Reminder - 2008 Physician Quality Reporting Initiative (PQRI) National Provider Conference Call with Question & Answer Session

The Centers for Medicare & Medicaid Services’ (CMS) Provider Communications Group will host the fifth in a series of national provider conference calls on the 2008 Physician Quality Reporting Initiative (PQRI).

Date: July 9, 2008
Conference Title: 2008 Physician Quality Reporting Initiative National Provider Call
Time: 3:30-5:00 EDT

Registration will close at 3:30 p.m. EDT on July 8, 2008, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time. To register for the call participants - click here. 

CWF July 4, 2008 Holiday Schedule

Any files received will be processed the following morning, July 5, 2008 and returned that day.

MLN Matters Articles from CMS

New:

SE0824 – Clarification of Medicare Bad Debt Policy Related to Accounts at a Collection Agency 

MM6081 – Private Contracting/Opting out of Medicare 

MM6001 – Medicare Acute Care Episode (ACE) Demonstration. CR 6001 rescinds and fully replaces CR 5767 

Revised:

MM5792 – Payment for Inpatient Hospital Visits - General (Codes 99221 – 99239) 

MM6084 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2008 

CMS HOLDING OF JULY CLAIMS

“The following Questions and Answers apply to the recent decision by the Centers for Medicare & Medicare Services to hold claims paid under the Medicare physician fee schedule (MPFS) up to 10 business days that contain July 2008 dates of service. 

Q1.   Will claims containing services paid under the MPFS be held that contain both June and July dates of service?
A1.   Yes, your local contractor will hold the entire claim for 10 business days.

Q2.   Will claims be held that contain both services paid under the MPFS and services paid under a separate fee schedule?
A2.   Yes, claims that contain both services paid and not paid under the MPFS will be held. For example, a claim with a July date containing an Evaluation and Management code and a drug code would be held.                                                                                                                 

Q3.   Does the holding of claims paid under the MPFS also include anesthesia and purchased diagnostic services?
A3.   Yes, contractors will hold all claims with dates of service July 1, 2008, and after that contain services paid under the MPFS, including anesthesia and purchased diagnostic services.”

Expiration of Therapy Cap Exceptions

The exceptions to outpatient therapy caps expire on June 30, 2008.  Outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after July 1, 2008.   To the extent possible, CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of outpatient physical therapy, occupational therapy and speech-language pathology claims for services furnished by physicians, non-physician practitioners, and therapists paid under the physician fee schedule, beginning July 1. 

Upcoming Lunch and Learn Teleconference - July 8, 2008

Please join us for our next Lunch and Learn - Observation Care Services - July 8, 2008 at 12:00 pm (EDT).  Click link above for more information.

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding News

The CMS has posted information on the Competitive Bidding Implementation Contractor (CBIC) website to clarify its policy with regard to mail order suppliers. This posting provides further guidance on common carriers and local storefront suppliers. Please visit the Supplier’s FAQ section by clicking link above for more information."

Additional Dates and Locations Added for our Upcoming E/M Scoresheet Basics Workshops

Attention Delaware, Maryland, District of Columbia Metropolitan Area (DCMA) including Prince Georges (MD) County, Montgomery (MD) County, Arlington (VA) County, Fairfax (VA) County, and the City of Alexandria (VA) providers. 

The Provider Outreach and Education team would like to welcome the providers in Delaware, Maryland, and District of Colombia Metropolitan Area (DCMA) including the Prince George (MD) county, Montgomery (MD) county, Arlington (VA) county, Fairfax (VA) county, and the City of Alexandria (VA) to Highmark Medicare Services.  In an effort to promote correct coding, Provider Outreach and Education will be offering a series of workshops focusing on Evaluation and Management (E/M) services.

For further regarding this workshop including registration information click the link above.

Private Contracting/Opting Out of Medicare

The Centers for Medicare and Medicaid Services (CMS) has updated the Medicare Benefit Policy Manual, Chapter 15, sections 40.5, 40.6, 40.9, 40.11, 40.13, 40.20, 40.26, and 40.35:

• The added sections clarify that the consequences for the failure on the part of a physician or practitioner to maintain opt-out apply regardless of whether or when a carrier/MAC notifies a physician or practitioner of the failure to maintain opt-out.
  
• A new paragraph was also added to clarify that in situations where a violation is not discovered by the carrier/MAC during the 2 year opt-out period when the violation actually occurred, then the requirements are applicable from the date that the first violation for failure to maintain opt-out occurred until the end of the opt-out period during which the violation occurred (unless the physician or practitioner takes good faith efforts to restore opt-out conditions, for example, by refunding the amounts in excess of the charge limits to beneficiaries with whom he or she did not sign a private contract).

Click here to review CR6081 on CMS’ website. You can also review CMS' MLN Matters Article by clicking here. 

Common Working File (CWF) Northeast Host Dark Day on Saturday, July 19, 2008

On Saturday, July 19, 2008, the CWF Northeast Host will be conducting a history purge.

Due to the anticipated duration of this activity and to ensure the completion of weekly processing and scheduled data center maintenance, there will be a CWF dark day on that Saturday. This will mean there will be no access to the Health Insurance Master Record (HIMR), which is usually available until noon on Saturdays.

All files received from satellites for Friday’s cycle will be completed prior to bringing CWF production down. If for any reason satellite files are received late Saturday morning, they will be processed by CWF after the history purge has been completed.

Local Coverage Determinations (LCDs) Updates

Notice of Final Policies 

The following Part B Local Coverage Determinations (LCDs) were presented at the February 14, 2008 Contractor Advisory Committee (CAC) meeting.  These LCDs are hereby released as final and will become effective August 20, 2008. 

• I-6J - Approved Drugs and Biologicals
• I-7V - Erythropoiesis Stimulating Agents (ESAs)
• M-62F - Scanning Computerized Ophthalmic Diagnostic Imaging
• R-13 - Radiation Therapy Services     
• Z-56G - Trigger Point Injections
• Z-61B - Paravertebral Facet Joint Nerve Block and Sacroiliac Joint Injection

The following MAC J12 Local Coverage Determinations (LCDs) have been revised: 

• L27529 - Scanning Computerized Ophthalmic Diagnostic Imaging
• L27497 - Fluorescein and Indocyanine Green Angiography
• L27507 - Ophthalmic A and B Scans

The Medicare DMEPOS Competitive Bidding Program begins July 1, 2008.

All the information that you need to know as a DMEPOS supplier or an enrolled Medicare provider who refers beneficiaries for DMEPOS is available on the CMS DMEPOS Competitive Bidding dedicated website.Please visit the Announcement and Communication link for the most recent news.

Hold Claims Paid Under the Medicare Physician Fee Schedule (MPFS)

To the extent possible, CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning July 1. Click the link above to read the article in its entirety.

July 4th Holiday EDI Availability

Highmark Medicare Services will be observing the July 4th Holiday on July 4, 2008. Our business doors will be closed and the EDI Services Help Desk will not be available. However, you may continue utilizing EDI services. On July 4, 2008, our EDI platforms will be available for claim submission, report retrieval, ERA, and beneficiary eligibility transactions. There will not be a batch claim processing cycle executed for this date. Medicare checks and ERA will not be generated on this day. The MCS Edit Report for EDI claims received after 4 PM on July 3, 2008, will be available for retrieval on July 8, 2008.

2008 Physician Quality Reporting Initiative (PQRI) National Provider Conference Call with Question & Answer Session

The Centers for Medicare & Medicaid Services (CMS), Provider Communications Group, will host the fifth in a series of national provider conference calls on the 2008 Physician Quality Reporting Initiative (PQRI). Conference call details:

Date: July 9, 2008
Conference Title: 2008 Physician Quality Reporting Initiative National Provider Call
Time: 3:30-5:00 (EDT)

A PowerPoint slide presentation will be posted to the PQRI webpage.  In order to receive the call-in information, you must register for the call. Registration will close at 3:30 p.m. (EDT) on July 8, 2008, or when available space has been filled. 

A replay option will be available shortly following the end of the call from 5:30 p.m. (EDT), 7/9/2008, until 11:59 p.m. (EDT), 7/16/2008. The call in data for the replay is (800) 642-1687 and the passcode is 52755102.

MLN Matters Articles from CMS

New:

MM6090 – Claim Status Category Code and Claim Status Code Update 

MM6095 – July 2008 Update to the Ambulatory Surgical Center (ASC) Payment System; Summary of Payment Policy Changes 

MM6085 – Screening Pelvic Examination 

MM6111 – October Quarterly Update to 2008 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement 

MM6060 – New Waived Tests 

Medicare FFS NPI Update & Part B Issues Identified

As of 5/23/08, the National Provider Identifier (NPI) became mandatory on all HIPAA claims transactions and on Medicare paper transactions as well.

MLN Matters Article from CMS

New:

MM6104 – 2008 Physician Quality Reporting Initiative (PQRI) Establishment of Alternative Reporting Periods and Reporting Criteria 

July 1 is coming! Medicare DMEPOS Competitive Bidding Program News

The Ombudsmen for the DMEPOS Competitive Bidding Program are now available to assist providers, suppliers, and beneficiaries by providing information and education and by facilitating the resolution of complaints and concerns.

MLN Matters Articles from CMS

New:

MM6119 – Phase 2 Manual Revisions for the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program 

MM6046 – Inappropriate Denials of Claims for Percutaneous Transluminal Angioplasty (PTA) of Carotid Arteries Concurrent with Stenting Based on Facility Recertification Due Dates 

MM6112 – Payment for Complex Rehabilitative Power Mobility Device (PMD) Services that Span the Implementation Date of DMEPOS Competitive Bidding Programs in Competitive Bidding Areas 

MM6091 – Notification of New Quarterly Updates to the Ambulance Fee Schedule Public Use File (PUF) 

MM6101 – July 2008 Quarterly Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program 

MM6086 – Hospitals Exempt from Present on Admission (POA) Reporting (i.e. non-Inpatient Prospective Payment System (IPPS) Hospitals) and the Grouper 

SE0821 – Reminder – Medicare Provides Coverage of Diabetes Screening Tests 

Revised:

SE0806 – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: Grandfathering, Repair and Replacement, Mail Order Diabetic Supplies and Advance Beneficiary Notices (ABNs) – The second in a series of articles on the new DMEPOS competitive bidding program. 

SE0807 – Important Exceptions and Special Circumstances that Occur under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: – The third in a series of articles on the new DMEPOS competitive bidding program. 

MM5978 – Phase 1 of Manual Revisions to Reflect Payment Changes for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items as a Result of the DMEPOS Competitive Bidding Program and the Deficit Reduction Act of 2005