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. Update on Claims Processing for Ordering/Referring Providers
2. The Patient Protection and Affordable Care Act (PPACA)
3. PPACA: Extension of Moratorium That Allows Independent Laboratories to Bill for the Technical Component (TC) of Physician Pathology Services Furnished to Hospital Patients
4. PPACA: Extension of Therapy Cap Exceptions Process
5. PPACA: Continuation of Payments to Indian Health Service (IHS) Providers, Suppliers, Physicians, and other Practitioners for Certain Part B Services
6. PPACA: Extension of the Outpatient Hold-Harmless Provision
7. PPACA: Extension of Reasonable Cost Payment for Clinical Lab Tests Performed by Hospitals with Fewer than 50 Beds in Qualified Rural Areas
8. PPACA: Timely Filing Requirements for Medicare Fee-For-Service Claims
9. PPACA: Medicare Home Health Rural Add-On
10. 2010 Physician Quality Reporting Initiative & Electronic Prescribing Incentive Program National Provider Call with Question & Answer Session
11. CMS Public Website Address Change
12. New from the Medicare Learning Network
13. New Data Format for Medicare National Correct Coding Initiative Edit Files
14. Pricer Updates for Inpatient Rehabilitation Facility PPS and Inpatient PPS
15. April 5-11 is National Public Health Week and April 7 is World Health Day!
16. Acumen's Study on the Medicare Wage Index: Final Report Part II
17. A new "twist" in the law makes it easier to save on your prescription drug costs.
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1. Update on Claims Processing for Ordering/Referring Providers
The Centers for Medicare & Medicaid Services (CMS) will delay until January 3, 2011, 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)).
This delay 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 contains the 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.
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2. The Patient Protection and Affordable Care Act (PPACA)
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). The Centers for Medicare & Medicaid Services (CMS) is working hard to expeditiously implement the new law. The law's Medicare fee-for-service provisions have varying effective dates and our first priority is to address provisions with the earliest effective dates. CMS is committed to assuring Medicare providers are well informed as early as possible. For that reason, CMS is urging you to be on the alert for notices and instructions from CMS and from your Medicare fiscal intermediary, carrier, or Medicare Administrative Contractor, on forthcoming policy and operational changes as we implement the PPACA.
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3. PPACA: Extension of Moratorium That Allows Independent Laboratories to Bill for the Technical Component (TC) of Physician Pathology Services Furnished to Hospital Patients
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the moratorium that allows independent laboratories to bill for the TC of physician pathology services furnished to patients in hospitals, effective for claims with dates of service on and after January 1, 2010, through December 31, 2010.
In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, CMS stated that it would implement a policy to pay only the hospital for the TC of physician pathology services furnished to hospital patients. At the request of industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed. Subsequent legislation formalized a moratorium on the implementation of the rule.
Although the previous extension of the moratorium expired at the end of 2009, Section 3104 of the Patient Protection and Affordable Care Act restored the moratorium retroactive to January 1, 2010. Therefore, independent laboratories may now submit claims to Medicare for the TC of physician pathology services furnished to patients of a hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed. This policy is effective for claims with dates of service on or after January 1, 2010, through December 31, 2010. If an independent laboratory previously submitted a claim for services covered by this provision and the claim was denied, the laboratory may contact its Medicare contractor for further instructions.
Please be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
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4. PPACA: Extension of Therapy Cap Exceptions Process
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the exceptions process for outpatient therapy caps (see Section 3103). Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished on or after January 1, 2010, through December 31, 2010.
The therapy caps are determined on a calendar year basis, so all patients began a new cap year on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.
Please be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
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5. PPACA: Continuation of Payments to Indian Health Service (IHS) Providers, Suppliers, Physicians, and other Practitioners for Certain Part B Services
Section 630 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) allowed IHS facilities to bill for other Part B services, which were not previously covered under Section 1848 of the Act, and expanded the scope of items and services for which payment would be made to IHS providers, suppliers, physicians, and other practitioners for a 5-year period beginning January 1, 2005. Section 630 expired on December 31, 2009.
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. Section 2902 of the new law permanently extends Section 630 of the MMA, retroactive to January 1, 2010. The specific Part B services involved are:
· Ambulance services;
· Clinical laboratory services;
· Part B drugs processed by the J4 A/B Medicare Administrative Contractor (MAC) and the Durable Medical Equipment MACs;
· Influenza and pneumonia vaccinations;
· Durable medical equipment;
· Therapeutic shoes;
· Prosthetics and orthotics;
· Surgical dressings, splints and casts; and
· Screening and preventive services not covered prior to the implementation of
Section 630 of the MMA.
Indian Health Service providers, suppliers, physicians and other practitioners should contact their Medicare Administrative Contractor for further guidance regarding IHS claims affected by the new law, for dates of service January 1, 2010, and after, that have been denied.
Note: It will take approximately two weeks from the date that you receive this message for contractors to update their systems to be able to pay correctly for these services. You may want to wait until the claims processing system is updated before submitting any new claims containing IHS services.
Please be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
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6. PPACA: Extension of the Outpatient Hold-Harmless Provision
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which extends the Outpatient Hold Harmless provision, effective for dates of service on and after January 1, 2010, through December 31, 2010, to rural hospitals with 100 or fewer beds and to all sole community hospitals and Essential Access Community Hospitals regardless of bed size.
Please be on the alert for more information pertaining to the PPACA and its impact on past and future claims.
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7. PPACA: Extension of Reasonable Cost Payment for Clinical Lab Tests Performed by Hospitals with Fewer than 50 Beds in Qualified Rural Areas
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). Section 3122 of the PPACA re-institutes reasonable cost payment for clinical lab tests performed by hospitals with fewer than 50 beds in qualified rural areas as part of their outpatient services for cost reporting periods beginning on or after July 1, 2010, through June 30, 2011. This could affect services performed as late as June 30, 2012.
If you are a hospital who qualifies under Section 3122, you do not need to take any action. You will receive reasonable cost reimbursement for an entire year, starting with your cost reporting period beginning on or after July 1, 2010.
Please be on the alert for more information pertaining to the PPACA.
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8. PPACA: Timely Filing Requirements for Medicare Fee-For-Service Claims
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program.
The time period for filing Medicare FFS claims is specified in Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and in the Code of Federal Regulations (CFR), 42 CFR Section 424.44. Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service.
Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010. The following rules apply to claims with dates of service prior to January 1, 2010. Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules. Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010.
Section 6404 of the PPACA also permits the Secretary to make certain exceptions to the one-year filing deadline. At this time, no exceptions have been established. However, proposals for exceptions will be specified in future proposed rulemaking.
Please be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
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9. PPACA: Medicare Home Health Rural Add-On
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which creates a 3% add-on to payments made for home health services to patients in rural areas. The add-on applies to episodes ending on or after April 1, 2010, through December 31, 2016. Similar to temporary rural add-on provisions in the past, claims that report a rural state code (code beginning with 999) as the Core Based Statistical Area (CBSA) code for the beneficiary’s residence will receive the additional 3% payment. The CBSA code is reported associated with value code 61 on home health claims.
The Centers for Medicare & Medicaid Services is working to expeditiously implement the home health rural add-on provision, Section 3131(c), of the PPACA. Be on the alert for more information about this provision and its impact on past and future claims. Further, be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
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10. 2010 Physician Quality Reporting Initiative & Electronic Prescribing Incentive Program National Provider Call with Question & Answer Session
The Centers for Medicare & Medicaid Services’ (CMS) Provider Communications Group will host a national provider conference call on the 2010 Physician Quality Reporting Initiative (PQRI) and Electronic Prescribing Incentive Program (eRx). This toll-free call will take place from 3:30 p.m. – 5:00 p.m., EDT, on Thursday, April 15, 2010.
The PQRI is voluntary quality reporting program that provides an incentive payment to identified individual eligible professionals (EPs), and beginning with the 2010 PQRI, group practices who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-For-Service (FFS) beneficiaries.
The PQRI was first implemented in 2007 as a result of section 101 of the Tax Relief and Health Care Act of 2006 (TRHCA), and further expanded as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).
The eRx Incentive Program is an incentive program for eligible professionals initially implemented in 2009 as a result of section 132(b) of the MIPPA. The eRx Incentive Program promotes the adoption and use of eRx systems by individual eligible professionals (and beginning with the 2010 eRx Incentive Program, group practices).
Following a few program announcements and updates, the lines will be opened to allow participants to ask questions of CMS PQRI and eRx subject matter experts.
Educational products are available on the PQRI dedicated web page located at, http://www.cms.hhs.gov/PQRI , on the CMS website, in the Educational Resources section, as well as educational products are available on the eRx dedicated web page located at http://www.cms.hhs.gov/ERxIncentive on the CMS website. Feel free to download the resources prior to the call so that you may ask questions of the CMS presenters.
Conference call details:
Date: April 15, 2010
Conference Title: Physician Quality Reporting Initiative (PQRI) - National Provider Call
Time: 3:30 p.m. EDT
To receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation. Registration will close at 3:30 p.m. EDT on April 14, 2010, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.
1. To register for the call participants need to go to:
http://www.eventsvc.com/palmettogba/041510
2. Fill in all required data.
3. Verify that your time zone is displayed correctly in the drop down box.
4. Click "Register".
5. You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. Note: Please print and save this page, in the event that your server blocks the confirmation emails. If you do not receive the confirmation email, please check your spam/junk mail filter as it may have been directed there.
For those of who will be unable to attend, a transcript of the call will be available at least one week after the call at http://www.cms.hhs.gov/pqri on the CMS website.
If you require services for the hearing impaired please send an email to: Medicare.TTT@PalmettoGBA.com.
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11. CMS Public Website Address Change
On Friday, April 2, 2010, the Centers for Medicare & Medicaid Services (CMS) will be changing our website address from www.cms.hhs.gov to www.cms.gov. Existing bookmarks and links from other websites will continue to work following this address change.
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12. New from the Medicare Learning Network
The revised Ambulance Fee Schedule Fact Sheet (January 2010), which provides general information about the Ambulance Fee Schedule including how payment rates are set for ground and air ambulance services, is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, visit http://www.cms.gov/MLNGenInfo/ , scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”
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Now Available! Special Edition MLN Matters Article #SE1011 - Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696)
The Centers for Medicare & Medicaid Services (CMS) has released a Special Edition MLN Matters article that provides guidance on the edits required to be identified in Part B claims from Medicare providers or suppliers who furnish items or services as a result of orders or referrals. Medicare providers and suppliers who order or refer items or services for Medicare beneficiaries must submit an enrollment application to Medicare by using Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or by completing the paper enrollment application (CMS-855I). The article, SE1011, “Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696),” is available at http://www.cms.gov/MLNMattersArticles/downloads/SE1011.pdf on the CMS website.
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13. New Data Format for Medicare National Correct Coding Initiative Edit Files
Beginning with the April 2010 update, the Centers for Medicare and Medicaid Services (CMS) will now post the National Correct Coding Initiative (NCCI) Edit files in Excel 2007 and in text formats. Because Excel 2007 can support a larger number of rows, each code range will be contained in one file as opposed to multiple files. This should correct the incompatibility issues that some of our users experienced last quarter with the Excel 2003 files.
Please be aware that Excel 2003 and earlier versions of the software have a maximum row count of 65,536. Some of the NCCI Edit files exceed the maximum row count. If you do not have Excel 2007, please use the text format to import the data into an application that can support larger files.
For more information on NCCI edits and to download the files, visit the web page at
http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
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14. Pricer Updates for Inpatient Rehabilitation Facility PPS and Inpatient PPS
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Personal Computer (PC) Pricer Updates
The Fiscal Years (FY) 2008, FY 2009, and FY 2010 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) PC Pricers have been updated with corrected outlier calculation logic and are ready for download from the Centers for Medicare & Medicaid Services (CMS) web page at http://www.cms.hhs.gov/PCPricer/06_IRF.asp. If you use the IRF PPS PC pricers, please go to the page above and download the latest versions of the pricers, posted 03/26/10, in the Downloads section.
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Inpatient Prospective Payment System (PPS) Personal Computer (PC) Pricer Updates
The Fiscal Year (FY) 2009 Inpatient PPS PC Pricer has been updated on the web for FY 2009 claims with corrected provider data from January 2010. In addition, the FY 2010 Inpatient PPS PC Pricer has been updated on the web for FY 2010 claims with corrected provider data from January 2010. If you use these pricers, please go to the Inpatient PPS PC Pricer page at http://www.cms.hhs.gov/PCPricer/03_inpatient.asp and download the latest versions of the pricers in the Downloads section.
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15. April 5-11 is National Public Health Week and April 7 is World Health Day!
In the spirit of National Public Health Week and World Health day, the Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare provides coverage for a variety of preventive services. By encouraging your Medicare patients to take advantage of covered preventive services, you can help them lead longer, fuller, healthier lives.
Medicare Covered Preventive Services
Medicare provides coverage for the following preventive services for eligible Medicare beneficiaries:
· Abdominal Aortic Aneurysm Screening,
· Adult Immunizations,
· Bone Mass Measurements,
· Cancer Screenings,
· Cardiovascular Screenings,
· Diabetes-Related Services and Screenings,
· Glaucoma Screenings,
· Smoking and Tobacco-Use Cessation Counseling, and
· Initial Preventive Physical Examination.
For More Information
· CMS has developed a variety of educational products and resources to help health care professionals and their staff become familiar with coverage, coding, billing, and reimbursement for the many preventive services and screenings covered by Medicare.
o The Medicare Learning Network (MLN) Preventive Services Educational Products Web Page ~ provides descriptions and ordering information for Medicare Learning Network (MLN) preventive services educational products and resources for health care professionals and their staff. http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp
o The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers and Other Health Care Professionals ~ This comprehensive resource contains coverage, coding, and payment information for the many preventive services covered by Medicare. http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
o Quick Reference Information: Medicare Preventive Services ~ This chart contains coverage, coding, and payment information for the many preventive services covered by Medicare in an easy-to-use quick-reference format. http://www.cms.hhs.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf
o The Preventive Services Educational Products PDF ~ This PDF document contains links to downloadable versions of the many products the MLN has available related to Medicare-covered preventive services, including brochures, quick reference guides, and more. http://www.cms.hhs.gov/MLNProducts/Downloads/education_products_prevserv.pdf
o To order hard copies of certain MLN products, please visit the MLN homepage at: http://www.cms.hhs.gov/mlngeninfo Scroll down to “Related Links Inside CMS” and click on “MLN Product Ordering Page”
· For more information about World Health Day, please visit the World Health Organization’s web site at: http://www.who.int/world-health-day/en
· For more information about National Public Health Week, please visit the American Public Health Association’s web site at: http://www.nphw.org/nphw10/home1.htm
Thank you for helping CMS improve the health of patients with Medicare by joining in the effort to educate eligible beneficiaries about the importance of taking advantage of the many preventive services covered by Medicare.
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16. Acumen's Study on the Medicare Wage Index: Final Report Part II
In the Fiscal Year (FY) 2010 hospital inpatient prospective payment system final rule (74 FR 43824), the Centers for Medicare & Medicaid Services (CMS) discussed that the focus of Acumen's second final report on the wage index would be on the methodology of wage index construction and would cover issues related to the definition of wage areas and methods of adjusting for differences among neighboring wage areas. Acumen's Final Report Part II is now available on its Website.
The Final Report Part II can be found at the following link: http://www.acumenllc.com/reports/cms/Medicare_Wage_Index_Part_2.pdf. To find all 3 Acumen wage index reports – Final Report Part II, Final Report Part I, and the 2008 Interim Report – please see: http://www.acumenllc.com/reports/cms/.
CMS contacts for the Acumen wage index study: Project Officer: Craig Caplan, ORDI (Craig.Caplan@cms.hhs.gov); Philip Cotterill, ORDI (Philip.Cotterill@cms.hhs.gov); Valerie Miller, CMM (Valerie.Miller@cms.hhs.gov).
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17. A new "twist" in the law makes it easier to save on your prescription drug costs.
http://www.ssa.gov/prescriptionhelp/
Under a new law, more Medicare beneficiaries could qualify for Extra Help with their Medicare prescription drug plan costs because some things no longer count as income and resources. The Extra Help is estimated to be worth an average of $3,900 per year. To qualify for the Extra Help, a person must be on Medicare, have limited income and resources, and reside in one of the 50 states or the District of Columbia.
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Professor Emeritus -- Dr. Tom Seymour from West Fargo, North Dakota -- Professor, Minot State University, MSU Faculty Regents Award (2015) -- PAST Peer Reviewer (Higher Learning Commission - Chicago); - Author and Presenter Board of Directors, SRT Communications, Inc and Minot City Alderman - Ward 5 (2010-June, 2016) PAST - Editor-in-Chief (North Dakota State Senator (2002-2010) 2017-Cass County Electric Cooperative- Board of Directors
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