CMS

ICD-9-CM Annual Update

The annual update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) will occur effective October 1, 2003. An ICD-9-CM code is required on all paper and electronic claims billed to Medicare carriers with the exception of ambulance claims (specialty type 59) effective October 1, 2003. Medicare carriers will accept both the old and new ICD-9-CM codes for dates of service October 1, 2003, through December 31, 2003.

The CMS website www.cms.hhs.gov/medlearn/icd9code.asp contains the new, revised, and deleted ICD-9-CM codes that are effective for dates of service on or after October 1, 2003. You are encouraged to visit the National Center for Health Statistics (NCHS) website at www.cdc.gov/nchs/icd9.htm. You may purchase ICD-9-CM books from technical bookstores or technical publishing companies.

Reference: CMS Program Memorandum Change Request 2763; Transmittal AB-03-091 See the complete transmittal on the CMS website at http://cms.hhs.gov/manuals/pm_trans/AB03091.pdf

New Tracking Sheet

CMS has posted a new tracking sheet to re-evaluate the inclusion of ICD-9-CM codes 584, 585 and 586 (acute renal failure,chronic renal failure and renal failure unspecified) in the Urine Culture Bacterial NCD. Public comment date is 8/7/2003. Urine Culture Bacterial (Re-evaluation of Inclusion of Renal Failure in the List of ICD-9-CM Codes Covered) New tracking sheet announcing review of lab NCD.

Changes to the Laboratory NCD Edit Software

October 1, 2003

Effective October 1, 2003, changes to the edit software for clinical diagnostic laboratory National Coverage Determinations (NCDs) will be implemented to include the new ICD-9-CM codes which are updated annually.

New ICD-9-CM codes can render some of the presently covered codes inappropriate. Most commonly, codes are expanded so that additional digits are necessary. For example, a code that presently is displayed as 4 digits may be expanded to require 5 digits. The coding changes below are considered ministerial in that existing codes within the NCD are replaced with the more current code structure or adding new codes that are within an existing covered range. Since CMS provides a 90 day grace period for the existing codes, both the existing and current ICD-9 codes will be accepted. Effective January 1, 2004, only the current ICD-9 codes will be accepted.

The following ICD-9 changes will be made to the lab NCD edit software for services furnished on or after October 1, 2003.

For more information on Lab NCDs, please see CMS website: http://cms.hhs.gov/ncdr.

Reference: CMS Program Memorandum Change Request 2814; Transmittal AB-03-104.

OIG

The OIG has released a final inspection report that found that over half of providers in the active Unique Physician/Practitioner Identification Number (UPIN) database had at least one practice setting record with inaccurate information. CMS intends to use data in the UPIN Registry to enumerate the National Provider System. However, if inaccurate data are used to populate the system, the new identifiers will not meet their full potential as a protection for the Medicare program and the people it serves. OIG recommends that CMS correct inaccurate and incomplete information in the UPIN Registry and deactivate practice settings that are not used. CMS concurred with the recommendations.

Arkansas Medicare Services

Urinalysis, AC-02-015

Policy was revised to allow diagnosis codes 639.0, 639.3, 639.8, 643.0, 643.10, 643.11, 643.13, 648.00-648.04, 648.80-648.84 and V28.8 (CPTs 81000, 81001, 81002, 81003, 81005, 81007 and 81015) which correlate with "Indications and Limitations" item 8 relating to pregnant patients. This is an expansion of policy and effective retroactively back to date of service August 15, 2002.

HER2 TESTING, AC-99-515

Added Vysis PathVysion HER2 DNA Probe (CPTs 83950, 88271 and 88342) to the list of FDA approved tests in the "Description" and "I&L" effective with the FDA approved date of 08/28/2002.

Reference: http://www.arkmedicare.com/provider/mrdpolb/polmanindex1.asp

Missouri Medicare Services

HER2 Testing, AC-99-515

The Vysis PathVysion HRT2 DNA Probe (CPTs 83950, 88271 and 88342) has been added to the list of allowable tests that determine overexpression of HER2. This is effective with date of service August 28, 2002 as per the FDA approval letter.

Urinalysis, AC-02-015

Policy was revised to allow diagnosis codes 639.0, 639.3, 639.8, 643.0, 643.10, 643.11, 643.13, 648.00-648.04, 648.80-648.84 and V28.8 (CPTs 81000, 81001, 81002, 81003, 81005, 81007 and 81015) which correlate with "Indications and Limitations" item 8 relating to pregnant patients. This is an expansion of policy and effective retroactively back to date of service August 15, 2002.

Reference: http://www.momedicare.com/provider/medpol/polmanindex1.asp

New York (Empire Medicare)

Prostate Specific Antigen, LB012E00

Coordinated LMRP for Empire New Jersey and New York. Incorporated NCD information on Total PSA into LMRP. Added information on complexed PSA. CPTs G0103, 84152, 84153 and 84154.

B-Type Natriuretic Peptide (BNP), LB10E00

Added LMRP for CPT 83880.

Human Immunodeficiency Virus Testing (Prognosis Including Monitoring), LB011E00

Added LMRP for CPTs 87536 and 87539.

Viral Hepatitis Serology Tests, LB013E00

This policy revision complements the Medicare National Coverage Decision on Acute Hepatitis Panel (CPTs 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87380), published in the Federal Register, November 23, 2001, 66FR 58788, as part of the Negotiated Rulemaking for Clinical Diagnostic Laboratory Services. Added CPT 87341 to LMRP. Added and deleted covered Diagnosis codes.

Reference: http://www.empiremedicare.com/trainb/lmpb.htm

Electronic Submission of Medicare Claims to be Required

Effective October 16, 2003

The HIPAA Administrative Simplification Compliance Act (ASCA) prohibits the Department of Health and Human Services (DHHS) from paying Medicare claims that are submitted on paper. It requires that all Medicare claims be submitted electronically, unless certain waiver criteria are met.

DHHS will publish a regulation to implement this new authority. That regulation is expected to include further detail to define the waiver criteria such as the circumstances when it would not be considered possible to submit claims electronically, and other situations in which it may be permissible to submit a paper claim.

Medicare "waiver" for small providers billing on paper

Regulations for clarifying the exceptions are expected to be published soon along with instructions on the "waiver" process. If you meet the small provider exception just continue to bill via paper. The term "small provider of services or supplier" is being defined to mean:

• a physician, practitioner, facility, or supplier with fewer that 10 full-time equivalent employees and
• a provider of services with fewer than 25 full-time equivalent employees

To read the entire article go to: http://www.cms.gov/hipaa/hipaa2/Smallproviderwaiverltr06-24-03.doc.

NHIC

Local Modifiers Eliminated

The Administrative Simplification provisions of HIPAA direct the federal government to adopt national electronic standards for automated transfer of certain health care data between health care payers, plans and providers. This will enable entire health care industry to communicate electronic data using a single set of standards, thus eliminating all nonstandard formats currently in use.

As part of this process, NHIC has evaluated their local modifiers and made the decision to eliminate the following modifiers, as of January 1, 2004:

Northern California

* To identify clinical laboratory tests referred to another lab, independent clinical laboratories (provider specialty 69 only) must use: Modifier - 90 Reference (Outside) Laboratory

** Changes have been made to provider enrollment files to capture the information for Northern California previously reflected by use of the modifiers. Effective immediately, providers may cease billing with the modifiers.

Reference:  NHIC