NOTE: Should you have landed here as a result of a search engine (or
other) link, be advised that these files contain material that is copyrighted
by the American Medical Association. You are forbidden to download
the files unless you read, agree to, and abide by the provisions of the
copyright statement. Read the copyright statement now and you will
be linked back to here.
JM Part A Medicare Advisory
What’s Inside...
Latest Medicare News for JM Part A
CMS e-News...................................................................................................................2
CMS Proposes 2018 Payment and Policy Updates for Medicare
Hospital Admissions, Releases a Request for Information.......................................3
Multiple Provider Information.....................................................................................4
There is Still Time to Evaluate Our Services!...........................................................4
July 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing
Files and Revision to Prior Quarterly Pricing Files..................................................5
FISS Implementation of the Restructured Clinical Lab Fee Schedule......................7
eAudit to Generate Reports for Claims under Complex Medical Review!...............8
Action Needed: Due to Increased CMS Security Requirements, eServices Portal
Users Must Sign Up for Multi-Factor Authentication (MFA) by July 1, 2017.........9
We’d Love Your Feedback!..................................................................................... 11
eServices Makes Asking a Medicare Question Easier!...........................................12
Managing Multiple eService Accounts Just Got Easier with Account Linking!.....13
Get Your Medicare News Electronically.................................................................13
Medicare Learning Network® (MLN)....................................................................14
CallBack Assist........................................................................................................15
Hospital Information...................................................................................................15
Payment for Moderate Sedation Services...............................................................15
Update to Common Working File (CWF) Blood Editing on Medicare
Advantage (MA) Enrollees’ Inpatient Claims for Indirect Medical Education
(IME) Payment........................................................................................................17
Next Generation Accountable Care Organization (NG ACO) – All Inclusive
Population Based Payment (AIPBP) Implementation.............................................18
Learning and Education Information........................................................................19
Innovation Today for Success Tomorrow
Workshop..................19
Educational Events Where You Can Ask Questions and Get Answers
from Palmetto GBA.................................................................................................21
Medical Policy Information........................................................................................22
Part A Local Coverage Determinations (LCDs) Updates........................................22
Part A/B Medicare Administrative Contractor (MAC) Local Coverage
Determinations (LCDs) Updates.............................................................................23
palmettogba.com/jma
The JM Part A Medicare Advisory contains coverage, billing and other information for Jurisdiction M Part A.
This information is not intended to constitute legal advice. It is our official 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 JM Part A 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/Medicare.
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, 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 © 2012
American Dental Association (ADA). All rights reserved.
May 2017
Volume 2017, Issue 05
Medical Policy Information (Continued)
Response to Comments for the Somatosensory Testing Local Coverage
Determination (LCD) – LCD Number: L33471......................................................24
Part A/B Local Coverage Determinations (LCDs) Article Updates........................25
Provider Enrollment Information..............................................................................27
Provider Enrollment Revalidation – Cycle 2..........................................................27
Tools That You Can Use...............................................................................................35
Medicare Credit Balance Report Module................................................................35
Split Billing Module................................................................................................36
Helpful Information.....................................................................................................37
Contact Information for Palmetto GBA Part A.......................................................37
Innovation Today for Success Tomorrow
Workshop
Palmetto GBA - JM A/B MAC will present an informative workshop in Virginia and West Virginia that will provide information related to the most common errors identified through a variety of data analysis and tips to avoid
them. This workshop sessions will held on Wednesday, Mary 24, 2017 in Charleston, West Virginia and on
Thursday, May 25, 2017 in Roanoke, Virginia.
For more information and registration instructions to attend these workshop session, please go to Page 19 of this
issue.
CMS E-NEWS
CMS e-News will contain a week’s worth of Medicare-related messages from the Centers of Medicare &
Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely
about Medicare-related topics. Please share with appropriate staff. To view the most recent issues, please
copy and paste the following links into your Web browser:
April 20, 2017
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-04-20-eNews.
pdf
April 13, 2017
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-04-13-eNews.
pdf
April 6, 2017
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-04-06-eNews.
pdf
March 30, 2017
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2017-03-23-eNews.
pdf
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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CMS Proposes 2018 Payment and Policy Updates for Medicare Hospital Admissions,
Releases a Request for Information
Proposed rule seeks transparency, flexibility, program simplification and innovation to transform the
Medicare program.
On April 14, CMS issued a proposed rule external link (https://www.federalregister.gov/
documents/2017/04/28/2017-07800/medicare-program-hospital-inpatient-prospective-paymentsystems-for-acute-care-hospitals-and-long) that would update 2018 Medicare payment and polices when
patients are admitted into hospitals. The proposed rule aims to relieve regulatory burdens for providers;
supports the patient-doctor relationship in health care; and promotes transparency, flexibility, and innovation
in the delivery of care.
“Through this proposed rule we want to reduce burdens for hospitals so they can focus on providing high
quality care for patients,” said CMS Administrator Seema Verma. “Medicare is better able to support the
work of dedicated hospitals and clinicians who provide the care that people need with these more flexible
and simplified approaches.”
CMS is committed to transforming the health care delivery system – and the Medicare program – by
putting a strong focus on patient-centered care, so providers can direct their time and resources to patients
and improve outcomes. In addition to the payment and policy proposals, CMS is releasing a Request
for Information to solicit ideas for regulatory, policy, practice and procedural changes to better achieve
transparency, flexibility, program simplification and innovation. This will inform the discussion on future
regulatory action related to inpatient and long-term hospitals.
In relieving providers of administrative burdens and encouraging patient choice, CMS is proposing:
• a one year regulatory moratorium on the payment policy threshold for patient admissions in long-term
care hospitals while CMS continues to evaluate long-term care hospital policies
• to reduce clinical quality measure reporting requirements for hospitals that have implemented electronic
health records
Due to the combination of proposed payment rate increases and other proposed policies and payment
adjustments, CMS projects that hospitals would see a total increase in inpatient operating prospective
payments of 2.9 percent in fiscal year 2018. CMS also projects that, based on the changes included in the
proposed rule, payments to long-term care hospitals would decrease by approximately 3.75 percent in fiscal
year 2018.
For More Information:
• Full text of this excerpted CMS press release external link (issued April 14) (https://www.cms.gov/
Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-14.html)
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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• CMS fact sheet external link (https://www.cms.gov/Newsroom/
MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-04-14.
html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending)
MULTIPLE PROVIDER INFORMATION
There is Still Time to Evaluate Our Services!
There is still time to share your experiences about the services we provide. Please complete the MAC
Satisfaction Indicator (MSI) survey. These survey results will help us find ways to better serve you.
To take the survey, go to:
https://cfigroup.qualtrics.com/jfe/form/SV_3WeVjGWpc5NQXOJ?MAC_BRNC=11&MAC=JM –
Palmetto
Thank you for the feedback provided to us throughout 2016. We made a lot of improvements to our services
and have more planned in the coming months.
In response to the provider feedback we created the following educational resources and enhancements:
• Developed Part A EDI Enrollment Instructions Guide Module
• Developed Provider Enrollment Training Modules
o Part A Provider Enrollment 101 Module
o Part A Provider Enrollment – PECOS Module
• Enhanced the Website Search Feature: Updated the web content manager algorithm to assure the newest
postings display first as new items are posted
Computer Telephony Integration (CTI) or ‘screen pop’ was implemented in January of 2017. This
technology enables our Interactive Voice Response Unit (IVR) to interact with our inquiry tracking system.
Providers using the IVR enter their NPI, PTAN and tax identification number along with beneficiary
information for claim specific inquiries. Your provider and claim specific information auto-populates the
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Customer Service Associate’s (CSA) inquiry record eliminating the need for you to repeat the information
to the CSA. Please ensure you provide this information as prompted each and every time to call our
consolidated toll-free number.
You are able to press ‘0’ at any time in the IVR to reach a CSA. This ‘opt-out’ feature allows the caller to
speak directly with a CSA when the inquiry is complex or the caller knows the information needed is not
available in the IVR. It is important to note that the caller will be referred back to the IVR for information
that is available in the IVR. When you opt-out of the IVR, you will be prompted to provide your provider
specific and claim information. It is important to supply all information when prompted so the CSA receives
your information as soon as your call is answered.
We continue to streamline the IVR messages to reduce the number of messages and to provide options for
bypassing the message. This is an ongoing effort that is projected for completion by the end of June.
Our Outreach and Education Team heard the provider community feedback about wanting more
opportunities for questions and answers and as a result, we have started highlighting these monthly offerings
in our Medicare Advisory in a section called ‘Educational Events Where You Can Ask Questions and
Get Answers from Palmetto GBA’. We hope you will consider attending some of our events this year.
Thank you for your feedback.
July 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and
Revision to Prior Quarterly Pricing Files
MLN Matters® Number: MM10016
Related CR Release Date: April 7, 2017
Related CR Transmittal Number: R3746CP
Related Change Request (CR) Number: 10016
Effective Date: July 1, 2017
Implementation Date: July 3, 2017
Provider Type 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) 9945 provides the July 2017 quarterly update and instructs MACs to download and
implement the July 2017 ASP drug pricing files and, if released by the Centers for Medicare & Medicaid
Services (CMS), the revised April 2017, January 2017, October 2016, and July 2016 Average Sales Price
(ASP) drug pricing files for Medicare Part B drugs. Medicare will use these files to determine the payment
limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after July 3,
2017, with dates of service July 1, 2017, through September 30, 2017. MACs will not search and adjust
claims previously processed unless brought to their attention.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Background
The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply
contractors with the ASP and Not Otherwise Classified (NOC) drug-pricing files for Medicare Part B drugs
on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code
Editor (OCE) through separate instructions. The following files are related to this most recent update:
• July 2017 ASP and ASP NOC – Effective Dates of Service: July 1, 2017, through September 30, 2017
• April 2017 ASP and ASP NOC – Effective Dates of Service: April 1, 2017, through June 30, 2017
• January 2017 ASP and ASP NOC – Effective Dates of Service: January 1, 2017, through March 31, 2017
• October 2016 ASP and ASP NOC – Effective Dates of Services: October 1, 2016, through December 31,
2016
• July 2016 ASP and ASP NOC – Effective Dates of Service: July 1, 2016, through September 30, 2016
For any drug or biological not listed in the ASP or NOC drug-pricing files, MACs will determine the
payment allowance limits in accordance with the policy described in the “Medicare Claims Processing
Manual,” Chapter 17, Section 20.1.3, which is available at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c17.pdf. For any drug or biological not listed in the
ASP or NOC drug-pricing files that is billed with the KD modifier, contractors shall determine the payment
allowance limits in accordance with instructions for pricing and payment changes for infusion drugs
furnished through an item of Durable Medical Equipment (DME) on or after January 1, 2017, associated
with the passage of the 21st Century Cures Act.
Additional Information
The official instruction issued to your MAC regarding this change is available at https://www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3746CP.pdf.
If you have any questions, please contact your MAC at their toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document History
Date of Change
April 7, 2017
Description
Initial Article Released
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
FISS Implementation of the Restructured Clinical Lab Fee Schedule
MLN Matters® Number: MM9837 Revised
Related Change Request (CR) #: CR 9837
Related CR Release Date: March 23, 2017
Effective Date: January 1, 2018
Related CR Transmittal #: R3740CP Implementation Date: July 3, 2017
Note: This article was revised on March 23, 2017, to reflect the revised CR9837 issued that day. In
the article, the CR release date, transmittal number, and the Web address for accessing CR9837 are
revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for clinical laboratory providers submitting claims to Medicare
Administrative Contractors (MACs) for services paid under the Clinical Lab Fee Schedule (CLFS) and
provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9837 informs MACs about the changes to the Fiscal Intermediary Shared System
(FISS) to incorporate the revised CLFS containing the National fee schedule rates. Make sure that your
billing staffs are aware of these changes.
Background
Section 216 of Public Law 113-93, the “Protecting Access to Medicare Act of 2014,” added Section 1834A
to the Social Security Act (the Act). This provision requires extensive revisions to the payment and coverage
methodologies for clinical laboratory tests paid under the CLFS. The Centers for Medicare & Medicaid
Services (CMS) published the CLFS final rule “Medicare Clinical Diagnostic Laboratory Tests Payment
System Final Rule” (https://www.gpo.gov/fdsys/pkg/FR-2016-06-23/pdf/2016-14531.pdf) (CMS1621-F) was displayed in the Federal Register on June 17, 2016, and was published on June 23, 2016, which
implemented the provisions of the new legislation.
The final rule set forth new policies for how CMS sets rates for tests on the CLFS and is effective for dates
of service on and after January 1, 2018. Beginning on January 1, 2017, applicable laboratories will be
required to submit private payor rate data to CMS. (See MLN Matters Article SE1619 (https://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
SE1619.pdf) for further details of the laboratory data reporting requirements.) In general, with certain
designated exceptions, the payment amount for a test on the CLFS furnished on or after January 1, 2018,
will be equal to the weighted median of private payer rates determined for the test, based on data collected
from laboratories during a specified data collection period. In addition, a subset of tests on the CLFS,
Advanced Diagnostic Laboratory Tests (ADLTs), will have different data, reporting, and payment policies
associated with them. In particular, the final rule discusses CMS’ proposals regarding:
• Definition of “applicable laboratory” (who must report data under Section 1834A of the Act)
• Definition of “applicable information” (what data will be reported)
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7
05/2017
• Data collection period
• Schedule for reporting data to CMS
• Definition of ADLT
• Data Integrity
• Confidentiality and public release of limited data
• Coding for new tests on the CLFS
• Phased in payment reduction
Additional Information
The official instruction, CR9837, issued to your MAC regarding this change is available at https://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3740CP.pdf.
MLN Matters Article SE1619 has more details at https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1619.pdf.
The final regulation for the revised CLFS is available at https://www.gpo.gov/fdsys/pkg/FR-2016-06-23/
pdf/2016-14531.pdf.
If you have any questions, please contact your MAC at their toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document History
• November 10, 2016 - Initial article released
• March 23, 2017 - Article revised to reflect revised CR9837. In the article, the CR release date,
transmittal number, and the Web address of the CR are revised. All other information remains the same.
eAudit to Generate Reports for Claims under Complex Medical Review!
Electronic Audit (eAudit) is a new function available in the eServices online portal, which allows providers
the ability to access personal reports of audit results for claims which have been chosen for Complex
Medical Review by various Medicare review contractors.
eAudit gives providers the opportunity to see what claims may be pending Complex Medical Review
currently and the results of any recent review decisions.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8
05/2017
This information can be used for self-assessment of provider performance on Medicare audits utilizing
a dashboard which contains the most common denial reasons. The eAudit tool currently features CERT
contractor claim review data with JM Medicare Administrative Contractor (MAC) Medical Review and JM
Appeal review data coming soon!
How do I use the eAudit function?
To get started, log into the eServices portal using your user ID and select the eAudit tab, which is located
under the eReview tab. The screen will automatically populate with a summary table of your CERT audit
data by error code category. Full details can be found in the eServices User Guide.
If you don’t already have an eService account, register for one today.
Example of eAudit in eServices
Action Needed: Due to Increased CMS Security Requirements, eServices Portal Users
Must Sign Up for Multi-Factor Authentication (MFA) by July 1, 2017
Why You Need It:
It’s easier than you might think for someone to steal your password. Multi-factor authentication (MFA) can
help your eServices account remain secure even if someone manages to obtain your password without your
knowledge.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9
05/2017
How It Works:
The eServices MFA is an extra layer of security. Users may log into eServices and access the “My Account”
tab in order to turn on this optional feature. Once activated, signing into your eServices account will work a
little differently:
1. You’ll enter your password as usual
2. Then, you’ll select your preferred method of delivery between email or a text message
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
3. Once you receive your verification code, you will enter it in the verification box and you’re in
Deadline to Sign Up:
• Providers have from now through March 31, 2017, to sign up for multi-factor authentication for each
active user ID voluntarily.
• April 1, 2017 to June 31, 2017, providers will be required to sign up for multi-factor authentication at
enrollment, password reset and recertification.
• Effective July 1, 2017, if you have not yet signed up for MFA, your account will automatically be set to
MFA with the email address associated with the user ID.
Note: Providers who have linked their accounts will only need to sign up for MFA for their default
account.
eServices User Manual:
Please see the eServices User Manual for more information.
We’d Love Your Feedback!
Palmetto GBA is committed to continuously improve your customer experience. We welcome your feedback
on your experiences with the PalmettoGBA.com website and the eServices portal. As a visitor to the
Palmetto GBA’s website, you may be presented with an opportunity to take the website satisfaction survey. The next time the survey is offered to you, please agree to participate and provide us with your feedback.
You have the opportunity to explain your comments, share your honest opinions, and tell us what you like
and what you would like to see us improve. If you find a feature or tool specifically helpful, let us know
including any suggestions for making them simpler to use.
We continuously analyze your feedback and develop enhancements plans to better assist you with your
experience. We value your opinion and look forward to hearing from you.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11
05/2017
eServices Makes Asking a Medicare Question Easier!
Palmetto GBA is pleased to announce the newest addition to our eService options---Secure eChat! This
innovative feature allows providers to interact with designated Palmetto GBA staff so they can receive realtime assistance locating information on any topics or specialties they are searching for on the Palmetto GBA
website or within the eServices online portal. The Secure eChat feature also allows users to dialogue with
an online operator who can assist with patient or provider specific inquires or address questions that require
the sharing of PHI information! Using Secure eChat is simple! This free portal is available to all Medicare
providers as long as you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file
with Palmetto GBA. Once in the eServices portal, from the bottom right corner select either Medicare
Inquiries or eServices Help. If you do not have an eServices account, you can get started by clicking this
eServices link https://www.onlineproviderservices.com/ecx_improvev2/.
The Secure eChat feature is available during business hours to assist providers.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12
05/2017
Managing Multiple eService Accounts Just Got Easier with Account Linking!
Palmetto GBA is excited to announce the highly anticipated eService enhancement- Account Linking! No
longer will providers need a separate login for each PTAN and NPI combination. Palmetto GBA now gives
users the ability to link their previously assigned eServices user IDs under one default ID. Getting started
is simple! Users should log into eServices with the user ID that they wish to designate as their default login
ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged
into eServices, they will select the My Account Tab and then access the Account Linking sub-tab. This will
allow the provider to choose the accounts they wish to link.
Note: Providers are only able to link active eServices accounts.
Once your accounts are linked you will be able to log in, click a drop down menu that lists all your linked
NPI and PTAN combinations attached to your ID, and select the individual account you’d like to view.
For complete step-by-step instructions, please view the eServices User Guide external link (http://www.
palmettogba.com/eServicesuserguide).
Get Your Medicare News Electronically
The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity
to stay informed about:
•
•
•
•
Medicare incentive programs
Fee Schedule changes
New legislation concerning Medicare
And so much more!
How to register to receive the Palmetto GBA Medicare Listserv:
Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online
form. Be sure to select the specialties that interest you so information can be sent.
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 three days of your registration.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Medicare Learning Network® (MLN)
Want to stay informed about the latest changes to the Medicare Program? Get connected with the
Medicare Learning Network® (MLN) – the home for education, information, and resources for health care
professionals.
The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid
Services (CMS) and the brand name for official CMS education and information for health care
professionals. It provides educational products on Medicare-related topics, such as provider enrollment,
preventive services, claims processing, provider compliance, and Medicare payment policies. MLN products
are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets,
web-based training courses (many of which offer continuing education credits) – all available to you free of
charge!
The following items may be found on the CMS web page at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
index.html
• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have
opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.
• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related
Links” and select “MLN Product Ordering Page.”
• MLN Product of the Month: highlights a Medicare provider education product or set of products each
month along with some teaching aids, such as crossword puzzles, to help you learn more while having
fun!
Other resources:
• MLN Publications List: contains the electronic versions of the downloadable publications. These products are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html.
You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by
date, topic, title, or format.
MLN Educational Products Electronic Mailing List
To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the
MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you
will receive an e-mail when new and revised MLN products are released.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14
05/2017
To subscribe to the service:
1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or
Unsubscribe’ link under the ‘Options’ tab on the right side of the page.
2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!
If you would like to contact the MLN, please email CMS at [email protected].
CallBack Assist
CallBack Assist was implemented to improve the wait times during peak calling periods of the day.
CallBack Assist allows providers to opt out for a same-day callback from a customer service representative
(CSR). Typically, the callback occurs within one hour. This feature is a contact center best practice among
the industry. Providers are encouraged to try this new option when offered to avoid long wait times for
assistance.
HOSPITAL INFORMATION
Payment for Moderate Sedation Services
MLN Matters® Number: MM 10001
Related Change Request (CR) #: CR 10001
Related CR Release Date: April 14, 2017
Effective Date: January 1, 2017
Related CR Transmittal #: R3747CP
Implementation Date: May 15, 2017
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare
Administrative Contractors (MACs) for moderate sedation and anesthesia services provided to Medicare
beneficiaries.
What You Need to Know
Change Request (CR) 10001 revises existing Medicare Claims Processing Manual language to bring
the manual in line with current payment policy for moderate sedation and anesthesia services. Providers
should refer to the revised Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician
Practitioners), Sections 50 and 140 for information regarding the reporting of moderate sedation and
anesthesia services. The revision is attached to CR10001. Make sure your billing staff is aware of these
revisions.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Key Manual Changes
General Payment Rule
The fee schedule amount for physician anesthesia services furnished is, with the exceptions noted, based
on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The
base unit for each anesthesia procedure is communicated to the MACs by means of the Healthcare Common
Procedure Coding System (HCPCS) file released annually. The Centers for Medicare & Medicaid Services
(CMS) releases the conversion factor annually. The base units and conversion factor are available at https://
www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html.
Moderate Sedation Services Furnished in Conjunction with and in Support of Procedural Services
Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most
intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional
anesthesia and general anesthesia. Moderate sedation is a drug induced depression of consciousness during
which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia
care.
Practitioners will report the appropriate CPT and/or HCPCS code that accurately describes the moderate
sedation services performed during a patient encounter, which are performed in conjunction with and in
support of a procedural service, consistent with CPT guidance.
Other Manual Revisions to Sections 50 and 140
There are other minor revisions to these manual sections and those revised manual sections are attached to
CR10001.
Additional Information
Your MAC will not search their files to either retract payment for claims already paid or to retroactively pay
claims. They will adjust impacted claims that you bring to their attention.
To view the official instruction, CR 10001 issued to your MAC regarding this change, refer to https://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3747CP.pdf.
If you have any questions, please contact your MAC at their toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document History
Date
04-14-2017
Description
Initial article released.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16
05/2017
Update to Common Working File (CWF) Blood Editing on Medicare Advantage (MA)
Enrollees’ Inpatient Claims for Indirect Medical Education (IME) Payment
MLN Matters® Number: MM10012
Related Change Request (CR) #: CR 10012
Related CR Release Date: April 7, 2017
Effective Date: October 1, 2017
Related CR Transmittal #: R1819OTN
Implementation Date: October 2, 2017
Provider Types Affected
This MLN Matters® Article is intended for approved teaching hospitals submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 10012 informs MACs about the changes to the Common Working File (CWF) to
bypass blood services editing on claims submitted by approved teaching hospitals for Medicare Advantage
(MA) enrollees for Indirect Medicare Education (IME) payment (Type of Bill (TOB) 11x, Prospective
Payment System (PPS) indicator Y, condition code 04 and condition code 69). CR10012 contains no new
policy. It improves the implementation of existing Medicare payment policies. Make sure that your billing
staffs are aware of these changes.
Background
Approved teaching hospitals submit inpatient claims for MA beneficiaries to their MAC to receive an IME
payment and so Original Medicare Part A can include the inpatient days in the Medicare/Supplemental
Security Income fraction. Original Medicare Part A does not track utilization of benefits for beneficiaries
enrolled in an MA plan. Therefore utilization edits should not apply to an IME only inpatient claim. The
Centers for Medicare & Medicaid Services was notified that when an inpatient claim from a teaching
hospital for an MA beneficiary is submitted with blood revenue codes, the CWF is setting blood related
edits. CR10012 corrects this problem.
Additional Information
To view the official instruction, CR10012, issued to your MAC regarding this change, refer to https://www.
cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1819OTN.pdf.
If you have any questions, please contact your MAC at their toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document History
Date of Change
April 7, 2017
Description
Initial article released
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17
05/2017
Next Generation Accountable Care Organization (NG ACO) – All Inclusive Population
Based Payment (AIPBP) Implementation
MLN Matters Number: SE17011
Article Release Date: April 20, 2017
Related CR Transmittal Number: N/A
Related Change Request (CR) Number: N/A
Effective Date: January 1, 2017
Implementation Date: January 3, 2017
Provider Types Affected
This MLN Matters Article is intended for physicians, hospitals, and other providers who are participating
in Next Generation Accountable Care Organization (NGACOs) Model and submitting claims to Medicare
Administrative Contractors (MACs) under the All-Inclusive Population Based Payment (AIPBP) alternate
payment mechanism for certain services for Medicare beneficiaries.
Provider Action Needed
Special Edition (SE) article SE17011 reminds providers of the implementation of the AIPBP payment
mechanism for participating ACOs.
Background
The NGACO Model offers ACOs the option to participate in a payment mechanism called AIPBP under
which the ACO takes on responsibility for entering into payment arrangements with its providers and paying
claims, in place of claims being paid by Medicare’s Fee-For-Service (FFS) systems. The goal of AIPBP is to
establish a monthly cash flow for AIPBP-participating ACOs and a mechanism for ACOs to enter payment
arrangements with Next Generation Participants and Preferred Providers. Conceptually, AIPBP builds on
population-based payments (PBP) in the Pioneer ACO Model and available in the NGACO Model, but
enables even greater flexibility in establishing payment relationships between the ACO and its providers.
Under AIPBP, participating ACOs will receive a monthly lump-sum payment outside of the FFS system
and be responsible for paying Next Generation Participants and Preferred Providers with whom they have
entered into written AIPBP Payment Arrangement agreements. The monthly payment will be based on
an estimation of the care that will be provided to aligned beneficiaries in the performance year by AIPBPparticipating providers.
Reconciliation will occur following the performance year to true up the monthly payments (based on
estimation) versus what AIPBP-participating providers would have been paid under FFS.
All participating providers will continue to submit FFS claims to CMS, which will fully adjudicate the
claims, but will not make payment to providers who have agreed to participate in AIPBP except for add-on
payments for inpatient hospitals (specifically operating outlier payments, operating disproportionate share
hospital [DSH] payments, operating indirect medical education [IME] payments, Medicare new technology
payments, and Islet isolation cell transplantation payments.).
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
ACOs had an annual election to participate in AIPBP from among three alternate payment mechanisms in
2017; the ACO’s Providers/Suppliers and Preferred Providers will agree to participate on a provider-byprovider basis (that is, not all Providers/Suppliers, or Preferred Providers will have claims reduced up to
100 percent). All AIPBP-participating providers will receive a 100-percent reduction to their claims if they
see an aligned beneficiary, unless that aligned beneficiary has opted out of medical claims data sharing with
the ACO or if the claim is for substance abuse-related services. If an AIPBP-participating provider sees a
beneficiary not aligned to an ACO, they would not receive the reduction.
Providers who do not have an AIPBP Payment Arrangement with an ACO, whether in the ACO or not,
will continue to receive normal FFS reimbursements for all the beneficiaries they treat, including aligned
beneficiaries. Medicare systems will continue to view providers and beneficiaries as being FFS.
As mentioned, providers continue to submit all FFS claims to CMS, which will make coverage and liability
determinations and assess beneficiary liability. Beneficiary liabilities will be calculated based on what
Medicare would have paid in absence of AIPBP, and Medicare Summary Notices (MSNs) should reflect the
amount that would have been paid (as is currently done for PBP). Similarly, Medicare will continue to send
remittance notices to AIPBP-participating providers (just as they would receive remittance notices if not
participating in AIPBP).
If you have any questions, please contact your MAC at their toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document History
Date of Change
April 20, 2017
Description
Initial article release.
LEARNING AND EDUCATION INFORMATION
Innovation Today for Success Tomorrow
Workshop
Palmetto GBA - JM A/B MAC will present an informative workshop in Virginia and West Virginia that will
provide information related to the most common errors identified through a variety of data analysis and tips
to avoid them. Palmetto GBA’s ultimate goal is to have educated and compliant providers who know how to
accurately and skillfully apply the information they learn to their documentation and billing practices.
These workshops are intended to keep providers apprised of Medicare guidelines as well as using
technology for better results. The recommended participants are administrators, billers, nurses and other
healthcare professionals that submit claims to Medicare.
Part A: These workshops are tailored for Medicare providers and their staff that bill Palmetto GBA for Part
A claims on the CMS UB-04 claim electronic equivalent.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19
05/2017
Each Part A session will include:
• Electronic Data Interchange (EDI) Updates
• Medicare A Updates
• eServices Online Secure Portal
• Data Analysis Driven Topics
• Provider Enrollment Revalidations
• Clinical Focus: Medical Review Strategy and Denials
Part A: Charleston, WV
Registration: 7:30 - 8 a.m. ET
Time: 8 a.m. - 12 p.m. ET
Date: May 24, 2017
Location:
West Virginia University Auditorium at Charleston Area Medical Center (CAMC)
3110 MacCorkle Avenue SE
Charleston, WV 25304
Parking: There is a visitor parking garage at the hospital next to the auditorium. Hourly fees apply ($1 per
½ hour; $4 maximum). Valet parking is also available at the main entrance of the hospital during regular
business hours for a $7 fee. The workshop will be held at the West Virginia University auditorium,
which is a building to the left of the hospital (if you are facing the hospital). Please plan to arrive early
to allow time for parking and walking to the auditorium.
Part A: Roanoke, VA
Registration: 7:30 - 8 a.m. ET
Time: 8 a.m. - 12 p.m. ET
Date: May 25, 2017
Location:
Holiday Inn Tanglewood – Roanoke
4468 Starkey Road
Roanoke, VA 24018
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20
05/2017
Educational Events Where You Can Ask Questions and Get Answers from Palmetto
GBA
Don’t Miss this Wonderful Opportunity!
If you are in search of an opportunity to interact with and get answers to your Medicare billing, coverage
and documentation questions from Palmetto GBA’s Provider Outreach and Education (POE) department,
please see these educational offerings which have a question and answer session:
Quarterly Ask
the Contractor
Teleconferences
(ACTs)
ACTs are intended to open the communication channels between providers
and Palmetto GBA, which allows for timely identification of problems
and information-sharing in an informal and interactive atmosphere. These
teleconferences will be held at least quarterly via teleconference.
Quarterly Updates
Webcasts
Preceding the presentation, providers are given an opportunity to ask questions
both on the topics discussed as well as any other question they may have. While
we encourage providers to submit questions prior to the call, this is not required.
Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question
form). Once the form is completed, please fax it to (803) 935-0140, Attention:
Ask-the-Contractor Teleconference
The Quarterly Update Webcasts are intended to provide ongoing, scheduled
opportunities for providers to stay up to date on Medicare requirements.
Event Registration
Portal
Providers are able to type a question and have it responded to by the POE
department throughout the webcast. At the end of the presentation the moderator
will also read and respond to questions submitted by attendees in order to share the
responses with the group at large.
Visit our Event Registration Portal to find information on upcoming educational
events and seminars.
This is a complete listing of both our face-to-face outreach opportunities as well as
our teleconference and webcast listings. Providers are able to dialogue with POE
and get answers to their questions at all of these educational events.
If you have a question that you need an answer to today or a claims specific question which requires the
disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at 1-855-696-0705.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21
05/2017
MEDICAL POLICY INFORMATION
Part A Local Coverage Determinations (LCDs) Updates
Revised ICD-10 LCDs
The table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view
these revised LCDs, go to www.PalmettoGBA.com/jma/lcd. Under the Medical Policies section, select
Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active
LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order.
Title
LCD Number
Revision Number
Stretta Procedure
LCD Number: L34553
Revision Number: 4
Changes/Additions/Deletions
Effective Date
Under Coverage Indications, Limitations and/or Medical
Necessity – Limitations removed the words “and safety” from
the third bullet and revised the verbiage to read “significant
long-term studies confirming efficacy have not been carried
out”.
04/13/2017
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22
05/2017
Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations
(LCDs) Updates
Revised ICD-10 LCDs
The table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view
these revised LCDs, go to www.PalmettoGBA.com/jma/lcd. Under the Medical Policies section, select
Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active
LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order.
Title
LCD Number
Revision Number
Application of Skin
Substitutes
LCD Number: L36466
Revision Number: 3
Changes/Additions/Deletions
Effective Date
Under CMS National Coverage Policy - Added the title
“Reasonable and Necessary Provisions in LCDs” to CMS
Internet-Only Manual Publication 100-08 Chapter 13 Section
13.5.1 and added the word “Application” to CMS Ruling 95-1
(V). Under Coverage Indications, Limitations and/or Medical
Necessity - Revised the sentence in the second paragraph to
read “This LCD is applicable to the use of Skin Substitutes or
Cellular and/or Tissue Based Products (CTPs) for treatment of
Lower Extremity (lower extremity encompasses the region of
the body from the hip to the toes) Non-Healing Wounds”. For
Regulatory Status, 1. Human Cells, Tissues, and Cellular
and Tissue-Based Products, revised the sentence to read
“Establishments producing HCT/Ps must register with the FDA
and list their HCT/Ps”. For Limitations bullet eight added the
word “an” to the sentence to now read “…will require the use
of an appropriate wound preparation…” Under Associated
Information-Documentation Requirements revised the
verbiage for item 10, second bullet to read “Name of skin
substitute and how the product is supplied” and for the second
sentence in the sixth bullet revised the verbiage to read “When
the manufacturer does not supply the unit identification, the
record must document such.” Under Utilization Guidelines
fifth paragraph changed the word from “used” to “uses”. Under
Sources of Information and Basis for Decision-corrected
spelling, added article titles, added supplement numbers and
author initials to various references.
04/22/2017
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
23
05/2017
Corneal Pachymetry
Under Coverage Indications, Limitations and/or Medical
4/23/2017
LCD Number: L34512 Necessity –Indications and Limitations revised the verbiage
Revision Number: 8
in the second paragraph to read “The lifetime limit ONLY
applies for measurements done to assess corneal thickness in
conjunction with a glaucoma diagnosis. The limit does not apply
in cases where the assessment of corneal thickness is required
after ocular trauma (surgical or accidental) has been sustained,
including the management of bullous keratopathy resulting from
surgical or accidental trauma, or in Fuch’s dystrophy.” Under
ICD-10 Codes That Support Medical Necessity- deleted the
following unspecified eye ICD-10 codes: H40.1190, H40.1191,
H40.1192, H40.1193, H40.1194, H40.1290, H40.1291,
H40.1292, H40.1293, H40.1294, H40.1390, H40.1391,
H40.1392, H40.1393, H40.1394, H40.159, H40.249 and
H40.60X0. Total Joint Arthroplasty Under Coverage Indications, Limitations and/or Medical
04/13/2017
LCD Number: L33456 Necessity- added a sixth paragraph to read “Occasionally, there
Revision Number: 11
may be a need to perform a reoperation on a previous total hip
or total knee replacement. This is often referred to as a revision
total knee or revision total hip. Circumstances that lead to the
need for a revision total hip or knee are continued disabling pain
and/or continued decline in function which can be attributed
to failure of the primary joint replacement. Failure can be due
to infection involving the joint, substantial bone loss in the
structures supporting the prosthesis, fracture, aseptic loosening
of the components and wear of the prosthetic components”.
Under Sources of Information and Basis for Decisioncorrected the title of the second reference to read “Total Knee
Replacement” and formatted the fourth reference in the AMA
manual citation format.
Wireless Capsule
05/05/2017
Under ICD-10 Codes that Support Medical Necessity - added
Endoscopy
Q85.8 to Group 1.
LCD Number: L36427
Revision Number: 3
Response to Comments for the Somatosensory Testing Local Coverage Determination
(LCD) – LCD Number: L33471
The comment period for the Somatosensory Testing Local Coverage Determination (LCD) L34433 began
on 2/6/17 and ended on 3/23/17. No comments were received from the provider community. The Effective
Date for this LCD is 05/29/2017.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
24
05/2017
Part A/B Local Coverage Determinations (LCDs) Article Updates
Revised ICD-10 LCD Article Updates
The table below provides a summary of a recent Part A/B MAC ICD-10 LCD article revision/update. To
view these revised LCD articles, go to www.PalmettoGBA.com/jma/lcd. In the Articles section select
Coverage Articles. Under the Articles for Contractor Browser section, make sure the Active Articles
category is selected and the click on the Submit button. The LCD articles are listed in alphabetical order.
Title
LCD Article
ID Number
Revision Number
Corneal Pachymetry
Once in a Lifetime
Limit
LCD Article Number:
A54556
Revision Number: 3
Changes/Additions/Deletions
Effective Date
Under Article Text revised the verbiage in the second sentence
04/21/2017
to read “The following diagnoses indicate corneal trauma,
optical surgery or other corneal indications such as keratoconus,
bullous keratopathy or other corneal dystrophies” and added
ICD-10 codes H18.11, H18.12 and H18.13.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
25
05/2017
Self-Administered
Drug Exclusion List
LCD Article Number:
A53066
Revision Number: 7
Self-Administered
Drug Exclusion List
LCD Article Number:
A53066
Revision Number: 6
Under Article Text – The first paragraph was corrected to read
05/07/2017
“The Medicare program provides limited benefits for outpatient
prescription drugs. The program covers drugs that are furnished
“incident-to” a physician’s service provided that the drugs are
not “usually self-administered” by the patient. Section 112 of
the Benefits, Improvements & Protection Act of 2000 (BIPA),
amended §§1861(s)(2)(A) and 1861(s)(2)(B) of the Social
Security Act (SSA) to redefine this exclusion. The prior statutory
language referred to those drugs “which cannot be selfadministered”. Implementation of the BIPA provision requires
interpretation of the phrase “not usually self-administered” by
the patient” and revised the third paragraph to read “For purpose
of this exclusion, the term ‘usually’ means more than 50 percent
of the time for all Medicare beneficiaries who use the drug.
Therefore, if a drug is self-administered by more than 50 percent
of Medicare beneficiaries, the drug is excluded from coverage
and this A/B MAC may not make any Medicare payment for
it”. For Self-Administered Drug Process Flow revised the
verbiage in the sixth bullet to read “Assess all information
to determine whether the drug is covered under the benefit
category and notify providers via the Palmetto GBA website”.
Under Excluded CPT/HCPCS Codes – Table Format – added
the following: exclusion end date to J1562 Injection, Immune
Globulin (Vivaglobin), 100mg, Lantus ® to Descriptor Brand
Name for code J1815, “Protropin” to Descriptor Brand Name
for J2940 and Biotropin ®. Corrected the spelling of Zorbtive®
under Descriptor Brand Name for J2941, corrected the spelling
to “Tesamorelin” under Descriptor Brand Name for J3490. A
registered trademark symbol was added to “SymlinPen 60®” and
“SymlinPen 120®” for Descriptor Brand Name for J3490. The
spelling of “Alirocumab” corrected under Descriptor Brand
Name for J3590. The trademark symbol was changed to the
Registered Trademark symbol on Repatha® for J3590. Lantus®
from Descriptor Brand Name for J3590 was deleted and
Lupron® was removed from Descriptor Brand Name for J9218
as this medication is administered by a physician. An exclusion
end date was added for Q0515 Injection, Sermorelin Acetate, 1
mcg.
Under Non-Excluded CPT-HCPCS Codes – Table Format
05/07/2017
- the Exclusion End Date for Sermorelin Acetate, 1mcg and
Injection, Immune Globulin (Vivaglobin), 100mg should read
05/07/2017.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
26
05/2017
PROVIDER ENROLLMENT INFORMATION
Provider Enrollment Revalidation – Cycle 2
MLN Matters® Number: SE1605 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 10, 2017, to correct the table on page 6. The last row should have
stated the date as “November 29 – December 14, 2017.” All other information is unchanged.
Provider Types Affected
This Medicare Learning Network (MLN) Matters® Special Edition Article is intended for all providers and
suppliers who are enrolled in Medicare and required to revalidate through their Medicare Administrative
Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), Medicare Carriers, Fiscal
Intermediaries, and the National Supplier Clearinghouse (NSC)). These contractors are collectively referred
to as MACs in this article.
Provider Action Needed
STOP – Impact to You
Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to
revalidate their Medicare enrollment information under new enrollment screening criteria. The Centers for
Medicare & Medicaid Services (CMS) has completed its initial round of revalidations and will be resuming
regular revalidation cycles in accordance with 42 CFR §424.515. In an effort to streamline the revalidation
process and reduce provider/supplier burden, CMS has implemented several revalidation processing
improvements that are captured within this article.
CAUTION – What You Need to Know
Special Note: The Medicare provider enrollment revalidation effort does not change other aspects of
the enrollment process. Providers/suppliers should continue to submit changes (for example, changes of
ownership, change in practice location or reassignments, final adverse action, changes in authorized or
delegated officials or, any other changes) as they always have. If you also receive a request for revalidation
from the MAC, respond separately to that request.
GO – What You Need to Do
1. Check http://go.cms.gov/MedicareRevalidation for the provider/suppliers due for revalidation;
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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2. If the provider/supplier has a due date listed, CMS encourages you to submit your revalidation within
six months of your due date or when you receive notification from your MAC to revalidate. When either
of these occur:
• Submit a revalidation application through Internet-based PECOS located at https://pecos.cms.hhs.
gov/pecos/login.do, the fastest and most efficient way to submit your revalidation information.
Electronically sign the revalidation application and upload your supporting documentation or sign
the paper certification statement and mail it along with your supporting documentation to your
MAC; or
• Complete the appropriate CMS-855 application available at https://www.cms.gov/Medicare/
Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.
html;
• If applicable, pay your fee by going to https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do;
and
• Respond to all development requests from your MAC timely to avoid a hold on your Medicare
payments and possible deactivation of your Medicare billing privileges.
Background
Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers
to revalidate their Medicare enrollment information under new enrollment screening criteria. CMS has
completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance
with 42 CFR §424.515. This cycle of revalidation applies to those providers/suppliers that are currently and
actively enrolled.
What’s ahead for your next Medicare enrollment revalidation?
Established Due Dates for Revalidation
CMS has established due dates by which the provider/supplier’s revalidation application must reach the
MAC in order for them to remain in compliance with Medicare’s provider enrollment requirements. The
due dates will generally be on the last day of a month (for example, June 30, July 31 or August 31). Submit
your revalidation application to your MAC within 6 months of your due date to avoid a hold on your
Medicare payments and possible deactivation of your Medicare billing privileges. Generally, this due date
will remain with the provider/supplier throughout subsequent revalidation cycles.
• The list will be available at http://go.cms.gov/MedicareRevalidation and will include all enrolled
providers/suppliers. Those due for revalidation will display a revalidation due date, all other providers/
suppliers not up for revalidation will display a “TBD” (To Be Determined) in the due date field. In
addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be
available at http://go.cms.gov/MedicareRevalidation on the CMS website.
IMPORTANT: The list identifies billing providers/suppliers only that are required to revalidate. If you
are enrolled solely to order, certify, and/or prescribe via the CMS-855O application or have opted out
of Medicare, you will not be asked to revalidate and will not be reflected on the list.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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• Due dates are established based on your last successful revalidation or initial enrollment (approximately
3 years for DME suppliers and 5 years for all other providers/suppliers).
• In addition, the MAC will send a revalidation notice within 2-3 months prior to your revalidation due
date either by email (to email addresses reported on your prior applications) or regular mail (at least two
of your reported addresses: correspondence, special payments and/or your primary practice address)
indicating the provider/supplier’s due date.
Revalidation notices sent via email will indicate “URGENT: Medicare Provider Enrollment
Revalidation Request” in the subject line to differentiate from other emails. If all of the emails
addresses on file are returned as undeliverable, your MAC will send a paper revalidation notice to at
least two of your reported addresses: correspondence, special payments and/or primary practice address.
NOTE: Providers/suppliers who are within 2 months of their listed due dates on http://go.cms.gov/
MedicareRevalidation but have not received a notice from their MAC to revalidate, are encouraged
to submit their revalidation application.
• To assist with submitting complete revalidation applications, revalidation notices for individual group
members, will list the identifying information of the organizations that the individual reassigns benefits.
Large Group Coordination
Large groups (200+ members) accepting reassigned benefits from providers/suppliers identified on the
CMS list will receive a letter from their MACs listing the providers linked to their group that are required
to revalidate for the upcoming 6 month period. A spreadsheet detailing the applicable provider’s Name,
National Provider Identifier (NPI) and Specialty will also be provided. CMS encourages the groups to
work with their practicing practitioners to ensure that the revalidation application is submitted prior to the
due date. We encourage all groups to work together as only one application from each provider/supplier
is required, but the provider must list all groups they are reassigning to on the revalidation application
submitted for processing. MACs will have dedicated provider enrollment staff to assist in the large group
revalidations.
Groups with less than 200 reassignments will not receive a letter or spreadsheet from their MAC, but can
utilize PECOS or the CMS list available on http://go.cms.gov/MedicareRevalidation to determine their
provider/supplier’s revalidation due dates.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Unsolicited Revalidation Submissions
All unsolicited revalidation applications submitted more than 6 months in advance of the provider/supplier’s
due date will be returned.
• What is an unsolicited revalidation?
o If you are not due for revalidation in the current 6 month period, your due date will be listed as
“TBD” (To Be Determined). This means that you do not yet have a due date for revalidation. Please
do not submit a revalidation application if there is NOT a listed due date.
o Any off-cycle or ad hoc revalidations specifically requested by CMS or the MAC are not considered
unsolicited revalidations.
• If your intention is to submit a change to your provider enrollment record, you must submit a ‘change of
information’ application using the appropriate CMS-855 form.
Submitting Your Revalidation Application
IMPORTANT: Each provider/supplier is required to revalidate their entire Medicare enrollment
record.
A provider/supplier’s enrollment record includes information such as the provider’s individual practice
locations and every group that benefits are reassigned (that is, the group submits claims and receives
payments directly for services provided). This means the provider/supplier is recertifying and revalidating
all of the information in the enrollment record, including all assigned NPIs and Provider Transaction Access
Numbers (PTANs).
If you are an individual who reassigns benefits to more than one group or entity, you must include all
organizations to which you reassign your benefits on one revalidation application. If you have someone
else completing your revalidation application for you, encourage coordination with all entities to which you
reassign benefits to ensure your reassignments remain intact.
The fastest and most efficient way to submit your revalidation information is by using the Internetbased PECOS.
To revalidate via the Internet-based PECOS, go to https://pecos.cms.hhs.gov/pecos/login.do. PECOS
allows you to review information currently on file and update and submit your revalidation via the Internet.
Once completed, YOU MUST electronically sign the revalidation application and upload any supporting
documents or print, sign, date, and mail the paper certification statement along with all required supporting
documentation to your appropriate MAC IMMEDIATELY.
PECOS ensures accurate and timelier processing of all types of enrollment applications, including
revalidation applications. It provides a far superior alternative to the antiquated paper application process.
To locate the paper enrollment applications, refer to https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html 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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Getting Access to PECOS:
To use PECOS, you must get approved to access the system with the proper credentials which are obtained
through the Identity and Access Management System, commonly referred to as “I&A”. The I&A system
ensures you are properly set up to submit PECOS applications. Once you have established an I&A account
you can then use PECOS to submit your revalidation application as well as other enrollment application
submissions.
To learn more about establishing an I&A account or to verify your ability to submit applications using
PECOS, please refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN903764.pdf.
If you have questions regarding filling out your application via PECOS, please contact the MAC that
sent you the revalidation notice. You may also find a list of MAC’s at https://www.cms.gov/Medicare/
Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf.
For questions about accessing PECOS (such as login, forgot username/password) or I&A, contact the
External User Services (EUS) help desk at 1-866-484-8049 or at [email protected].
Deactivations Due to Non-Response to Revalidation or Development Requests
It is important that you submit a complete revalidation application by your requested due date and you
respond to all development requests from your MACs timely. Failure to submit a complete revalidation
application or respond timely to development requests will result in possible deactivation of your Medicare
enrollment.
If your application is received substantially after the due date, or if you provide additional requested
information substantially after the due date (including an allotted time period for US or other mail receipt)
your provider enrollment record may be deactivated. Providers/suppliers deactivated will be required to
submit a new full and complete application in order to reestablish their provider enrollment record and
related Medicare billing privileges. The provider/supplier will maintain their original PTAN; however, an
interruption in billing will occur during the period of deactivation resulting in a gap in coverage.
NOTE: The reactivation date after a period of deactivation will be based on the receipt date of the new
full and complete application. Retroactive billing privileges back to the period of deactivation will not be
granted. Services provided to Medicare patients during the period between deactivation and reactivation are
the provider’s liability.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Revalidation Timeline and Example
Providers/suppliers may use the following table /chart as a guide for the sequence of events through the
revalidation progression.
Action
Revalidation list posted
Issue large group notifications
MAC sends email/letter
notification
MAC sends letter for
undeliverable emails
Revalidation due date
Apply payment hold/issue
reminder letter (group members)
Deactivate
Timeframe
Approximately 6 months prior to
due date
Approximately 6 months prior to
due date
75 – 90 days prior to due date
Example
March 30, 2017
75 – 90 days prior to due date
July 2 - 17, 2017
Within 25 days after due date
September 30, 2017
October 25, 2017
60 – 75 days after due date
March 30, 2017
July 2 - 17, 2017
November 29 – December 14,
2017
Deactivations Due to Non-Billing
Providers/suppliers that have not billed Medicare for the previous 12 consecutive months will have
their Medicare billing privileges deactivated in accordance with 42 CFR §424.540. The effective date of
deactivation will be 5 days from the date of the corresponding deactivation letter issued by the MACs
notifying the providers/suppliers of the deactivation action.
Providers/suppliers who Medicare billing privileges are deactivated will be required to submit a new full
and complete application in order to reestablish their provider enrollment record and related Medicare
billing privileges. The provider/supplier will maintain their original PTAN; however, an interruption in
billing will occur during the period of deactivation resulting in a gap in coverage.
Application Fees
Institutional providers of medical or other items or services and suppliers are required to submit an
application fee for revalidations. The application fee is $560.00 for Calendar Year (CY) 2017. CMS has
defined “institutional provider” to mean any provider or supplier that submits an application via PECOS
or a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and nonphysician practitioner organizations), or CMS-855S forms.
All institutional providers (that is, all providers except physicians, non-physicians practitioners, physician
group practices and non-physician practitioner group practices) and suppliers who respond to a revalidation
request must submit the 2017 enrollment fee (reference 42 CFR 424.514) with their revalidation application.
You may submit your fee by ACH debit, or credit card. To pay your application fee, go to https://pecos.
cms.hhs.gov/pecos/feePaymentWelcome.do and submit payment as directed. A confirmation screen will
display indicating that payment was successfully made. This confirmation screen is your receipt and you
should print it for your records. CMS strongly recommends that you include this receipt with your uploaded
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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documents on PECOS or mail it to the MAC along with the Certification Statement for the enrollment
application. CMS will notify the MAC that the application fee has been paid. Revalidations are processed
only when fees have cleared.
SUMMARY:
• CMS will post the revalidation due dates for the upcoming revalidation cycle on http://go.cms.gov/
MedicareRevalidation for all providers/suppliers. This list will be refreshed periodically. Check this list
regularly for updates.
• MACs will continue to send revalidation notices (either by email or mail) within 2-3 months prior to
your revalidation due date. When responding to revalidation requests, be sure to revalidate your entire
Medicare enrollment record, including all reassignment and practice locations. If you have multiple
reassignments/billing structures, you must coordinate the revalidation application submission with all
parties.
• If a revalidation application is received but incomplete, the MACs will develop for the missing
information. If the missing information is not received within 30 days of the request, the MACs will
deactivate the provider/supplier’s billing privileges.
• If a revalidation application is not received by the due date, the MAC may place a hold on your
Medicare payments and deactivate your Medicare billing privileges.
• If the provider/supplier has not billed Medicare for the previous 12 consecutive months, the MAC will
deactivate their Medicare billing privileges.
• If billing privileges are deactivated, a reactivation will result in the same PTAN but an interruption in
billing during the period of deactivation. This will result in a gap in coverage.
• If the revalidation application is approved, the provider/supplier will be revalidated and no further action
is needed.
Additional Information
To find out whether a provider/supplier has been mailed a revalidation notice go to http://go.cms.gov/
MedicareRevalidation on the CMS website.
A sample revalidation letter is available at http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf on the CMS
website. A revalidation checklist is available at http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.html on the CMS website.
For more information about the enrollment process and required fees, refer to MLN Matters® Article
MM7350, which is available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM7350.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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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For more information about the application fee payment process, refer to MLN Matters Article SE1130,
which is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/SE1130.pdf on the CMS website.
The MLN fact sheet titled “The Basics of Internet-based Provider Enrollment, Chain and Ownership System
(PECOS) for Provider and Supplier Organizations” is designed to provide education to provider and supplier
organizations on how to use Internet-based PECOS to enroll in the Medicare Program and is available at
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
downloads/MedEnroll_PECOS_ProviderSup_FactSheet_ICN903767.pdf on the CMS website.
To access PECOS, your Authorized Official must register with the PECOS Identification and Authentication
system. To register for the first time go to https://pecos.cms.hhs.gov/pecos/PecosIAConfirm.
do?transferReason=CreateLogin to create an account.
For additional information about the enrollment process and Internet-based PECOS, please visit the
Medicare Provider-Supplier Enrollment webpage at http://www.cms.gov/Medicare/Provider-Enrollmentand-Certification/MedicareProviderSupEnroll/index.html.
If you have questions, contact your MAC. Medicare provider enrollment contact information for each
State can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
MedicareProviderSupEnroll/Downloads/contact_list.pdf.
Document History
Date of Change
April 10, 2017
March 15, 2017
February 22, 2016
Description
The article was revised to correct the table on page 6. The last row should
have stated the date as “November 29 – December 14, 2017.”
The updated article revised the table on page 6 and added additional
information after that table.
Initial article released
This advisory should be shared with all health care practitioners and managerial members of the provider/
supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www.
PalmettoGBA.com/jma.
Address Changes
Have you changed your address or other significant information recently? To update this information,
please complete and submit a CMS 855A form. The most efficient way to submit your information is by
Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your
Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the
CMS website. To obtain the hard copy form plus information on how to complete and submit it – visit the
Palmetto GBA website (www.PalmettoGBA.com/jma).
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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TOOLS THAT YOU CAN USE
Medicare Credit Balance Report Module
This interactive module provides assistance with completing the Medicare Credit Balance Report (CMS838). A credit balance is an improper or excess payment made to a provider as a result of patient billing or
claims processing errors.
Providers must submit this report quarterly. Failure to submit the report, within 30 days of each quarter end,
may result in suspension of payments and your eligibility to participate in the Medicare program.
To access the Medicare Credit Balance Report Module on the Palmetto GBA website, select the link below:
http://www.palmgba.com/elearn/CreditBalanceReport/story.html
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Split Billing Module
To determine if split billing is required for your claim submission to Medicare, you can use the Split Billing
Module. To access this module from the Palmetto GBA website select the link below:
http://palmgba.com/elearn/SplitBilling/story.html
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
HELPFUL INFORMATION
Contact Information for Palmetto GBA Part A
Department
Appeals
Contact Information
Palmetto GBA
Part A Appeals
Mail Code: AG-630
P.O. Box 100238
Columbia, SC 29202-3238
Fax: (803) 699-2425
Type of Inquiry
• Request for
Redeterminations •
Redetermination Form
For Fed Ex/UPS/Certified Mail
Palmetto GBA
Part A Appeals
Mail Code: AG-630
Building One
2300 Springdale Drive
Camden, SC 29020
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
37
05/2017
Contact Center
(Provider)
Palmetto GBA
Part A PCC
Mail Code: AG-840
P.O. Box 100238
Columbia, SC 29202-3238
• General coverage and
Medicare-related questions
• Crossover questions
• Questions regarding claim
filing requirements
•
Explanation of denial
Provider Contact Center: 855-696-0705
reasons
• IVR resources
Our PCC Representatives are ready to answer your
questions about billing problems and other issues. Please • MSP resources
see the following links for more guidance about the Part A • Modifier guidelines
Interactive Voice Response (IVR) and contacting the Call • Medical record
documentation questions
Center.
• Written Inquiries
IVR Flowchart
http://www.palmettogba.com/Palmetto/Providers.Nsf/
files/IVR_Part_A_Flowchart.pdf/$File/IVR_Part_A_
Flowchart.pdf
Call Flowchart
http://www.palmettogba.com/Palmetto/Providers.Nsf/
files/IVR_Flowchart.pdf/$File/IVR_Flowchart.pdf
IVR Conversion Tool
http://www.palmettogba.com/palmetto/ivrt.nsf/
Main?OpenForm
Part A PCC Hours: 8 a.m. to 4:30 p.m. ET
Email
Email Part A to have your inquiry answered. Please do not
include any Protected Health 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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Cost Report
Cost Report Filing
•
Cost Reports
Mailing Address
Palmetto GBA
Attn: Cost Report Acceptance
Mail Code: AG-330
P.O. Box 100144
Columbia, SC 29202-3144
•
Checks
Fed Ex/UPS/Certified Mail Address
Palmetto GBA
Attn: Cost Report Acceptance
Mail Code: AG-330
2300 Springdale Drive
Building One
Camden, SC 29020-1728
Credit Balance
Reporting for NC
Cost Report Overpayment Address (checks only)
Palmetto GBA
Medicare Finance
Mail Code: AG-260
P.O. Box 100277
Columbia, SC 29202-3277
Regular and Certified Mail
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100278
Columbia, SC 29202-3278
• Questions or concerns
regarding credit balance
reports
Fed Ex/UPS/Overnight Courier
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
Reports may be faxed to:
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277
If you have questions about your Credit Balance Report,
please call the Provider Contact Center at: 855-696-0705
All email inquiries may be sent to Credit.Balance@
PalmettoGBA.com
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
39
05/2017
Credit Balance
Reporting for SC
Regular and Certified Mail
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100277
Columbia, SC 29202-3278
• Questions or concerns
regarding credit balance
reports
Fed Ex/UPS/Overnight Courier
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
Reports may be faxed to:
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277
If you have questions about your Credit Balance Report,
please call the Provider Contact Center at: 855-696-0705
All email inquiries may be sent to Credit.Balance@
PalmettoGBA.com
Credit Balance
Regular and Certified Mail
Reporting for VA and Palmetto GBA
WV
Attn: Credit Balance Reporting
P.O. Box 100109
Columbia, SC 29202-3278
• Questions or concerns
regarding credit balance
reports
Fed Ex/UPS/Overnight Courier
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
Reports may be faxed to:
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277
If you have questions about your Credit Balance Report,
please call the Provider Contact Center at: 855-696-0705
Customer Service
Center (Beneficiary)
All email inquiries may be sent to Credit.Balance@
PalmettoGBA.com
1-800-Medicare (1-800-633-4227)
TTY: 877-486-2048
• All questions related to the
Medicare program
Visit the Medicare website at www.medicare.gov
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Electronic Data
Interchange (EDI)
for NC and SC
Palmetto GBA
Part A EDI
Mail Code: AG-420
P.O. Box 100145
Columbia, SC 29202-3145
• EDI enrollment
Provider Contact Center: 855-696-0705
• Electronic Remittance
Advice (ERA)
• Administrative
Simplification and
Compliance Act (ASCA)
• PC-ACE Pro 32 (billing
software)
• Direct Data Entry (billing
software)
• Other EDI-related issues • Monday to Friday 6 a.m. – 8
p.m. ET
• Saturday 6 a.m. - 4 p.m. ET
• Sunday: Not Available
• EDI enrollment
DDE Hours of Availability
Electronic Data
Interchange (EDI)
for VA and WV
NGS EDI Help Desk: 855-696-0705
• Electronic Remittance
Advice (ERA)
• PC-ACE Pro 32 (billing
software)
• Direct Data Entry (billing
software)
Freedom of
Information Act
(FOIA) Requests
Medical Affairs
• Other EDI-related issues • FOIA requests
Palmetto GBA
FOIA Coordinator
Mail Code: AG-615
P.O. Box 100190
Columbia, SC 29202-3190
Palmetto GBA
Part A Medical Affairs
Mail Code: AG-300
P.O. Box 100238
Columbia, SC 29202-3238
• Local coverage
determinations (LCDs)
Send emails to [email protected]
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Medical Review
Palmetto GBA
Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238
• Responding to Additional
Documentation Requests
(ADRs)
• Responses to our requests
for medical records
Please call the Provider Contact Center (PCC) at 855696-0705 for Medical Review questions.
Medicare Secondary
Payer (MSP)
Fed Ex/UPS/Overnight Courier
Palmetto GBA MAC
Mail Code: AG-230
2300 Springdale Drive, Building One
Camden, SC 29020
Fax: (803) 699-2432
For questions/concerns related to MSP records, contact
the Benefits Coordination & Recovery Center (BCRC)
at: 855-798-2627 (TTY/TDD at 855-797-2627 for
the hearing and speech impaired). Customer Service
Representatives are available to provide you with quality
service Monday through Friday from 8 a.m. to 8 p.m. ET,
except holidays.
• MSP questions
• Questions regarding
beneficiary’s primary or
secondary records
Mailing addresses are available on the CMS website.
(https://www.cms.gov/Medicare/Coordination-ofBenefits-and-Recovery/Coordination-of-Benefits-andRecovery-Overview/Contacts/Contacts-page.html)
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Overpayments
NC Part A Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100278
Columbia, SC 29202-3277
• Overpayments
• Checks for cost report and
credit balances
SC Part A Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100277
Columbia, SC 29202-3277
VA and WV Part A Providers
Palmetto GBA
Medicare Part A Overpayments
Mail Code: AG-340
P.O. Box 100109
Columbia, SC 29202-3109
Provider Inquiries:
For inquiries regarding overpayments, please call the
Provider Contact Center at 855-696-0705.
Fax Numbers:
• To send any financial correspondence to the
overpayment department by fax, please fax this
information to (803) 419-3275.
Provider Audit
To request an immediate offset, fax your request to (803)
462-2574.
Palmetto GBA
Provider Audit
Mail Code: AG-320
P.O. Box 100144
Columbia, SC 29202-3144
Palmetto GBA
Cost Report Appeals and Reopenings
Mail Code: AG-380
P.O. Box 100144
Columbia, SC 29202-3144
• Issues related to cost reports,
desk reviews, audits and
settlements
• Issues related to the filing
of cost report appeals and
reopenings
Email:
Filing of Cost Report Appeals
[email protected]
Filing of Cost Report Reopenings
[email protected]
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Provider Enrollment
Palmetto GBA
Part A Provider Enrollment
Mail Code: AG-331
P.O. Box 100144
Columbia, SC 29202-3144
• Enrollment (credentialing)
questions
For inquiries regarding provider enrollment, please call
the PCC at 855-696-0705.
• Change address, add a
location or add a new
member to a provider group
• Request CMS-855 B, I or R
forms
• Independent Diagnostic
Testing Facility (IDTF)
enrollment
• Electronic Funds Transfer
(EFT) CMS 588 form
• Medicare Participating
Physician or Supplier
Agreement (PAR) CMS 460
form
• How to obtain a National
Provider Identifier (NPI)
• Participation corrections
• IRS 1099 tax form
corrections
• Consent forms
• Educational training requests
Provider Outreach
Palmetto GBA
and Education (POE) Part A POE
Mail Code: AG-830
P.O. Box 100238
Columbia, SC 29202-3238
Provider
Reimbursement
• Request a speaker for
association meetings in your
state
For education, please complete the Education Request
Form. To access this document, go to the Forms Web page
at www.PalmettoGBA.com/jma/forms
Palmetto GBA
• Submission of interim rate
Provider Reimbursement
information
Mail Code: AG-330
• Reimbursement issues
P.O. Box 100144
Columbia, SC 29202-3144
• Reimbursement specialist
Phone Number: (803) 382-6104
• Submission of certificates
Fax updated certificates for diabetes education,
mammography and PET scan to the reimbursement
department at (803) 935-0262.
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017
Zone Program
Integrity Contractor
(ZPIC)
AdvancedMed, an NCI Company
520 Royal Parkway, Suite 100
Nashville, TN 37214
Phone Number: (615) 871-2361
Website: www.nciinc.com/about-us/advancemed
• Fraud
• Abuse
• Questionable billing
practices
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
45
05/2017
NOTES
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. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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05/2017