February 1, 2010, Home Health & Hospice Medicare A ... - CGS

use and while they may serve other uses, CMS does not offer to maintain this product for purposes otherthan Medicare Fee-for-Service. You can find these documents athttp://www.cms.hhs.gov/MFFS5010D0/20_Technical%20Documentation.asp#TopOfPage on the CMS Website.Additional InformationThe official instruction, CR 6721, issued to your carrier, FI, A/B MAC, RHHI, and DME MAC regardingthis change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R623OTN.pdf on the CMSWeb site.You can also review the Final Rule as published in the Federal Register on January 16, 2009, by theDepartment of Health and Human Services 45 CFR Part 162, Subpart N—Health Care Claim Status athttp://edocket.access.gpo.gov/2009/pdf/E9-740.pdf on the Internet.You can find more information about HIPAA Version 5010 and NCPDP Version D.0. athttp://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp on the CMS Web site. A specialedition MLN Matters ® article, SE0832, on the ICD-10 code set is available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0832.pdf on the CMS Web site.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. CPT onlycopyright 2009 American Medical Association.Coverage of Kidney Disease Patient Education ServicesThe 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: MM6557 Related Change Request (CR) #: 6557Related CR Release Date: December 18, 2009 Effective Date: January 1, 2010Related CR Transmittal #: R1876CP and R117BP Implementation Date: April 5, 2010Provider Types AffectedThis article affects physicians, providers, and suppliers submitting claims to Medicare contractors (carriers,fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), and/or regional homehealth intermediaries (RHHIs)) for Kidney Disease Education services provided to Medicare beneficiariesdiagnosed with Stage IV chronic kidney disease (CKD).Provider Action Needed STOP – Impact to YouThis article is based on CR 6557 which implements Kidney Disease Education (KDE) Services as aMedicare Part B covered benefit for Medicare beneficiaries diagnosed with Stage IV CKD.Home Health & Hospice February 1, 2010 6Medicare A Newsline Vol. 17, No. 5

KDE Billing InstructionsCR 6557 instructs Medicare contractors to pay for KDE services that meet the following conditions:• No more than 6 sessions of KDE services are provided in a beneficiary’s lifetime;• Sessions billed in increments of one hour (if the session is less than 1 hour, it must last at least 31minutes in order to be billed, in which case a session less than one hour and longer than 31 minutes isbillable as one session);• Sessions furnished either individually or in a group setting of 2 to 20 individuals (who need not all beMedicare beneficiaries); and• Furnished, upon the referral of the physician managing the beneficiary’s kidney condition, by a qualifiedperson meaning a:o Physician, physician’s assistant, nurse practitioner, or clinical nurse specialist;o Hospital, critical access hospital (CAH), skilled nursing facility (SNF); comprehensive outpatientrehabilitation facility (CORF), home health agency (HHA), or hospice, that is located in a rural area;oro Hospital or CAH that is paid as if it were located in a rural area (hospitals and CAHs reclassified asrural under section 42 CFR 412.103).The following providers are not ‘qualified persons’ and are excluded from furnishing KDE services:• A hospital, SNF, CORF, HHA, or hospice located outside of a rural area (using the Actual GeographicLocation Core Based Statistical Area (CBSA) to identify facilities located outside of a rural area underthe Medicare Physician Fee Schedule (MPFS)), unless the services are furnished by a hospital or CAHthat is treated as being in a rural area (such claims are denied with Claims Adjustment Reason Code(CARC) 170 (Payment is denied when performed/billed by this type of provider)) and MedicareSummary Notice (MSN) 21.6 (This item or service is not covered when performed, referred, or orderedby this provider.); and• Renal dialysis facilities (Type of Bill (TOB) 72x).CMS issued two new HCPCS codes G0420 and G0421 to be used to report covered KDE service in theJanuary 2010 Integrated Outpatient Code Editor (IOCE) and MPFS Database and identified the paymentamounts in the final 2010 MPFS. One of these HCPCS codes must be present, along with ICD-9-CM code585.4 (chronic kidney disease, Stage IV (severe)), in order for a claim to be processed and paid correctly.Medicare contractors will deny claims for KDE services billed without ICD-9-CM code 585.4 using CARC167 (This (these) diagnosis(es) is(are) not covered.)Medicare contractors will deny claims with HCPCS G0420 or G0421 and ICD-9-CM 585.4 for more than 6sessions using claims adjustment reason code (CARC) 119 (benefit maximum for this time period oroccurrence has been reached).Medicare will not pay a professional claim and an institutional claim for HCPC G0420 or G0421 and ICD-9-CM 585.4 where both claims contain the same date of service. If such claims are received, the initialclaim is paid and subsequent claims are denied using CARC 18 (Duplicate claim/service).NOTE: If a signed Advance Beneficiary Notice (ABN) was provided, Medicare contractors will use GroupCode PR (patient responsibility), and the liability falls to the beneficiary. If an ABN was not provided,contractors use Group Code CO (contractual obligation) and the liability falls to the provider.Home Health & Hospice February 1, 2010 8Medicare A Newsline Vol. 17, No. 5

The following additional billing requirements are applicable to KDE claims submitted by institutionalproviders to MACs or FIs:• MACs/FIs will reimburse for KDE Services when rendered in a rural area and submitted on thefollowing TOBs: 12X, 13X, 22X, 23X, 34X, 75X, 81X, and 82X. NOTE: TOB 85X is reimbursable forKDE Services regardless of the provider’s geographical location.• MACs/FIs will use the Actual Geographic Location CBSA to identify facilities located in rural areasunder the MPFS.• KDE Services are covered when claims containing the above-mentioned TOBs are received fromsection 401 hospitals (the provider is found on the annual updated Table 9C of the Inpatient ProspectivePayment System final rule);• Revenue code 0942 (Other therapeutic services; education/training) should be reported when billing forKDE Services on TOBs 22X, 23X, 34X, 75X, 81X, 82X, and 85X;• Medicare will return to provider hospice claims, TOBs 81X and 82X, billing forked services withrevenue code 0942 when any other services are also included:• Hospices must include value code 61 or G8 when billing for G0420 or G0421; and• Hospital outpatient departments should bill for KDE Services under any valid/appropriate revenue code,and they are not required to report revenue 0942. Maryland hospitals under jurisdiction of the HealthServices Cost Review Commission, TOBs 12X and 13X, are paid on an inpatient Part B basis inaccordance with the terms of the Maryland Waiver.Additional InformationBe aware that Medicare contractors will not search their files for claims with service dates on or afterJanuary 1, 2010, that are processed prior to the implementation of CR 6557. However, if you identify suchclaims to your Medicare contractor, they will adjust them. The official instruction, CR 6557, was issued viatwo transmittals, one revising the Medicare Claims Processing Manual, (CMS Pub. 100-04), Chapter 32,Section 20, and one for revisions to the Medicare Benefit Policy Manual, (CMS Pub. 100-02), Chapter 15,Section 310. These transmittals are available athttp://www.cms.hhs.gov/Transmittals/downloads/R1876CP.pdf andhttp://www.cms.hhs.gov/Transmittals/downloads/R117bp.pdf, respectively, on the CMS Web site. If youhave questions regarding this issue, refer to the “Contact Us” page of our Web site and select “TelephoneUs” 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. CPT onlycopyright 2008 American Medical Association.Home Health & Hospice February 1, 2010 9Medicare A Newsline Vol. 17, No. 5

with providers/suppliers or other parties outside the CMS contractor’s organization. The files referenced inthe business requirements of this CR contain both published and unpublished MUE values. In the MUEfiles each HCPCS code has an associated “Publication Indicator”. A Publication Indicator of “0” indicatesthat the MUE value for that code is confidential, is not in the CMS official publication of the MUE values,and should not be shared with providers/suppliers or other parties outside the CMS contractor’sorganization. A Publication Indicator of “1” indicates that the MUE value for that code is published andmay be shared with other parties.The full set of MUEs is available for the CMS contractors only via the Baltimore data center (BDC). A testfile will be available about 2 months before the beginning of each quarter, and the final file will be availableabout 6 weeks before the beginning of each quarter. Note that MUE file updates are a full replacement.The MUE adds, deletes, and changes lists will be available about 5 weeks before the beginning of eachquarter.This CR provides updates and clarifications to MUE requirements established in 2006.B. Policy: The NCCI contractor produces a table of MUEs. The table contains ASCII text and consists ofsix columns (Refer to Appendix 1 – Tabular Presentation of the Format for the MUE Transmission). Thereare three format charts, one for contractors using the Medicare Carrier System (MCS), one for contractorsusing the VIPS Medicare System (VMS) system, and one for the contractors using the FISS system.Contractors shall apply MUEs to claims with a date of service on or after the beginning effective date of anedit and before or on the ending effective date.Further, CMS is setting MUEs to auto-deny the claim line item with units of service in excess of the valuein column 2 of the MUE table. Pub. 100-08, PIM, Chapter 3, Section 5.1, indicates that automated review isacceptable for medically unlikely cases and apparent typographical errors.The CMS will set the units of service for each MUE high enough to allow for medically likely dailyfrequencies of services provided in most settings.Since claim lines are denied, denials may be appealed.Appeals shall be submitted to local contractors not the MUE contractor, Correct Coding Solutions, LLC.Note that, quarterly, the NCCI contractor will provide files to CMS with a revised table of MUEs andcontractors will download via the Network Data Mover.Furthermore, if Medicare contractors identify questions or concerns regarding the MUEs, they shall bringthose concerns to the attention of the NCCI contractor. The NCCI contractor may refer those concerns toCMS, and CMS may act to change the MUE limits after reviewing the issues and/or upon reviewing dataand information concerning MUE claim appeals.Finally, a denial of services due to an MUE is a coding denial, not a medical necessity denial. Aprovider/supplier shall not issue an Advance Beneficiary Notice of Noncoverage (ABN) in connection withservices denied due to an MUE and cannot bill the beneficiary for units of service denied based on an MUE.The denied units of service shall be a provider/supplier liability.The CMS will distribute the MUEs as a separate file for each shared system when the quarterly NCCI editsare distributed.Home Health & Hospice February 1, 2010 11Medicare A Newsline Vol. 17, No. 5

APPENDIX 1TABULAR PRESENTATION OF THE FORMAT FOR THEMUE TRANSMISSIONBelow are layouts for each of the shared systems. A description of each column on the layouts is providedbelow. Note that all layouts are the same.The first column contains HCPCS codes (5 positions). The second column of the first format chart containsthe maximum units of service A/B MACs and Medicare fiscal intermediaries shall allow per claim line perday for the HCPCS code in column one (5 positions with no decimal places). The second column of thesecond format chart contains the maximum units of service A/B MACs and Medicare carriers shall allowper claim line per day for the HCPCS code in column one (5 positions with no decimal places). The secondcolumn of the third format chart contains the maximum units of service DME MACs shall allow per claimline per day for the HCPCS code in column one (5 positions with no decimal places). The third column isthe Corresponding Language Example Identification (CLEID) Number (12 positions including a decimalpoint). The CLEID information is for reference only. The fourth column states the beginning effective datefor the edit (7 positions in YYYYDDD format), and the fifth column states the ending effective date of theedit (7 positions in YYYYDDD format). For example, April 1, 2007, is recorded as 2007091 meaning the91st day of 2007. The fifth column will remain blank until an ending effective date is determined. The lastcolumn indicates whether CMS will publish the MUE units athttp://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage on the CMS Web site. A “1”indicates that CMS will publish the MUE units on the CMS Web site.Format for Claims Processed Using the FISS SystemHCPCSCODEMAXIMUMMAC/FIUNITSCLEID #BEGINNINGEFFECTIVEDATEENDINGEFFECTIVEDATEPUBLICATIONINDICATORAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESDEFINITIONS:DATESA = ALPHANUMERIC CHARACTERX = NUMERIC CHARACTERYYYYXXX = JULIAN DATEPUBLICATION INDICATORNO = CMS WILL NOT PUBLISH -- DO NOT SHAREYES = CMS WILL PUBLISH -- OK TO SHAREHome Health & Hospice February 1, 2010 12Medicare A Newsline Vol. 17, No. 5

Format for Claims Processed Using the MCS SystemHCPCSCODEMAXIMUMMAC/CARRIERUNITSCLEID #BEGINNINGEFFECTIVEDATEENDINGEFFECTIVEDATEPUBLICATIONINDICATORAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESDEFINITIONS:DATESA = ALPHANUMERIC CHARACTERX = NUMERIC CHARACTERYYYYXXX = JULIAN DATEPUBLICATON INDICATORNO = CMS WILL NOT PUBLISH -- DO NOT SHAREYES = CMS WILL PUBLISH -- OK TO SHAREFormat for Claims Processed Using the VMS SystemHCPCSCODEMAXIMUMDME MACUNITSCLEID #BEGINNINGEFFECTIVEDATEENDINGEFFECTIVEDATEPUBLICATIONINDICATORAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESAAAAA XXXXX AA.AAAAAAAAA YYYYDDD YYYYDDD 0=NO1=YESDEFINITIONS:DATESA = ALPHANUMERIC CHARACTERX = NUMERIC CHARACTERYYYYXXX = JULIAN DATEPUBLICATON INDICATORNO = CMS WILL NOT PUBLISH -- DO NOT SHAREYES = CMS WILL PUBLISH -- OK TO SHAREHome Health & Hospice February 1, 2010 13Medicare A Newsline Vol. 17, No. 5

News from CMS for Home Health ProvidersLimitation on Home Health Prospective Payment System (HH PPS) Outlier PaymentsThe 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: MM6759 Related Change Request (CR) #: 6759Related CR Release Date: December 23, 2009 Effective Date: January 1, 2010Related CR Transmittal #: R1883CP Implementation Date: January 25, 2010Provider Types AffectedHome health agencies (HHAs) submitting bills to regional home health intermediaries (RHHI) for servicesto Medicare beneficiaries are affected.Provider Action NeededThis article, based on CR 6759, provides HHAs with public notification of the 10 percent annual cap onoutlier payments that is effective January 1, 2010. Medicare RHHIs will implement the claims processingrequirements for the outlier limitations provided in the update to the Medicare Claims Processing Manual,Chapter 10. The manual update is available as part of the official instruction CR 6759 (see “AdditionalInformation” section below for the Web address of CR 6759). You should ensure that your billing staffs areaware of this change.BackgroundBoth the Notice of Proposed Rulemaking (NPRM) and Final Rule regarding 2010 HH PPS payment updatesincluded discussions of the outlier policy. Those rules outlined the rationale for revising outlier paymentsfor calendar year (CY) 2010 to include an annual limitation on outlier payments that can be paid to eachhome health agency (HHA). Effective January 1, 2010, for CY 2010, the outlier payments made to eachHHA will be subject to an annual limitation. Medicare systems will ensure that outlier payments compriseno more than 10 percent of the HHA’s total HH PPS payments for the year.Note from Cahaba: The limitation on outlier payments will impact any claim paid under the HH PPSthat has a “TO” date on or after January 1, 2010.Note that Medicare will not pay partial outlier payments. Outlier payments will be made for a particularclaim only if the entire outlier payment on a claim does not result in the limitation being met for an HHA.When a calculated outlier is not paid due to the limitation, the HHA will be notified via claim adjustmentreason code 45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.)on the accompanying remittance advice.Quarterly ReconciliationSince the payment of subsequent claims may change whether an HHA has exceeded the limitation,Medicare will conduct a quarterly reconciliation process. All claims where an outlier amount wascalculated but not paid when the claim was first processed will be reprocessed. If the outlier can be paid,the claim will be adjusted to increase the payment by the outlier amount.Home Health & Hospice February 1, 2010 14Medicare A Newsline Vol. 17, No. 5

This quarterly reconciliation process occurs after each calendar quarter has ended and an additional monthhas elapsed to allow claims for that quarter to be received. For example, the first calendar quarter endsMarch 30. Claims for HH PPS episodes ending in the first quarter continue to be received in April. Thereconciliation process will begin in May.Note from Cahaba: As a result of CR 6759, the Fiscal Intermediary Standard System (FISS) hasimplemented a new screen that can be accessed from the Inquiry Menu via FISS Direct Data Entry(DDE). The new screen, “Home Health Pymt Totals” (67) will provide HH PPS payment information.Instructions on how to access this information and field descriptions will be forthcoming.Additional InformationIf you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select“Telephone Us” to call the Provider Contact Center.The official instruction, CR 6759, issued to your RHHI regarding this change, may be viewed athttp://www.cms.hhs.gov/Transmittals/downloads/R1883CP.pdf on the CMS Web site. This instructioncontains the updates added to the Medicare Claims Processing Manual, (CMS Pub. 100-04), Chapter 10.The final regulation CMS-1560-F, Home Health Prospective Payment System Rate Update is available athttp://www.cms.hhs.gov/HomeHealthPPS/HHPPSRN/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=3&sortOrder=ascending&itemID=CMS1230142&intNumPerPage=10 on the CMS Web site.The Medicare Learning Network product catalog contains a fact sheet, entitled Home Health ProspectivePayment System, which provides information about coverage of home health services and elements of theHome Health Prospective Payment System. The fact sheet is available athttp://www.cms.hhs.gov/MLNProducts/downloads/HomeHlthProsPaymt.pdf on the CMS Web site.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. CPT onlycopyright 2009 American Medical Association.Implementation of Home Health Agency Program Safeguard ProvisionsThe 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: MM6750 Related Change Request (CR) #: 6750Related CR Release Date: December 18, 2009 Effective Date: January 1, 2010Related CR Transmittal #: R318PI Implementation Date: January 1, 2010Home Health & Hospice February 1, 2010 15Medicare A Newsline Vol. 17, No. 5

Provider Types AffectedHome health agencies (HHAs) submitting claims to Medicare contractors (fiscal intermediaries (FIs), A/BMedicare administrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) forservices provided to Medicare beneficiaries.Provider Action NeededThis article is based on CR 6750, which implements two provisions from the HHA Prospective PaymentSystem Final Rule (CMS-1560-F). The first provision requires an HHA whose Medicare billing privilegeshave been deactivated to undergo a State survey or obtain accreditation from a CMS-approved accreditingorganization prior to having its billing privileges reactivated. The second provision holds that an HHA maynot undergo a change of ownership or transfer of ownership if the effective date of the change or transferoccurs within 36 months of: (1) the effective date of the provider’s enrollment in Medicare, or (2) theeffective date of the last ownership change or transfer for the HHA. The provider must instead enroll as anew HHA, undergo a State survey or obtain accreditation from a CMS-approved accrediting organization,and sign a new provider agreement.BackgroundAn “ownership change” includes any of the following:• Change of ownership (CHOW);• Acquisition/merger;• Consolidation;• Change request reporting a 5 percent or greater ownership change (including , stock transfer or assetsale); or• Change request reporting a change in partners, regardless of the percentage of ownership involved.If a Medicare contractor receives an application for an ownership change from an HHA, it willdetermine whether the effective date of the transfer is within 36 months of either the effective date ofthe provider’s initial enrollment in Medicare or last ownership change. The Medicare contractor willverify the effective date of the ownership transfer by requesting a copy of the transfer agreement, salesagreement, bill of sale, etc., rather than relying upon the projected date of the sale listed on the application.If the transfer date falls within the 36-month period after the effective date of the provider’senrollment in Medicare or last ownership change, the Medicare contractor will return the application andnotify the provider that, per 42 CFR 424.550(b), the HHA must:• Enroll as an initial applicant;• Obtain a new State survey or accreditation from a CMS-approved accrediting organization after it hassubmitted its initial enrollment application and the Medicare contractor has made a recommendation forapproval to the State; and• Sign a new provider agreement as part of the initial enrollment.As the new owner must enroll as a new provider, the Medicare contractor will also deactivate the HHA’sbilling privileges if the sale has already occurred. If the sale has not occurred, the contractor will alert theHHA that it must submit a CMS-855A voluntary termination application (seehttp://www.cms.hhs.gov/cmsforms/downloads/cms855a.pdf on the CMS Web site).Home Health & Hospice February 1, 2010 16Medicare A Newsline Vol. 17, No. 5

If the transfer date is more than 36 months after the effective date of the provider’s enrollment inMedicare or most recent ownership change, the application can be processed normally, without the needfor a new State survey or an approval from an approved accreditation organization.Additional InformationThe official instruction, CR 6750, issued to your FI, A/B MAC, and RHHI regarding this change may beviewed at http://www.cms.hhs.gov/Transmittals/downloads/R318PI.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“Telephone Us” 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.January 2010 Integrated Outpatient Code Editor (I/OCE) Specifications Version 11.0The 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: MM6761 Related Change Request (CR) #: 6761Related CR Release Date: December 11, 2009 Effective Date: January 1, 2010Related CR Transmittal #: R1872 Implementation Date: January 4, 2010Provider Types AffectedThis article is for providers submitting claims to Medicare contractors (fiscal intermediaries (FIs), Medicareadministrative contractors (MACs), and/or regional home health intermediaries (RHHIs)) for outpatientservices provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System(OPPS) and for outpatient claims from any non-OPPS provider not paid under the OPPS, and for claims forlimited services when provided in a home health agency not under the Home Health Prospective PaymentSystem, or claims for services to a hospice patient for the treatment of a non-terminal illness.Provider Action NeededThis article is based on CR 6761, which describes changes to the I/OCE and OPPS to be implemented in theJanuary 2010 OPPS and I/OCE updates. Be sure billing staffs are aware of these changes.BackgroundCR 6761 describes changes to billing instructions for various payment policies implemented in the January2010 OPPS update. The January 2010 Integrated Outpatient Code Editor (I/OCE) changes are alsodiscussed in CR 6761. Attached to CR 6761 are lengthy specifications for the I/OCE. A summary of thechanges for January 2010 is within Appendix M of Attachment A of CR 6761 and that summary is capturedin the following key points:Home Health & Hospice February 1, 2010 17Medicare A Newsline Vol. 17, No. 5

• For CY 2010, Medicare is modifying edit 74 for TOB 85x to apply edit 74 to conditional orindependently bilateral codes (indicator 1 or 3) with modifier 50 and more than one unit of service onthe same or multiple lines on the same day, with the same revenue code. Medicare will exclude anybilateral lines with any other modifier present. This applies to bill type 85x with revenue code 96x, 97xor 98x.• For CY 2010, Medicare will bypass diagnosis edits (1-5) for bill types 322 and 332 if the FROM date ison/after 9/26 and on/before 9/30.• Effective August 3, 2009, Medicare will apply a mid-quarter National Coverage Determination (NCD)date for code G9143.• Effective September 1, 2009, Medicare will apply a mid-quarter approval date for codes G9141 andG9142.• Effective September 28, 2009, Medicare will add new code 90470 retroactively.• Effective September 28, 2009, Medicare will apply a mid-quarter NCD approval date for codes 75558,75560, 75562, and 75564.• For CY 2010, Medicare will:o Add code 92520 to the ‘Sometimes Therapy’ list and logic;o Update composite Ambulatory Payment Classification (APC) requirements (add/delete codes asspecified in the Preliminary Summary of Data Changes document attached to CR 6761);o Change the Status Indicator (SI) for ‘blank’ revenue code 0657, from ‘M’ to ‘A’, when submitted onbill types 81x and 82x;o Make Healthcare Common Procedure Coding System (HCPCS) /APC/SI changes as specified byCMS in the Preliminary Summary of Data Changes attached to CR 6751;o Implement version 15.3 of the National Correct Coding Initiative (as modified for hospitals/OPPS);o Add new modifiers as specified In CR 6751;o Update procedure/device and device/procedure edit requirements;o Update FB/FC device reduction amounts and crosswalk;o Make SI assignment changes for blank revenue codes as specified by CR 6751;o Revise the description for Payment Method Flag #1 as follows –From: “Based on OPPS coverage or billing rules, the service is not paid”To: “Service not paid based on coverage or billing rules”;o Change descriptive references for code G0379 from ‘Direct admission…’ to ‘Direct referral…’; ando Create 508-compliant versions of the specifications & Summary of Data Changes documents forpublication on the CMS Web site.Additional InformationIf you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select“Telephone Us” to call the Provider Contact Center.The official instruction (CR6761) issued to your Medicare MAC and/or FI is available athttp://www.cms.hhs.gov/Transmittals/downloads/R1872CP.pdf on the CMS Web site.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. CPT onlycopyright 2008 American Medical Association.Home Health & Hospice February 1, 2010 18Medicare A Newsline Vol. 17, No. 5

January 2010 Update of the Hospital Outpatient Prospective Payment System(OPPS)—RevisedThe Centers for Medicare & Medicaid Services (CMS) has issued a revision to the Medicare LearningNetwork (MLN) Matters article, “January 2010 Update of the Hospital Outpatient Prospective PaymentSystem (OPPS),” which was published in the January 1, 2010, Home Health & Hospice Medicare ANewsline. This MLN Matters article and other CMS articles can be found on the CMS Web site at:http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters ® Number: MM6751 Revised Related Change Request (CR) #: 6751Related CR Release Date: December 21, 2009 Effective Date: January 1, 2010Related CR Transmittal #: R1873CP and R116BP Implementation Date: January 4, 2010Note: This article was revised on December 22, 2009, to reflect a revised CR 6751 that was issued onDecember 21, 2009. In this article, the CR release date, transmittal number, and Web address foraccessing CR 6751 were revised. All other information is the same. The revised CR 6751 also has anew Table 12 with correct wage index values for providers. The revised CR is athttp://www.cms.hhs.gov/Transmittals/downloads/R1882CP.pdf on the CMS Web site.Provider Types AffectedProviders submitting claims to Medicare contractors (fiscal intermediaries (FIs), Part A/B Medicareadministrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for outpatientservices provided to Medicare beneficiaries and paid under the OPPS.Provider Action NeededThis article is based on CR 6751, which describes changes to the OPPS to be implemented in the January2010 OPPS update. Be sure billing staffs are aware of these changes.BackgroundCR 6751 describes changes to and billing instructions for various payment policies implemented in theJanuary 2010 OPPS update. The January 2010 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricerwill reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory PaymentClassification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified inthis notification.The January 2010 revisions to the I/OCE data files, instructions, and specifications are provided in CR6761, “January 2010 Integrated Outpatient Code Editor (I/OCE) Specifications Version 11.0.” Once CR6761 is issued, a related MLN Matters ® will be available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6761.pdf on the CMS Web site. Theremainder of this article provides details on the changes conveyed by CR 6751.Changes to Device Edits for January 2010Claims for OPPS services must pass two types of device edits to be accepted for processing: procedure-todeviceedits and device-to-procedure edits. Procedure-to-device edits, which have been in place for manyHome Health & Hospice February 1, 2010 19Medicare A Newsline Vol. 17, No. 5

procedures since 2005, continue to be in place. These edits require that when a particular proceduralHCPCS code is billed, the claim must also contain an appropriate device code.Since January 1, 2007, CMS also has required 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 device-toprocedureedits are designed to ensure that the costs of these devices are assigned to the appropriate APC inOPPS ratesetting.The most current edits for both types of device edits can be found athttp://www.cms.hhs.gov/HospitalOutpatientPPS/ on the CMS Web site. Failure to pass these edits willresult in the claim being returned to the provider.Billing for “Sometimes Therapy” Services that May be Paid as Non-Therapy Services for HospitalOutpatientsSection 1834(k) of the Act, as added by Section 4541 of the Balanced Budget Act (BBA), allows payment at80 percent of the lesser of the actual charge for the services or the applicable fee schedule amount for alloutpatient therapy services; that is, physical therapy services, speech-language pathology services, andoccupational therapy services. As provided under Section 1834(k)(5) of the Social Security Act (or theAct), a therapy code list was created based on a uniform coding system (that is, the HCPCS) to identify andtrack these outpatient therapy services paid under the Medicare Physician Fee Schedule (MPFS).The list of therapy codes, along with their respective designation, can be found athttp://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage on the CMS Website. Two of the designations that are used for therapy services are: “always therapy” and “sometimestherapy.” An “always therapy” service must be performed by a qualified therapist under a certified therapyplan of care, and a “sometimes therapy” service may be performed by an individual outside of a certifiedtherapy plan of care.Under the OPPS, separate payment is provided for certain services designated as “sometimes therapy”services if these services are furnished to hospital outpatients as a non-therapy service, that is, without acertified therapy plan of care. Specifically, to be paid under the OPPS for a non-therapy service, hospitalsSHOULD NOT append the therapy modifier GP (physical therapy), GO (occupational therapy), or GN(speech language pathology), or report a therapy revenue code 042x, 043x, or 044x in association with the“sometimes therapy” codes listed in the table below.To receive payment under the MPFS, when “sometimes therapy” services are performed by a qualifiedtherapist under a certified therapy plan of care, providers should append the appropriate therapy modifierGP, GO, or GN, and report the charges under an appropriate therapy revenue code, specifically 042x, 043x,or 044x. This instruction does not apply to claims for “sometimes therapy” codes furnished as therapyservices in the hospital outpatient department and paid under the MPFS.Effective January 1, 2010, CPT code 92520 (Laryngeal function studies (i.e., aerodynamic testing andacoustic testing)), is newly designated as a “sometimes therapy” service under the MPFS. CPT code 92520is not a new code, however, its “sometimes therapy” designation is new and effective January 1, 2010.Under the OPPS, hospitals will receive separate payment when they bill CPT code 92520 as a non-therapyservice.The list of HCPCS codes designated as “sometimes therapy” services that may be paid as non-therapyservices when furnished to hospital outpatients as of January 1, 2010, is displayed in the following table.Home Health & Hospice February 1, 2010 20Medicare A Newsline Vol. 17, No. 5

Table 1- Services Designated as “Sometimes Therapy” that May be Paid as Non-Therapy Services forHospital Outpatients as of January 1, 2010HCPCSCodeLong Descriptor92520 Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g.,high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpeland forceps), with or without topical application(s), wound assessment, and instruction(s) forongoing care, may include use of a whirlpool, per session; total wound(s) surface area less thanor equal to 20 square centimeters97598 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g.,high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpeland forceps), with or without topical application(s), wound assessment, and instruction(s) forongoing care, may include use of a whirlpool, per session; total wound(s) surface area greaterthan 20 square centimeters97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia(e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), woundassessment, and instruction(s) for ongoing care, per session97605 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topicalapplication(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s)surface area less than or equal to 50 square centimeters97606 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topicalapplication(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s)surface area greater than 50 square centimeters0183TLow frequency, non-contact, non-thermal ultrasound, including topical application(s), whenperformed, wound assessment, and instruction(s) for ongoing care, per dayPartial Hospitalization APCs (APC 0172 and APC 0173)For CY 2010, CMS is updating the two Partial Hospitalization Program (PHP) per diem payment rates:APC 0172 (Level I Partial Hospitalization (3 services)) and APC 0173 (Level II Partial Hospitalization (4 ormore services)). When a community mental health center (CMHC) or hospital outpatient departmentprovides three units of partial hospitalization services and meets all other partial hospitalization paymentcriteria, the CMHC or hospital would be paid through APC 0172. When the CMHC or hospital outpatientdepartment provides four or more units of partial hospitalization services and meets all other partialhospitalization payment criteria, the hospital would be paid through APC 0173. The following tableprovides the updated per diem payment rates.Table 2-Updated Per Diem Payment Rates for Partial Hospitalization APCs2010 APC 2010 Long Descriptor Payment Rate0172 (Level I Partial Hospitalization (3 units of service)) $149.840173 (Level II Partial Hospitalization (4 units or more units of service)) $210.89Payment for Multiple Imaging Composite APCsEffective for services furnished on or after January 1, 2009, multiple imaging procedures performed duringa single session using the same imaging modality are paid by applying a composite APC paymentHome Health & Hospice February 1, 2010 21Medicare A Newsline Vol. 17, No. 5

methodology. The services are paid with one composite APC payment each time a hospital bills for secondand subsequent imaging procedures described by the HCPCS codes in one imaging family on a single dateof service. The I/OCE logic determines the assignment of the composite APCs for payment. Prior toJanuary 1, 2009, hospitals received a full APC payment for each imaging service on a claim, regardless ofhow many procedures were performed during a single session.The composite APC payment methodology for multiple imaging services utilizes three imaging families(Ultrasound, CT and CTA, and MRI and MRA) and five composite APCs: APC 8004 (UltrasoundComposite); APC 8005 (CT and CTA without Contrast Composite); APC 8006 (CT and CTA with ContrastComposite); APC 8007 (MRI and MRA without Contrast Composite); and APC 8008 (MRI and MRA withContrast Composite). When a procedure is performed with contrast during the same session as a procedurewithout contrast, and the two procedures are within the same family, the “with contrast” composite APC(either APC 8006 or 8008) is assigned.CMS has updated the list of specified HCPCS codes within the three imaging families and five compositeAPCs to reflect HCPCS coding changes for CY 2010. Specifically, we added CPT code 74261 (Computedtomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material) andCPT code 74262 (Computed tomographic (CT) colonography, diagnostic, including image postprocessing,with contrast materials(s) including non-contrast images, if performed) to the CT and CTA family, andremoved CPT code 0067T (Computed tomographic (CT) colonography (i.e., virtual colonoscopy);diagnostic), which was replaced by these CPT codes.The specified HCPCS codes within the three imaging families and five composite APCs for CY 2010 areprovided in Table 3 of CR 6751, which is available athttp://www.cms.hhs.gov/Transmittals/downloads/R1882CP.pdf on the CMS Web site.Cardiac Rehabilitation ServicesCMS deleted Section 200.5 of Chapter 4 of the Medicare Claims Processing Manual (CMS Pub. 100-04)and reserved it for future use. The coding requirements for cardiac rehabilitation services have been movedto Chapter 32 (Billing Requirements for Special Services), Section 140 (Cardiac Rehabilitation Programs,Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs). Section 140.1contains coverage and coding requirements for cardiac rehabilitation services furnished on or beforeDecember 31, 2009. Sections 140.2 and 140.3 have been added and include coverage and codingrequirements for cardiac rehabilitation and intensive cardiac rehabilitation services beginning January 1,2010. The revised manual chapters are available as an attachment to CR 6751.Pulmonary Rehabilitation ServicesCMS added Section 140.4 to Chapter 32 (Billing Requirements for Special Services), Section 140 (CardiacRehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary RehabilitationPrograms). It includes coverage and coding requirements for pulmonary rehabilitation services beginningJanuary 1, 2010.Outpatient Observation ServicesCMS deleted Section 290.3 of Chapter 4 of the Medicare Claims Processing Manual (CMS Pub. 100-04)and reserved it for future use. This section, “Billing and Payment for Observation Services Furnished Priorto January 1, 2006,” is no longer relevant for claims processing purposes. In addition, CMS is makingminor revisions to Section 290.5.2 (Billing and Payment for Direct Referral for Observation Care FurnishedBeginning January 1, 2008) to reflect the change in the code descriptor of HCPCS code G0379 (Directreferral for hospital observation care), which is effective January 1, 2010.Home Health & Hospice February 1, 2010 22Medicare A Newsline Vol. 17, No. 5

Kidney Disease EducationSection 152(b) of MIPPA added kidney disease education (KDE) as a Medicare Part B covered benefiteffective January 1, 2010, for beneficiaries diagnosed with Stage IV chronic kidney disease (CKD).Medicare will cover up to and including six KDE sessions for beneficiaries referred by the physicianmanaging the beneficiary’s kidney condition when the beneficiary has been diagnosed with Stage IV CKD.To be covered, these services must be furnished by a “qualified person”. A qualified person is a physician,physician assistant, nurse practitioner, or clinical nurse specialist or a provider of services located in a ruralarea; or a hospital or critical access hospital (CAH) that is treated as being located in a rural area underSection 412.103 of the Code of Federal Regulations (CFR). Renal dialysis facilities and providers ofservices located outside a rural area, except for hospitals or CAHs that are treated as being located in a ruralarea under CFR Section 412.103, are excluded from the definition of a “qualified person.”KDE services furnished by rural providers of services, including a hospital or CAH that is treated as beinglocated in a rural area under CFR Section 412.103, are paid under the Medicare Physician Fee Schedule.KDE services should be reported using the HCPCS codes G0420 (Face-to-face educational services relatedto the care of chronic kidney disease; individual, per session, per one hour) and G0421 (Face-to-faceeducational services related to the care of chronic kidney disease; group, per session, per one hour). Furtherinformation on billing, coverage, and payment of KDE services can be found in the Medicare Benefit PolicyManual, (CMS Pub. 100-02) Chapter 15, Section 310 and the Medicare Claims Processing Manual, (CMSPub 100-04) Chapter 32, Section 20, as discussed in CR 6557.Billing for Allogeneic and Autologous Stem Cell Transplant ProceduresCMS added Section 231.11 to the Medicare Claims Processing Manual, (CMS Pub. 100-04) Chapter 4, toclarify billing for allogeneic stem cell transplant procedures when provided in the outpatient setting.Allogeneic stem cell transplant procedures are payable under Part A or Part B depending upon whether thetransplant takes place in the inpatient or outpatient setting. Payment for allogeneic stem cell acquisitionservices (including harvesting procedures) is packaged into the payment for the transplant procedure whenprovided in the outpatient setting. CMS also updated Chapter 4, Section 231.10 and Chapter 3, Section90.3.3 to reflect that allogeneic stem cell transplant procedures may be billed and paid under Part B whenprovided in the hospital outpatient setting.Payment for Brachytherapy SourcesFor CY 2010, CMS proposed and finalized payment for brachytherapy sources using prospective ratesbased on Medicare claims data. For CY 2009 and most previous years, brachytherapy sources have beenpaid based on charges adjusted to a hospital’s cost. The Medicare Improvement for Patients and ProvidersAct of 2008 (MIPPA) requires CMS to pay for brachytherapy sources for the period of July 1, 2008, throughDecember 31, 2009, at hospitals’ charges adjusted to the costs. CMS, therefore, has continued payingbrachytherapy sources based on charges adjusted to cost for CY 2009. The status indicators of separatelypayable brachytherapy source HCPCS codes (except HCPCS code C2637) that were previously paid atcharges adjusted to cost remain “U,” which is the status indicator for separately payable brachytherapysources irrespective of the payment methodology applied. CMS established status indicator “U” effectiveJanuary 1, 2009.These changes are reflected in the table below for all sources (with the exception of HCPCS code C2637,which is non-payable). In addition, because they will be paid prospectively beginning on January 1, 2010,brachytherapy sources will be eligible for outlier payments and for the rural sole community hospital (SCH)adjustment. The HCPCS codes for brachytherapy sources, long descriptors, status indicators, and APCs forCY 2010 are listed in Table 4, the comprehensive brachytherapy source table below.Home Health & Hospice February 1, 2010 23Medicare A Newsline Vol. 17, No. 5

NOTE: When billing for stranded sources, providers should bill the number of units of the appropriatesource HCPCS C-code according to the number of brachytherapy sources in the strand, and should not billas one unit per strand. See Transmittal 1259, CR 5623, issued June 1, 2007, for further information onbilling for brachytherapy sources and the OPPS coding changes made for brachytherapy sources effectiveJuly 1, 2007. The MLN Matters® article related to CR 5623 is available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5623.pdf on the CMS Web site.Table 4- Comprehensive List of Brachytherapy Source HCPCS Codes as of January 1, 2010CY 2010HCPCSCodeCY 2010 Long DescriptorCY2010SICY2010APCA9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie U 2632C1716 Brachytherapy source, non-stranded, Gold-198, per source U 1716C1717 Brachytherapy source, non-stranded, High Dose Rate Iridium-192, per U 1717sourceC1719 Brachytherapy source, non-stranded, Non-High Dose Rate Iridium-192, U 1719per sourceC2616 Brachytherapy source, non-stranded, Yttrium-90, per source U 2616C2634 Brachytherapy source, non-stranded, High Activity, Iodine-125, greater U 2634than 1.01 mCi (NIST), per sourceC2635 Brachytherapy source, non-stranded, High Activity, Palladium-103, U 2635greater than 2.2 mCi (NIST), per sourceC2636 Brachytherapy linear source, non-stranded, Palladium-103, per 1MM U 2636C2637 Brachytherapy source, non-stranded, Ytterbium-169, per source B N/AC2638 Brachytherapy source, stranded, Iodine-125, per source U 2638C2639 Brachytherapy source, non-stranded, Iodine-125, per source U 2639C2640 Brachytherapy source, stranded, Palladium-103, per source U 2640C2641 Brachytherapy source, non-stranded, Palladium-103, per source U 2641C2642 Brachytherapy source, stranded, Cesium-131, per source U 2642C2643 Brachytherapy source, non-stranded, Cesium-131, per source U 2643C2698 Brachytherapy source, stranded, not otherwise specified, per source U 2698C2699 Brachytherapy source, non-stranded, not otherwise specified, per source U 2699Billing for Drugs, Biologicals, and Radiopharmaceuticalsa. Reporting HCPCS Codes for All Drugs, Biologicals, and RadiopharmaceuticalsHospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals,regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for theitems used. It is also of great importance that hospitals billing for these products make certain that thereported units of service of the reported HCPCS codes are consistent with the quantity of a drug, biological,or radiopharmaceutical that was used in the care of the patient.More complete data from hospitals on the drugs and biologicals provided during an encounter would helpimprove payment accuracy for separately payable drugs and biologicals in the future. CMS stronglyencourages hospitals to report HCPCS codes for all drugs and biologicals furnished, if specific codes areavailable.Home Health & Hospice February 1, 2010 24Medicare A Newsline Vol. 17, No. 5

CMS’ longstanding policy under the OPPS is to refrain from instructing hospitals on the appropriaterevenue code to use to charge for specific services. While CMS does not require hospitals to use revenuecode 0636 (Pharmacy-Extension of 025x; Drugs Requiring Detailed coding (a)) when billing for drugs andbiologicals that have HCPCS codes, whether they are separately payable or packaged, CMS believes that apractice of billing all drugs and biologicals with HCPCS codes under revenue code 0636 would beconsistent with National Uniform Billing Committee (NUBC) billing guidelines and would provide it withthe most complete and detailed information for future ratesetting. CMS’ standard ratesetting methodologyis to rely on hospital cost and charge information as it is reported to us by hospitals through the claims dataand cost reports.CMS reminds hospitals that under the OPPS, if two or more drugs or biologicals are mixed together tofacilitate administration, the correct HCPCS codes should be reported separately for each product used inthe care of the patient. The mixing together of two or more products does not constitute a "new" drug asregulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process. Inthese situations, hospitals are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS codeC9399, Unclassified Drug or Biological, is for new drugs and biologicals that are approved by the FDA onor after January 1, 2004, for which a HCPCS code has not been assigned.Unless otherwise specified in the long description, HCPCS descriptions refer to the non-compounded, FDAapprovedfinal product. If a product is compounded and a specific HCPCS code does not exist for thecompounded product, the hospital should report an appropriate unlisted code such as J9999 or J3490.b. New CY 2010 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, andRadiopharmaceuticalsFor CY 2010, several new HCPCS codes have been created for reporting drugs and biologicals in thehospital outpatient setting, where there have not previously been specific codes available. These new codesare listed in Table 5 below.Table 5-New CY 2010 HCPCS Codes Effective for Certain Drugs, Biologicals, andRadiopharmaceuticalsCY 2010HCPCSCodeCY 2010 Long DescriptorCY2010SICY 2010APCA9583 Injection, gadofosveset trisodium, 1 ml G 1299C9254 Injection, lacosamide, 1 mg K 9254C9255 Injection, paliperidone palmitate, 1 mg G 9255C9256 Injection, dexamethasone intravitreal implant, 0.1 mg G 9256J0586 Injection, abobotulinumtoxintypeA, 5 units K 1289J1680* Injection, human fibrinogen concentrate, 100 mg G 1290J2793 Injection, Rilonacept K 1291J9155 Injection, degarelix, 1 mg G 1296Q0138Injection, Ferumoxytol, for treatment of iron deficiency anemia, 1mgG 1297*Note: HCPCS code J1680 is identified as a blood clotting factor and, as such, is subject to the CY 2010blood clotting factor furnishing fee.Home Health & Hospice February 1, 2010 25Medicare A Newsline Vol. 17, No. 5

c. Other Changes to CY 2010 HCPCS Codes for Certain Drugs, Biologicals, andRadiopharmaceuticalsMany HCPCS codes for drugs, biologicals, and radiopharmaceuticals have undergone changes in theirHCPCS code descriptors that will be effective in CY 2010. In addition, several temporary HCPCS C-codeshave been deleted effective December 31, 2009, and replaced with permanent HCPCS codes in CY 2010.Hospitals should pay close attention to accurate billing for units of service consistent with the dosagescontained in the long descriptors of the active CY 2010 HCPCS codes.Table 6-Other CY 2010 HCPCS Code Changes for Certain Drugs, Biologicals, andRadiopharmaceuticalsCY 2009HCPCS CY 2009 Long DescriptorCode90378 Respiratory syncytial virus immuneglobulin (RSV-IgIM), for intramuscularuse, 50 mg, each90663 Influenza virus vaccine, pandemicformulation90669 Pneumococcal conjugate vaccine,polyvalent, when administered to childrenyounger than 5 years, for intramuscularuseA9500 Technetium tc-99m sestamibi, diagnostic,per study dose, up to 40 millicuriesCY 2010HCPCS CY 2010 Long DescriptorCode90378 Respiratory syncytial virus,monoclonal antibody, recombinant,for intramuscular use, 50 mg, each90663 Influenza virus vaccine, pandemicformulation, H1N190669 Pneumococcal conjugate vaccine, 7valent, for intramuscular useA9500Technetium tc-99m sestamibi,diagnostic, per study doseA9535 Injection, methylene blue, 1 ml Q9968 Injection, non-radioactive, noncontrast,visualization adjunct (e.g.,methylene blue, isosulfan blue), 1mgA9605Samarium sm-153 lexidronamm,therapeutic, per 50 millicuriesA9604Samarium SM-153 lexidronam,therapeutic, per treatment dose, up to150 millicuriesC9245 Injection, romiplostim, 10 mcg J2796 Injection, Romiplostim, 10microgramsC9246 Injection, gadoxetate disodium, per ml A9581 Injection, gadoxetate disodium, 1 mlC9247Iobenguane, I-123, diagnostic, per studydose, up to 10 millicuriesA9582Iodine I-123 iobenguane, diagnostic,per study dose, up to 15 millicuriesC9249 Injection, certolizumab pegol, 1 mg J0718 Injection, certolizumab pegol, 1 mgC9251 Injection, C1 esterase inhibitor (human),10 unitsJ0598 Injection, C1 esterase inhibitor(human), 10 unitsC9252 Injection, plerixafor, 1 mg J2562 Injection, Plerixafor, 1 mgC9253 Injection, temozolomide, 1 mg J9328 Injection, temozolomide, 1 mgHome Health & Hospice February 1, 2010 26Medicare A Newsline Vol. 17, No. 5

CY 2009HCPCSCodeC9358C9359CY 2009 Long Descriptor CY 2010HCPCSCodeDermal substitute, native, nondenaturedcollagen (SurgiMend Collagen Matrix),per 0.5 square cmPorous purified collagen matrix bone voidfiller (Integra Mozaik OsteoconductiveScaffold Putty, Integra OSOsteoconductive Scaffold Putty), per 0.5ccC9358C9359CY 2010 Long DescriptorDermal substitute, native, nondenaturedcollagen, fetal bovineorigin (SurgiMend Collagen Matrix),per 0.5 square centimetersPorous purified collagen matrix bonevoid filler (Integra MozaikOsteoconductive Scaffold Putty,Integra OS Osteoconductive ScaffoldPutty), per 0.5 ccJ0460 Injection, atropine sulfate, up to 0.3 mg J0461 Injection, atropine sulfate, 0.01 mgJ0530 Injection, penicillin g benzathine and J0559 Injection, penicillin G benzathinepenicillin g procaine, up to 600,000 unitsand penicillin G procaine, 2500 unitsJ0540J0550Injection, penicillin g benzathine andpenicillin g procaine, up to 1,200,000unitsInjection, penicillin g benzathine andpenicillin g procaine, up to 2,400,000unitsJ0559J0559Injection, penicillin G benzathineand penicillin G procaine, 2500 unitsInjection, penicillin G benzathineand penicillin G procaine, 2500 unitsJ0585 Botulinum toxin type a, per unit. J0585 Injection, onabotulinumtoxina, 1 unitJ0587 Botulinum toxin type b, per 100 units J0587 Injection, rimabotulinumtoxinb, 100unitsJ0835 Injection, cosyntropin, per 0.25 mg J0833 Injection, cosyntropin, not otherwisespecified, 0.25 mgJ0835 Injection, cosyntropin, per 0.25 mg J0834 Injection, cosyntropin (cortrosyn),0.25 mgJ1565 Injection, respiratory syncytial virusimmune globulin, intravenous, 50 mg90379 Respiratory syncytial virus immuneglobulin (rsv-igiv), human, forintravenous useJ7192J7322Factor viii (antihemophilic factor,recombinant) per i.u.Hyaluronan or derivative, synvisc, forintra-articular injection, per doseJ7192J7325Factor viii (antihemophilic factor,recombinant) per i.u., not otherwisespecifiedHyaluronan or derivative, synvisc orsynvisc-one, for intra-articularinjection, 1 mgJ9170 Injection, docetaxel, 20 mg J9171 Injection, docetaxel, 1 mgQ2009 Injection, fosphenytoin, 50 mg Q2009 Injection, Fosphenytoin, 50 mgphenytoin equivalentQ2023 Injection, factor viii (antihemophilicfactor, recombinant) (Xyntha), per i.u.J7185 Injection, factor viii (antihemophilicfactor, recombinant) (xyntha), peri.u.Q2024 Injection, bevacizumab, 0.25 mg C9257 Injection, bevacizumab, 0.25 mgHome Health & Hospice February 1, 2010 27Medicare A Newsline Vol. 17, No. 5

d. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective January 1,2010For CY 2010, payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals is madeat a single rate of ASP+4 percent, which provides payment for both the acquisition cost and pharmacyoverhead costs associated with the drug, biological or therapeutic radiopharmaceutical. In CY 2010, asingle payment of ASP+6 percent for pass-through drugs, biologicals and radiopharmaceuticals is made toprovide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items.CMS notes that for the first quarter of CY 2010, payment for drugs and biologicals with pass-through statusis not made at the Part B Drug Competitive Acquisition Program (CAP) rate, as the CAP was suspendedbeginning January 1, 2009. Should the Part B Drug CAP be reinstituted sometime during CY 2010, wewould again use the Part B drug CAP rate for pass-through drugs and biologicals if they are a part of thePart B drug CAP, as required by the statute.In the CY 2010 OPPS/ASC final rule with comment period, CMS states that payments for drugs andbiologicals based on ASPs will be updated on a quarterly basis as subsequent quarter ASP submissionsbecome available. Effective January 1, 2010, payment rates for many drugs and biologicals have changedfrom the values published in the CY 2010 OPPS/ASC final rule with comment period as a result of the newASP calculations based on sales price submissions from the third quarter of CY 2009. In cases whereadjustments to payment rates are necessary, changes to the payment rates will be incorporated in the January2010 release of the OPPS Pricer. CMS is not publishing the updated payment rates in CR 6751. However,the updated payment rates effective January 1, 2010, can be found in the January 2010 update of the OPPSAddendum A and Addendum B at http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp on the CMSWeb site.e. Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2009, through June 30, 2009The payment rates for several HCPCS codes were incorrect in the April 2009 OPPS Pricer. The correctedpayment rates are listed below and have been installed in the January 2010 OPPS Pricer, effective forservices furnished on April 1, 2009, through implementation of the July 2009 update. Claims processedwith the incorrect rates will be adjusted if you bring such claims to the attention of your contractor.Table 7-Updated Payment Rates for Certain HCPCS Codes Effective April 1, 2009, through June 30,2009CY 2009HCPCSCodeCY2009SICY2009APCShort DescriptorCorrectedPaymentRateCorrected MinimumUnadjustedCopaymentC9245 G 9245 Injection, romiplostim $44.81 $8.79J1260 K 0750 Dolasetron mesylate $4.54 $0.91J2778 K 9233 Ranibizumab injection $399.55 $79.91f. Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2009, through September 30,2009The payment rates for several HCPCS codes were incorrect in the July 2009 OPPS Pricer. The correctedpayment rates are listed below and have been installed in the January 2010 OPPS Pricer, effective forservices furnished on July 1, 2009, through implementation of the October 2009 update. Claims processedwith the incorrect rates will be adjusted if you bring such claims to the attention of your contractor.Home Health & Hospice February 1, 2010 28Medicare A Newsline Vol. 17, No. 5

Table 8-Updated Payment Rates for Certain HCPCS Codes Effective July 1, 2009, throughSeptember 30, 2009CY 2009HCPCSCodeCY2009SICY2009APCShort DescriptorCorrectedPaymentRateCorrected MinimumUnadjustedCopaymentC9354 G 9354 Veritas collagen matrix, cm2 $11.77 $2.31C9364 G 9364 Porcine implant, Permacol $18.46 $3.62J1520 K 0921 Gamma globulin 7 CC inj $102.15 $20.43g. Correct Reporting of Biologicals When Used As Implantable DevicesWhen billing for biologicals where the HCPCS code describes a product that is solely surgically implantedor inserted, whether the HCPCS code is identified as having pass-through status or not, hospitals are toreport the appropriate HCPCS code for the product. In circumstances where the implanted biological haspass-through status, either as a biological or a device, a separate payment for the biological or device ismade. In circumstances where the implanted biological does not have pass-through status, the OPPSpayment for the biological is packaged into the payment for the associated procedure.When billing for biologicals where the HCPCS code describes a product that may either be surgicallyimplanted or inserted or otherwise applied in the care of a patient, hospitals should not separately report thebiological HCPCS codes, with the exception of biologicals with pass-through status, when using these itemsas implantable devices (including as a scaffold or an alternative to human or nonhuman connective tissue ormesh used in a graft) during surgical procedures. Under the OPPS, hospitals are provided a packaged APCpayment for surgical procedures that includes the cost of supportive items, including implantable deviceswithout pass-through status. When using biologicals during surgical procedures as implantable devices,hospitals may include the charges for these items in their charge for the procedure, report the charge on anuncoded revenue center line, or report the charge under a device HCPCS code (if one exists) so these costswould appropriately contribute to the future median setting for the associated surgical procedure.h. Correct Reporting of Units for DrugsHospitals and providers are reminded to ensure that units of drugs administered to patients are accuratelyreported in terms of the dosage specified in the full HCPCS code descriptor. Units should be reported inmultiples of the units included in the HCPCS descriptor. For example, if the description for the drug code is6 mg, and 6 mg of the drug was administered to the patient, the units billed should be 1. As anotherexample, if the description for the drug code is 50 mg, but 200 mg of the drug was administered to thepatient, the units billed should be 4. Providers and hospitals should not bill the units based on the way thedrug is packaged, stored, or stocked. If the HCPCS descriptor for the drug code specifies 1 mg and a 10 mgvial of the drug was administered to the patient, hospitals should bill 10 units, even though only 1 vial wasadministered. The HCPCS short descriptors are limited to 28 characters, including spaces, so shortdescriptors do not always capture the complete description of the drug. Therefore, before submittingMedicare claims for drugs and biologicals, it is extremely important to review the complete long descriptorsfor the applicable HCPCS codes.i. Payment for Therapeutic RadiopharmaceuticalsBeginning in CY 2010, nonpass-through separately payable therapeutic radiopharmaceuticals are paid underthe OPPS based upon the ASP. If ASP data are unavailable, payment for therapeutic radiopharmaceuticalswill be provided based on the most recent hospital mean unit cost data. Therefore, effective January 1,2010, the status indicator for separately payable therapeutic radiopharmaceuticals is “K” to reflect theirHome Health & Hospice February 1, 2010 29Medicare A Newsline Vol. 17, No. 5

separately payable status under the OPPS. Similar to payment for other separately payable drugs andbiologicals, the payment rates for nonpass-through separately payable therapeutic radiopharmaceuticals willbe updated on a quarterly basis.Table 9-Nonpass-Through Separately Payable Therapeutic Radiopharmaceuticals Effective January1, 2010CY 2010HCPCSCodeCY 2010 Long DescriptorFinal CY2010 APCFinalCY2010 SIA9517 Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie 1064 KA9530 Iodine I-131 sodium iodide solution, therapeutic, per millicurie 1150 KA9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, 1643 Kup to 40 millicuriesA9545 Iodine I-131 tositumomab, therapeutic, per treatment dose 1645 KA9563 Sodium phosphate P-32, therapeutic, per millicurie 1675 KA9564 Chromic phosphate P-32 suspension, therapeutic, per millicurie 1676 KA9600 Strontium Sr-89 chloride, therapeutic, per millicurie 0701 KA9604 Samarium SM-153 lexidronam, therapeutic, per treatment dose, upto 150 millicuries1295 Kj. Reporting of Outpatient Diagnostic Nuclear Medicine ProceduresCMS applies nuclear medicine procedure-to-radiolabeled product edits in the I/OCE effective January 2008that require a radiolabeled product to be present on the same claim as a nuclear medicine procedure forpayment under the OPPS to be made. These edits have been revised quarterly, based on informationprovided to us by members of the public with regard to certain clinical scenarios. CMS is updating the listsof nuclear medicine procedures and radiolabeled products for CY 2010. The complete list of updatednuclear medicine procedure-to-radiolabeled product edits can be found athttp://www.cms.hhs.gov/HospitalOutpatientPPS/02_device_procedure.asp#TopOfPage on the CMS Website.With the specific exception of HCPCS code C9898 (Radiolabeled product provided during a hospitalinpatient stay) to be reported by hospitals on outpatient claims for nuclear medicine procedures to indicatethat a radiolabeled product that provides the radioactivity necessary for the reported diagnostic nuclearmedicine procedure was provided during a hospital inpatient stay, hospitals should only report HCPCScodes for products they provide in the hospital outpatient department and should not report a HCPCS codeand charge for a radiolabeled product on the nuclear medicine procedure-to-radiolabeled product edit listsolely for the purpose of bypassing those edits present in the I/OCE.As stated in the October 2009 OPPS update, in the rare instance when a diagnostic radiopharmaceutical maybe administered to a beneficiary in a given calendar year prior to a hospital furnishing an associated nuclearmedicine procedure in the subsequent calendar year, hospitals are instructed to report the date theradiolabeled product is furnished to the beneficiary as the same date that the nuclear medicine procedure isperformed. CMS believes that this situation is extremely rare and we expect that the majority of hospitalswill not encounter this situation.Home Health & Hospice February 1, 2010 30Medicare A Newsline Vol. 17, No. 5

k. Payment Offset for Pass-Through Diagnostic RadiopharmaceuticalsEffective for nuclear medicine services furnished on and after April 1, 2009, CMS implemented a paymentoffset for pass-through diagnostic radiopharmaceuticals under the OPPS. As discussed in Transmittal 1702,CR 6416, issued March 13, 2009, pass-through payment for a diagnostic radiopharmaceutical is thedifference between the payment for the pass-through product and the payment for the predecessor productthat, in the case of diagnostic radiopharmaceuticals, is packaged into the payment for the nuclear medicineprocedure in which the diagnostic radiopharmaceutical is used. The MLN Matters ® article related to CR6416 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6416.pdf on the CMSWeb site.Effective April 1, 2009, the diagnostic radiopharmaceutical reported with HCPCS code C9247 (Iobenguane,I-123, diagnostic, per study dose, up to 10 millicuries) was granted pass-through status under the OPPS andassigned status indicator “G.” Therefore, in CY 2009, when HCPCS code C9247 is billed on the sameclaim with a nuclear medicine procedure, CMS reduces the amount of payment for the pass-throughdiagnostic radiopharmaceutical reported with HCPCS code C9247 by the corresponding nuclear medicineprocedure’s portion of its APC payment associated with “policy-packaged” drugs (offset amount) so noduplicate radiopharmaceutical payment is made.For CY 2010, HCPCS code C9247 is being replaced with HCPCS code A9582 (Iodine I-123 iobenguane,diagnostic, per study dose, up to 15 millicuries) and HCPCS code A9582 will continue on pass-throughstatus for CY 2010. Therefore, for CY 2010, HCPCS code A9582 will be assigned status indicator “G” andwill be subject to the pass-through payment offset for pass-through diagnostic radiopharmaceuticals. Theoffset will cease to apply when this diagnostic radiopharmaceutical expires from pass-through status.The “policy-packaged” portions of the CY 2010 APC payments for nuclear medicine procedures may befound on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/APF/list.asp#TopOfPage inthe download file labeled 2010 OPPS Offset Amounts by APC.CY 2010 APCs to which nuclear medicine procedures are assigned and for which we expect a diagnosticradiopharmaceutical payment offset could be applicable in the case of a pass-through diagnosticradiopharmaceutical are displayed in the following table.Table 10-APCs to Which Nuclear Medicine Procedures are Assigned for CY 2010CY 2010 APC CY 2010 APC Title0307 Myocardial Positron Emission Tomography (PET) imaging0308 Non-Myocardial Positron Emission Tomography (PET) imaging0377 Level II Cardiac Imaging0378 Level II Pulmonary Imaging0389 Level I Non-imaging Nuclear Medicine0390 Level I Endocrine Imaging0391 Level II Endocrine Imaging0392 Level II Non-imaging Nuclear Medicine0393 Hematologic Processing & Studies0394 Hepatobiliary ImagingHome Health & Hospice February 1, 2010 31Medicare A Newsline Vol. 17, No. 5

CY 2010 APCCY 2010 APC Title0395 GI Tract Imaging0396 Bone Imaging0397 Vascular Imaging0398 Level I Cardiac Imaging0400 Hematopoietic Imaging0401 Level I Pulmonary Imaging0402 Level II Nervous System Imaging0403 Level I Nervous System Imaging0404 Renal and Genitourinary Studies0406 Level I Tumor/Infection Imaging0408 Level III Tumor/Infection Imaging0414 Level II Tumor/Infection Imagingl. Introduction of Payment Offset for Pass-Through Contrast AgentsAs discussed in the CY 2010 OPPS/ASC final rule with comment period, effective for pass-through contrastagents furnished on and after January 1, 2010, when a contrast-enhanced procedure that is assigned to aprocedural APC with a “policy-packaged” drug amount greater than $20 (that is not an APC containingnuclear medicine procedures) is billed on the same claim with a pass-through contrast agent on the samedate of service, CMS will reduce the amount of payment for the contrast agent by the correspondingcontrast-enhanced procedure’s portion of its APC payment associated with “policy-packaged” drugs (offsetamount) so no duplicate contrast agent payment is made.CY 2010 procedural APCs for which CMS expects a contrast agent payment offset could be applicable inthe case of a pass-through contrast agent are identified in the table below this section. Pass-throughpayment for a contrast agent is the difference between the payment for the pass-through product and thepayment for the predecessor product that, in the case of a contrast agent, is packaged into the payment forthe contrast-enhanced procedure in which the contrast agent is used. For CY 2010, when a contrast agentwith pass-through status is billed with a contrast-enhanced procedure assigned to any procedural APC listedin this section’s table on the same date of service, a specific pass-through payment offset determined by theprocedural APC to which the contrast-enhanced procedure is assigned will be applied to payment for thecontrast agent to ensure that duplicate payment is not made for the contrast agent.Effective January 1, 2009, contrast agent HCPCS code C9246 (Injection, gadoxetate disodium, per ml) wasgranted pass-through status under the OPPS and was assigned status indicator “G.” As the pass-throughoffset methodology was not in place for contrast agents in CY 2009, payments for HCPCS code C9246 werenot reduced by the corresponding contrast-enhanced procedure’s portion of its APC payment associatedwith “policy-packaged” drugs (offset amount).For CY 2010, HCPCS code C9246 is being replaced with HCPCS code A9581 (Injection, gadoxetatedisodium, 1 ml) and HCPCS code A9581 will continue on pass-through status for CY 2010. In addition,HCPCS code A9583 (Injection, gadofosveset trisodium, 1 ml) describes a contrast agent that has beengranted pass-through status beginning January 1, 2010. Both HCPCS codes A9581 and A9583 will beassigned status indicator “G” and will be subject to the payment offset methodology for contrast agents.Home Health & Hospice February 1, 2010 32Medicare A Newsline Vol. 17, No. 5

Therefore, in CY 2010 CMS will reduce the payment for HCPCS codes A9581 and A9583 by the estimatedamount of payment that is attributable to the predecessor contrast agent that is packaged into payment forthe associated contrast-enhanced procedure reported on the same claim on the same date as HCPCS codeA9581 or A9583 if the contrast-enhanced procedure is assigned to one of the APCs listed in the table below.The “policy-packaged” portions of the CY 2010 APC payments that are the offset amounts may be found onthe CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/APF/list.asp#TopOfPage in thedownload file labeled 2010 OPPS Offset Amounts by APC.When HCPCS code A9581 or A9583 is billed on a claim on the same date of service as one or moreprocedures assigned to an APC listed in the following table, the OPPS Pricer will identify the offset amountor amounts that apply to the contrast-enhanced procedures that are reported on the claim. Where there is asingle contrast-enhanced procedure reported on the claim with a single occurrence of either HCPCS codeA9581 or A9583, the OPPS Pricer will identify a single offset amount for the procedure billed and adjustthe offset by the wage index value that applies to the hospital submitting the claim. Where there aremultiple contrast procedures on the claim with a single occurrence of the pass-through contrast agent, theOPPS Pricer will select the contrast-enhanced procedure with the single highest offset amount and adjust theselected offset amount by the wage index value of the hospital submitting the claim. When a claim hasmore than one occurrence of either HCPCS code A9581 or A9583, the OPPS Pricer will rank potentialoffset amounts associated with the units of contrast-enhanced procedures on the claim and identify a totaloffset amount that takes into account the number of occurrences of the pass-through contrast agent on theclaim and adjust the total offset amount by the wage index value of the hospital submitting the claim. Theadjusted offset amount will be subtracted from the APC payment for the pass-through contrast agentreported with either HCPCS code A9581 or A9583. The offset will cease to apply when each of thesecontrast agents expires from pass-through status.Table 11-APCs to Which a Pass-Through Contrast Agent Offset May Be Applicable for CY 2010CY 2010 APC CY 2010 APC Title0080 Diagnostic Cardiac Catheterization0082 Coronary or Non-Coronary Atherectomy0083 Coronary or Non-Coronary Angioplasty and Percutaneous Valvuloplasty0093 Vascular Reconstruction/Fistula Repair without Device0104 Transcatheter Placement of Intracoronary Stents0128 Echocardiogram with Contrast0152 Level I Percutaneous Abdominal and Biliary Procedures0229 Transcatheter Placement of Intravascular Shunts0278 Diagnostic Urography0279 Level II Angiography and Venography0280 Level III Angiography and Venography0283 Computed Tomography with Contrast0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast0333 Computed Tomography without Contrast followed by Contrast0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrastfollowed by ContrastHome Health & Hospice February 1, 2010 33Medicare A Newsline Vol. 17, No. 5

CY 2010 APC CY 2010 APC Title0375 Ancillary Outpatient Services When Patient Expires0383 Cardiac Computed Tomographic Imaging0388 Discography0418 Insertion of Left Ventricular Pacing Elect.0442 Dosimetric Drug Administration0653 Vascular Reconstruction/Fistula Repair with Device0656 Transcatheter Placement of Intracoronary Drug-Eluting Stents0662 CT Angiography0668 Level I Angiography and Venography8006 CT and CTA with Contrast Composite8008 MRI and MRA with Contrast CompositeDrug Administration ServicesAs discussed in the CY 2010 OPPS/ASC final rule with comment period, drug administration services willcontinue to be reported using the full set of drug administration CPT codes with the following exception.CMS notes that new CPT code 90470 (H1N1 immunization administration (intramuscular, intranasal),including counseling when performed) has been created by CPT for administration of the H1N1 vaccine forCY 2010. We are assigning this code status indicator “E” for OPPS payment purposes in CY 2010.Hospitals that administer the H1N1 vaccine should continue to use HCPCS code G9141 (Influenza A(H1N1) drug administration (includes the physician counseling the patient/family) for services furnished onor after September 1, 2009. Further information related to H1N1 codes can be found in Transmittal 547, CR6633, issued August 28, 2009.Changes to OPPS Pricer Logica. Rural sole community hospitals and essential access community hospitals (EACHs) will continue toreceive a 7.1 percent payment increase for most services in CY 2010. The rural SCH and EACHpayment adjustment excludes drugs, biologicals, items and services paid at charges reduced to cost, anditems paid under the pass-through payment policy in accordance with section 1833(t)(13)(B) of the Act,as added by section 411 of Pub. L. 108-173.b. New OPPS payment rates and copayment amounts will be effective January 1, 2010. All coinsurancerates will be limited to a maximum of 40 percent of the APC payment rate. Copayment amounts for eachservice cannot exceed the inpatient deductible of $1,100.c. For hospital outlier payments under OPPS, there will be no change in the multiple threshold of 1.75 for2010. This threshold of 1.75 is multiplied by the total line-item APC payment to determine eligibilityfor outlier payments. This factor also is used to determine the outlier payment, which is 50 percent ofestimated cost less 1.75 times the APC payment amount. The payment formula is (cost-(APC paymentx 1.75))/2.d. However, there will be a change in the fixed-dollar threshold in CY 2010. The estimated cost of aservice must be greater than the APC payment amount plus $2,175 in order to qualify for outlierpayments. The previous fixed-dollar threshold for CY 2009 was $1,800.Home Health & Hospice February 1, 2010 34Medicare A Newsline Vol. 17, No. 5

e. For outliers for Community Mental Health Centers (bill type 76x), there will be no change in themultiple threshold of 3.4 for 2010. This threshold of 3.4 is multiplied by the total line-item APCpayment for APC 0173 to determine eligibility for outlier payments. This multiple amount is also usedto determine the outlier payment, which is 50 percent of estimated costs less 3.4 times the APC paymentamount. The payment formula is (cost-(APC 0173 payment x 3.4))/2.f. Effective January 1, 2010, MIPPA provisions authorizing payment for brachytherapy sources (statusindicator “U”) at charges reduced to cost expire, and Pricer will make payment based on final CY 2010prospective payment rates. Note that the payment and copayment reduction for the Hospital OutpatientQuality Data Reporting Program (HOP QDRP) (section j.) will apply to brachytherapy sourcesbeginning January 1, 2010. Brachytherapy sources are eligible to receive outlier payments.Brachytherapy sources are not subject to the wage adjustment, but do receive the adjustment for ruralsole community hospitals and essential access community hospitals.g. Effective January 1, 2010, MIPPA provisions authorizing payment for therapeutic radiopharmaceuticalsat charges reduced to cost expire, and Pricer will make prospective payment based either on the ASP forthose therapeutic radiopharmaceuticals for which manufacturers submit ASP data or on mean unit cost.Therapeutic radiopharmaceuticals without pass-through status will have a status indicator of “K”beginning in CY 2010. Like other drugs and biologicals, therapeutic radiopharmaceuticals are noteligible to receive outlier payments or the adjustment for rural sole community hospitals and essentialaccess hospitals, and are not wage-adjusted.h. Effective January 1, 2009, status indicator “R” is used to denote blood and blood products for paymentpurposes. Blood and blood products are eligible to receive outlier payments. Blood and blood productsare not subject to wage adjustment, but do receive the adjustment for rural sole community hospitals andessential access community hospitals.i. Effective January 1, 2010, no devices are eligible for pass-through payment in the OPPS Pricer logic.There are no associated APC offset amounts or specific logic assigning device payment to associatedAPC payment for determining outlier eligibility and payment.j. Effective January 1, 2010, the OPPS Pricer will apply a reduced update ratio of 0.980 to the paymentand copayment for hospitals that fail to meet their HOP QDRP reporting requirements or that fail tomeet CMS validation edits. The reduced payment amount will be used to calculate outlier payments.k. Effective January 1, 2010, there will be 1 diagnostic radiopharmaceutical receiving pass-throughpayment in the OPPS Pricer logic. For APCs containing nuclear medicine procedures, Pricer willreduce the amount of the pass-through diagnostic radiopharmaceutical payment by the wage-adjustedoffset for the APC with the highest offset amount when the radiopharmaceutical with pass-throughappears on a claim with a nuclear procedure. The offset will cease to apply when the diagnosticradiopharmaceutical expires from pass-through status. The offset amounts for diagnosticradiopharmaceuticals are the “policy-packaged” portions of the CY 2010 APC payments for nuclearmedicine procedures and may be found athttp://www.cms.hhs.gov/HospitalOutpatientPPS/APF/list.asp#TopOfPage in the download file labeled2010 OPPS Offset Amounts by APC.l. Effective January 1, 2010, there will be 2 contrast agents receiving pass-through payment in the OPPSPricer logic. For a specific set of APCs identified elsewhere in this update, Pricer will reduce theamount of the pass-through contrast agent by the wage-adjusted offset for the APC with the highestoffset amount when the contrast agent with pass-through status appears on a claim on the same date ofservice with a procedure from the identified list of APCs with procedures using contrast agents. Theoffset will cease to apply when the contrast agent expires from pass-through status. The offset amountsfor contrast agents are the “policy-packaged” portions of the CY 2010 APC payments for proceduresusing contrast agents and may be found on the CMS Web site.Home Health & Hospice February 1, 2010 35Medicare A Newsline Vol. 17, No. 5

m. Pricer will update the payment rates for drugs, biologicals, and therapeutic radiopharmaceuticals whenthose payment rates are based on ASP on a quarterly basis.n. Effective January 1, 2010, CMS is adopting the FY 2010 Inpatient Prospective Payment System (IPPS)post-reclassification wage index values with application of out-commuting adjustment authorized bysection 505 of Pub. L. 108-173 to non-IPPS hospitals discussed below.Wage Indices for Non-IPPS Hospitals Eligible for the Out-Commuting Adjustment Authorized bySection 505 of Pub. L. 108-173Wage indexes for Non-IPPS hospitals eligible for the Out-Commuting Adjustment authorized by Section505 of Public Law 108-173 can be found in Table 12 of CR 6751.Coverage DeterminationsThe fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under theOPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, orservice may be paid if covered by the program. Fiscal intermediaries (FIs)/Medicare administrativecontractors (MACs) determine whether a drug, device, procedure, or other service meets all programrequirements for coverage. For example, FIs/MACs determine that it is reasonable and necessary to treat thebeneficiary’s condition and whether it is excluded from payment.Additional InformationIf you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select“Telephone Us” to call the Provider Contact Center.The official instruction (CR 6751) was issued to your Medicare A/B MAC and/or fiscal intermediary viatwo transmittals. The first transmittal, R1882CP, modifies the Medicare Claims Processing Manual and islocated at http://www.cms.hhs.gov/Transmittals/downloads/R1882CP.pdf on the CMS Web site. Thesecond transmittal, R116BP, provides the revisions to the Medicare Benefit Policy Manual and thattransmittal is located at http://www.cms.hhs.gov/Transmittals/downloads/R116BP.pdf on that same site.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. CPT onlycopyright 2009 American Medical Association.News from CMS for Hospice ProvidersTracking the Hospice Attending Physician’s National Provider Identifier (NPI) forValidating Hospice Part B Payments—RevisedThe Centers for Medicare & Medicaid Services (CMS) has issued a revision to the Medicare LearningNetwork (MLN) Matters article, “Tracking the Hospice Attending Physician’s National Provider IdentifierHome Health & Hospice February 1, 2010 36Medicare A Newsline Vol. 17, No. 5

(NPI) for Validating Hospice Part B Payments,” which was published in the January 1, 2010, Home Health& Hospice Medicare A Newsline. This MLN Matters article and other CMS articles can be found on theCMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters ® Number: MM6540 Revised Related Change Request (CR) #: 6540Related CR Release Date: December 23, 2009 Effective Date: January 1, 2010 for OPTIONALreporting by hospices; April 1, 2010 forMANDATORY reporting by hospicesRelated CR Transmittal #: R1885CP Implementation Date: January 4, 2010Note: This article was revised on December 24, 2009, to reflect changes made to CR 6540 onDecember 23, 2009. The article was revised to show that the reporting instructions for hospices areOPTIONAL beginning January 1, 2010, but are required as of April 1, 2010. Also, the CR releasedate, transmittal number and the Web address for accessing the CR were revised.Provider Types AffectedHospices submitting claims to Medicare contractors (A/B Medicare administrative contractors (A/B MACs),and/or regional home health intermediaries (RHHIs)) for services provided to Medicare beneficiaries in ahospice benefit period.What You Need to KnowThis article is based on CR 6540 which is meant to ensure that the hospice reported data in the Notice ofElection (NOE) and claims for the attending physician which may be a Nurse Practitioner (NP) meet thedefinition of attending physician/NP in the Code of Federal Regulations (CFR), while also reporting thehospice physician responsible for certifying the terminal illness.BackgroundEffective with NOEs/claims with effective dates or dates of service on or after January 1, 2010, hospicesmay begin to report the National Provider Identifier (NPI) of the attending physician/NP in the attendingphysician field of the NOE and claim. For NOEs/claims with effective dates or dates of service on or afterApril 1, 2010, hospices must report this data. The 42 CFR 418.3 defines the attending physician as:• A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State inwhich he or she performs that function or action or NP who meets the training, education, andexperience requirements as described in 42 CFR 410.75; and• Is identified by the individual, at the time of his/her election to receive hospice care, as having themost significant role in the determination and delivery on the individual’s medical care.In addition, for claims with dates of service on or after January 1, 2010, and on NOEs with effective dateson or after January 1, 2010, the hospice may begin to enter, in the “Other Physician” field on theNOE/claim, the NPI and name of the hospice physician responsible for certifying the patient is terminallyill, with a life expectancy of 6 months or less if the disease runs its normal course. Hospices are required toreport this data on NOEs/claims with effective dates or dates of service on or after April 1, 2010. Note thatboth the attending physician and other physician fields should be completed even if the hospice physiciancertifying the terminal illness is the same as the attending physician.Additional InformationThe official instruction, CR 6540, issued to your A/B MAC or RHHI regarding this change may be viewedat http://www.cms.hhs.gov/Transmittals/downloads/R1885CP.pdf on the CMS Web site.Home Health & Hospice February 1, 2010 37Medicare A Newsline Vol. 17, No. 5

If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select“Telephone Us” 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.Additional Data Collection on Hospice Claims—RevisedThe Centers for Medicare & Medicaid Services (CMS) has issued a revision to the Medicare LearningNetwork (MLN) Matters article, “Additional Data Collection on Hospice Claims,” which was published inthe June 1, 2009, Home Health & Hospice Medicare A Newsline. This MLN Matters article and other CMSarticles can be found on the CMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters ® Number: MM6440 Revised Related Change Request (CR) #: 6440Related CR Release Date: May 15, 2009Effective Date: October 1, 2009, for optionalreporting by hospices and January 1, 2010, formandatory reporting by hospicesRelated CR Transmittal #: R1738CP Implementation Date: October 5, 2009Note: This article was revised on January 6, 2010, to clarify that the mandatory reportingrequirement is effective for claims with dates of service on or after January 1, 2010. All otherinformation remains the same.Provider Types AffectedHospices billing regional home health intermediaries (RHHIs) or Medicare administrative contractors (A/BMACs) for providing routine home care, continuous home care, or respite care to Medicare beneficiaries.Provider Action Needed STOP – Impact to YouEffective January 1, 2010, hospices must report additional detail for visits with the appropriate revenuecodes (RCs) and HCPCS codes, or their claims will be returned.CAUTION – What You Need to KnowCR 6440, from which this article is taken, requires hospices (effective for claims with dates of service on orafter January 1, 2010) to report additional data on claims for Medicare payment that describe the servicesprovided when delivering routine home care, continuous home care, and respite care.GO – What You Need to DoYou should make sure that your billing staffs are aware of these new requirements. See the “Background”section for details.Home Health & Hospice February 1, 2010 38Medicare A Newsline Vol. 17, No. 5

BackgroundOver the past several years the Medicare Payment Advisory Commission (MedPAC), the GeneralAccounting Office, and the Office of the Inspector General have all recommended that CMS collect morecomprehensive data in order to better evaluate trends in the utilization of the Medicare hospice benefit.In response, CMS began collecting additional data on hospice claims beginning in January 2007 with CR5245, which required the reporting of a Healthcare Common Procedure Coding System (HCPCS) code onthe claim to describe the location where services were provided. CR 5245 also required reporting ofcontinuous home care time in 15-minute increments. (You can find the MLN Matters ® article related to CR5245 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5245.pdf on the CMS Web site).In April 2008, CMS issued CR 5567, requiring Medicare hospices (effective July 2008) to provide detail onclaims about the number of physician, nurse, aide, and social worker visits provided to beneficiaries. (Youcan find the MLN Matters ® article related to CR 5567 athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5567.pdf on the CMS Web site).Since then, MedPAC and industry representatives have informed CMS that the newly required claimsinformation was not comprehensive enough to accurately reflect hospice care, and this restricts Medicare’sability to ensure optimal payment accuracy in the hospice benefit. Of particular concern, was the fact thatCMS was not requiring that visit intensity be reported. Reporting visit intensity would improve Medicare’sability to analyze the services provided in this growing benefit.Reporting RequirementsCR 6440, from which this article is taken, requires that (effective January 1, 2010) hospices begin to reportadditional detail for visits on their claims. Specifically, on a separate line on your claims for all routinehome care (RHC), continuous home care (CHC), and respite care billing, you must report:• Each visit performed by nurses, aides, and social workers, whom you employ, along with theirassociated time per visit (in 15-minute increments) with the time reported using the associated HCPCSG-code as follows:• Revenue code 055x (nursing services) with HCPCS G0154,• Revenue code 057x (aide services) with HCPCS G0156, or• Revenue code 056x (medical social services) with HCPCS G0155.• Each RHC, CHC, and respite visit that physical therapists, occupational therapists, and speech-languagetherapists performed and their associated time per visit (in 15-minute increments), with the time reportedusing the associated HCPCS G-code as follows:• Revenue Code 042x (physical therapy) with HCPCS G0151,• Revenue Code 043x (occupational therapy) with HCPCS G0152, or• Revenue Code 044x (speech language therapy) with HCPCS G0153.• Report each telephone call that social workers made to the patient or the patient’s family using revenuecode 0569 and HCPCS G-code G0155 for the length of the call, with each call being a separate lineitem. Report only those telephone calls that are necessary for the palliation and management of theterminal illness and related conditions as described in the patient’s plan of care (such as counseling orspeaking with a patient’s family or arranging for a placement). Report only social worker phone callsrelated to providing and or coordinating care to the patient and family, and documented as such in theclinical records.Home Health & Hospice February 1, 2010 39Medicare A Newsline Vol. 17, No. 5

When recording any visit or social worker phone call time, you should sum the time for each visit or call,rounding to the nearest 15-minute increment and report in the unit field on the line level the units as amultiplier of the visit time defined in the HCPCS description. Do not include travel time or documentationtime in the time recorded for any visit or call. Additionally, you may not include interdisciplinary grouptime in time and visit reporting.The following table displays these new reporting requirements.Data Collection Requirements for Hospices Delivering Routine Home Care, Continuous Home Care,and Respite Care Effective January 1, 2010Revenue CodeRequiredHCPCS CodeRequired Detail042xPhysical TherapyG0151043xOccupational TherapyG0152044xSpeech Therapy – Language Pathology055xSkilled Nursing056xMedical Social Services056xOther Medical Social Services057xAideG0153G0154G0155G0155G0156Identify each visit, or social worker phone call,on a separate line item with the appropriateline item date of service and a charge amount.The units reported on the claim are themultiplier for the total time of the visit definedin the HCPCS description.Note: Effective for claims with dates of service on or after January 1, 2010, Medicare contractors will returnyour claims with reason code 31428 that do not contain revenue codes 0655 and 0656, but DO contain oneor more of visit revenue codes 042x, 043x, 044x, 055x, 056x, or 57x without the appropriate HCPCS code.They will also return claims with reason code 31429 containing revenue code 0569 when billed withoutHCPCS code G0155.Additional Key Points in CR6440• Charges associated with the reported revenue codes 42x, 43x, 44x, 55x, 56x, and 57x are covered underthe hospice bundled payment and are reflected in the payment for the level of care billed on the claim.No additional payment is made on the visit revenue lines. These visit charges will be identified on theprovider remittance advice notice with reason code 97 (“Payment adjusted because the benefit for thisservice is included in the payment / allowance for another service / procedure that has already beenadjudicated.”) and code CO (Contractual Obligation).• If a hospice patient is receiving respite care in a contract facility, you should not report visit and timedata by non-hospice staff.• Billing of physician visits to hospice patients is not changing, and is unaffected by CR 6440.Home Health & Hospice February 1, 2010 40Medicare A Newsline Vol. 17, No. 5

• Data on claims for chaplains/spiritual counselors or volunteers will not be collected at this time, butreporting of this data will be in a future phase of the data collection.• For general inpatient (GIP) care, the reporting of visit intensity data is not required at this time.Providers should continue to report the number of GIP visits in accordance with CR 5567. Additionally,the units for visits under GIP level of care continue to reflect the number of visits per week, and visitreporting by non-hospice staff is exempted when hospice patients in a contract facility are receivingGIP.Additional InformationYou can find more information about the additional data collection requirements on hospice claims by goingto CR 6440, located at http://www.cms.hhs.gov/Transmittals/downloads/R1738CP.pdf on the CMS Website. You will find the updated Medicare Claims Processing Manual, Ch. 11 (Processing Hospice Claims),§30.3 (Data Required on Claim to FI) as an attachment to that CR.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select“Telephone Us” to call the Provider Contact Center.Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.News from Cahaba for Home Health and Hospice ProvidersClarification on Submitting Medicare Secondary Payer (MSP) Claims/AdjustmentsThe following provides clarification about submitting MSP claims/adjustments according to therequirements provided in Change Request 6426, effective October 5, 2009. Previous information wasprovided to you in e-mail messages dated September 30 and October 9, 2009, and in the November 1, 2009,Home Health & Hospice Medicare A Newsline.BackgroundChange Request (CR) 6426 requires that CAS segments be submitted on MSP claims and adjustmentswhere the primary insurance had made a payment. CAS segments are not utilized when MSP claims andadjustments are entered directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry(DDE) environment. The following provides additional clarification in regard to how to submit MSPclaims/adjustments in certain MSP situations.Home Health & Hospice February 1, 2010 41Medicare A Newsline Vol. 17, No. 5

Submit MSP Claims/Adjustments via:When:FISS DDE • Services are unrelated to an open MSP record (liability,workers’ comp, no-fault, etc.)• The primary insurance denied payment.Electronically (i.e., a billing software inthe American National Standard Institute(ANSI) ASC X12N 837 4010-A1 format(e.g., PC-Ace Pro32 v. 2.14))PaperNote: If your facility does not have awaiver due to meeting the small providerexception, (CMS Pub. 100-04, Ch. 24,§90), see the instructions below underthe “Unable to Submit ClaimsElectronically” header.• Claim is for services where another insurer has made apayment.• Claims where another insurer is primary, and there is apossibility/expectation that the primary insurer willmake a payment in the future. Example, services arerelated to a liability record; however, there was no promptresponse/payment (within 120 days) from the primaryinsurer after submitting your claim to them.• Claims where the primary insurer applied the chargesto the deductible.• Claims where the beneficiary has coverage throughBlack Lung. Refer to Cahaba’s Federal Black Lung (BL)Program Web page for additional information.Important Reminders• Correcting MSP Claims and AdjustmentsIf an MSP claim/adjustment was submitted electronically, and is returned to provider (RTP) (status/locationT B9997) for correction, you must resubmit the claim electronically. If you correct the claim via FISSDDE, the claim/adjustment will receive reason code 31265 and will remain in the RTP file.• Verify Required Data Entered Based on Claim’s Type of Bill (TOB)To avoid needlessly resubmitting an MSP claim numerous times, it is important that providers verify that allrequired claim data is present for the type of bill they are submitting (example, home health final claim orhospice claim), and that the information (including the required MSP claim data) is complete and correct.• Unable To Submit Claims ElectronicallyIf you are unable to submit claims electronically using the 837 format:Step 1: Submit a claim via FISS DDE showing Medicare as the primary payer. This will result in theclaim being rejected.Please be aware that claims may reject to FISS status/location (S/LOC) R B75XX or R B9997.If your claim rejects to an R B75XX S/LOC, it will remain there for at least 75 days. Providerswill be unable to submit an adjustment to a rejected claim until it moves to a finalized R B9997S/LOC.Home Health & Hospice February 1, 2010 42Medicare A Newsline Vol. 17, No. 5

Step 2: Submit a hardcopy (paper) adjustment to the rejected (R B9997) claim and include all theinformation regarding payment from the primary payer source. This includes the amountreceived as payment (if payment was received), the amount the provider is obligated to acceptas payment in full, and any deductible or coinsurance amounts that were applied. Foradditional information about submitting MSP information, refer to Cahaba’s “MedicareSecondary Payer (MSP) Billing: Quick Reference Tool at:https://www.cahabagba.com/rhhi/education/materials/quick_msp.pdfHardcopy (paper) claims and adjustments can be mailed to the following address:Cahaba GBAMedicare A ClaimsP.O. Box 9169Des Moines, IA 50306-9169Change Request 6426For additional information, you can find the official instruction (CR 6426) for this requirement by visitinghttp://www.cms.hhs.gov/transmittals/downloads/R70MSP.pdf on the CMS Web site. You will find theupdated Medicare Secondary Payer (MSP) Manual, (CMS Pub 100-05) Ch. 5 (Contractor PrepaymentProcessing Requirements), §40.7.3.2 (Medicare Secondary Payment Part A Claims Determination forServices Received on 837 Institutional Electronic or Hardcopy Claims Format) as an attachment to that CR.The related Medicare Learning Network (MLN) article is located at:http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6426.pdfChanges to Hospice Benefit Period Information on ELGA/ELGHThe Common Working File (CWF) has changed the ELGA/ELGH screens that display the hospice benefitperiod information. Effective January 4, 2010, ELGA/ELGH displays any applicable hospice periods thathave a termination date that is six months prior to the date entered in the ‘APP DATE’ field. If no date isentered, the ELGA/ELGH displays hospice periods that have a termination date that is six months prior tothe current date. As a result, if you wish to view current hospice benefit period information, you must entera future date (within 6 months) in the ‘APP DATE’ field.The following examples show information using the ELGH eligibility screen. The same results will displaywhen the ELGA eligibility screen is used.Home Health & Hospice February 1, 2010 43Medicare A Newsline Vol. 17, No. 5

Example 1: ABC Home Health is admitting a new patient and checks the ELGH screen for Medicareeligibility information. In this example, the current date is entered in the ‘APP DATE’ field. If the ‘APPDATE’ field is left blank, the same results will display.ELGH CWF PART A ELIGIBILITY SYSTEM ELGASAT101/08/2010 14:23:00 INQUIRY BY HOME HEALTH AGENCYENTER THE FOLLOWING FIELDS:HIC NUMBER : 123456789ASURNAME : SmithINITIAL : JDATE OF BIRTH : 01011920 (MMDDCCYY)SEX CODE : MREQUESTOR ID : 0011INTER NO : 00011NPI INDICATOR :N-NPI or BlankPROVIDER NO : XXXXXXHOST-ID : GL, GW, KS, MA, PA, NE, SE, SO, SWAPP DATE : 01082010 (MMDDCCYY)REASON CODE : 1RESPONSE CODE : PThe most recent hospice benefit period, 09/26/2009 – 11/24/2009 displays because the ‘TERM DATE’ of11/24/2009 is within 6 months prior to the current date of 01/08/2010, which was entered in the ‘APPDATE’ field.ELGH CWF PART A ELIGIBILITY SYSTEM ELGHCRO01/08/2010 14:23:33 HOSPICE INFORMATION PAGE 09 OF 09HOS-REC CN 123456789A NM SMITH IT J DB 01011920 SX MHOSPICE PERIOD 1 PERIOD 2 PERIOD 3 PERIOD PERIODSTART DATE 05/29/2009 07/28/2009 09/26/2009TERM DATE 07/27/2009 09/25/2009 11/24/2009PROVIDER NO XXXXXX XXXXXX XXXXXXINTER NO XXXXX XXXXX XXXXXREVOC INDNote in Example 1 (above) that a revocation indicator does not display in the ‘REVOC IND’ field.Therefore, it is possible that the beneficiary is still receiving hospice benefits. To determine if thebeneficiary is enrolled in a more recent hospice benefit period, you need to enter a future date in the ‘APPDATE’ field. Refer to Example 2.Home Health & Hospice February 1, 2010 44Medicare A Newsline Vol. 17, No. 5

Example 2: A future date of 05/01/2010 is entered in the ‘APP DATE’ field.ELGH CWF PART A ELIGIBILITY SYSTEM ELGASAT101/08/2010 14:23:00 INQUIRY BY HOME HEALTH AGENCYENTER THE FOLLOWING FIELDS:HIC NUMBER : 123456789ASURNAME : SmithINITIAL : JDATE OF BIRTH : 01011920 (MMDDCCYY)SEX CODE : MREQUESTOR ID : 0011INTER NO : 00011NPI INDICATOR :N-NPI or BlankPROVIDER NO : XXXXXXHOST-ID : GL, GW, KS, MA, PA, NE, SE, SO, SWAPP DATE : 05012010 (MMDDCCYY)REASON CODE : 1RESPONSE CODE : PIn this example, only the two most recent benefit periods display because, the ‘TERM DATE’ dates for eachperiod, 11/24/2009 and 01/23/2010, are within six months prior to the date entered in the ‘APP DATE’field.ELGH CWF PART A ELIGIBILITY SYSTEM ELGHCRO01/08/2010 14:44:47 HOSPICE INFORMATION PAGE 09 OF 09HOS-REC CN 123456789A NM SMITH IT J DB 01011920 SX MHOSPICE PERIOD 1 PERIOD 2 PERIOD PERIOD PERIODSTART DATE 09/26/2009 11/25/2009TERM DATE 11/24/2009 01/23/2010PROVIDER NO XXXXXX XXXXXXINTER NO XXXXX XXXXXREVOC INDNote: In Example 2, if the future date of 07/25/2010 or after would be entered in the ‘APP DATE’ field, nohospice benefit period information would display because the ‘TERM DATE’ is not within 6 months priorto the date entered.If you are having difficulty determining whether the beneficiary is in a 60- or 90-day benefit period, wesuggest that you review the ELGA/ELGH eligibility screens again, after your Notice of Election (NOE) hasprocessed (status/location P B9997). Once the NOE is processed, the ELGA/ELGH screens will update toidentify the Start and Term dates of the hospice benefit period to which your admission applies.In addition, the CWF system release also changed how hospice benefit period information is displayed onthe ELGA/ELGH eligibility screens. Previously, the most recent benefit period information was displayedon the left side of the screen. With these changes, the most recent benefit information now displays on theright.The hospice benefit period information is also provided on Cahaba’s Interactive Voice Response (IVR).If you have questions about this information, please call a customer service representative in our ProviderContact Center at 1-866-539-5592.Home Health & Hospice February 1, 2010 45Medicare A Newsline Vol. 17, No. 5

Before You Call Cahaba, Read This!From October 1, 2008, through September 30, 2009, the home health (877-299-4500) and hospice (866-539-5592) Customer Service Representatives (CSRs) answered 51,690 questions from home health and hospiceproviders. Based on a review of the topics most asked during October through December 2009, theFrequently Asked Questions (FAQs) for the top inquiries received in Cahaba’s Home Health & HospiceProvider Call Center (PCC) have been updated. The updated FAQs can be accessed on our Web site usingthe following link: http://www.cahabagba.com/rhhi/faqs/index.htmProviders should use all of our self-service technology tools to resolve their Medicare questions beforecontacting a CSR*. A variety of resources are available to assist you. The FAQs and the “Resources for theMost Common Medicare Part A Provider Questions” Web page are valuable resources to refer to beforecalling a CSR. Additional resources include Cahaba’s Interactive Voice Response (IVR) unit or other selfservicetechnology, Cahaba’s and CMS’s Web site, Cahaba and CMS Listserv messages, and a wide varietyof Internet-based provider educational offerings. Providers without Internet access may request a copy ofthe FAQs or other materials posted to Cahaba’s Web site by calling the Provider Outreach and Educationdepartment at 515-471-7335.In looking at the reasons why home health and hospice agencies most frequently call Cahaba, the five issuesbelow represent 34% of all inquiries received. Please review the following information and use theresources cited prior to calling Cahaba for assistance. If the issue still is not resolved, we would encourageyou then to call the PCC for help.Reason for CallExplain reasoncode assigned toclaim needingcorrection. Thereason codes mostinquired aboutinclude:Number ofPrior to Calling Cahaba:Calls4,774 Review the Top Claim Submission Errors and How to Resolve Webpage, which includes links to “Web help” pages for each of the reasoncodes listed.Hospice37402U5181Home Health311473175538107U538GU538IHome Health & Hospice February 1, 2010 46Medicare A Newsline Vol. 17, No. 5

Reason for CallClaim submittedoverlaps anotherepisode, benefitperiod or claimNumber ofPrior to Calling Cahaba:Calls4,372 At a minimum, ensure that you are reviewing ELGH pages 3, 9 and/orELGA pages 2, 4 for home health episodes of care or hospice benefitperiods prior to admission and submitting home health or hospicebilling transactions to Medicare. For more information about thesescreens, use the Checking Beneficiary Eligibility section of FISSReference Guide to assist.Prior to transferring or receiving a home health or hospice patientto/from another home health or hospice facility, review the informationon the following Web pages:Home Healthwww.cahabagba.com/rhhi/claims/home_health/bene_transfer.htmwww.cahabagba.com/rhhi/claims/errors_U538I.htmHospicewww.cahabagba.com/rhhi/claims/hospice/transfer.htmwww.cahabagba.com/rhhi/claims/hospice/seq_billing.htmwww.cahabagba.com/rhhi/claims/errors_u5106.htmPrior to discharging or readmitting a home health or hospice patient,review the information on the following Web pages:Home Healthwww.cahabagba.com/rhhi/claims/home_health/discharge_readmit.htmwww.cahabagba.com/rhhi/claims/errors_U538G.htmIf the dates of service of a home health episode overlap an inpatientstay, review:www.cahabagba.com/rhhi/claims/home_health/overlap.htmwww.cahabagba.com/rhhi/claims/errors_c7080.htmHospicewww.cahabagba.com/rhhi/claims/hospice/discharge_revoke.htmHome Health & Hospice February 1, 2010 47Medicare A Newsline Vol. 17, No. 5

Reason for CallClaim needingcorrection due tomissing or invalidcodeNumber ofPrior to Calling Cahaba:Calls3,610 For assistance in billing appropriate codes (i.e., source of admission,patient status, revenue, HCPC) on home health and hospice billingtransactions, review:Home Health• Claims Filing Web pages• Billing Codes quick reference toolFor questions regarding which positions of the HIPPS code mustmatch on home health RAPs/claims or submitting the appropriateHIPPS code when billing supplies on home health claims, review:www.cahabagba.com/rhhi/claims/errors_38107.htmwww.cahabagba.com/rhhi/claims/errors_31147.htmHospice• Claims Filing Web pages• Billing Codes quick reference toolHome Health and HospiceFor information on the codes required for Medicare Secondary Payer(MSP) claims, or adjusted or cancelled claims, review:• MSP Billing quick reference tool• MSP Web page• Claims Correction section, FISS Reference Guide• Adjustments/Cancels Web pageRequestinstructions forfiling/billingservices toMedicare3,142 Instructions most requested:Home Health• Billing RAPs/final claims:Claims Filing Web pages• Billing non-routine supplies:HH PPS Claims With Non-Routine Supplies (NRS) Web pageClaims Processing and Reimbursement Changes for Home HealthSupplies Web pageClaim Page 02 – Entering a RAP or Claim Web pageHospice• Billing Hospice Physician Services quick reference tool• Submitting hospice revocation indicator:Claim Page 01 — Entering a Hospice Claim Web pageOccurrence Code 42 Omitted Web pageHome Health & Hospice February 1, 2010 48Medicare A Newsline Vol. 17, No. 5

Reason for CallClaim rejectedbecause ofbeneficiaryeligibility recordNumber ofCallsPrior to Calling Cahaba:1,686 Check ELGH/ELGA screens prior to submitting claims to Medicare.For assistance in updating the beneficiary’s name, Medicareentitlement dates, or date of death, contact the Social SecurityAdministration at 1-800-772-1213.Medicare Advantage plan enrollment dates:• Contact individual MA plan to update incorrect dates• Submit services to MA Plan, if Option Code “C” on ELGH pg. 5or ELGA pg. 1, and no hospice election impacts dates of service(DOS)Medicare Secondary Payer records:• Contact the Coordination of Benefits Contractor (COBC) at 1-800-999-1118 to update records• If date(s) of service overlap an MSP record:• Submit claim to primary insurance, if appropriate• Submit Medicare claim with MSP information (see the resourceslisted above for assistance with Medicare MSP claims)NOTE: RAPs/NOEs are always submitted with Medicare as theprimary payerIf the dates of service on your home health final claim fall outsideepisodes posted to beneficiary record, review the information on theCorrecting Home Health Episode Information Posted to the CommonWorking File (CWF) Web page.For additional information for home health providers, see theResolving Rejected Home Health Claims Caused by Billing ErrorsWeb page.If incorrect dates were posted for a hospice benefit period provided byyour hospice facility, see the Canceling a Notice of Election or BenefitPeriod Web page.*Source of information, the Medicare Contractor Beneficiary and Provider Communications Manual (Pub.100-9, Chapter 6)Home Health & Hospice February 1, 2010 49Medicare A Newsline Vol. 17, No. 5

Availability of the Provider Contact Center (PCC)Medicare is a continuously changing program, and it is important that we provide correct and accurateanswers to your questions. To better serve the provider community, the Centers for Medicare & MedicaidServices (CMS) allows the provider contact centers the opportunity to offer training to our customer servicerepresentatives (CSRs). Listed below is the date and time the home health and hospice PCC (1-877-299-4500 and 1-866-539-5592) will be closed for training. We will continue to notify you of future CSRtraining dates in the Home Health & Hospice Medicare A Newsline.CSR Training DateFebruary 15, 2010 (Federal Holiday)Time8:00 a.m.—4:30 p.m. Central TimeNews from Cahaba for Hospice ProvidersReminder of Physician Narrative and Attestation Requirement on HospiceCertificationsAs a reminder, the August 6, 2009, Federal Register mandated that hospice certifications/recertificationsmust now include a brief narrative by the certifying physician to explain their clinical findings that supportthe patient’s life expectancy of six months or less. The narrative shall include a statement under thephysician signature attesting that by signing, the physician confirms that he/she composed the narrativebased on his/her review of the patient’s medical record, or if applicable, his or her examination of thepatient. The narrative must be composed by the same physician that signs the certification/recertification.Our Medical Review Department has informed us that many hospices are complying with the use of thephysician narrative requirement; however, the attestation statement is missing. Our Medical Review staffwill deny hospice claims which do not include this attestation statement on the narrative for thecertification/recertification. Therefore, ensure your hospice agency has implemented the necessary steps toinclude the attestation statement on narratives for your certifications and recertifications. For moreinformation about this requirement, please view the “Reminder – New Hospice Certification/RecertificationRequirements” article on page 28 of the October 1, 2009, Medicare A Newsline, or the “HospiceCertification/Recertification Requirements” Web page.Home Health & Hospice February 1, 2010 50Medicare A Newsline Vol. 17, No. 5

Cahaba Learning CornerFebruary and March 2010 Education EventsTo register for educational events, go to the “Calendar of Educational Events” page on our Web site.Select the event title for registration instructions.‣ “Medicare Secondary Payer (MSP) for Home Health & Hospice Agencies” WebinarDate: February 2, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: January 28, 2010Intended Audience: This Webinar is intended for home health and hospice agency staff, includingbillers, administrators, and financial personnel.Description: This Webinar will examine the situations when Medicare is the secondary payer toother types of insurance, as well as the recent changes for submitting MSP claims to Medicare.Resources for assisting in understanding MSP will also be identified and discussed.‣ “OASIS-C and Payment” WebinarDate: February 4, 2010Time: Noon – 1:30 p.m. Central TimeRegistration Deadline: February 1, 2010Intended Audience: Home health clinicians, administrators, QI coordinators.Description: This Webinar will cover the OASIS-C updated items and drive the HIPPS code forproper payment. Learn about new guidance, tools for reporting the proper response on the OASISitems, and how these drive payment.‣ “The Nuts and Bolts of Medicare Part A” WebinarDate: February 9, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: February 4, 2010Intended Audience: This Webinar is intended for home health and hospice providers who are newto the Medicare program, have staff new to Medicare, or who have 25 or fewer full-timeemployees.Description: This Webinar will provide a general overview of the Medicare program, with a focuson the Medicare Part A benefits, coverage criteria, and beneficiary costs. A review of criticalresources available to home health and hospice providers will also be discussed.Home Health & Hospice February 1, 2010 51Medicare A Newsline Vol. 17, No. 5

Cahaba GBA Learning Corner‣ “Home Health Billing – Part 1” WebinarDate: February 16, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: February 11, 2010Intended Audience: New home health providers or home health agencies with staff who are newto home health billing, and small home health agencies who have 25 or fewer full-time employees.Description: This event will provide basic education regarding home health eligibilityrequirements and billing a typical Request for Anticipated Payment (RAP), a final claim as well asappropriately submitting non-routine supplies. Resources for avoiding common home healthbilling errors will also be provided.‣ “Clinician’s ABCs of the Home Health Benefit” WebinarDate: February 18, 2010Time: Noon – 1:30 p.m. Central TimeRegistration Deadline: February 15, 2010Intended Audience: Home health clinicians, administrators, QI coordinatorsDescription: This Webinar will provide basic home health benefit information, including thequalifying criteria, what is a “skilled service” and what makes it medically necessary. Other topicsto be discussed include local coverage determinations and medical review.‣ “Hospice Billing – Part 1” WebinarDate: February 23, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: February 18, 2010Intended Audience: New hospice providers or hospices with staff who are new to hospice billing,and small hospice agencies who have 25 or fewer full-time employees.Description: This event will provide basic education regarding hospice eligibility requirements andbilling a notice of election (NOE) and a hospice claim as well as a review of levels of care andbilling of physician services. Resources for avoiding common hospice billing errors will also beprovided.Home Health & Hospice February 1, 2010 52Medicare A Newsline Vol. 17, No. 5

Cahaba GBA Learning Corner‣ “Clinician’s Intro to the Medicare Hospice Benefit” WebinarDate: February 25, 2010Time: Noon – 1:30 p.m. Central TimeRegistration Deadline: February 22, 2010Intended Audience: Hospice clinicians, administrators, QI coordinators.Description: This Webinar will provide basic hospice benefit information, including the qualifyingcriteria of election, certification and terminal prognosis. Other topics to be discussed include thehospice local coverage determinations and medical review.‣ “Home Health Billing – Part 2” WebinarDate: March 2, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: February 25, 2010Intended Audience: New home health providers or home health agencies with staff who are newto home health billing, and small home health agencies who have 25 or fewer full-time employees.Description: This event will discuss how to avoid billing errors for overlapping episodes and datesof service; appropriately submitting claims for special home health billing situations, andsubmitting demand and no-pay bills to Medicare. An overview of common home health billingerrors and resources for avoiding them will also be presented.‣ “Hospice Billing – Part 2” WebinarDate: March 9, 2010Time: Noon – 2:00 p.m. Central TimeRegistration Deadline: March 4, 2010Intended Audience: New hospice providers or hospices with staff who are new to hospice billing,and small hospice agencies who have 25 or fewer full-time employees.Description: This Webinar will present how and when to submit a cancel NOE, how to cancel abenefit period, appropriate billing of discharge/revocation claims, including the posting of revocationswhen omitted, and billing in transfer situations. In addition, the use of the advance beneficiary notice(ABN) will also be discussed as well as various billing situations and top billing errors and availableresources.Home Health & Hospice February 1, 2010 53Medicare A Newsline Vol. 17, No. 5

Cahaba GBA Learning Corner‣ “OASIS-C and Payment” Webinar (NOTE: This is a repeat of the February 4, 2010,presentation)Date: March 18, 2010Time: Noon – 1:30 p.m. Central TimeRegistration Deadline: March 12, 2010Intended Audience: Home health clinicians, administrators, QI coordinators.Description: This Webinar will cover the OASIS-C updated items and drive the HIPPS code forproper payment. Learn about new guidance, tools for reporting the proper response on the OASISitems, and how these drive payment.‣ “Online Courses” are computer-based and can be launched from the convenience of your owndesk. All courses are free and open to anyone.Course TitleAdjusting and Canceling ClaimsAdvanced Hospice BillingAppeals ProcessBasics of ICD-9-CM Coding for HomeHealth CliniciansBeginner Hospice BillingBeginner Home Health BillingCERT (Comprehensive Error Rate Test)Checking Claims StatusComprehending Medicare ClaimsProcessingMedicare Coding (Insight into)Medicare Cost Report (Introduction to)Medical Review (Getting a view of)Medicare Secondary PayerOverview of MedicareDescriptionLearn how to adjust or cancel claims.Learn about advanced hospice billing topics.Learn about the Medicare appeals process.Learn the basics ICD-9-CM coding.Learn the basics of hospice billing.Learn the basics of home health billing.Learn about the CERT Program.Learn how to use the Fiscal Intermediary StandardSystem (FISS) to check the status of your claims.Learn about Medicare claims processing.Learn the basics about Medicare coding.Learn the basics about the Medicare Cost ReportLearn the basics of the Medical review process.Learn the basics of Medicare Secondary Payer.Learn the basics about the Medicare program.Home Health & Hospice February 1, 2010 54Medicare A Newsline Vol. 17, No. 5

Cahaba GBA Learning Corner‣ “Online Courses” (continued)Course TitleProvider EnrollmentVerifying Beneficiary EligibilityDescriptionLearn about provider enrollment and how to apply.Learn how to identify various eligibilityinformation by using ELGA and ELGH.Please note these courses were designed specifically for providers served by Cahaba. You can findadditional national courses under the Medicare Learning Network.‣ Didn’t find what you were looking for? Visit our Web site—it provides a variety of valuableinformation and is continuously updated.‣ Stay Informed! Subscribe to the Cahaba E-mail Notification Service to receive the most currenthome health and hospice Medicare information. This service is free. When you subscribe, we’llsend you periodic e-mails telling you about new or updated information that has been added to ourWeb site. Your e-mail address will not be shared with other subscribers or given to advertisers, andonce subscribed, you can unsubscribe from the list, or change your e-mail address at any time.Home Health & Hospice February 1, 2010 55Medicare A Newsline Vol. 17, No. 5