CMS

Decision Memo  https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=167
Publication Date: October 03, 2005

CMS has determined that ICD-9-CM diagnosis code V76.44, Prostate cancer screening, is not appropriately included on the list of ICD-9-CM codes that are not covered by Medicare. CMS intends to modify the list of “ICD-9-CM Codes Denied” in the Laboratory NCD Coding Manual. This change affects the entire 23 negotiated clinical diagnostic laboratory NCDs. Since removal of V76.44 from the codes denied list would automatically result in inappropriate inclusion on the list of covered diagnoses for blood counts, CMS has also added V76.44 to the list of codes that do not support medical necessity for blood counts.

  CMS

Medlearn Matters  MM3946
Publication Date: July 29, 2005 (revised)
Effective Date: January 01, 2006

Medicare will modify the duplicate claim edit to reject all clinical laboratory services submitted to payers when it is determined that another payer has already paid for the same service on the same date of service, with the exception of those claims containing the “91” modifier. This modified edit applies to all laboratory claims with dates of service on or after January 1, 2006.

When claims are denied as a result of this edit, Medicare payers will use remark code N347 on the remittance advice to show “Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.”

  CMS

Medlearn Matters  MM4106
Publication Date: September 23, 2005
Effective Date: August 21, 2005
Implementation Date: October 03, 2005, but no later than October 31, 2005

To facilitate claims processing and track services and items provided to victims of Hurricane Katrina and any future disasters, CMS has established a new condition code and modifier for providers to use on disaster related claims. The new condition code and modifier are for use by providers submitting claims for beneficiaries who are Katrina disaster patients in any part of the country and are effective for dates of service on and after August 21, 2005. The new codes are the following:

• The new condition code is DR - Disaster Related
• The new modifier is CR - Catastrophe/Disaster Related

  CMS

Medlearn Matters  SE0555

Providers and suppliers may now apply for their NPI on the National Plan and Provider Enumeration System (NPPES) web site, https://nppes.cms.hhs.gov. The NPPES is the only source for NPI assignment.

The NPI will replace healthcare provider identifiers in use today in standard healthcare transactions by the above dates. The application and request for an NPI does not replace the enrollment process for health plans. Enrolling in health plans authorizes you to bill and be paid for services.

Healthcare providers should apply for their NPIs as soon as it is practicable for them to do so. This will facilitate the testing and transition processes and will also decrease the possibility of any interruption in claims payment. Providers may apply for an NPI in one of three ways:

• An easy web-based application process is available at https://nppes.cms.hhs.gov.
• A paper application may be submitted to an entity that assigns the NPI (the Enumerator). A copy of the application, including the Enumerator’s mailing address, is available at https://nppes.cms.hhs.gov. A copy of the paper application may also be obtained by calling the Enumerator at 1-800-465-3203 or TTY 1-800-692-2326.
• With provider permission, an organization may submit a request for an NPI on behalf of a provider via an electronic file.

Providers should be aware of the NPI readiness schedule for each of the health plans with which they do business, as well as any practice management system companies or billing companies (if used). They should determine when each health plan intends to implement the NPI in standard transactions and keep in mind that each health plan will have its own schedule for this implementation. Your other health plans may provide guidance to you regarding the need to submit both legacy numbers and NPIs.

Providers should submit their NPI(s) on standard transactions only when the health plan has indicated that they are ready to accept the NPI. Providers should also ensure that any vendors they use will be able to implement the NPI in time to meet the compliance date.

  CMS

Publication Date: September 23, 2005

The proposed rule adopting standards for electronic health care claims attachments was published in the Federal Register. Health care claims attachments are those documents and information required by health plans to adjudicate certain claims. The proposed rule, mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), adopts two new X12 transaction standards, an HL7 messaging standard to carry clinical information in the response transaction, and HL7 specifications for the content or “questions” that may be asked in each of the six attachment types. This proposed rule also adopts the Logical Observation Identifiers Names and Codes (LOINC^®) as a new HIPAA code set to be used to identify the questions and answers (attachment information). The standards allow for the transmission of structured or coded data, as well as images and text. The proposed rule solicits comments from the affected industries on several key issues, including the adoption of LOINC^® and its use for the HIPAA transactions, the appropriateness of the six proposed attachment types, business requirements for attachments that would accompany the original claim (unsolicited attachments), and the cost-benefit implications of adopting this transaction set. The public comment period is open until November 22.

The proposed rule can be found at: http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-18927.pdf

  CMS

Medlearn Matters  MM3923
Publication Date: July 22, 2005
Effective Date: October 01, 2005
Implementation Date: October 03, 2005

Note: Typographic errors were also identified and corrected in reason codes 52, 57, 70, 76 and 146. No codes were retired.

The complete list, including changes made from November 01, 2004 through February 28, 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.

  California Medicare—United Government Services

Medicare Memo:  No 2005-8.0
Publication Date: September 19, 2005
Effective Date: October 01, 2005

California Customer Service and Claims Workloads transferred to Wisconsin, effective October 1, 2005. Customer service telephone lines for both beneficiary and provider customer service are now handled by key UGS Customer Service representatives.

There will be very few changes apparent to the provider community. The same customer service you are accustomed to will continue under the same UGS management direction.

What is Changing
The fax number and address for Customer Service. The new information follows:
Fax Number: 414-226-5260

Address:
P. O. Box 2005
Milwaukee, WI 53201-2005

What is Not Changing
Telephone Numbers
The telephone numbers are not changing. Providers will continue to call the existing telephone numbers:
Toll Free 1-866-380-4745
Hours 8:00 AM - 4:30 PM Pacific
Hawaii, Guam and Northern Mariana Islands
Toll Free 1-866-849-7244
Hours 9:00 AM - 5:30 PM Pacific
Beneficiaries will continue to call 1-800-Medicare.

  Kansas, Nebraska and Northwest Missouri—Medicare

Medicare Memorandum  091505
Publication Date: September 13, 2005
Effective Date: October 01, 2005

CMS announced that the HIPAA contingency period for claims sent to Medicare would end on October 01, 2005. This termination does not apply to claims that Medicare sends outbound to other payers that have signed a coordination of benefits (COB) trading partner agreement for the transfer of claims by Medicare. It does apply to claims sent to Medicare for secondary payment following processing by a primary payer, however. Therefore, effective October 01, 2005, electronic MSP claims must comply with all X12 837 version 4010A1 implementation guide requirements, and include standard claim adjustment reason (CAS) codes to describe adjustments that a primary payer made during adjudication, or they will be rejected.

  Kansas Medicare

Online Training  MSP Course

Medicare Secondary Payer (MSP) is the term used by Medicare when it is not responsible for paying a claim first. When Medicare began on July 1, 1966, it was the primary payer for all beneficiaries, except for those who received benefits from the Federal Black Lung Program, Workers’ Compensation (WC), and those that receive all covered health care services through the Veterans Health Administration (VHA) program. Beginning in 1980, changes to Medicare laws increased the number of coverage and benefit programs that are primary to Medicare. These changes help to preserve the Medicare Trust Fund and limit the beneficiary's out-of- pocket costs. However, these changes also made the billing process more complex, especially when trying to determine if Medicare is the first or second payer.

  California Medi-Cal

Medi-Cal Update:  What’s New 6956
Publication Date: August 22, 2005
Effective Date: August 22, 2005

Claims Appeal Status Available from the Provider Telecommunications Network (PTN) and the Medi-Cal Web Site Effective August 22, 2005, providers may determine the status of their appeals using the Provider Telecommunications Network (PTN) and/or the Medi-Cal Web site. The PTN allows providers to access their appeal status. The Medi-Cal Web site allows providers to access both their appeal status and copies of appeal letters for their records.

  California Medi-Cal

Electronic Transactions: Biller Updates  HIPAA News 6964
Publication Date: September 01, 2005
Effective Date: October 24, 2005

Providers may link paper attachments to their 837 v.4010A1 Professional electronic health care claims submitted through the Point of Service (POS) device. The Department of Health Services (DHS) is introducing this new process to allow providers who submit electronic claims through the POS device to mail in their paper attachments.

To submit paper attachments linked to a POS device claim, providers must use an Attachment Control Form (ACF) as the coversheet for the supporting attachments. The ACF has a pre-printed Attachment Control Number (ACN), which providers input during their electronic claim submission in a specified field. Providers submit the electronic claim and mail the ACF along with the paper attachments to Medi-Cal. Medi-Cal then links the paper attachments and electronic claim for processing. Providers have a maximum of 40 calendar days after the electronic claim is submitted to mail the ACF along with the supporting documentation to Medi-Cal.

To begin using the new process, providers will need a supply of ACFs and ACF envelopes, which can be ordered by calling the Telephone Service Center (TSC) at 1-800-541-5555.

The POS Device User Guide will be updated to include step-by-step instructions in October 2005.

  California Medi-Cal

Medi-Cal Update:  What’s New 6922
Publication Date: July 27, 2005
Effective Date: October 22, 2005

Statewide issuance of the new Medi-Cal Benefits Identification Card (BIC) is now complete. All Medi-Cal recipients should have a new BIC with a 14-character alphanumeric ID number. Recipients who have not received a new BIC should contact their county welfare office.

  California Medi-Cal

Medi-Cal Clinical Laboratory Services Request for Application (RFA) 04-35199 Administrative Bulletin 12 issued by the Department of Health Services (DHS), Office of Medi-Cal Procurement (OMCP) on Sept 19, 2005, announces the cancellation of Request for Application (RFA) 04-35199, Medi-Cal Clinical Laboratory Services. This action is being taken pursuant to Section 8.f. of the RFA and is being made in the best interests of the Department. Consistent with Department policy, all applications and copies were subject to confidential destruction.

While the Department has cancelled this procurement, it is looking at modifying processes and procedures that will enable the Department to achieve the contracting goals. Until such time as new procedures are adopted, all clinical laboratories are to continue to conduct business with the Department as usual.