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Education for Providers

March 2008 Medicare B Hotline Bulletin - Read, search, or download the latest issue of our quarterly provider bulletin.
(Posted February 28, 2008)

Educational Articles

These articles cover a variety of topics that are important to the provider community.

Articles that are also published in the Medicare B Hotline Bulletin, our provider newsletter, will remain on this page for two months, or until the bulletin in which it appears is posted on our Web site, whichever is later.

Rabies Vaccination (GEN) - Revised 1-31-06
Posted January 31, 2006

Immunization for beneficiaries that have had contact with or exposure to rabies is a payable service. Medicare will not cover vaccination of veterinarians, animal handlers, spelunkers (cave explorers) or laboratory workers, who may get the vaccine without actual exposure, but in anticipation of exposure.

Providers wishing to submit claims for the vaccination of a beneficiary who has had contact with or exposure to rabies should utilize the following CPT codes:

90375	Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use
90376	Rabies immune globulin, heat treated (RIg-HT), human, for intramuscular and/or subcutaneous use
90675	Rabies vaccine, for intramuscular use

If previously unvaccinated for rabies, codes 90675 and either 90375 or 90376 would be reported on day 0 and code 90675 would be reported for the subsequent injections, days 3, 7, 14, and 28. Rabies immune globulin can be given until the 7th day after the first dose of Rabies vaccine.

If previously immunized for rabies and with documented adequate rabies antibody titer, Rabies immune globulin is not given and Rabies vaccine is given days 0 and 3.

The Rabies vaccine and Rabies immune globulin are to be used as directed in the Food and Drug Administration (FDA) approved package label.

Please include the drug name, dosage administered, and the route of administration. If procedure codes 90375 or 90376 are utilized, include the patient’s weight in Item 19 of the CMS-1500 form, or, if an electronic biller, in the appropriate narrative field.

Only ICD-9-CM code V01.5 (Contact with or exposure to communicable diseases, rabies) is to be reported in the detail diagnosis field.

Documentation must be made available to the carrier upon request.

New Self-Service Options on the Toll-Free Provider Line (GEN)
Posted December 28, 2005

The Upstate Medicare Division (UMD) is pleased to announce improved and expanded self-service options now available via the Interactive Voice Response (IVR) Unit.

The Centers for Medicare & Medicaid Services (CMS) has provided guidance to contractors regarding the quality and number of self-service options that are made available to providers. Under the direction of Change Request (CR) 3376, CMS requires Medicare providers to use the IVR to access eligibility and claim status information. As a result, providers seeking eligibility and claim status information from customer service representatives (CSRs) will be educated on the use of the IVR and directed to call the IVR to obtain that information.

UMD prides itself on the customer service given to our provider community, and with the introduction of these new self-service options, our CSRs can dedicate their time to the more complex provider inquiries. UMD is confident that with your use of these self-service options and with your cooperation, success will be achieved.

For a brief description of the new menu options available on the IVR, access the Interactive Voice Response (IVR) Unit Guide

Draft Local Coverage Determination on Pegaptanib (Macugen™) (GEN) (PHY)
Posted October 5, 2005

In response to the many comments received on the draft local coverage determination (LCD) on pegaptanib (Macugen™), the Upstate Medicare Division (UMD) and the other New York State Medicare Part B contractors have decided not to implement this draft policy. We will continue to review the comments already received, as well as the evolving scientific literature, and await further coverage decisions for the drug by the Centers for Medicare & Medicaid Services (CMS). Reimbursement for the drug will continue to be made on an individual consideration basis, consistent with Food and Drug Administration (FDA) approval for the drug, scientific literature, and the current community standard of care.

Reminder – Submission of Claims with Attachments (GEN)
Posted September 13, 2005

Effective October 16, 2003, the Administrative Simplification Compliance Act (ASCA) and 42 CFR 424-32 require that all Medicare claims be submitted electronically, with a few limited exceptions. Those exceptions can be found in the Medicare Claims Processing Manual (Pub. 100-04) Chapter 24, §90.

We previously published a detailed article on page 20 of the March 2004 Medicare B Hotline Bulletin, which provided information regarding this requirement. Providers may refer to that bulletin to review the article.

For any claim submitted to Medicare, whether submitted electronically or on paper, please do not provide attached documentation with your claim. If we are unable to process a claim without additional necessary information, we will request the necessary documentation via additional documentation request (ADR).

Macugen® Treatment of Wet Age-Related Macular Degeneration (GEN)
Posted March 18, 2005

Macugen®, pegaptanib sodium injection, received approval from the Food and Drug Administration (FDA) on December 17, 2004, for the treatment of (wet) age-related macular degeneration. Coverage will be allowed from that date when used as directed in the FDA-approved package insert.

Macugen® should be used for a single disease at this time; the disease is wet macular degeneration. Macugen® should be administered by sterile intraocular injection. The frequency of administration of Macugen® should not exceed once each six weeks.

Coding Guidelines

ICD-9-CM code 362.52	Wet macular degeneration
J3490	Macugen®, pegaptanib sodium injection (The provider should include the name of the drug Macugen® and the number of milligrams (0.3 mg) given in Item 19 of the CMS-1500 form, or the electronic equivalent.)
92235	Fluorescein angiography
67028 Use RT LT Modifiers	Intravitreal injection of a pharmacologic agent separate procedure
E&M service	Modifier 25 may be used for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. If modifier 25 applies to the patient scenario, on the date of the injection 67028, an evaluation and management service may be billed. Otherwise, an evaluation and management service may not be billed on the date of the service.

Documentation should include a fluorescein angiogram prior to the initial injection. After previous injections or therapy using Macugen® and before each subsequent treatment, a new fluorescein angiogram may be performed to establish the continued existence of wet age-related macular degeneration.

Documentation will not be required with the submission of each claim. Provider records, for example, fluorescein angiograms, should prove the existence of wet age-related macular degeneration outlined above and be submitted upon request by the Medicare contractor.

The fee for pegaptanib sodium may be found on our Web site at www.umd.nycpic.com/drug2005.html, under "Not Otherwise Classified (NOC) Drug Fees," J3490, pegaptanib sodium, listed alphabetically.

Use of LMRPs and LCDs When Submitting Claims to Medicare
Posted April 21, 2004

The Upstate Medicare Division (UMD) utilizes multiple local medical review policies/local coverage determinations (LMRPs/LCDs) for making claim decisions regarding services billed to Medicare. There are times when more than one LMRP or LCD may be applicable and associated to a service or procedure that is being performed.

One example of where more than one LMRP/LCD would apply is with post-void residual. The following policies reference post-void residual:

Measurement of Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (#GU001G02).
Pelvic and Transvaginal Ultrasound Procedures (#R-96-4).
Abdominal Ultrasound Procedures (#R-96-3).
Urodynamics (#GU004G02).

When clinical need only warrants determination of post-void residual in the office setting, with no other ultrasound investigation, the correct code to bill is code 51798 (measurement of post-voiding residual, urine and/or bladder capacity by ultrasound, non-imaging). The correct LMRP to follow when performing post-void residual in an office setting would be Measurement of Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (#GU001G02). However, when a post-void residual is being performed in a radiology setting, one of two different LMRPs may be applicable, either Abdominal Ultrasound Procedures (#R-96-3) or Pelvic and Transvaginal Ultrasound Procedures (#R-96-4). The Abdominal Ultrasound Procedures LMRP involves procedure code 76700 (ultrasound, abdominal, B-scan and/or real time with image documentation; complete) and procedure code 76705 (ultrasound, limited – e.g., single organ, quadrant, follow-up). The Pelvic and Transvaginal Ultrasound Procedures LMRP involves procedure code 76856 (ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, complete) and procedure code 76857 (ultrasound, limited or follow-up – e.g., for follicles). Therefore, when billing a post-void residual, it is important to consider the circumstances related, whether office or radiology setting, in performing this procedure, so that the correct policy is associated to the service you have billed. It is then important to apply the correct policy guidelines within that policy when billing this service to Medicare.

Another example of where more than one LMRP/LCD would be applicable to a service is with code 62368 (electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with programming). The following policies reference this procedure:

Baclofen Intrathecal Therapy (#DR021W01).
Implanted Catheter/Pump for Opioid Infusion via Intrathecal Epidural Drug Delivery System (#S-99-4).
Epidural/Intrathecal Injections for Chronic Pain Management (#S-99-5).

We receive multiple claims with code 62368 billed, and this procedure is reviewed in the Medical Review Department. Of the three policies listed above, the documentation that we receive for review dictates which policy we must apply and which guidelines will need to be followed. Each of these policies has specific indications, limitations, and diagnosis requirements associated with them. Therefore, when you are submitting a claim for code 62368, it is important for you to be aware of these multiple policies and follow the applicable policy guidelines for the claims you bill to Medicare. If a patient is receiving the drug baclofen, it is necessary to follow the guidelines in the Baclofen Intrathecal Therapy (#DR021W01) LMRP. If narcotics are being administered into an implanted pump, the Implanted Catheter/Pump for Opioid Infusion via Intrathecal Epidural Drug Delivery System (#S-99-4) LMRP should be followed. Lastly, the Epidural/Intrathecal Injections for Chronic Pain Management (#S-99-5) LMRP should be followed for non-narcotic use. Depending on the procedure you are performing and the reason you are performing it, you will need to utilize and apply the LMRP/LCD guidelines of the policy associated with that procedure.

The two above situations are just two examples of where more than one policy may apply to a service you are billing to Medicare. There are other LMRPs and LCDs in existence that share a relationship with each other as well. We want you to have an awareness of these circumstances and feel that this information will be helpful to our provider community.

We invite you to view all of our LMRPs and LCDs on the "Medical Policies" section of our Web site at www.umd.nycpic.com/lcdcopy.html.

Implantable Automatic Defibrillators - Coding Information

The following coding information supplements the information on implantable automatic defibrillators published in the September 2003 Medicare B Hotline Bulletin. Please refer to the September bulletin for complete coverage information and billing instructions.

Codes Payable Under OPPS
The new G codes listed below are payable under the Outpatient Prospective Payment System (OPPS) effective October 1, 2003. These new G codes are not payable under the Medicare Physician Fee Schedule and, therefore, should not be billed to Medicare carriers.

G0297
G0298
G0299
G0300
ICD-9-CM Procedure Code 37.94 (for 11X TOBs)

Codes Payable by Medicare Carriers
The physician should bill for the appropriate service from the range of CPT codes below. These services should be billed to the appropriate Medicare carrier for payment.

33240
33241
33243
33244
33245
33246
33249

Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including Program Memoranda, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the Update. The purpose of the Quarterly Provider Update is to:

Inform providers about new developments in the Medicare program;

Assist providers in understanding CMS programs and complying with Medicare regulations and instructions;

Ensure that providers have time to react and prepare for new requirements;

Announce new or changing Medicare requirements on a predictable schedule; and

Communicate the specific days that CMS business will be published in the Federal Register.

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update ListServe at list.nih.gov/cgi-bin/wa?SUBED1=cms-qpu&A=1.

The Quarterly Provider Update can be accessed at www.cms.hhs.gov/QuarterlyProviderUpdates. We encourage you to bookmark this Web site and visit it often for this valuable information.

Billing Procedures for Transportation of Portable X-Ray Equipment and Personnel - Revised 4-10-03

Only a single, reasonable transportation payment for each trip a portable x-ray supplier makes to a particular location is allowed. When more than one Medicare patient is x-rayed at the same location, e.g., a nursing home, the single fee schedule transportation payment is prorated among all patients receiving the services.

Due to problems with the current billing procedures for portable x-ray services that were published in the March 2003 Medicare B Hotline Bulletin, the following procedures will be effective for claims received on or after May 1, 2003, or dates of service January 1, 2003, and after.

Report R0070 for a single patient transport.

Report R0075 for a multiple patient transport. Prorate the single allowable transport charge among all patients. The number of units billed in Item 24G of the claim form should reflect the total number of patients seen. Failure to furnish this information may result in claim denial.

In the interim, to ensure proper payment, it may be necessary for our office to request additional information.

Sulzer Inter-Op Acetabular Shell Recall Settlement with CMS - Provider Information

The Centers for Medicare & Medicaid Services (CMS) and Sulzer Orthopedics have resolved a dispute concerning the application of the Medicare Secondary Payer (MSP) laws to a Sulzer recall of certain Inter-Op acetabular shells for hip implants. This article summarizes the dispute and its resolution and provides guidance to physicians and other suppliers on the actions the physicians and other suppliers need to take as a result.

In December 2000, Sulzer Orthopedics recalled approximately 17,500 Inter-Op acetabular shells used in connection with hip implant procedures. Sulzer advised providers, physicians and recipients that it would cover the cost of "unreimbursed medical expenses" related to the monitoring and possible replacement of the hip implants and related services. The MSP laws preclude Medicare payment for services when payment has been made, or can reasonably be expected to be made, under a liability insurance policy or plan (including a plan of self-insurance). The CMS considered Sulzer's initial assurance of payment for "unreimbursed medical expenses" to constitute a "reasonable expectation of payment under a liability insurance policy or plan" and held that Sulzer (and its insurers) were the primary payers for these services. Sulzer disagreed and takes the position that it is not subject to recovery under the MSP provisions.

The CMS and Sulzer agreed to try to resolve the dispute through negotiation. The CMS asked its Medicare contractors to advise providers and suppliers to hold claims while it determined whether the claims should be sent to Sulzer or the appropriate Medicare contractor for processing. If a physician or other supplier did not wish to await such guidance from CMS, it could submit a paper claim with the annotation that the claim was related to the Sulzer recall. Such claims were to be held by the Medicare contractors until CMS determined whether Medicare should process the claims.

The CMS and Sulzer have reached a final settlement regarding the processing of claims related to medical services provided to Medicare beneficiaries in conjunction with a revision of a recalled Inter-Op acetabular shell. Under the settlement, Medicare will process any claims for such services and should not look to Sulzer, its liability insurance plans, the Sulzer Class Action Settlement, or the Medicare beneficiaries for repayment of any claims in connection with the hip implant devices. Other Medicare payment and coverage rules for these services will be applied. The CMS has further agreed that Medicare will consider there to exist "good cause" for failure to submit an assigned physician or other supplier claim within 1 year of the date of service but filed before November 30, 2002, if the supplier submits a hard copy claim and includes with the claim a signed statement that the services delineated on the claim were related to a revision of a Sulzer Inter-Op acetabular shell that was recalled in December 2000; and the delay in submitting the claim was attributable to CMS's advice to hold claims. Physicians and other suppliers are encouraged to submit claims related to the Sulzer recall as soon as possible.

If a physician or other supplier submits an initial claim to Medicare for primary payment and receives such primary payment, under the terms of the settlement, physicians or other suppliers may bill Sulzer for Medicare deductibles, Medicare coinsurance and services not covered by Medicare under applicable Medicare coverage guidelines. If a physician or other supplier receives a payment from Sulzer, its liability insurance plans or the Sulzer Class Action Settlement, it may not bill Medicare on a secondary payer basis.

Liability Cases Involving Certain Recalled Sulzer Inter-Op Acetabular Shells for Hip Implants - Attorney Information

The Centers for Medicare & Medicaid Services (CMS) and Sulzer Orthopedics et al. (Sulzer) have reached a final settlement regarding the processing of claims related to medical services provided to Medicare beneficiaries in conjunction with a revision of a Sulzer Inter-Op acetabular shell recalled by Sulzer in December 2000. The settlement affects Medicare recovery claims that Medicare may have asserted or may assert against the proceeds of any settlement, judgment or award a beneficiary may receive from Sulzer et al. or its liability insurance on a liability claim brought against Sulzer.

In order to assure that such cases are handled properly, attorneys representing affected Medicare beneficiaries are asked to write to the Special Lead Medicare Contractor for Sulzer Settlement and identify themselves and their clients that are Medicare beneficiaries. The Special Lead Contractor will work with the attorneys to assure that the case is handled properly. The mailing address for the special Lead Contractor is as follows:
Medicare Secondary Payer Department
Sulzer Settlement Liability Cases
Chisholm Administrative Services
1215 South Boulder
Tulsa, Oklahoma 74101

Loss of Patient Files or Records Due to Disaster

Question:

What if a physician has lost all patient files and records when the building was damaged? What should the physician do?

Answer:

The Centers for Medicare and Medicaid Services (CMS) recognizes that during this time of emergency, the primary concern of providers, including physicians, needs to remain the delivery of patient care. However, once the immediate crisis has passed, CMS' Division of Medical Review will issue formal instructions regarding medical record documentation for claims processing purposes in the event of a disaster. These instructions will be released in the next few weeks and will appear in Chapter 3 of the Program Integrity Manual. This instruction will make it clear that in the event of a disaster, be it natural or man-made, all provider types will be granted temporary administrative relief from Medicare documentation requirements. In the case of destruction of original medical records but where backup records (such as microfilmed records) exist, Medicare contractors will accept reproduced medical records. In the case of complete destruction of all original and backup records, Medicare contractors will accept partially recreated medical records or an attestation that no medical records exist. Only in instances where fraud is suspected will the Medicare contractor request information to verify the extent of the damage experience by the provider.

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This page updated
May 13, 2008