Oct-Nov 00 Part A Bulletin - Medicare

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2 TABLE OF CONTENTS Table of Contents In This Issue .............................................. 1 From the Intermediary Medical Director A Physician’s Focus Diagnosis and Procedure Coding ............... 3 Administrative About the Medicare A Bulletin ..................... 5 General Information Changes to the Remittance Advice Notice .................................................. 6 Overpayment Interest Rate ......................... 6 Update of Rates for Ambulatory Surgical Center (ASC) Payments ...................... 6 General Coverage Ocular Photodynamic Therapy (OPT) ......... 7 Additional Coverage for Autologous Stem Cell Transplantation ..................... 7 Medicare Beneficiaries Participating in Medicare Qualifying Clinical Trials ...... 8 Hospital Services Outpatient Hospital Services Proper Billing of Outpatient Pathology Services under the Outpatient Prospective Payment System ............ 11 Proper Billing of Units for Intrathecal Baclofen under the Outpatient Prospective Payment System ............ 12 Inpatient Hospital Services Interim Process for Certain “Inpatient Only” Code Changes ........................ 12 Skilled Nursing Facility Services Skilled Nursing Facility Adjustment Billing: Adjustments to HIPPS Codes Resulting from MDS Corrections ........................................ 13 Annual Update to the Prospective Payment System (PPS) Pricer and Health Insurance Prospective Payment System (HIPPS) Coding Changes 14 Payment of Skilled Nursing Facility Claims for Beneficiaries Disenrolling from Terminating Medicare+Choice (M+C) Plans Who Have Not Met the 13-Day Hospital Stay Requirements .............. 14 Local and Focused Medical Review Policies General Information About Medical Policies .............................. 17 Medical Policy Table of Contents .............. 17 Final Medical Policies 44388: Colonoscopy ................................. 18 78472: Cardiac Blood Pool Imaging ......... 22 80100: Qualitative Drug Screen ................ 25 83540: Iron ................................................ 28 84484: Troponin ........................................ 30 93875: Noninvasive Extracranial Arterial Studies .................................. 33 95004: Allergy Skin Test............................ 37 95115: Allergen Immunotherapy ............... 39 95934: H-Reflex Study .............................. 41 G0102: Prostate Cancer Screening .......... 43 J0001: Self-Administrative Drugs ............. 45 J1440: G-CSF (Filgrastim, Neupogen®) .. 47 Q0136: Non-ESRD Epoetin (Procrit) ........ 50 Addition to Previously Published Medical Policy J9999: Antineoplastic Drugs-Irinotecan (Camptosar®) Addition to Policy........ 53 2001 ICD-9-CM Coding Changes Medical Policy Changes Relating to the 2001 ICD-9-CM Update ............... 53 Outpatient Prospective Payment System Coding Information for Hospital Outpatient Prospective Payment System ............................................... 56 First Update to the Coding Information for Hospital Outpatient Prospective Payment System ................................ 71 Educational Resources www.floridamedicare.com - Florida Medicare Provider Website ................ 81 Order Form - 2000 Part A Materials .......... 82 Other Information Index to Medicare A Bulletin .................. 83 Important Addresses, Telephone Numbers, and Websites .................... 87 The Florida Medicare A Bulletin Medicare A Bulletin Vol. 2, No. 5 October/November 2000 Publications Staff Millie C. Pérez Pauline Crutcher Shari Bailey Bill Angel The Medicare A Bulletin is published bimonthly by the Medicare Publications Department, to provide timely and useful information to Medicare Part A providers in Florida. Questions concerning this publication or its contents may be directed in writing to: Medicare Part A Publications P.O. Box 2078 Jacksonville, FL 32231-0048 CPT five-digit codes, descriptions, and other data only are copyrighted by American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. ICD-9-CM codes and their descriptions used in this publication are copyright© 1998 under the Uniform Copyright Convention. All rights reserved. Third-party websites. This document contains references to sites operated by third parties. Such references are provided for your convenience only. BCBSF and/or FCSO do not control such sites and are not responsible for their content. The inclusion of these references within this document does not suggest any endorsement of the material on such sites or any association with their operators. October/November 2000
A A A A PP PP A PHYSICIAN HYSICIAN HYSICIAN HYSICIAN’’’’’SSSSS HYSICIAN FOCUS FF OCUS OCUS OCUS OCUS DDDDD FROM THE INTERMEDIARY MEDICAL DIRECTOR FF Diagnosis and Procedure Coding Traditional Medicare implementation of the Outpatient Prospective Payment System has re-emphasized the importance of diagnosis and procedure coding in the correct payment of claims. The Health Care Financing Administration (HCFA) developed a new classification system, ambulatory payment classifications (APCs), with definitions based on HCFA Common Procedure Coding System (HCPCS) codes. International Classification of Diseases, Clinical Modification (ICD- CM) diagnosis codes were used in the research and development. It is important to remember that traditional Medicare utilizes two claim processing systems, one administered by carriers (Part B) requiring a HCFA-1500 claim form, and another administered by intermediaries (Part A and Part B of A- claims to intermediaries paid out of B funds) requiring a HCFA-1450 (UB-92) claim form. Within these formats are diagnosis and procedure coding requirements for services depending on the type of provider, type of service, type of payment program, HCFA instructions, and carrier/intermediary instructions. Providers need to be alert to the details of these requirements and not assume a procedure code definition unique to a service on a HCFA-1500 claim line translates to a definition on a UB-92 outpatient claim line. The following is a brief overview of diagnosis and procedure coding sources used in Medicare. There are two related classifications of diseases. The International Classification of Diseases (ICD) is the classification used to code and classify mortality data from death certificates. The International Classification of Diseases, Clinical Modification (ICD-CM) is used to code and classify morbidity data from the inpatient and outpatient records, physician and ancillary provider offices, and most National Center for Health Statistic (NCHS) surveys. The NCHS serves as the World Health Organization (WHO) Collaborating Center for the Classification of Diseases for North America and is responsible for coordination of all official disease classification activities in the United States relating to the ICD and its use, interpretation, and periodic revision. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the current official system of assigning codes to diagnoses associated with traditional Medicare claims and of assigning codes to procedures associated with Medicare part A inpatient claims only. The ICD-9-CM consists of a tabular list containing a numerical list of the disease code numbers; an alphabetical index to the disease entries; and a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list). The NCHS and HCFA, through the ICD-9-CM Coordination and Maintenance Committee, oversee all changes and modifications to the ICD-9-CM. Suggestions for modifications come from both the public and private sectors. Interested parties are asked to submit recommendations for modification. The implementation date of ICD-10-CM has not been announced and will be based on the process for adoption of standards under the Health Insurance Portability Act of 1996 with a two year implementation window once the final notice has been published in the Federal Register. HCFA developed HCPCS (HCFA Common Procedure Coding System) in 1983 as a three level coding system to provide a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies. Level I codes are the adopted American Medical Association CPT-4 (Current Procedural Terminology, 4th edition) that has been revised annually since 1983. Level II codes are published nationally by HCFA in order to augment CPT-4 and address non-physician services. Level III codes are established by local carriers/intermediaries and address new procedures and other nuances. HCFA is in the process of reducing and eliminating local codes. The CPT Editorial Panel is authorized to revise, update, or modify CPT. It is comprised of 16 members- 11 nominated by the AMA’s Board of Trustees and one each from the Blue Cross and Blue Shield Association, the Health Insurance Association of America, HCFA, the American Hospital Association, and October/November 2000 The Florida Medicare A Bulletin 3
Page 1: Bulletin A Newsletter for Florida M
Page 5 and 6: About The Medicare A Bulletin Octob
Page 7 and 8: CC GGGGGENERAL ENERAL ENERAL ENERAL
Page 9 and 10: Medicare Beneficiaries Participatin
Page 11 and 12: HH OOOOOUTPATIENT UTPATIENT UTPATIE
Page 13 and 14: NN FF October/November 2000 The Flo
Page 15 and 16: Annual Update to the PPS Pricer ...
Page 17 and 18: PP MMMMMEDICAL EDICAL EDICAL EDICAL
Page 19 and 20: 44388: Colonoscopy (continued) •
Page 21 and 22: 44388: Colonoscopy (continued) Star
Page 23 and 24: 78472: Cardiac Blood Pool Imaging (
Page 25 and 26: 80100: Qualitative Drug Screen LOCA
Page 27 and 28: 80100: Qualitative Drug Screen (con
Page 29 and 30: 83540: Iron (continued) ICD-9-CM Co
Page 31 and 32: 84484: Troponin (continued) HCPCS S
Page 33 and 34: LOCAL AND FOCUSED MEDICAL REVIEW PO
Page 35 and 36: 93875: Noninvasive Extracranial Art
Page 37 and 38: LOCAL AND FOCUSED MEDICAL REVIEW PO
Page 39 and 40: 95115: Allergen Immunotherapy Polic
Page 41 and 42: 95934: H-Reflex Study Policy Number
Page 43 and 44: G0102: Prostate Cancer Screening LO
Page 45 and 46: J0001: Self-Administered Drugs Poli
Page 47 and 48: J1440: G-CSF (Filgrastim, Neupogen
Page 49 and 50: J1440: G-CSF (Filgrastim, Neupogen
Page 51 and 52: Q0136: Non-ESRD Epoetin (Procrit) (
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LOCAL AND FOCUSED MEDICAL REVIEW PO
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2001 ICD-9-CM Coding Changes (conti
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OUTPATIENT PROSPECTIVE PAYMENT SYST
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October/November 2000 The Florida M
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A Abortion Services, Medicare Cover
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INDEX TO MEDICARE A BULLETIN R (con
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IMPORTANT ADDRESSES , TELEPHONE NUM
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Oct-Nov 00 Part A Bulletin - Medicare

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