CMS  CR 2987
Publication Date: February 18, 2005
Effective Date: April 01, 2005
Implementation Date: July 01, 2005

CMS has established units of service edits called Medicare Unbelievable Edits (MUEs) effective July 01, 2005. The edits will test the same beneficiary, procedure code, dates of service and billing provider against a criteria number of units of service. Beginning April 01, 2005 the CCI edits will contain a revised table of MUEs. The MUE table will be provided on a quarterly basis to Medicare Part B to the Outpatient Code Editor (OCE) maintainer for installation into the OCE for hospitals subject to outpatient prospective payment system bill types 12x and 13x. The OCE will generate the edit for MUEs, which will result in a line item rejection. CMS will require quarterly updates to the MUE table as part of CCI instructions.

CMS  70.8.8.1
Publication Date: December 39, 2004
Effective Date: January 31, 2005

Revision 420 extends the 1 year limit under §1848(g)(4), of the Social Security Act, claim filing provision if "good cause" is shown. If an assigned claim is filed more than one year after the date of service, but within the time limits specified in §70.8.6, Chapter 1, of the carrier, and if the carrier determines that good cause exists, they will treat it as a timely-filed claim for payment and compliance monitoring purposes and waive the 10 percent payment reduction for that service. The time limit for filing may not be extended beyond the time limits specified in §70.8.6, chapter 1, of the manual, unless administrative error is applicable. If an assigned service is filed after the time limits specified in §70.8.6, chapter 1, of the manual, the 10 percent payment reduction will be waived only for administrative error.

CMS  CR 3467
Publication Date: November 26, 2004
Effective Date: January 03, 2005

Effective January 03, 2005 CR 3467 extends the provision of Section 542 of Benefits Improvement Protection Act of 2000 (BIPA) for services furnished in 2005 and 2006. Section 542 of BIPA allows the carrier to continue to pay independent laboratories under the physician fee schedule for the technical component of physician pathology services furnished to patients of a covered hospital.

Section 542 of BIPA provided that Medicare carriers could continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital during 2001 and 2002. For this provision, covered hospital means a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999. The carrier will require independent laboratories that had an arrangement on or prior to July 22, 1999 with a covered hospital to bill for these services to provide a copy of this agreement or other documentation substantiating that an arrangement was in effect between the hospital and independent laboratory as of that date in order to pay the claim. This CR extends the provision for services provided during 2005 and 2006.

Additional Reference: Transmittal 456  CR 3675.

CMS  CR 3557
Publication Date: December 23, 2004
Effective Date: January 25, 2005

CMS issued a correction to the Medicare Claims Processing Manual to correct text in illustrative examples in an existing Medicare Claims Processing manual section to show the appropriate dates on which interest is due, the appropriate total number of days for which interest payment is due, and the correct interest to be paid on certain Medicare claims not paid timely.

CMS  CR 3483
Publication Date: November 19, 2004
Effective Date: April 01, 2005

CMS has reissued a revision for payment policy for AMCC tests performed out of carrier's jurisdiction. CMS has outlined the policy in CR 3483 which will become effective April 01, 2005.

CR 3483 changes this policy for all AMCC tests. Effective April 01, 2005, if AMCC tests/panels are referred to another laboratory(s) for processing, your carrier must calculate the amount payable for each locality in which the particular test or panel is performed.

CMS  CR 3679
Publication Date: January 28, 2005
Effective Date: July 01, 2005

Effective July 01, 2005 CMS will implement a new Remittance Advice (RA) message for claim items denied due to the CWF duplicate claim edit for referred clinical diagnostic/purchased diagnostic service claims:

• Carriers will use the following remark code on remittance advice notices generated for a referred clinical diagnostic/purchased diagnostic service claim line item denied as a duplicate of a previously paid service: "Your claim for a referred clinical diagnostic/purchased diagnostic service cannot be paid because payment has been made for this service in another carrier jurisdiction."

CMS  MM3659
Publication Date: January 21, 2005
Effective Date: July 01, 2005

Medicare pays for one Pap smear every year for high risk beneficiaries and one Pap smear every two years for low risk beneficiaries. Currently, Medicare does not edit to see if a low risk Pap Screen has been paid when processing a high risk Pap Screen for the same patient. Beginning for dates of service on and after July 01, 2005, these types of claims will deny appropriately.

In instances where unsatisfactory screening Pap smear specimens have been collected and sent to the clinical laboratory and the clinical laboratory is unable to interpret the test results, another specimen is needed. When billing for sending another specimen to the clinical laboratory, the physicians should use HCPCS code Q0091 along with modifier 76, which will bypass the frequency editing and allow payment to be made for reconveyance of the specimen.

Effective for services rendered on and after July 01, 2005, where physicians must perform a screening Pap smear that they know will not be covered by Medicare because the low risk beneficiary has already received a covered screening Pap smear in the past two years, the physicians should obtain an ABN and can bill using Q0091-GA to receive the appropriate denial.

V72.31 will be added to the edits in the Medicare system for low risk beneficiaries. The V72.31 diagnosis code is to be used on Pap smear claims to indicate the beneficiary is a low risk patient, but only when a full gynecological examination is performed.

The following chart lists the diagnosis codes that Medicare recognizes for low risk or high risk patients for screening Pap smear services with V72.31 recognized as of July 01, 2005.

Low Risk Diagnosis Codes Definitions

• V76.2 Special screening for malignant neoplasms, cervix
• V76.47 Special screening for malignant neoplasm, vagina
• V76.49 Special screening for malignant neoplasm, other sites

Note: providers use this diagnosis for women without a cervix.

• V72.31 Routine gynecological examination

Note: This diagnosis should only be used when the provider performs a full gynecological examination.

High Risk Diagnosis Code

• V15.89 Other

CMS  CR 3650
Publication Date: February 04, 2005
Effective Date: April 01, 2005

CMS announced that the FDA has waived seven more tests under the test categorization scheme established by CLIA. The tests and their CPT codes are:

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 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

California – Medi-Cal  Bulletin 366
Publication Date: January 2005
Effective Date: February 01, 2005

The January 2005 Medi-Cal Update bulletin announced changes to the scope of services for laboratory testing for Chlamydia trachomatis and Neisseria gonorrheoeae under the Family PACT Program.

Implementation, which was scheduled for February 01, 2005, is rescinded to allow for further study of the issue. For reference and until further notice, Family PACT is not reimbursing for CPT code 87801. The program continues to reimburse for codes 87100, 87290, 87491 and 87591. Restrictions as defined in the January bulletin for codes 87205, 87490, and 87590 are also postponed.

California – Medi-Cal  Bulletin 364
Publication Date: January 2005
Effective Date: February 01, 2005

ICD-9 diagnosis codes required to bill for prenatal cystic fibrosis screening CPT-4 codes were incorrectly stated in the October 2004 Medi-Cal Update. Providers must use ICD-9 code V26.3 when billing for codes 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83901, 83904 and 83912. In addition, this diagnosis code must be documented in the diagnosis field (Box 21) of the claim. The updated information is reflected on manual replacement pages path molec 2 (Part 2).

California - Medi-cal  Bulletin 366
Publication Date: January 2005
Effective Date: February 01, 2005

The QuantiFERON-TB blood test is a new benefit reimbursable with CPT-4 code 86849 (unlisted immunology procedure) for only the following circumstances.

• Initial and serial testing of individuals with increased risk of latent tuberculosis infection (LTBI), such as recent foreign immigrants, injection-drug users, employees of correctional institutions and residents of homeless shelters
• Initial and serial testing for individuals who by history are at low risk for LTBI but whose future activity may place them at increased risk of exposure, such as healthcare workers and military personnel
• Individuals who require the test to meet entrance requirements for school and certain workplaces

Claim Completion
Claims submitted for QuantiFERON-TB blood tests must include the following in the Reserved For Local Use field (Box 19) or on an attachment to the claim.

• QuantiFERON-TB blood test
• Recipient age (must be 18 years of age or older)
• Medical justification

Providers also must submit with the claim:

• An invoice for the blood test

Refer to manual replacement pages path an over 6 (Part 2) and path immun 2 and 3 (Part 2).

California – Medi-Cal  Bulletin 365
Publication Date: January 2005
Effective Date: February 01, 2005

Current Medi-Cal policy requires providers to bill using the highest level of diagnosis code available on a given date of service. Effective January 01, 2005, claims billed with an invalid diagnosis code will be returned. The code must provide the highest level of specificity available in order to be valid. For example, if a provider bills with a 3–digit diagnosis code when a 4–digit or 5–digit diagnosis code is available, the 3–digit code is considered invalid and the claim will be returned. This policy does not apply to medical transportation claims.

California - Medi-Cal  Bulletin 366
Publication Date: January 2005
Effective Date: February 01, 2005

Effective for dates of service on or after February 01, 2005, HCPCS code Z2004 (surgical pathology, gross and microscopic examination of presumptively normal tissue[s] obtained in conjunction with an abortion procedure) is discontinued as a billable code. Instead, providers must use CPT-4 codes 88300 (Level I - surgical pathology, gross examination only) or 88304 (Level III - surgical pathology, gross and microscopic examination), but not for both, for the surgical pathology, gross and microscopic examination of presumptively normal tissue(s) obtained in conjunction with an abortion procedure.

Codes 88300 and 88304 are not to be separately reimbursed if billed by the same provider, for the same recipient, for the same date of service, as abortion procedure codes 59840, 59841, 59850, 59851, 59852, 59855, 59856 or 59857 when billed:

• For a female recipient and
• With an ICD-9 abortion diagnosis code (635 - 635.9, 636 - 636.9, 637 - 637.9, 638 - 638.9) or
• With an unwanted pregnancy code (V61.7 - V61.79)

Note: If the claim documents that the surgical pathology is for a specimen other than that resulting from an abortion procedure, the claim may be separately reimbursed.

HHS Office of Inspector General  Exclusion Program
Publication Date: February 2005

The 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.