A Medicare Update

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. Delay in Implementing Phase 2 of CRs 6417 and 6421



2. Only 3 Days Left to Bid for the Round 1 Rebid of the DMEPOS Competitive Bidding Program



3. Bidder Alert for DMEPOS Competitive Bidding



4. Physician Quality Reporting Initiative (PQRI) Program Announcement



5. 2010 Electronic Prescribing Incentive (eRx) Program Announcement



6. MLN Matters Article #MM6740 - Revisions to Consultation Services Payment Policy



7. Nursing Home Five-Star Quality Rating System – December News



8. Your December Flu Message



9. Extra Help for Medicare Beneficiaries Paying for Prescription Drugs













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1. Delay in Implementing Phase 2 of CRs 6417 and 6421



The Centers for Medicare & Medicaid Services (CMS) will delay, until April 5, 2010, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)). CRs 6417 and 6421 are applicable to Part B claims only.



The delay in implementing Phase 2 of these CRs will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.



Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non-physician practitioner’s National Provider Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.



CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.



For physicians and non-physician practitioners who order or refer—



· If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs.gov/MedicareProviderSupEnroll.

· If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

· If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

· If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.



If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.



CMS actions to mitigate the number of informational messages:



Since many Part B providers and suppliers are receiving a high volume of informational messages in their Remittances, CMS is taking the following actions to reduce the number of informational messages being generated:



1. Prior to the implementation of Phase 2, CMS will systematically add the NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose enrollment records are in PECOS but do not contain their NPIs. Because the NPI is one of the matching criteria used in implementing the two new edits on the Ordering/Referring Provider, it is essential that the NPI be in the PECOS enrollment record. Because the data file used to implement the two edits contains only the eligible physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will add many more physicians and non-physician practitioners to that data file.

2. Prior to the implementation of Phase 2, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program. The name displayed will be that of the physician or non-physician practitioner as it appears in his or her PECOS enrollment record. This will allow Part B providers and suppliers who furnish and bill for items or services based on orders or referrals to determine if the Ordering/Referring Provider being identified in their claims will pass the two new edits prior to submitting the claims to Medicare.

3. Prior to the implementation of Phase 2, CMS will issue instructions to carriers and A/B MACs that will assist them in processing enrollment applications from physicians who are employed by the Department of Veterans Affairs, the Public Health Service, and the Department of Defense Tricare program. The instructions will also state that the teaching physician should be reported as the Ordering/Referring Physician in situations where a resident orders or refers items or services for Medicare beneficiaries. The instructions will also note that dentists and pediatricians, who sometimes order or refer items or services for Medicare beneficiaries, may be enrolling in Medicare in order to continue to order and refer.

4. CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters Article on the implementation of these two new edits. This MLN Matters Article will expand upon the information currently available in MLN Matters Articles MM 6417 and MM 6421.



Note: If you have problems accessing any hyperlink in this message, please copy and paste the URL into your Internet browser.

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2. Only 3 Days Left to Bid for the Round 1 Rebid of the DMEPOS Competitive Bidding Program



The Centers for Medicare & Medicaid Services (CMS) is currently accepting bids for the Round 1 Rebid of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. All bids must be submitted in DBidS, the on-line bidding system, by 9 p.m. prevailing Eastern Time on December 21, 2009; all required hardcopy documents that must be included as part of the bid package must be postmarked by 11:59 p.m. on December 21, 2009. You will not be permitted to alter or amend your bid after the close of bidding.



Here are some important things to remember when submitting your bid:

· You must submit your bid in DBidS using the user ID you received during registration. By now you should have already logged into DBidS and have started completing your bid application online. Please note that you must answer at least 2 and up to 10 authentication questions the first time you log in.

· All bidders must submit certain required hardcopy documents as specified in the Request for Bids (RFB) instructions. It is very important that you review Appendix B of the RFB instructions and the sample financial statements to ensure your documents include the required information. If you have already submitted your financial documents, you may still amend those documents until bidding closes on December 21, 2009. You are required to indicate your bidder number on each page of your hardcopy documents.

· If you submitted financial documents by the Covered Document Review Date (CDRD), November 21, 2009, you will receive an e-mail about your financial documents from the Competitive Bidding Implementation Contractor (CBIC) by December 29, 2009. If you submitted all financial documents, the e-mail will confirm that the CBIC received all financial documents and that no further action from you is required. If you did not submit all financial documents, the e-mail will alert you to expect a letter notifying you of the missing financial documents. The letter notifying you of missing financial documents will be mailed to your authorized official by January 4, 2010. The letter will identify the missing document(s) as of the CDRD. You will be required to submit only the indicated missing financial document(s) within 10 business days of the notification. If you did not submit any financial documents by the CDRD, you will not receive an e-mail or a letter about your financial documents. Remember, the covered document review process does not indicate whether the financial documents are accurate, acceptable, or in accordance with the RFB instructions. You cannot submit revised versions of previously submitted financial documents after December 21, 2009.

· If you did not submit any hardcopy financial documents by the CDRD, you are still required to submit all required hardcopy documents specified in the Request for Bids (RFB) instructions by 11:59 p.m. on December 21, 2009.

· The Round 1 Rebid competitive bidding areas (CBAs), product categories, DBidS information, bidder charts, educational materials, and complete RFB instructions can be found on the CBIC web site, www.dmecompetitivebid.com. You should review this information prior to submitting your bid(s).

If you have any questions about the bidding process, please contact the CBIC Customer Service Center at 1-877-577-5331.

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3. Bidder Alert for DMEPOS Competitive Bidding



Here is some important information for you to consider if you are planning to use a consultant for the preparation of your bid(s):



Question: May bidders use a consultant for the preparation of their bids?



Answer: While bidders may use consultants to assist in the preparation of their bids, each bidder is responsible for validating and submitting its own bid. All bids must comply with all terms and conditions of the Request for Bids (RFB), regardless of whether a consultant is used.



Question: Are certain consultants or certain consultant services not appropriate for assisting in bid preparation?



Answer: If a bidder decides to use a consultant, any consultation service must be consistent with the DMEPOS competitive bidding program authorizing regulations and the RFB and permissible under all applicable Federal laws.



If a supplier uses a consultant, the supplier may not knowingly use a consultant that compares that supplier’s bid with, or knowingly makes bid item prices identical or substantially the same as, the bid of another bidder(s). Consultants must not violate any Federal antitrust law or engage in anticompetitive behavior (e.g., comparing different suppliers’ bids or knowingly advising different suppliers to submit identical or substantially identical bid prices) in preparing bids. CMS reviews the financial capacity of each bidder to supply DMEPOS at the bid price and determines whether a bid is bona fide, and, generally, whether the bid complies with the applicable law, regulations, and RFB. CMS will reject a bid that is not bona fide or does not otherwise comply with the law, regulations, or RFB. If you suspect a consultant may be engaging in practices that violate antitrust laws, please contact the CBIC Customer Service Center at 1-877-577-5331.



If a bidder uses a consultant, the bidder needs to verify that the information prepared by the consultant is accurate and can be certified as true by the bidder. Bidders certify that their bids are true, accurate and complete when they approve Form B in DBidS. Approving Form B also certifies that the bidder understands that any omission, misrepresentation, or falsification of any information contained in the bid and all required attachments and supplemental information or contained in any communication supplying information to CMS or the CBIC may be punishable by criminal, civil, or other administrative actions including revocation of approval, fees, and/or imprisonment under Federal law.

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4. Physician Quality Reporting Initiative (PQRI) Program Announcement



2010 Physician Quality Reporting Initiative Educational Products are Now Available!

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the posting of 2010 Physician Quality Reporting Initiative (PQRI) educational products to the PQRI webpage at www.cms.hhs.gov/PQRI on the CMS website:

2010 PQRI Quality Measure List- this document identifies the 179 quality measures (this includes 175 individual quality measures and the 4 measures in the Back Pain measures group, which are not reportable as individual PQRI quality measures) selected for the 2010 PQRI

2010 PQRI Quality Data Code (QDC) Categories – a table that outlines, for each measure, each QDC that should be reported for a corresponding quality action performed by the individual EP as noted in the measures specification. This determines how each code will be used when calculating performance rates. This also clarifies those measures that require 2 or more QDCs to report satisfactorily. Insufficiently reporting the QDCs (as specified in the 2010 PQRI measure specifications) will result in invalid reporting.

2010 Single Source Code Master- this file includes a numerical listing of all codes included in 2010 PQRI for incorporation into billing software.

2010 PQRI Measure Specifications Manual for Claims and Registry; Reporting of Individual Measures and Release Notes- this zip file contains two documents which are the authoritative documents that describe 1) the 2010 measure specifications (including codes and reporting instructions) for the 175 individual PQRI quality measures for claims or registry-based reporting and 2) changes from the 2009 PQRI Measure Specifications in the form of release notes delineated by measure number.

2010 PQRI Implementation Guide- provides guidance about how to implement 2010 PQRI claims-based reporting of measures to facilitate satisfactory reporting of quality data codes by EPs.

2010 PQRI Measures Groups Specifications Manual and Release Notes- Measures group specifications that are different from those of the individual measures that form the group. The specifications and instructions for measures group reporting are, therefore, provided in a separate manual. This zip file contains two documents which are the authoritative documents that describe 1) the 2010 measures groups specifications (including codes and reporting instructions) for the 13 PQRI measures groups for claims or registry-based reporting and 2) changes from the 2009 PQRI Measures Groups Specifications Manual in the form of release notes.

Getting Started with 2010 PQRI Reporting of Measures Groups - provides guidance about implementing the 2010 PQRI measures groups.

2010 PQRI Measure Applicability Validation Process for Claims-Based Reporting of Individual Measures- provides guidance for those eligible professionals who satisfactorily submit quality-data codes for fewer than three PQRI measures, and how the measure-applicability validation process will determine whether they should have submitted QDCs for additional measures.

2010 PQRI Measure-Applicability Validation Process Release Notes- the release notes for the changes occurring for the 2010 PQRI Measure Applicability Validation Process (MAV).

2010 Measure-Applicability Validation Process Flow Chart- a chart that depicts the Measure Applicability Validation Process (MAV)

Group Practice Reporting Option (GPRO) Requirements for Submission of 2010 PQRI Data- provides guidance on how a group practice can self-nominate to participate in the GPRO for 2010 data submission.

2010 PQRI GPRO Disease Modules and Preventive Care Measures- a document containing a list of the 2010 PQRI GPRO Measures

2010 PQRI GPRO Narrative Measure Specifications- this document contains descriptions of the 2010 PQRI GPRO measures.

Registry Requirements for Submission of 2010 PQRI Data on Behalf of Eligible Professionals- this document describes the high-level requirements for a registry to qualify to submit under the registry-based reporting alternatives for 2010. This document also outlines how a registry can become qualified for 2010 data submission.

To access the 2010 PQRI educational products, visit the following page http://www.cms.hhs.gov/PQRI/02_Spotlight.asp#TopOfPage on the CMS website. Once on the Spotlight page, view the listing of educational products and the corresponding webpages where they can be found.

Further information on the 2010 PQRI Program may be found in the final 2010 Medicare Physician Fee Schedule rule with comment period (74 FR 61788 through 61861) that was published in the Federal Register on October 30, 2009. The final rule can be found on the Physician Quality Reporting Initiative webpage at www.cms.hhs.gov/PQRI on the CMS website, click on the Statute/Regulations/Program Instructions section page at left.

Reporting for the 2010 PQRI begins January 1, 2010. Please note there is no need to sign up or pre-register in order to participate.

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5. 2010 Electronic Prescribing Incentive (eRx) Program Announcement



2010 Electronic Prescribing Incentive (eRx) Educational Products are Now Available!

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the posting of 2010 Electronic Prescribing Incentive (eRx) Program educational products to the eRx webpage at www.cms.hhs.gov/ERxIncentive on the CMS website:

· 2010 eRx Measure Specifications and Release Notes- Provides guidance on the 2010 eRx measure specifications for claims or registry-based reporting and release notes describing changes from the 2009 eRx measure specifications.



· Claims-Based Reporting Principles for the 2010 eRx Incentive Program- provides guidance on the principles for reporting the eRx measure on claims for the 2010 eRx Incentive Program.



· 2010 EHR Measure Specifications for eRx and Release Notes- provides guidance on The 2010 EHR measure specifications for eRx and release notes. In addition it details the specifications contain a detailed description of data element names and codes.



· 2010 EHR Downloadable Resource- an Excel spreadsheet listing 2010 EHR information.



· Group Practice Reporting Option (GPRO) Requirements for Submission of 2010 eRx Data- provides guidance on the Group Practice Reporting Option (GPRO) requirements for submission of 2010 eRx data.



· GPRO eRx Measure Specifications- provides guidance on the specifications for the eRx measure for use in the 2010 eRx GPRO.

To access the 2010 eRx educational products, visit the following page http://www.cms.hhs.gov/PQRI/02_Spotlight.asp#TopOfPage on the CMS website. Once on the Spotlight page, view the listing of educational products and the corresponding webpages they can be found on.

Further information on the 2010 eRx Incentive Program may be found in the final 2010 Medicare Physician Fee Schedule rule with comment period (74 FR 61788 through 61861) that was published in the Federal Register on October 30, 2009. The final rule can be found on the Electronic Prescribing Incentive Program webpage at www.cms.hhs.gov/ERxIncentive on the CMS website, click on the Statute/Regulations/Program Instructions section page at left.

Reporting for the 2010 eRx begins January 1, 2010. Please note there is no need to sign up or pre-register in order to participate.

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6. MLN Matters Article #MM6740 - Revisions to Consultation Services Payment Policy



MM6740 - Revisions to Consultation Services Payment Policy



This article pertains to Change Request (CR) 6740, which alerts physicians and non-physician practitioners that effective January 1, 2010, the Current Procedural Terminology (CPT) consultation codes (ranges 99241-99245 and 99251-99255) are no longer recognized for Medicare Part B payment. Effective for services furnished on or after January 1, 2010, physicians and non-physician practitioners should code a patient evaluation and management visit with E/M codes that represents where the visit occurs and that identify the complexity of the visit performed. For more information, please view the article located at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf on the CMS website.

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7. Nursing Home Five-Star Quality Rating System – December News



1. The Five-Star provider preview reports will be available beginning Tuesday, December 15, 2009. Providers can access the report from the Minimum Data Set (MDS) State Welcome pages available at the State servers for submission of Minimum Data Set data.

Provider Preview access information:

· Visit the MDS State Welcome page available on the State servers where you submit MDS data to review your results.

· To access these reports, select the Certification and Survey Provider Enhanced Reports (CASPER) Reporting link located at the bottom of the login page.

· Once in the CASPER Reporting system,

i. Click on the 'Folders' button and access the Five-Star Report in your 'st LTC facid' folder,

ii. Where st is the 2-digit postal code of the state in which your facility is located, and

iii. Facid is the state assigned facid of your facility.

2. BetterCare@cms.hhs.gov is available to address any questions and concerns about the December’s data. The helpline will reopen in January 2010.

3. Nursing Home Compare will update with December’s Five-Star data on Thursday, December 24, 2009.

4. Please visit http://www.cms.hhs.gov/CertificationandComplianc/13_FSQRS.asp for the latest Five-Star Quality Rating system information.

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8. Your December Flu Message



Flu Season is Here!



Annual outbreaks of the seasonal flu usually occur from late fall to early spring. Typically, 5 to 20 percent of Americans get the seasonal flu, resulting in approximately 36,000 flu-related deaths.[1]



If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu by recommending an annual seasonal influenza vaccination. Medicare provides coverage of the seasonal flu vaccine and its administration. And don’t forget to immunize yourself and your staff. Protect yourself, your staff, your patients, and your family and friends.



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 seasonal influenza virus vaccine and its administration as well as related educational resources for health care professionals and their staff, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS website. You will find a variety of resources that explain Medicare coverage and claims submission policies related to the seasonal influenza vaccine.



For information on Medicare policies related to H1N1 influenza, please go to http://www.cms.hhs.gov/H1N1 on the CMS website.

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[1] Flu.gov. 2009. About the Flu [online]. Washington DC: The U.S. Department of Health and Human Services, 2009 [cited 30 November 2009]. Available from the World Wide Web:
(http://www.flu.gov/individualfamily/about/index.htm )

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9. Extra Help for Medicare 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. This can mean big savings on prescription drug costs.

· Encourage people with Medicare to file for Extra Help online: https://secure.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/staticpages/ships.aspx or by calling 1-800-MEDICARE.

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Lucretia James

Division for Medicare Health Plans Operations
Centers for Medicare & Medicaid Services
Region VIII
1600 Broadway, Suite 700
Denver, CO 80202
(303) 844-1568
lucretia.james@cms.hhs.gov







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[1] Flu.gov. 2009. About the Flu [online]. Washington DC: The U.S. Department of Health and Human Services, 2009 [cited 30 November 2009]. Available from the World Wide Web:
(http://www.flu.gov/individualfamily/about/index.htm )