CMS

Medicare Secondary Payer Rules

Outreach Hospital Laboratories will no longer be required to obtain information from beneficiaries to determine if there is another payor primary to Medicare. Medicare reform law (P.L. 108-173) prohibits the Government from requiring an outpatient hospital lab to do more in this regard than it demands of independent labs.

"CB" Modifier For Dialysis Services

CMS has issued changes to CR 2475 Transmittal AB-02-175 regarding use of the -CB modifier for dialysis services. The guidance issued on submission of the "CB" modifier is being modified to no longer require that the provider/supplier determine that the beneficiary is in a SNF Part A stay. A provider or supplier may use the "CB" modifier only when it has determined that (a) the beneficiary has ESRD entitlement, (b) the test is related to the dialysis treatment for ESRD, (c) the test is ordered by a doctor providing care to patients in the dialysis facility, and (d) the test is not included in the dialysis facility’s composite rate payment.

Reference:  Transmittal 69, Change Request 2906, Pub. 100-04.

Claim Billing Instructions Revised

Effective for claims received on or after April 1, 2004, the name, address, and zip code of the service location for all services other than those furnished in place of service home (12) must be entered in Item 32 of the CMS 1500 claims form (or appropriate electronic claim field). If this information is missing or incomplete, assigned claims will be returned as unprocessable.

Reference:  Transmittal 6, Change Request 2912, Pub. 100-04.

90-Day Grace Period Elimination

CMS is instructing carriers and fiscal intermediaries to eliminate the 90-day grace period for billing discontinued HCPCS codes.

Reference:  Transmittal 89, Change Request 3093 Pub. 100-04.

Lab-to-Lab Referrals

On February 6, 2004, the Centers for Medicare and Medicaid Services issued Transmittal 85 Change Request (CR) 3090, which provides instructions to resolve billing issues when a laboratory refers a specimen for testing by another laboratory in another Carrier's jurisdiction ("lab-to-lab referral").

CMS had previously published the instructions on October 31, 2003 as Transmittal 23 Change Request (CR) 2193, with an effective date of April 1, 2004. CR 3090 supersedes CR 2193 and full implementation of the instructions will now be for dates of service on or after July 1, 2004.

Reference:  Transmittal 85, Change Request 3090 Pub. 100-04.

NCD

Laboratory National Coverage Determination - Update

The following diagnosis codes are being added to the Serum Iron Studies NCD with an effective date of April 5, 2004 to the list of "ICD-9-CM Codes covered by Medicare":

• 403.01,  Hypertensive renal disease, malignant, with renal failure
• 403.11,  Hypertensive renal disease, benign, with renal failure
• 403.91,  Hypertensive renal disease, unspecified, with renal failure
• 404.02,  Hypertensive heart and renal disease, malignant, with renal failure
• 404.03,  Hypertensive heart and renal disease, malignant, with heart and renal failure
• 404.12,  Hypertensive heart and renal disease, benign, with renal failure
• 404.13,  Hypertensive heart and renal disease, benign, with heart and renal failure
• 404.92,  Hypertensive heart and renal disease, unspecified, with renal failure
• 404.93,  Hypertensive heart and renal disease, unspecified, with heart and renal failure

Reference:  Decision Memo for Serum Iron Studies (Expansion of the Chronic Renal Failure Covered Codes to Include Hypertensive Renal Disease) (CAG-00194N).

National Provider Identifier (NPI)

Final Rule Published

The Final Rule adopting the HIPAA standard unique health identifier for health care providers was published in the Federal Register on January 23, 2004. Health care providers can begin applying for NPIs on the effective date of the final rule, which is May 23, 2005. All health care providers are eligible to be assigned NPIs; health care providers who are covered entities must obtain and use NPIs. All HIPAA covered entities must use NPIs by the compliance dates (May 23, 2007 for all but small health plans; May 23, 2008 for small health plans).

To view the final rule:  "45 CFR Part 162" in the Federal Register.

NHIC

California

NHIC in Northern California has used this modifier for some time to identify when an incorrect procedure code or modifier has been submitted and changed by us when processing the claim. Effective March 3, 2004 NHIC in Southern California will implement this practice and use CC to identify when modifiers inconsistent with a procedure or service, or are not Medicare modifiers, are submitted on a claim. Medicare will remove and replace the inconsistent modifier with CC. This modifier is not to be billed. The purpose is to notify the provider on the Standard Paper Remittance statement that there has been a change to the initial claim.

New England

NHIC has made updates to their LMRPs, which are now going to be called LCDs effective in Feb 2004.

To view the index visit:  Final Local Coverage Determination Index.

Those impacted include:   Apolipoprotein, Lyme Disease and Molecular Diagnostics.

Medi-Cal

Reimbursement Rate

California Medi-Cal has established reimbursement rates for services previously listed as "By Report" for dates of service on or after October 1, 2003. Accordingly, the services listed below may now be billed electronically.

The maximum reimbursement rates are as follows:

Note: The maximum reimbursement rate for CPT-4 codes 88144 and 88145 is $21.20. These codes are reimbursable only for dates of service on or before September 22, 2003.

The updated rates are reflected on manual replacement pages rates max lab 1,2, 4, 5, 7 and 8 (Part 2).