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RAILROAD MEDICARE ADVISORY
Latest Part B News for Railroad Medicare
What’s Inside...
Administration
CMS Quarterly Provider Update .............................................................................................2
Provider Customer Service Center Training & Closure Dates ................................................3
Reporting Principal and Interest Amounts When Refunding Previously Recouped Money
on the Remittance Advice (RA) ..........................................................................................4
Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.2,
Effective July 1, 2016 ..........................................................................................................6
Drugs and Biologicals
Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs ....8
Education
Education Now Available.......................................................................................................13
Get Your Railroad Medicare News Electronically .................................................................14
Electronic Data Interchange (EDI)
Remittance Advice Remark and Claims Adjustment Reason Code and Medicare Remit Easy
Print and PC Print Update .....................................................................................................15
ICD-10
ICD-10-CM Diagnosis Codes for Bone Mass Measurement .............................................16
Medicine
Updates to Medicare’s Organ Acquisition and Donation Payment Policy ...........................18
Laboratory
Changes to the Laboratory National Coverage Determination (NCD) Edit Software
for July 2016 ......................................................................................................................21
Etcetera
CMS e-News ..........................................................................................................................23
palmettogba.com/rr
The Medicare Advisory contains coverage, billing and other information for Railroad Medicare. This information is
not intended to constitute legal advice. It is our ofϐicial notice to those we serve concerning their responsibilities
and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no
cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow
the guidelines. The Railroad Medicare Advisory includes information provided by the Centers for Medicare &
Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any
time. This bulletin should be shared with all health care practitioners and managerial members of the provider
staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/rr.
CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part
of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code
on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2015
American Dental Association (ADA). All rights reserved.
May 2016
Volume 2016, Issue 5
CMS 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
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 listserv (electronic mailing list) at
https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.
We encourage you to bookmark the Quarterly Provider Update Web site at
www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. html
and visit it often for this valuable information.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
2
5/2016
Provider Customer Service Center Training &
Closure Dates
The Centers for Medicare & Medicaid Services (CMS) has approved allowing Medicare
provider service centers to close up to eight hours per month for provider Customer
Service Advocates (CSAs) training and/or staff development. The goal is to help CSAs
improve the consistency and accuracy of their responses to provider questions; enhance
their awareness and understanding of Medicare policies and issues; and facilitate CSAs’
retention of the facts of their training by increasing its frequency.
When our CSAs participate in training and developmental sessions on Thursdays of
each month, you may use our online provider portal called eServices. eServices provides
claim status, duplicate remittances, patient eligibility and much more. Register now
at www.PalmettoGBA.com/eServices. Please refer to the training schedule below for
specific closure dates and times.
Date
Phones Closed
April 28, 2016
PCC closed from 2:15-4:45 for training
May 12, 2016
PCC closed from 2:15-4:45 for training
May 26, 2016
PCC closed from 2:15-4:45 for training
May 30, 2016
Office closed/ Memorial Day
July 4, 2016
Office closed/ Independence Day
September 5, 2016
Office closed/ Labor Day
October 10, 2016
Office closed/ Columbus Day
November 11, 2016
Office closed/ Veteran’s Day
November 24-25, 2016
Office closed/ Thanksgiving
December 23, 2016
Office closed/Christmas Eve
December 26, 2016
Office closed/Christmas Day
January 2, 2017
Office closed/ New Year’s Day
Please note that we will attempt to provide advance notice of any changes to the above training schedule via the website, IVR features and automatic email notices.
If you have not already done so, we encourage you to sign up for automatic email notices of updates to our website. Subscribing to our Email Updates is the fastest way to find out about Medicare changes that may affect you. There is no charge for the service, and we will not share your email address with others. To register, go to Email
Updates on our website at http://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm. If you have any questions, please contact our provider service center at our toll-free number at 888-355-9165. For information regarding claims status or eligibility, please call the Interactive Voice Response (IVR) at 877­
288-7600 or use the Palmetto GBA eServices tool, located at http://www.PalmettoGBA.com/eServices. CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3
5/2016
Reporting Principal and Interest Amounts When Refunding
Previously Recouped Money on the Remittance Advice (RA)
MLN Matters® Number: MM9168
Revised Related Change Request (CR) #: CR 9168
Related CR Release Date: March 24, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R1639OTN
Implementation Date: July 5, 2016
Note: This article was revised on April 19, 2016, to reflect the revised CR9168 issued on March 24. In the
article, the CR release date, transmittal number, and the Web address for accessing the CR are revised. All
other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers who submit claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9168 explains to providers who received a favorable appeals decision that it will be
easier and consequently more transparent to identify the claim and/or the refund of principal and interest paid
by Medicare. Your MAC will make sure that the remittance advices are reporting the refunded principal and
interest amounts separately, and provide individual claim information. CR9168 applies to electronic remittance
advice (ERA) only.
Background
Currently reporting of refunded principal and interest amounts for all related claims on the Remittance Advice
(RA) is shown as one lump sum amount. This practice creates problems for the provider community as this
is not conducive to posting payment properly. Providers have the money but are not able to identify the claim
and/or the refund of principal and interest paid by Medicare.
CR9168 instructs MACs to report the principal and interest separately, and also to provide individual claim
information. Specifically, the reporting will be in the Provider Level Balance (PLB) segment of the 835 with
an example as follows:
PLB Details - Reporting Principal Refunds
PLB03-1: WW to report overpayment recovery (negative sign for the amount in PLB04) being refunded
PLB03-2 Positions 1 – 25: Account Payable (AP) Invoice Number
PLB03-2 Positions 26 – 50: Claim Adjustment Account Receivable (AR) number
PLB 04: Refund Amount (Principal Refund Amount)
PLB Details - Reporting Interest Refunds
PLB03-1: RU to report interest paid (negative sign for the amount in PLB04)
PLB03-2 Positions 1 – 25: AP Invoice Number
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4
5/2016
PLB03-2Positions 26 – 50: Claim Adjustment AR number
PLB04: Interest Amount on Refund
Additional Information
The official instruction, CR 9168 issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1639OTN.pdf on the
Centers for Medicare & Medicaid Services website.
Document History
• The article was revised on April 19, 2016 to reflect the revised CR9168 issued on March 24.
Denial Resolution Tool
The Palmetto GBA Denial Resolution tool, located on the home page under Forms/Tools, includes resources
for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you
pick up the phone.
•
•
•
Access denial reasons in plain language
Scroll through the titles to locate your procedure
Use the Palmetto GBA search engine to search by remark code
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5
5/2016
Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.2, Effective July 1, 2016
MLN Matters® Number: MM9516
Related Change Request (CR) #: CR 9516
Related CR Release Date: March 18, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3482CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9516 informs MACs about the release of the latest package of National Correct Coding
Initiative (NCCI) edits, Version 22.2, which will be effective July 1, 2016. Make sure that your billing staffs
are aware of these changes.
Background
The Centers for Medicare & Medicaid Services (CMS) developed the NCCI edits to promote national correct
coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.
The latest package of CCI edits, Version 22.2, effective July 1, 2016, will be available via the CMS Data Center
(CDC). A test file will be available on or about May 2, 2016, and a final file will be available on or about May
17, 2016.
Version 22.2 will include all previous versions and updates from January 1, 1996, to the present. In the past,
CCI was organized in two tables: Column 1/Column 2 Correct Coding Edits and Mutually Exclusive Code
(MEC) Edits.
In order to simplify the use of NCCI edit files (two tables), on April 1, 2012, CMS consolidated these two edit
files into the Column One/Column Two Correct Coding edit file. Separate consolidations have occurred for the
two practitioner NCCI edit files and the two NCCI edit files used for OCE. It will only be necessary to search
the Column One/Column Two Correct Coding edit file for active or previously deleted edits.
CMS no longer publishes a Mutually Exclusive edit file on its website for either practitioner or outpatient
hospital services, since all active and deleted edits will appear in the single Column One/Column Two Correct
Coding edit file on each website. The edits previously contained in the Mutually Exclusive edit file are NOT
being deleted but are being moved to the Column One/Column Two Correct Coding edit file.
Refer to the CMS NCCI webpage for additional information at
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6
5/2016
Note: The coding policies developed are based on coding conventions defined in the American Medical
Association’s Current Procedural Terminology manual, national and local policies and edits, coding guidelines
developed by national societies, analysis of standard medical and surgical practice, and review of current
coding practice.
Additional Information
The official instruction, CR9516, issued to your MAC regarding this change, is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3482CP.pdf on the CMS
website.
eServices: Claim Status
To check on a particular claim status, please enter the HICN and other required
b
beneficiary
information, as well as the date(s) of service. Should you not know
the exact date of service, you are able to enter a span or range of up to 45
days. Please keep in mind, retrieving claims older than six months takes a little
longer than something more current. Claims older than three years may not
b searchable. For more information about eServices and the many services
be
it offers, please visit our website at http://www.PalmettoGBA.com/eServices.
Review and Print Electronic Remittances –
via eRemits
Palmetto GBA is pleased to offer eRemits through our eServices, a free, webbased,
provider self-service tool. You can view or print remittances, which are
b
available for approximately one year. In addition, eServices will let you store
remittances and utilize search features to find specific information on the notices. eRemits are available to be
accessed every day between the hours of 8 a.m. and 7 p.m. ET.
To use eServices, you must have an Electronic Data Interchange (EDI) Agreement on file with Palmetto GBA.
If you are already submitting claims electronically, you do not have to submit a new EDI Enrollment Agreement.
For more information on EDI, please visit our website at www.PalmettoGBA.com/EDI.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7
5/2016
Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs
MLN Matters® Number: SE1434
Revised Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Note: This article was revised on April 18, 2016, to show additional date changes related to the delayed
enforcement of the Part D prescriber enrollment requirement until February 1, 2017. All other information
remains the same.
Provider Types Affected
This MLN Matters® Special Edition is intended for physicians, dentists, and other eligible professionals
who write prescriptions for Medicare beneficiaries for Medicare Part D drugs. The article is also directed to
Medicare Part D plan sponsors.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) finalized CMS-4159-F, “Medicare Program; Contract
Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug
Benefit Programs” on May 23, 2014. CMS later published CMS-6107-IFC, “Medicare Program; Changes to
the Requirements for Part D Prescribers,” an interim final rule with comment (“IFC”), that made changes to
the Final Rule (CMS-4159-F), on May 6, 2015. Together, these rules require virtually all physicians and other
eligible professionals, including dentists, who write prescriptions for Part D drugs to be enrolled in an approved
status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, except
in very limited circumstances. To allow sufficient time for the prescribers to enroll in Medicare and the Part
D sponsors and the Pharmacy Benefit Managers (PBMs) to make the complex system enhancements needed
to comply with the prescriber enrollment requirements, CMS announced a delay in enforcement of this rule
until February 1, 2017. Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment
applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by August 1,
2016, or earlier, to ensure that MACs have sufficient time to process the applications and opt-out affidavits and
avoid their patients’ prescription drug claims from being denied by their Part D plans, beginning February 1,
2017 (Enrollment functions for physicians and other prescribers are handled by MACs).
The purpose of these rules are to ensure that Part D drugs are prescribed only by physicians and eligible
professionals who are qualified to do so under state law and under the requirements of the Medicare program
and who do not pose a risk to patient safety. By implementing these rules, CMS is improving the integrity
of the Part D prescription drug program by using additional tools to reduce fraud, waste, and abuse in the
Medicare program. Prescribers who are determined to have a pattern or practice of prescribing Part D drugs
that are abusive and represents a threat to the health and safety of Medicare enrollees or fails to meet Medicare
requirements will have their billing privileges revoked under 42 USC 424.535 (a)(14).
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8
5/2016
Background
If you write prescriptions for covered Part D drugs and you are not already enrolled in Medicare in an approved
status or have a valid record of opting out, you should submit an enrollment application or an opt-out affidavit
to your Medicare Administrative Contractor (MAC) by August 1, 2016, or earlier, so that the prescriptions you
write for Part D beneficiaries are coverable on and after February 1, 2017.
To enroll in Medicare for the limited purpose of prescribing:
You may submit your enrollment application electronically using the Internet-based Provider Enrollment,
Chain, and Ownership System (PECOS) located at https://www.cms.gov/medicare/provider-enrollment-and­
certification/medicareprovidersupenroll/internetbasedpecos.html or by completing the paper CMS-855O
application, which is available at
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855o.pdf on the CMS website, which
must be submitted to the MAC that services your geographic area. Note that there is no application fee required
for your application submission. For step-by-step instructions, refer to the PECOS how-to guide, available
at http://go.cms.gov/orderreferhowtoguide or watch an instructional video at http://go.cms.gov/videotutorial.
The CMS-855O is a shorter, abbreviated form and takes minimal time to complete. While the CMS-855O form
states it is for physicians and non-physician practitioners who want to order and certify, it is also appropriate
for use by prescribers, who want to enroll to also prescribe Part D drugs. (CMS is in the process of updating
the CMS-855O form). If you do not see your specialty listed on the application, please select the Undefined
Physician/Non-Physician Type option and identify your specialty in the space provided.
Note: Dentists are recognized by Medicare as physicians and should select the “Part B Physician
Specialties” option and specify General Dentist in the free form text box.
The average processing time for CMS-855O applications submitted online is 45 days versus paper submissions
which is 60 days. However, your application could be processed sooner depending on the MAC’s current
workload.
To enroll to bill for services (and prescribe Part D drugs):
To enroll in Medicare to bill for your services, you may complete the CMS-855I application. The CMS-855R
should also be completed if you wish to reassign your right to bill the Medicare program and receive Medicare
payments for some or all of the services you render to Medicare beneficiaries. All actions can be completed via
PECOS or the paper enrollment application. For more information on enrolling in Medicare to bill for services
refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf If you are a physician or nonphysician practitioner who wants to opt-out of Medicare, you must submit an opt-out affidavit to the MAC
that services your geographic area. Physicians and non-physician practitioners should be aware that if they
choose to opt-out of Medicare, they are not permitted to participate in a Medicare Advantage Plan. In addition,
once a physician or non-physician practitioner has opted out they are not permitted to terminate their opt-out
affidavit early. Section 1802(b)(3)(B)(ii) of the Act establishes the term of the opt-out affidavit. The Act does
not provide for early termination of the opt-out term. Under CMS regulations, physicians and practitioners
who have not previously submitted an opt-out affidavit under Section 1802(b)(3) of the Act, may choose to
terminate their opt-out status within 90 days after the effective date of the opt-out affidavit, if the physician or
practitioner satisfies the requirements of 42 CFR § 405.445(b). No other method of terminating opt-out status
before the end of the two year opt-out term is available.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9
5/2016
Prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician/
practitioner opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid
opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If physicians and
practitioners that file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew
at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative
Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next
opt-out period. Valid opt-out affidavits signed before June 16, 2015 will expire 2 years after the effective date
of the opt out. If physicians and practitioners that filed affidavits effective before June 16, 2015, want to extend
their opt out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all
MACs with which they would have filed claims absent the opt-out. For more information on the opt-out process,
refer to MLN Matters® article SE1311, titled “Opting out of Medicare and/or Electing to Order and Certify Items
and Services to Medicare Beneficiaries,” which is available at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1311.pdf and https://www.cms.gov/
Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2015-06-25­
eNews.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending&imagelink=y#_Toc422891549
on the CMS website.
CMS would like to highlight the following limitations that apply to billing and non-billing providers:
• A resident is defined in 42 CFR § 413.75 as an intern, resident, or fellow who participates in an approved
medical residency program, including programs in osteopathy, dentistry, and podiatry, as required in order to
become certified by the appropriate specialty board. Interns, residents, and fellows may enroll in Medicare
to prescribe if the state licenses them. Licensure can include a provisional license or similarly- regulated
credential. Un-licensed interns, residents, and fellows must specify the teaching physician who is enrolled
in Medicare as the authorized prescriber on a prescription for a Part D drug (assuming this is consistent with
state law). Licensed residents have the option to either enroll themselves or use the teaching physician’s
name on prescriptions for Part D drugs, unless state law specifies which name is to be used. CMS strongly
encourages teaching physicians and facilities to ensure that the NPI of the lawful prescriber under state
law is included on prescriptions to assist pharmacies in identifying the correct prescriber and avoid follow
up from the pharmacies, which experience rejected claims from Medicare Part D plans due to missing or
wrong prescriber NPIs on the claims.
• The prescriber enrollment requirements also apply to physicians and non-physician practitioners who write
prescriptions for Part D drugs and are employed by a Part A institutional provider (e.g., hospital, Federally
Qualified Health Center (FQHC), Rural Health Center (RHC)). Since Part A institutional providers may
bill for services provided by an employed physician or non-physician practitioner, the physician or nonphysician practitioner may not have separately enrolled, unless he or she is also billing for Part B services.
Therefore, if the physician or non-physician practitioner prescribes Part D drugs as an employee of the
institutional provider, he or she must be enrolled in an approved status for their prescriptions to be coverable
under Part D beginning June 1, 2016.
• “Other authorized prescribers” are exempt from the Medicare Part D prescriber enrollment requirement.
In other words, prescriptions written by “other authorized prescribers are still coverable under Part D,
even if the prescriber is not enrolled in or opted out of Medicare. For purposes of the Part D prescriber
enrollment requirement only, “other authorized prescribers” are defined as individuals other than physicians
and eligible professionals who are authorized under state or other applicable law to write prescriptions
but are not in a provider category that is permitted to enroll in or opt-out of Medicare under the applicable
statutory language. CMS believes “other authorized prescribers” are largely pharmacists who are permitted
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10 5/2016
to prescribe certain drugs in certain states, but based on the applicable statute, pharmacists are not able to
enroll in or opt-out of Medicare.
If you believe you are an “other authorized prescriber” and are not a pharmacist, please contact
[email protected]. In addition, CMS strongly recommends that pharmacists in particular make
sure that their primary taxonomy associated with their NPI in the National Plan & Provider Enumeration System
(NPPES) reflects that they are a pharmacist. To review and update your NPPES information, please go to the
National Plan & Provider Enumeration System webpage at
https://nppes.cms.hhs.gov/NPPES/Welcome.do. Upon enforcement of the regulation, Part D plans will need
to be able to determine if the prescriber is a pharmacist in order to properly adjudicate the pharmacy claim at
point-of-sale.
In an effort to prepare the prescribers and Part D sponsors for the February 1, 2017 enforcement date, CMS
has made available an enrollment file that identifies physician and eligible professional who are enrolled
in Medicare in an approved or opt-out status. However, the file does not specify if a particular prescriber is
eligible to prescribe, as prescribing authority is largely determined by state law. The enrollment file is available
at https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx on the CMS website. The file
contains production data but is considered a test file since the Part D prescriber enrollment requirement is
not yet applicable. An updated enrollment file will be generated every two weeks, with a purposeful goal of
providing updates twice a week by the date of enforcement.
The file displays physician and eligible professional eligibility as of and after November 1, 2014, (that is,
currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any periods,
prior to November 1, 2014, for which a physician or eligible professional was not enrolled in an approved or
opt-out status will not be displayed on the enrollment file. However, any gaps in enrollment after November 1,
2014, for which a physician or eligible professional was not enrolled in an approved or opt-out status will be
reflected on the file with its respective effective and end dates for that given provider. For opted out providers,
the opt-out flag will display a Y/N (Yes/No) value to indicate the periods the provider was opted out of Medicare.
The file will include the provider’s:
• (NPI);
• First and Last Names;
• Effective and End Dates; and
• Opt-out Flag
Example 1 – Dr. John Smith’s effective date of enrollment is January 1, 2014. Since he was enrolled prior
to the generation of the test file, his effective date will display as November 1, 2014. Dr. Smith submits an
enrollment application to voluntarily withdraw from Medicare effective December 15, 2014. Dr. Smith will
appear on the applicable file as:
NPI
First Name
Last Name
123456789
John
Smith
Effective
Date
11/01/2014
End Date
Opt-out Flag
12/15/2014
N
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11
5/2016
Example 2 - Dr. Mary Jones submits an affidavit to opt-out of Medicare, effective December 1, 2014. Since
she has opted out after the generation of the test file, her effective date will display as December 1, 2014. After
the 2 year opt-out period expires, Dr. Jones decides she wants to enroll in Medicare to bill, order, and certify,
or to write prescriptions. The enrollment application is received on January 31, 2017, and the effective date
issued is January 1, 2017. Dr. Jones will display on the applicable file as:
NPI
First Name
Last Name
987654321
987654321
Mary
Mary
Jones
Jones
Effective
Date
12/01/2014
01/01/2017
End Date
Opt-out Flag
12/01/2016
Y
N
After the enforcement date of February 1, 2017, the applicable effective dates on the file will be adjusted to
February 1, 2017, and it will no longer be considered a test file. All inactive periods prior to February 1, 2017,
will be removed from the file and it will only contain active and inactive enrollment or opt-out periods as of
February 1, 2017, and after. The file will continue to be generated every two weeks, with a purposeful goal of
providing updates twice a week by the date of enforcement. Part D sponsors may utilize the file to determine a
prescriber’s Medicare enrollment or opt-out status when processing Part D pharmacy claims. The file will not
validate the provider’s ability to prescribe under applicable laws. Please submit questions or issues encountered
in accessing the file to [email protected].
Additional Information
For more information on the enrollment requirements, visit https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html
on the CMS website. If you have questions and need to speak with the Part B contractor that handles your enrollment, you may find their toll-free number at MAC List on the CMS website. For a list of Frequency Asked Questions (FAQs) refer to http://www.cms.gov/Medicare/Provider-Enrollment­
and-Certification/MedicareProviderSupEnroll/Downloads/CMS-4159_FAQs.pdf on the CMS website. Document History
Date of Change
April 18, 2016
April 7, 2016
December 5, 2014
October 20, 2015
Description
The article was revised to amend additional dates in the article to reflect the delayed
enforcement date of February 1, 2017.
The article was revised to communicate changes to and the delayed enforcement of
the Part D prescriber enrollment requirement until February 1, 2017, and to provide
clarifying information regarding the enrollment process.
The article was revised to add language to emphasize that form CMS-855O is
appropriate for use by prescribers.
The article was revised to communicate changes to and the delayed enforcement
of the Part D prescriber enrollment requirement until June 1, 2016, and to provide
clarifying information regarding the enrollment process.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12
5/2016
Education Now Available
The “Understanding the Railroad Medicare
Medical Review Program Webcast” recording
covers the basics of the Medical Review
program. It discusses why we conduct reviews,
the different types of review we conduct, and
your rol in the medical review process. We also
share helpful resources and answer frequently
asked questions. Please view at http://tinyurl.
com/h6llo7t.
A list of current system-related claims payment issues is
available on our website. These issues were reported to the
Centers for Medicare & Medicaid Services (CMS) and/or the
Multi-Carrier System (MCS). Please check often for updates
before contacting the provider contact center. The issues are identified by stand alone articles and will be updated
as needed. Be sure to sign-up to receive updates using the “Article Update Notification” feature.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
13
5/2016
Get Your Railroad Medicare News Electronically
The Railroad Medicare listserv is a wonderful communication tool that offers its members the opportunity to
stay informed about:
•
•
Medicare incentive programs
New legislation concerning Medicare
•
•
Fee Schedule changes
And so much more!
What is needed to receive updates?
• Internet access and an e-mail address
• Completion of the form below
• Railroad Medicare will enter the information you provide into the online registration
• This information will not be shared with any mailing list
Note: Once the registration information is entered, you will receive a confirmation/welcome message informing
you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within 3 days
of your registration.
Fax the completed form to (803) 264-9844
User Name
(E-mail address cannot be used for user name or password)
Print First and Last Name
Password
S3cret*1
(Your confirmation e-mail will instruct you on how to change this
password later.)
Your E-mail Address
Topics (mark those you’re interested in staying informed about)
Ambulance
Federally Qualified Health Center
Physical/Occupational Therapy
Ambulatory Surgical Center
General - Railroad Medicare
Physician
Anesthesia/Pain Management
Gynecology
Podiatry
Cardiovascular
Hematology/Oncology
Primary Care
Chiropractic
Independent Diagnostic Testing Facility
Psychology/Psychiatry
Community Mental Health Center
Nephrology
Radiology
Diagnostic Tests
Non-Physician Practitioners
Surgery
Drugs/Biologicals
Ophthalmology/Optometry
Electronic Date Interchange (EDI)
Pathology & Laboratory
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14
5/2016
Remittance Advice Remark and Claims Adjustment Reason
Code and Medicare Remit Easy Print and PC Print Update
MLN Matters® Number: MM9466
Related Change Request (CR) #: CR 9466
Related CR Release Date: April 1, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3489CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers who submit claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
CR9466 updates the Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC)
lists. It also instructs Medicare system maintainers to update Medicare Remit Easy Print (MREP) and PC
Print. Make sure that your billing staffs are aware of these changes and obtain the updated MREP or PC Print
software if they use that software.
Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, instructs health plans to be able to
conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy
states that CARCs and RARCs, as appropriate, that provide either supplemental explanation for a monetary
adjustment or policy information that generally applies to the monetary adjustment of a claim or service, are
required in the remittance advice and coordination of benefits transactions.
The Centers for Medicare & Medicaid Services (CMS) instructs MACs and Shared Systems, if appropriate, to
conduct updates based on the code update schedule that results in publication of updated code lists three times
a year (around March 1, July 1, and November 1).
Medicare’s Shared System Maintainers (SSMs) are responsible for implementing appropriate code deactivation,
making sure that any deactivated code is not used in original business messages, but the deactivated code in
derivative messages is allowed. SSMs must make sure that Medicare does not report any deactivated code on
or before the effective date for deactivation as posted on the Washington Publishing Company (WPC) website.
If any new or modified code has an effective date past the implementation date specified in CR9466, MACs
will implement on the date specified on the WPC website. The WPC website is available at
http://www.wpc-edi.com/Reference on the Internet.
In case of any discrepancy in the code text as posted on WPC website and as reported in any CR, the
WPC version should be implemented.
CR9466 advises the SSMs and MACs to perform the updates posted on the WPC based on the March 1, 2016
CARC and RARC code change lists.
Additional Information
The official instruction, CR9466, issued to your MAC regarding this change, is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3489CP.pdf on the CMS
website.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
15
5/2016
ICD-10-CM Diagnosis Codes for Bone Mass Measurement
MLN Matters® Number: SE1525
Revised Related Change Request (CR) #: CR9252
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Note: This article was revised on April 12, 2016, to clarify the removal of a code (originally stated as M85.8)
from the list of codes that providers may report on page 2 of the article. The code that was removed is M85.80
(Other specified disorders of bone density and structure, unspecified site). All other information is the same.
Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories and other providers submitting
claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) will implement Change Request (CR) 9252 on January
4, 2016, effective October 1, 2015. (See related MLN Matters® article MM9252 at https://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM5521.pdf.)
This CR establishes the list of covered conditions and corresponding ICD-10-CM diagnosis codes approved for
Bone Mass Measurement studies according to the requirements set forth in National Coverage Determination
(NCD) 150.3. CR9252 and accompanying spreadsheet inadvertently omitted the condition of osteopenia and
the ICD-10-CM codes that describe it which are classified to subcategory M85.8- Other specified disorders of
bone density and structure. The codes and conditions identified within this subcategory are considered covered
indications for bone mass measurement under NCD 150.3 and providers should report these appropriately
according to medical documentation. Additional guidance and education as to the updated complete list of
covered indications will be forthcoming as CMS continues to review this issue and the systems updates required.
Background
Under ICD-9-CM, the term “Osteopenia” was indexed to ICD-9-CM diagnosis code 733.90 (Disorder of
bone and cartilage). This code was listed as a covered condition under the Business requirement 5521.1.1 for
CR 5521/NCD 150.3, dated May 11, 2007, when reported with CPT code 77080. (See related MLN Matters
article MM5521 at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/MM5521.pdf.) The accompanying Benefit Policy Manual, Publication 100­
02, chapter 15, section 80.5.6, Beneficiaries Who May Be Covered, includes: 2. An individual with vertebral
abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.
Under ICD-10-CM, the term “Osteopenia” is indexed to ICD-10-CM subcategory M85.8- Other specified
disorders of bone density and structure, within the ICD-10-CM Alphabetic Index. The codes within this
subcategory were inadvertently omitted from the CMS spreadsheet that accompanied CR 9252 containing the
list of covered conditions and corresponding diagnosis codes. These are considered covered for NCD 150.3
indications.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16
5/2016
Below is the list of ICD-10-CM diagnosis codes within subcategory M85.8- that providers may report as
covered indications in addition to the current list provided in CR 9252 and its accompanying CMS spreadsheet.
• M85.811 Other specified disorders of bone density and structure, right shoulder
• M85.812 Other specified disorders of bone density and structure, left shoulder
• M85.821 Other specified disorders of bone density and structure, right upper arm
• M85.822 Other specified disorders of bone density and structure, left upper arm
• M85.831 Other specified disorders of bone density and structure, right forearm
• M85.832 Other specified disorders of bone density and structure, left forearm
• M85.841 Other specified disorders of bone density and structure, right hand
• M85.842 Other specified disorders of bone density and structure, left hand
• M85.851 Other specified disorders of bone density and structure, right thigh
• M85.852 Other specified disorders of bone density and structure, left thigh
• M85.861 Other specified disorders of bone density and structure, right lower leg
• M85.862 Other specified disorders of bone density and structure, left lower leg
• M85.871 Other specified disorders of bone density and structure, right ankle and foot
• M85.872 Other specified disorders of bone density and structure, left ankle and foot
• M85.88 Other specified disorders of bone density and structure, other site
• M85.89 Other specified disorders of bone density and structure, multiple sites
Document History
Date of Change Description
April 12, 2016
The article was revised to clarify the removal of a code (originally stated as
M85.8) from the list of codes that providers may report on page 2 of the article.
The code that was removed is M85.80 (Other specified disorders of bone density
and structure, unspecified site).
April 6, 2016
The article was revised to remove the code M85.8 from the list of codes that may
be reported by providers on page 2.
October 28, 2015 Initial issuance of article
Appeals Calculator Self Service Tool
Providers may appeal claims that are partially or fully denied, as long as the claim has ‘appeal rights’. Different
levels of appeals have different timelines in which the appeal rights are valid. Access the Appeals Calculator
tool under Forms/Tools on the home page to calculate the your claims appeal deadlines.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17
5/2016
Updates to Medicare’s Organ Acquisition and Donation Payment Policy MLN Matters® Number: SE1608
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: April 1, 2016
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Special Edition article is intended for all providers and suppliers who submit claims
or Medicare cost reports (MCRs) to Medicare Administrative Contractors (MACs) for organ procurement,
transplant, and histocompatibility laboratory services provided to Medicare beneficiaries.
What You Need to Know
This article is intended to assist providers and suppliers by offering information and resources to clarify Medicare’s
organ acquisition and donation payment policy for organ procurement, transplant, and histocompatibility
laboratory services provided to Medicare beneficiaries. The information does not convey any new or changed
policy, but conveys clarification language in the “Provider Reimbursement Manual (PRM),” CMS Pub. 15-1,
chapter 31. This clarification is provided to ensure appropriate reporting of organ acquisition costs, including
those in a living Kidney Paired Donation (KPD) exchange, to achieve proper Medicare reimbursement.
Background
CMS issued chapter 31 of the PRM to clarify Medicare’s payment policy regarding organ acquisition costs,
formerly found in chapter 27, sections 2770 through 2775.4. In response to questions raised by the transplant
community, chapter 31 clarifies the accounting and reporting of KPD exchange costs in the MCR. The chapter
also clarifies the appropriate methodology for counting organs.
• Section 3106 clarifies the accounting for costs of services in a living KPD exchange, provides a detailed
example of an exchange, and summarizes the example in a chart.
• Section 3115 clarifies the methodology for counting organs, including those procured and transplanted en
bloc.
Highlights from Section 3106, Kidney Paired Donations
• KPDs are similar to directed living donations; however, when the living donor and recipient do not match,
they can consent to participate in a KPD matching program that matches living donor/recipient pairs with
other living donor/recipient pairs. KPD exchanges can occur when two or more living donor/recipient
pairs match each other; often, the living donor and matched recipient are at different certified transplant
centers (CTCs).
• The costs of all hospital and physician services for pre-transplant living donor and recipient evaluations
become acquisition costs and are included in the MCR of the recipient’s CTC. Similarly, when a recipient
and donor do not match and elect to participate in a KPD matching program, the costs of the initial living
donor evaluations are incurred by the original intended recipient’s CTC, regardless of whether the living
donor actually donates to their original intended recipient, a KPD matched recipient, or does not donate at all.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18 5/2016
• In a KPD exchange, once the donor is matched with a recipient, any additional tests requested by the
recipient’s CTC, but performed by the donor’s CTC are billed as charges reduced to cost to the recipient’s
CTC and included as acquisition costs on the MCR of the recipient CTC. This is true regardless of whether
an actual donation occurs.
• When a donor’s CTC procures and sends a kidney to a recipient’s CTC, the donor’s CTC bills the recipient’s
CTC the donor CTC’s charges reduced to cost for the reasonable costs associated with procuring, packaging,
and transporting the kidney. The donor’s CTC records these costs on its MCR as kidney acquisition costs
and offsets any payments received from the recipient’s CTC against its kidney acquisition costs. The
recipient’s CTC records as part of its kidney acquisition costs, the amounts billed by the donor’s CTC
for the reasonable costs associated with procuring, packaging, and transporting the organ as well as any
additional testing performed and billed by the donor’s CTC. These costs must be reasonable and necessary.
• When a donor’s CTC does not procure a kidney, but the donor travels to the recipient’s CTC for the
procurement, the reasonable costs associated with the procurement are included on the MCR of the recipient’s
CTC. Travel expenses of the living donor are not allowable Medicare costs.
Highlights from Section 3115, Counting Organs
• Organ procurement organizations (OPOs) and CTCs are responsible for accurately counting both Medicare
and non-Medicare organs to ensure that costs are properly allocated on the MCR. The OPO and CTC must
count organs procured and transplanted en bloc (two organs transplanted as one unit) as one organ. This
can include, but is not limited to, en bloc kidneys and en bloc lungs.
• Medicare usable organs include organs transplanted into Medicare beneficiaries (excluding Medicare
Advantage beneficiaries), organs that had partial payments by a primary insurance payer in addition to
Medicare, organs sent to other CTCs, organs sent to OPOs and kidneys sent to military renal transplant
centers (MRTCs) that have a reciprocal sharing agreement with the OPO in effect prior to March 3, 1988,
and approved by the contractor. Medicare usable organs do not include organs used for research, organs
sent to veterans’ hospitals, organs sent outside the United States, organs transplanted into non-Medicare
beneficiaries, organs that were totally paid by primary insurance other than Medicare, organs that were paid
by a Medicare Advantage plan, organs procured from a non-certified OPO and kidneys sent to MRTCs that
do not have a reciprocal sharing agreement with the OPO in effect prior to March 3, 1988, and approved
by the contractor.
• Kidneys counted as Medicare kidneys include those sent to CTCs, certified OPOs, or MRTCs (with a
reciprocal sharing agreement with the OPO in effect prior to March 3, 1988, and approved by the contractor).
It does not include kidneys sent to foreign countries, VA hospitals, or MRTCs (without a reciprocal sharing
agreement with the OPO in effect prior to March 3, 1988, and approved by the contractor), or those used
for research.
Information and Resources
The following resources are available to find additional information regarding Medicare’s organ acquisition
and donation payment policy:
• PRM Transmittal 471 containing – CMS Pub. 15-1, chapter 31 at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R471PR1.pdf;
• PRM – CMS Pub. 15-2, chapters 33 and 40 at https://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Paper-Based-Manuals-Items/CMS021935.html;
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19 5/2016
• “Medicare Claims Processing Manual” – CMS Pub. 100-04 at https://www.cms.gov/
Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.
html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending; and
• “Medicare Benefit Policy Manual” – CMS Pub. 100-02 at https://www.cms.gov/Regulations­
and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.
html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending.
eServices Eligibility
eServices, by Palmetto GBA, allows you to search for patient eligibility,
which is a functionality of HETS. HETS requires you to enter beneficiary
last name and HICN, in addition to either the birth date or first name. See
options below:
• HICN, Last Name, First Name, Birth Date
• HICN, Last Name, Birth Date
• HICN, Last Name, First Name
For more information about eServices and the many services it offers, please visit our website at
http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20 5/2016
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2016
MLN Matters® Number: MM9584
Related Change Request (CR) #: CR 9584
Related CR Release Date: March 25, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3485CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 9584 informs MACs about changes that will be included in the July 2016 quarterly
release of the edit module for clinical diagnostic laboratory services. Make sure that your billing staffs are
aware of these changes.
For the July 2016 update, effective for services furnished on or after July 1, 2016, International Classification
of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes E61.1, M79.641, M79.642, M79.644,
and M79.645 are added to the list of ICD-10-CM codes that are covered by Medicare for the Serum Iron
Studies (190.18) NCD.
Additional Information
The official instruction, CR9584, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3485CP.pdf on the CMS
website.
Medicare Physician Fees Lookup Tool
Use the Medicare Physician Fee Lookup Tool, located on our home page. The new Physician Fee Schedule
tool saves our customers time and money by providing a ‘one stop shop’! Customers can locate fees for the
2013 through 2016 throughout the United States. The tool can search up to five codes and each code shows
the allowance, all of the indicator rules such as the Global Surgery modifiers and Multiple Surgery rules. This
tool helps customers research more than a fee; they can determine if the wrong modifier was appended to a
service, or if the service was subject to multiple surgery rules.
The fees and indicator files are downloadable and customers can easily save the data to their systems for future
use. Customers are saying...
• An excellent tool to find all kinds of data relative to CPT codes without having to slog through the entire
database!
• I like the new look up tool. I liked the old look
up tool on the CMS website but this one is nice
and gives everything you need to know about
a code, all on one inquiry. Thanks.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21 5/2016
Interactive Tools
These guides provide instruction
on how to complete or interpret the
following forms. They are available
on the home page, under Forms/Tools.
Remittance Advice
EDI Agreement
EDI Application
EDI Provider
Authorization
CMS 1500 Claim Form
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22
5/2016
CMS e-News
e-News contains a week’s worth of Medicare-related messages instead
of many different messages being sent to you throughout the week.
This notification process ensures planned, coordinated messages are
delivered timely about Medicare-related topics.
_______________________________________
MLN Connects™ Provider eNews
MLN Connects™ Provider eNews for March 31, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-03-31-eNews.pdf
MLN Connects™ Provider eNews for April 7, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-07-eNews.pdf
MLN Connects™ Provider eNews for April 14, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-14-eNews.pdf
MLN Connects™ Provider eNews for April 21, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-21-eNews.pdf
Receive ADRs Electronically: Go Green via eServices
Providers can now opt to receive Additional Documentation Requests (ADRs)
through eServices. If your claim is selected for review, you can receive your
request as it is generated – instead of by mail (which decreases the amount of
time you have to respond).
This new process is free, secure and easy to use. Our messaging function in eServices will send an inbox
message to let users know that an ‘eLetter’ is now available. This new process delivers the electronic document
as a link within the secure message once you sign into eServices.
For more information about eServices and the many services it offers, please visit our website at
www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23
5/2016
CMS Offers FREE Medicare Training for Providers
CMS Web Training
The Centers for Medicare & Medicaid Services (CMS) has launched a series of education and training
programs designed to leverage emerging Internet and satellite technologies to offer just-in-time training
to Medicare providers and suppliers throughout the United States. Many of these programs include free,
downloadable computer/Web based training courses. These courses are also available on CD-ROM.
http://www.cms.gov/MLNGenInfo
Railroad Medicare Customer Information and Outreach
Important Telephone Numbers
Provider Contact Center
888-355-9165
Palmetto GBA
Railroad Medicare
P.O. Box 10066
Augusta, GA 30999-0001
Interactive Voice Response (IVR) System
877-288-7600
Telephone Reopenings
888-355-9165
www.PalmettoGBA.com/RR
Electronic Data Interchange (EDI)
Technical Support
888-355-9165
Beneficiary Contact Center
800-833-4455
TTY 877-566-3572
Attention: Billing Manager
24
5/2016