Medicare and Medicaid Information From Denver, CO

Hello Everyone,
Please enjoy the information contained in this edition of Frontier Focus. Please be sure to share it with your members, colleagues, providers and office billing staff. Thank you for your continued efforts to broadcast Medicare information to the providers in Region VIII.


Table of Contents

1. New From the Medicare Learning Network

2. Your Latest NPI Update!

3. Physician Quality Reporting Initiative Self Serve Look-Up Tool is Now Available!

4. Important Information about the Reporting Hospital Quality Data for Annual Payment Update Program

5. Medicare Solicits Nominees for Advisory Panel for Next Phase of DMEPOS Competitive Bidding Program

6. CMS Provides Guidance on DMEPOS Accreditation for Pharmacy Suppliers

7. Medicare Publishes Billing Edits to Reduce Payment Errors

8. CMS Issues Final Rule to Empower Medicaid Beneficiaries to Direct Personal Assistance Services

9. SNF PC Pricer for FY 2009

10. CMS Issues New Resources on ESRD Conditions for Coverage

11. CMS-1390-N on Display at the Federal Register

12. Your October Flu Shot Reminder

13. Extra Help for Beneficiaries Paying for Prescription Drugs




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1. New From the Medicare Learning Network

Medicare Part B Drug Competitive Acquisition Program (CAP): 2009 CAP Postponement Article
A Medicare Learning Network (MLN) Matters Special Edition article on the 2009 CAP postponement is now available on the CMS website. This article contains billing, drug ordering, claims processing, and other information for Participating CAP Physicians on the transition from CAP to the ASP “buy and bill” methodology for 2009. This article is available on the CMS website at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0833.pdf.

Additional information on the CAP and the program’s postponement for 2009 is available on the CMS CAP website at: http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp.

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ICD-10-CM/PCS Article Now Available
A new MLN Matters Special Edition Article entitled, “SE0832 – The ICD-10 Clinical Modification/Procedure Coding System (CM/PCS)—The Next Generation of Coding,” has recently been released. Go to
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0832.pdf to view it.
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2. Your Latest NPI Update!

The NPI Registry option to search by ‘Doing Business As’ (DBA) name has been temporarily removed from the NPI Registry search page while we make enhancements to the system. The DBA search option is expected to be available by Friday, October 10, 2008.


Need More Information?

Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste the URL into your web browser to view the intended information.

Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand CMS webpage.
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3. Physician Quality Reporting Initiative Self Serve Look-Up Tool is Now Available!

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a new self-service look-up tool is now available on the PQRI Portal at, http://www.qualitynet.org/pqri on the internet, which allows an eligible professional at the Tax Identification Number (TIN) level to see if their 2007 PQRI Feedback Report is available. Once on the site, go to the "Verify TIN Report Portlet" which is located at the bottom left of the page. Enter the TIN and a message appears that indicates if a 2007 PQRI Feedback Report is or is not available.

This self-service look-up tool does not allow the eligible professional to view their 2007 PQRI Feedback Report. The availability of the 2007 PQRI Feedback Report is helpful for the eligible professional to know because it enables them to decide if they need to register for an IACS account at this time so that they can log into the PQRI Portal and view their 2007 PQRI Feedback Report. Additional information can be found in MLN Matters Special Edition articles SE0830-- Steps for Individual Eligible Professionals to Access Their 2007 Physician Quality Reporting Initiative (PQRI) Feedback Reports Personally (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0830.pdf) and SE0831-- Steps for Organizations to Access Their 2007 Physician Quality Reporting Initiative (PQRI) Feedback Reports (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0831.pdf) .

In addition, the eligible professional can call the QualityNet Help Desk in order to determine if a 2007 PQRI Feedback Report is available. The representatives at the QualityNet Help Desk can only inform the provider if a 2007 PQRI Feedback Report is available; they are unable to disclose the information on the 2007 PQRI Feedback Report. The QualityNet Help Desk can be reached via telephone at 1-866-288-8912 from the hours of 7am-7pm CST or via email at Qnetsupport@ifmc.sdps.org.

NOTE: The TIN must be the one used by the eligible professional to submit Medicare claims and valid PQRI quality data codes for dates of service July 1 – December 31, 2007.
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4. Important Information about the Reporting Hospital Quality Data for Annual Payment Update Program

Because of the recent hurricanes’ devastating impact, the Centers for Medicare & Medicaid Services (CMS) will grant a data submission waiver to Prospective Payment System (PPS) hospitals. Due to the hurricanes, some hospitals are unable to meet the submission of quality data requirements for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) for Fiscal Year 2010. The CMS is exercising its authority to waive data submission requirements under Section 1886(b) (3) (A) (vii) (II) of the Social Security Act, in the following states: * Louisiana * Texas Process:The submission waiver for Hospital Quality Alliance Acute Myocardial Infarction (AMI), Heart Failure, Pneumonia, and Surgical Care Improvement Project (SCIP) clinical process measures is granted for the second calendar quarter 2008 for all hospitals in counties designated as directly affected by the storm(s) (see Appendix A for a list of counties as designated by FEMA). The submission waiver for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measure is granted for the third calendar quarter 2008 for all hospitals in counties designated as directly affected by the storm(s) (see Appendix A for a list of counties as designated by FEMA). In addition, hospitals in other counties in these states are authorized to submit requests for a data submission waiver to their CMS Regional Division of Quality Improvement office based on individual circumstances.
Clinical Process Measure Data Submission ScheduleDischarges Due to Clinical Warehouse2Q-08 Apr-Jun 08 Nov-15-08 HCAHPS Data Submission ScheduleDischarges Due to Clinical Warehouse3Q-08 July-Sept.08 Jan-14-09The rationale for waivers for the clinical process measures listed above for second quarter 2008 is that hospital medical records were destroyed due to the storm, and hospitals are unable to report data for this period. The rationale for waivers for the HCAHPS survey measure for third quarter 2008 is that hospitals ability to contact and survey patients may have been impaired during and after the storm, and hospitals may be unable to report data for this period. Additionally, the validation waiver for Hospital Quality Alliance Acute Myocardial Infarction (AMI), Heart Failure, Pneumonia, and Surgical Care Improvement Project (SCIP) clinical process measures is granted for the first calendar quarter 2008 for all hospitals in counties designated as directly affected by the storm(s) (see Appendix A for a list of counties as designated by FEMA). In addition, hospitals in other counties in these states are authorized to submit requests for a data submission waiver to their CMS Regional Division of Quality Improvement office based on individual circumstances. Under Section 1886(b) (3) (A) (vii) (II) of the Social Security Act that hospitals shall submit data in a form and manner, and at a time, specified by the Secretary, CMS has authority to modify the submission requirements for hospitals.
Hospitals that have questions about this process should contact their local Quality Improvement Organization (QIO). A list of QIO contacts for each state/territory is available online at http://www.qualitynet.org/dcs/ContentServer?cid=1138900297541&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page.
Appendix A:List of Counties by State Designated Disaster Counties
LouisianaAll parishesTexasAngelina, Austin, Brazoria, Chambers, Cherokee, Fort Bend, Galveston, Grimes, Hardin, Harris, Houston, Jasper, Jefferson, Liberty, Madison, Matagorda, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Trinity, Tyler, Walker, Waller, and Washington Counties.
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5. Medicare Solicits Nominees for Advisory Panel for Next Phase of DMEPOS Competitive Bidding Program

MEMBERS TO PROVIDE GUIDANCE ON OPERATIONAL ISSUES

The Centers for Medicare & Medicaid Services (CMS) is soliciting nominations for individuals to serve on the Program Advisory and Oversight Committee (PAOC) that advises CMS on various issues relating to the competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

The PAOC was initially established in 2004, as required by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), to advise CMS on the design and implementation of a competitive bidding program for DMEPOS that would build on the successes of two pilot projects that had shown that competitive bidding could reduce prices of DMEPOS without adversely affecting beneficiary access or compromising quality.

Because the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) delayed implementation of and made certain changes to the competitive bidding program, and extended the PAOC for two years through December 31, 2011, CMS is ending the term of service for current PAOC members.

The PAOC will be comprised of 10 and 12 members from the following broad categories:

· Beneficiary/consumer representatives;
· Physicians and other practitioners;
· Suppliers;
· Professional standards organizations;
· Financial standards specialists (that is, economist/certified public accountant); and
· Association representatives.
· CMS may consider nominees for additional categories if it finds that their expertise will help to ensure the successful implementation of the program

Nominations are due to CMS by November 3, 2008. For more information, please see the CMS Web site at: http://www.cms.hhs.gov/center/dme.asp

To read the CMS press release issued on October 1, 2008, click here: http://www.cms.hhs.gov/apps/media/press_releases.asp
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6. CMS Provides Guidance on DMEPOS Accreditation for Pharmacy Suppliers

On September 3, 2008, the Centers for Medicare & Medicaid Services (CMS) announced a list of Durable Medical Equipment Prosthetics/Orthotics, and Supplies (DMEPOS) providers that were exempt from meeting the quality standards for DMEPOS accreditation. CMS would like to clarify that pharmacists and pharmacies were not included in this provider exemption; therefore, pharmacists and pharmacies do need to obtain accreditation. For example, if a pharmacy is providing DMEPOS supplies to Medicare beneficiaries, such as diabetic supplies and enteral/parenteral nutrition, they would need to be accredited by the September 30, 2009 deadline. For more information about DMEPOS Accreditation, please visit the web page at http://www.cms.hhs.gov/medicareprovidersupenroll/.
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7. Medicare Publishes Billing Edits to Reduce Payment Errors

The Centers for Medicare & Medicaid Services (CMS) recently announced that, beginning October 1, 2008, it will publish most of the edits utilized in its Medically Unlikely Edit (MUE) program to improve the accuracy of claims payments.

“It is always our aim to ensure that CMS pays for appropriate services, at the same time protecting the Medicare Trust funds and the American taxpayer,” said CMS Acting Administrator Kerry Weems. “This program is going to help us dramatically reduce costly payment errors.”

CMS established the MUE program to reduce payment errors for Medicare Part B claims. Claims processing contractors utilize these edits to assure that providers and suppliers do not report excessive services. The edits are applied during the electronic processing of all claims. These edits check the number of times a service is reported by a provider or supplier for the same patient on the same date of service. Providers and suppliers report services on claims using HCPCS/CPT codes along with the number of times (i.e., units of service) that the service is provided.

Prior studies, including one by the U.S Department of Health and Human Services’ Office of the Inspector General in May 2006, identified significant Medicare overpayments because provider or supplier claims sometimes report services with too many units of service. These errors may be caused by numerous factors, including clerical errors and coding errors.

CMS first implemented the MUE program January 1, 2007, with edits for about 2,600 HCPCS/CPT codes. There have been quarterly updates adding additional codes. The October 1, 2008, version of MUE will contain edits for about 9,700 HCPCS/CPT codes that have been assigned unit values for MUEs. MUEs are cumulative for each quarter. However, CMS will not publish all MUEs on October 1, 2008. CMS has not yet determined if there have been any savings in the MUE program since it was implemented.

The edits were developed by CMS with the cooperation and participation of national health care organizations representing physicians, hospitals, non-physician practitioners, laboratories, and durable medical equipment suppliers. CMS also utilized claims data in its analysis of MUE.

The edits can be found on the CMS Website at http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.

At the start of each calendar quarter, CMS will publish most MUEs active for that quarter. Although the October 1, 2008, publication will contain most MUEs, additional ones will be published on January 1, 2009. CMS is not able to publish all active MUEs because some are primarily designed to detect and deter questionable payments rather than billing errors. Publishing those MUEs would diminish their effectiveness.
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8. CMS Issues Final Rule to Empower Medicaid Beneficiaries to Direct Personal Assistance Services

A final rule that would allow more Medicaid beneficiaries to be in charge of their own personal assistance services, including personal care services, instead of having those services directed by an agency, was recently announced by the Centers for Medicare & Medicaid Services (CMS).
The rule, on display today at the Federal Register, guides states who wish to allow Medicaid beneficiaries who need help with the activities of daily living to hire, direct, train or fire their own personal care workers. Beneficiaries could even hire qualified family members who may already be familiar with the individual’s needs to perform personal assistance (not medical) services.
A copy of the regulation is available on the Federal Register’s Website at:
http://federalregister.gov/OFRUpload/OFRData/2008-23102_PI.pdf

The press release has been posted to the CMS Newsroom at:
http://www.cms.hhs.gov/apps/media/press_releases.asp
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9. SNF PC Pricer for FY 2009

The Centers for Medicare & Medicaid Services (CMS) has released the SNF PC Pricer for FY 2009. If you use SNF PC Pricer software, please go to the web page at http://www.cms.hhs.gov/PCPricer/04_SNF.asp#TopOfPage and download version FY 2009.0, posted on October 1, 2008.
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10. CMS Issues New Resources on ESRD Conditions for Coverage

Frequently Asked Questions

Thank you to all of our colleagues in the renal care community who submitted questions to the Centers for Medicare & Medicaid Services (CMS) about our recently released ESRD Conditions for Coverage final rule. In response to these inquiries, we have already provided many of you with individual responses to your questions; however, to share the benefit of these questions with the entire community, CMS has developed a “Frequently Asked Questions” document that condenses many of the questions we received from you. The FAQs are available online at http://www.cms.hhs.gov/center/esrd.asp on the CMS website. To view them, click on the second Spotlight.


Crosswalk: Former Conditions versus Revised Conditions

As another tool to help you understand the new Conditions for Coverage, CMS has developed a crosswalk that compares the former conditions to the final revised conditions, which were issued in the Federal Register on April 15, 2008. The crosswalk will help you navigate the new organization structure of the condition as well as some revised provisions of the conditions themselves. The crosswalk is available online at http://www.cms.hhs.gov/center/esrd.asp on the CMS website. To view the Crosswalk, click on the third Spotlight.

We hope you find these tools helpful as you work to implement the revised conditions. For more information, please visit us online at http://www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp on the CMS website.
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11. CMS-1390-N on Display at the Federal Register

CMS-1390-N (Medicare Program; Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates: Final Fiscal Year 2009 Wage Indices and Payment Rates) went on display at the Federal Register on September 29, 2008. The Notice includes tables listing the final wage indices, hospital reclassifications, payment rates, impacts, and other related tables effective for fiscal year (FY) 2009. It will be published on October 3. To view the Notice, go to the web page at:

http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=4&sortOrder=descending&itemID=CMS1215562&intNumPerPage=10
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12. Your October Flu Shot Reminder

Flu Season Is Upon Us! Begin now to take advantage of each office visit as an opportunity to encourage your patients to get a flu shot. It’s still their best defense against combating the flu this season. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.) And don’t forget, health care personnel can spread the highly contagious flu virus to patients. Protect Yourself. Don’t Get the Flu. Don’t Give the Flu. Get Your Flu Shot.
Remember - Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug.

For information about Medicare’s coverage of the influenza virus vaccine and its administration as well as related educational resources for health care professionals, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS website.
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13. Extra Help for Beneficiaries Paying for Prescription Drugs

Do You Know Someone Who Is Having Trouble Paying For Prescription Drugs?
Medicare Can Help!

· If an individual has limited income and resources, they may qualify for extra help from Medicare. It could be worth over $3,300 in savings on prescription drug costs per year.
· Encourage people with Medicare to file for Extra Help online: https://s044a90.ssa.gov/apps6z/i1020/main.html or by calling Social Security at 1-800-772-1213 to apply over the phone.
· State Health Insurance Information Program (SHIP) offices can assist with the application. Find contact information for a local SHIP Counselor at http://www.medicare.gov/contacts/static/allStateContacts.asp or by calling
1-800-MEDICARE.
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Lucretia James
Centers for Medicare & Medicaid Services
Region VIII
1600 Broadway, Suite 700
Denver, CO 80202
(303) 844-1568
lucretia.james@cms.hhs.gov