CMS

CMS coverage policies for diagnostic and screening PSAs

As a result of negotiated rule making, an NCD was developed for the diagnostic PSA test.

In Program Memo AB-03-132, the CMS instructed local contractors to include a provider education article regarding diagnostic and screening PSA tests in their next regularly scheduled bulletin.

The key points:

• Diagnostic PSA testing is subject to a national Medicare coverage policy which specifies the CPT code covered (84153) as well as the necessary clinical indications and the ICD-9 diagnosis codes recognized as justifying medical necessity.
• Screening PSA testing is covered annually by Medicare for male beneficiaries age 50 and older.
• Use HCPCS code G0103 for the screening PSA test.

Reference:  Transmittal AB-03-132

Medicare Diagnosis Requirement

As of this Oct. 1, 2003 all laboratory claims must contain a valid ICD-9 diagnosis code, with the service coded to the highest degree of specificity. Otherwise, they will be returned as "unprocessable." The change applies to both electronic and paper claim formats.

CCI

Changes to Correct Coding Edits, Version 9.3

Effective October 1, 2003, Correct Coding Initiative (CCI) Edits Version 9.3 will be implemented. CMS implemented national CCI Edits in 1996 for the purpose of identifying and eliminating the incorrect code of medical services.

New Conflicts have been added:

The following codes were added as mutually exclusive procedures:

The following codes were deleted from the conflicting codes lists:

An extensive list of mutually exclusive surgical pathology (biopsy) codes have been added.

CCI Edits posted on Website

In an effort to improve its services, CMS has announced that it will post National Correct Coding Initiative Edits on its Website. Previously these edits were available by subscription only. The NCCI edits will be posted as a spreadsheet and will be updated quarterly:  http://cms.hhs.gov/physicians/cciedits/default.asp

NCD Coding Changes

CMS has expanded the ICD-9 diagnosis codes under its national coverage decisions (NCDs) for prothrombin time and fecal occult blood tests. The original policies listed ICD-9 863.0 to 863.9, injury to gastrointestinal tract, among the covered diagnoses for both tests. CMS has added codes 863.91-863.95 and 863.99.

Visit:   http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=97

Medicare To Accept Non-Compliant HIPAA Transactions

To avoid severe disruptions in healthcare providers' cash flow and operations, CMS announced Sept 23, 2003 that it will implement a contingency plan to accept and process claims in electronic formats now in use beyond the Oct 16th deadline. CMS will evaluate progress to determine how long this contingency plan will last.

The press release is located at:   http://www.cms.hhs.gov/media/press/release.asp?Counter=870

ICD-9-CM Annual Update - Revised

The annual update of the ICD-9-CM, ninth edition 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.

Three new diagnosis codes have been added.

The three new ICD-9-CM diagnosis codes are:

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,  http://www.cms.hhs.gov/medlearn/icd9code.asp, has been updated with the new ICD-9-CM diagnosis codes.

Additional reference:  http://www.cdc.gov/nchs/icd9.htm

OIG Reviews Lab Pricing Structures

The HHS Office of Inspector General is proposing a significant change in the government's interpretation of Medicare and Medicaid's prohibition against discriminatory pricing.

The proposal, announced in the Sept 15, 2003 Federal Register, would limit charges billed to Medicare or Medicaid at no more than 120% of their usual charge to other customers, including charges to physicians. Current law bans labs and other healthcare providers from charging Medicare and Medicaid "substantially in excess" of their "usual charges," but excludes physician pricing.

NHIC

Fecal Leukocyte Examination during calendar year 2003

NHIC will permit the use of HCPCS code Q0111 (Wet mounts, including preparations of vaginal, cervical or skin specimens) for fecal leukocyte examination claims submitted by facilities with a valid Provider Performed Microscopy (PPM) procedure CLIA certificate with dates of services on or after Jan 1, 2003. NHIC will retroactively adjust any claims brought to their attention.

The HCPCS code G0026 (fecal leukocyte examination) was discontinued on 12/31/2002. The HCPCS code 89055 (fecal leukocyte count) was a possible code to be used for the discontinued G0026. However, under CLIA, the fecal leukocyte examination permitted for a PPM procedure certificate does not include a fecal leukocyte count. The HCPCS code 89055 is under revision for calendar year (CY) 2004.

Reference:   http://www.medicarenhic.com/articles/fecalexam_0903.htm

California Medi-Cal

The new "proposed" Medi-Cal rates are now on line at the DHS lab contracting website:   http://www.dhs.ca.gov/omcp/html/Clinical%20labs%20download.htm.

The new lab reimbursement fee schedule will apply to all laboratory procedures, regardless of who bills them, with one exception: hospital outpatient departments whose rates cannot be reduced because of the orthopedic lawsuit. In the orthopedic lawsuit, the courts determined that the state of California should reimburse hospitals at a significantly higher rate for outpatient services provided to Medi-Cal enrollees. Thus, the state does not have the authority to change the reimbursement schedule for outpatient services provided by hospitals to Medi-Cal patients.

Medi-Cal is issuing a special letter to independent clinical labs notifying them that the new Medi-Cal fees will be effective Oct 1, 2003.