CMS

Medicare Matters  MM4156 (PDF).
Publication Date: December 30, 2005
Effective Date: April 03, 2006

General Rule: The Date of Service (DOS) of the test shall be the date the specimen was collected.

Variation: If a specimen is collected over a period that spans two calendar days, then the DOS shall be the date the collection ended.

Exception: If a specimen was stored for more than 30 calendar days before testing (otherwise known as “an archived specimen”), the DOS of the test shall be the date the specimen was obtained from storage.

  CMS

Transmittal 752:  CR 4161 (PDF).
Publication Date: November 18, 2005
Implementation Date: April 03, 2006

CR4161 announces the following changes:

• ICD-9-CM code V76.44 (special screening for malignant neoplasms, prostate) will be removed from the list of ICD-9-CM codes not covered by Medicare. This list of codes affects all 23 negotiated laboratory NCDs.
• ICD-9-CM code V76.44 (special screening for malignant neoplasms, prostate) will be added to the list of ICD-9-CM codes that do not support Medical Necessity in the Blood Counts NCD.
• ICD-9-CM codes 158.8 (Malignant neoplasms, specific parts of peritoneum) and 158.9 (Malignant neoplasms, peritoneum, unspecified) will be added to the list of ICD-9-CM codes covered by Medicare in the Tumor Antigen by Immunoassay CA 125 NCD.

  CMS

Medicare Matters:  CR 4023 (PDF).
Publication Date: November 29, 2005 (Revised)
Implementation Date: April 03, 2006

CR 4023 was revised on November 29, 2005, to clarify that the end date of the transition period for the revised CMS-1500 form is February 1, 2007.

Effective January 03, 2006, Medicare will begin accepting the NPI on the 837 and 276 4010A1 transactions with certain restrictions. With the scheduled implementation of the National Provider Identifier (NPI) in 2007, CMS has begun the process of making the necessary system changes to accommodate the NPI. The implementation will be completed in 3 stages. The first stage will be in effect beginning January 03, 2006 and pertains to Electronic Data Interchange.

In this first stage, the NPI will be accepted on the inbound 837 4010A1 file but will not be used for Medicare processing. The Medicare legacy provider number must continue to be submitted in addition to the NPI for Medicare processing. When an NPI is received on an inbound 837 file, it will be mapped to the outbound COB/COBC file issued in response to the inbound claim. Additionally, the NPI will be accepted on the 276 Claim Status Inquiry and returned on the 277 Claim Status Response transactions.

The implementation of stage 1 will allow for the acceptance of the NPI by removing existing pre-pass edits which currently reject claims submitted with the “XX” qualifier in the NM108 segment. In tandem, new pre-pass edits have been created to validate the value of the NPI and to ensure the provider’s corresponding Medicare legacy number or UPIN number continues to be submitted on the inbound 837 4010A1 file. New pre-pass edits have also been created for the 276 transaction to ensure the validity of the NPI on any claim status inquiry transaction.

In stage 2 (the subject of CR 4023)
October 02, 2006 – May 22, 2007:
CMS systems will accept an existing legacy Medicare billing number and/or an NPI on claims. If there is any issue with the provider’s NPI and no Medicare legacy identifier is submitted, the provider may not be paid for the claim. Therefore, Medicare strongly recommends that providers, clearinghouses, and billing services continue to submit the Medicare legacy identifier as a secondary identifier. Medicare will be capable of sending the NPI as primary provider identifier and legacy identifier as a secondary identifier in outbound claim, claim status response, remittance advice (electronic but not paper), and eligibility response electronic transactions.

May 23, 2007 – Forward:
CMS systems will only accept NPI numbers. Coordination of benefit transactions sent to small health plans will continue to carry legacy identifiers, if requested by such a plan, through May 22, 2007.

  CMS

Medicare Matters:  CR 3835 (PDF).
Publication Date: October 01, 2005 (Revised)
Implementation Date: April 03, 2006

Medicare will implement a redefined Type of Bill (TOB) 14x to avoid overpayment for lab services furnished to non-patients. Any hospital (including a Critical Access Hospital (CAH)) receiving such specimens is to bill for the lab test on a TOB 14x.

Lab services performed for non-patients by a CAH or a hospital subject to a state of Maryland waiver, will be paid on the Part B clinical diagnostic lab fee schedule.

Since the definition of 14x was changed, in the early 1990s, to be for “all referred diagnostic services”, CMS lost the ability to differentiate between the lab specimens of outpatients and of non-patients. Consequently, TOB 14x could not be used to drive differential payment. The change is being implement due to the need to distinguish between outpatients and non-patients for certain pathology tests, and an upcoming demonstration project that will only apply to non-patients.

  CMS

Transmittal 752:  CR 4177 (PDF).
Publication Date: November 10, 2005
Effective Date: April 03, 2006

Currently, suppliers, physicians, and non-physician practitioners are allowed to bill for diagnostic, radiology, consultation services, and equipment with the use of Surrogate UPIN OTH000. Surrogate UPINs were intended to be used during an interim period when a UPIN has been requested but has not yet been received.

CR 4177 announces that CMS will no longer accept the Surrogate UPIN OTH000 to identify the ordering or referring physicians on claims submitted by billers, suppliers, physicians, and non-physician practitioners, effective for dates of service April 01, 2006, and later.

  CMS

Medicare Matters:  CR 4136 (PDF).
Publication Date: December 13, 2005
Effective Date: January 01, 2006

CLIA regulations require a facility to be appropriately certified for each test performed. To ensure CMS pays only 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.

Tests That Do Not Required QW Modifier
Tests listed in the following table do not require a QW modifier to be recognized as a waived test:

  CMS
    Retro-Active Change to Travel Fees

Medicare Matters  MM4144 (PDF).
Publication Date: November 10, 2005
Effective Date: January 01, 2006

For dates of service on or after September 1, 2005, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient.

The standard mileage rate for transportation costs was increased by the Federal Government’s Treasury Department to 48.5 cents a mile effective September 1, 2005 and this increase is incorporated into the fees for travel codes P9603 and P9604.

Effective January 01, 2006, the Federal Government‘s Treasury Department will decrease the standard mileage rate for transportation costs from 48.5 cents a mile to 44.5 cents a mile. The reimbursement rates for P9603 and P9604 are expected to decrease to $0.895 per mile and $8.95 per flat rate trip basis respectively.

  NHIC

Effective Date: January 01, 2006

The following LCDs will be retired: Amylase; Clinical Use of Hepatitis C Virus (HCV) Molecular Tests; Cytogenetic Studies; Gonadotropin: Follicle Stimulating Hormone and Luteinizing Hormone; Sedimentation Rate, Erythrocyte; Non-Automated and Sedimentation Rate, Erythrocyte; Automated; Syphillis Testing and Troponin.

  NHIC

Effective Date: January 01, 2006

Medicare will no longer handle Telephone Redeterminations. All Redetermination requests must be submitted in writing to NHIC. Additional information is available in the New Appeals Process:   Medicare Matters 3944 (PDF) or by contacting NHIC Customer Service Department.

Previously, parties had the right to request a review or reconsideration over the telephone, however the regulations no longer provide this right. As of January 01, 2006, please submit your request for redetermination in writing to:

Northern California
Medicare Redeterminations
P.O. Box 2800
Chico, CA 95927-2800

Southern California
Medicare Redeterminations
P.O. Box 272854
Chico, CA 95927-2854

New England
Medicare Redeterminations
P.O. Box 1000
Hingham, MA 02044-1000

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005

The 2006 updates to the Current Procedural Terminology, Fourth Edition, (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) Level II codes become effective for Medicare on January 01, 2006. The Medi-Cal program has not yet adopted the 2006 updates. Do not use 2006 codes to bill for Medi-Cal services until notified to do so in a future Medi-Cal Update.

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005
Effective Date: January 2, 2006

The following HCPCS Level II laboratory procedure codes are Medi-Cal benefits:

These codes must be billed with modifier -ZS. Providers billing these codes must meet Clinical Laboratory Improvement Amendment (CLIA) requirements.

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005
Effective Date: January 02, 2006

Interim HCPCS codes X0700 (portable X-ray, two patients) and X0702 (portable X-ray, three or more patients) will no longer be reimbursable. Providers should use national HCPCS codes R0070 (transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or location; one patient seen) or R0075 (…more than one patient seen, per patient) when billing for portable X-ray services. In addition, HCPCS code Q0092 (set-up portable X-ray equipment) will also be reimbursable. None of the above codes may be split-billed.

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005

To clarify current Medi-Cal billing policy on cystic fibrosis screening procedures, providers are reminded that CPT-4 codes 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83901, 83904 and 83912 are used to bill for molecular diagnostic techniques for various clinical purposes. Additionally, the following billing policy applies for these codes:

• When used to bill for the purpose of cystic fibrosis screening tests, providers must also use ICD-9 code V26.3, which must be documented in the diagnosis field (Box 21).
• When used to bill for tests other than cystic fibrosis screening, the claims must be billed with valid ICD-9 codes other than V26.3.

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005

Effective immediately, the address for the Presumptive Eligibility (PE) section has changed. Please send all PE forms to the new address:

Department of Health Services
Presumptive Eligibility Support Unit
MS 4607
P.O. Box 997417
Sacramento, CA 95899-7417

  California — Medi-Cal

Medi-Cal Update  Bulletin 377 (PDF).
Publication Date: December 2005
Effective Date: November 15, 2005

Claims for CPT-4 code 87621 billed by Family PACT providers without the primary “S” diagnosis code and were denied for an incorrect diagnosis code need to be resubmitted by those providers with an appropriate primary diagnosis “S” code as well as one of the ICD-9 codes in order to be reimbursed.