Medicare Bulletin - June 2016...Medicare Bulletin Jurisdiction 15 HOME HEALTH & HOSPICE Bold, italicized material is excerpted from the American Medical Association Current Procedural

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Medicare BulletinJurisdiction 15

JUNE 2016 • W W W.CGSMEDICARE .COM

Reaching Out to the Medicare

Community

© 2016 Copyright, CGS Administrators, LLC.

http://www.cgsmedicare.com

Medicare BulletinJurisdiction 15

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Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2016-06 JUNE 2016 2

HOME HEALTH PROVIDERS

MM9608: Corrections to Recoding in the Home Health Pricer Program 3

HOME HEALTH & HOSPICE PROVIDERS

CGS Website Updates 4

Claim Adjustment Segment (CAS) Information Required When Billing Medicare Secondary Payer (MSP) Claims/Adjustments 6

General or Claim Specific Questions When Calling the Provider Contact Center 9

MLN Connects™ Provider eNews 10

MM8822 (Revised): Reclassification of Certain Durable Medical Equipment HCPCS Codes Included in Competitive Bidding Programs (CBP) from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category 11

MM9168 (Revised): Reporting Principal and Interest Amounts When Refunding Previously Recouped Money on the Remittance Advice (RA) 13

MM9466: Remittance Advice Remark and Claims Adjustment Reason Code and Medicare Remit Easy Print and PC Print Update 15

MM9553 (Revised): April 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.1 16

Provider Contact Center (PCC) Training 19

Upcoming Educational Events 19

http://go.cms.gov/MLNGenInfo

http://go.cms.gov/MLNGenInfo

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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters are available at no cost from our website at http://www.cgsmedicare.com. © 2016 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN • GR 2016-06 JUNE 2016

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For Home Health Providers

MM9608: Corrections to Recoding in the Home Health Pricer Program

The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2016-MLN-Matters-Articles.html

MLN Matters® Number: MM9608Related CR Release Date: April 1, 2016Related CR Transmittal #: R3487CP

Change Request (CR) #: CR 9608 Effective Date: January 1, 2016 Implementation Date: April 25, 2016

Provider Types Affected

This MLN Matters® Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

What You Need to Know

Change Request (CR) 9608 announces the installation of a corrected Home Health (HH) Pricer program on April 25, 2016. CR9608 also requires Medicare Administrative Contractors (MACs) to adjust certain HHA claims to correct recoding errors that resulted in inaccurate payments.

Background

The Centers for Medicare & Medicaid Services (CMS) has identified an error in the Home Health (HH) Pricer program that causes incorrect Original Medicare payments to Home Health Agencies (HHAs).

The HH Pricer program routinely validates whether the Health Insurance Prospective Payment System (HIPPS) code on a claim is supported by the appropriate number of therapy

The Medicare Learning Network ® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more. To stay informed about all of the CMS MLN products, refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf and subscribe to the CMS electronic mailing lists. Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.

Medicare Learning Network ®: A Valuable Educational Resource!


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2016-MLN-Matters-Articles.html


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MailingLists_FactSheet.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

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services. If the number of therapy services is higher or lower than what is reflected in the HIPPS code, the Pricer recodes the claim and a HIPPS code corresponding to the actual therapy services is paid.

Since the January 2016 update to the HH Pricer, the program performed this action incorrectly when the provider-submitted HIPPS codes began with 5, or when 20 or more therapy visits were provided and the provider-submitted code was recoded to a HIPPS code beginning with 5. As a result of this error, claims that were recoded to a different payment group were assigned incorrect HIPPS codes.

To correct these errors, CMS has revised the HH Pricer; this revision will be implemented on April 25, 2016. After this implementation is completed, your MAC will correct your payments by adjusting HH claims that meet the following criteria:

yy Type of Bill 032x other than 0322,

yy APC-HIPPS codes in the 5xxxx range, and

yy Claim receipt dates on or after January 1, 2016.

Further, the MACs will complete these claims adjustments within 30 days of the installation date of the revised HH Pricer.

Additional Information

The official instruction, CR9608 issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3487CP.pdf on the CMS website.

If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.

For Home Health and Hospice Providers

CGS Website Updates

CGS has recently made updates to their website, giving providers additional resources to assist with billing Medicare-covered services appropriately.

Please review the following updates:

yy The “Top Claim Submission Errors (Reason Codes) and How to Resolve” Web page at http://www.cgsmedicare.com/hhh/education/materials/cses.html for the home health reason codes 32907 and 32243 were revised to update the screen prints to show the appropriate skilled nursing G codes that became effective January 1, 2016. The deleted code G0154 was removed.

yy The home health “Untimely Face-To-Face Encounter” Web page at http://www.cgsmedicare.com/hhh/education/materials/untimely_ftf.html was updated to add a note to reflect the changes in CR 9385, which instructs the medical reviewer to apply OC code 48 when it is determined that the face-to-face encounter was untimely. The services dates following the date of the encounter will be noncovered. The Common Working File (CWF) will automatically be updated to show the OC 48 date as the date of revocation on the current benefit period. Therefore, a discharge claim is not required. Once the encounter occurs, the patient can be readmitted, provided they meet all of the eligibility requirements, and a new Notice of Election will need to be submitted.

yy The “Chapter Five: Claims Correction” document of the Fiscal Intermediary Standard System (FISS) Guide at http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_5-claims_correction_menu.pdf has been updated.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3487CP.pdf


http://www.cgsmedicare.com/hhh/education/materials/cses.html

http://www.cgsmedicare.com/hhh/education/materials/untimely_ftf.html

http://www.cgsmedicare.com/hhh/education/materials/untimely_ftf.html

http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_5-claims_correction_menu.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_5-claims_correction_menu.pdf

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yy The “Chapter Four: Claims and Attachments” document of the Fiscal Intermediary Standard System (FISS) Guide at http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_4-claims_and_attachments_menu.pdf has been updated.

yy A sample of the Provider Enrollment Revalidation envelope (http://www.cgsmedicare.com/img/articles/cope32609.jpg) has been posted to the “Provider Enrollment Revalidation” Web page at http://www.cgsmedicare.com/hhh/enrollment/Revalidation.html.

yy The Contracting Officer’s Representative contact information was updated on the “Home Health & Hospice Contact Information” Web page at http://www.cgsmedicare.com/hhh/cs/telephone_numbers.html.

yy The “Jurisdiction 15 Home Health & Hospice Provider Outreach and Education (POE) Advisory Group” Web page at http://www.cgsmedicare.com/hhh/education/Advisory_Groups.html has been updated by adding the meeting minutes to the March 2016 Home Health and Hospice Advisory Group meetings.

yy A new question/answer was added to the “Home Health Clinical FAQs” Web page at http://www.cgsmedicare.com/hhh/education/faqs/hh_clinical_faqs.html asking if a medical director can sign the home health plan of care (POC) when the physician who initiated the POC is not willing or is unavailable to sign.

yy A new question/answer was added to the “Home Health Face-to-Face (FTF) Encounters FAQ” Web page at http://www.cgsmedicare.com/hhh/education/faqs/hh_ftf_encounters.html asking if a resident can perform and sign the home health FTF encounter.

yy The “Ask-the-Contractor (ACT) Questions and Answers” Web page at http://www.cgsmedicare.com/hhh/education/faqs/act/act_qa031616.html now includes the questions/answers from the March 16, 2016, “Home Health & Hospice: What’s New” Ask-the-Contractor Teleconference (ACT).

yy The “Home Health Face-to-Face (FTF) Encounter” Web page at http://www.cgsmedicare.com/hhh/coverage/hh_coverage_guidelines/hh_ftf_encounter.html was updated to reflect changes in regard to who performs and signs the FTF encounter, the FTF documentation, and the additional resources.

yy The “Home Health Top Medical Review Denial Reason Codes” Web page at http://www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html has been updated with the January – March 2016 quarterly medical review denial data.

yy The “Hospice Top Medical Review Denial Reason Codes” Web page at http://www.cgsmedicare.com/hhh/medreview/hos_denial_reasons.html has been updated with the January – March 2016 quarterly medical review denial data.

yy The mailing address on the “Home Health & Hospice Duplicate Remittance Advice Request Form” at http://www.cgsmedicare.com/hhh/claims/fees/pdf/duplicate_remittance_advice_req.pdf has been updated.

yy The “Recovery Audit Program” Web page at http://www.cgsmedicare.com/hhh/medreview/recovery_audit_program.html was revised to change the name of the Region C Recovery Audit Contractor (RAC), from Connolly, LLC to Cotiviti, LLC.

yy The Home Health Quick Resource Tool, “Face-To-Face (FTF) Encounters for Home Health Certification” at http://www.cgsmedicare.com/hhh/education/materials/pdf/ftf.pdf has been updated to correct the reference to the Code of Federal Regulations in the “Who – Performed by:” section.


http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_4-claims_and_attachments_menu.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_4-claims_and_attachments_menu.pdf

http://www.cgsmedicare.com/img/articles/cope32609.jpg

http://www.cgsmedicare.com/img/articles/cope32609.jpg

http://www.cgsmedicare.com/hhh/enrollment/Revalidation.html

http://www.cgsmedicare.com/hhh/enrollment/Revalidation.html

http://www.cgsmedicare.com/hhh/cs/telephone_numbers.html

http://www.cgsmedicare.com/hhh/cs/telephone_numbers.html

http://www.cgsmedicare.com/hhh/education/Advisory_Groups.html

http://www.cgsmedicare.com/hhh/education/Advisory_Groups.html

http://www.cgsmedicare.com/hhh/education/faqs/hh_clinical_faqs.html

http://www.cgsmedicare.com/hhh/education/faqs/hh_ftf_encounters.html

http://www.cgsmedicare.com/hhh/education/faqs/hh_ftf_encounters.html

http://www.cgsmedicare.com/hhh/education/faqs/act/act_qa031616.html

http://www.cgsmedicare.com/hhh/education/faqs/act/act_qa031616.html

http://www.cgsmedicare.com/hhh/coverage/hh_coverage_guidelines/hh_ftf_encounter.html

http://www.cgsmedicare.com/hhh/coverage/hh_coverage_guidelines/hh_ftf_encounter.html

http://www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html

http://www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html

http://www.cgsmedicare.com/hhh/medreview/hos_denial_reasons.html

http://www.cgsmedicare.com/hhh/medreview/hos_denial_reasons.html

http://www.cgsmedicare.com/hhh/claims/fees/pdf/duplicate_remittance_advice_req.pdf

http://www.cgsmedicare.com/hhh/claims/fees/pdf/duplicate_remittance_advice_req.pdf

http://www.cgsmedicare.com/hhh/medreview/recovery_audit_program.html

http://www.cgsmedicare.com/hhh/medreview/recovery_audit_program.html

http://www.cgsmedicare.com/hhh/education/materials/pdf/ftf.pdf

http://www.cgsmedicare.com/hhh/education/materials/pdf/ftf.pdf

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Claim Adjustment Segment (CAS) Information Required When Billing Medicare Secondary Payer (MSP) Claims/Adjustments

Change Request (CR) 8486 implemented changes that now allow providers to submit Medicare Secondary Payer (MSP) claims and adjustments via the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). This CR also requires all MSP claims, regardless of whether they are submitted electronically (5010 format), or via the FISS DDE, to include claim adjustment segment (CAS) information. The following provides details about submitting CAS information on MSP claims/adjustments.

FISS DDE

If you enter an MSP claim via the FISS DDE, the CAS information must be entered on the new “MSP Payment Information” screen (MAP1719). This screen is accessible by pressing F11 from Claim Page 03. The “MSP Payment Information” screen for “Primary Payer 1” will display. Entry for a second payer (if there is one) is available by pressing F6 to display the “MSP Payment Information” screen for “Primary Payer 2.”

MAP1719 PAGE 03 CGS J15 MAC – HHH REGION ACMFA552 MM/DD/YYXXXXXXX SC INST CLAIM ENTRY C201611F HH:MM:SSHIC XXXXXXXXA TOB XXX S/LOC S B0100 PROVIDER M S P P A Y M E N T I N F O R M A T I O N RI: PRIMARY PAYER 1 MSP PAYMENT INFORMATION PAID DATE: 102015 PAID AMOUNT: 200.00 GRP PR CARC 119 AMT 2800.00 GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT GRP CARC AMT PROCESS COMPLETED --- PLEASE CONTINUE PRESS PF3-EXIT PF5-BKWD PF6-FWD PF7-PREV PF8-NEXT PF9-UPDT PF10-LEFT

Electronically

If you enter an MSP claim electronically (5010 format), the CAS information is reported in Loops 2320 – 2330I as follows:

PAID DATE yy 2330B DTP segment Primary Adjudication or Payment DatePAID AMOUNT yy 2320 AMT segment Primary Payer Paid AmountGRP yy 2320 CAS segment Claim Level Adjustments

yy CAS01 CO PR OA CARC yy 2320 CAS segment Claim Level Adjustments

yy CAS02 Adjustment Reason Codeyy CAS05, CAS08, CAS11, CAS14, CAS17 if multiple CARCs for the same group code


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AMT yy 2320 CAS segment Claim Level Adjustments yy CAS03 Adjustment Amountyy CAS06, CAS09, CAS12, CAS15, CAS18 if multiple CARCs for the same group code

Paper MSP Claims

MSP paper claims may only be submitted when services are related to Black Lung, or when the provider meets the small provider exception as indicated in the Centers for Medicare & Medicaid Services (CMS) Pub. 100-04, Ch. 24 §90 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf).

Note: Paper claims related to Black Lung, must include a copy of the Department of Labor (DOL) denial notice and a copy of workers’ compensation insurer denial notice (if applicable). Paper claims submitted due to the small provider exception must include the prior payer’s remittance statement and documentation indicating that the provider meets the small provider exception. The CGS Claims department will enter the required CAS information based on the submitted documentation.

CAS Information

The prior payer’s 835 Electronic Remittance Advice (ERA) typically includes CAS information. The following table provides the “MSP Payment Information” (Map1719) field descriptions and guidance on how to complete the fields.

FISS Field How to CompletePAID DATE Enter the paid date shown on the primary payer’s remittance advice. PAID AMOUNT

Enter the paid amount shown on the primary payer’s remittance advice. This amount must equal the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.

GRP Enter the Group Code shown on the primary payer’s remittance advice. Valid codes are: CO Contractual ObligationPI Payer Initiated ReductionsOA Other AdjustmentPR Patient Responsibility

NOTE: Group Code CO should only be used when Value Code 44 (Obligated to Accept as Payment in Full, or OTAF).

CARC Enter the Claim Adjustment Reason Code (CARC) shown on the primary payer’s remittance advice. This is a 4-digit field. This must be a valid code. If the CARC code is a 2 (coinsurance amount), enter a “2,” not “02.”

NOTE: CARC codes explain why there is a difference between the total billed amount and the paid amount. The word ‘adjustment’ in relation to a CARC code is not the same as a “claim” adjustment (type of bill 327 or 817).

For a current list of valid CARC codes, refer to the Washington Publishing Company website at http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ You can also search through a list of CARC codes by accessing the FISS DDE Inquiry screen option 68 (ANSI REASON CODES) and type “C” in the RECORD TYPE field.

AMT Enter the dollar amount associated with the group code and CARC.

NOTE: This dollar amount reflects the difference between what was billed by the provider and what was paid by the primary payer.

The AMT field must equal the total submitted charges (revenue code 0001) minus the amount entered in the PAID AMOUNT field (the amount paid by the primary payer). For example:

Total billed amount (0001 revenue code) 2000.00Minus PAID AMOUNT (primary paid amount) - 1500.00Equals the AMT field 500.00


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

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FISS Field How to CompleteAMT NOTE: If Value Code 44 is billed, the dollar amount entered in the AMT field must be the

difference between the total charges and the VC 44 amount.

Total billed amount (0001 revenue code) 2000.00Minus the Value Code 44 amount - 1500.00Equals the AMT field 500.00

If the CAS code information is not available from the prior payer, providers need to determine the appropriate Group Code and Claim Adjustment Reason Code (CARC) to submit. This information is available from the following websites:

yy Washington Publishing Company - http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

yy CAQH (Access the current version of the CORE Code Combinations) - http://www.caqh.org/core/ongoing-maintenance-core-code-combinations-caqh-core-360-rule

Return to Provider (RTP) Reason Codes

MSP claims will automatically be sent to the RTP file when one or more of the following reason codes apply.

Reason Code Reason Code Description/How to Resolve31686 The dollar amount in the PD AMT field on the MSP Payment Information screen (MAP 1719) is not equal to the

submitted charges and there are no entries present in the GROUP or CARC fields. How to Resolve: Verify that the PAID AMOUNT field equals the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47. The GRP and CARC fields must also be completed.

31687 This reason code has been assigned to your claim because:yy The claim shows Medicare primary but there is information present on the MSP Payment Information screen

(MAP 1719) for Primary Payer 1 or Primary Payer 2How to Resolve: If Medicare is primary, the MSP Payment Information screen for Primary Payer 1 and Primary Payer 2 must be blank. yy Medicare is secondary and no information is present on the MSP Payment Information Screen (MAP 1719) for

Primary Payer 1.How to Resolve: If Medicare is the secondary payer, the MSP Payment Information screen for Primary Payer 1 must be completed. yy Medicare is secondary and the MSP Payment Information screen (MAP 1719) has information present for

Primary Payer 2How to Resolve: If Medicare is the secondary payer, the MSP Payment Information screen for Primary Payer 1 must be completed. Information for primary payer 2 is only required when Medicare is the tertiary payer. yy Medicare is the tertiary payer and information is missing on the MSP Payment Information screen (MAP 1719)

for Primary Payer 1 or Primary Payer 2How to Resolve: If Medicare is the tertiary payer, the MSP Payment Information screen for Primary Payer 1 and Primary Payer 2 must be completed. yy Medicare is secondary or tertiary and the PD DT or PD AMT field on the MSP Payment Information screen

(MAP 1719) is blank for Primary Payer 1 and/or Primary 2 (Note: zeros (0.00) may be entered in the PD AMT field. However no entry or blank space is acceptable)How to Resolve: When Medicare is the primary or tertiary payer, the PAID DATE and PAID AMOUNT fields must be completed. Enter the paid date shown on the primary payer’s remittance advice in the PAID DATE field, and enter the paid amount shown on the primary payer’s remittance advice in the PAID AMOUNT field. This amount must equal the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.yy Medicare is secondary and at least one GROUP/CARC combination is not present for Primary Payer 1

How to Resolve: When Medicare is the secondary payer, the GRP and CARC field for Primary Payer 1 on the “MSP Payment Information” screen (MAP 1719) must be completed. yy Medicare is tertiary and at least one GROUP/CARC combination is not present for Primary Payer 2

How to Resolve: When Medicare is the tertiary payer, the GRP and CARC field for Primary Payer 2 on the “MSP Payment Information” screen (MAP 1719) must be completed.




http://www.caqh.org/core/ongoing-maintenance-core-code-combinations-caqh-core-360-rule

http://www.caqh.org/core/ongoing-maintenance-core-code-combinations-caqh-core-360-rule

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Reason Code Reason Code Description/How to Resolve31688 This claim was submitted showing Medicare as the secondary or tertiary payer and one of the following

has occurred: yy An invalid CARC code has been entered on the MSP Payment Information screen (MAP1719)yy The PAID DATE field on the MSP Payment Information screen (MAP1719) is prior to the effective date for one

or more of the CARC codes enteredyy The PAID DATE field on the MSP Payment Information screen (MAP1719) occurs after the termination date for

one or more or the CARC codes entered.How to Resolve: The CARC code entered must be a valid code. Refer to the Washington Publishing Company website at http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ for a list of valid codes and the date it became valid.

31689 The claim has been submitted showing Medicare as the secondary or tertiary payer and the dollar amount entered in the PAID AMOUNT field on the MSP Payment Information screen (MAP1719) is not equal to the dollar amount entered for the MSP Value code (12, 13, 14, 15, 41, 43 or 47). How to Resolve: Review the dollar amount entered in the PAID AMOUNT field on the MSP Payment Information screen and ensure that it equals the dollar amount entered for MSP Value Codes 12, 13, 14, 15, 16, 43, and 47.

31690 Primary Payer information has been entered on the MSP Payment Information screen (MAP1719) (F11 on page 3 of claim) for Primary Payer 2; however, information is not present for Primary Payer 1. If there is only one primary payer, information must be entered only for Primary Payer 1. How to Resolve: When Medicare is the secondary payer, the MSP Payment Information screen for Primary Payer 1 must be completed. The Primary Payer 2 screen is only completed when Medicare is the tertiary payer.

31691 The claim has been submitted showing Medicare as the secondary payer; the total submitted charges on the claim minus the total of the CARC amounts on the MSP Payment Information screen (MAP1719) does not equal the PAID AMT field on the screen. How to Resolve: The AMT field on the MSP Payment Information screen must equal the total submitted charges (revenue code 0001) minus the amount entered in the PAID AMOUNT field (the amount paid by the primary payer and the amount submitted with Value Codes 12, 13, 14, 15, 16, 43, or 47. For example: $5000.00 (revenue code 0001) - $4000.00 (primary paid amount (also the amount entered in the PAID AMOUNT field, which must equal VC 12, 13, 14, 15, 16, 43, or 47)= $1000.00 (AMT field)

31693 Medicare is not the primary payer and the date entered in the PAID DATE field is not valid or is in the wrong format for Primary Payer 1 or Primary Payer 2. The correct format is MMDDYY. Correct and F9 or resubmit the claim. How to Resolve: The PAID DATE field on the MSP Payment Information screen must be a valid date and in the correct format (MMDDYY).

For additional guidance with submitting MSP claims, please refer to the following resources:

yy “Medicare Secondary Payer Billing & Adjustments” quick resource tool at http://www.cgsmedicare.com/hhh/education/materials/pdf/msp_billing.pdf

yy “Submitting Medicare Secondary Payer (MSP) Claims and Adjustments” at http://cgsmedicare.com/hhh/education/materials/submitting_msp.html


General or Claim Specific Questions When Calling the Provider Contact Center

To protect the privacy of Medicare beneficiaries and providers, Medicare Administrative Contractors (MACs), like CGS, are required to authenticate certain elements before releasing beneficiary-specific information. When calling the CGS Provider Contact Center (PCC), the Customer Service Representative (CSR) will ask if you have a general question, or a claim specific question. General questions do not require authentication; therefore, this allows the CSR to determine whether they can bypass the authentication process.



http://www.cgsmedicare.com/hhh/education/materials/pdf/msp_billing.pdf

http://cgsmedicare.com/hhh/education/materials/submitting_msp.html

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General questions are those that do not require the CSR to access the claims processing system (Fiscal Intermediary Standard System (FISS)), or eligibility systems (ELGA/ELGH). Claims specific questions are those that do require the CSR to access FISS, or ELGA/ELGH.

NOTE: General questions about a beneficiary’s Medicare eligibility can often be answered through the Interactive Voice Response (IVR) system and the CGS Web Portal, myCGS at http://www.cgsmedicare.com/mycgs/manual.html on the CGS website. CSRs will refer providers back to the IVR if they have eligibility or claim status questions. However, CSRs may be able to assist with more detailed eligibility questions pertaining to Medicare Secondary Payer (MSP) or Health Maintenance Organizations (HMOs), etc.

Please refer to the following table as a guide in determining if your question is general or claim specific.

General Question Claim Specific QuestionExamples include, but are not limited to:yy How to read a remittance advice; yy How to find information on the CGS or the CMS website;yy Benefit guidelines;yy Questions about coverage (not related to a specific beneficiary); or yy Requesting a mailing address or telephone number.

• Medicare eligibility information;• Claim information (pending/processed);• Preventive Services – Next Eligible date; or • Overlapping claim information.

Claim–specific/eligibility questions require the CSR to authenticate the following elements:

yy Provider National Provider Identifier (NPI), Provider Transaction Access Number (PTAN) and the last five digits of their Tax Identification Number (TIN).

yy Beneficiary’s health insurance claim number (HICN), the first six letters of the beneficiary’s last name, the first letter of the beneficiary’s first name, and their date of birth.


MLN Connects™ Provider eNews

The MLN Connects™ Provider eNews contains a weeks worth of Medicare-related messages issued by the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, please contact CMS at [email protected].

yy April 21, 2016 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-21-eNews.pdf

yy April 28, 2016 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-28-eNews.pdf

yy May 5, 2016 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-05-eNews.pdf

yy May 12, 2016 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-12-eNews.pdf


http://www.cgsmedicare.com/mycgs/manual.html

http://www.cgsmedicare.com/mycgs/manual.html

mailto:[email protected]

mailto:[email protected]

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-21-eNews.pdf








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MM8822 (Revised): Reclassification of Certain Durable Medical Equipment HCPCS Codes Included in Competitive Bidding Programs (CBP) from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category

The Centers for Medicare & Medicaid Services (CMS) has revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2016-MLN-Matters-Articles.html

MLN Matters® Number: MM8822 Revised Related CR Release Date: March 23, 2016 Related CR Transmittal #: R1638OTNChange Request (CR) #: CR 8822

Effective Date: July 1, 2016 - except in Round 1 Re- compete CBP areas where effective date is January 1, 2017Implementation Date: July 5, 2016 - except for A/B and HHH MACs where implementation is 10/3/2016

Note: This article was revised on March 24, 2016, due to a revised Change Request.The revised CR adds business requirements 8822.6.2, 8822.6.3 and 8822.7 (bottom of page 7 and top of page 8 of this article), which provides instructions to the MACs for calculating the lump sum purchases. In the article, the transmittal number, CR issue date, and the Web address for accessing CR8822 are revised. All other information is unchanged.


This MLN Matters® Article is intended for suppliers and Home Health Agencies (HHAs) submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) or Home Health & Hospice MACs for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provided to Medicare beneficiaries.


CR 8822 provides instructions for the upcoming reclassification of certain Durable Medical Equipment (DME) Healthcare Common Procedure Coding System (HCPCS) codes, that are included in Round 2 and Round 1 Re-compete DMEPOS CBPs, from the inexpensive and routinely purchased DME payment category to the capped rental DME payment category.

CR 8822 follows CR 8566, Rescind and Replace of CR 8409: Reclassification of Certain Durable Medical Equipment from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category, which was released on March 25, 2014.

You can find the associated MLN Matters® article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8566.pdf on the CMS website. Make sure your billing staffs are aware of these changes.

Background

Medicare defines routinely purchased DME (set forth at 42 CFR §414.220(a)(2)) as equipment that was acquired by purchase on a national basis at least 75 percent of the time during the period July 1986 through June 1987. A review of expensive items that have been classified as routinely purchased equipment since 1989 (that is, new codes added to the HCPCS after 1989 for items costing more than $150) showed inconsistencies in applying the definition.

As a result, a review of the definition of routinely purchased DME was published in the Federal Register (CMS-1526-F) along with notice of DME items (codes) requiring a revised payment category. Also in that rule, the Centers for Medicare & Medicaid Services (CMS)




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8566.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8566.pdf

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established that DME wheelchair accessories that are capped rental items furnished for use as part of a complex rehabilitative power wheelchair (wheelchair base codes K0835 – K0864), will be paid under the associated lump sum purchase option set forth at 42 CFR § 414.229(a)(5) and Section 1834(a)(7)(A)(iii) of the Social Security Act. If the beneficiary declines the purchase option, the supplier must furnish the items on a capped rental basis and payment will be made on a monthly rental basis in accordance with the capped rental payment rules.

In order to align the payment category with the required regulatory definition, the HCPCS codes in the table below will reclassify to the capped rental payment category effective:

yy July 1, 2016: Items furnished in all areas except the nine Round 1 Re-compete CBAs; and

yy January 1, 2017: Items furnished in the nine Round 1 Re-compete CBAs.

HCPCS Codes for Items Reclassified to Capped Rental DME CategoryHCPCS Code DescriptionE0197 Support SurfacesE0140, E0149 WalkersE0985, E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015, K0070 Wheelchairs Options/AccessoriesE0955 Wheelchair Seating

Further Details from CR8822:

1. In Round 1 Re-compete CBAs, payment for HCPCS codes shown in the above table will be made under the inexpensive and routinely purchased (IN) payment category for dates of service July 1, 2016 through December 31, 2016. Your MAC will recognize that the capped payment category requires payment of 10 percent of the purchase price for the first three months and 7.5 percent for each of the remaining rental months 4 through 13. You should also be aware that payment amounts will be based on the lower of the supplier’s actual charge and the fee schedule amount. Your MAC will return as unprocessable claims for the inexpensive and routinely purchased codes described above that are billed with the KH, KI and KJ modifiers. Such unprocessable claims will be returned with 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) N519 (Invalid combination of HCPCS modifiers) and Group Code CO (Contractual Obligation).

2. Effective for claims with dates of service on or after July 1, 2016, for items furnished in Round 2 CBAs, your MAC will cease any IN category rental payments for the codes in the above table and start payment under the Capped Rental (CR) payment category; applying a determination of the number of rental months paid (which cannot exceed 13 rental months combined from dates of service before and after the effective date (July 1, 2016)).

3. Effective for claims with dates of service on or after January 1, 2017, for items furnished in Round 1 Re-compete CBAs, your MAC will cease any IN rental payments for these codes, and start payment under the Capped Rental (CR) payment category; applying a determination of the number of rental months paid (which cannot exceed 13 rental months combined from dates of service before and after the effective date (January 1, 2017)).

4. Effective July 1, 2016, in all areas except the nine Round 1 CBAs, your MACs will process and pay claims for wheelchair base codes K0835 – K0864): E1020, E1028, E2368, E2369, E2370, E2375, K0015, and E0955 (when applicable) on a lump sum purchase basis when used with complex rehabilitative power wheelchairs.


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5. Effective January 1, 2017, in all areas including the Round 1 Re-compete CBAs, your MACs will process and pay claims for the codes K0835 – K0864): E1020, E1028, E2368, E2369, E2370, E2375, K0015, and E0955 (when applicable) on a lump sum purchase basis when used with complex rehabilitative power wheelchairs.

6. When Home Health/Hospice (HHHs) providers bill codes E0197, E0140, E0149, E0985, E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015, K0070 and E0955 for services outside a competitive bid area on or after July 1, 2016, payment will be made on a capped rental basis.

7. When HHHs bill E1020, E1028, E2368, E2369, E2370, E2375, K0015, and E0955 for services outside a competitive bid area on or after July 1, 2016, MACs will process such claims on a lump sum purchase basis, where applicable, when used with a complex rehabilitative wheelchair base (K0835-K0864). Note that for this requirement, MACs will calculate the fee for the lump sum purchase basis (NU modifier - Purchase of new equipment) for these items as the rental price times ten. The fee for a used item lump sum purchase basis (UE modifier - Purchase of used equipment) will be 75 percent of the purchase fee.

Note: Contractors will not search their files but will adjust claims brought to their attention between July 1, 2016, and October 3, 2016, for previously processed claims that meet the requirements stated in 6 and 7 above.


The official instruction, CR 8822 issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1638OTN.pdf on the CMS website.


Document History

Date of Change DescriptionMarch 24, 2016 The article was revised due to a revised Change Request. The revised CR adds business

requirements 8822.6.2, 8822.6.3 and 8822.7 (bottom of page 7 and top of page 8 of this article), which provides instructions to the MACs for calculating the lump sum purchases. In the article, the transmittal number, CR issue date, and the Web address for accessing CR8822 are revised. All other information is unchanged.


MM9168 (Revised): Reporting Principal and Interest Amounts When Refunding Previously Recouped Money on the Remittance Advice (RA)


MLN Matters® Number: MM9168 Revised Related CR Release Date: March 24, 2016Related CR Transmittal #: R1639OTN

Change Request (CR) #: CR 9168 Effective Date: July 1, 2016Implementation Date: July 5, 2016

Note: This article was revised on April 19, 2016, to reflect the revised CR9168 issued on March 24. 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.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1638OTN.pdf




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This MLN Matters® Article is intended for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 9168 explains to providers who received a favorable appeals decision that it will be easier and consequently more transparent to identify the claim and/or the refund of principal and interest paid by Medicare. Your MAC will make sure that the remittance advices are reporting the refunded principal and interest amounts separately, and provide individual claim information. CR9168 applies to electronic remittance advice (ERA) only.

Background

Currently reporting of refunded principal and interest amounts for all related claims on the Remittance Advice (RA) is shown as one lump sum amount. This practice creates problems for the provider community as this is not conducive to posting payment properly. Providers have the money but are not able to identify the claim and/or the refund of principal and interest paid by Medicare.

CR9168 instructs MACs to report the principal and interest separately, and also to provide individual claim information. Specifically, the reporting will be in the Provider Level Balance (PLB) segment of the 835 with an example as follows:

PLB Details - Reporting Principal Refunds

PLB03-1: WW to report overpayment recovery (negative sign for the amount in PLB04) being refunded

PLB03-2 Positions 1 – 25: Account Payable (AP) Invoice Number

PLB03-2 Positions 26 – 50: Claim Adjustment Account Receivable (AR) number

PLB 04: Refund Amount (Principal Refund Amount)

PLB Details - Reporting Interest Refunds

PLB03-1: RU to report interest paid (negative sign for the amount in PLB04)

PLB03-2 Positions 1 – 25: AP Invoice Number

PLB03-2 Positions 26 – 50: Claim Adjustment AR number

PLB04: Interest Amount on Refund


The official instruction, CR 9168 issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1639OTN.pdf on the Centers for Medicare & Medicaid Services website.


Document History

The article was revised on April 19, 2016 to reflect the revised CR9168 issued on March 24.




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MM9466: Remittance Advice Remark and Claims Adjustment Reason Code and Medicare Remit Easy Print and PC Print Update

The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2016-MLN-Matters-Articles.html

MLN Matters® Number: MM9466 Related CR Release Date: April 1, 2016Related CR Transmittal #: R3489CP

Change Request (CR) #: CR 9466 Effective Date: July 1, 2016Implementation Date: July 5, 2016


This MLN Matters® Article is intended for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

CR9466 updates the Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) lists. It also instructs Medicare system maintainers to update Medicare Remit Easy Print (MREP) and PC Print. Make sure that your billing staffs are aware of these changes and obtain the updated MREP or PC Print software if they use that software.

Background

The Health Insurance Portability and Accountability Act (HIPAA) of 1996, instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states that CARCs and RARCs, as appropriate, that provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment of a claim or service, are required in the remittance advice and coordination of benefits transactions.

The Centers for Medicare & Medicaid Services (CMS) instructs MACs and Shared Systems, if appropriate, to conduct updates based on the code update schedule that results in publication of updated code lists three times a year (around March 1, July 1, and November 1).

Medicare’s Shared System Maintainers (SSMs) are responsible for implementing appropriate code deactivation, making sure that any deactivated code is not used in original business messages, but the deactivated code in derivative messages is allowed. SSMs must make sure that Medicare does not report any deactivated code on or before the effective date for deactivation as posted on the Washington Publishing Company (WPC) website. If any new or modified code has an effective date past the implementation date specified in CR9466, MACs will implement on the date specified on the WPC website. The WPC website is available at http://www.wpc-edi.com/Reference on the Internet.

In case of any discrepancy in the code text as posted on WPC website and as reported in any CR, the WPC version should be implemented.

CR9466 advises the SSMs and MACs to perform the updates posted on the WPC based on the March 1, 2016 CARC and RARC code change lists.




http://www.wpc-edi.com/Reference

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The official instruction, CR9466, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3489CP.pdf on the CMS website.



MM9553 (Revised): April 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.1


MLN Matters® Number: MM9553 Revised Related CR Release Date: March 22, 2016Related CR Transmittal #: R3483CP

Change Request (CR) #: CR 9553Effective Date: April 1, 2016Implementation Date: April 4, 2016

Note: This article was revised on March 23, 2016, to reflect the revised CR9553, issued on March 22. In the article, the transmittal number, CR issue date, and the Web address for accessing CR9553 are revised. In addition, a row was added to the table at the top of page 6 to show added editing for NCD effective date for code G0475. All other information remains the same.


This MLN Matters® Article is intended for providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries.


Change Request (CR) 9553 provides the Integrated Outpatient Code Editor (I/OCE) instructions and specifications that will be used under the Outpatient Prospective Payment System (OPPS) and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. Make sure that your billing staffs are aware of these changes. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/ on the Centers for Medicare & Medicaid Services (CMS) website. These specifications contain the appendices mentioned in the table below.

Key Changes for April 2016 I/OCE

The modifications of the IOCE for the April 2016 v17.1 release are summarized in the following table. Note that some I/OCE modifications in the update may be retroactively added to prior releases. If so, the retroactive date appears in the ‘Effective Date’ column.






http://www.cms.gov/OutpatientCodeEdit

http://www.cms.gov/OutpatientCodeEdit

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Effective Date

Edits Affected Modification

10/1/2015 2, 3, 86 Update diagnosis editing for ICD-10 diagnosis codes (see quarterly data files, Dx10Map):yy Removes age restrictions for specific newborn and pediatric diagnosis codes that are to be used

throughout the patient’s lifetime;yy Additions and removal of age edits for specific maternity diagnosis codes;yy Removes sex restriction for specific diagnosis codes currently restricted for female patients; andyy Additional codes added to the list of manifestation diagnosis codes.

1/1/2016 Implement new logic to identify pass-through drugs and biologicals present for payment offset; output each offset amount condition present with Payer Value codes QR, QS, QT and identify the pass-through drug or biological procedures for payment offset with new payment adjustment flag values (see OPPS special processing logic, Table 5, Table 7 and Appendix G).

1/1/2016 Implement new logic to identify terminated device intensive procedures reported with modifier 73; output the device portion amount with Payer Value code QQ and identify the device intensive procedure reported with modifier 73 with a payment adjustment flag (see OPPS special processing logic, Table 5, Table 7 and Appendix G).

1/1/2016 Implement new logic to identify device credit conditions for device intensive Ambulatory Payment Classifications (APCs) when Condition Code 49, 50 or 53 is present; output the device credit amount with Payer Value code QQ and identify the device intensive procedure with a payment adjustment flag (see OPPS special processing logic, Table 5, Table 7 and Appendix G).

4/1/2016 6, 91 Implement edit 91 for Rural Health Clinic (RHC) claims with bill type 71x to be returned if non-covered services are reported (see special processing logic for FQHC PPS claims, Appendix F (a) and Appendix M); update the description for edit 91 to include RHC. Implement edit 6 for RHC (see Appendix F (a)).

1/1/2016 Update the program logic for CT scan payment reduction when not meeting National Electrical Manufacturers Association (NEMA) standards to assign payment adjustment flag 14 to the multiple imaging composite APC line if CT modifier is not present but there are composite constituent codes present that do report modifier CT (see OPPS special processing logic and Appendix K).

1/1/2016 45 Update the logic for edit 45 to include criteria for inpatient separate procedures reported on the same claim as a comprehensive APC procedure with a Status Indicator (SI) = J1.

1/1/2016 Update Appendix L to include procedure codes with SI = C in the list of non-allowed procedures by SI for OPPS claims.

1/1/2016 Update the program logic for pass-through device payment offset to not provide the offset if the primary comprehensive APC procedure (SI = J1) is not paired with a pass-through device code present on the claim (see OPPS special processing logic and Appendix L).

1/1/2016 Update Appendix E with a note for setting the Payment Method Flag to 2 for laboratory codes with SI = Q4 that result in final assignment of SI = A.

1/1/2016 Update the program logic for comprehensive APC 5881 (inpatient procedure where patient expired) to correctly exclude services designated as comprehensive APC exclusions when reported on the same day when APC 5881 is assigned.

1/1/2015 Update program logic for comprehensive APC processing to recognize modifier 50 for comprehensive APC procedures that may be eligible for complexity adjustment (see Appendix L).

1/1/2016 Update the program logic for Grandfathered Tribal Federally Qualified Health Center (FQHC) claims to identify the single payable visit (payment indicator 14) for each day if the claim contains multiple days (see Appendix M).

1/1/2016 Update the program logic for Grandfathered Tribal FQHC claims to assign the composite adjustment flag only for the single payable visit for the day (see Appendix M).

1/1/2016 Modify the output of the Payer Value Code and Amount field to pass blanks for the Value Code label (QN-QW) and zero-fill the Amount portion of the field if conditions for payment offset are not present on the claim (see Table 5 of the I/OCE specifications).

Note: If conditions for edit 24 (Date out of OCE range) are present, Payer Value Code and Amount is blank (no zero-fill).


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Effective Date

Edits Affected Modification

1/1/2016 Add the following new Payer Value Codes to the field output (see Table 5): yy QP: Placeholder reserved for future use yy QQ: Terminated procedure with pass-through device OR condition for device credit presentyy QR: First APC pass-through drug or biological offsetyy QS: Second APC pass-through drug or biological offsetyy QT: Third APC pass-through drug or biological offset

Revise the following Payer Value Code descriptions:yy QN: First APC device offsetyy QO: Second APC device offset

1/1/2016 Add the following new Payment Adjustment Flag values (see Table 7 and Appendix G):yy 15: Placeholder reserved for future useyy 16: Terminated procedure with pass-through deviceyy 17: Condition for device credit present yy 18: Offset for first pass-through drug or biological yy 19: Offset for second pass-through drug or biological yy 20: Offset for third pass-through drug or biological

Revise the following Payment Adjustment Flag descriptions: yy 12: Offset for first device pass-through yy 13: Offset for second device pass-through

1/1/2016 Correction of the issue with the interactive PC IOCE product that caused claims to not complete processing to the output report when the pass-through device offset amount was greater than $999.99.

1/1/2016 The following clarifying information is added (no change to software program logic):yy Direct Referral logic to include J1 procedures (page 46) with the SI = T criteriayy Critical Care packaged ancillary codes (page 11): update SI values for codes subject to modifier 59

exception. yy Conditionally packaged laboratory codes (page 12): laboratory codes that are always packaged with SI

= N, and removal of SI J1 and J2 (comprehensive APCs) from list of OPPS services by SI under which laboratory codes with SI = Q4 are changed to SI = A for claims with bill type 13x.

11/24/2015 67 Add mid-quarter editing for Food and Drug Administration (FDA) approval of code 90653 (SI changed to L).4/13/2015 68 Add mid-quarter editing for NCD effective date for code G0475.4/1/2016 Update the following procedure lists for the release (see quarterly data files):

yy Procedures not recognized under OPPS (SI=B)yy Conditionally packaged laboratory services (SI=Q4)yy FQHC non-covered services- Device offset pairs- Device list (edit 92)yy Comprehensive APC exclusionsyy New pass-through drug and biological/APC offsetyy New device intensive procedures for terminated procedure and device credit (Value Code QQ)

4/1/2016 Make all HCPCS/APC/SI changes as specified by CMS (quarterly data files).4/1/2016 20, 40 Implement version 22.1 of the NCCI (as modified for applicable outpatient institutional providers).

Note: Readers should also read through the entire document and note the highlighted sections, which also indicate changes from the prior release of the software.


The official instruction, CR9553, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3483CP.pdf on the CMS website.





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Document History

Date of Change DescriptionMarch 23 The article was revised to reflect the revised CR9553, issued on March 22. In the article,

the transmittal number, issue date, and the Web address for accessing CR9553 are revised. In addition, a row was added to the table at the top of page 6 to show added editing for NCD effective date for code G0475.

March 14 Initial Issuance


Provider Contact Center (PCC) Training

Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs). The list below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will be closed for training.

Date PCC Training/ClosuresThursday, June 9, 2016 Thursday, June 23, 2016 8:00 a.m. – 10:00 a.m. Central Time

The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For additional information, go to http://www.cgsmedicare.com/hhh/index.html and click the “myCGS” button on the left side of the Web page.

For your reference, access the “Home Health & Hospice 2016 Holiday/Training Closure Schedule” at http://www.cgsmedicare.com/hhh/help/pdf/2016_holiday_schedule.pdf for a complete list of PCC closures.


Upcoming Educational Events

The CGS Provider Outreach and Education department offers educational events through webinars and teleconferences throughout the year. Registration for live events is required. For upcoming events, please refer to the Calendar of Events Home Health & Hospice Education Web page at http://www.cgsmedicare.com/hhh/education/Education.html. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.


http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

http://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

http://www.cgsmedicare.com/hhh/index.html

http://www.cgsmedicare.com/hhh/help/pdf/2016_holiday_schedule.pdf

http://www.cgsmedicare.com/hhh/education/Education.html

Documents

Medicare Bulletin - June 2016...Medicare Bulletin Jurisdiction 15 HOME HEALTH & HOSPICE Bold, italicized material is excerpted from the American Medical Association Current Procedural