2012-11 - National Government Services

A CMS Contracted Agent 

Medicare Monthly Review 

Issue No. MMR 2012-11 November 2012 

Contents 

National Government Services – Articles for Part A and Part B Providers Page 

Local Coverage Determinations and Article Revisions and Updates Effective November 2012 2 

National Government Services – Articles for Part A Providers Page 

Important Announcement for All Current HP EDC Mainframe Users in Illinois and Wisconsin 6 

Centers for Medicare & Medicaid Services – Articles for Part A and Part B Providers Page 

General Update to Chapter 15 of the Program Integrity Manual (PIM) - Part IX (MM8019) 10 

Influenza Vaccine Payment Allowances - Annual Update for 2012-2013 Season (MM8047 

Revised) 

16 

Annual Clotting Factor Furnishing Fee Update 2013 (MM8049) 19 

Reasonable Charge Update for 2013 for Splints, Casts, and Certain Intraocular Lenses (MM8051) 22 

2012-2013 Seasonal Influenza (Flu) Resources for Health Care Professionals (SE1242) 25 

Medicare Guidance Regarding Meningitis Outbreak (SE1246) 30 

Centers for Medicare & Medicaid Services – Articles for Part A Providers Page 

October 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.3 (MM8035) 34 

Centers for Medicare & Medicaid Services – Articles for Part B Providers Page 

New Waived Tests (MM8054) 38 

A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs 

(SE1229) 

43 

Correct Provider Billing of Line Item Rendering Physician on the Paper UB-04 Claims Form 

(SE1241) 

Contact Information can be found on our Web site at: http://www.NGSMedicare.com. 

Medicare policies can be accessed from the Medical Policy Center section of our Web site. Providers without access to the 

Internet can request hard copies from National Government Services. 

CPT five-digit c odes, descriptions, and o ther data only are c opyright 2013 American Medical Association. All Rights Reserved. 

No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice 

medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. Applicable 

FARS /DFARS c lauses apply. 

This bulletin should be shared with all health care practitioners and managerial members of the providers/suppliers staff. 

Bulletins issued during the last two years are available at no cost from our Web site at www.NGSMedicare.com. 

CPT codes and descriptors are only copyright 2013 American Medical Association (or such other date publication of CPT) 

The Medicare Monthly Review 1 MMR 2012-11, November 2012 

49

National Government Services Articles for Part A & B Providers 

Local Coverage Determinations and Article Revisions and Updates Effective 

November 2012 

New policy effective November 1, 2012: 

Combined Ovarian Cancer Biomarker Tests Local Coverage Determination (LCD) – L32589/A51802 

OVA-1 is an ovarian cancer blood test that is reported to detect ovarian cancer in a pelvic mass. It is an 

aggregation of five biomarkers, beta 2-microglobulin, apolipoprotein A-1, CA-125, transferrin and 

transthyretin. The Risk of Ovarian Malignancy Algorithm (ROMA), is another test which combines the 

same traditionally proven tumor marker, CA-125, with HE-4, human epidydimus protein 4, a relatively 

new protein marker produced by the over-expression of the gene WFDC2, and associated with epithelial 

ovarian neoplasia. At the present time, National Government Services does not find either the OVA-1 or 

the ROMA test to be superior in clinical value to the use of CA-125, a mucin family glycoprotein 

encoded by the MUC 16 gene, and found in over 90% of women with ovarian neoplasia. CA-125 has 

limited specificity; its use in the evaluation of women with a pelvic mass is covered per the National 

Coverage Determination (NCD) Tumor Antigen by Immunoassay-CA 125 (CMS IOM Publication 100-03, 

Medicare National Coverage Determinations (NCD) Manual, Section 190.28 [352 KB]). Broader use as a 

diagnostic test for symptoms of abdominal and pelvic discomfort remains controversial and noncovered. 

October Revisions: 

Self-Administered Drug Exclusion List – Medical Policy Article (R6) (A47846) 

Article published 10/11/2012 (R6): Certolizumab pegol, 1 mg (Cimzia ®) (J0718) has been moved from the 

excluded list to the non-excluded list effective 10/15/2012. 

Stretta Procedure (L26863) 

R6 (effective 10/11/2012): Annual LCD review per Centers for Medicare & Medicaid Services (CMS) 

Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 

13.4[C]. (233 KB) Content reviewed, and no changes required other than for minor formatting. No 

comment and notice periods required and none given. 

Stretta Procedure – Supplemental Instructions Article (SIA) (A46183) 

Article published October 2012: Annual review per CMS IOM Publication 100-08, Medicare Program 

Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) Content reviewed and detailed guidelines on ABN 

modifiers have been deleted and should be accessed from the CMS IOM Publication 100-04, Medicare 

Claims Processing Manual, Chapter 30. (1021 KB) Minor formatting changes were also made. 

November Revisions: 

Category III Current Procedural Terminology ® (CPT) Codes (L25275) 

R14 (effective 11/01/2012): A reconsideration request was received on July 19, 2012 for intravascular 

optical coherence tomography (coronary native vessel or graft) during diagnostic evaluation and/or 

therapeutic intervention, including imaging supervision, interpretation, and report; initial vessel (0291T) 

and intravascular optical coherence tomography (coronary native vessel or graft) during diagnostic 

evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report; 

each additional vessel (0292T). No changes were made in coverage. Sources were added to the “Sources 

of Information and Basis for Decision” section of the LCD. No comment and notice period required and 

none given. 


The Medicare Monthly Review 2 MMR 2012-11, November 2012

Category III CPT ® Code Coverage – Related to LCD L25275 (A46075) 

Article published November 2012: Based on a reconsideration request, CPT code 0191T has been added 

as payable when billed for patients with mild to moderate glaucoma on medication and performed with 

cataract surgery effective for dates of service 11/01/2012. International Classification of Diseases, Clinical 

Modification, 9th Revision (ICD-9-CM) codes, 365.71 and 365.72, should be reported to support medical 

necessity. Outdated information for CPT codes 0024T, +0049T, +0056T, 0088t and 01635T has been 

removed from the “Indications” section. In the “Other Comments” section sources have been added for 

CPT codes 0191T, 0245T-0248T, 0256T-0259T and 0295T-0298T. 

Category III CPT ® Codes – SIA (A44880) 

Article published November 2012: Detailed guidelines on ABN modifiers have been deleted and should 

be accessed from the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30. (1021 

KB) Minor template changes were made to reflect current template language. 

Colorectal Cancer Screening – Medical Policy Article (A50548) 

Article published November 2012: Revised the following coding guideline to include the specific CPT 

and Healthcare Common Procedure Coding System (HCPCS) codes: 

Claims for colorectal cancer screening services (CPT code 82270 and HCPCS codes G0104, G0105, 

G0106-26, G0120-26, G0121 and G0328) are payable under Medicare Part B in the following places 

of service: office (11), urgent care facility (20), outpatient hospital (22), hospital emergency room 

(23), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32) and 

independent clinic (49). 

Add the following coding guidelines for HCPCS codes G0106 and G0120 (global and technical 

component): 

o Claims for HCPCS codes G0106 and G0120 (global billing) are payable under Medicare Part B 

in the following places of service: office (11), urgent care facility (20) and independent clinic 

(49). 

o Claims for HCPCS codes G0106-TC and G0120-TC are payable under Medicare Part B in the 

following places of service: office (11), urgent care facility (20), independent clinic (49), 

federally qualified health center (50) and rural health clinic (72). 

o Detailed guidelines on ABN modifiers have been deleted and should be accessed from the 

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30. (1021 KB) 

Coverage and Billing FDG Positron Emission Tomography (PET) Scans – Medical Policy Article 

(A51614) 

Article published November 2012: The list of ICD-9 codes covered for both Initial treatment strategy and 

Subsequent treatment strategy (modifiers PI or PS) has been revised to remove ICD-9 codes 183.2-183.5 

and 183.9, to comply with the coverage defined in the CMS IOM Publication 100-03, Medicare National 

Coverage Determinations (NCD) Manual, Section 220.6.17, Part 4. (1.25 MB) These codes are now listed 

under the section for covered ICD-9 codes for Initial treatment strategy and Subsequent treatment 

strategy for Clinical research use (Modifiers PI or PS and QO). 

Denosumab (Prolia , Xgeva ) – Related to LCD L25820 (A50361) 

Article published November 2012: The “Indications” section has been revised to add Food & Drug 

Administration (FDA) approval for denosumab (Prolia ®) as a treatment to increase bone mass in men 

with osteoporosis at high risk for fracture defined as a history of osteoporotic fracture, or multiple risk 

factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy 

effective 09/02/2012. The “ICD-9 Codes that are Covered” paragraph section has been revised to include 

men in the language “for treatment to increase bone mass in postmenopausal women and men with 



osteoporosis at high risk for fracture or postmenopausal women and men with osteoporosis who have 

failed or are intolerant to other available osteoporosis therapy.” The “Documentaion and Utilization” 

requirements have also been revised to include men with osteoporosis. In the “Sources of Information” 

section the FDA label date for denosumab (Prolia ®) has been revised. 

Nerve Conduction Studies (NCS)/Electromyography (EMG) (L26869) 

R10 (effective 11/01/2012): The existing LCD was resubmitted to all National Government Services Part 

A, Part B, and Medicare Administrative Contractor (MAC) jurisdictions for public and Carrier Advisory 

Committee (CAC) comment from 05/10/2012 through 06/23/2012. Specific limitations for nerve 

conduction studies, CPT code 95905, have been added. The reference to the “American Board of Physical 

Therapy Specialists in Neurophysiology” has been corrected to read “American Board of Physical 

Therapy Specialist in Clinical Electrophysiology.” 

Nerve Conduction Studies (NCS)/Electromyography (EMG) – SIA (A51823) 

Article published November 2012: The existing LCD and SIA were resubmitted to all National 

Government Services Part A, Part B and MAC jurisdictions for public and CAC comment from 05/10/2012 

through 06/23/2012. Coding guidelines were revised to specify that CPT code 95905 should be used for 

any motor and/or sensory conduction study using a preconfigured electrode array, where electrode 

placement is not individualized to the patient’s unique anatomy, and to list codes which should not be 

billed with CPT code 95905. This article replaces article A50265, effective 11/01/2012. 

Nonvascular Extremity Ultrasound (L28178) 

R6 (effective 10/01/2012): Annual LCD review per CMS IOM Publication 100-08, Medicare Program 

Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) The entire LCD was reviewed. Removed obsolete 

explanatory note regarding CPT code 76880 from the “CPT/HCPCS Codes” section. Minor formatting 

and template changes were made. No comment and notice periods required and none given. 

Nonvascular Extremity Ultrasound – SIA (A48353) 

Article published November 2012: Annual review per CMS IOM Publication 100-08, Medicare Program 

Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) The entire article was reviewed. Detailed 

guidelines on ABN modifiers have been deleted and should be accessed from the CMS IOM Publication 

100-04, Medicare Claims Processing Manual, Chapter 30. (1021 KB) 

Removed obsolete references to CPT code 76880 from the following coding guidelines as well as the 

“CPT/HCPCS Codes” and “Other Comments” sections. Use CPT code 76942 when billing for ultrasonic 

guidance for needle biopsy. It would be inappropriate to use CPT code 76881 or 76882 in this situation. 

Claims for ultrasound of the extremity, CPT code 76881 or 76882, must be reported with the appropriate 

site modifier (LT or RT or both). Minor formatting and template changes were made. 

Outpatient Physical and Occupational Therapy Services (L26884) 

R15 (effective 11/01/2012): The existing LCD and SIA were resubmitted to all National Government 

Services Part A and Part B jurisdictions for public and CAC comment from 05/10/2012 through 

06/23/2012. Documentation requirements were revised to state that additional documentation of referring 

physician re-examination and re-evaluation in cases of therapy services that exceed the 90 day 

certification period or the therapy cap may be requested. References to Supportive Documentation 

Recommendations have been revised to refer to Supportive Documentation Requirements (at specified 

intervals) in the policy. A statement that Progress reports will be required every 5 visits where therapy 

exceeds the cap was added to Documentation Requirements. 



Outpatient Psychiatry and Psychology Services (L26895) 

R14 (effective 11/01/2012): The following paragraph has been removed from the “Indications” section 

under “Coverage Criteria:” 

Individualized Treatment Plan. Services must be prescribed by a physician and provided under an 

individualized written plan of treatment established by a physician after any needed consultation with 

appropriate staff members. The plan must state the type, amount, frequency, and duration of the 

services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only 

a few brief services will be furnished.) (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 

6, Section 70.1). 

No comment and notice periods required and none given. 

Ranibizumab (e.g., Lucentis) and Aflibercept (e.g., Eylea) – Related to LCD L25820 (A46091) 

Article published November 2012: The “Indications” section has been revised to include FDA approval 

of aflibercept for macular edema following central retinal vein occlusion (CRVO) effective for dates of 

service on or after 09/21/2012. The “Utilization” section has been revised to add recommended dosage 

information for aflibercept when used in the treatment of macular edema following retinal vein occlusion 

(CRVO). The “ICD-9 Codes that are Covered” section has been revised to separate the payable diagnoses 

for ranibizumab and aflibercept. ICD-9 code.362.83 billed along with ICD-9-CM code 362.35 has been 

added as payable diagnoses for aflibercept when billed for the treatment of macular edema following 

retinal vein occlusion (CRVO) effective for dates of service on or after 09/21/2012. 

Rituximab (Rituxan ®) (effective 2010) – Related to LCD L25820 (A49636) 

Article published November 2012: A reconsideration request was received for autoimmune encephalitis. 

No changes were made in coverage. Sources were added to the “Sources of Information” section of the 

article. 

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L28488) 

R8 (effective 11/01/2012): Annual LCD review per CMS IOM Publication 100-08, Medicare Program 

Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) The entire policy was reviewed and no changes 

required other than for minor formatting. No comment and notice required and none given. 

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) – Supplemental Instructions 

Article (A48003) 

Article published November 2012: Annual review per CMS IOM Publication 100-08, Medicare Program 

Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) Content reviewed and minor formatting changes 

made. Detailed guidelines on ABN modifiers have been deleted and should be accessed from the CMS 

IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30. 

Varicose Veins of the Lower Extremity, Treatment of (L25519) 

R8 (effective 11/01/2012): CPT code 76942 was removed from the “CPT/HCPCS Codes” section and in the 

explanatory note in the “ICD-9-CM Codes that Support Medical Necessity” section and replaced with 

CPT code 76937. Annual LCD review per CMS IOM Publication 100-08, Medicare Program Integrity 

Manual, Chapter 13, Section 13.4[C]. (233 KB) The entire LCD was reviewed. Minor template changes 

were made to reflect current template language. No comment and notice periods required and none 

given. 



Varicose Veins of the Lower Extremity, Treatment of – SIA (A44614) 

Article published November 2012: CPT code 76942 was removed from the “CPT/HCPCS Codes” section 

and in the coding guideline listed below and replaced with CPT code 76937. 

Coverage for CPT codes 76937, 93965, 93970 and 93971 is not limited to diagnoses described in the LCD 

Varicose Veins of the Lower Extremity, Treatment of (L25519). 

Due to a typographical error, CPT code 93770 was included in the “CPT/HCPCS Codes” section. The 

correct CPT code should be 93970. Annual LCD review per CMS IOM Publication 100-08, Medicare 

Program Integrity Manual, Chapter 13, Section 13.4[C]. (233 KB) The entire article was reviewed. Detailed 

guidelines on ABN modifiers have been deleted and should be accessed from the CMS IOM Publication 

100-04, Medicare Claims Processing Manual, Chapter 30. (1021 KB) Minor template changes were made to 

reflect current template language. 

National Government Services Articles for Part A Providers 

Important Announcement for All Current HP EDC Mainframe Users in Illinois and 

Wisconsin 

Impact: Part A Providers in Illinois and Wisconsin 

The HP EDC mainframe system is migrating from the current HP NETMENU to CA TPX. 

What is CA TPX? 

CA TPX (Terminal Productivity Executive) is an application that manages multiple virtual sessions 

concurrently on one workstation. TPX allows you to switch between many different sessions without 

having to sign on and off repeatedly. This quick reference article was created based on the information 

provided by HP. 

What Does This Mean to You? 

Part A providers who currently access the HP mainframe to submit and view claims using access option 2 

HP will access the mainframe using a different option, 5 HP TPX. This is a change in how to access the 

mainframe only; the actual mainframe screens are not changing due to this transition. You will use the 

same USER ID and password that you currently use for accessing the mainframe via option 2 HP and will 

continue to view only those menus and items that you already have security authorization to access. 

However, the HP EDC cannot guarantee that the HP CA TPX functionality will be identical to that used 

by CDS. 

When Should I Make This Change? 

The new option (5 HPTPX) is now available and you should make this change as soon as possible prior to 

December 2012. Please note that the mainframe access will permanently switch over to CA TPX by 

December 2012 in preparation for closing down option 2 HP. 

User IDs for 5 HP TPX 

User IDS and passwords used to access option 5 HP TPX are the same USER IDs and passwords currently 

in use for accessing the mainframe using option 2 HP. 

How Do You Get Started? 

Open the mainframe application just as you currently do. When you reach the first screen select “5 HP 

TPX” as illustrated below: 



Enter “5” in the area next to “Enter Request” (in place of 2) and select the “enter” key on your keyboard. 

You will reach the following screen where you can enter your USER ID and password. As a reminder, use 

the same USER ID and password that you currently use for accessing the mainframe using option 2 HP. 

When a valid USER ID and password are used, the CA TPX menu will appear (see example below) and 

will show only those applications that you currently have security authorization to access. 


The Medicare Monthly Review 7 MMR 2012-11, November 2012 

5

Your User ID 

For Example: ACPFA121 

The Session/Application Identifier (APPLID) is listed in the Session/Application Identifier (Sessid) 

Column. From the TPX Menu, enter the APPLID (from Sessid column) for the application you want to 

enter on the Command Line and select the enter key on your keyboard. 

Please refer to the HP EDC CA TPX User Reference Guide, available under “Manuals” on the National 

Government Services Web site for more detailed information. 

The HPTC list is available from the WPC. To view the October 2012 changes, visit the WPC Web site at 

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



Centers for Medicare & 

Medicaid Services 

Articles for Part A&B 

Providers

News Flash - 

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

REVISED product from the Medicare Learning Network® (MLN) 

• “Contractor Entities At A Glance: Who May Contact You About Specific Centers for 

Medicare & Medicaid Services (CMS) Activities,” Educational Tool, ICN 906983, 

Downloadable only. 

MLN Matters® Number: MM8019 Related Change Request (CR) #: CR 8019 

Related CR Release Date: October 19, 2012 Effective Date: November 20, 2012 

Related CR Transmittal #: R435PI Implementation Date: November 20, 2012 

General Update to Chapter 15 of the Program Integrity Manual (PIM) - Part IX 

Provider Types Affected 

This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to 

Medicare contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), 

carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries. 

What You Need to Know 

This article is based on Change Request (CR) 8019, which updates Chapter 15 of the Medicare 

Program Integrity Manual (PIM). That chapter deals with Medicare provider enrollment. The majority of 

the revisions are editorial in nature. However, there are several policy updates in this CR related to: 

• Correspondence addresses; 

• Out-of-state practice locations; 

• Submission of Change of Ownership (CHOW) applications after an initial or CHOW application 

has been submitted; and 

• The scope of revocations and re-enrollment bars. 

Disclaimer 

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to 

statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of 

either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and 

accurate statement of their contents. CPT only copyright 2011 American Medical Association. 

10 

Page 1 of 6

MLN Matters® Number: MM8019 Related Change Request Number: 8019 

Make sure that your enrollment staffs are aware of these manual updates. See the Background 

Section for more details on the policy changes. 

Background 

The key changes made to Chapter 15 of the PIM are as follows: 

Correspondence Addresses 

The correspondence address must be one where the Medicare contractor can contact the applicant to 

resolve any issues once the provider is enrolled in the Medicare program. It can be any address the 

provider chooses, including that of a billing agency, management services organization, chain home 

office, or the provider’s representative (e.g., attorney, financial advisor). The provider, however, 

remains ultimately responsible for all Medicare enrollment-related correspondence that the contractor 

sends to him/her/it at this address. For instance, if a provider uses its chain home office as the 

correspondence address, the provider is still the party responsible for replying to revalidation letters, 

requests for information, etc. 

Also, an e-mail address listed on your enrollment application can be a generic e-mail address. It need 

not be that of a specific individual. Note that the contractor may accept a particular e-mail address if it 

has no reason to suspect that it does not belong to or is not somehow associated with the provider. 

Out-of-State Practice Locations – Form CMS-855A 

If a provider is adding a practice location in another State that is within the provider’s current 

contractor’s jurisdiction, a separate, initial Form CMS-855A enrollment application is not required if the 

following 5 conditions are met: 

• The location is not part of a separate organization (e.g., a separate corporation, partnership); 

• The location does not have a separate Tax Identification Number (TIN) and Legal Business 

Name (LBN); 

• The State in which the new location is being added does not require the location to be 

surveyed; 

• The applicable Medicare Regional Office (RO) does not require the new location or its owner 

to sign a separate provider agreement; and 

• The location is not a Federally Qualified Health Center (FQHCs are required to separately 

enroll each site). 

Consider the following examples: 

1. The Medicare contractor’s jurisdiction consists of States X, Y and Z. Jones Skilled Nursing 

Facility (JSNF), Inc., is enrolled in State X with 3 sites. It wants to add a fourth site in State Y. 

The new site will be under JSNF, Inc. JSNF will not be establishing a separate corporation, 

LBN or TIN for the site, and - per the State and RO - a separate survey and provider 

agreement are not necessary. Since all 5 conditions above are met, JSNF can add the fourth 

location via a change of information request, rather than an initial application. The change 

Disclaimer 

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, 

regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law 

or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. 

CPT only copyright 2011 American Medical Association. 

11 

Page 2 of 6


request must include all information relevant to the new location (e.g., licensure, new 

managing employees). To the extent required, the contractor shall create a separate 

Provider Enrollment, Chain, and Ownership System (PECOS) enrollment record for the State 

Y location. 

2. The contractor’s jurisdiction consists of States X, Y and Z. JSNF, Inc., is enrolled in State X 

with 3 locations. It wants to add a fourth location in State Y but under a newly created, 

separate legal entity - JSNF, LP. The fourth location must be enrolled via a separate, initial 

Form CMS-855A. 

3. The contractor’s jurisdiction consists of States X, Y and Z. Jones Hospice (JH), Inc., is 

enrolled in State X with 1 location. It wants to add a second location in State Z under JH, Inc. 

However, it has been determined that a separate survey and certification of the new location 

are required. A separate, initial Form CMS-855A for the new location is required. 

Out-of-State Practice Locations – Form CMS-855B 

If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a 

separate, initial Form CMS-855B enrollment application is not required if the following 5 conditions are 

met: 

• The location is not part of a separate organization (e.g., a separate corporation, partnership); 


Name (LBN); 

• The State in which the new location is being added does not require the location to be 

surveyed; 

• The applicable RO does not require the new location or its owner to sign a separate supplier 

agreement; and 

• The location is not an Independent Diagnostic Testing Facility (IDTFs are required to 

separately enroll each site). 


1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., 

is enrolled in State X with 3 locations. It wants to add a fourth location in State Y. The new 

location will be under JGP, Inc. JGP will not be establishing a separate corporation, LBN or 

TIN for the fourth location. Since there is no State or RO involvement with group practices, 

all 5 conditions are met. JGP can add the fourth location via a change of information request, 

rather than an initial application. The change request must include all information relevant to 

the new location (e.g., licensure, new managing employees). To the extent required, the 

contractor shall create a separate enrollment record in the Provider Enrollment, Chain, and 

Ownership System (PECOS) for the State Y location. 


is enrolled in State X with 3 locations. It wants to add a fourth location in State Y, but under 

Disclaimer 





12 

Page 3 of 6


a newly created, separate entity - Jones Group Practice, LP. The fourth location must be 

enrolled via a separate, initial Form CMS-855B. 


is enrolled in State X with 3 locations. It wants to add a fourth location in State Q. Since State 

Q is not within the contractor’s jurisdiction, a separate initial enrollment for the fourth location 

is necessary. 

4. The contractor’s jurisdiction consists of States X, Y and Z. Jones Ambulatory Surgical Center 

(JASC), Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in State 

Z under JASC, Inc. However, it has been determined that a separate survey and certification 

of the new site are required. A separate, initial Form CMS-855B is therefore necessary. 

Out-of-State Practice Locations – Form CMS-855I 

If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a 

separate, initial Form CMS-855I enrollment application is not required if the following conditions are 

met: 

• The location is not part of a separate organization (e.g., a separate solely-owned corporation), 

and 


Name (LBN). 


1. The contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, a sole proprietor, is 

enrolled in State X with 2 locations. He wants to add a third location in State Y under his 

social security number and his sole proprietorship’s employer identification number. He can 

add the third location via a change of information request, rather than an initial application. 

The change request must include all information relevant to the new location (e.g., licensure). 

To the extent required, the contractor shall create a separate PECOS enrollment record for 

the State Y location. 

2. The contractor’s jurisdiction consists of States X, Y and Z. Dr. Jones, LLC (a solely-owned 

limited liability company) is enrolled in State X with 2 locations. Dr. Jones wants to add a third 

location in State Y but as a sole proprietorship, not as part of Dr. Jones, LLC. Since the new 

location is not part of the same organizational entity, it must be enrolled via a separate, initial 

Form CMS-855I. 

Submission of CHOW Applications after an Initial or CHOW Application 

has been Submitted 

(This section does not apply to Home Health Agencies) 

In situations where (1) the provider submits a Form CMS-855A initial application or CHOW application 

and (2) a Form CMS-855A CHOW application is subsequently submitted but before the Medicare 

contractor has received the tie-in notice from the RO, the contractor shall abide by the following: 

Disclaimer 





13 

Page 4 of 6


• Situation 1 – The provider submitted an initial application followed by a CHOW application, and a 

recommendation for approval has not yet been made with respect to the initial application – The 

contractor shall reject both applications and require the provider to re-submit an initial application 

with the new owner’s information. 

• Situation 2 – The provider submitted a CHOW application followed by another CHOW application, 

and a recommendation for approval has not been made for the first application – The contractor 

shall process both applications – preferably in the order in which they were received – and shall, 

if recommendations for approval are warranted, refer both applications to the State/RO in the 

same package. The accompanying notice/letter to the State/RO shall explain the situation. 

• Situation 3 – The provider submitted an initial application followed by a CHOW application, and a 

recommendation for approval of the initial application has been made – The contractor shall: 

1. Reject the CHOW application. 

2. Notify the State/RO via letter (sent via mail or e-mail) that there has been a change of 

ownership (the new owner should be identified) and that the contractor will be requiring the 

provider to resubmit a new initial application containing the new owner’s information. 

3. Request via letter that the provider submit a new initial Form CMS-855A application 

containing the new owner’s information within 30 days of the date of the letter. If the provider 

fails to do so, the contractor shall reject the initial application and notify the provider and the 

State/RO of this via letter. If the provider submits the application, the contractor shall process 

it as normal and, if a recommendation for approval is made, send the revised application 

package to the State/RO with an explanation of the situation; the initially submitted application 

becomes moot. If the newly submitted application is denied, however, the initially submitted 

application is denied as well; the contractor shall notify the provider and the State/RO 

accordingly. 

• Situation 4 – The provider submitted a CHOW application followed by another CHOW application, 

and a recommendation for approval has been made for the first application – The contractor 

shall: 

1. Notify the State/RO via e-mailed letter that a CHOW application has been submitted (the new 

owner should be identified) and that the contractor will be requiring the provider to resubmit a 

new initial application containing the new owner’s information. 

2. Process the new CHOW application as normal. If a recommendation for approval is made, the 

contractor shall send the revised CHOW package to the State/RO with an explanation of the 

situation; the first CHOW application becomes moot. If the newly submitted CHOW 

application is denied, the first application is denied as well; the contractor shall notify the 

provider and the State/RO accordingly. 

Disclaimer 





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Scope of Revocation and Reenrollment Bar 

A chart has been added to chapter 15 of the PIM that outlines the extent to which (1) a particular 

revocation generally applies to the provider’s other locations and (2) the re-enrollment bar applies. 

The chart is in Section 15.27.2.F of that chapter. 

Additional Information 

The official instruction, CR8019, issued to your FI, RHHI, carrier and A/B MAC regarding this change, 

may be viewed at http://www.cms.hhs.gov/Regulations-and- 

Guidance/Guidance/Transmittals/Downloads/R435PI.pdf on the CMS website. The entire revised 

Chapter 15 of the PIM is attached to that CR. 

If you have any questions, please contact your FI, RHHI, carrier or A/B MAC at their toll-free number, 

which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 

Programs/provider-compliance-interactive-map/index.html on the CMS website. 

News Flash - Vaccination is the Best Protection Against the Flu — Influenza Vaccine Prices Are 

Now Available. Each office visit is an opportunity to check your patients’ seasonal influenza (flu) and 

pneumonia immunization status and to start protecting your patients as soon as your 2012-2013 

seasonal flu vaccine arrives. Ninety percent of flu-related deaths and more than half of flu-related 

hospitalizations occur in people age 65 and older. Seniors also have an increased risk of getting 

pneumonia, a complication of the flu. Remind your patients that seasonal flu vaccinations and a 

pneumococcal vaccination are recommended for optimal protection. Medicare provides coverage for 

one seasonal influenza virus vaccine per influenza season for all Medicare beneficiaries. Medicare 

generally provides coverage of pneumococcal vaccination and its administration once in a lifetime for 

all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal vaccinations 

based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides 

coverage for these vaccines and their administration with no co-pay or deductible. And don’t forget to 

immunize yourself and your staff. Know what to do about the flu. 

Remember – Influenza vaccine plus its administration and pneumococcal vaccine plus its 

administration are covered Part B benefits. Influenza vaccine and pneumococcal vaccine are NOT 

Part D-covered drugs. CMS has posted the 2012-2013 Seasonal Influenza Vaccines Pricing. You 

may also refer to the MLN Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - 

Annual Update for 2012-2013 Season.” 

For more information on coverage and billing of the flu vaccine and its administration, please visit the 

CMS Medicare Learning Network® Preventive Services Educational Products and CMS 

Immunizations web pages. And, while some providers may offer the flu vaccine, others can help 

their patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a 

free, online service where users can search for locations offering flu vaccines. 

Disclaimer 





15 

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News Flash – 



NEW product from the Medicare Learning Network® (MLN) 

“Communicating With Your Medicare Patients”, Fact Sheet, ICN 908063, Downloadable 

MLN Matters® Number: MM8047 Revised Related Change Request (CR) #: CR 8047 

Related CR Release Date: October 3, 2012 Effective Date: August 1, 2012 

Related CR Transmittal #: R2562CP Implementation Date: No later than December 28, 2012 

Note: This article was revised on October 4, 2012, to reflect a revised Change Request (CR) 8047 that was 

released on October 3, 2012. The revised CR changed the implementation date to "No later than December 

28, 2012." The Transmittal Number, CR date and the web link to the CR was also changed. All other 

information remains unchanged. 

Influenza Vaccine Payment Allowances - Annual Update for 2012-2013 Season 


This MLN Matters® Article is intended for physicians and providers submitting claims to Medicare 

contractors (carriers, Fiscal Intermediaries (FIs), and Part A/B Medicare Administrative Contractors 

(A/B MACs)) for influenza vaccines provided to Medicare beneficiaries. 

Provider Action Needed 

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8047 in order to 

update payment allowances, effective August 1, 2012, for seasonal influenza virus vaccines when 

payment is based on 95 percent of the Average Wholesale Price (AWP). Be sure your billing staffs are 

aware of this update. 

Disclaimer 





16 

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Background 

CR8047 provides payment allowances for the following seasonal influenza virus vaccine codes when 

payment is based on 95 percent of the AWP (except for when payment is based on reasonable cost 

where the vaccine is furnished in a hospital outpatient department, a Rural Health Clinic, or a 

Federally Qualified Health Center): 

• Current Procedural Terminology (CPT) codes 90654, 90655, 90656, 90657, 90660, and 

90662; and 

• Healthcare Common Procedure Coding System (HCPCS) codes Q2034, Q2035, Q2036, 

Q2037, and Q2038. 

Effective for dates of service on or after August 1, 2012, the Medicare Part B payment allowance for: 

• CPT 90655 is $16.456 

• CPT 90656 is $12.398 

• CPT 90657 is $6.023 

• HCPCS Q2035 (Afluria®) is $11.543 

• HCPCS Q2036 (Flulaval®) is $9.833 

• HCPCS Q2037 (Fluvirin®) is $14.051 

• HCPCS Q2038 (Fluzone®) is $12.046 

Note: The Medicare Part B payment allowance for HCPCS Q2034 (Agriflu®) and HCPCS Q2039 (Flu 

Vaccine Adult - Not Otherwise Classified) will be determined by the local claims processing contractor. 

Payment for the following may be made if the local claims processing contractor determines its use is 

medically reasonable and necessary for the beneficiary: 

• CPT 90654 (Flu vaccine, Intradermal, Preservative free (Fluzone ID®)); 

• CPT 90660 (FluMist®, a nasal influenza vaccine); or 

• CPT 90662 (Fluzone High-Dose®). 

Effective for dates of service on or after August 1, 2012, when payment is based on 95 percent of the 

AWP, the Medicare Part B payment allowance for: 

• CPT 90654 is $18.981 

• CPT 90660 is $23.456 

• CPT 90662 is $30.923 

Disclaimer 





17 

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The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP and are 

updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug Pricing Files. 

Note: Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician 

practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal 

vaccination must take assignment on the claim for the vaccine. 

Medicare contractors will not search their files to either retract payment for claims already paid or to 

retroactively pay claims. However, contractors will adjust claims brought to their attention. 


The official instruction, CR8047, issued to your Medicare contractor (carrier, (FI), and A/B MAC) 

regarding this change, may be viewed at http://www.cms.hhs.gov/Regulations-and- 

Guidance/Guidance/Transmittals/Downloads/R2562CP.pdf on the CMS website. 

If you have any questions, please contact your carrier, (FI), or A/B MAC at their toll-free number, 



News Flash - Vaccination is the Best Protection Against the Flu ‐ Each office visit is an opportunity to check 

your patients’ seasonal influenza (flu) and pneumonia immunization status and to start protecting your 

patients as soon as your 2012‐2013 seasonal flu vaccine arrives. Ninety percent of flu‐related deaths and 

more than half of flu‐related hospitalizations occur in people age 65 and older. Seniors also have an 

increased risk of getting pneumonia, a complication of the flu. Remind your patients that seasonal flu 

vaccinations and a pneumococcal vaccination are recommended for optimal protection. 

Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all Medicare 

beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its administration once 

in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal 

vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides 

coverage for these vaccines and their administration with no co-pay or deductible. Also, don’t forget to 

immunize yourself and your staff. Know what to do about the flu. 

Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a 

Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine prices when 

they are available. For more information on coverage and billing of the flu vaccine and its administration, 

please visit the CMS Medicare Learning Network® Preventive Services Educational Products and CMS 

Immunizations web pages. While some providers may offer the flu vaccine, others can help their patients 

locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free, online service 

where users can search for locations offering flu vaccines. 

Disclaimer 





18 

Page 3 of 3



News Flash – The ICD-10-related implementation date is now October 1, 2014, as announced in final 

rule CMS-0040-F issued on August 24, 2012. This final rule is available at 

http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html on the Centers for 

Medicare & Medicaid Services (CMS) website. The switch to the new code set will affect every aspect of 

how your organization provides care, but with adequate planning and preparation, you can ensure a 

smooth transition for your practice. Keep Up to Date on ICD-10. Please visit the ICD-10 website for the 

latest news and resources to help you prepare. 

MLN Matters® Number: MM8049 Related Change Request (CR) #: 8049 

Related CR Release Date: September 28, 2012 Effective Date: January 1, 2013 

Related CR Transmittal #: R2554CP 

Implementation Date: January 7, 2013 

Annual Clotting Factor Furnishing Fee Update 2013 


This MLN Matters® Article is intended for physicians and other providers billing Medicare Carriers, Fiscal 

Intermediaries (FIs), Part A/B Medicare Administrative Contractors (MACs), or Regional Home Health 

Intermediaries (RHHIs) for services related to the administration of clotting factors to Medicare 

beneficiaries. 


This article is based on Change Request (CR) 8049 and announces that for Calendar Year 2013, the 

clotting factor furnishing fee of $0.188 per unit is included in the published payment limit for clotting factors. 

For dates of service in 2013, the clotting factor furnishing fee of $0.188 per unit is added to the payment 

when no payment limit for the clotting factor is included in the Average Sales Price (ASP) or Not Otherwise 

Classified (NOC) drug pricing files. Please be sure your billing staffs are aware of this fee update. 

Disclaimer 





19 

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Background 

Section 1842(o)(5)(C) of the Social Security Act (added by the Medicare Modernization Act Section 

303(e)(1)) requires, beginning January 1, 2005, that a clotting factor furnishing fee be paid separately if 

you furnish clotting factor; unless the costs associated with furnishing the clotting factor are paid through 

another payment system. 

The Centers for Medicare & Medicaid Services (CMS) includes the clotting factor furnishing fee in the 

published national payment limits for clotting factor billing codes. When the national payment limit for a 

clotting factor is not included on the ASP Medicare Part B Drug Pricing File, or the NOC Pricing File; your 

carrier, FI, RHHI, or A/B MAC must make payment for the clotting factor as well as make payment for the 

furnishing fee. 

The clotting factor furnishing fees applicable for dates of service in each Calendar Year (CY) are listed 

below: 


Clotting Factor Furnishing Fee 

CY 2005 $0.140 per unit 

CY 2006 $0.146 per unit 

CY 2007 $0.152 per unit 

CY 2008 $0.158 per unit 

CY 2009 $0.164 per unit 

CY 2010 $0.170 per unit 

CY 2011 $0.176 per unit 

CY 2012 $0.181 per unit 

CY2013 $0.188 per unit 

The official instruction, CR 8049 issued to your Medicare Carrier, FI, RHHI, or A/B MAC regarding this 

change may be viewed http://www.cms.gov/Regulations-and- 


If you have any questions, please contact your carrier, FI, RHHI, or A/B MAC at their toll-free number, 



Disclaimer 





20 

Page 2 of 3


News Flash - As your patients age, their immune systems may weaken. This weakening can make seniors more 

susceptible to complications from seasonal influenza (flu). Now is the perfect time to remind your patients that seasonal 

influenza vaccination is the best defense against the flu. Medicare provides coverage for one flu vaccine and its 

administration per influenza season for seniors and other Medicare beneficiaries with no co-pay or deductible. Talk with 

your Medicare patients about their risk for getting the flu and start protecting your patients as soon as your 2012-2013 

seasonal flu vaccine arrives. Also, don’t forget to immunize yourself and your staff. Know what to do about the flu. 

Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza vaccine is NOT a 

Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine prices when they are 

available. 

For more information on coverage and billing of the flu vaccine and its administration, please visit the CMS Medicare 

Learning Network® Preventive Services Educational Products and CMS Immunizations web pages. While some 

providers may offer the flu vaccine, others can help their patients locate a vaccine provider within their local community. 

HealthMap Vaccine Finder is a free, online service where users can search for locations offering flu vaccines. 

Disclaimer 





21 

Page 3 of 3



News Flash – Registration is now open to all suppliers interested in participating in the Round 1 

Recompete of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 

(DMEPOS) Competitive Bidding Program. In order to submit a bid for the Round 1 Recompete, you must 

first register in the Individuals Authorized Access to the CMS Computer Services (IACS) online 

application. Once you have registered in IACS, you will receive a user ID and password to access the 

online DMEPOS Bidding System (DBidS).You must register even if you registered during a previous 

round of competition (Round 1 Rebid, Round 2, or the national mail-order competition). Only suppliers 

who have a user ID and password will be able to access DBidS; suppliers that do not register will not be 

able to bid. Registration for the recompete will close on Friday, October 19, 2012, at 9pm prevailing 

Eastern Time. To register, go to the Competitive Bidding Implementation Contractor (CBIC) website 

found at http://www.dmecompetitivebid.com on the Internet. Click on Round 1 Recompete, and 

then click on "REGISTRATION IS OPEN” above the Registration clock. If you have any questions about 

the registration process, please contact the CBIC Customer Service Center at 877-577-5331 between 

9am and 9pm, Eastern Time, Monday through Friday. 


Related CR Release Date: October 12, 2012 Effective Date: January 1, 2013 

Related CR Transmittal #: R2565CP Implementation Date: January 7, 2013 

Reasonable Charge Update for 2013 for Splints, Casts, and Certain Intraocular 

Lenses 


This MLN Matters® Article is intended for physicians, providers, and suppliers billing Medicare 

contractors (Fiscal Intermediaries (FIs), carriers, and A/B Medicare Administrative Contractors 

(MACs)) for splints, casts, and certain intraocular lenses provided to Medicare beneficiaries. 

Disclaimer 





22 

Page 1 of 3



This article, based on Change Request (CR) 8051, instructs Medicare contractors regarding the 

calculation of reasonable charges for payment of claims for splints, casts, and intraocular lenses 

furnished in Calendar Year (CY) 2013. 

Background 

Payment continues to be made on a reasonable charge basis for splints and casts, as well as 

intraocular lenses implanted in a physician's office. 

• For splints and casts, the Q-codes are to be used when supplies are indicated for cast and 

splint purposes. This payment is in addition to the payment made under the physician fee 

schedule for the procedure for applying the splint or cast. 

• For intraocular lenses, payment is only made on a reasonable charge basis for lenses 

implanted in a physician's office (codes V2630, V2631, and V2632). 

The 2013 payment limits for splints and casts will be based on the 2012 limits that were announced in 

CR7628 last year, increased by 1.7 percent, the percentage change in the CPI-U for the 12-month 

period ending June 30, 2012. (You may view the article related to CR7628 at 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- 

MLN/MLNMattersArticles/downloads//MM7628.pdf on the Centers for Medicare & Medicaid 

Services (CMS) website.) The IIC update factor for 2013 is 1.7 percent. 

A list of the 2013 payment limits for splints and casts is as follows: 

2013 Payment Limits for Splints and Casts 

A4565 $8.26 Q4013 $15.13 Q4026 $113.30 Q4039 $7.91 

Q4001 $47.00 Q4014 $25.51 Q4027 $18.15 Q4040 $19.77 

Q4002 $177.62 Q4015 $7.57 Q4028 $56.67 Q4041 $19.20 

Q4003 $33.75 Q4016 $12.75 Q4029 $27.75 Q4042 $32.78 

Q4004 $116.86 Q4017 $8.75 Q4030 $73.05 Q4043 $9.61 

Q4005 $12.45 Q4018 $13.94 Q4031 $13.87 Q4044 $16.39 

Q4006 $28.05 Q4019 $4.38 Q4032 $36.52 Q4045 $11.15 

Q4007 $6.23 Q4020 $6.98 Q4033 $25.88 Q4046 $17.93 

Q4008 $14.02 Q4021 $6.47 Q4034 $64.38 Q4047 $5.56 

Q4009 $8.31 Q4022 $11.68 Q4035 $12.94 Q4048 $8.97 

Q4010 $18.70 Q4023 $3.25 Q4036 $32.20 Q4049 $2.03 

Q4011 $4.15 Q4024 $5.84 Q4037 $15.79 

Q4012 $9.36 Q4025 $36.29 Q4038 $39.56 

Medicare contractors will make payments for splints and casts furnished in 2013 based on the lower of 

the actual charge or the above payment limits. 

Disclaimer 





23 

Page 2 of 3



The official instruction, CR8015, issued to your FI, carrier, and A/B MAC regarding this change, may 

be viewed at http://www.cms.hhs.gov/Regulations-and- 


If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, which 

may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 


News Flash - Vaccination is the Best Protection Against the Flu - Each office visit is an opportunity to 

check your patients’ seasonal influenza (flu) and pneumonia immunization status and to start 

protecting your patients as soon as your 2012-2013 seasonal flu vaccine arrives. Ninety percent of flurelated 

deaths and more than half of flu-related hospitalizations occur in people age 65 and older. 

Seniors also have an increased risk of getting pneumonia, a complication of the flu. Remind your 

patients that seasonal flu vaccinations and a pneumococcal vaccination are recommended for optimal 

protection. 

Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all 

Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its 

administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of 

additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal 

vaccination status. Medicare provides coverage for these vaccines and their administration with no copay 

or deductible. Also, don’t forget to immunize yourself and your staff. Know what to do about the 

flu! 

Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza 

vaccine is NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013 

Influenza Vaccine prices when they are available. For more information on coverage and billing of the 

flu vaccine and its administration, please visit the CMS Medicare Learning Network® Preventive 

Services Educational Products and CMS Immunizations web pages. While some providers may 

offer the flu vaccine, others can help their patients locate a vaccine provider within their local 

community. HealthMap Vaccine Finder is a free, online service where users can search for locations 

offering flu vaccines. 

Disclaimer 





24 

Page 3 of 3

News Flash - 



NEW products from the Medicare Learning Network® (MLN) 

• “Providing the Annual Wellness Visit (AWV),” Booklet, ICN 907786, Downloadable 

MLN Matters® Number: SE1242 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 

2012-2013 Seasonal Influenza (Flu) Resources for Health Care Professionals 


All Medicare fee-for-service (FFS) physicians, non-physician practitioners, providers, suppliers, and 

other health care professionals who order, refer, or provide seasonal flu vaccines and vaccine 

administration provided to Medicare beneficiaries 


• Keep this Special Edition MLN Matters article and refer to it throughout the 2012 - 2013 flu 

season. 

• Take advantage of each office visit as an opportunity to encourage your patients to protect 

themselves from the seasonal flu and serious complications by getting a seasonal flu shot. 

Disclaimer 





25 

Page 1 of 5

MLN Matters® Number: SE1242 Related Change Request Number: N/A 

• Continue to provide the seasonal flu shot as long as you have vaccine available, even after the 

new year. 

• Don’t forget to immunize yourself and your staff. 

Introduction 

Annual outbreaks of seasonal flu typically occur as early as October and as late as May, with peak 

months in January and February. Illness from seasonal flu usually lasts one to two weeks, and flurelated 

complications include pneumonia and dehydration. Approximately 5 to 20 percent of 

Americans catch the seasonal flu each year. Getting the flu vaccine is your best protection against 

the flu. 1 

The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that 

Medicare Part B reimburses health care providers for seasonal flu vaccines and their administration. 

(Medicare provides coverage of the seasonal flu vaccine without any out-of-pocket costs to the 

Medicare patient. No deductible or copayment/coinsurance applies.) 

Protect You and Your Family From the Flu! 

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious 

complications by using every office visit as an opportunity to recommend they take advantage of the 

annual seasonal flu shot benefit covered by Medicare. And don’t forget, health care providers and 

their staff can spread the highly contagious flu virus to their patients. Don’t forget to immunize 

yourself and your staff. 

Educational Products for Health Care Professionals 

CMS has developed a variety of educational resources to help Medicare FFS health care 

professionals understanding coverage, coding, billing, and reimbursement guidelines for seasonal flu 

vaccines and their administration. 

1. MLN Seasonal Influenza Related Products for Health Care Professionals 

• MLN Matters Article MM8047: Influenza Vaccine Payment Allowances – Annual Update 

for 2012-2013 Season – This article contains the payment allowances for the 2012-2013 flu 

season. You can download it at http://www.cms.gov/Outreach-and-Education/Medicare- 

Learning-Network-MLN/MLNMattersArticles/Downloads/MM8047.pdf on the CMS 

website. 

1 Flu.gov. 2012. Seasonal Flu [online]. Washington D.C.: The U.S. Department of Health and Human Services, 2010 [cited 3 

October 2012]. Available from the World Wide Web: http://www.flu.gov/about_the_flu/seasonal/index.html 

Disclaimer 





26 

Page 2 of 5


• Quick Reference Information: Medicare Part B Immunization Billing - This educational 

tool is designed to provide education on Medicare-covered preventive immunizations. 

Available in print and as a downloadable PDF at http://www.cms.gov/Outreach-and- 

Education/Medicare-Learning-Network- 

MLN/MLNProducts/downloads/qr_immun_bill.pdf on the CMS website. 

• Quick Reference Information: Preventive Services - This educational tool is designed to 

provide education on the Medicare-covered preventive services. Available as a downloadable 

PDF at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- 

MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf on the CMS website. 

• Preventive Immunizations – This booklet is designed to provide education on the seasonal 

influenza, pneumococcal, and Hepatitis B vaccines. Available as a downloadable PDF at 


MLN/MLNProducts/Downloads/Preventive-Immunizations-ICN907787.pdf on the CMS 

website. 

• MLN Preventive Services Educational Products Web Page - This Medicare Learning 

Network ® (MLN) web page provides descriptions of all MLN preventive services related 

educational products and resources designed specifically for use by Medicare FFS health 

care professionals. View this page at http://www.cms.gov/Outreach-and- 

Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html on 

the CMS website. 

• Preventive Services Educational Products PDF – This PDF provides a list of all MLN 

products related to Medicare-covered preventive services. View this PDF at 


MLN/MLNProducts/downloads/education_products_prevserv.pdf on the CMS website. 

2. Other CMS Resources 

• Seasonal Influenza Vaccines 2012 Pricing is at http://www.cms.gov/Medicare/Medicare- 

Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2012ASPFiles.html on the 

CMS website. 

• Immunizations web page is at 

http://www.cms.gov/Medicare/Prevention/Immunizations/index.html on the CMS website. 

• Prevention General Information is at 

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html on the CMS 

website. 

• CMS Frequently Asked Questions are available at http://questions.cms.gov/faq.php on 

the CMS website. 

Disclaimer 





27 

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• Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations available 

at http://www.cms.gov/Regulations-and- 

Guidance/Guidance/Manuals/downloads/bp102c15.pdf on the CMS website. 

• Medicare Claims Processing Manual – Chapter 18, Preventive and Screening Services 

available at http://www.cms.gov/Regulations-and- 

Guidance/Guidance/Manuals/downloads/clm104c18.pdf on the Internet. 

3. Other Resources 

The following non-CMS resources are just a few of the many available in which clinicians may find 

useful information and tools to help increase seasonal flu vaccine awareness and utilization during 

the 2012 – 2013 flu season: 

• Advisory Committee on Immunization Practices are at 

http://www.cdc.gov/vaccines/recs/acip/default.htm on the Internet. 

• American Lung Association’s Influenza (Flu) Center is at http://www.lungusa.org on the 

Internet. This website provides a flu clinic locator at http://www.flucliniclocator.org on the 

Internet. Individuals can enter their zip code to find a flu clinic in their area. Providers can also 

obtain information on how to add their flu clinic to this site. 

• Other sites with helpful information include: 

• Centers for Disease Control and Prevention - http://www.cdc.gov/flu; 

• Flu.gov - http://www.flu.gov; 

• Food and Drug Administration - http://www.fda.gov; 

• Immunization Action Coalition - http://www.immunize.org; 

• Indian Health Services - http://www.ihs.gov/; 

• National Alliance for Hispanic Health - http://www.hispanichealth.org; 

• National Foundation For Infectious Diseases - http://www.nfid.org/influenza; 

• National Library of Medicine and NIH Medline Plus - 

http://www.nlm.nih.gov/medlineplus/immunization.html; 

• National Network for Immunization Information - http:/www.immunizationinfo.org; 

• National Vaccine Program - http://www.hhs.gov/nvpo; 

• Office of Disease Prevention and Health Promotion - 

http://odphp.osophs.dhhs.gov; 

• Partnership for Prevention - http://www.prevent.org; and 

Disclaimer 





28 

Page 4 of 5


• World Health Organization - http://www.who.int/en on the Internet. 

Beneficiary Information 

For information to share with your Medicare patients, please visit http://www.medicare.gov on the 

Internet. 

News Flash - Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for 

all Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its 

administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional 

pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. 

Medicare provides coverage for these vaccines and their administration with no co-pay or deductible. Also, 

don’t forget to immunize yourself and your staff. Know what to do about the flu. 

Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a 

Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine prices when 

they are available. For more information on coverage and billing of the flu vaccine and its administration, 

please visit the CMS Medicare Learning Network® Preventive Services Educational Products and CMS 

Immunizations web pages. While some providers may offer the flu vaccine, others can help their patients 

locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free, online service 

where users can search for locations offering flu vaccines. 

Disclaimer 





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News Flash - 


“Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & 

Medicaid Services (CMS) Activities,” Educational Tool, ICN 906983, Downloadable 

MLN Matters® Number: SE1246 Related Change Request (CR) #: Not Applicable 



Medicare Guidance Regarding Meningitis Outbreak 


This MLN Matters® Special Edition Article is intended for physicians, providers and suppliers 

submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Durable Medical 

Equipment Medicare Administrative Contractors (DME MACs) and A/B Medicare 

Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries. 


STOP – Impact to You 

The Centers for Medicare & Medicaid Services (CMS) is providing direction to Medicare contractors 

based on the Centers for Disease Control and Prevention’s (CDC) interim treatment guidance for 

Central Nervous System (CNS). This guidance is also related to parameningeal infections and septic 

arthritis associated with contaminated steroid products produced by the New England Compounding 

Center (NECC). This guidance is available on the CDC website at 

http://www.cdc.gov/hai/outbreaks/clinicians/index.html on the Internet. 

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CAUTION – What You Need to Know 

The CDC recommends diagnostic and therapeutic activities for symptomatic patients. Therefore, CMS 

believes that, aside from oral drugs, items and services to diagnose and treat patients who have 

received contaminated medications qualify for the Medicare Part A or Part B benefit. 

CMS urges all Medicare contractors to review the CDC website at 

http://www.cdc.gov/hai/outbreaks/clinicians/faq_meningitis_outbreak.html regularly for updates 

and specific actions they should take to ensure timely access to CDC recommended items and 

services. 

Due to the severity of this situation, CMS advises providers that Medicare contractors are expected to 

expedite all coverage determination requests for these items and services to include antifungal 

medication. 

The CDC has identified the following states as having received potentially-contaminated steroid 

products: 

California Michigan Pennsylvania 

Connecticut Minnesota Rhode Island 

Florida Nevada South Carolina 

Georgia New Hampshire Tennessee 

Idaho New Jersey Texas 

Illinois New York Virginia 

Indiana North Carolina West Virginia 

Maryland Ohio 

While clinics in these states received contaminated products, patients in additional states may be 

affected. Check the CDC’s Multistate Fungal Meningitis Outbreak Investigation web page regularly for 

the latest news and information about the outbreak. The website is available at: 

http://www.cdc.gov/hai/outbreaks/clinicians/faq_meningitis_outbreak.html on the Internet. 

GO – What You Need to Do 

Make sure that your medical and billing staffs are aware of this guidance. 


If you have any questions, please contact your FI, carrier, DME MAC or A/B MAC at their toll-free 

number, which may be found at http://www.cms.gov/Research-Statistics-Data-and- 

Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS 

website. 

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Vaccination is the Best Protection Against the Flu — Influenza Vaccine Prices Are Now Available [↑] 

Each office visit is an opportunity to check your patients’ seasonal influenza (flu) and pneumonia immunization 

status and to start protecting your patients as soon as your 2012-2013 seasonal flu vaccine arrives. Ninety 

percent of flu-related deaths and more than half of flu-related hospitalizations occur in people age 65 and 

older. Seniors also have an increased risk of getting pneumonia, a complication of the flu. Remind your 

patients that seasonal flu vaccinations and a pneumococcal vaccination are recommended for optimal 

protection. Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all 

Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its 

administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional 

pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination 

status. Medicare provides coverage for these vaccines and their administration with no co-pay or 

deductible. And don’t forget to immunize yourself and your staff. Know what to do about the flu. 

Remember – Influenza vaccine plus its administration and pneumococcal vaccine plus its administration are 

covered Part B benefits. Influenza vaccine and pneumococcal vaccine are NOT Part D-covered drugs. CMS 

has posted the 2012-2013 Seasonal Influenza Vaccines Pricing. You may also refer to the MLN Matters® 

Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 2012-2013 Season.” 

For more information on coverage and billing of the flu vaccine and its administration, please visit the CMS 

Medicare Learning Network® Preventive Services Educational Products and CMS Immunizations web 

pages. And, while some providers may offer the flu vaccine, others can help their patients locate a vaccine 

provider within their local community. HealthMap Vaccine Finder is a free, online service where users can 

search for locations offering flu vaccines. 

Disclaimer 





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Articles for Part A 

Providers



News Flash – The ICD-10-related implementation date is now October 1, 2014, as announced in final 

rule CMS-0040-F issued on August 24, 2012. This final rule is available at 

http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html on the Centers for 

Medicare & Medicaid Services (CMS) website. The switch to the new code set will affect every aspect of 

how your organization provides care, but with adequate planning and preparation, you can ensure a 

smooth transition for your practice. Keep Up to Date on ICD-10. Please visit the ICD-10 website for the 

latest news and resources to help you prepare. 


Related CR Release Date: August 31, 2012 Effective Date: October 1, 2012 

Related CR Transmittal #: R2540CP Implementation Date: October 1, 2012 

October 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 

13.3 


This MLN Matters® Article is intended for providers submitting claims to Medicare contractors (Fiscal 

Intermediaries (FIs), Medicare Administrative Contractors (MACs), and/or Regional Home Health 

Intermediaries (RHHIs)) for outpatient services provided to Medicare beneficiaries that are paid under 

the Outpatient Prospective Payment System (OPPS) and also for outpatient claims from any non- 

OPPS provider not paid under the OPPS, and for claims for limited services provided by a home 

health agency not under the Home Health Prospective Payment System, or for claims for services to a 

hospice patient for the treatment of a non-terminal illness. 

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This article is based on Change Request (CR) 8035, which describes changes to be implemented in 

the October 2012 Outpatient Prospective Payment System (OPPS) and Integrated Outpatient Code 

Editor (I/OCE) updates. Be sure your billing staff is aware of these changes. 

Background 

Medicare’s I/OCE routes all institutional outpatient claims (including non-OPPS hospital claims) 

through a single integrated OCE which eliminates the need to update, install, and quarterly maintain 

two separate OCE software packages. It will be utilized under the OPPS and Non-OPPS for hospital 

outpatient departments, community mental health centers, all non-OPPS providers, and for limited 

services when provided by a home health agency not under the Home Health Prospective Payment 

System, or to a hospice patient for the treatment of a non-terminal illness. 

CR 8035, from which this article is taken, informs the FIs, A/B MACs, RHHIs and the Fiscal 

Intermediary Shared System (FISS) that the I/OCE was updated for October 1, 2012, and provides 

them with the instruction and specification changes to be implemented in the October 2012 OPPS and 

I/OCE updates. 

The full list of I/OCE specifications can now be found at 

http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html on the Centers for 

Medicare & Medicaid Services (CMS) website. 

A summary of the changes for October 2012 can be found in Appendix M, and the Preliminary 

Summary of Data Changes Integrated OCE v 13.3 document that are attachments to CR8305, and 

that summary is captured in the following key points: 

• Effective January 1, 2006, Medicare removed ICD-9-CM diagnosis code 7511 (Atresia and 

stenosis of small intestine) from the list of pediatric diagnoses, age 0-17 years old. Edit 2 is 

affected. 

• Effective January 1, 2012, Medicare removed the procedure/device code pair requirements 

for procedure code 57288; 

• Effective June 27, 2012, apply a mid-quarter National Coverage Determination approval date 

to code 43755; 

• Implement version 18.3 of the NCCI (as modified for applicable institutional providers 


The official instruction, CR 8035 issued to your FI, RHHI, or A/B MAC regarding this change may be 

viewed at http://www.cms.hhs.gov/Regulations-and- 


Disclaimer 





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If you have any questions, please contact your FI, RHHI, or A/B MAC at their toll-free number, which 

may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 


News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may weaken. 

This weakening can make seniors more susceptible to complications from seasonal influenza (flu). Now is the perfect 

time to remind your patients that seasonal influenza vaccination is the best defense against the flu. Medicare provides 

coverage for one flu vaccine and its administration per influenza season for seniors and other Medicare beneficiaries 

with no co-pay or deductible. Talk with your Medicare patients about their risk for getting the flu and start protecting your 

patients as soon as your 2012-2013 seasonal flu vaccine arrives. Also, don’t forget to immunize yourself and your staff. 

Know what to do about the flu. 



available. 





Disclaimer 





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Articles for Part B 

Providers



News Flash – On August 24, Health and Human Services (HHS) Secretary Kathleen Sebelius 

announced a final rule that will save time and money for physicians and other health care providers by 

establishing a unique Health Plan Identifier (HPID). The rule is one of a series of changes required by 

the Affordable Care Act to cut red tape in the health care system and will save up to $6 billion over ten 

years. Currently, when a health care provider bills a health plan, that plan may use a wide range of 

different identifiers that do not have a standard format. As a result, health care providers run into a 

number of time-consuming problems, such as misrouting of transactions, rejection of transactions due to 

insurance identification errors, and difficulty determining patient eligibility. The change announced on 

August 24 will greatly simplify these processes. For more information, see the Fact Sheet related to this 

final rule. 

MLN Matters® Number: MM8054 Related Change Request (CR) #: 8054 

Related CR Release Date: September 28, 2012 Effective Date: January 1, 2013 

Related CR Transmittal #: R2553CP Implementation Date: January 7, 2013 

New Waived Tests 


This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare 

contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to 

Medicare beneficiaries. 


STOP – Impact to You 

This article is based on Change Request (CR) 8054 which informs Medicare contractors that there are 

36 newly added waived tests. In addition, the new CPT code, 86803QW, was assigned for the 

hepatitis C antibody test performed using the OraQuick HCV Rapid Antibody Test and OraQuick 

Visual Reference Panel. 

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CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The 

CPT codes that the Centers for Medicare & Medicaid Services (CMS) considers to be laboratory tests 

under CLIA (and thus requiring certification) change each year. CR 8054, from which this article is 

taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits. 

GO – What You Need to Do 

Make sure that your billing staffs are aware of these changes. See the Background and Additional 

Information Sections of this article for further details regarding these changes. 

Background 

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be 

appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for 

laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of 

waiver, laboratory claims are currently edited at the CLIA certificate level. If you do not have a valid, 

current Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to 

your Medicare Carrier or A/B MAC for a Current Procedural Terminology (CPT) code that is 

considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be 

impacted. 

Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests 

under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized 

as a waived test. (However, the tests mentioned on the first page of the list attached to CR8054 (i.e., 

CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a 

QW modifier to be recognized as a waived test.) 

CPT Code Effective Date Description 

86803QW November 29, 2011 OraQuick HCV Rapid Antibody Test and 

OraQuick Visual Reference Panel 

87809QW April 24, 2012 AdenoPlus (human eye fluid) 

81003QW May 8, 2012 McKesson 120 Urine Analyzer 

81003QW May 11, 2012 Acon Laboratories, Inc. Foresight U120 Urine 

Analyzer 

86294QW May 15, 2012 LifeSign Status BTA 

82055QW May 25, 2012 Alere Toxicology Services, iScreen Saliva 

Alcohol Test Strip 

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82055QW May 25, 2012 American Screening Corporation, Reveal 

Saliva Alcohol Test Strip 

G0434QW May 29, 2012 BTNX Inc Rapid Response X-Press Drug 

Test Cassette 


Test Cassette Amp/Amphetamine 


Test Secobarbital Cassette 


Test Oxazepam Cassette 


Test Strip 


Test Strip Amp/Amphetamine 


Test Secobarbital Strip 


Test Oxazepam Strip 


Test (COC/Cocaine){Cup format} 


Test (MET/Methamphetamine){Cup format} 


Test 

(MDMA/Methylenedioxymethamphetamine){C 

up format} 


Test (MOP/Morphine){Cup format} 


Test (MTD/Methadone){Cup format} 


Test Morphine (2000){Cup format} 


Test (PCP/Phencyclidine){Cup format} 

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Test Notriptyline{Cup format} 


Test (COC/Cocaine){Dip card format} 


Test (MET/Methamphetamine){Dip card 

format} 


Test 

(MDMA/Methylenedioxymethamphetamine){D 

ip card format} 


Test (MOP/Morphine){Dip card format} 


Test (MTD/Methadone){Dip card format} 


Test Morphine (2000){Dip card format} 


Test (PCP/Phencyclidine){Dip card format} 


Test Notriptyline{Dip card format} 

83036QW May 30, 2012 Bayer AICNow+ Professional Use 

87880QW June 7, 2012 Mooremedical Strep A Rapid Test - Dipstick 

G0434QW July 13, 2012 Ultimate Analysis Cup UA Cups 

86701QW July 20, 2012 bioLytical INSTI HIV-1 Antibody Test 

{Fingerstick Whole Blood} 

G0433QW July 20, 2012 OraSure Technologies OraQuick In-Home 

HIV Test {Oral Fluid} 

The new CPT code, 86803QW, has been assigned for the hepatitis C antibody test performed using the 

OraQuick HCV Rapid Antibody Test and OraQuick Visual Reference Panel. 

Disclaimer 





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The official instruction, CR 8054 issued to your carrier and A/B MAC regarding this change may be 

viewed at http://www.cms.hhs.gov/Regulations-and- 


If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may 

be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 


News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may weaken. 

This weakening can make seniors more susceptible to complications from seasonal influenza (flu). Now is the perfect 

time to remind your patients that seasonal influenza vaccination is the best defense against the flu. Medicare provides 

coverage for one flu vaccine and its administration per influenza season for seniors and other Medicare beneficiaries 

with no co-pay or deductible. Talk with your Medicare patients about their risk for getting the flu and start protecting your 

patients as soon as your 2012-2013 seasonal flu vaccine arrives. Also, don’t forget to immunize yourself and your staff. 

Know what to do about the flu. 



available. 





Disclaimer 





42 

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News Flash – Are you billing correctly for ordered/referred services? Will you be impacted when the 

Centers for Medicare & Medicaid Services (CMS) turns on the edits for these services? See the revised 

MLN Matters® articles SE1221, SE1011, and MLN fact sheets “Medicare Enrollment Guidelines for 

Ordering/Referring Providers ” and “The Basics of Medicare Enrollment for Physicians Who 

Infrequently Receive Medicare Reimbursement ” to learn what you need to do. 

MLN Matters® Number: SE1229 Related Change Request (CR) #: N/A 



A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) 

Programs 


This MLN Matters® Article Special Edition about Medication Therapy Management (MTM) services is intended 

for physicians, pharmacists, nurses, and other health care providers who treat Medicare beneficiaries with Part 

D coverage. 


This MLN release is intended to make you aware of changes in Medicare Part D MTM programs that will affect 

your patients, and introduce you to three new MTM forms that your patients are likely to share with you. 

Your patients may ask you if they would benefit from MTM services. If you have patients enrolled in Part D 

MTM programs, you may also be contacted by MTM providers who are required to monitor patients’ medication 

therapies from all their health care providers. This may result in recommendations that are shared with you 

about unsafe or dangerous interactions and therapeutic alternatives. Your patients may also receive 

recommendations about how to use their medications properly. 

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MTM Providers Are Important Partners with You 

MTM providers work with physicians to deliver the best medication therapy to patients and to coordinate their 

medication therapy across multiple practitioners. The latest clinical information is used by MTM providers when 

reviewing patients’ medication therapy, such as updates to the Beers criteria for high-risk medications and 

revised monographs for old and new medications. MTM providers also listen to patients’ concerns about their 

medications and may offer recommendations to physicians and patients to help achieve their goals of therapy. 

As always, physicians make the final decisions about changes in drug therapy. 

When Will MTM Providers Contact You? 

Your patients enrolled in MTM may receive an interactive Comprehensive Medication Review (CMR) any time 

during the year. 

• The MTM provider may reach out to you in order to clarify your patient’s medical history prior to a review 

or information received from your patient during the review, such as why and how they are supposed to 

use their medications. 

• After a CMR, the MTM provider may contact you with questions or recommendations about your patient’s 

medications, or your patient may call you to discuss suggestions they received from the MTM provider. 

Targeted Medication Reviews (TMRs) are processed throughout the year, no less often than quarterly, to 

identify specific or potential medication-related problems. You may be contacted by the MTM provider if a TMR 

identifies a potential medication-related problem for your patient. 

Other communications may be sent to you periodically throughout the year. These communications are 

intended to help resolve other potential medication-related problems or identify other opportunities to optimize 

your patient’s medication use. 

What is Changing? 

Beginning January 2013, if your patients are enrolled in a Part D MTM program, they will receive a printed 

standardized summary, Form CMS-10396, as a reference about their CMR. This summary will include a Cover 

Letter, Medication Action Plan, and Personal Medication List. Your patients are encouraged to share these 

documents with you and other healthcare providers at their regular visits and request updates as needed. 

Examples of the three forms follow: 

Disclaimer 


regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or 

regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only 

copyright 2011 American Medical Association. 

44 

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Cover Letter 

• The Cover Letter reminds your patient of their CMR, introduces the Medication Action Plan and Personal 

Medication List, and describes how to contact the MTM program. 

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Medication Action Plan 

• The Medication Action Plan describes the specific action items for your patient to help resolve issues of 

current drug therapy and achieve the goals of medication treatment. Your patient can keep notes of their 

progress and use it to clarify and discuss any concerns about their medications and treatment plans with 

you. 

• The MTM provider will send separate recommendations to you if needed. 

Personal Medication List 

• The Personal Medication List is a reconciled list of the medications used by your patient at the time of the 

review. Information from your patient, Medicare Part D claims data, or other sources may be used to 

develop the list. It is intended to help your patient understand their medications and how they relate to 

their treatment plans. Your patient can make notes on their Personal Medication List such as when and 

why they stopped taking a medication. 

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• You can use the Personal Medication List as verification of your patient’s current medication regimen and 

provide written adjustments, as needed. The medication list can also improve communication with you 

and other healthcare providers seen by your patient. 

How Do You Refer Patients to MTM Services? 

Calling the prescription drug plan directly is the best way to find out if your patient is eligible for that plan’s MTM 

services. You can also refer your patient to their local State Health Insurance Assistance Program (SHIP) 

office. A local SHIP counselor can be found through a search function at 

https://shiptalk.org/public/home.aspx?ReturnUrl=%2fdefault.aspx on the SHIPtalk.org website. 

Summary 

Medicare Part D MTM programs promote coordinated care and improve medication use through services that 

engage the patient, their physicians, and other healthcare providers. Starting in 2013, you will begin to see three 

new forms that your patients may receive if they are enrolled in a Part D MTM program. These forms are intended to 

Disclaimer 





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provide the patient with information about their medication use and also be used as a platform for discussion with 

you and their other health care providers. 


For additional information about Medicare Part D MTM programs and the standardized CMR summary 

documents, go to http://www.cms.gov/Medicare/Prescription-Drug- 

Coverage/PrescriptionDrugCovContra/MTM.html on the CMS website. 

Please send any general questions about Part D MTM programs to PartD_MTM@cms.hhs.gov via e-mail. 

Questions about a specific plan’s MTM services or eligibility criteria should be addressed to that Part D plan. 

News Flash - Vaccination is the Best Protection Against the Flu - Each office visit is an opportunity to check 

your patients’ seasonal influenza (flu) and pneumonia immunization status and to start protecting your 

patients as soon as your 2012-2013 seasonal flu vaccine arrives. Ninety percent of flu-related deaths and 

more than half of flu-related hospitalizations occur in people age 65 and older. Seniors also have an 

increased risk of getting pneumonia, a complication of the flu. Remind your patients that seasonal flu 

vaccinations and a pneumococcal vaccination are recommended for optimal protection. 

Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all Medicare 

beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its administration once 

in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal 

vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides 

coverage for these vaccines and their administration with no co-pay or deductible. Also, don’t forget to 

immunize yourself and your staff. Know what to do about the flu! 

Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza vaccine 

is NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine 

prices when they are available. For more information on coverage and billing of the flu vaccine and its 

administration, please visit the CMS Medicare Learning Network® Preventive Services Educational 

Products and CMS Immunizations web pages. While some providers may offer the flu vaccine, others can 

help their patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a 

free, online service where users can search for locations offering flu vaccines. 

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News Flash – 




• “Complying with Medicare Signature Requirements” Fact Sheet, ICN 905364, 

Downloadable only. 

MLN Matters® Number: SE1241 Related Change Request (CR) #: 7578 

Related CR Release Date: February 17, 2012 Effective Date: January 1, 2012 

Related CR Transmittal #: R1046OTN Implementation Date: July 2, 2012 

Correct Provider Billing of Line Item Rendering Physician on the Paper UB-04 

Claims Form 


This MLN Matters® Special Edition Article is intended for providers who submit claims on the paper 

UB-04 claims form to Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs) 

for services provided to Medicare beneficiaries. 


In collaboration with the National Uniform Billing Committee’s (NUBC) reporting of the Line Item 

Rendering Physician element on paper claims, the Centers for Medicare & Medicaid Services (CMS) 

would like to inform you of the correct process for paper claims received on or after January 1, 2012. 

This change does not apply for claims received prior to January 1, 2012. 

This special article informs you of the following for reporting the Line Item Rendering Physician 

element on paper claims when the Line Item Rendering Physician is required. 

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49 

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MLN Matters® Number: SE1241 Related Change Request Number: 7578 

The claim level Rendering Provider (Loop ID 2310D) is required when the Rendering Provider is 

different than the Attending Provider. For Medicare purposes this is required under federal regulatory 

requirements that call for a “combined claim”, that is, a claim that includes both facility and 

professional components (Critical Access Hospital Claim billing under Method II, Federally Qualified 

Health Centers, and Rural Health Clinics). The line level Rendering Provider is required when the 

Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D 

(claim level). Again, for Medicare purposes this is required under federal regulatory requirements that 

call for a “combined claim,” that is, a claim that includes both facility and professional components 

(Critical Access Hospital Claim billing under Method II, Federally Qualified Health Centers, and Rural 

Health Clinics*). 

• Place the line item Rendering Physician National Provider Identifier (NPI) in Form Locator 43 

(Revenue Code Description) for the line item that contains the services identified. 

Medicare’s Fiscal Intermediary Shared System (FISS) edits require that the Line Item Rendering 

Physician information be transmitted when providers submit a combined claim; that is, claims that 

include both facility and professional components, need to report the rendering physician or other 

practitioner at the line level if it differs from the rendering physician/practitioner reported at the claim 

level. Affected Medicare providers are Critical Access Hospitals billing under Method II and Federally 

Qualified Health Centers. 

For the 5010 version of the 837 I, FISS shall accept the line level rendering physician/practitioner 

information at the line level (loop 2420C). As a reminder, you should verify your systems edit logic for 

correct application of this data element. 

* Rural Health Clinics are not impacted at this time since they do not do detailed billing. 


You may also want to review the MLN Matters® Article related to CR7578. That article is available at 


MLN/MLNMattersArticles/Downloads/MM7578.pdf on the CMS website. 

If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be 

found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 


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2012-11 - National Government Services

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