| April 22, 2005 |
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Quarterly Update to CCI Edits
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CMS CR 2987
Effective Date: April 01, 2005
The Centers for Medicare & Medicaid Services (CMS) has released the Quarterly Update to Correct Coding
Initiative (CCI) edits, Version 11.1, effective April 01, 2005.
Version 11.1 will include all previous versions and updates from January 01, 1996, to the present and will
be organized into tables. Table 1 contains Column 1/Column 2 Correct Coding Edits and table 2 contains Mutually Exclusive
Code (MEC) Edits. The current update reflects the following changes:
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| CORRECT CODING EDITS |
| Column 1 |
Column 2 |
Effective
Date |
Modifier* |
| 84481 |
84480 |
20050401 |
0 |
| 87140 |
87269 |
20050401 |
1 |
| 87147 |
87329 |
20050401 |
1 |
| 87253 |
87269 |
20050401 |
1 |
| 87253 |
87329 |
20050401 |
1 |
| 87253 |
87660 |
20050401 |
1 |
| 87254 |
87269 |
20050401 |
1 |
| 88161 |
88160 |
20050401 |
0 |
| * 0=not allowed 1=allowed 9=not applicable |
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| MUTUALLY EXCLUSIVE EDITS |
| Column 1 |
Column 2 |
Effective
Date |
Modifier |
| 84160 |
84156 |
20050401 |
1 |
| 84160 |
84157 |
20050401 |
1 |
| 87149 |
87660 |
20050401 |
1 |
| * 0=not allowed 1=allowed 9=not applicable |
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NCD Revisions
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CMS CR 3722
Publication Date: March 11, 2005
Effective Date: April 01, 2005
The Centers for Medicare & Medicaid Services announced there is no recurring update to the NCD laboratory edit
software for April 2005.
Labs should continue using the version of the edit module included in the January 2005
release.
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New Waived Test
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CMS List of Waived Tests
CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that
Medicare and Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities
with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level.
Listed below are the latest tests approved by the FDA as waived tests under the CLIA. The Current Procedural
Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test.
| CPT Code / Modifier |
Effective Date |
Description |
| 86703QW |
06-25-2004 |
OraSure OraQuick Advance Rapid HIV-1/2 Antibody Test {Oral Fluid,Fingerstick Whole Blood and Venipuncture Whole Blood} |
| 84443QW |
08-18-2004 |
ThyroTec, Inc. ThryoTest Whole Blood TSH Test |
| 87880QW |
10-29-2004 |
Beckman Coulter ICON DS Strep A Test |
| 87880QW |
10-29-2004 |
Laboratory Supply Company (LSC) PEP Strep A Cassette Test |
| 87880QW |
10-29-2004 |
Laboratory Supply Company (LSC) PEP Strep A Dipstick Test |
| 87880QW |
10-29-2004 |
Stanbio Laboratory EZ-Well Strep A Rapid Device Test |
| 83036QW |
11-09-2004 |
Provalis Diagnostics In2it In-Office Analyzer (II) A1C Prescription Home Use Test System |
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Update to Submission of Purchased Services
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CMS CR3481
Publication Date: October 29, 2004
Effective Date: April 04, 2005
CR 3481 instituted a national abstract file of the Medicare Physician Fee Schedule (MPFS) containing
Healthcare Common Procedure Coding System (HCPCS) codes billable as purchased diagnostic tests and
interpretations for every locality throughout the country. Effective April 01, 2005, suppliers, including
laboratories, physicians, and IDTFs, are to bill their local carrier for purchased diagnostics tests and
interpretations, regardless of the location where the service was furnished. However, until further notice,
CMS is delaying the implementation of the billing instructions specified in CR 3481 for purchased
diagnostic service claims submitted by physicians due to a locality reporting issue.
Effective April 01, 2005, carriers should price claims based on the ZIP code of the location where the
service was rendered when submitted by a laboratory or IDTF, using a CMS-supplied abstract file of the
MPFS containing the HCPCS codes that are payable under the MPFS as either a purchased test or
interpretation for the calendar year. Until further notice, carriers should pay the local rate for purchased
interpretation claims when submitted by a physician. Carriers should accept and process claims when
billed by suppliers enrolled in the carrier’s jurisdiction, regardless of the location where the service
was furnished.
Some Medicare carriers use a claims processing system (known as the ViPS Medicare Part B system) to
process Medicare claims. These carriers will not implement this change at this time. Those carriers are:
- Empire Medicare Services
- Blue Cross Blue Shield of Kansas
- Triple–S
- GHI
Until further notice, physicians and independent diagnostic testing facilities who bill these carriers should
continue to follow the billing instructions provided in CR 3630 issued on December 23, 2004.
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Updated LCD
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Kansas – Medicare L9269
Effective Date: April 13, 2005
Medicare Kansas has retired the following LCD / HER-2/NEU GENE AMPLIFICATION AND OVEREXPRESSION TESTS effective 4/13/2005.
The procedure codes are: 88342, 88367 and 88368
- 174.0 to 174.0
- 174.2 to 174.2
- 174.3 to 174.3
- 174.4 to 174.4
- 174.5 to 174.5
- 174.6 to 174.6
- 174.8 to 174.8
- 174.9 to 174.9
- V70.1 to V70.9
- V72.81 to V72.84
- 174.0 to 174.0
- 174.2 to 174.2
- V70.1 to V70.9
- V701.0 to V701.9
- V72.81 to V72.84
- 174.0 to 174.0
- 174.2 to 174.2
- V701.0 to V701.9
- V72.81 to V72.84
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| Updated LCD
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New York – Empire Medicare YPTH27r2
Publication Date: February 28, 2005
Effective Date: April 15, 2005
Empire Medicare New York has updated LCD 84066 / Phosphatase, acid, prostatic effective 04/15/2005 to include the following ICD-9 Codes.
- 199.0
- 199.1
- 600.01
- 600.10
- 600.11
- 600.21
- 600.90
- 600.91
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| Multi-Carrier System
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New York – Empire Medicare MCS
Effective Date: May 02, 2005
Empire Medicare New York is transitioning to the Multi-Carrier System (MCS) on May 02, 2005. As a result,
the Companion Guide for HIPAA-compliant 837 X12 4010A1 claim transactions is being updated. In addition, the
new MCS Edit Report will replace the Medicare Part B VMS Submitter Report (commonly known as the validation
report) for all electronic claim submitters.
One of the major advantages of electronic billing is notification of billing errors within 24–48 hours
of claim submission, which affords the provider / submitting entity the opportunity to quickly correct and
resubmit rejected claims. Currently, the Medicare Part B VMS Submitter Report is used to report claim
rejection information. Due to Empire Medicare Services’ migration to the MCS system, the MCS Edit Report will
be the standard validation report. The new report will provide more detailed claim rejection information.
The MCS Edit Report is available approximately 24–48 hours after sending a file that was accepted on the
997 Functional Acknowledgement. The MCS Edit Report will be available for viewing or download for 30 calendar
days. Once it is downloaded, it will remain on the file for 11 days. It is important to dial–in regularly to
retrieve any available reports to ensure you know whether Medicare has accepted your claims for adjudication
or if the claims were rejected and need to be corrected and resubmitted.
Without this report, you will not know whether your claims were received or rejected by Medicare. Claims
rejected on this report will not be processed by Medicare or be reported on the Standard Paper Remittance
(SPR), Electronic Remittance Advice (ERA), or the Interactive Voice Recognition System (IVR).
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Sputum Procedure Billing and Rate Update |
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California – Medi-Cal Bulletin 368
Publication Date: March 2005
Effective Date: April 04, 2005
Sputum Procedure Billing and Rate Update Effective for dates of service on or after April 04,
2005, CPT–4 code 89220 (sputum, obtaining specimen, aerosol induced technique) is no longer billed "By
Report," and also is exempt from the Clinical Laboratory Improvement Amendment (CLIA) edits. The Medi–Cal
maximum reimbursement rate for this code is $10.33. This updated information is reflected on manual replacement
page rates max lab 8 (Part 2).
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10% Reduction in Independent Lab Fees
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Florida – Medicaid Bulletin 364
Publication Date: January 2005
Effective Date: February 01, 2005
Florida Medicaid has published notice that effective for dates of service beginning on April 01, 2005,
Medicaid is implementing a 10% reduction for all Medicaid independent laboratory fees. The reduction was
mandated by the Florida Legislature because no contract will be in place by April 01, 2005. Conference
Report HB 1835 - FY 2004-2005, line 210: "If by April 01, 2005, because of litigation or for other
reasons, the agency has been unable to enter into a risked-based contract with a single or multiple
independent laboratories where Medicaid payment is made on a per eligible per month basis, the agency
shall reduce all Medicaid fees for all independent laboratory procedures by 10 percent."
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National Provider Identifier Enumerator
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Department of Health and Human Services Award Notice
Award Date: February 24, 2005
Publication Date: February 25, 2005
Department of Health and Human Services (DHHS) announced on April 05, 2005 the enumerator contractor
for performing the support functions for the National Provider Identifier project.
As the enumerator for the NPI project, Fox System Inc. will process applications from health care providers
and operate a help desk to assist health care providers in obtaining the new standard unique health care provider
identification number (the NPI). The assignment of NPIs will begin later this year.
The standard unique identifier for health care providers is mandated by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and will eventually become the primary health care provider identifier for
standard transactions.
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Exclusions & Reinstatements
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HHS Office of Inspector General Exclusion Program
Publication Date: March 2005
The Office of Inspector General (OIG), under Congressional mandate contained in sections 1128 and 1156,
established a program to exclude individuals and entities from participating in federally funded health care
programs.
Follow the link above to review the Excluded Entities, and the Excluded Entities Reinstated.
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