April 1, 2010, Home Health & Hospice Medicare A Newsline - CGS

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Additional InformationThe official instruction, CR 6757, issued to your RHHI regarding this change may be viewed athttp://www.cms.hhs.gov/Transmittals/downloads/R1904CP.pdf on the CMS Web site.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article maycontain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be ageneral summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review thespecific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.April 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare LearningNetwork (MLN) Matters article. This MLN Matters article and other CMS articles can be found on theCMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM6857 Related Change Request (CR) #: 6857Related CR Release Date: February 26, 2010 Effective Date: April 1, 2010Related CR Transmittal #: R1924CP Implementation Date: April 5, 2010Provider Types AffectedProviders submitting claims to Medicare contractors (fiscal intermediaries (FIs), Medicare administrativecontractors (MACs), and/or regional home health intermediaries (RHHIs)) for outpatient services providedto Medicare beneficiaries and paid under the OPPS.Provider Action NeededThis article is based on CR 6857, which describes changes to the OPPS to be implemented in the April 2010OPPS update. Be sure billing staffs are aware of these changes.BackgroundApril 2010 OPPS UpdateCR 6857 describes changes to and billing instructions for various payment policies implemented in theApril 2010 OPPS update. The April 2010 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer willreflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Codeadditions, changes, and deletions identified in this notification.April 2010 revisions to I/OCE data files, instructions, and specifications are provided in CR 6857, “April2010 Integrated Outpatient Code Editor (I/OCE) Specifications Version 11.1.”Home Health & Hospice April 1, 2010 13Medicare A Newsline Vol. 17, No. 7
Key OPPS Updates for April 20101. Procedure and Device Edits for April 2010Procedure-to-device edits require that when a particular procedural HCPCS code is billed, the claim mustalso contain an appropriate device code. Failure to pass these edits will result in the claim being returned tothe provider. Device-to-procedure edits require that a claim that contains one of a specified set of devicecodes be returned to the provider if it fails to contain an appropriate procedure code. The updated lists ofboth types of edits can be found under “Device, Radiolabeled Product, and Procedure Edits” athttp://www.cms.hhs.gov/HospitalOutpatientPPS/ on the CMS Web site.2. Editing of Hospital Part B Inpatient ServicesBlood and blood products are not included in the list of services that may be covered when furnished topersons who are inpatients, but for whom no Medicare inpatient coverage is available. Therefore, no Part Bpayment may be made for them.The Medicare Claims Processing Manual, Chapter 4, §240.1 is revised to add revenue codes 038x (Bloodand Blood Components) and 039x (Administration, Processing and Storage for Blood and BloodComponents) to the table of revenue codes that are not allowed to be reported on a claim for payment ofservices furnished to hospital inpatients for whom there is no Medicare Part A coverage of their inpatienthospital care (12x type of bill (TOB)).The instruction is also revised to reflect that these edits are currently locally controlled by the Medicare A/BMAC or FI and are not imbedded in the FI Standard System.For more information, you may view the Medicare Benefits Policy Manual, Chapter 6, §2 for the servicesfor which payment may be made under the Part B Medicare hospital outpatient benefit for services tohospital inpatients and the Medicare Claims Processing Manual, Chapter 4, §240 for claims processinginstructions for these claims.3. Clarification to Coding Requirements for Pulmonary Rehabilitation Services Furnished On orAfter January 1, 2010Section 140.4 .1 (Coding Requirements for Pulmonary Rehabilitation Services Furnished On or AfterJanuary 1, 2010), Chapter 32 in the Medicare Claims Processing Manual, is being revised to reflectinstructions to hospitals and practitioners’ offices for reporting respiratory or pulmonary services furnishedto a patient when those services do not meet the diagnosis and coverage criteria for pulmonary rehabilitationservices.4. Warfarin TestingEffective August 3, 2009, Medicare covers pharmacogenomic testing to predict warfarin responsivenessonly in the context of an approved, clinical study, in addition to the coverage criteria outlined in theMedicare National Coverage Determinations (NCD) Manual, Chapter 1, §90.1, and in the Medicare ClaimsProcessing Manual, Chapter 32, §240. New Level II HCPCS code G9143 was developed to enableimplementation of this new coverage policy. Pharmacogenomic testing for warfarin response is a once-in-alifetimetest absent any reason to believe that the patient’s personal genetic characteristics would changeover time.Under the hospital OPPS, HCPCS code G9143 will be assigned status indicator “A” effective in the April2010 update, and payment for this lab test will be made under the clinical lab fee schedule (CLFS).Home Health & Hospice April 1, 2010 14Medicare A Newsline Vol. 17, No. 7
Page 1 and 2: Home Health & HospiceMedicare A New
Page 3 and 4: H1N1 Influenza ImmunizationsMedicar
Page 5 and 6: Revised Medicare Physician Fee Sche
Page 7 and 8: classified (NOC) drug pricing files
Page 9 and 10: DisclaimerThis article was prepared
Page 11 and 12: BCTransfer From AnotherHome Health
Page 13: BackgroundWhen the National Uniform
Page 17 and 18: carrier or A/B MAC cannot provide a
Page 19 and 20: Note: Medicare contractors may adju
Page 21 and 22: Additional InformationFor complete
Page 23 and 24: Implementation of Home Health Agenc
Page 25 and 26: Provider Types AffectedThis article
Page 27 and 28: A. CMS has alerted MAC audit staff
Page 29 and 30: interpretation is billed and no E/M
Page 31 and 32: The provider may not bill the patie
Page 33 and 34: Claims in the “S MXXXX” status/
Page 35 and 36: In addition, the provider will also
Page 37 and 38: For more detailed information about
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Page 41 and 42: Medicare Credit Balance Quarterly R
Page 43 and 44: MAP1B41 CAHABA GBA - RHHI ACPFAT01
Page 45 and 46: Resolving Reason Code U538FThe Caha
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April 1, 2010, Home Health & Hospice Medicare A Newsline - CGS

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