CMS

Common Working File (CWF) Duplicate Claim Edit for the Technical Component (TC) of Radiology and Pathology Laboratory Services Provided to Hospital Patients
Transmittal: 1221CP (PDF).
Effective Date: April 01, 2007

CMS will install systems edits to prevent improper payments to independent laboratories for the TC of pathology laboratory services provided to beneficiaries during a covered inpatient hospital stay or provided on the same date of service as an outpatient service. This change applies to claims with dates of service on or after January 1, 2007, where the claim is received on or after April 1, 2007.

Key Points

• Effective for claims received on or after April 1, 2007, Medicare will reject/deny reject a Part B TC or globally billed pathology service with a service date on or after January 1, 2007, that falls within the admission and discharge dates of a covered hospital inpatient stay when billed by a physician/supplier. Such services will also be rejected/denied when they match with a date of service of a hospital outpatient bill (bill types 13X and 85X) previously processed by Medicare.
• If providers submit a TC of a pathology service with a service date that falls within the admission and discharge dates of a covered hospital inpatient stay the carrier will use Remittance Advice Reason Code 109 “Claim not covered by this payer/contractor.” when denying a service line item.
• Where Medicare systems detect that a Part B TC or globally billed physician pathology service has been paid and Medicare subsequently receives a hospital inpatient bill for the same date of service, the Medicare carrier will adjust a TC of a physician pathology service line item and recoup the payment made for that service from the physician/supplier. The Medicare carrier will also adjust a TC of a pathology service for an outpatient claim. The same Remittance Advice Reason Code of 109 will be used in such cases.
• Effective for claims received on or after April 1, 2007, the carrier will deny an incoming Part B TC or globally billed physician pathology service line item with a service date that falls outside the occurrence span code 74 (non-covered level of care) from and through dates plus one day on a posted hospital inpatient bill. Again, the carrier will use Remittance Advice Reason Code 109. In addition, the Medicare carrier will recoup payment made to the physician/supplier if a subsequent hospital inpatient bill is received for those same services.
• Carriers will not search their files to either retract payment or retroactively pay claims prior to the implementation of CR5347. However, they will adjust claims if they are brought to their attention.

  CMS

Transmittal: 1225CP (PDF).
Effective Date: May 23, 2007

Medicare fee for service (FFS) announces that it is establishing a contingency plan that follows the DHHS guidance.

Medicare FFS will evaluate the number of submitted claims containing a NPI. If this analysis demonstrates a sufficient number of submitted claims contain a NPI, Medicare will begin to reject claims without NPIs on July 01, 2007. If, however, there are not sufficient claims containing NPIs in the May analysis, Medicare FFS will assess compliance in June 2007 and determine whether to begin rejecting claims in August 2007.

For some period after May 23, 2007, Medicare FFS will:

• Allow continued use of legacy numbers on transactions;
• Accept transactions with only NPIs; and
• Accept transactions with both legacy numbers and NPIs.

After May 23, 2008, legacy numbers will NOT be permitted on ANY inbound or outbound transactions.

Important Information

CR 5595 also provides specific important information that you should be aware of:

• Once a decision is made to require NPIs on claims, Medicare FFS will notify (in advance) providers and Medicare contractors about the date that claims without NPIs for primary providers will begin to be rejected. That date will supersede all dates announced in previous CRs and MLN Matters articles.
• In editing NPIs, Medicare considers billing, pay-to and rendering providers to be primary providers who must be identified by NPIs, or the claims will be rejected once the decision is made to reject.
• All other providers (including referring, ordering, supervising, facility, care plan oversight, purchase service, attending, operating and “other” providers) are considered to be secondary providers. Legacy numbers are acceptable for secondary providers until May 23, 2008. If a secondary provider’s NPI is present, it will only be edited to assure it is a valid NPI.

  CMS

Deceased Providers who died before obtaining a NPI
Transmittal: 1216CP (PDF).
Effective Date: May 23, 2007

Those submitting claims on behalf of physicians and providers who died before obtaining a National Provider Identifier (NPI), where such submitted claims were received by a Medicare contractor after May 23, 2007. Because deceased providers may not have NPIs, this article discusses what representatives of those providers need to do in order to submit claims that need to be paid.

If an individual provider dies before obtaining an NPI, the following apply:

• A representative of the estate of a proprietor cannot apply for an NPI for that provider posthumously.
• If a provider dies before obtaining an NPI and claims for that provider are received by a Medicare contractor after May 23, 2007, and Medicare (the Medicare contractor, the Medicare Online Survey and Certification Reporting System (OSCAR), of the National Supplier Clearinghouse (NSC)) has not been notified of the death, the claims will reject when received by Medicare due to the absence of the provider’s NPI.
• At that point, the claim submitter would be expected to contact the Medicare contractor to which the claims were submitted to discuss payment of the claims and report the provider’s death. Toll free number of the Medicare contractors are available at on the CMS website.
• The State in which a provider furnishes care will continue to be responsible for notification of Medicare of the death of a provider following existing procedures. Since some States send such notifications on a quarterly basis, CMS is implementing the following procedures to enable affected claims to be paid more promptly:
• Because Medicare will reject an electronic claim received without an NPI after May 23, 2007, in cases where the provider died prior to obtaining an NPI, the provider’s representative will need to submit the claim on paper.
• A representative of the estate should then contact the claims processing contractor, who will notify the provider that they must submit the claims on paper and that they must annotate the claim to state that the provider is deceased in Item 19.

  CMS

Transmittal: 1215CP (PDF).
Effective Date: April 01, 2007

CR5489 makes the following updates to the CMS-1500 requirements:

• The requirement to submit the provider’s Social Security Number in Box 25 has been removed;
• The requirement to report the PIN of the Skilled Nursing Facility in Box 23 has been removed; and
• Clarification language was added to Box 17a, indicating the qualifier 1G precedes the Unique Physician Identification Number (UPIN)

In addition, language has been added regarding the completion of Item 25 (the provider of service or supplier federal tax identification number). Medicare providers are not required to complete this item for crossover claim purposes, since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the Coordination of Benefits (COB) outbound claim. However, tax identification information is used in the determination of accurate National Provider Identification (NPI) reimbursement. Thus, reimbursement of claims submitted without tax identification information may be delayed.

Medi–Cal — California

April 2007 | GM Bulletin 393.

Effective for dates of service on or after May 1, 2007, CPT-4 code 88150 (cytopathology, slides, cervical or vaginal; manual screening under physician supervision) will be replaced with code 88164 (cytopathology, slides, cervical or vaginal [the Bethesda System]; manual screening under physician supervision) for the Presumptive Eligibility (PE) program. The Bethesda System is the current standard for gynecological cytology reporting.

NHIC — California

April 2007
Northern California 31140 L23501
Southern California 31146 L23501

The following Local Coverage Determination (LCD) has been revised:

Flow Cytometry and Immunocytochemistry for Cancer Diagnoses and Prognoses - Added ICD-9-CM code 283.2, per provider request.