NOTE: Should you have landed here as a result of a search engine (or
other) link, be advised that these files contain material that is copyrighted
by the American Medical Association. You are forbidden to download
the files unless you read, agree to, and abide by the provisions of the
copyright statement. Read the copyright statement now and you will
be linked back to here.
PART B MEDICARE ADVISORY
July 2016
Volume 2016, Issue 7
Latest Medicare News for Part B
What’s Inside...
Administration
CMS Quarterly Provider Update ............................................................................................. 3
Going Beyond Diagnosis ........................................................................................................3
Get Your Medicare News Electronically ................................................................................. 5
Claim Status Category and Claim Status Codes Update ........................................................ 7
October Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled
Nursing Facility Consolidated Billing Enforcement ........................................................... 8
Recovering Overpayments from Providers Who Share Tax Identification Numbers .......... 10
Drugs and Biologicals
JW Modifier: Drug Amount Discarded/Not Administered to any Patient ........................... 11
Education
Educational Events Now Available ........................................................................................ 13
Fee Schedules and Reimbursement
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) July Calendar Year (CY) 2016 Update .............................................................................. 14
Medicine
Coding Revisions to National Coverage Determinations (NCDs) ....................................... 17
Ambulatory Surgical Center (ASC
July 2016 Update of the Ambulatory Surgical Center (ASC) Payment System ................... 19
Chiropractors
Educational Resources to Assist Chiropractors with Medicare Billing ................................ 25
Continued >>
palmettogba.com/JMB
The Part B Medicare Advisory contains coverage, billing and other information for Part B. This information is not
intended to constitute legal advice. It is our ofϐicial notice to those we serve concerning their responsibilities and
obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost
on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the
guidelines. The Part B Medicare Advisory includes information provided by the Centers for Medicare & Medicaid
Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins
are available at no-cost from our website at http://www.PalmettoGBA.com/JMB.
CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part
of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code
on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2015
American Dental Association (ADA). All rights reserved.
End-Stage Renal Disease (ESRD)
Update to Pub. 100-02, Chapter 11 End-Stage Renal Disease (ESRD) for Calendar Year (CY) 2016 .......................29
Etcetera
Medical Director’s Desk ............................................................................................................................................... 37
CMS e-News ................................................................................................................................................................. 51
CallBack Assist
CallBack Assist was implemented to improve the wait times during peak calling periods of the day. CallBack
Assist allows providers to opt out for a same-day callback from a customer service representative (CSR).
Typically, the callback occurs within one hour. This feature is a contact center best practice among the industry.
Providers are encouraged to try this new option when offered to avoid long wait times for assistance.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
2
7/2016
CMS Quarterly Provider Update
The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid
Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare
including program memoranda, manual changes and any other instructions that could affect providers.
Regulations and instructions published in the previous quarter are also included in the update. The purpose of
the Quarterly Provider Update is to:
•
•
•
•
•
Inform providers about new developments in the Medicare program
Assist providers in understanding CMS programs and complying with Medicare regulations and instructions
Ensure that providers have time to react and prepare for new requirements
Announce new or changing Medicare requirements on a predictable schedule
Communicate the specific days that CMS business will be published in the ‘Federal Register’
To receive notification when regulations and program instructions are added throughout the quarter, sign up
for the Quarterly Provider Update listserv (electronic mailing list) at
https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.
We encourage you to bookmark the Quarterly Provider Update Web site at
www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. html
and visit it often for this valuable information.
Going Beyond Diagnosis
Preventing Payment Errors by
Improving Provider-Payer Communication
A failure to communicate is the number one cause of Medicare claims denials. Palmetto GBA’s Going Beyond
Diagnosis (GBD) process helps reduce Medicare denials by supporting the dissemination of best practices and
process improvements. The GBD Blog was established to provide a platform for discussing the challenges and
complexities of communicating health care encounters and to provide potential solutions to identify the root
causes for specific communication errors.
The GBD Blog and Twitter ID @BeyondDx are part of Palmetto GBA’s innovative strategy for increasing the
capacity of Medicare providers to improve the quality of healthcare records and effectively decrease the claims
payment error rate. The success of this social media approach to communicating with healthcare stakeholders
depends on your active participation.
True innovation requires collaboration. Please join the on-line GBD community by visiting the GBD Blog at
http://palmgba.com/gbd/ or signing-up to follow us on Twitter @BeyondDx.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3
7/2016
Palmetto GBA Advanced Clinical Editing System (P-ACE)
Palmetto GBA Advanced Clinical Editing System (P-ACE) is available to all direct submitters as well as
those who transmit claims via clearinghouses/billing services. New CEM ‘Smart edits’ will appear on claim
rejection reports (277CA) as Palmetto GBA deploys P-ACE to the electronic claim submission process for
professional claims.
•
•
•
•
P-ACE returns pre-adjudicated claims information through claim acknowledgement transaction reports
sent by your clearinghouse based on the Medicare 277CA
All direct submitters will receive the Medicare 277CA report with the new smart edits
Claims failing the pre-adjudication editing process are not forwarded to the claims adjudication system
P-ACE will work with your current clearinghouse/billing service workflow so you can modify claims before
the MCS system receives them
After you have reviewed the Smart Edit, if you choose not to change the claims, you can resubmit in its original
format and it will pass to the MCS claims adjudication system for processing. P-ACE is available to you at no
cost! No downloads or software is required. P-ACE is incorporated in your normal EDI stream.
Unsure what the P-ACE Smart Edit means?
Smart Edits are not directives, but rather considerations for appropriate claims processing based upon the
information submitted on the claim. Medicare will continue to require that all documentation and coverage
requirements are met prior to providers making the claim change.
To use the P-ACE Smart Edit Lookup tool, enter the P-ACE Smart Edit # from/for the claim. On the second
screen you will see the P-ACE Smart Edit Message, description, and any additional information pertinent to
your claim. Only P-ACE Smart Edit #’s listed in the Advance Clinical Editing page table will display.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4
7/2016
Get Your Medicare News Electronically
The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity
to stay informed about:
• Medicare incentive programs
• Fee Schedule changes
• New legislation concerning Medicare
• And so much more!
How to register to receive the Palmetto GBA Medicare Listserv:
Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online
form. Be sure to select the specialties that interest you so information can be sent.
Note: Once the registration information is entered, you will receive a confirmation/welcome message informing
you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within 3 days
of your registration.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5
7/2016
Medicare Learning Network® (MLN)
Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare
Learning Network® (MLN) – the home for education, information, and resources for health care professionals.
The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services
(CMS) and the brand name for official CMS education and information for health care professionals. It provides
educational products on Medicare-related topics, such as provider enrollment, preventive services, claims
processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of
formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses
(many of which offer continuing education credits) – all available to you free of charge!
The following items may be found on the CMS web page at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.html
• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To
access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the
catalog, you may either click on the title of a product or you can click on the type of “Formats Available.”
This will link you to an online version of the product or the Product Ordering Page.
• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products
are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and
select “MLN Product Ordering Page.”
• MLN Product of the Month: highlights a Medicare provider education product or set of products each
month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!
Other resources:
• MLN Publications List: contains the electronic versions of the downloadable publications. These products
are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and­
Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. You will then be able
to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.
MLN Educational Products Electronic Mailing List
To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN
Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive
an e-mail when new and revised MLN products are released.
To subscribe to the service:
1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or
Unsubscribe’ link under the ‘Options’ tab on the right side of the page.
2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!
If you would like to contact the MLN, please email CMS at MLN@cms.hhs.gov.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6
7/2016
Claim Status Category and Claim Status Codes Update
MLN Matters® Number: MM9550
Related Change Request (CR) #: CR 9550
Related CR Release Date: May 20, 2016
Effective Date: October 1, 2016
Related CR Transmittal #: R3527CP
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9550 informs MACs about the changes to Claim Status Category Codes and Claim
Status Codes. Make sure that your billing staffs are aware of these changes.
Background
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all covered entities to
use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance
Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards
adopted under HIPAA for electronically submitting health care claims status requests and responses. These
codes explain the status of submitted claim(s).
Proprietary codes may not be used in the ASC X12 276/277 transactions to report claim status.
The National Code Maintenance Committee meets at the beginning of each ASC X12 trimester meeting
(January/February, June, and September/October) and makes decisions about additions of new codes, as well
as modifications and retirement of existing codes. The Committee has decided to allow the industry 6 months
for implementation of newly added or changed codes.
The codes sets are available at
http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ and
http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/.
Included in the code lists are specific details, including the date when a code was added, changed, or deleted.
All code changes approved during the June 2016 committee meeting will be posted on the above mentioned
websites on or about July 1, 2016.
The Centers for Medicare & Medicaid Services (CMS) will issue future CRs regarding the need for future
updates to these codes. These code changes are to be used in editing of all ASC X12 276 transactions processed
on or after the date of implementation and to be reflected in the ASC X12 277 transactions issued on and after
the date of implementation of CR9550.
Additional Information
The official instruction, CR9550 issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3527CP.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7
7/2016
October Quarterly Update to 2016 Annual Update of HCPCS
Codes Used for Skilled Nursing Facility Consolidated Billing
Enforcement
MLN Matters® Number: MM9688
Related Change Request (CR) #: CR 9688
Related CR Release Date: June 17, 2016
Effective Date: October 1, 2016
Related CR Transmittal #: R3546CP
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to all Medicare
Administrative Contractors (MACs) for services to Medicare beneficiaries who are in a Part A Skilled Nursing
Facility (SNF) stay.
Provider Action Needed
This article is based on Change Request (CR) 9688 updates to the lists of Healthcare Common Procedure Coding
System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment
System (PPS). Changes to Current Procedure Terminology (CPT)/HCPCS codes and Medicare Physician
Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in
accordance with policy for SNF consolidated billing in the “Medicare Claims Processing Manual,” Chapter
6, Section 20.6 at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf. Make sure
your staffs are aware of these updates.
Background
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are
excluded from the Consolidated Billing (CB) provision of the SNF PPS. Services excluded from SNF PPS
and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. Services not
appearing on the exclusion lists submitted on claims to MACs, including Durable Medical Equipment MACs
(DME MACs), will not be paid by Medicare to any providers other than a SNF. For non-therapy services,
SNF CB applies only when the services are furnished to a SNF resident during a covered Part A stay; however,
SNF CB applies to physical and occupational therapies and speech-language pathology services whenever
they are furnished to a SNF resident, regardless of whether Part A covers the stay. In order to assure proper
payment in all settings, Medicare systems must edit for services provided to SNF beneficiaries both included
and excluded from SNF CB.
The updated lists for institutional and professional billing are available at
http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html.
Section 1888 of the Social Security Act codifies SNF PPS and CB. The new coding identified in each update
describes the same services that are subject to SNF PPS payment by law. No additional services will be added
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8
7/2016
by these routine updates; that is, new updates are required by changes to the coding system, not because the
services subject to SNF CB are being redefined. Other regulatory changes beyond code list updates will be
noted when and if they occur.
Your MAC will re-open and re-process claims which you bring to their attention, for claims with dates of service
on or after January 1, 2016, that have previously been denied/rejected incorrectly prior to the implementation
of CR9688.
Additional Information
The official instruction, CR9688, issued to your MAC regarding this change, is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3546CP.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9
7/2016
Recovering Overpayments from Providers Who Share Tax
Identification Numbers
MLN Matters® Number: SE1612
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Article is intended for providers of services and suppliers who share the same Tax
Identification Number (TIN) even though they may have different National Provider Identifiers or other billing
numbers used to bill Medicare.
What You Need to Know
Section 1866j(6) of the Social Security Act (https://www.ssa.gov/OP_Home/ssact/title18/1866.htm)authorizes
the Secretary to make any necessary adjustments to the payments of a provider of services or supplier who
shares a TIN with a provider of services or supplier that has an outstanding Medicare overpayment. The
Secretary of Health and Human Services is authorized to adjust the payments of such a provider of services or
supplier regardless of whether it has been assigned a different billing number or NPI from that of the provider
of services or supplier with the outstanding Medicare overpayment.
In January 2016, the Centers for Medicare & Medicaid Services (CMS) enhanced its financial accounting
system to include a function that allows CMS to recover payments made to a provider of services or supplier
that shares the same TIN with a provider of services or supplier that has an outstanding Medicare overpayment
across multiple states within a Medicare Administrative Contractor (MAC) jurisdiction.
Additional Information
You may review section 1866j(6) at https://www.ssa.gov/OP_Home/ssact/title18/1866.htm.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10
7/2016
JW Modifier: Drug Amount Discarded/Not Administered to
any Patient
MLN Matters® Number: MM9603
Revised Related Change Request (CR) #: CR 9603
Related CR Release Date: June 9, 2016
Effective Date: January 1, 2017
Related CR Transmittal #: R3539CP
Implementation Date: January 3, 2017
Note: This article was revised on June 10, 2016, to reflect the revised CR9603 issued on June 9. The CR was
revised to change the effective and implementation dates. The article is revised accordingly. In the article,
the CR release date, transmittal number and link to the CR were also changed. All other information remains
the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for drugs or biologicals administered to Medicare beneficiaries.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued CR 9603 to alert MACs and providers of the
change in policy regarding the use of the JW modifier for discarded Part B drugs and biologicals.
Effective January 1, 2017, providers are required to:
• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages
that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP)
for Part B drugs and biologicals) and
• Document the discarded drug or biological in the patient’s medical record when submitting claims with
unused Part B drugs or biologicals from single use vials or single use packages that are appropriately
discarded
Make sure that your billing staffs are aware of these changes. Remember that the JW modifier is not used on
claims for CAP drugs and biologicals.
Background
The “Medicare Claims Processing Manual,” Chapter 17, Section 40 provides policy detailing the use of the JW
modifier for discarded Part B drugs and biologicals. The current policy allows MACs the discretion to determine
whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details
regarding how the discarded drug or biological information should be documented.
Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and
biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with
discarded Part B drugs and biologicals.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11
7/2016
Additional Information
The official instruction, CR9603, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3538CP.pdf.
Document History
Document
Description
History
June 10, 2016 The article was revised to reflect a revised CR9603. The CR revision changed the
effective and implementation dates. In the article, the CR release date, transmittal number
and link to the CR were also changed. All other information remains the same.
May 25, 2016 The article was revised to reflect an updated CR. That CR updated the X-Ref
Requirement number in the CR’s Supporting Information Section. In the article, the CR
release date, transmittal number and link to the CR was changed. All other information
remains the same.
Denial Resolution Tool
The Palmetto GBA Denial Resolution tool, located on the home page under Forms/Tools, includes resources
for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you
pick up the phone.
•
•
•
Access denial reasons in plain language
Scroll through the titles to locate your procedure
Use the Palmetto GBA search engine to search by remark code
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12
7/2016
Educational Events Now Available…Don’t Miss this
Wonderful Opportunity!
Join the Provider Outreach and Education event listed below to learn about the Medicare program.
Event Title
Date/Time
Access
Ask the Contractor
Teleconference
Topic: to be
determined
August 11,
2016
10 a.m. ET
Teleconference Phone Number: 866-745-0425
Pass code: 87678891
Medicare Updates,
Changes and
Reminders Webcast
September
15, 2016
10 a.m. ET
http://event.on24.com/wcc/r/1061960/
A391FE4BEBC539944AB7A594A5E0C67E
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
13
7/2016
Quarterly Update to the Medicare Physician Fee Schedule
Database (MPFSDB) - July Calendar Year (CY) 2016 Update
MLN Matters® Number: MM9633
Related Change Request (CR) #: CR 9633
Related CR Release Date: May 20, 2016
Effective Date: January 1, 2016
Related CR Transmittal #: R3528CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9633 amends payment files that were issued to your MAC based upon the CY 2016
MPFS Final Rule published in the Federal Register on November 16, 2015. These payment files are to be
effective for services furnished between January 1, 2016, and December 31, 2016. Make sure your billing
staff is aware of these changes.
Background
Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary
to implement relative values for physicians’ services.
Key Changes in CR9633
Unless otherwise stated, the changes included in the July update to the 2016 MPFSDB are effective for dates
of service on and after January 1, 2016.
The key changes for the July update, effective as of January 1, 2016, are as follows.
CPT/HCPCS
Action
G0296
Multiple Surgery = 0; Diagnostic Imaging Family Indicator = 99
G9678
Procedure Status = C (Effective for services on or after 7-1-2016.)
10036
Multiple Surgery Indicator = 0
37188
Multiple Surgery Indicator = 0
45346
Endo Base Code = 45330
61651
Multiple Surgery Indicator = 0
65855
Bilateral Indicator = 1
69209
PC/TC indicator = 3
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14
7/2016
The following new codes in CR9636 have also been added to the MPFSDB.
CPT/
Short Descriptor
Procedure RVU
HCPCS
Status
Code
Q5102
Inj., infliximab biosimilar
E
no RVUs
Q9981
rolapitant, oral, 1mg
E
no RVUs
Q9982
flutemetamol f18 diagnostic
E
no RVUs
Q9983
florbetaben f18 diagnostic
E
no RVUs
Effective Date
4-5-16
7-1-16
7-1-16
7-1-16
For more information on the codes in CR9636, you may want to review the related MLN Matters Article MM9636
at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/MM9636.pdf.
CPT Codes effective on or after July 1, 2016
The new CPT Category III codes listed below have been added to the MPFSDB effective for dates of service
on and after July 1, 2016.
There are no RVUs for these codes, and the following payment policy indicators are the same for each code:
Procedure Status = C, Multiple Surgery = 0, Bilateral Surgery = 0, Assistant at Surgery = 0, Co-Surgeons = 0,
Team Surgeons = 0, PC/TC = 0, Physician Supervision of Diagnostic Procedures = 09, and Diagnostic Imaging
Family = 99. The Global Surgery Days for 0437T, 0439T, and 0443T = ZZZ; the rest are YYY.
CPT Code
Short Descriptor Long Descriptor
0437T
Impltj synth
Implantation of non-biologic or synthetic implant (eg, polypropylene)
rnfcmt abdl wal
for fascial reinforcement of the abdominal wall (List separately in
addition to code for primary procedure)
0438T
Tprnl plmt
Transperineal placement of biodegradable material, peri-prostatic (via
biodegrdabl matrl needle), single or multiple, includes image guidance
0439T
Myocrd contrast Myocardial contrast perfusion echocardiography; at rest or with stress,
prfuj echo
for assessment of myocardial ischemia or viability (List separately in
addition to code for primary procedure)
0440T
Abltj perc uxtr/
Ablation, percutaneous, cryoablation, includes imaging guidance; upper
perph nrv
extremity distal/peripheral nerve
0441T
Abltj perc lxtr/
Ablation, percutaneous, cryoablation, includes imaging guidance; lower
perph nrv
extremity distal/peripheral nerve
0442T
Abltj perc plex/
Ablation, percutaneous, cryoablation, includes imaging guidance; nerve
trncl nrv
plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443T
R-t spctrl alys
Real time spectral analysis of prostate tissue by fluorescence
prst8 tiss
spectroscopy
0444T
1st plmt drug elut Initial placement of a drug-eluting ocular insert under one or more
oc ins
eyelids, including fitting, training, and insertion, unilateral or bilateral
0445T
Sbsqt plmt drug Subsequent placement of a drug-eluting ocular insert under one or more
elut oc ins
eyelids, including re-training, and removal of existing insert, unilateral
or bilateral
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
15
7/2016
Note: MACs will not search their files to either retract payment for claims already paid or to retroactively pay
claims. However, they will adjust claims brought to their attention.
Additional Information
The official instruction, CR9633 issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3528CP.pdf.
Medicare Physician Fees Lookup Tool
Use the Medicare Physician Fee Lookup Tool, located on our home page. The Physician Fee Schedule tool
saves our customers time and money by providing a ‘one stop shop’! Customers can locate fees for the 2013
through 2016 throughout the United States. The tool can search up to five codes and each code shows the
allowance, all of the indicator rules such as the Global Surgery modifiers and Multiple Surgery rules. This
tool helps customers research more than a fee; they can determine if the wrong modifier was appended to a
service, or if the service was subject to multiple surgery rules. The fees and indicator files are downloadable
and customers can easily save the data to their systems for future use.
Secure eChat
This secure, innovative feature allows providers to interact with designated Palmetto GBA staffers so they can
receive real-time assistance with inquiries they are searching for on the website. Users can dialogue with an
online operator who will provide help locating information on any topics or specialties on the Palmetto GBA
website. The eChat button will appear at the bottom, right side of the browser screen, when eChat is available.
Concierge Service for
Large Provider Practices and Institutions
We now offer concierge service for large provider practices and institutions. Concierge service is intend­
ed to assist providers with a large number of claims questions. Providers will need to supply Palmetto
GBA with a detailed list of the claims questions at a minimum of one week in advance of the scheduled
conference call in order to provide ample opportunity for research prior to the call. During the scheduled
teleconference, a CSR will be prepared to respond to the submitted claims questions or will seek additional
information if needed to aid us in our research. To request concierge service, providers simply contact the
Provider Contact Center at 1-855-696-0705 and a CSR will assist in scheduling the teleconference.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16
7/2016
Coding Revisions to National Coverage Determinations
(NCDs)
MLN Matters® Number: MM9631
Revised Related Change Request (CR) #: CR 9631
Effective Date: October 1, 2016 - unless noted differently in CR9631
Related CR Release Date: June 3, 2016
Related CR Transmittal #: R1672OTN
Implementation Date: October 3, 2016
Note: This article was revised on June 6, 2016, to reflect the revised CR9631 issued on June 3, 2016. In the
article, the CR release date, transmittal number, and the Web address for accessing the CR are revised. All
other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
CR9631 is the 8th maintenance update of International Classification of Diseases, Tenth Revision (ICD-10)
conversions and other coding updates specific to national coverage determinations (NCDs). The majority of
the NCDs included are a result of feedback received from previous ICD-10 NCD CRs, specifically CR7818,
CR8109, CR8197, CR8691, CR9087, CR9252, and CR9540, while others are the result of revisions required
to other NCD-related CRs released separately. Review MLN Matters® Articles MM7818 (https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/
MM7818.pdf), MM8109 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM8109.pdf), MM8197 (https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8197.pdf), MM8691 (https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/
MM8691.pdf), MM9087 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM9087.pdf), MM9252 (https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9252.pdf), and MM9540 (https://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/
MM9540.pdf) for information pertaining to these CR’s.
Background
The translations from ICD-9 to ICD-10 are not consistent one-to-one matches, nor are all ICD-10 codes
appearing in a complete General Equivalence Mappings (GEMS) guide or other mapping guides appropriate
when reviewed against individual NCD policies. In addition, for those policies that expressly allow MAC
discretion, there may be changes to those NCDs based on current review of those NCDs against ICD-10 coding.
For these reasons, there may be certain ICD-9 codes that were once considered appropriate prior to ICD-10
implementation that are no longer considered acceptable.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17
7/2016
No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be
implemented via the current, long-standing NCD process. Updated NCD coding spreadsheets related to CR9631
are available at https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9631.zip.
Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases
as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs
continue to be implemented via the current, long-standing NCD process.
To be specific, CR9631 makes adjustments to the following NCDs:
• NCD 20.4 -Implantable Automatic Defibrillators
• NCD 20.7 -Percutaneous Transluminal Angioplasty (PTA)
• NCD 20.9 - Artificial Hearts
• NCD 20.29 - Hyperbaric Oxygen Therapy
• NCD 50.3 - Cochlear Implants
• NCD 110.18 - Aprepitant
• NCD 210.3 - Colorectal Cancer Screening
• NCD 220.4 - Mammography
• NCD 230.9 - Cryosurgery of Prostate
• NCD 260.9 - Heart Transplants
• NCD 210.4 - Smoking/Tobacco-Use Cessation Counseling
• NCD 210.4.1 - Counseling to Prevent Tobacco Use
Additional Information
The official instruction, CR 9631, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1672OTN.pdf.
Document History
• June 6, 2016 - revised due to revised CR - no substantive change to the article.
• May 17, 2016 - initial issuance.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18
7/2016
July 2016 Update of the Ambulatory Surgical Center (ASC)
Payment System
MLN Matters® Number: MM9668
Related Change Request (CR) #: CR 9668
Related CR Release Date: May 27, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3531CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for Ambulatory Surgical Centers (ASCs) submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Request (CR) 9668 informs MACs about changes to and billing instructions for various payment policies
implemented in the July 2016 ASC payment system update. As appropriate, this notification also includes
updates to the Healthcare Common Procedure Coding System (HCPCS). Make sure that your billing staffs
are aware of these changes.
Background
Included in CR9668 are updates to the ASC payment system, payment rates for separately payable drugs and
biologicals, including descriptors for newly created Level II HCPCS codes for drugs and biologicals (ASC
DRUG files), ASC billing edits, and the CY 2016 ASC payment rates for covered surgical and ancillary services
(ASCFS file). There is also an update to Chapter 14, Section 10 of the “Medicare Claims Processing Manual,”
which is attached to CR9668.
Key Changes in CR9668
1. Billing Instructions for Intensity Modulated Radiation Therapy (IMRT) Planning
Payment for the services identified by Current Procedural Terminology (CPT) codes 77280, 77285, 77290,
77295, 77306 through 77321, 77331, and 77370 are already included in the ASC payment for CPT code 77301
(IMRT planning). Effective, July 1, 2016, these codes should not be reported by ASCs in addition to CPT code
77301 when provided as part of the development of the IMRT plan.
2. Upper Eyelid Blepharoplasty and Blepharoptosis Repair
The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow ASCs to bill for separate
payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure
(CPT codes 67901-67908) on the ipsilateral upper eyelid. Any removal of upper eyelid skin in the context of
an upper eyelid blepharoptosis surgery is considered a part of the blepharoptosis surgery and is already be
included in the payment rate. Also ASCs cannot bill a blepharoplasty to Medicare and the beneficiary cannot
be separately charged for a cosmetic surgery regardless of the amount of upper eyelid skin that is removed on
a patient receiving a blepharoptosis repair because removal of (any amount) of upper eyelid skin is part of the
blepharoptosis repair. In addition, the following are not permitted:
• Operating on the left and right eyes on different days when the standard of care is bilateral eyelid surgery
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19
7/2016
•
•
•
•
•
•
•
•
Charging the beneficiary an additional amount for a cosmetic blepharoplasty when a blepharoptosis repair
is performed
Charging the beneficiary an additional amount for removing orbital fat when a blepharoplasty or a
blepharoptosis repair is performed
Performing a blepharoplasty on a different date of service than the blepharoptosis procedure for the purpose
of unbundling the blepharoplasty or charging the beneficiary for a cosmetic surgery
Performing blepharoplasty as a staged procedure, either by one or more surgeons (note that under certain
circumstances a blepharoptosis procedure could be a staged procedure)
Billing for two procedures when two surgeons divide the work of a blepharoplasty performed with a
blepharoptosis repair
Using modifier 59 to unbundle the blepharoplasty from the ptosis repair on the claim form; this applies to
both physicians and facilities
Treating medically necessary surgery as cosmetic for the purpose of charging the beneficiary for a cosmetic
surgery
Using an Advance Beneficiary Notice of Noncoverage for a service that would be bundled into another
service if billed to Medicare.
3. Category III CPT Codes Effective July 1, 2016
The American Medical Association (AMA) releases Category III CPT codes twice per year: in January, for
implementation beginning the following July, and in July, for implementation beginning the following January.
For the July 2016 update, CMS is implementing in the ASC Payment System five Category III CPT codes that
the AMA released in January 2016 for implementation on July 1, 2016. The long and short descriptors, and
ASC Payment Indicators (PIs) for these codes are shown in Table 1.
Table 1 - Category III CPT Codes Effective July 1, 2016
CPT Code Long Descriptor
0438T
Transperineal placement of biodegradable material,
peri-prostatic (via needle), single or multiple,
includes image guidance
0440T
Ablation, percutaneous, cryoablation, includes
imaging guidance; upper extremity distal/peripheral
nerve
0441T
Ablation, percutaneous, cryoablation, includes
imaging guidance; lower extremity distal/peripheral
nerve
0442T
Ablation, percutaneous, cryoablation, includes
imaging guidance; nerve plexus or other truncal
nerve (eg, brachial plexus, pudendal nerve)
0443T
Real time spectral analysis of prostate tissue by
fluorescence spectroscopy
Short Descriptor
Tprnl plmt biodegrdabl
matrl
ASC PI
G2
Abltj perc uxtr/perph nrv
G2
Abltj perc lxtr/perph nrv
G2
Abltj perc plex/trncl nrv
G2
R-t spctrl alys prst8 tiss
G2
Payment rates for these services are in Addendum AA of the July 2016 ASC Update that is posted at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20
7/2016
HCPCS code C9743 will be deleted June 30, 2016 since it will be replaced with Category III CPT code 0438T
effective July 1, 2016.
4. Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective July 1, 2016
For CY 2016, payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals is made at
a single rate of ASP + 6 percent, which provides payment for both the acquisition cost and pharmacy overhead
costs associated with the drug, biological or therapeutic radiopharmaceutical. In CY 2016, a single payment
of ASP + 6 percent for pass-through drugs, biologicals and radiopharmaceuticals is made to provide payment
for both the acquisition cost and pharmacy overhead costs of these pass-through items. Payments for drugs
and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become
available. Updated payment rates effective July 1, 2016 are in the July 2016 ASC Addendum BB at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html.
b. Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates
Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactively.
These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected
payments rates will be accessible at
http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html on the first date of the
quarter. Suppliers who think they may have received an incorrect payment for drugs and biologicals impacted
by these corrections may request MAC adjustment of the previously processed claims.
c. New CY 2016 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and
Radiopharmaceuticals
Seven new HCPCS codes have been created for reporting drugs and biologicals in the ASC setting. These new
codes, their descriptors, PIs, and their effective dates are listed in Table 2.
Table 2 – New CY 2016 HCPCS Codes
Radiopharmaceuticals
HCPCS Code Long Descriptor
C9476
Injection,
daratumumab, 10 mg
C9477
Injection, elotuzumab,
1 mg
C9478
Injection, sebelipase
alfa, 1 mg
C9479*
Instillation,
ciprofloxacin otic
suspension, 6 mg
C9480
Injection, trabectedin,
0.1 mg
Q9981
Rolapitant, oral, 1 mg
Q5102**
Injection, infliximab,
biosimilar, 10 mg
and Dosage Descriptors for Certain Drugs, Biologicals, and
Short Descriptor
Injection, daratumumab
ASC PI
K2
Effective Date
7/1/2016
Injection, elotuzumab
K2
7/1/2016
Injection, sebelipase alfa
K2
7/1/2016
Instill, ciprofloxacin otic
K2
7/1/2016
Injection, trabectedin
K2
7/1/2016
Rolapitant, oral, 1mg
Inj., infliximab biosimilar
K2
K2
7/1/2016
4/5/2016
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21
7/2016
*Note on reporting C9479: Each vial of C9479 contains 60 mg, or 10 doses. If one single use vial is used for
both patient’s ears with the remainder of the drug in the vial unused, then two units of C9479 should be reported
as administered to the patient; any discarded amount should be reported with the JW modifier according to
the Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 40 - Discarded Drugs
and Biologicals.
**Note on Q5102: the effective date of Q5102 is 4/5/2016.
d. Biosimilar Biological Product Payment and Required Modifiers
ASC claims for separately paid biosimilar biological products are now required to include a modifier that
identifies the manufacturer of the specific product. The modifier does not affect payment determination, but is
used to distinguish between biosimilar products that appear in the same HCPCS code but are made by different
manufacturers.
• Q5101: This is a reminder that for claims with dates of service January 1, 2016 and later, Q5101 must
be submitted with a modifier to identify the manufacturer of the biosimilar product. Currently, the ZA
modifier is the only manufacturer/modifier that may be submitted with Q5101. Claims submitted without
the modifier cannot be processed.
• Q5102: Effective April 5, 2016, Q5102 (Inj., infliximab biosimilar) is payable in the ASC setting, where
there has not previously been a specific code available. Q5102 must be submitted with a modifier to
identify the manufacturer of the biosimilar product. Currently, the ZB modifier is the only manufacturer/
modifier that may be submitted with this HCPCS. Claims submitted without the modifier will be returned
as unprocessable.
• When these claims are returned, MACs will use the following messages when returning these claims:
• Claim Adjustment Reason Code (CARC) 4 – The procedure code is inconsistent with the modifier used
or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present.
• Remittance Advice Remark Code (RARC) MA-130- Your claim contains incomplete and/or invalid
information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new
claim with the complete/correct information.
• Group Code: CO (Contractual Obligation)
The biosimilar HCPCS codes and required modifiers are listed in Table 3.
Table 3 – Biosimilar Biological Product Payment and Required Modifiers
HCPCS Code Short Descriptor
ASC PI FDA Approval Modifier
Date
Q5101
Inj filgrastim g-csf
K2
03/06/2015
ZA-Novartis/
biosim
Sandoz
Q5102
Inj., infliximab
K2
04/05/2016
ZB – Pfizer/
biosimilar
Hospira
Modifier
Effective Date
01/01/2016
04/05/2016
e. Other Changes to CY 2016 HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals
Effective July 1, 2016, HCPCS code Q9982, flutemetamol f18 diagnostic, will replace HCPCS code C9459,
Flutemetamol f18. The ASC payment indicator will remain K2. “Pass-Through Drugs and Biologicals.”
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22
7/2016
Effective July 1, 2016, HCPCS code Q9983, florbetaben f18 diagnostic, will replace HCPCS code C9458,
Florbetaben f18. The ASC payment will remain K2, “Pass-Through Drugs and Biologicals.”
Both C9458 and C9459 have a termination date of 6/30/2016. Other Changes to CY 2016 HCPCS Codes for
Certain Drugs, Biologicals, and Radiopharmaceuticals Effective July 1, 2016 are listed in Table 4.
Table 4 – Other Changes to CY 2016 HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals
Effective July 1, 2016
HCPCS
Short
Long Descriptor
ASC PI Added Date Termination
Code
Descriptor
Date
C9459
Flutemetamol Flutemetamol f18, diagnostic, per K2
01/01/2016 06/30/2016
f18
study dose, up to 5 millicuries
Q9982
flutemetamol Flutemetamol F18, diagnostic, per K2
07/01/2016
f18 diagnostic study dose, up to 5 millicuries
C9458
Florbetaben
Florbetaben f18, diagnostic, per
K2
01/01/2016 06/30/2016
f18
study dose, up to 8.1 millicuries
Q9983
florbetaben
Florbetaben f18, diagnostic, per
K2
07/01/2016
f18 diagnostic study dose, up to 8.1 millicuries
C9743
Bulking/
Injection/implantation of bulking
G2
06/30/2016
spacer
or spacer material (any type) with
material impl or without image guidance (not
to be used if a more specific code
applies)
5. Coverage Determinations
The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the
ASC payment system does not imply coverage by the Medicare program, but indicates only how the product,
procedure, or service may be paid if covered by the program. Medicare Administrative Contractors (MACs)
determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For
example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether
it is excluded from payment.
Additional Information
The official instruction, CR9668 issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3531CP.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23
7/2016
eServices: Claim Status
To check on a particular claim status, please enter the HICN and other required
beneficiary
information, as well as the date(s) of service. Should you not know
b
the exact date of service, you are able to enter a span or range of up to 45
days. Please keep in mind, retrieving claims older than six months takes a little
longer than something more current. Claims older than three years may not
b searchable. For more information about eServices and the many services
be
it offers, please visit our website at http://www.PalmettoGBA.com/eServices.
Review and Print Electronic Remittances –
via eRemits
Palmetto GBA is pleased to offer eRemits through our eServices, a free, webb
based,
provider self-service tool. You can view or print remittances, which are
available for approximately one year. In addition, eServices will let you store
remittances and utilize search features to find specific information on the notices. eRemits are available to be
accessed every day between the hours of 8 a.m. and 7 p.m. ET.
To use eServices, you must have an Electronic Data Interchange (EDI) Agreement on file with Palmetto GBA.
If you are already submitting claims electronically, you do not have to submit a new EDI Enrollment Agreement.
For more information on EDI, please visit our website at www.PalmettoGBA.com/EDI.
A list of current system-related claims
payment issues is available on our website.
These issues were reported to the Centers
for Medicare & Medicaid Services (CMS)
and/or the Multi-Carrier System (MCS).
Please check often for updates before
contacting the provider contact center. The
issues are identified by stand alone articles
and will be updated as needed.
Be sure to sign-up to receive updates using
the “Article Update Notification” feature.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
24
7/2016
Educational Resources to Assist Chiropractors with
Medicare Billing
MLN Matters® Number: SE1603
Revised Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Note: This article was revised on June 21, 2016, to add a reference and link to an educational video on Improving
the Documentation of Chiropractic Services (https://www.youtube.com/watch?v=tMiw1X9KvDA) that gives
a thorough presentation on medical necessity and proper documentation. All other information is unchanged
Provider Types Affected
This Special Edition (SE) MLN Matters® article is intended for Chiropractors submitting claims to Medicare
Administrative Contractors (MACs) for chiropractic services provided to Medicare beneficiaries.
This article is part of a series of SE articles prepared for Chiropractors by CMS in response to the request for
educational materials at the September 24, 2015 Special Open Door Forum titled: Improving Documentation
of Chiropractic Services.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) is providing this article in order to provide education
for chiropractic billers on accessing the correct resources for proper billing. This article is intended to be a
comprehensive resource for chiropractic documentation and billing.
Be aware of these policies along with any local coverage determinations (LCDs) for these services in your area
that might limit circumstances under which active/corrective chiropractic services are paid.
Background
In 2014, the Comprehensive Error Testing Program (CERT) that measures improper payments in the Medicare
Fee-for-Service program reported a 54 percent error rate for Chiropractic services. The majority of those
errors were due to insufficient documentation/documentation errors. This article provides a detailed list of
informational/educational resources that can help chiropractors avoid these errors. Those resources are as follows:
Enrollment Information
The “Medicare General Information, Eligibility, and Entitlement Manual,” Chapter 5, includes Section 70.6,
“Chiropractors”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ge101c05.pdf). This section
outlines the definition of a chiropractor, licensure and authorization to practice, and minimum standards.
The “Medicare Benefit Policy Manual,” Chapter 15, “Covered Medical and Other Health Services,” includes
Section 40.4, “Definition of Physician/Practitioner”
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
25
7/2016
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf). This section
explains that the opt out law does not define physician to include a chiropractor; therefore, a chiropractor may
not opt out of Medicare and provide services under a private contract.
The “Medicare Program Integrity Manual,” Chapter 15 “Medicare Enrollment,” includes Section 15.4.4.11,
“Physicians” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c15.pdf).
This section explains that a physician must be legally authorized to practice medicine by the State in which he/
she performs such services in order to enroll in the Medicare Program and to retain Medicare billing privileges.
A chiropractor who meets Medicare qualifications may enroll in the Medicare Program.
Coverage, Documentation, and Billing
The other articles in this series of articles on chiropractic services are SE1601 (https://www.cms.gov/Outreach­
and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1601.pdf), which
discusses Medicare’s medical record documentation requirements for chiropractic services, and SE1602 (https://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
SE1602.pdf), which discusses the importance of using the AT modifier on claims for chiropractic services.
MLN Matters Article MM3449 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network­
MLN/MLNMattersArticles/downloads/mm3449.pdf), discusses Revised Requirements for Chiropractic Billing
of Active/Corrective Treatment and Maintenance Therapy, Full Replacement of CR3063.
The “Medicare Benefit Policy Manual,” Chapter 15, “Covered Medical and Other Health Services”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf), includes the
following sections explaining coverage for a chiropractor’s services:
• 30.5: Chiropractor’s Services;
• 220.1.3: Certification and Recertification of Need for Treatment and Therapy Plans of Care;
• 240: Chiropractic Services – General; This section establishes that payment for chiropractic services is
based on the Medicare Physician Fee Schedule (MPFS) and that payment is made to the beneficiary or, on
assignment, to the chiropractor.
• 240.1.1: Manual Manipulation;
• 240.1.2: Subluxation May Be Demonstrated by X-Ray or Physician’s Exam;
• 240.1.3: Necessity for Treatment;
• 240.1.4: Location of Subluxation; and
• 240.1.5: Treatment Parameters.
The Chiropractic Local Coverage Determinations (LCDs) for MACs include ICD-10 Coding Information
for ICD-10 Codes that support the medical necessity for Chiropractor services. Each contractor has an LCD
for Chiropractors. There may be additional documentation information in your LCD. There are links to the
chiropractic LCDs in the additional information section of this article. Some of those LCDs are as follows:
• National Government Services (LCD L33613);
• First Coast Options, Inc (LCD L33840);
• CGS Administrators, LLC (LCD L33982);
• Noridian Healthcare Solutions, LLC (Jurisdiction F) (LCD L34009);
• Noridian Healthcare Solutions, LLC (Jurisdiction E) (LCD 34242);
• Wisconsin Physicians Service Insurance Corporation (LCD L34585); and
• Novitas Solutions, Inc (LCD L35424).
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
26
7/2016
The Fact Sheet “Misinformation on Chiropractic Services” (https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf) is designed to
provide education on Medicare regulations and policies on chiropractic services to Medicare providers. It
includes information on the documentation needed to support a claim submitted to Medicare for medical services.
The MLN Matters® Article – SE (Special Edition) 1101 Revised “Overview of Medicare Policy Regarding
Chiropractic Services” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/SE1101.pdf) highlights Medicare policy regarding coverage of chiropractic
services for Medicare beneficiaries.
The MLN Matters® Article – SE1305 Revised “Full Implementation of Edits on the Ordering/Referring
Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417,
6421, 6696, and 6856)” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/SE1305.pdf) explains that chiropractors are not eligible to order or refer
supplies or services.
The “Medicare Claims Processing Manual,” Chapter 1 “General Billing Requirements”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf) includes the
following sections which apply to billing for a chiropractor’s services:
• 30.3.12: Carrier Annual Participation Program;
• 30.3.12.1: Annual Open Participation Enrollment Process;
• 30.3.12.1.2: Annual Medicare Physician Fee Schedule File Information; and
• 80.3.2.1.3: A/B MAC (B) Specific Requirements for Certain Specialties/Services.
The “Medicare Claims Processing Manual,” Chapter 12 “Physicians/Nonphysician Practitioners,” includes
Section 220, “Chiropractic Services”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf). This section
explains the documentation requirements when billing for a chiropractor’s services. Also the claims processing
edits related to payment for a chiropractor’s services are explained.
The “Medicare Claims Processing Manual,” Chapter 26 “Completing and Processing Form CMS-1500 Data
Set,” includes Section 10.4, “Items 14-33 – Provider of Service or Supplier Information”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf). This section
includes specific instructions for chiropractic services for items 14, 17, and 19.
The “NCCI Policy Manual for Medicare Services”
(https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/NCCI_Policy_Manual.zip)
under the Downloads section. Chapter XI, “Medicine, Evaluation and Management Services (CPT Codes
90000-99999),” includes information on chiropractic manipulative treatment.
More Resources: A chiropractor is eligible to receive incentive payments under the Physician Quality Reporting
System (PQRS), Electronic Prescribing (eRx) Incentive Program, and Electronic Health Record (EHR) Incentive
Program. Information on reporting these measures is available in the Physician and Other Enrolled Health
Care Professionals pathway.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
27
7/2016
The “Medicare Claims Processing Manual, Chapter 23 “Fee Schedule Administration and Coding Requirements,”
includes Section 30, “Services Paid Under the Medicare Physician’s Fee Schedule”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf). This section
explains that a chiropractor is paid under the MPFS.
The booklet MLN Guided Pathways - Provider Specific Medicare Resources, pages 25-28, contains many
resources useful for chiropractic billing at https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf.
Advance Beneficiary Notice (ABN) Information
The “Medicare Benefit Policy Manual,” Chapter 15 “Covered Medical and Other Health Services,” includes
reference to Advance Beneficiary Notices (ABNs) in Section 240.1.3, “Necessity for Treatment”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf).
The “Medicare Claims Processing Manual,” Chapter 23 “Fee Schedule Administration and Coding
Requirements,” includes Section 20.9.1.1, “Instructions for Codes With Modifiers (Carriers Only)”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf). This section
outlines the modifiers that may be used when a chiropractor notifies a beneficiary the item or service may not
be covered.
The Medicare Claims Processing Manual,” Chapter 30, “Financial Liability Protections,”
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf) includes
detailed instructions on completing the ABN and use of the GA modifier.
Information about the ABN, including downloadable forms is available at
https://www.cms.gov/MEDICARE/medicare-general-information/bni/abn.html on the CMS website.
Additional Information
You may want to review the educational video on Improving the Documentation of Chiropractic Services
(https://www.youtube.com/watch?v=tMiw1X9KvDA) which gives a thorough presentation on medical necessity
and proper documentation.
Document History
Date of Change Description
June 21, 2016
The article was revised to add a reference and link to an educational video on
Improving the Documentation of Chiropractic Services that gives a thorough
presentation on medical necessity and proper documentation.
March 16, 2016 Initial article post
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
28
7/2016
Update to Pub. 100-02, Chapter 11 End-Stage Renal Disease
(ESRD) for Calendar Year (CY) 2016
MLN Matters® Number: MM9541
Related Change Request (CR) #: CR 9541
Related CR Release Date: June 3, 2016
Effective Date: January 1, 2016
Related CR Transmittal #: R224BP
Implementation Date: September 6, 2016
Provider Types Affected
This MLN Matters® Article is intended for End-Stage Renal Disease (ESRD) facilities that submit claims to
Medicare Administrative Contractors (MACs) for ESRD services provided to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 9541 updates Chapter 11 of the “Medicare Benefit Policy Manual” to reflect the
provisions in the Calendar Year (CY) 2016 ESRD Prospective Payment System (PPS) final rule. There are no
new coverage policies, payment policies, or codes introduced in CR9541. Specific policy changes and related
business requirements were addressed in CR9367, as discussed in MLN Matters article MM9367 at https://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
MM9367.pdf.
Background
The End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) provides a single payment to ESRD
facilities, that is, hospital-based and freestanding facilities, that cover all the resources used in providing an
outpatient dialysis treatment. This includes supplies and equipment used to administer dialysis in the ESRD
facility or at a patient’s home, drugs, biologicals, laboratory tests, training, and support services.
The ESRD PPS base rate is adjusted for patient-level case mix and facility-level characteristics. For CY 2016,
in accordance with the American Taxpayers Relief Act of 2012
(ATRA; Section 632(c)), The Centers for Medicare & Medicaid Services (CMS) analyzed the case-mix payment
adjustments using more recent data.
CMS revised the adjustments by changing the adjustment payment amounts based on an updated regression
analysis using Calendar Years (CYs) 2012 and 2013 ESRD claims and cost report data. CMS also removed two
comorbidity payment adjustments (bacterial pneumonia and monoclonal gammopathy). Because the updated
regression analysis conducted enabled CMS to analyze and revise the case-mix payment adjustments, CMS also
revised the low-volume payment adjustment and implemented a payment adjustment for rural ESRD facilities.
For CY 2016, in accordance with the Protecting Access to Medicare Act of 2014 (PAMA) (Section 217(c)),
CMS finalized a drug designation process for:
1. Determining when a product would no longer be considered an oral-only drug; and
2. Including new injectable and intravenous products into the bundled payment under the ESRD PPS.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
29
7/2016
Updates to the “Medicare Benefit Policy Manual”
The key clarifications/updates to the “Medicare Benefit Policy Manual” are as follows:
Section 20.2
To the extent a laboratory test is performed to monitor the levels or effects of any of the drugs that were
specifically excluded from the ESRD PPS, these tests would be separately billable. The following table lists
the drug categories that were excluded from the ESRD PPS and the rationale for their exclusion. Laboratory
services furnished to monitor the medication levels or effects of drugs and biologicals that fall in those categories
would not be considered to be furnished for the treatment of ESRD.
DRUG CATEGORIES EXCLUDED FROM THE ESRD PPS BASE RATE FOR THE PURPOSE OF
REPORTING LABS
Drug Category
Rationale for Exclusion
Anticoagulant
Drugs labeled for non-renal dialysis conditions and not for vascular access.
Antidiuretic
Used to prevent fluid loss.
Antiepileptic
Used to prevent seizures.
Anti-inflammatory
May be used to treat kidney disease (glomerulonephritis) and other
inflammatory conditions.
Antipsychotic
Used to treat psychosis.
Antiviral
Used to treat viral conditions such as shingles.
Cancer management
Includes oral, parenteral and infusions. Cancer drugs are covered under a
separate benefit category.
Cardiac management
Drugs that manage blood pressure and cardiac conditions.
Cartilage
Used to replace synovial fluid in a joint space.
Coagulants
Drugs that cause blood to clot after anti-coagulant overdose or factor VII
deficiency
Cytoprotective agents
Used after chemotherapy treatment
Endocrine/metabolic
Used for endocrine/metabolic disorders such as thyroid or endocrine deficiency,
management
hypoglycemia, and hyperglycemia
Erectile dysfunction
Androgens were used prior to the development of ESAs for anemia management
management
and currently are not recommended practice. Also used for hypogonadism and
erectile dysfunction.
Gastrointestinal
Used to treat gastrointestinal conditions such as ulcers and gallbladder disease
management
Immune system
Anti-rejection drugs covered under a separate benefit category.
management
Migraine management Used to treat migraine headaches and symptoms
Musculoskeletal
Used to treat muscular disorders such as prevent muscle spasms, relax muscles,
management
improve muscle tone as in myasthenia gravis, relax muscles for intubation and
induce uterine contractions
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
30
7/2016
Pharmacy handling
for oral anti-cancer,
anti-emetics and
immunosuppressant
drugs
Pulmonary system
management
Radiopharmaceutical
procedures
Unclassified drugs
Vaccines
Not a function performed by an ESRD facility
Used for respiratory/lung conditions such as opening airways and newborn
apnea
Includes contrasts and procedure preparation
Should only be used for drugs that do not have a HCPCS code and therefore
cannot be identified
Covered under a separate benefit category
Also, effective January 1, 2016, the lipid panel is no longer considered to be a renal dialysis service. However,
if the panel is furnished for the treatment of ESRD it is the responsibility of the ESRD facility and should be
reported on the facility’s claim.
Section 20.3
The ESRD PPS functional category is a distinct grouping of drugs and biologicals, as determined by CMS,
whose end action effect is the treatment or management of a condition or conditions associated with ESRD.
The Drug Designation Process is dependent on the functional categories, as discussed in Section 20.3.1., below
in this article.
Drugs and biologicals always considered to be renal dialysis services are those used for access management,
anemia management, bone and mineral metabolism management, and cellular management. ESRD facilities
are responsible for furnishing these drugs directly or under arrangement. This includes any drug or biological
that is furnished in the ESRD facility or taken by the patient outside of the ESRD facility.
Erythropoiesis Stimulating Agents (ESAs), such as epoetin alfa (EPOGEN®) and darbepoetin alfa (ARANESP®)
when furnished to Medicare ESRD patients are always considered to be renal dialysis services and included in
the ESRD PPS. Monthly dosages of these ESAs are subject to Medicare’s ESA claims monitoring policy. See the
“Medicare Claims Processing Manual,” Chapter 8, Section 60.4.1 for more information on the ESA monitoring
policy at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf.
NOTE: ESA dose edits are applied prior to pricing so that ESAs are not overvalued in determining eligibility
for outlier payments.
Drugs and biologicals included in the ESRD PPS base rate that may be used for both the treatment of ESRD
and for reasons other than the treatment of ESRD are those used as antiemetics, anti-infectives, antipruritics,
anxiolytics, excess fluid management, fluid and electrolyte management including volume expanders, and pain
management. ESRD facilities are responsible for furnishing these drugs directly or under arrangement when
they are prescribed for the treatment of ESRD. This includes any drug or biological that is furnished in the
ESRD facility or taken by the patient outside of the ESRD facility.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
31
7/2016
ESRD facilities are responsible for furnishing antibiotics for access site infections directly or under arrangement.
When antibiotics are used at home by a patient to treat an infection of the catheter site or peritonitis associated
with peritoneal dialysis, the antibiotics are included in the ESRD PPS and may not be paid separately. This
includes antibiotics that may be added to a patient’s dialysate solution for the purposes of vascular accessrelated and peritonitis infections.
Any other drugs (other than those categories described above and below) when used for the treatment of ESRD
are also included in the ESRD PPS. For example,
• Patient A experiences nausea or pain during a hemodialysis dialysis treatment and requires medications.
Any medication furnished during the dialysis treatment or after the treatment is considered a renal dialysis
service and may not be billed separately.
• Patient B experiences anxiety with dialysis treatments and is prescribed anti-anxiety medication during
and between the dialysis treatments. Any medications furnished in preparation for the dialysis treatment,
during the dialysis treatment or after the dialysis treatment, is considered a renal dialysis service and may
not be billed separately.
• Any drug or biological added to patient dialysate solutions.
Functional Categories Included in the ESRD Base Rate but May be Used for Dialysis and Non-Dialysis
Purposes
Category
Rationale for Association
Antiemetic
Used to prevent or treat nausea and vomiting related to dialysis. Excludes
antiemetics used for purposes unrelated to dialysis, such as those used in
conjunction with chemotherapy as these are covered under a separate benefit
category.
Anti-infectives
Used to treat vascular access-related and peritonitis infections. May include
antibacterial and antifungal drugs.
Antipruritic
Drugs in this classification have multiple clinical indications. Use within an
ESRD functional category includes treatment for itching related to dialysis.
Anxiolytic
Drugs in this classification have multiple actions. Use within an ESRD
functional category includes treatment of restless leg syndrome related to
dialysis.
Excess Fluid Management Drug/fluids used to treat fluid excess/overload.
Fluid and Electrolyte
Intravenous drugs/fluids used to treat fluid and electrolyte needs.
Management Including
Volume Expanders
Pain Management
Drugs used to treat vascular access site pain and to treat pain medication
overdose, when the overdose is related to medication provided to treat
vascular access site pain.
Oral-only forms of renal dialysis drugs and biologicals that have no other form of administration will be
included in the ESRD PPS as a Part B renal dialysis service. Implementation of renal dialysis oral-only
drugs has been delayed until January 1, 2025.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
32
7/2016
Section 20.3.1 – Drug Designation Process
A. Definition of a New Injectable or Intravenous Product
A new injectable or intravenous product is an injectable or intravenous product that is approved by the Food
and Drug Administration (FDA) under section 505 of the Federal Food, Drug, and Cosmetic Act or section 351
of the Public Health Service Act, commercially available, assigned a Healthcare Common Procedure Coding
System (HCPCS) code, and designated by CMS as a renal dialysis service.
B. Determination
To make the determination as to whether a product is a new injectable or intravenous drug or biological; whether
the new injectable or intravenous drug or biological is a renal dialysis service; and whether the new injectable
or intravenous drug or biological fits into an existing functional category CMS will:
1. Review the new product’s FDA labeling data and information;
2. Review the new product’s information presented for obtaining a HCPCS code; and
3. Conduct an internal medical review following the announcement of the new product’s FDA and HCPCS
decision.
If a new injectable or intravenous drug is used to treat or manage a condition for which there is an ESRD PPS
functional category, the new drug would be considered included in the ESRD PPS bundled payment and no
separate payment is available. If the new injectable or intravenous drug is used to treat or manage a condition
for which there is not an ESRD PPS functional category, the following steps occur:
1. The new injectable or intravenous drug or biological would be paid for using a transitional drug add-on
payment adjustment;
2. At the next rulemaking opportunity, CMS would add a new functional category applicable to the new
injectable or intravenous drug or biological being used in the treatment of ESRD;
3. The new injectable or intravenous product would be added to the ESRD PPS bundled payment following
payment of the transitional drug add-on payment adjustment.
C. Transitional Drug Add-On Payment Adjustment
If the new injectable or intravenous drug or biological is used to treat or manage a condition for which there
is not an ESRD PPS functional category, CMS will pay for the drug or biological using a transitional drug
add-on payment adjustment. The transitional drug add-on payment is based on payment methodologies under
Section 1847A and would continue for a period of 2 years. During the time that injectable or intravenous drugs
and biologicals
are paid the transitional drug add-on payment adjustment, the drug or biological is not considered an outlier
service.
D. Determination of When an Oral-Only Renal Dialysis Service Drug or Biological is No Longer Oral-Only
An oral-only renal dialysis service drug or biological is a drug or biological with no injectable equivalent or
other form of administration other than an oral form. An oral-only renal dialysis service drug or biological is no
longer considered oral-only when a non-oral version of the oral-only drug or biological is approved by the FDA.
Section 60
Based on the refinement of the ESRD PPS, effective January 1, 2016, adult case-mix payment adjustments are
made for four comorbidity categories (two acute and two chronic) as discussed in detail in the revised section
60, which also includes detailed examples. The revised Section 60 is included as part of CR9541 and the Web
address for accessing the CR is in the Additional Information section of this article.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
33
7/2016
In addition, the revised Section 60 shows that beginning January 1, 2016, the ESRD PPS provides a 1.008
percent payment adjustment for ESRD facilities located in a rural Core Based Statistical Area.
Additional Information
The official instruction, CR9541, issued to your MAC regarding this change is available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R224BP.pdf.
Related MLN Matters Article MM9367 is available at https://www.cms.gov/Outreach-and-Education/Medicare­
Learning-Network-MLN/MLNMattersArticles/Downloads/MM9367.pdf.
Chapter 8, Section 60.4.1 of the “Medicare Claims Processing Manual” is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf.
eServices Eligibility
eServices, by Palmetto GBA, allows you to search for patient eligibility,
which is a functionality of HETS. HETS requires you to enter beneficiary
last name and HICN, in addition to either the birth date or first name. See
options below:
•
•
•
HICN, Last Name, First Name, Birth Date
HICN, Last Name, Birth Date
HICN, Last Name, First Name
For more information about eServices and the many services it offers, please visit our website at
http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
34
7/2016
Appeals Calculator Self-Service Tool
Providers may appeal claims that are partially or fully denied, as long as the claim has ‘appeal rights’. Different
levels of appeals have different timelines in which the appeal rights are valid. Access the Appeals Calculator
tool under Forms/Tools on the home page to calculate the your claims appeal deadlines.
Global Surgery Denial Tool
If the procedure code was denied with remittance message CO-B15/CO-97 (claim/service denied/reduced
because this procedure/service is not paid separately OR payment is included in the allowance for another
service/procedure), then use the following worksheet to see what, if any, corrections you can make to your
claim. Just answer a few questions, and the tool will provide you with information to help you with your service.
Access the Global Surgery Denial tool under Forms/Tools on the home page.
Global Surgery Calculator Self-Service Tool
This tool will allow you to calculate both 10 and 90 day global surgery periods. You can also look up your
2016 procedure code global days requirement by using this tool. Just enter the procedure code in the tool and
the global surgery indicator information will appear. Access the Global Surgery Calculator tool under Forms/
Tools on the home page.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
35
7/2016
Interactive
Tools
These guides provide instruction
on how to complete or interpret the
following forms. They are available
on the home page, under Forms/Tools.
Remittance Advice
EDI Agreement
EDI Application
EDI Provider
Authorization
CMS 1500 Claim Form
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
36
7/2016
Medical Director’s Desk
Medical Affairs publishes Medicare Local Coverage Determination (LCDs)
and medically related articles in this special section of the Medicare Advisory.
We encourage you to help us maintain accurate LCDs. Please review LCDs and
address your comments and concerns to your Carrier Advisory Committee specialty
representative or contact the Medical Affairs Department.
Medical articles are published in the Medicare Advisory to provide education
and alert Medicare providers of billing/coding issues. Remember, physicians and
non-physician practitioners (NPPs) who bill Medicare are responsible for accurate
service coding. Errors may result in overpayment requests or Recovery Auditor
(RA) referrals. If you purchase a new device or need to submit claims for a new
procedure, please review applicable service codes and descriptions in the current
CPT and HCPCS manuals. If you question the recommended service procedures
received from other sources such as manufacturers, send your inquiry and the
device description to the Medical Affairs Department.
To contact the Medical Affairs Department:
e-mail: B.Policy@PalmettoGBA.com
Mail: Part B Medical Affairs, AG-300
Palmetto GBA
PO Box 100190
Columbia, SC 29202-3190
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
37
7/2016
Part B Local Coverage Determinations
Policy Title
Implantable Infusion
Pump
L33461
Rev #7
Response to Comments
Effective Date
The comment period began on 2/8/16 and ended on 3/24/16. Comments were received 7/25/16
from the provider community and are listed below:
Comment: The commenter requested that list of covered drugs for intrathecal infusion
be expanded to include sufentanil, clonidine, ropivicaine, fentanyl, gabapentin, and
droperidol due to the fact that a large number of chronic pain patients do not maintain a
long term sustained response to intrathecal morphine.
Response: In consideration of this request the medical director performed a literature
review regarding the intrathecal use of these drugs for long term pain management. The
medical director also consulted a former Palmetto GBA CAC member who is a nationally
recognized expert on chronic pain management. Based upon available peer reviewed
literature, input from the expert, and the current recommendations of the Polyanalgesic
Consensus Conference, the coverage will be expanded to include sufentanil and
clonidine. There is sufficient data to support the safety and efficacy of these drugs for
intrathecal use. There is limited or no data to support the use of ropivicaine, gabapentin,
or droperidol. Fentanyl is already a covered drug in the LCD that is currently in effect.
The notice period begins on 6/9/16 and the LCD becomes final on 7/25/16.
The following revisions were made to the final LCD:
Under CPT/HCPCS Codes Group 1: Paragraph removed fluxuride and added sufentanil
and clonidine.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
38
7/2016
Allergy Skin Testing
L33417
Rev #3
The comment period began on 2/8/16 and ended on 3/24/16. Comments were received 7/25/16
from the provider community and are listed below:
Comment: “Food allergen testing for patients who present with gastrointestinal
symptoms suggestive of food Intolerance,” is non-covered by Medicare. As a result,
this would exclude testing for eosinophilic esophagitis, and for anaphlaxis that presents
with GI symptoms alone.”
Response: Eosinophilic esophagitis and anaphylaxis due to unspecified foods, as well as
anaphylaxis due to specific foods (i.e. peanuts), are covered diagnoses under this LCD.
An anaphylactic reaction to a food that is manifested by GI symptoms alone without any
of the more serious components of anaphylaxis such as cardiovascular and respiratory
compromise would be far less common than isolated GI symptoms due solely to food
intolerance, thus routine diagnostic testing for food allergy in light of isolated GI
symptoms suggestive of food intolerance would not be of diagnostic value in most cases.
However, if the treating physician has reason to suspect that the isolated gastrointestinal
symptoms are manifestations of the much more serious issues of eosinophilic esophagitis
or a true anaphylactic reaction, he or she should use their professional judgment in
performing such testing. Documentation of such a circumstance in the medical record
can be presented on appeal and would be considered in the determination as to whether
this testing in those cases is medically reasonable and necessary.
Comment: “We further respectfully request clarification regarding the first two bullets
on page five of the draft policy. The first bullet states, “Medicare would not expect that
more than 30 tests per year are medically necessary, for code 95017, for the management
of an individual patient. More than 20 tests per year may be allowed upon review when
the clinical circumstances documented in the patient’s medical record substantiate the
need for additional tests.” For 95017, it is first indicated a maximum of 30 tests per year
would be permitted, but then indicates that more than 20 tests would require an exception
which is inconsistent. The second bullet states, “Medicare would not expect that more
than 12 tests per year are medically necessary, for code 95018, for the management of
an individual patient. More than 20 tests per year may be allowed upon review when the
clinical circumstances documented in the patient’s medical record substantiate the need
for additional tests.” This statement seems contradicatory in that for 95018, 12 tests are
permitted per year, but more than 20 tests per year would require approval.”
Response: Palmetto GBA acknowledges that these statements under the “Utilization
Guidelines” section of the LCD are contradictory. They will be revised accordingly.
The notice period begins on 6/9/16 and the LCD becomes final on 7/25/16.
The following revisions were made to the final LCD:
Under Associated Information- Utilization Guidelines changed 20 to 30 tests per year
under the 5th bullet and changed 10 to 12 tests per year under the 6th bullet.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
39
7/2016
Special
Electroencephalography
L33447
Rev #5
The comment period began on 2/8/16 and ended on 3/24/16. Comments were received 7/25/16
from the provider community and are listed below:
Comment 1:
Change the language from “resting” to routine for the description of a baseline EEG.
Response 1:
This change was made to the LCD.
Comment 2:
CPT 95950 is seldom used and is not a code for an ambulatory EEG. This CPT code
should be removed from an ambulatory EEG policy.
Response 2:
CPT code 95950 was removed from the LCD.
Comment 3:
Remove the reference to “video” in the description of ambulatory EEG. Video is seldom
used in that setting.
Response 3:
These references were removed from the LCD.
Comment 4:
Most often 95953 (ambulatory EEG) is done for spell characterization. Rarely is it done
for surgical evaluation of epilepsy. The latter is done in the hospital and we use code
95951 for that.
Response 4:
CPT code 95951 was removed from the LCD.
Comment 5:
When doing ambulatory EEG for 72 hours, the last 24 hours of data are not very good.
The electrodes are no longer making good contact and some may have come off as the
patient has had them on for a long time. We will sometimes do two rounds of 48 hours
of monitoring and get better data that way.
Response 5:
Policy language was changed to reflect this time frame.
Comment 6:
Sometimes the diagnosis is not established with one round of monitoring with 95953
and may need to be repeated at a later date.
Response 6:
Accommodation for this contingency was added to the policy language.
Comment 7:
Under Utilization Guidelines: Consider change of language…“ It is anticipated that once
the diagnosis has been established, this study will not be repeated for the same diagnosis,
nor…..” The reason I think this modification would be good, it’s that occasionally I
see patients with epilepsy who develop new “spells” that are different from their past
spells. It can be very difficult to determine if these are epileptic or non-epileptic spells. I
recognize that (although low yield), a repeat EEG might be helpful. Often these patients
will need EMU evaluation to more definitely sort out the basis of these spells.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
40
7/2016
Special
Electroencephalography
L33447
Rev #5 continued
Response 7:
This language change was made to the LCD.
7/25/16
Comment 8:
Under “Indication” it is noted that one indication might include “Adjusting antiepileptic medication levels”, but then the Utilization Guidelines “say “…nor will it be
used in the monitoring of a therapeutic regimen”… I cannot recall using the EEG to
adjust anti-epileptic medication levels.
Response 8:
This conflicting language was corrected in the LCD.
Comment 9:
Under Indications would make small change….”Differentiating between neurological,
cardiac, and psychiatric related problems”. I added psychiatry since this is often one the
main reasons why we obtain a prolonged EEG…the hope that we can catch a spell to
determine if the patient his having epileptic or non-epileptic events.
Response 9:
This language was added to the LCD.
Comment 10:
Under documentation requirements: I agree that one should be done before a prolonged
ambulatory EEG. My only concern is the one year limitation. I wonder if there might not
be the opportunity to waive the one-year timeframe in patients who have a longer history
of epilepsy, or who have had routine EEG testing in the somewhat more distant past.
Response 10:
This is a reasonable request, but is not feasible in this context as there are two issues that
would be problematic: A. How would one determine how far back would such a study
still be valid in the context of current patient symptomatology? B. Medicare claims
systems cannot reliably locate a prior claim to validate this requirement further than a 1
year look back. This language was not changed in the LCD.
The notice period begins on 6/9/16 and the LCD becomes final on 7/25/16.
The following revisions were made to the final LCD:
Under Coverage Indications, Limitations and/or Medical Necessity removed “resting”
from the description of a baseline EEG, added psychiatric related problems, removed
adjusting anti epileptic medication levels, changed the time frame for ambulatory EEGs
and added that the study will not be repeated for the same diagnosis. Under Associated
Information- Documentation Requirements removed CPT codes 95950 and 95951,
“resting”, and changed 72 hours to 48 hours. Under Associated Information- Utilization
Guidelines added that the study will not be repeated for the same diagnosis. Under
CPT/HCPCS Codes Group 1: Paragraph removed CPT codes 95950 and 95951 and
“resting”. Under CPT/HCPCS Codes Group 1: Codes removed CPT codes 95950 and
95951.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
41
7/2016
Policy Title
Mohs Micrographic
Surgery (MMS)
L33436
Rev #3
Blepharoplasty, Eyelid
Surgery, and Brow Lift
L33765
Rev #3
LCD Revisions
Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes C44.510
and C44.520 as requested.
Effective Date
7/07/16
Under CMS National Coverage Policy deleted sections §50 Form CMS-R-131 Advance
Beneficiary Notice of Noncoverage (ABN) and §50.1 Introduction-General Information
from the CMS Internet Only Manual, Pub. 100-04, Medicare Claims Processing Manual,
Chapter 30, citation. Under Coverage Guidance the first paragraph was rewritten. Under
Limitations and/or Medical Necessity – Lower Eyelid Surgery in the second paragraph
“would” was changed to “could”. Under General Information – Documentation
Requirements in the second paragraph “a statement” was deleted. Under Associated
Information –Section A. Patient Complaints and Physical Signs added the section
titled For Reconstructive Surgery. Under Associated Information – Section B. added
“COLOR” in the first sentence. The last section titled, For Reconstructive Surgery was
added.
HbA1c
Under Sources of Information and Basis for Decision updated the URLs for Standards
L33431
of Medical Care in Diabetes - 2016 for Prevention or delay of type 2 diabetes and Older
Rev #6
adults.
Virtual Colonoscopy (CT Under CMS National Coverage Policy “SSA” was removed from the first reference.
Colonography)
The second reference was corrected from the Social Security Act §1862(a)(1)(H) to the
L33452
Social Security Act §1861(pp). Part 4 was added to the sixth reference. The abbreviation
Rev #3
for chapter was replaced with the full word in references seven and eight. The “s”
was removed from the word “Manuals” in the eighth reference. Under Sources of
Information and Basis for Decision, the citations were corrected to conform to the
American Medical Association citation style. In citation number 2: the letter “B” was
added to “Pineau” to complete the author’s name. In citation number 9, the initial “M”
was added to the first name of “Morrin” to complete the author’s name. In reference
number 11, the author “Goisto”, was corrected to “Giusti”. The spelling of Endoluminal
was corrected in citation number 13.
Vertebroplasty/Vertebral Under CMS National Coverage Policy Title XVIII of Social Security Act §1862(a)(1)
Augmentation L33473 (A) added verbiage “for the diagnosis or treatment of illness or injury or to improve
Rev#5
the functioning of a malformed body member” and revised the title for 42 CFR
§411.15 (k)(1). Under Coverage Guidance Coverage Indications, Limitations and/or
Medical Necessity the word “It” was deleted twice and replaced with “Vertebroplasty
augmentation”. Under Sources of Information and Basis for Decision deleted “et al”
and added author names to reference #2 and corrected the journal title for reference
#3. The publication number was corrected for reference #16. Throughout the LCD
capitalization, spelling and punctuation were corrected.
06/09/16
06/3/16
06/3/16
06/3/16
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
42
7/2016
Wireless Gastrointestinal
Motility Monitoring
Systems
L33455
Rev #3
Chemodenervation
L33458
Rev #8
Article Title
Bevacizumab Off-Label
Ophthalmologic Use
Article
A53595
Rev # 6
Bevacizumab Off-Label
Ophthalmologic Use
Article
A53595
Rev #7
Implantable Infusion
Pump Coding & Billing
Guidelines Article
A53005
Rev #8
Implantable Infusion
Pump Coding & Billing
Guidelines Article
A53005
Rev #9
Under CMS National Coverage Policy the acronym SSA was removed throughout the
section. The word “check-ups” was replaced with “examinations” in the second citation.
The spelling of “diagnostic” was corrected in the fourth citation. In references five
through seven, the “s” was removed from “Manuals” and “Publication” was abbreviated
to “Pub.”. The abbreviation for chapter was replaced with the word “Chapter”, in the
sixth reference. The “s” was added to “requirements” in the seventh citation. Under
Coverage Indications, Limitations and/or Medical Necessity “SmartPill” was rewritten
“SmartPill®”, to denote the trademark. The words “is” and “approved” were added and
the acronyms FDA and GI were defined. Under Indications corrected “Mobility” to
Motility” and created two sentences to form the paragraph, adding “s” to patient in the
third bullet. Under Limitations an “a” was added before the word “pacemaker”. Under
Associated Information – Documentation Requirements the paragraph was rephrased
to more clearly define the documentation requirements. Under Sources of Information
and Basis for Decision the month was removed from the first four references and the
formatting corrected. The citations were corrected to conform to the American Medical
Association citation style.
Under CPT/HCPCS Codes Group 1: Paragraph added verbiage related to achalasia.
Under CPT/HCPCS Codes Group 1: Codes deleted CPT code 43201. Under ICD-10
Codes that Support Medical Necessity deleted Group 1: Paragraph stating CPT code
43201; HCPCS codes J0585, J0586, J0587, J0588 and Group 1: Codes including ICD­
10 code K22.0.
Articles
Under Article Guidance removed FDA indications for first or second line treatment.
Replaced “experts” with “specialists” and rephrased the last sentence of the first
paragraph. Moved the first sentence from Article Text to last sentence of Article
Guidance. Under Article Text clarified correct billing of bevacizumab for ophthalmic
use. The second paragraph was added to provide instructions in the billing of injection
procedures (CPT code 67028), use of bilateral modifier (-50), and right and left eye.
Added third paragraph to provide instructions in the use of ICD-10 codes. The fourth,
fifth, and sixth paragraphs clarify the billing of vials from the manufacturer, discarded
quantities, and single-dose syringes obtained from a compounding pharmacy.
Under Revision Effective Date corrected the date to read 05/26/2016. The effective date
for Revision 6 should correctly read 05/26/2016.
06/03/16
7/5/16
Effective Date
05/19/16
05/26/16
Under Article Text the information contained in the second paragraph was transferred 05/19/16
into the first paragraph. Billing information and an example of completing the CMS
1500 in paragraph four was merged into the third paragraph and “HFCA” 1500
was updated to CMS 1500. Information that Evaluation and Management codes are
separately reimbursed was corrected to read that these services are not separately
payable unless the practitioner provides a significant, separately identifiable service. The
pharmacy compounding fee was removed from the fourth paragraph. The “Medication
Price” list was deleted. Under Statutory Requirements URL(s) the URLs were removed.
Under Rules and Regulations URL(s) the URL was removed. Under CMS Manual
Explanations URL(s) the URL was removed.
Under Revision Effective Date corrected the date to read 05/26/2016. The effective date 05/26/16
for Revision 8 should correctly read 05/26/2016.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
43
7/2016
Repeat or Duplicate
Services on the Same
Day
Article A53482
Rev #2
Under Article Guidance, added “and/or” and “in fact” to the first paragraph. Added 05/19/16
clarification related to the refiling of claims. IVR and OPS were defined. Under Article
Text instructions were provided in the first paragraph related to corrections of previously
submitted claims and medical necessity denials. Subsequent paragraphs and sections
detail the billing of services that may appear to be duplicate services, the use of modifiers,
and units submitted on claims.
Under Revision Effective Date corrected the date to read 05/26/2016. The effective date 05/26/16
for Revision 2 should correctly read 05/26/2016.
Repeat or Duplicate
Services on the Same
Day
Article A53482
Rev #3
Sacroiliac-Bone Implant Under Article Guidance the paragraph was rephrased for clarity. Under Article Text 06/09/16
System
“Palmetto GBA” was removed from the second sentence.
Article A53452
Rev #4
Date of
Retired Articles
Retirement
06/7/16
Percutaneous
This article is being retired effective 6/7/16 due to varithena being included in the
Endovenous Ablation
Procedure & Varithena Varicose Veins of the Lower Extremities L33454 LCD.
A54406
Part A/B Local Coverage Determination
Policy Title
LCD Revisions
Effective Date
Under Indications, Limitations and/or Medical Necessity – Abdominal CT the 07/03/16
paragraph describing the requirements of the CT equipment was deleted and moved
to the last paragraph under Pelvic CT. The medical necessity criteria for a CT of the
abdomen was clarified. A notation was added that CT angiography is not addressed in
this LCD. Under Pelvic CT the first paragraph was reworded and the last paragraph
addresses the requirements of the CT equipment. A statement was added related to
the use of contrast material. Under CPT/HCPCS Codes removed CPT code 74174
[Computed tomographic angiography, abdomen and pelvis, with contrast material(s),
including noncontrast images, if performed, and image postprocessing Computed
tomographic angiography, abdomen, with contrast material(s), including noncontrast
images, if performed, and image postprocessing]. Under Sources of Information and
Basis for Decision the initial “J” was added to “Lee” in the fourth citation.
Debridement of Wounds Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes L89.111, 6/16/16
L89.112, L89.113 and L89.114 as these codes were inadvertently omitted.
L35938
Rev #7
The title of the LCD was changed to Non-Coverage of Extracorporeal Shock Wave 06/09/16
Non-Coverage of
Lithotripsy for Musculoskeletal Conditions. Under Coverage Indications, Limitations
Extracorporeal Shock
and/or Medical Necessity – Coverage Guidance the first paragraph was rephrased for
Wave Lithotripsy
clarity. Under Coverage Indications, Limitations and/or Medical Necessity the sections
for Musculoskeletal
Musculoskeletal Conditions, Plantar Fasciitis, Tendinitis of the Elbow (Lateral
Conditions
Epicondylitis) were removed. The last three sentences of the final paragraph were not
L35627
changed and “when used in the treatment of musculoskeletal conditions” was added to
Rev #3
the fourth sentence. Under Bill Type Codes all codes were removed. Under Sources of
Information and Basis for Decision a second reference was cited.
CT of the Abdomen and
Pelvis
L34415
Rev #8
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
44
7/2016
Total Joint Arthroplasty
L33456
Rev #7
Application of Skin
Substitutes
L36466
Rev #1
Rituximab
L35026
Rev #8
Under ICD-10 Codes that Support Medical Necessity- Group 1 added ICD-10 codes 06/16/16
M05.89, M06.09, M06.89, M08.09, M08.29, M08.89, M08.99, M80.051S, M80.052S,
M80.851S, M80.852S, M84.351S, M84.352S, M84.451S, M84.452S, M84.551S,
M84.552S, M84.651S, M84.652S, M96.661, M96.662, S32.301S, S32.302S, S32.311S,
S32.312S, S32.314S, S32.315S, S32.391S, S32.392S, S32.401S, S32.402S, S32.411S,
S32.412S, S32.414S, S32.415S, S32.421S, S32.422S, S32.424S, S32.425S, S32.431S,
S32.432S, S32.434S, S32.435S, S32.441S, S32.442S, S32.444S, S32.445S, S32.451S,
S32.452S, S32.454S, S32.455S, S32.461S, S32.462S, S32.464S, S32.465S, S32.471S,
S32.472S, S32.474S, S32.475S, S32.481S, S32.482S, S32.484S, S32.485S, S32.491S,
S32.492S, S32.591S, S32.592S, S32.601S, S32.602S, S32.611S, S32.612S, S32.614S,
S32.615S, S32.691S, S32.692S, S32.89XS, S72.011S, S72.012S, S72.021S, S72.022S,
S72.024S, S72.025S, S72.031S, S72.032S, S72.034S, S72.035S, S72.041S, S72.042S,
S72.044S, S72.045S, S72.051S, S72.052S, S72.061S, S72.062S, S72.064S, S72.065S,
S72.091S, S72.092S, S72.101S, S72.102S, S72.111S, S72.112S, S72.114S, S72.115S,
S72.121S, S72.122S, S72.124S, S72.125S, S72.131S, S72.132S, S72.134S, S72.135S,
S72.141S, S72.142S, S72.144S, S72.145S, S72.21XS, S72.22XS, S72.24XS, S72.25XS,
S72.391S, S72.392S, S72.8X1S, S72.8X2S, S79.001S, S79.002S, S79.011S, S79.012S,
S79.091S and S79.092S. Under ICD-10 Codes that Support Medical Necessity- Group
2 Asterisk corrected T84.0101A to now read T84.010A. Under ICD-10 Codes that
Support Medical Necessity- Group 3 added ICD-10 codes C40.21, C40.22, M05.49,
M05.79, M05.89, M06.09, M06.89, M84.461S, M84.462S, M84.561S, M84.562S,
M84.661S, M84.662S, M96.661, M96.662, M96.671, M96.672, S72.401S, S72.402S,
S72.411S, S72.412S, S72.414S, S72.415S, S72.421S, S72.422S, S72.424S, S72.425S,
S72.431S, S72.432S, S72.434S, S72.435S, S72.441S, S72.442S, S72.444S, S72.445S,
S72.451S, S72.452S, S72.454S, S72.455S, S72.461S, S72.462S, S72.464S, S72.465S,
S72.471S, S72.472S, S72.491S, S72.492S, S72.8X1S, S72.8X2S, S79.101S, S79.102S,
S79.111S, S79.112S, S79.121S, S79.122S, S79.131S, S79.132S, S79.141S, S79.142S,
S79.191S, S79.192S, S82.001S, S82.002S, S82.011S, S82.012S, S82.014S, S82.015S,
S82.021S, S82.022S, S82.024S, S82.025S, S82.031S, S82.032S, S82.034S, S82.035S,
S82.041S, S82.042S, S82.044S, S82.045S, S82.091S, S82.092S, S82.101S, S82.102S,
S82.121S, S82.122S, S82.124S, S82.125S, S82.131S, S82.132S, S82.134S, S82.135S,
S82.141S, S82.142S, S82.144S, S82.145S, S82.161S, S82.162S, S82.191S, S82.192S,
S89.001S, S89.002S, S89.011S, S89.012S, S89.021S, S89.022S, S89.031S, S89.032S,
S89.041S, S89.042S, S89.091S and S89.092S. Under ICD-10 Codes that Support
Medical Necessity- Group 4 added ICD-10 codes T84.042S and T84.043S.
05/19/16
Added CPT/HCPCS Codes- Group 2 for Part A services only
Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes N04.0, 7/08/16
N04.1, N04.2, and N05.2. Under Coverage Indications, Limitations and/or Medical
Necessity revised the verbiage in the last sentence from “Other off label uses will not be
covered at this time.” to read “Other off label uses will be considered for coverage at the
discretion of Palmetto GBA.”
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
45
7/2016
Articles
Once in a Lifetime
Abdominal Aortic
Aneurysm (AAA)
Screening Article
A55071
New
Once in a Lifetime Abdominal Aortic Aneurysm (AAA) Screening Article
06/23/16
Once in a lifetime abdominal aortic aneurysm (AAA) screening is only covered under
certain specified conditions.
When billing for AAA screenings, the following ICD-10 codes should be billed:
* Z13.6 for the encounter for screening of cardiovascular disorders and either
** The most appropriate code for tobacco usage: F17.210, F17.211, F17.213, F17.218
and F17.219 OR
* Z84.89 for family history of other specified conditions
Note: G0389 is the only ultrasound service that is payable for AAA screening under
Medicare services. No other CPT/HCPCS codes are covered.
Per the CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing
Manual, Chapter 18, Section 110.2 and 110.3.2,
Payment may be made for a one-time ultrasound screening for AAA for beneficiaries
who meet the following criteria:
(i) receives a referral for such an ultrasound screening from the beneficiary’s attending
physician, physician assistant, nurse practitioner or clinical nurse specialist;
(ii) receives such ultrasound screening from a provider or supplier who is authorized to
provide covered ultrasound diagnostic services;
(iii) has not been previously furnished such an ultrasound screening under the Medicare
Program; and
(iv) is included in at least one of the following risk categories
(I) has a family history of abdominal aortic aneurysm;
(II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime;
or
(III) is a beneficiary who manifests other risk factors in a beneficiary category
recommended for screening by the United States Preventive Services Task
Force regarding AAA, as specified by the Secretary of Health and Human
Services, through the national coverage determination process.***
*For risk category (I) note that Z84.89 is an “other specified” code and requires that the
condition be reflected in the medical record, therefore family history of abdominal aortic
aneurysm must be documented in the medical record.
**For risk category (II)
***For risk category (III) USPST does not currently have any additional screening
recommendations at B or above grade at this time.
Effective for services furnished on or after January 1, 2007, the following code,
modifiers, and type of service (TOS) are used for AAA screening services:
G0389: Ultrasound, B-scan and or real time with image documentation; for abdominal
aortic aneurysm (AAA) screening
Short Descriptor: Ultrasound exam AAA screen
Modifiers: TC, 26
TOS: 4
Bill Types: 12x, 13x, 22x, 23x, 71x, 73x, 85x
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
46
7/2016
Screening Colonoscopy
Converted to a
Diagnostic and/
or Therapeutic
Colonoscopy Article
A55069
New
If during a colonoscopy a pathology is encountered that necessitates an intervention 10/01/15
which converts the screening colonoscopy to a diagnostic/therapeutic colonoscopy, the
appropriate CPT code which includes the –PT modifier for the diagnostic/therapeutic
colonoscopy must be submitted with the Z80.0 diagnosis.
1) choose the correct CPT code which describes the procedure that was attempted:
CPT 45380
CPT 45381
CPT 45382
CPT 45384
CPT 45385
2) append the –PT modifier to the CPT code. The –PT modifier indicates a screening
colonoscopy has been converted to a diagnostic test or other procedure.
3) use an appropriate ICD-10 diagnosis code to indicate the procedure was a screening
procedure. The diagnosis Z80.0- Family history of malignant neoplasm of digestive
organs can be used for screening of beneficiaries at high risk.
Note: Z80.0 does not appear as an ICD-10 code that supports medical necessity in
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy LCD L34454 because this LCD
addresses ONLY procedures performed for diagnostic and/or therapeutic purposes.
LCD L34454 does not address criteria for the performance of or coding for screening
procedures or screening procedures that are converted to diagnostic/therapeutic
procedures based upon unanticipated pathology encountered during the visualization
of the colon.
FDA Approval
of Keytruda®
(Pembrolizumab)
for Treatment of
Unresectable or
Metastatic Melanoma
A53795
Rev #7
FDA Approval
of Keytruda®
(Pembrolizumab)
for Treatment of
Unresectable or
Metastatic Melanoma
A53795
Rev #8
This article has a retroactive effective date of 10/01/2015.
Under Associated Contract Numbers added 11201, 11301, 11401, and 11501. Under 06/30/16
Article Text revised the verbiage to include the FDA indication for metastatic non-small
cell lung cancer (NSCLC) whose tumors express PD-L1 as determined by an FDAapproved test with disease progression on or after platinum-containing chemotherapy.
For the treatment of unresectable and metastatic melanoma deleted the following
verbiage, “...disease progression following ipilimumab and, if BRAF V600 mutation
positive, a BRAF inhibitor.” Deleted the requirement for drug name and National Drug
Code (NDC) number to be included for claims submission from the fourth paragraph,
the fifth bullet. Under Covered ICD-10 Codes added ICD-10 codes for NSCLC. These
ICD-10 codes are effective as of 10/02/2015.
Under Article Title the title was revised to now read FDA Approved Indications for 06/30/16
KEYTRUDA® (Pembrolizumab).
Retired Articles
Retirement of
the Current FDA
Approved Indications
for KEYTRUDA®
(Pembrolizumab) Article
A53842
The article Current FDA Approved Indications for KEYTRUDA® (Pembrolizumab) 06/29/16
A53842 is being retired on 06/29/2016 as it has been incorporated into the FDA
Approval of Keytruda® (Pembrolizumab) for Treatment of Unresectable or Metastatic
Melanoma Article A53795 effective 06/30/2016.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
47
7/2016
MoDX LCD/Article Upates
LCDs
MolDX-CDD:
ProMark Risk Score
DL36665
GlycoMark Testing
for Glycemic Control
DL36761
4KScore Assay
DL36763
MolDX: Breast
Cancer Assay:
Prosigna
*DL36125
Draft MolDX LCDs
Description
New Draft Policy
Comment Period
06/13/2016 – 07/29/2016
New Draft Policy
06/13/2016 – 07/29/2016
New Draft Policy
06/13/2016 – 07/29/2016
Male breast cancer CPT codes were removed making the policy more
06/13/2016 – 07/29/2016
restrictive; therefore the policy was placed back in draft status for June CAC.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
48
7/2016
Articles
MolDX: Billing and
Coding for Lynch
Syndrome Testing
Services
A54987/M00131
NEW
New MolDX Articles
Description
Publish Date
As per the LCD MolDX: Genetic Testing for Lynch Syndrome (LS),
4/1/2016
laboratory providers must follow a stepped approach to meet the reasonable
and necessary criteria. To progress to each subsequent step, refer to the
indications detailed in the policy.
Step 1:
LS screening to detect the presence of a defective mismatch pair may be
performed by ONE or both of the following methods:
1. Immunohistochemistry (IHC) for MLH1, MLH2, MSH6, and PMS2
2. Microsatellite instability analysis (MSI)
To bill services for this step, choose the appropriate codes for methods(s)
performed:
Test
CPT Code
UOS
IHC-initial
88342
1
IHC-ea.addl.
88341
3
AND/OR
Method 2
MSI
81301
1
If results from methods 1 or 2 are abnormal, proceed to step 2.
Method 1
Step2:
LS definitive testing may be performed by ONE of the following methods:
1. Next generation sequencing (NGS or “hotspot”) testing platforms,
OR
2. Non-NGS testing platforms
To bill services for this step, choose ONE method:
Step 2
Method 1
Test
Hereditary colon cancer disorders
genomic sequence panel
OR
CPT
Code
UOS
81435
1
Step 2
Non-NGS testing: Continue steps as indicated by LCD
Method 2
Step 3
BRAF V600E
81210
1
Step 4
MLH1, Promoter Methylation
81288
1
Step 5A
MLH1
81292
1
Step 5B
MSH2
81295
1
Step 5C
MSH6
81298
1
Step 5D
PMS2
81317
1
Step 6
EpCAM
81403
1
Note: For Non-NGS testing (Step 2-6, Method 2), you may ONLY progress
to the subsequent genetic test IF additional information is necessary to rule
out or diagnose LS.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
49
7/2016
LCD/Article
MolDX: Breast
Cancer Biomarkers
to Guide Adjuvant
Chemotherapy
DL36719
LCD
MolDX: Molecular
Diagnostic Tests
(MDT)
L35025
Rev # 10
MolDX: Molecular
Diagnostic Tests
(MDT)
L35025
Rev # 11
MolDX: NRAS
Genetic Testing
L35073
Rev # 8
MolDX: Genetic
Testing for BCR­
ABL Negative
Myeloproliferative
Disease
L36044
Rev # 4
MolDX: Molecular
RBC Phenotyping
L36074
Rev # 4
MolDXCDD: NSCLC,
Comprehensive
Genomic Profile
Testing
L36143
Rev # 4
Retired LCD/Article
Description
Since the drafting of this policy, additional information has been identified
that we feel will significantly impact this policy and would likely result in a
significant revision. As such, we are retiring this draft.
Revised LCDs
Description
Updated to remove items we no longer follow:
• PTI are no longer an option
• Suspension of claims that omit Z-Code IDs- we reject codes
• Correct POC for MK and MolDX
Date Retired
5/18/2016
Effective Date
4/21/2016
Typographical error.
6/20/2016
Under Coverage Guidance Coverage Indications, Limitations and/or Medical
Necessity section moved “Technology Assessments (TA) down and removed
the following last sentence “Prior to completion of this TA and published
coverage determination.”
Replaced CPT code 81404 in the opening sentence with CPT code 81311.
1/01/2016
81404 was the correct code in 2015 but was changed to 81311 for 2016.
Clarification for NGS testing. Added verbiage to cover NGS testing
4/28/2016
Added statement regarding RBC phenotyping of MM patients eligible for
daratumumab therapy (anti CD-38), Inclusion of ICD-10 codes:C90.00,
C90.01, and C90.02. and added 3 additional references under sources of
information.
Corrected typographical error from the equal (=) symbol to the less than or
equal to (≤) symbol for light smokers
5/19/2016
11/27/2016
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
50
7/2016
CMS e-News
e-News contains a week’s worth of Medicare-related messages instead
of many different messages being sent to you throughout the week.
This notification process ensures planned, coordinated messages are
delivered timely about Medicare-related topics.
_______________________________________
MLN Connects™ Provider eNews
MLN Connects™ Provider eNews for May 26, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-26-eNews.pdf
MLN Connects™ Provider eNews for June 2, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-06-02-eNews.pdf
MLN Connects™ Provider eNews for June 9, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-06-09-eNews.pdf
MLN Connects™ Provider eNews for June 16, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-06-16-eNews.pdf
MLN Connects™ Provider eNews for June 23, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-06-23-eNews.pdf
Receive ADRs Electronically:
Go Green via eServices
Providers can now opt to receive Additional Documentation Requests (ADRs)
through eServices. If your claim is selected for review, you can receive your
request as it is generated – instead of by mail (which decreases the amount of
time you have to respond).
This new process is free, secure and easy to use. Our messaging function in eServices will send an inbox
message to let users know that an ‘eLetter’ is now available. This new process delivers the electronic document
as a link within the secure message once you sign into eServices.
For more information about eServices and the many services it offers, please visit our website at
www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
51
7/2016
CMS Offers FREE Medicare Training for Providers
CMS Web Training
The Centers for Medicare & Medicaid Services (CMS) has launched a series of education and training
programs designed to leverage emerging Internet and satellite technologies to offer just-in-time training
to Medicare providers and suppliers throughout the United States. Many of these programs include free,
downloadable computer/Web based training courses. These courses are also available on CD-ROM.
http://www.cms.gov/MLNGenInfo
Palmetto GBA Medicare Customer Information and Outreach
Important Telephone Numbers
Training Available
Provider Contact Center
(855) 696-0705 (Toll-Free)
To request a Medicare Education meeting/seminar
at no cost to you, complete and fax the form located
on the
http://www.PalmettoGBA.com/JMB/forms.
Electronic Data Interchange (EDI)
Technical Support
(855) 696-0705
http://www.PalmettoGBA.com/Medicare
Medicare Beneficiary Call Center
Important Sources For You
1-800-MEDICARE (1-800-633-4227)
TTY 1-877-486-2048
•
•
•
http://www.cms.gov
http://www.cms.gov/MLNGenInfo
http://www.cms.gov/CMSforms/CMSforms/list.asp
Attention: Billing Manager
52
7/2016