Submit the remittance advices with the claim(s) in question identified, along with a reason for the correction.
• Submit a list that contains the beneficiary name, HIC number, ICN, date of service, along with a request to correct the item billed or paid incorrectly and the reason for the change.

Requests for corrections should be sent to the appropriate post office box.

• For Northern California: Medicare Written Inquiries, PO Box 2006, Chico, CA 95927-2006.
• For Southern California: Medicare Adjustments, PO Box 272857, Chico, CA 95927-2857.
• For New England: Medicare Written Inquiries, P.O. Box 1000; Hingham, MA 02044.

Reference:  NHIC.

California - NHIC

• Amylase
  Publication Date: September 22, 2004
  Effective Date: October 01, 2004

  The LMRP for Amylase (CPT code 82150) has been updated to include the following change:

  • Deleted information in the Non-covered ICD-9 Codes section due to duplicative information.

  Reference: NHIC Policy  03-02.1R2.

California - NHIC
Publication Date: November 20, 2004

If you discover that an overpayment of Medicare funds has occurred, you are expected to notify the program and take appropriate actions to remedy the situation.

Please complete and forward the appropriate information to NHIC, your Medicare contractor. The attached form is required, or a similar document containing the following information, to accompany every unsolicited/voluntary refund so that receipt of check is properly recorded and applied. If specific patient/HIC/Claim # information is not provided, no appeal rights can be afforded with respect to the refund. Providers/physicians/suppliers, and other entities who are submitting a refund under the OIG’s Self-Disclosure Protocol or who are under a CIA, are not afforded appeal rights as stated in the signed agreement presented by the OIG.

National Heritage Insurance Company (NHIC) would like to emphasize the importance of submitting voluntary refunds with proper information to ensure that the refund is processed accurately and on a timely basis. All funds returned to the program should include relevant information to properly account for the refund.

• Fill out the "Overpayment Refund Form" completely for each claim, (if available, submit a copy of the Remittance Advice (RA) or Medicare Summary Notice (MSN) with the claim highlighted and notated with the exact amount of the refund and the reason for the refund), or
• Submit a spread sheet listing the following information for each claim:
• Claim Internal Control Number (ICN) from the Medicare RA/MSN
• Patient HIC Number from the Medicare RA/MSN
• Patient’s Name as shown exactly on the Medicare RA/MSN
• Date of Service
• Procedure Code
• Refund Reason
• Refund Amount
• For OIG Reporting Requirements:

Do you have a Corporate Integrity Agreement with OIG? ____ Yes ____No

Are you a participant in the OIG Self-Disclosure Protocol? ____ Yes ____ No

In addition:

• Be sure to use the claim identifying information from the Medicare RA/MSN that you received. Do not use your own internal account numbers, patient numbers, or invoice dates, etc.
• Make checks payable to: Medicare
• Submit Medicare Secondary Payer (MSP) refunds to:
• For New England: Medicare Cash Accounting, P.O. Box 9103, Hingham, MA 02044
• For Northern California: Medicare Secondary Payer Refunds, P.O. Box 951, Marysville, CA 95901
• For Southern California: Medicare Cash Accounting, P.O. Box 515301, Los Angeles, CA 90051-6601
• Submit all other refunds to:
• For New England: Medicare Cash Accounting, P.O. Box 9103, Hingham, MA 02044
• For Northern California: Medicare Cash Accounting, P.O. Box 391, Marysville CA 95901
• For Southern California: Medicare Cash Accounting, P.O. Box 515301, Los Angeles, CA 90051-6601

Reference:   Voluntary Refunds  NHIC.

California - NHIC
Publication Date: September 23, 2004
Effective Date: December 01, 2004

A reminder to all providers that item 11 must be completed on the CMS-1500 claim form. Although this information has been required by CMS, NHIC has not been screening for it. Effective December 01, 2004, NHIC will begin to audit the paper claim form for this information, and if it is missing, your claim will be rejected.

Reference:   Info for Providers  Medicaid Update.

California - Medi-cal
Publication Date: October 2004
Effective Date: October 18, 2004

The 2004 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II and Local Level III codes are effective for Medi-Cal for dates of service on or after October 18, 2004 and policies were published in the September Medi-Cal Update. Additional policy changes are highlighted below.

Radiology
Codes Requiring Split Bill Modifiers
HCPCS radiopharmaceutical codes A9525 and A9528 – A9532 are 100 percent professional and must be billed with modifiers -26 or -ZS. The codes are billable by hospitals or radiologists.

Maximum Reimbursement: Code Combinations
Only one code in the combination of CPT-4 codes 70250 v. 70260 will be reimbursed if billed for the same date of service, same provider.

California - Medi-Cal
Effective Date: January 2005

Beginning January 2005, Medi-Cal will be issuing new Benefits Identification Cards (BIC) with a 14-character BIC ID. A statewide phase-in process will be used to issue cards to all Medi-Cal recipients. The Department of Health Services' goal is to replace all 10-character BIC IDs by July 01, 2005.

You can see a facsimile of the letter:  EDS letter.

California – Medi-Cal
Publication Date: November 2004

Effective for dates of service on or after December 1, 2004, CPT-4 code 76604 (ultrasound, chest, B-scan [includes mediastinum] and/or real time with image documentation) is a Medi-Cal benefit. This practice is limited to four claims per year, for the same recipient, by any provider. Additional claims for this code must be accompanied with appropriate medical justification.The updated information is reflected on manual replacement pages radi 8 (Part 2) and tar and non cd7 2 (Part 2).

California – Medi-Cal
Publication Date: November 2004

Effective for dates of service on or after December 1, 2004, CPT-4 code 76800 (ultrasound, spinal canal and contents) is a Medi-Cal benefit. Code 76800 is reimbursable for recipients 5 years of age or younger, for up to two procedures per calendar year for the same recipient, any provider. Additionally, code 76800 is reimbursable only when billed in conjunction with one of the following ICD-9 diagnosis codes, which must be documented in the Primary ICD-9-CM field (Box 21):
  

California – Medi-Cal
Publication Date: November 2004

Effective for dates of service on or after December 1, 2004, reimbursement guidelines for Positron Emission Tomography (PET) scans when billed with CPT-4 code 78810 (tumor imaging, positron emission tomography [PET], metabolic evaluation) will be expanded to include the restaging of recurrence of residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation for recipients with a serum thyroglobulin level greater than 10 mg/ml and a negative 1-131 whole body scan.

Reminder: Reimbursement for CPT-4 code 78810 requires a Treatment Authorization Request (TAR) for medical documentation or the claim will be denied.

The updated information is reflected on manual replacement page radi nuc 2 (Part 2).

Medi-Cal Update:  Bulletin 364.

Medicare:  New York – Empire