In This Issue:

CMS:

• Clinical Trial Claims
• COBA Medigap Claim-Based Crossover Process
• Legacy Provider IDs Prohibited on Claims
• Medicare Clinical Laboratory Services Competitive Bidding Demonstration Implemented
• Modifiers Added for Clinical Trials
• New Automated Test
• NPI Critical Dates
• Referred or Ordered Services Denied
• TC Changes of Physician Pathology Services

Source:   Transmittal: 310 (PDF).
Effective Date: 04/01/2008

Medicare claims forms will be modified to accommodate the 8-digit clinical trial number for claims received on or after April 1, 2008. Reporting this number is voluntary and claims submitted without the clinical trial number will be paid the same as claims containing a number.

Source:   Transmittal: 1420 (PDF).
Effective Date: 10/01/2007

CMS has decided to not require Medicare Part B contractors to update their internal insurer tables or files with each Medigap insurer’s newly assigned Coordination of Benefits Agreement (COBA) Medigap claim-based ID, as was previously prescribed in CR 5662. This is because, the contractors’ front-end system now simply verifies that a Medigap claim-based crossover identifier on an incoming claim is syntactically correct (5 digits, beginning with a “5”). CMS’ Common Working File (CWF) system is now tasked with validation of the actual ID submitted on incoming claims. Effective with CR 5837, all Part B contractors will discontinue publication of their routine Medigap newsletters.

Source:   Transmittal: 1432 (PDF).
Effective Date: 05/23/2008

When you report a Provider Legacy Identifier on Medicare CMS-1500 or CMS-1450 (UB-04) claims, Medicare will return them as unprocessable.

CMS requires the NPI to be submitted on these claim forms. When returning these claims, your contractors will use an appropriate message and Remittance Advice Remark code, such as:

N257 Missing/incomplete/invalid billing provider primary identifier.

Note that contractors will not return claims in certain situations where an NPI is not required (e.g., foreign claims, deceased provider claims, and other situations as allowed by CMS in the future). Such claims will be processed with established procedures for such claims.

Source:   Transmittal: 56 (PDF).
Effective Date: 07/01/2008

CR 5772 implements CMS Medicare Clinical Laboratory Services Competitive Bidding Demonstration in the first Competitive Bidding Area (San Diego-Carlsbad-San Marcos, California metropolitan statistical area, or CBA1); and changes some of the demonstration’s requirements that were stated in CR5205, issued August 1, 2006.

Specifically, CR5772 requires that:
The demonstration covers tests provided to beneficiaries enrolled in the traditional fee-for-service (FFS) Medicare program who reside in the competitive bidding area (CBA1) during the 3-year demonstration period Required bidders that do not bid, or bid and do not win, may serve as a reference laboratory to laboratories participating in the demonstration. However, they would not be allowed to bill Medicare directly for demonstration tests performed for Medicare FFS beneficiaries residing in the CBA.

Laboratories not required to bid: These laboratories will be paid under the competitively set demonstration fee schedule for the duration of the demonstration.

• CMS will exempt laboratories that supply less than $100,000 annually in demonstration tests to Medicare FFS beneficiaries residing in the CBA from submitting bids.
• CMS will exempt laboratories providing services exclusively to beneficiaries entitled to Medicare by reason of end-stage renal disease (ESRD) from submitting bids. (Tests that are paid as part of the ESRD payment bundle are excluded from the demonstration.)
• CMS will exempt laboratories providing services exclusively to beneficiaries in nursing facilities or receiving home health services from submitting bids.

The demonstration in CBA1 is scheduled to begin on July 1, 2008.

Source:   Transmittal: 1418 (PDF).
Effective Date: 01/01/2008

CMS is discontinuing the QA (FDA Investigational Device Exemption), QR (Item or Service Provided in a Medicare Specified Study), and QV (Item or Service Provided as Routine Care in a Medicare Qualifying Clinical Trial) HCPCS modifiers as of December 31, 2007, and creating two new modifiers that will be used solely to differentiate between routine and investigational clinical services.

These new modifiers will be included in the 2008 Annual HCPCS Update and are effective for dates of service on and after January 1, 2008:

Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study. Q0 replaces QA and QR.

Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study. Q1 replaces QV.

Source:   Transmittal: 83 (PDF).
Effective Date: 07/01/2008

CMS issued Change Request (CR) 5874 to alert providers that existing CPT code 82330, Calcium; ionized is being paid as in individual test and was not included in the AMCC Panel Payment Algorithm. That changes effective July 1, 2008.

Key Points

• In order to determine payment for the new code 80047 using the AMCC Panel Payment Algorithm, existing code 82330, Calcium; ionized, will be added as an AMCC panel code.
• Payment code ATP23 has also been included in the clinical laboratory fee schedule data file to correspond to the AMCC panel code addition.
• The CPT code 80047 Basic metabolic panel (Calcium, ionized) is comprised of:
• Calcium; ionized (82330);
• Carbon dioxide (82374);
• Chloride (82435);
• Creatinine (82565);
• Glucose (82947);
• Potassium (84132);
• Sodium (84295); and
• Urea Nitrogen (BUN) (84520)

For ESRD dialysis patients, CPT code 82330 Calcium; ionized will be included in the calculation for the 50/50 rule. The new panel code 80047 cannot be billed for services ordered through an ESRD facility. All tests billed for services ordered through an ESRD facility must be billed individually, not in an organ disease panel.

This special edition article,  SEO802 (PDF), is being provided by CMS in order to clear up some confusion that providers are experiencing regarding the March 1, 2008 implementation of the NPI on professional claims, and the May 23, 2008 requirement for ONLY the NPI on all HIPAA electronic transactions and their paper versions.

The following charts illustrate expected claim results for different identifiers, or combinations of identifiers, submitted in the primary provider fields on the Medicare FFS 837P and CMS-1500.

*Claims will reject when there is not a match on the Medicare NPI Crosswalk. You must correct any data which may be preventing an NPI/legacy match on the NPI crosswalk. The correction might require that you file a CMS-855 Medicare Provider Enrollment form with your Medicare carrier, A/B MAC, or DME MAC a process which can take a number of months to accomplish.

**HIPAA electronic transactions (837I, 837P, 837COB, NCPDP, 276/277, 270/271, and 835), paper claims and SPR remittance advice.

Source:  Transmittal: 235 (PDF).
Effective Date: 05/23/2008

Effective with claims received on or after May 23, 2008, Medicare will not pay for referred or ordered services; unless the name and NPI of the ordering, referring and attending, operating, other, or service facility providers are completed on the claims. Further, in accordance with the NPI final rule; effective May 23, 2008, when reported on a claim, the identifier for such a provider must be an NPI, regardless of whether the provider is a covered entity, or participates in the Medicare program. Therefore, Medicare will not pay for referred or ordered services, or items, unless the name and NPI number of the ordering, referring and attending, operating, other, or service facility provider are on the claim. If, after several unsuccessful attempts to obtain the NPI; CR 5890, requires that the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields.

Source:   Transmittal: 1440 (PDF).
Effective Date: 01/01/2008

Qualifying independent laboratories may continue to bill Medicare directly for the TC of certain physician pathology services provided to patients as part of a covered hospital inpatient stay or outpatient hospital service, through June 30, 2008.

Key Points

• Independent laboratories that qualify to bill for the TC of a physician pathology service furnished to an inpatient or outpatient of a covered hospital may continue to bill their carrier or Part A/B MAC for these services through June 30, 2008.
• Effective on or after July 1, 2008, only the hospital may bill for the TC of a physician pathology service provided to a hospital inpatient or outpatient.
• A covered hospital refers to a hospital that has an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which the laboratory furnished the TC of physician pathology services to fee-for service Medicare beneficiaries who were patients of the hospital.
• The hospital cannot bill under the Outpatient Prospective Payment System (OPPS) for the TC of physician pathology services if the laboratory that services that hospital outpatient is receiving payment from its carrier or A/B MAC under the Medicare physician fee schedule.