CMS

Change Request:  5047 (PDF).

A brief hold will be placed on Medicare payments for all claims during the last 9 days of the Federal fiscal year (September 22 through September 30, 2006). These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 02, 2006.

This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.

Please note that payments will not be staggered and no advance payments will be allowed during this 9-day hold.

  CMS

Change Request:  5064 (PDF).

Effective July 01, 2006 the Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 12.2, will be implemented.

There are no Lab updates to the CCI edits for Version 12.2.

  CMS

Change Request:  5113 (PDF).

Effective January 01, 2006, the Clinical Laboratory Improvement Amendments (CLIA) number does not have to be included on claims submitted for HCPCS code 89049 [Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report].

CR5113 provides that HCPCS code 89049 is not considered a test under CLIA. Therefore, performing this test does not necessitate that a facility have any CLIA certificate, nor require a CLIA number on claims for its use.

  CMS

CMS Office of Information Services
Electronic Notification: June 30, 2006

The Centers for Medicare and Medicaid Services (CMS) has revised the Form CMS-1500 (12/90) to accommodate the reporting of the National Provider Identifier (NPI) which is scheduled for mandatory implementation on May 23, 2007. The revised Form CMS-1500 is the 08/05 version.

The new version will be implemented January 2, 2007. Providers will not be mandated to use the revised Form CMS-1500 (08/05) until April 02, 2007.

The following is the Form CMS-1500 (08/05) version implementation timeline (revised June 30, 2006):
January 02, 2007: Health plans, clearinghouses, and other information support vendors should be ready to handle and accept the revised Form CMS-1500 (08/05).

January 02, 2007- March 30, 2007: Providers can use either the current Form CMS-1500 (12/90) version or the revised Form CMS-1500 (08/05) version.

April 02, 2007: The current Form CMS-1500 (12/90) version is discontinued; only the revised Form CMS-1500 (08/05) will be accepted.

IMPORTANT: All claims re-billed on/after 4/2/07 must be submitted on the revised Form CMS-1500 (08/05).

To prevent the return of your paper claims:

• Do not submit the revised Form CMS-1500 (08/05) prior to January 2, 2007
• Do not submit your NPI on the current Form CMS-1500 (12/90)
• Do not submit the current Form CMS-1500 (12/90) on/after April 2, 2007

  CMS

Change Request:  5131 (PDF).

Effective January 01, 2006, CR5131 corrects an incorrect CPT code mentioned in CR4136.

CPT code 82271 was incorrectly listed as not requiring a QW modifier. The CPT code should have been 82272 and it does not require a QW modifier. All other information that outlines which tests require the “QW modifier” and which do not require the “QW modifier” remains the same as listed in CR4136.

  California — Medi-Cal

Medi-Cal Update:  Bulletin 384 (PDF), outlines the rate of hemoglobin A1C testing recommended for the Medi-Cal FFS population.

American Diabetes Association (ADA) Standards of Medical Care in Diabetes Monitoring Recommendations:

• Perform the A1C test  twice a year in patients that are at glycemic goal and stable metabolic status
• Perform the A1C test  every three months in patients that are not at glycemic goal or patients that have changing therapy
• Use  point-of-care testing of A1C to make therapy changes in a timely manner
• The goal A1C for most patients is 7 percent or below

Frequency of A1C testing may depend on the clinical situation, the treatment regimen used and the judgment of the clinician. Deviations from standard A1C goals and monitoring frequency may be appropriate for the following patients: pregnant, the young and the elderly (<13 years old and >65 years old), and those experiencing hypoglycemia.

  California — Medi-Cal

Medi-Cal Update:  Bulletin 383 (PDF).

Effective for dates of service on or after August 01, 2006, Family PACT (Planning, Access, Care and Treatment) is implementing diagnosis and procedure code changes.

And

Medi-Cal Update:  Bulletin 384 (PDF), contains a correction to lab procedures in the Family PACT Clinical Services Benefit published in Update Bulletin 283 (June 2006):

Restrictions
The following pathology CPT-4 codes are restricted to females ages 15 to 55 years of age: 87621, 88305 and 88307.

Deletions and Replacements
Syphilis: Range 091.0 – 097.9 is replaced with 091.0, 091.3, 092.9, 096, 097.1, 616.50, 608.89 and V01.6.

  California — Medi-Cal

Medi-Cal Update:  Bulletin 384 (PDF).

Effective retroactively for dates of service on or after November 1, 2005, CPT-4 code 88182 (flow cytometry, cell cycle or DNA analysis) is added as a Medi-Cal benefit.

Also effective retroactively for dates of service on or after November 1, 2005, the following flow cytometry codes have been assigned specific prices.

Codes 88184 and 88145 must be billed with modifier -TC (technical component). Codes 88187, 88188 and 88189 must be billed with modifier -26 (professional component).

The full descriptions and prices for the codes are:

CPT-4 Code	Description	Medi-Cal Rate
88182	Flow cytometry, cell cycle or DNA analysis	$88.27
88184	Flow cytometry cell surface, cytoplasmic, or nuclear marker, technical component only; first marker	$42.18
88185	each additional marker	$20.68
88187	Flow cytometry, interpretation; 2 to 8 markers	$55.98
88188	9 to 15 markers	$69.84
88189	16 or more markers	$92.02

No action is required on the part of providers. Claims submitted with these codes for dates of service beyond the six-month billing limit must include delay reason code “11” in the COB (Delay Reason) field (Box 24J) and documentation justifying the delay.

  California — Medi-Cal

Medi-Cal Update:  Bulletin 384 (PDF).

Effective retroactively for dates of service on or after November 01, 2005, CPT-4 codes 88367 and 88368 are Medi-Cal benefits. Also for the same dates of service, codes 88360, 88361, 88367 and 88368 have been assigned a specific price. No action is required on the part of providers. Claims submitted with these codes for dates of service beyond the six-month billing limit must include delay reason code “11” in the COB (Delay Reason) field (Box 24J) and documentation justifying the delay.

The full descriptions and prices for the codes are:

CPT-4 Code	Description	Medi-Cal Rate
88360	Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semi-quantitative, each antibody; manual	$90.06
88361	Using computer-assisted technology	$136.67
88367	Morphometric analysis, in situ hybridization, (quantitative or semi-quantitative) each probe; using computer-assisted technology	$169.79
88368	Manual	$120.09

Codes 88360 and 88361 cannot be billed with code 88342 (immunochemistry [including tissue immunoperoxidase], each antibody) unless each procedure is for a different antibody for the same recipient, same provider and date of service. Providers must document the different antibody in the Reserved For Local Use field (Box 19) or on an attachment.

  California — Medi-Cal

Medi-Cal Update  Part 1 (PDF).
Publication Date: June 2006

A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status codes as submitted by providers. Erroneous “from-through” dates or patient status billed by one provider and paid by Medi–Cal can result in the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the recipient. Providers see this on their Remittance Advice Details (RAD) as a claim denied by RAD code 010.