CMS

NPPES Data Dissemination Notice
Federal Register Vol.72, No. 103 (PDF).
 

CMS has published the National Plan and Provider Enumeration System (NPPES) Data Dissemination Notice on May 30, 2007.

• NPPES health care provider data that are required to be disclosed under the Freedom of Information Act (FOIA) will be made publicly available on June 28, 2007, 30 days after the publication date of the Notice.
• The FOIA-disclosable data will be made available in an initial file downloadable from the Internet, with monthly update files also downloadable from the Internet, and in a query-only database whereby users can query by NPI or provider name.
• The Notice encourages health care providers who have been assigned NPIs to review their NPPES data at this time and make any necessary updates or corrections prior to the end of the 30-day period to ensure that their information is accurate when disclosed by CMS. (Health care providers who are covered entities under HIPAA are required by regulation to update their NPPES data within 30 days of any change.)
• The Notice states that health care providers who wish to delete any NPPES data that was not required to be furnished in order to obtain an NPI may do so prior to the end of the 30-day period if they prefer that those data not be disclosed by CMS.

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Transmittal 207: CR5584 (PDF).
Effective Date: May 29, 2007

This article is based on Change Request (CR) 5584 which announces that the Centers for Medicare & Medicaid Services (CMS) will discontinue assigning Unique Physician Identification Numbers (UPINs) on June 29, 2007. The NPI will replace the use of UPINs and other existing legacy identifiers.

However, CMS recently announced a contingency plan that allows for use of legacy numbers for some period of time beyond May 23, 2007. Under the Medicare FFS contingency plan, UPINs and surrogate UPINs may still be used to identify ordering and referring providers and suppliers until further notice.

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Implementation of the Carrier Jurisdictional Pricing Rules for All Purchased Diagnostic Service Claims
Transmittal: CR5543 (PDF).
Effective Date: October 1, 2007

CR 5543 replaces the temporary physician billing instructions specified in CR 3630 (issued on December 23, 2004) with new billing procedures that (effective October 1, 2007) allow all physicians and suppliers to receive the correct payment amount for all purchased diagnostic services, including those performed outside of their local carrier’s/Medicare Administrative Contractor’s (MAC) jurisdiction.

• Effective for claims with dates of service on or after October 1, 2007, carriers/MACS will use the MPFS national abstract file for purchased diagnostic tests/interpretations to price all claims for purchased diagnostic services based on the ZIP code of the location where the service was rendered, including those submitted by physicians for purchased diagnostic services performed outside of the local carrier’s jurisdiction, in accordance with the carrier jurisdictional pricing rules specified in Chapter 1, Section 10.1.1 of the Medicare Claims Processing Manual.
• Physicians and suppliers must begin reporting the rendering physician’s/supplier’s information and the location where the service was rendered on all claims for purchased tests / interpretations with dates of services on or after October 1, 2007, including those for tests / interpretations performed outside of the local carrier’s jurisdiction, following the instructions for submitting a purchased diagnostic service claim in Chapter 1, Sections 10.1.1.2 and 30.2.9 of the Medicare Claims Processing Manual.
• Physicians and suppliers are reminded they may only submit claims for purchased tests / interpretations when these services are performed within the United States. (In this context, the term “United States” means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. See Chapter 1, Section 10.1.4 of the Medicare Claims Processing Manual for additional information.)

  CMS

Transmittal: SE0715 (PDF).

Under certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services, and modifier “–59” may be appropriate depending on the circumstances. Modifier “–59” is used to identify procedures / services that are not normally reported together, and this include the following procedures/services that are not ordinarily encountered or performed on the same day by the same physician:

• A different
• Session or patient encounter,
• Procedure or surgery,
• Site or organ system, or
• A separate
• Incision/excision,
• Lesion, or
• Injury (or area of injury in extensive injuries)

For the NCCI, the primary purpose of modifier “–59” is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.

Modifier “–59” and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

Use of modifier “–59” to indicate different procedures / surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier “–59”.

From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitute a single anatomic site.

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Noridian Part B Updates

Effective July 1, 2007 CMS has mandated that Medicare Part B carrier claims processing systems capture and process up to eight diagnosis codes on all claims (both paper and electronic).

Instructions on how to submit up to eight diagnosis codes on a paper claim submission form are as follows:

• You may place up to eight diagnosis codes on the claim form. The diagnosis that is pointed to in Item 24E must be placed in one of the four diagnoses entry spaces in Item 21. Any indicator other than a 1, 2, 3, or 4 in Item 24E will cause the claim to deny as unprocessable. Place additional diagnosis codes 5-8 (if necessary) in Item 19. Enter only the number (with decimal if needed) and separate each diagnosis in Item 19 with a comma. (For example: 719.41, 719.42, 816.00)
• The diagnosis codes listed in Item 19 should not be codes that are required for payment. If there are more than four diagnosis codes required for payment, submit a second claim form with the additional required codes in Item 21 on the second claim form. (For example: If CPT code “A” requires three diagnosis codes for payment and CPT “B” requires three different codes for payment, these two procedures would need to be billed on two separate claim forms so the processing system could pick up all six of the diagnosis codes as payable.)

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Phone & Written Inquires during the Medicare FFS NPI Contingency Plan
Transmittal: SE0721 (PDF).

Due to the Medicare FFS NPI contingency plan, the NPI will not be a required authentication element for general provider telephone and written inquiries until the date that the Centers for Medicare & Medicaid Services (CMS) requires it to be on all claim transactions. In this contingency environment, the provider transaction access number (PTAN) is your current legacy provider identification number. Your PTAN, which may be referred to as your legacy number by some Medicare Fee-for-Service provider contact centers (PCCs), will be the required authentication element for all inquiries to Interactive Voice Response (IVR) systems, customer service representatives (CSRs), and the written inquiries units.

Medicare FFS will give sufficient notice to providers of the contingency plan end date. Until the date, you will need to provide the following:

• For Inquiries to the IVR:
• PTAN / Legacy Number, depending upon the contractor
• For Inquiries to a CSR and Written Inquiries:
• PTAN / Legacy Number, depending upon the contractor, and
• Provider Name

  CMS

Transmittal: R1247CP (PDF).
Effective Date: July 1, 2007

Beginning July 2, 2007, you must use the Form CMS-1500, version (08-05) for paper claims submission to Medicare. Claims received on or after July 2, 2007 using Form CMS-1500, version (12-90) will be rejected.

  CMS

Transmittal: R1241CP (PDF).
Effective Date: July 2, 2007

This instruction includes Stage 3 NPI Changes for Transaction 835, and Standard Paper Remittance Advice, and Changes in Medicare Claims Processing Manual, Chapter 22 - Remittance Advice.

NPIs received on claims will be cross walked to the Medicare legacy number(s) for processing. Medicare’s internal provider files will continue to be based upon records established in relation to the legacy identifiers. The crosswalk may result in:

  CMS

Transmittal: R1242CP (PDF).
Effective Date: October 1, 2007

During the period from June through September 2007, CMS’ Coordination of Benefits Contractor (COBC) will sign national crossover agreements with Medigap claim-based crossover insurers and will assign new 5-digit Coordination of Benefits (COBA) Medigap claim-based crossover identifiers to these entities for inclusion on incoming Medicare claims.

October 1, 2007 is the effective date for completing the transition of the Medigap crossover process to the COBC.

Be aware that during the transition period from June through September 2007 the COBC will assign new 5-byte claim-based Coordination of Benefits Agreement (COBA) IDs to the Medigap insurers on a graduated basis throughout the three month period prior to the actual transition. Until CMS’ COBC assigns a new 5-digit COBA Medigap claim-based ID to a Medigap insurer, Medicare will continue to accept the older contractor-assigned OCNA or N-key identifiers for purposes of initiating Medigap claim-based crossovers. During June through September 2007, the affected contractors will also continue to cross claims over as normal to their Medigap claim-based crossover recipients. CMS will be regularly apprising the affected Medicare contractors when the COBC has assigned new COBA Medigap claim-based IDs to the Medigap insurers and will post this information on its COB web site so that contractors may direct providers to that link for purposes of obtaining regular updates.

  CMS

Transmittal: R1104CP (PDF).
Effective Date: March 1, 2007

CMS has released an article announcing the replacement of the UB-92 by the UB-04, effective March 1, 2007.

Starting May 23, 2007, all institutional paper claims must be submitted on the UB-04. The UB-92 will no longer be acceptable, even as an adjustment claim, after May 22, 2007.

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Empire Medicare News Post: 05/08/2007 (PDF).

National Government Services, Inc. for New York and New Jersey Medicare Part B will retire the Local Coverage Determinations (LCD) listed below, effective May 31, 2007. Based on analysis of their effectiveness, these LCDs are no longer useful for prepay, postpay, or educational purposes.

Retired Local Coverage Determinations (LCD) May 31, 2007

Two of the policies above are still covered under the Lab NCD policies:

NCD 190.19 Collagen Crosslinks
NCD 190.13 Human Immunodeficiency Virus Testing