CMS
Update
Medicare Matters MM4144
Publication Date: November 10, 2005
Effective Date: January 01, 2006
This article and related CR4144 contain important information regarding:
- The 2006 annual updates to the clinical laboratory fee schedule;
- Mapping for new codes for clinical laboratory tests; and
- Laboratory costs related to services subject to reasonable charge payments.
It is important that affected laboratories understand these changes to ensure correct and accurate payments from Medicare.
New Website
In addition, CMS developed the Clinical Laboratory website for Suppliers and Providers. This webpage incorporates information specific to Clinical Laboratories in a general area. CMS will continue to add information to this page as it becomes available, and hopes to improve both functionality and formatting to make the page more user-friendly.
The website, http://www.cms.hhs.gov/suppliers/clinlab/ contains a link to the Clinical Laboratory Fee Schedule for 2006.
Updates are currently posted on websites for the following carriers:
BCBS Kansas
Empire New York
NHIC
Noridian
WPS
United Government Services
CMS
Medicare Matters MM3681
Publication Date: March 04, 2005
Effective Date: July 01, 2005
Billing for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS). This instruction provides information contained in Change Request (CR) 3681 which compiles and clarifies Medicare procedures and policies for the billing of blood and blood products in the hospital outpatient setting. In particular, hospitals should note the portions of this instruction that inform them when to use new modifier BL when submitting claims for blood and blood products.
Modifier BL (Special Acquisition of Blood and Blood Products).
CMS
Announcing the new CMS website dedicated to providing all the latest NPI news for Fee–For–Service (FFS) Medicare providers! Visit: http://www.cms.hhs.gov/providers/npi/ on the Web! While this page is dedicated to the Medicare FFS community, it contains helpful information and links that may benefit all health care providers. Reminder—Health care providers are required by law to apply for a National Provider Identifier (NPI). To apply online, visit: http://www.cms.hhs.gov/providers/npi/apply.asp.
CMS
Remark Codes and Claim Adjustment Reason Codes MM4123
Publication Date: November 04, 2005
Effective Date: January 01, 2006
The complete list, including changes made from March 01, 2005 through June 30, 2005, of X12N 835 Health Care Remittance Advice Remark Codes and X12N 835 Health Care Claim Adjustment Reason Codes can be found at http://www.wpc-edi.com/codes.
| Code | New/ Modified/ Deactivated/ Retired |
Current Narrative | Comment |
| N348 | New | You chose that this service/supply/drug would be rendered/supplies and billed by a different practitioner/supplier. | Medicare Initiated |
| N349 | New | The administration method and drug must be reported to adjudicate this service. | Not Medicare Initiated |
| N350 | New | Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or an Unlisted procedure. | Not Medicare Initiated |
| N351 | New | Service date outside of the approved treatment plan service dates. | Not Medicare Initiated |
| N352 | New | There are no scheduled payments for this service. Submit a claim for each patient visit. | Not Medicare Initiated |
| N353 | New | Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim. | Not Medicare Initiated |
| N354 | New | Incomplete/invalid invoice | Not Medicare Initiated |
| N355 | New | The law permits exceptions to the refund requirement in two cases: - If
you did not know, and could not have reasonably been expected to know, that we would not
pay for this service; or - If you notified the patient in writing before providing the
service that you believed that we were likely to deny the service, and the patient signed
a statement agreeing to pay for the service.
If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request review of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position. If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision. The law also permits you to request an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination. The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days. Note: (New Code 8/1/05) |
Medicare Initiated |
CMS
Modification to Online Medicare Secondary Payer Questionnaire MM4098
Publication Date: October 21, 2005
Implementation Date: January 21, 2006
CMS received information that a prior instruction (CR3504) did not specifically mention all of the changes that were made to the “Medicare Secondary Payer (MSP) Questionnaire.” CR4098 identifies all of the changes made as part of CR3504 and makes additional changes to the model questionnaire. The official instructions issued to your Medicare carrier or intermediary regarding this change and the model questionnaire can be found at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS web site.
CMS
Voided, Canceled and Deleted Claims
Revision CR3627 MM3627
Publication Date: June 17, 2005
Implementation Date: October 01, 2006
Change Request (CR) 3627, describes new CMS procedures and specific instructions to Medicare contractors (carriers, intermediaries, and DMERCs) for voiding, canceling and deleting claims. As a result of these changes, providers should note that some claims they were able to delete in the past will no longer be deleted from Medicare’s systems, but will instead become denied claims.
Regarding NCD Edits
Medlearn Matters CR 4005
Publication Date: August 19, 2005
Effective Date: October 01, 2005
Implementation Date: October 03, 2005
The September 12, 2005 issue of the XIFIN e-Newsletter erroneously displayed 585.2 as a new ICD-9 code covering PSA. XIFIN corrected this mistake and the archived newsletter now correctly displays the information. XIFIN takes seriously its publishing of the e-Newsletter and includes a reference source in the article. XIFIN respectfully reminds “laboratories should always consult primary sources before applying any changes that may affect billing or financial reporting.”
California – NHIC
Change in the Amount in Controversy Requirements for Administrative Law Judge (ALJ) and Federal District Court Appeals
What’s New Appeals Amount Change 11/05
Publication Date: November 23, 2005
The amount that must remain in controversy for Administrative Law Judge (ALJ) hearing requests made before January 01, 2006 is $100. This amount will increase to $110 for requests made on or after January 01, 2006. The amount that must remain in controversy for Federal District Court review before January 01, 2006 is $1,050. This amount will increase to $1,090 for appeals to Federal District Court made on or after January 01, 2006.
The new codes will go into effect January 01, 2006 without a 90-day grace period for Medicare carriers and intermediaries.
California – Medi-Cal
Provider Manual Updated
Medi-Cal Update Bulletin 375
Publication Date: October 2005
Save Removed Manual Pages
Because administration of the County Medical Services Program (CMSP) transferred to Blue Cross
Life & Health Insurance Company (Blue Cross) for dates of service on or after October 01, 2005, CMSP
information is being updated in or removed from the Medi-Cal provider manuals.
California – Medi-Cal
Human Papillomavirus DNA or RNA
Test Restrictions Update
Medi-Cal Update Bulletin 375
Published Date: October 2005
Effective for dates of service on or after November 15, 2005
New reimbursement requirements will be initiated for Human Papillomavirus (HPV) test code 87621 (infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique). Reimbursement of HPV screening is supported for women who qualify to receive the following services:
- Follow-up of Low-grade Squamous Intraepithelial (LSIL) cytology result in women less than 21 years of age (HPV DNA testing at 12 months in lieu of cytology at six and 12 months is an option).
- Follow-up post colposcopy in women with Paps read as Atypical Squamous Cell, High Grade (ASC-H), LSIL, or HPV DNA positive Atypical Squamous Cells of Undetermined Significance (ASC-US) in whom Cervical Intraepithelial Neoplasia (CIN) is not identified at colposcopy (may be followed up at 12 months with HPV DNA testing in lieu of cytology at six and 12 months).
- Follow-up of women with biopsy proven CIN I (HPV DNA testing at 12 months in lieu of cytology at six and 12 months is an option).
- Follow-up in women post treatment of CIN II and III (HPV DNA testing at least six months after treatment in lieu of three follow-up Pap smears is an option).
Code 87621 may be billed with modifier -26, -TC or –ZS and is reimbursable once every 12 months, any provider, for female recipients 15 years of age or older when billed with one of the following ICD-9 codes:
| ICD-9
Code |
Description |
| 233.1 | Carcinoma in situ of breast and denitourinary system; cervix uteri |
| 622.11 | Dysplasia of cervix (uteri); mild dysplasia of cervix |
| 622.12 | Dysplasia of cervix (uteri); moderate dysplasia of cervix |
| 795.01 | Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US) |
| 795.02 | Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) |
| 795.03 | Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL) |
| 795.05 | Cervical high risk human papillomavirus (HPV) DNA test positive |
Non-Benefit Codes 87620 and 87622
HPV test codes 87620 (infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus,
human, direct probe technique) and 87622 (…papillomavirus, human, quantification) will be
non-benefits, effective for dates of service on or after November 1, 2005.
California – Medi-Cal
Medi-Cal Update Medi-Cal Bulletin
November 2005
The November Update is a list of providers who have been added to the Medi-Cal Suspended and Ineligible Provider List (S&I List) for the month of November.
The Medi-Cal Suspended and Ineligible Provider List is updated monthly.