CMS

National Coverage Analysis (NCA) Blood Glucose Testing (Revision of ICD-9-CM Codes for Osteomyelitis) (#CAG-00183N)

Centers for Medicare & Medicaid Services (CMS) has issued its intent to alter the list for covered diagnoses for blood glucose. It plans to delete the line that reads 730.07-730.27 and replace it with 730.07, 730.17 and 730.27.

Reference: www.cms.hhs.gov/ncdr/memo.asp?id=91

ESRD Policy

"ESRD Reimbursement for Automated Multi-Channel Chemistry Tests," transmittal A-03-033 sets forth the following three major policy changes:

1 ESRD facilities use one of three new modifiers when they order tests from hospitals labs: "CD" for the composite rate tests; "CE" for medically necessary tests outside the composite rate; and "CF" for test outside the composite rate with no medical justification.

2 ESRD facilities must individually bill all automated chemistry test using the three modifiers.

3 Intermediaries will identify all panel tests for a given date of service, divide the number of test with the "CD" modifier by the total number of tests with the three modifiers. If the quotient equals 50% or more, the intermediary will not allow any additional payment beyond the composite rate. IF it is less than 50%, it will pay separately for all panel tests for that date of service.

Fiscal Intermediaries will implement this procedure October 1, 2003. The agency will request approval to apply the new procedure to carriers in time for the January 2004 update.

CMS Adds Code for Screening Pap Smears

Effective October 1, 2003, CMS is adding two new low-risk diagnosis codes for pap smears & pelvic exams: V76.47 for malignant neoplasm, vagina and V76.49 for malignant neoplasm, other sites (for women without a cervix)

Medicare Additional Document Request (ADR) Policy

When a contractor cannot make a coverage determination based on the information on the claim, the contractor may solicit an ADR. As a general rule, if during pre- or post-payment review, a contractor chooses to send an ADR regarding a targeted lab service, it must solicit the documentation from the billing provider, and under certain circumstances, must also solicit documentation from the ordering provider.

Reference: CMS Transmittal 39, Mar. 14, 2003; effective date, Apr. 1, 2003.

New Time Frame for Appealing Medicare Claim Determinations

Effective April 1, 2003, physicians, suppliers and beneficiaries have an additional 60 days to file appeals of Medicare Part B claim determinations made on or after October 1, 20002.

The Medicare Benefits Improvements & Protection Act of 2000 (BIPA) implemented a uniform 120-day timeframe for requesting appeals of initial determinations for Part A and Part B claims. Prior to BIPA, requests for Part B reviews had to be filed within 180 days and requests for Part A reconsiderations had to be filed within 60 days of an initial determination.

Reference: Transmittal AB-03-039

NHIC

Electronic Eligibility 270/271 Transaction to be Supported in Real-Time

Effective July 1, 2003, NHIC will begin supporting the ANSI X12N Health Care Eligibility Benefit Inquiry/Response transaction 270 (in-bound)/271(out-bound eligibility response) version 4010A1 in real-time. The implementation guide for the ANSI X12N 270/271 transaction version 4010A1 may be obtained at www.wpc-edi.com/HIPAA. This implementation guide has been adopted for national use under HIPAA.

Effective October 16, 2003, the only electronic eligibility inquiry 270 transactions that will be accepted for eligibility data will be those transmitted in ANSI X12N version 4010A1 via IVANS or another qualified private network. Medicare will no longer accept batch transactions. If a provider is presently requesting eligibility information via the Carrier Bulletin Board System (CABBS), eligibility responses will no longer be issued via that system effective October 16, 2003.

High Sensitivity C-Reactive Protein

High sensitivity C Reactive Protein (CPT code 86141 - hsCRP) has been found to be related to atherogenic risk for cardiovascular disease or stroke. A review of recent literature supports this as the principal use of hs-CRP.

Medicare will consider hsCRP a screening test and, until such time that the literature can demonstrate more specific use in treatment decisions or outcome management apart from screening, they will not reimburse for the test.

Reference: www.medicarenhic.com/physician/ca/update.htm

CA Updates

Urinary FISH Test for Recurrent Bladder Cancer

Bladder cancer recurrence by fluorescent in situ hybridization (FISH) DNA probe technology of voided urine is a covered laboratory service.

Billing instructions - The unlisted cytogenetic study code 88299 must be used to report the test. Enter the name FISH Bladder Cancer Test in Item 19 of the CMS 1500 claim form or in the comments field of electronic claims.

ICD-9-CM Codes - a guideline of appropriate ICD-9-CM for patients diagnosed with bladder cancer can be found at the following link: www.medicarenhic.com/physician/ca/fishtest_0503.htm

Medicare Billing Update - Modifier Expansion

The Medicare Claims System has been modified to allow MCS carriers to read four modifier fields. In the past, whenever more than two modifiers were needed, they had to be placed in Item 19 (or the comments fields for electronic claims) with modifier 99 indicated on the line item following the procedure code. Effective immediately, you can submit up to four modifiers on paper claims or in the specific electronic fields.

Note: Modifiers 26, TC and QW must be billed in the first modifier field.

Reference: www.medicarenhic.com/articles/modexpand_0503.htm

LMRP Updates

The Apolipoprotein LMRP in Northern California has been retired and the non-coverage policy for Apolipoprotein in Southern California has been rescinded. These coverage decisions are not retro-active.

Eight LMRPs are being standardized between the North and the South. Once the additional diagnoses have been added to the LMRPs to make them standard in both regions, NHIC will evaluate the number of denials received and may retire LMRPs with low denial rates.

Reference: www.medicarenhic.com/lmrp/draft/ca/draftlmrpindex.htm