edition 7 ∙ winter 2018 - cgs medicare · updates to medicare’s cost report worksheet s-10 to...

This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters issued after 2014 are available at no cost from our website.

© 2018 Copyright, CGS Administrators, LLC.

EDITION 7 ∙ WINTER 2018

EDITION 7 ∙ WINTER 2018 2© 2018 Copyright, CGS Administrators, LLC.

Table of Contents

From the Medical DirectorUpdate on the Targeted Probe and Educate (TPE) Pilot .........3

News from the InsideJurisdiction B Provider Outreach and Education on New Medicare Cards - CGS Publication .................................4

myCGSClearinghouse/Billing Agent Users in myCGS— Coming January 4, 2018! - CGS Publication ...........................5

Coverage & BillingRequest for Information – Topical Oxygen Therapy Used for Wound Care - DME MAC Joint Publication ...............6

Correct Coding - Lithium Batteries – Revised - DME MAC Joint Publication ..................................................7

Correct Coding – PRO-FLEX® Prosthetic Foot (Össur) - DME MAC Joint Publication ..................................................8

Correct Coding - Insulin Used with Continuous External Insulin Infusion Pumps - DME MAC Joint Publication .............9

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2018 (MM10233) .............................................................................10

Clarification of the Billing of Immunosuppressive Drugs (MM10235) .............................................................................12

Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (SE1128 Revised) ..................................................................14

Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations (SE17018) .............................................18

Pharmacy Billing of Immunosuppressive Drugs (SE17032) ..............................................................................22

Medical PolicyCorrect Coding – HCPCS Coding of Surgical Dressings - Components to Report on the PDAC HCPCS Code Verification Application - DME MAC Joint Publication ..........24

Local Coverage Determination (LCD) Revision Summary for September 7, 2017 ............................................................26

Policy Article (PA) Revision Summary for October 12, 2017 ...................................................................26

LCD Revision Summary for October 19, 2017 .......................27

LCD and Policy Article Revisions Summary for October 26, 2017 ...................................................................27

Policy Article Revisions Summary for November 16, 2017 ................................................................28

Dear Physician - Glucose Monitors .......................................30

Dear Physician - Continuous Glucose Monitors ....................33

AppealsNotification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review ....36

MiscellaneousRevision to Publication 100.06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment (MM9815 Revised) ...........................................37

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs) (MM9893 Rescinded) ...................39

Guidance on Implementing System Edits for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (MM9904 Revised) ..............................39

IVIG Demonstration: Payment Update for 2018 (MM10343) .............................................................................42

Accepting Payment from Patients with a Medicare Set-Aside Arrangement (SE17019 Reissued) ........................43

Hurricane Maria and Medicare Disaster Related United States Virgin Islands and Commonwealth of Puerto Rico Claims (SE17028) ..............................................45

Updates to Medicare’s Cost Report Worksheet S-10 to Capture Uncompensated Care Data (SE17031) ....................50

Hurricane Nate and Medicare Disaster Related Alabama, Florida, Louisiana and Mississippi Claims (SE17034) ...........54

Medicare Fee-for-Service (FFS) Response to the 2017 California Wildfires (SE17035 Revised) .................................58

Fees & PricingOctober Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule (MM10248) ..................................61

January 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM10320) ........................................62

HCPCS UPDATESThe 2018 HCPCS Updates – New, Revised, and Discontinued HCPCS Codes .................................................64

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2017 Update (MM10234) ................................................................65

2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update (MM10262) .............................................................................66

eNews ............................................................................... 67

DME MAC Jurisdiction B Contact Information ................................................... 69

The CMS articles in this edition of the Insider are current as of November 13,2017


FROM THE MEDICAL DIRECTOR

Update on the Targeted Probe and Educate (TPE) Pilot

- CGS Publication The TPE Pilot, which became effective July 3 for Jurisdiction B (JB), has now been extended by CMS to be the on-going review program for all DMEMAC jurisdictions. With the TPE pilot start date having been so recent for JB, we are now beginning to assemble data on outcomes from Round One reviews of the initial suppliers who were chosen, and will determine the proper method for communicating any trends to the supplier community.

For TPE, approximately 40 claims from each supplier selected for the program will be reviewed at each of the three probe rounds. The decision to proceed to the next round of TPE will be made based on various factors, which will include (but is not limited to) the percentage of errors, amount of dollars denied, types of errors, and previous education provided.

About the basics for this program:

Additional Documentation Letters (ADR) letters: You will receive ADR letters for claims that are selected for TPE Probe reviews. ADRs are sent to the address that you have provided to the National Supplier Clearinghouse (NSC); so, please ensure the address on file at the NSC is accurate. The timeframe for submitting requested documentation for an ADR letter is 45 days. Please submit your documentation to CGS in accordance with the directions on the ADR letter as soon as possible in order to expedite your review and processing of your claim.

TPE Education: There already have been compliments about the effectiveness and overall supportive tone of the one-to-one educational sessions that are the mainstay for this program. We at CGS assign to each supplier under review a case manager nurse, who heads your team of other clinical reviewers. As audit responses start to come into our JB clinical staff, we have an opportunity to reach out to you to comment on missing or incomplete items, thus allowing for further items to be sent in for review.

Further education: Typically, your community coach from our JB Provider Outreach and Education Consultants sits in on your educational session with Medical Review to review the probe results. Please remember that you have all of the various resources that are on our Education JB website, including the CGS WIZARD, at your disposal. We encourage you to utilize these resources as you are receiving the results of your individual claim reviews. There is also the potential for specially crafted educational sessions to enable you to be ready for the next round of audits, should that happen.

How suppliers are chosen: We identify suppliers for TPE based on a variety of information that includes jurisdictional claim data, CERT data, and/or referrals from other agencies. Here is our experience as of the end of October:

y 42% of all claims reviewed through JB TPE have been approved.

y 27% of all suppliers who entered Round One did not move on to Round 2.

y Topics chosen for review for the initial Round One Audits include: Pap, Glucose Monitor Supplies, Immunosuppressive drugs, Nebulizer drugs, Oxygen concentrators, Spinal orthoses, Surgical dressings and Urological supplies. (These topics are subject to change for future audits.)


As the DME Medical Director for JB, I have a vested interest in seeing this program succeed as an effective strategy to improve improper claims submissions. My role is to offer assistance as needed to our Medical Review Department. I am happy to, from time to time, participate in educational sessions, yet the most important relationship for suppliers to develop during a TPE review is the one with your case manager nurse.

The TPE program, as of this Insider distribution in early January 2018, will be only six months old! So, much is still being learned regarding effective education, error rate reduction, and data review for appropriate selection of audit participants. If you as a supplier are relaxing because you have not yet received a letter of inclusion in this program, enjoy this time, but please do not cease educating your staff about compliance. Be ready! Please consult our web site and take advantage of our live programs, webinars and Ask the Contractor sessions. We have many written educational programs, too, as well as Dear Physician Letters and FAQs. Keep in touch about TPE with us! Also, remember there are other CMS audit contractors out there for whom you need to be ready.

I wish you and your staff a Happy and Healthy 2018!

Stacey V. Brennan, MD, FAAFP Medical Director, DME MAC, Jurisdiction B CGS Administrators, LLC

NEWS FROM THE INSIDE

Jurisdiction B Provider Outreach and Education on New Medicare Cards

- CGS Publication

Link to current version on the CGS website: https://www.cgsmedicare.com/jb/pubs/news/2017/09/cope4385.html

The Jurisdiction B Provider Outreach and Education Team is committed to assisting you in making a smooth transition from using Health Insurance Claim Numbers (HICNs) to the new Medicare Beneficiary Identifier (MBI) for Medicare transactions like billing, eligibility status, and claim status. In addition to disseminating CMS information through our ListServs, we have implemented a plan to make sure you have access to the latest information. Starting in October 2017, and running through December 2019, you can expect the following activities:

y New Medicare Card Project Webinars: This webinar will provide information on what you need to know about the new Medicare Beneficiary Identifier (MBI) that will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. The latest information on timelines, transition period, and resources will be provided. The first webinar was scheduled on October 19, 2017, and will be scheduled on a monthly basis through 2018. You may register to attend our webinars by visiting the Webinars page: https://www.cgsmedicare.com/jb/education/webinars.html

y Ask the Contractor Teleconferences (ACT): An update on New Medicare Cards project will be given, and time allotted to questions regarding the Medicare Beneficiary Identifier (MBI) during all quarterly ACTs. Stay tuned to our ListServs for notifications of when these calls are scheduled.

https://www.cgsmedicare.com/jb/pubs/news/2017/09/cope4385.html


https://www.cgsmedicare.com/jb/education/webinars.html

https://www.cgsmedicare.com/jb/education/webinars.html


y ListServs and social media: We will share any new information as soon as it is available, as well as regular updates and reminders in our ListServs and social media. Make sure your email subscriptions are up to date, by clicking the link to “Join/Update ListServ” (https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp) at the top of your screen. Social Media links are available under “Stay Connected” at the bottom of the CGS Medicare website (https://www.cgsmedicare.com/).

y Partnership with State Associations: We will also be partnering with state associations to make sure the latest information is provided at any scheduled events.

Be sure to refer to CMS’ New Medicare Cards page (https://www.cms.gov/Medicare/New-Medicare-Card/index.html) for complete information about the new Medicare Cards and Medicare Beneficiary Identifier (MBI): https://www.cms.gov/Medicare/New-Medicare-Card/index.html

Stay tuned as more information becomes available!

myCGS

Clearinghouse/Billing Agent Users in myCGS—Coming January 4, 2018!

- CGS Publication

Beginning January 4, 2018, myCGS will allow third party billers to register for myCGS using a new clearinghouse/billing agent (CHBA) role. The new role will offer several advantages to CHBA users:

y CHBA users will be able to see every supplier their company is authorized to view, rather than being limited to just one company.

y The CHBA role will be set up using the unique combination of Trading Partner ID + NPI + PTAN. These combinations are controlled by CEDI and approved by the owner of each NPI/PTAN.

y DMEPOS suppliers will be able to grant access to the CHBA company they use without having to approve/manage individual users.

y The ability to register as a CHBA will be based on information provided to us directly from CEDI.

The CEDI Supplier Authorization Form will be updated on January 2, 2018, to include a new section for suppliers to grant their clearinghouse/billing service access to their information via the DME MAC internet portals. Suppliers will need to complete the updated form granting CHBA access before CHBA users can register for myCGS. For information about submitting the form, visit the CEDI website at https://www.ngscedi.com/.

Note: Only suppliers who are set up or requesting to be set up for X12 837 claims with CEDI can request DME MAC portal access for a third party.

Stay tuned to our ListServ and the News page on our website (https://www.cgsmedicare.com/jb/index.html) for important details and instructions on the full registration process for CHBA users.

Learn about myCGS by visiting our myCGS page at https://www.cgsmedicare.com/jb/mycgs/index.html.

https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

https://www.cgsmedicare.com/

https://www.cms.gov/Medicare/New-Medicare-Card/index.html




https://www.ngscedi.com/

https://www.cgsmedicare.com/jc/index.html

https://www.cgsmedicare.com/jc/index.html

https://www.cgsmedicare.com/jb/mycgs/index.html

https://www.cgsmedicare.com/jb/mycgs/index.html


COVERAGE & BILLING

Request for Information – Topical Oxygen Therapy Used for Wound Care

- DME MAC Joint Publication


The DME MACs announce the solicitation of scientific articles regarding the subject of topical oxygen therapy (TOT) used for wound care. We are requesting that interested parties provide relevant clinical evidence regarding the generally accepted uses for the topical application of oxygen in clinical practice. The Centers for Medicare and Medicaid Services (CMS) has recently announced that the National Coverage Determination for TOT will be removed. TOT provided by durable medical equipment will fall within DME MAC jurisdiction. The information received from this solicitation will assist the DME MACs in this coverage evaluation.

Those interested in responding to this solicitation should take note that CMS requires that MAC contractors make coverage determinations using an evidence-based medical standard. This standard for clinical evidence is described in the CMS Program Integrity Manual (Internet-Only Manual, Pub. 100-08, Chapter 13, and Section 13.7.1) which states (in relevant part):

[S]hall be based on the strongest evidence available. The extent and quality of supporting evidence is key... The initial action in gathering evidence … shall always be a search of published scientific literature for any available evidence pertaining to the item or service in question. In order of preference:

y Published authoritative evidence derived from definitive randomized clinical trials or other definitive studies, and

y General acceptance by the medical community (standard of practice), as supported by sound medical evidence based on:

� Scientific data or research studies published in peer-reviewed medical journals;

� Consensus of expert medical opinion (i.e., recognized authorities in the field); or

� Medical opinion derived from consultations with medical associations or other health care experts.

There are limitations to the type of evidence that can be used for a MAC coverage determination. The CMS Program Integrity Manual section above goes on to state:

Acceptance by individual health care providers, or even a limited group of health care providers, normally does not indicate general acceptance by the medical community. Testimonials indicating such limited acceptance, and limited case studies distributed by sponsors with financial interest in the outcome, are not sufficient evidence of general acceptance by the medical community. The broad range of available evidence must be considered and its quality shall be evaluated before a conclusion is reached. [Emphasis added]

The DME MACs encourage respondents to consider these requirements as materials are collected and submitted.

The DME MACs are specifically interested in clinical trials using TOT performed during the last




10 years (September 2007- September 2017).

We request that full-text copies of all clinical articles be submitted. Abstracts, poster presentations, case studies, and other non-peer reviewed material will not be considered. All information must be submitted electronically in PDF format. The PDF must be unprotected and submitted as a readable, unencrypted document and not be a scanned image (OCR). Please email these documents to: [email protected].

Deadline for Submission of Information is 45 days from the publishing of this article: October 30, 2017.

The DME MACs appreciate your assistance.

Publication HistoryPublication Date: September 14, 2017 Originally Published

Correct Coding - Lithium Batteries – Revised



The DME MACs have recently had questions regarding the proper billing of lithium batteries. There are two types of lithium batteries: lithium batteries (standard) and lithium ion batteries. Lithium ion batteries are commonly used in consumer electronic devices and are rechargeable. Standard lithium batteries are disposable, non-rechargeable batteries. Suppliers must take care to properly distinguish between lithium ion and lithium batteries when billing claims to Medicare.

The following HCPCS codes are used to correctly code lithium batteries:

A4235 - REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH

A4601 - LITHIUM ION BATTERY, RECHARGEABLE, FOR NON-PROSTHETIC USE, REPLACEMENT

A4602 - REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 1.5 VOLT, EACH

E2397 - POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH

K0604 - REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 3.6 VOLT, EACH

K0605 - REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 4.5 VOLT, EACH

L7367 - LITHIUM ION BATTERY, RECHARGEABLE, REPLACEMENT

Code A4235 describes a lithium battery, not a lithium ion battery. This code is used to bill lithium batteries for glucose monitors, regardless of the voltage.

Codes A4602, K0604, and K0605 describe lithium batteries commonly used in external infusion pumps. Note that each code has an associated voltage.

mailto:Policycomments%40cgsadmin.com?subject=




Claims for lithium batteries for external insulin infusion pumps (E0784) that do not use a voltage described by either code A4602, K0604, and K0605 must be billed using code A9999 (MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED).

Code A4601 describes a lithium ion battery, not a lithium battery

Code E2397 describes lithium ion batteries used for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986).

Code L7367 describes lithium ion batteries for prosthetics.

Refer to the Contractor Supplier Manual, applicable Local Coverage Determination, related Policy Article, and Standard Documentation Article for additional information about applicable coverage, coding, and documentation requirements.

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com/

Publication HistorySeptember 21, 2017 Revised to include PMD codes for which E2397 may be used

January 1, 2015 Updated to add A4602

May 1, 2014 Original Publication

Correct Coding – PRO-FLEX® Prosthetic Foot (Össur)



There have been recent inquiries to the DME MACs regarding the correct HCPCS coding to be used for Medicare billing of the Össur PRO-FLEX® prosthetic foot. The company describes the product thusly in the “Instructions for Use”:

PRO-FLEX® is a prosthetic foot with anatomically located ankle pivot joint. Two supporting joints connect flexible carbon blades and act together with the main joint to provide progressive energy storing during the whole stance phase and a powerful push-off in the end of stance.

Based upon a review of publicly available information from the manufacturer and other sources, the correct HCPCS code for Medicare billing of the PRO-FLEX® prosthetic foot is:

L5979 (ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM)

This code is considered as all-inclusive for the PRO-FLEX® prosthetic foot. Use of other HCPCS codes to bill Medicare for any additional features and functions will be denied as

https://www.dmepdac.com/





incorrect coding.

Refer to the Lower Limb Prostheses LCD (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33787), related Policy Article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52496), and Standard Documentation Article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=55426) for additional information about coverage, coding, and documentation for prosthetic feet.

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com/.

Publication HistoryOctober 5, 2017 Original Publication

Correct Coding - Insulin Used with Continuous External Insulin Infusion Pumps



Recently the DME MACs have become aware of pharmacy billing to Medicare Part D for insulin used in a Durable Medical Equipment (DME) external insulin infusion pump (E0784 [EXTERNAL AMBULATORY INFUSION PUMP, INSULIN]). The DME MACs have jurisdiction for claims for DME and related supplies used with the DME items. Payment under Part D is prohibited when there is coverage under a Part B benefit. In the case of insulin, when it is administered via a Part B-covered DME pump, payment from Part D is excluded. All claims for DME and supplies used with DME items must be billed to the DME MACs.

The correct HCPCS code to use for billing insulin used with an E0784 pump is:

J1817 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS

Use of HCPCS codes J1815 [INJECTION, INSULIN, PER 5 UNITS] or J7799 [NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME] are incorrect coding and will be denied.

Refer to the External Infusion Pump LCD (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33794), related Policy Article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52507), Standard Documentation Requirements article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=55426) and DME MAC Supplier Manual for additional information on coverage, coding, documentation, and billing.

Correct coding is an essential element for correct claim payment. The Pricing, Data Analysis and Coding (PDAC) contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m.

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33787


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52496















CT, Monday through Friday, or e-mail questions to the PDAC by completing the DME PDAC Contact Form.

Publication HistoryOctober 19, 2017 Original Publication

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2018

Link to current version on the CMS website: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10233.pdf

MLN Matters® Number: MM10233Related CR Release Date: November 8, 2017 Related CR Transmittal Number: R3909CP

Related Change Request (CR) Number: 10233Effective Date: January 1, 2018Implementation Date: January 2, 2018

Note: This article was revised on November 9, 2017, to reflect a revised CR10233 issued on November 8. In the article, a paragraph was added to the Background section regarding changes to HCPCS codes A4595 and A4557. Also, the CR release date, transmittal number and the Web address for CR10233 are revised. All other information remains the same.

Provider Types AffectedThis MLN Matters® Article is intended for providers and suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services paid under the DMEPOS fee schedule.

Provider Action NeededChange Request (CR) 10233 provides the January 2018 quarterly update for the Medicare DMEPOS fee schedule. The instructions include information, when necessary, to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes. The Centers for Medicare & Medicaid Services (CMS) issued CR 10233 to provide the DMEPOS Competitive Bidding Program (CBP) January 2018 quarterly update. CR 10233 provides specific instructions to your DME MAC for implementing updates to the DMEPOS CBP Healthcare Common Procedure Coding System (HCPCS), ZIP code, and Single Payment Amount files. Note that quarterly updates are available on the DMEPOS CBP at https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Quarterly%20Updates.

BackgroundThe DMEPOS CBP was mandated by Congress through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The statute requires that Medicare replace the current fee schedule payment methodology for selected DMEPOS items with a competitive bid process. The intent is to improve the effectiveness of the Medicare methodology for setting DMEPOS payment amounts, which will reduce beneficiary out-of-pocket expenses and save the Medicare program money while ensuring beneficiary access to quality items and

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10233.pdf


https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Quarterly%20Updates

https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Quarterly%20Updates


services. Under the program, Medicare conducts a competition among suppliers who operate in a particular Competitive Bidding Area. Suppliers must submit a bid for selected products. Note that not all products or items are subject to competitive bidding. Bids are submitted electronically through a web-based application process and required documents are mailed. Bids are evaluated based on the eligibility, its financial stability and the bid price. Contracts are awarded to the Medicare suppliers who offer the best price and meet applicable quality and financial standards. Contract suppliers must agree to accept assignment on all claims for bid items and will be paid the bid price amount. The amount is derived from the median of all winning bids for an item.

The November 8, 2017 revision to CR10233 informs that effective January 1, 2018, the Round 2 Recompete and Round 2017 Single Payment Amount file has been updated to replace HCPCS codes A4595 and A4557 with HCPCS codes A4595KG and A4557KG. This change allows Medicare to accurately process and pay HCPCS code A4595 (Electrical stimulator supplies, 2 lead, per month) and A4557 (Lead wires, (e.g., apnea monitor)) according to competitive bidding payment rules when used in conjunction with a competitive bidding base unit, such as a Transcutaneous Electrical Nerve Stimulation (TENS). When furnishing items described by these codes to a beneficiary residing in a competitive bid area, suppliers should bill without the KG modifier when A4595 and A4557 are used with a NeuroMuscular Electrical Stimulation (NMES) device and with the KG modifier when used with a TENS device.

Additional InformationThe official instruction, CR10233, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3909CP.pdf.

The DMEPOS CBP site at https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Home includes information on all rounds of the CBP, including product categories, single payment amounts, and the ZIP codes of areas included in the CBP.

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-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.

Document History

DATE OF CHANGE DESCRIPTIONNovember 9, 2017 This article was revised to reflect a revised CR10233 issued on November 8. In the article,

a paragraph was added to the Background section regarding changes to HCPCS codes A4595 and A4557. Also, the CR release date, transmittal number, and the Web address for CR10233 are revised. All other information remains the same.

September 15, 2017 Initial Article Released

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3909CP.pdf


https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Home

https://www.dmecompetitivebid.com/palmetto/cbicrd2recompete.nsf/DocsCat/Home

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/



Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2016 American Medical Association. All rights reserved.

Copyright © 2017, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected]

The American Hospital Association (the “AHA”) has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Clarification of the Billing of Immunosuppressive Drugs


MLN Matters® Number: MM10235Related CR Release Date: September 1, 2017 Related CR Transmittal Number: R3856CP

Related Change Request (CR) Number: 10235Effective Date: October 2, 2017Implementation Date: October 2, 2017

Provider Types AffectedThis MLN Matters Article is intended for suppliers billing Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services provided to Medicare beneficiaries.

Provider Action NeededChange Request (CR) 10235 updates language in the “Medicare Claims Processing Manual,”

Chapter 17 (Drugs and Biologicals), Section 80.3 (Billing for Immunosuppressive Drugs), to remove a double negative statement and provide clear guidance to suppliers for when you may bill Medicare for immunosuppressive drugs. It provides no change in policy.

BackgroundThis section provides details to the updated manual section, which is a part of CR10235.

Following a beneficiary’s organ transplant, Medicare covers their immunosuppressive drugs in accordance with 1861(s)(2)(J) of the Social Security Act (the Act); which states that Medicare covers “prescription drugs used in immunosuppressive therapy furnished to an individual who receives an organ transplant for which payment is made under this title.”

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In the billing for immunosuppressive drugs, there are circumstances in which Medicare cannot locate, in Medicare’s claims database, the claim that would have confirmed that Medicare paid for the transplant. The claim may not appear in the database for reasons such as:

y At the time of the transplant, the beneficiary was enrolled in a Medicare Advantage plan that paid for the transplant. (Medicare Advantage data is not included in the Medicare Fee-For-Service (FFS) claims database). Although some encounter data may be available, it may be incomplete or may not contain coding information sufficient to identify a transplant claim.

y There may be instances in which claims related to a transplant are old and may not be identifiable in the claims database despite Medicare’s payment for the claim.

In these circumstances, your submission of the KX modifier (Specific Required Documentation on File) in the claim permits Medicare to make a reasonable assumption that: 1) You have documentation on file that indicates the date of the transplant, 2) The services furnished are medically necessary, and 3) Medicare paid for the transplant in accordance with the statute.

The use of the KX modifier is not required, but you should be aware that your DME MACs will accept claims for immunosuppressive drugs, received on and after July, 2008, without a KX modifier; but will deny the claim if the Centers for Medicare & Medicaid Services (CMS) cannot identify a record of a claim indicating that the transplant was paid for by Medicare FFS.

Further, if you furnish an immunosuppressive drug to a Medicare beneficiary, prescribed because the beneficiary had undergone an organ transplant; and, on and after July 1, 2008, submit a claim for this service that contains the KX modifier, you must:

1. Secure from the prescriber the date of such organ transplant and retain documentation of such transplant date in your files.

2. Attest that you have documentation on file that the beneficiary was eligible to receive Medicare Part A benefits at the particular date of the transplant and retain the documentation in your files.

3. Retain such documentation of the beneficiary’s transplant date, Medicare Part A eligibility, and that such transplant date precedes the Date of Service (DOS) for furnishing the drug.

Additional InformationThe official instruction, CR10235, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3856CP.pdf.


Document History

DATE OF CHANGE DESCRIPTIONSeptember 1, 2017 Initial article released.

Disclaimer The article above was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2015 American Medical Association. All rights reserved.






Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program

Link to current version on the CMS website: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf

MLN Matters® Number: SE1128 RevisedRelease Date of Revised Article: November 3, 2017Related CR Transmittal #: N/A

Related Change Request (CR) #: N/AEffective Date: N/AImplementation Date: N/A

Note: The article was revised to show the HETS QMB release will be in November 2017. Previously, the article was revised on October 18, 2017, to indicate that the Provider Remittance Advice and the Medicare Summary Notice for beneficiaries identifies the QMB status of beneficiaries and exemption from cost-sharing for Part A and B claims processed on or after October 2, 2017, and to recommend how providers can use these and other upcoming system changes to promote compliance with QMB billing requirements. All other information remains the same.

Provider Types AffectedThis article pertains to all Medicare physicians, providers and suppliers, including those serving beneficiaries enrolled in Original Medicare or a Medicare Advantage (MA) plan.

Provider Action NeededThis Special Edition MLN Matters® Article from the Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers and suppliers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing. Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or B deductibles, coinsurance, or copays for any Medicare-covered items and services.

Look for new information and messages in CMS’ HIPAA Eligibility Transaction System (HETS) (effective November 2017) and the Provider Remittance Advice (RA) (effective October 2, 2017), to identify patients’ QMB status and exemption from cost-sharing prior to billing. If you are an MA provider, contact the MA plan for more information about verifying the QMB status of plan members.

Implement key measures to ensure compliance with QMB billing requirements. Ensure that billing procedures and third-party vendors exempt individuals enrolled in the QMB program from Medicare charges. If you have erroneously billed an individual enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges he or she paid. For information about obtaining payment for Medicare cost-sharing, contact the Medicaid agency in the States in which you practice. Refer to the Background and Additional Information Sections below for further details and important steps to promote compliance.

BackgroundAll Original Medicare and MA providers and suppliers–not only those that accept Medicaid–must refrain from charging individuals enrolled in the QMB program for Medicare cost-sharing. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions. Providers and suppliers may bill State Medicaid programs for these costs, but States can limit Medicare cost-sharing payments under certain circumstances.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf



Billing of QMBs Is Prohibited by Federal LawFederal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances (see Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]). The QMB program is a State Medicaid benefit that assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance, and copays. In 2015, 7.2 million individuals (more than one out of 10 beneficiaries) were enrolled in the QMB program. See the chart at the end of this article for more information about the QMB benefit.

Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions (see Sections 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Act.)

Note that certain types of providers may seek reimbursement for unpaid Medicare deductible and coinsurance amounts as a Medicare bad debt discussed in Chapter 3 of the Provider Reimbursement Manual (Pub.15-1).

Refer to the Important Reminders Concerning QMB Billing Requirements Section below for key policy clarifications.

Inappropriate Billing of QMB Individuals PersistsDespite Federal law, improper billing of individuals enrolled in the QMB program persists. Many beneficiaries are unaware of the billing restrictions (or concerned about undermining provider relationships) and simply pay the cost-sharing amounts. Others may experience undue distress when unpaid bills are referred to collection agencies. For more information, refer to Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), Centers for Medicare & Medicaid Services July 2015.

Ways to Promote Compliance with QMB Billing RulesTake the following steps to ensure compliance with QMB billing prohibitions:

1. Establish processes to routinely identify the QMB status of your Medicare patients prior to billing for items and services.

y Beginning in November 2017, providers and suppliers can use Medicare eligibility data provided to Medicare providers, suppliers, and their authorized billing agents (including clearinghouses and third party vendors) by CMS’ HETS to verify a patient’s QMB status and exemption from cost-sharing charges. For more information on HETS, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/index.html.

y Original Medicare providers and suppliers can readily identify the QMB status of patients and billing prohibitions on the Medicare Provider RA, which will contain new notifications and information about a patient’s QMB status for Part A and B claims processed on or after October 2, 2017. Refer to Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System for more information about these improvements.

y MA providers and suppliers should also contact the MA plan to learn the best way to identify the QMB status of plan members.

2. Providers and suppliers may also verify patient’s QMB status through State online Medicaid eligibility systems or by asking patients for other proof such as their Medicaid

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929.html

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/Access_to_Care_Issues_Among_Qualified_Medicare_Beneficiaries.pdf



https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/index.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9911.pdf



identification card or a copy of their Medicare Summary Notice, the quarterly summary of claims sent to Original Medicare beneficiaries that reflects, among other things, the patients’ QMB status for Part A and B claims processed on or after October 2, 2017. Ensure that billing procedures and third-party vendors exempt individuals enrolled in the QMB program from Medicare charges and that you remedy billing problems should they occur. If you have erroneously billed individuals enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.

3. Determine the billing processes that apply to seeking payment for Medicare cost-sharing from the States in which you operate. Different processes may apply to Original Medicare and MA services provided to individuals enrolled in the QMB program. For Original Medicare claims, nearly all States have electronic crossover processes through the Medicare Benefits Coordination & Recovery Center (BCRC) to automatically receive Medicare-adjudicated claims.

y If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare RA.

y Understand the processes you need to follow to request payment for Medicare cost-sharing amounts if they are owed by your State. You may need to complete a State Provider Registration Process and be entered into the State payment system to bill the State.

Important Reminders Concerning QMB Billing RequirementsBe aware of the following policy clarifications on QMB billing requirements:

1. All Original Medicare and MA providers and suppliers–not only those that accept Medicaid–must abide by the billing prohibitions.

2. Individuals enrolled in the QMB program retain their protection from billing when they cross State lines to receive care. Providers and suppliers cannot charge individuals enrolled in QMB even if their QMB benefit is provided by a different State than the State in which care is rendered.

3. Note that individuals enrolled in QMB cannot choose to “waive” their QMB status and pay Medicare cost-sharing. The Federal statute referenced above supersedes Section 3490.14 of the State Medicaid Manual, which is no longer in effect.

QMB Eligibility and Benefits

Program Income Criteria*

Resources Criteria*

Medicare Part A and Part B Enrollment

Other Criteria Benefits

QMB Only

≤100% of Federal Poverty Line (FPL)

≤3 times SSI resource limit, adjusted annually in accordance with increases in Consumer Price Index

Part A*** Not Applicable • Medicaid pays for Part A (if any) and Part B premiums, and may pay for deductibles, coinsurance, and copayments for Medicare services furnished by Medicare providers to the extent consistent with the Medicaid State Plan (even if payment is not available under the State plan for these charges, QMBs are not liable for them)


QMB Eligibility and Benefits

Program Income Criteria*

Resources Criteria*

Medicare Part A and Part B Enrollment

Other Criteria Benefits

QMB Plus

≤100% of FPL

Determined by State

Part A*** Meets financial and other criteria for full Medicaid benefits

• Full Medicaid coverage

• Medicaid pays for Part A (if any) and Part B premiums, and may pay for deductibles, coinsurance, and copayments to the extent consistent with the Medicaid State Plan (even if payment is not available under the State plan for these charges, QMBs are not liable for them)

* States can effectively raise these Federal income and resources criteria under Section 1902(r)(2) of the Act.

*** To qualify as a QMB or a QMB plus, individuals must be enrolled in Part A (or if uninsured for Part A, have filed for premium-Part A on a “conditional basis”). For more information on this process, refer to Section HI 00801.140 of the Social Security Administration Program Operations Manual System.

Additional InformationFor more information about dual eligibles under Medicare and Medicaid, please visit https://www.medicaid.gov/affordable-care-act/dual-eligibles/index.html and https://www.medicaid.gov/medicaid/eligibility/medicaid-enrollees/index.html and refer to Dual Eligible Beneficiaries Under Medicare and Medicaid. For general Medicaid information, please visit http://www.medicaid.gov/index.html.

Document History

DATE OF CHANGE DESCRIPTIONNovember 3, 2017 Article revised to show the HETS QMB release will be in November 2017. All other

information remains the same.October 18, 2017 The article was revised to indicate that the Provider Remittance Advice and the Medicare

Summary Notice for beneficiaries identifies the QMB status of beneficiaries and exemption from cost-sharing for Part A and B claims processed on or after October 2, 2017, and to recommend how providers can use these and other upcoming system changes to promote compliance with QMB billing requirements. All other information remains the same.

August 23, 2017 The article was revised to highlight upcoming system changes that identify the QMB status of beneficiaries and exemption from Medicare cost-sharing, recommend key ways to promote compliance with QMB billing rules, and remind certain types of providers that they may seek reimbursement for unpaid deductible and coinsurance amounts as a Medicare bad debt.

May 12, 2017 This article was revised on May 12, 2017, to modify language pertaining to billing beneficiaries enrolled in the QMB program. All other information is the same.

January 12, 2017 This article was revised to add a reference to MLN Matters article MM9817, which instructs Medicare Administrative Contractors to issue a compliance letter instructing named providers to refund any erroneous charges and recall any existing billing to QMBs for Medicare cost sharing.

https://www.ssa.gov/OP_Home/ssact/title19/1902.htm

https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801140

https://www.medicaid.gov/affordable-care-act/dual-eligibles/index.html

https://www.medicaid.gov/affordable-care-act/dual-eligibles/index.html

https://www.medicaid.gov/medicaid/eligibility/medicaid-enrollees/index.html

https://www.medicaid.gov/medicaid/eligibility/medicaid-enrollees/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf

http://www.medicaid.gov/index.html

http://www.medicaid.gov/index.html



DATE OF CHANGE DESCRIPTIONFebruary 4, 2016 The article was revised on February 4, 2016, to include updated information for 2016

and a correction to the second sentence in paragraph 2 under Important Clarifications Concerning QMB Balance Billing Law on page 3.

February 1, 2016 The article was revised to include updated information for 2016 and a clarifying note regarding eligibility criteria in the table on page 4.

March 28, 2014 The article was revised on to change the name of the Coordination of Benefits Contractor (COBC) to BCRC.



Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2016 American Medical Association. All rights reserved.

Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations


MLN Matters® Number: SE17018Article Release Date: September 19, 2017 Related CR Transmittal Number: N/A

Related Change Request (CR) Number: N/AEffective Date: N/AImplementation Date: N/A

Provider Types AffectedThis MLN Matters® Article is intended for all providers, physicians, and other suppliers who bill in a situation where liability insurance (including self-insurance) is a consideration. The article is of particular importance for those who elect not to file the claim with Medicare, and instead seek payment for their services from a Medicare beneficiary’s liability insurance (including self-insurance) claim.





Provider Action NeededThis article is based on information received from Medicare beneficiaries, their legal counsel and other entities that assist these individuals, indicating that providers, physicians, and other suppliers that elect to seek payment from the beneficiary’s liability insurance claim instead of submitting the claim for items or services to Medicare have not generally billed in accordance with the instructions provided or referenced in this article. The FAQs in this article are intended to remind providers, physicians, and other suppliers of the fundamental guidance governing billing where liability insurance (including self-insurance) is involved. Please review your billing practices to be sure they are in line with the information below.

BackgroundLiability insurance (including self-insurance), no-fault insurance, and workers’ compensation benefits are primary payers to Medicare. However, CMS’ regulations and policy for liability insurance billing are distinct from those for no-fault insurance and workers’ compensation benefits. Because the liability insurance billing rules are different and place distinct obligations on providers, physicians, and other suppliers (including termination of liens tied to the expiration of Medicare’s timely filing requirements), it is important that these rules be reviewed in detail.

The options when seeking payment from the liability insurance, and the obligations and restrictions that accompany them, are discussed with more specificity in the “Internet Only Medicare Secondary Payer Manual” (Pub 100-05), Chapter 2, Section 40.2 found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c02.pdf. See also, MLN Matters Article MM7355 “Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault, and Workers’ Compensation (WC) Medicare Secondary Payer (MSP) Claims”. This article is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7355.pdf. (Although not the subject of this article, the instructions for situations involving no-fault insurance or workers’ compensation benefits can be found in Chapter 3 of the MSP Manual.)

FAQs for Liability Insurance (Including Self-Insurance) BillingQ1. What are the “promptly period” rules and do they apply when billing in situations involving liability insurance (including self-insurance)?

A1. The “promptly period” is 120 days after the earlier of: 1) the date the claim is filed with an insurer or a lien is filed against a potential liability settlement; or 2) the date the service was furnished or, in the case of inpatient hospital services, the date of discharge. The “promptly period” does apply even when a provider, physician, or other supplier is aware that liability insurance may end up indirectly funding the defendant’s settlement. However, following expiration of the 120 days or during that time if it is demonstrated (for example, a bill/claim that had been submitted but not paid) that liability insurance will not pay during the promptly period, the provider, physician, or other supplier has an option (with certain limitations) to bill Medicare or maintain a claim/lien against the liability insurance/beneficiary’s liability insurance settlement.

Q2. Who do I bill…Medicare or the liability insurance/beneficiary’s liability insurance settlement? (I hear so many different things. My patient was in an accident and I need to know whether to bill Medicare or the patient. My other patient is suing some manufacturer, what do I do about my bill for services to this patient?)

A2. Once the “promptly period” has expired, with the exception of the special rule for Oregon (see below), the provider, physician, or other supplier may bill either Medicare or the liability insurer/beneficiary’s liability insurance settlement as long as the Medicare timely filing period has not expired. Billing both Medicare and maintaining a claim against the liability insurance/beneficiary’s liability insurance settlement is not permitted. Once Medicare has been billed, the provider, physician, or other supplier is limited to Medicare’s approved amount or the limiting charge if the claim is non-assigned, even if they subsequently return any payment made by

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c02.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c02.pdf





Medicare. Claims/liens against the liability insurance/beneficiary’s liability settlement must be dropped once Medicare’s timely filing period has expired. See also the Q’s/A’s below for more detail.

Q3. What is the Oregon rule?

A3. By court order, there are very specific alternative billing rules for Oregon. Generally speaking, the provider, physician, or other supplier may bill either Medicare or the liability insurance if the liability insurer pays within 120 days. See the MSP Manual (CMS Pub. 100-05), Chapter 2, Section 40.2 for specifics on the Oregon rule.

Q4. Do Medicare’s timely filing rules still apply if the timely filing period expires while the provider, physician, or other supplier is waiting for the liability insurance payment/beneficiary’s liability insurance settlement? (It’s been 3 years and the patient’s case still hasn’t settled. Can I bill Medicare now?)

A4. The existence of a liability insurance or potential liability insurance situation does not change or extend Medicare’s timely filing requirements. If Medicare is not billed within the applicable timely filing period, the claim will be denied. Additionally, see the information below regarding the requirement that claims/liens against the liability insurance/beneficiary’s liability insurance settlement (with certain exceptions) be withdrawn once the timely filing period has expired.

Q5. How long can a claim/lien be maintained against the liability insurer/the beneficiary’s liability insurance settlement? (Can I direct bill/maintain my lien once Medicare’s timely filing period has expired?)

A5. CMS’ liability insurance billing policy is that providers are required to drop their claims/liens and terminate all billing efforts to collect from a liability insurer or a beneficiary once the Medicare timely filing period expires, unless the liability insurance claim was paid or settled prior to the expiration of the Medicare timely filing period.

y All such claims/liens must be withdrawn (except for claims related to items or services not covered by Medicare and for Medicare deductibles and co-insurance) when the provider, physician, or other supplier bills Medicare or when Medicare’s timely filing period has expired – whichever occurs first.

y If there is a settlement, judgment, award, or other payment before the timely filing period expires, the provider, physician, or supplier may maintain its claim/lien despite the expiration of the timely filing period.

y All such claims/liens are limited by state lien laws/requirements. The MSP provisions do not create lien rights when those rights do not exist under state law.

y Under the Oregon rule all such claims/liens must be withdrawn following the expiration of the applicable 120 day period.

Q6. How much can the provider, physician or other supplier bill the liability insurance/beneficiary’s liability insurance settlement? (What if the beneficiary’s case settled, but the amount was not large enough to pay everyone? What if Medicare and the attorney were paid, but because very little remained the attorney asked all the doctors and other providers to take reduced amounts; do we have to?; what about our bill?)

A6. Where Medicare has a recovery claim, Medicare’s claim has the priority right of recovery. In general, the provider, physician, or other supplier:

y Is limited to the Medicare approved amount (limiting charge when non-assigned) once they have billed Medicare, even if they return any payment received from Medicare.

y May charge actual charges but is limited to the amount available from the settlement less applicable procurement costs (for example, attorney fees, other litigation costs).


y May only bill for non-covered services, or co-insurance and deductibles, if Medicare timely filing has expired before payment or settlement. (In this context, non-covered services are the program exclusions such as measuring of eye refractions or services rendered to family members. Medical necessity denials are not included and are not billable in the example.)

y May not collect from the beneficiary until the proceeds are available to the beneficiary.

Q7. What about physician and other suppliers who do not participate in Medicare and do not submit an assigned claim (and would not be required to submit an assigned claim if they submitted a claim to Medicare) – what can they pursue?

A7. Such physicians and other suppliers can pursue liability insurance, but the amount may not exceed the limiting charge.

Q8. Are there risks involved in deciding whether to pursue the liability insurance vs. billing Medicare once the promptly period has expired?

A8. Providers, physicians, and other suppliers who do not file a Medicare claim once the “promptly period” has expired (and before timely filing has expired) run the risk that insurance proceeds will not be available or may be less than Medicare’s payment would have been if Medicare had been billed. They also run the risk that they will be limited to billing for co-insurance and deductibles if there is no payment or settlement before Medicare’s timely filing expires.

Q9. Are there additional rules if a patient receives both Medicare and Medicaid or other benefits?

A9. If the individual receives assistance from the state, additional regulations govern provider billing. If a Medicare beneficiary received Medicaid benefits at the time the services were rendered, providers should contact their state Medicaid office to obtain the state’s policy on provider billing.

Q10. What if the items or services in question are not covered by Medicare?

A10. If the items or services rendered are services that are not covered by the Medicare program, providers, physicians, and other suppliers may charge and collect actual charges without regard to whether the proceeds of the liability insurance are available to the beneficiary. (In this context, non-covered services are the program exclusions such as measuring of eye refractions or services rendered to family members. Medical necessity denials are not included and are not billable in the example.)

Additional InformationIf 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-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.

Document History

DATE OF CHANGE DESCRIPTIONSeptember 19, 2017 Initial Article Released





Pharmacy Billing of Immunosuppressive Drugs


MLN Matters® Number: SE17032Article Release Date: October 17, 2017 Related CR Transmittal Number: N/A


Provider Types AffectedThis MLN Matters Special Edition (SE) Article is intended for pharmacies billing Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for immunosuppressive drugs provided to Medicare beneficiaries who received an organ transplant that was paid for by Medicare.

Provider Action NeededChange Request (CR) 10235 highlighted updated language in the Medicare Claims Processing Manual, Chapter 17, Section 80.3. (Billing for Immunosuppressive Drugs) regarding the use of the KX modifier for certain claims for immunosuppressive drugs. See the related MLN Matters article (MM10235) at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10235.pdf. CR10235 also provided guidance to the MACs to abide by the updated language on processing claims for immunosuppressive drugs.

This article reminds pharmacy billing staff of the appropriate process for billing Medicare for immunosuppressive drugs using the KX modifier. This is especially important for pharmacies as the Health and Human Services Office of the Inspector General (OIG) recently determined that pharmacies did not comply with parts of this policy on a significant percentage of related claims. Be sure your staff is aware of the proper policy as summarized in the Background Section of this article.

BackgroundMedicare covers a beneficiary’s immunosuppressive drugs following a transplant in accordance with 1861(s)(2)(J) of the Social Security Act (the Act), which states that Medicare covers “prescription drugs used in immunosuppressive therapy furnished to an individual who receives an organ transplant for which payment is made under this title.”

The OIG reviewed a sample of 2014 claims and their objective was to determine whether Part B should have paid for immunosuppressive drugs billed with a KX modifier for beneficiaries for whom Medicare did not have a transplant record.

Medicare Part B (Part B) covers immunosuppressive drugs for beneficiaries who receive an organ transplant for which Medicare payment was made. When Medicare Fee-For-Service (FFS) pays for a transplant, a record of the transplant claim should be maintained in Medicare’s claim history. However, to accommodate certain circumstances in which Medicare cannot locate an FFS claim for a transplant in the beneficiary’s Medicare FFS claims database that would confirm that Medicare paid for the transplant, a pharmacy can submit an immunosuppressive drug claim with a KX modifier.

In the billing for immunosuppressive drugs, there are circumstances in which Medicare cannot locate, in Medicare’s claims database, the claim that would have confirmed that Medicare paid for the transplant. The claim may not appear in the database for reasons such as:

1. At the time of the transplant, the beneficiary was enrolled in a Medicare Advantage plan that paid for the transplant. (Medicare Advantage data is not included in the Medicare






FFS claims database). Although some encounter data may be available, it may be incomplete or may not contain coding information sufficient to identify a transplant claim.

2. There may be instances in which claims related to a transplant are old and may not be identifiable in the claims database despite Medicare’s payment for the claim.

In these circumstances, your submission of the KX modifier (Specific Required Documentation on File) in the claim permits Medicare to make a reasonable assumption that:

y You have documentation on file that indicates the date of the transplant

y The services furnished are medically necessary, and

y Medicare paid for the transplant in accordance with the statute.

The use of the KX modifier is not required, but you should be aware that your DME MACs will accept claims for immunosuppressive drugs, received on and after July, 2008, without a KX modifier; but will deny the claim if the Centers for Medicare & Medicaid Services (CMS) cannot identify a record of a claim indicating that the transplant was paid for by Medicare FFS.

Further, if you furnish an immunosuppressive drug to a Medicare beneficiary, prescribed because the beneficiary had undergone an organ transplant; and, on and after July 1, 2008, submit a claim for this service that contains the KX modifier, you must:

y Secure from the prescriber the date of such organ transplant and retain documentation of such transplant date in your files.

y Attest that you have documentation on file that the beneficiary was eligible to receive Medicare Part A benefits at the particular date of the transplant and retain the documentation in your files.

y Retain such documentation of the beneficiary’s transplant date, Medicare Part A eligibility, and that such transplant date precedes the Date of Service (DOS) for furnishing the drug.

Additional InformationIf 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-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/

To review MM 10235 visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10235.pdf.

A report on the OIG review referenced above is available at https://oig.hhs.gov/oas/reports/region6/61500018.pdf.

Document History

DATE OF CHANGE DESCRIPTIONOctober 17, 2017 Initial article released.





https://oig.hhs.gov/oas/reports/region6/61500018.pdf

https://oig.hhs.gov/oas/reports/region6/61500018.pdf





MEDICAL POLICY

Correct Coding – HCPCS Coding of Surgical Dressings - Components to Report on the PDAC HCPCS Code Verification Application



HCPCS coding of surgical dressing products requires reporting the amount (percent by weight) of each product’s constituent components. However, every individual component is not required to be included in the composition analysis reported in the PDAC Code Verification Application. To assist manufacturers in submitting the most accurate information, this article will review the relevant coding guidelines.

The Surgical Dressings LCD related Policy Article Coding Guidelines section says, in relevant part:

Products containing multiple materials (excluding basic construction elements such as backing material, adhesive used in borders, binders, preservatives, etc. (not all-inclusive)) are classified as either composite dressings or as multi-component dressings. Impregnated gauze dressing are not included in this classification.

Composite dressings (A6203-A6205) are products combining physically distinct components into a single dressing that provides multiple functions. These functions must include all of the following:

y A physical (not chemical) bacterial barrier that is present over the entire dressing pad and extends out into the adhesive border,





y An absorptive layer other than an alginate or other fiber gelling dressing, foam, hydrocolloid, or hydrogel, and

y Either a semi-adherent or a non-adherent property over the wound site.

Surgical dressings with a backing that provides a physical bacterial barrier but does not have an adhesive border do not meet the definition of a composite dressing because there is no assurance that it will prevent bacterial access to a wound. These types of dressings are to be coded as specialty absorptive dressings (A6251-A6253).

Multi-component dressings that are not classified as composite dressings are categorized according to the clinically predominant component. The clinically predominant component is defined based on the proportion of material(s) in the dressing. For example, a dressing that is 60 percent hydrocolloid and 40 percent alginates would be categorized as a hydrocolloid dressing. HCPCS Coding is determined based on the following:

y Products where a single material comprises greater than 50% (by weight) of a product’s composition are coded based upon the applicable specific HCPCS code for that material. If a specific HCPCS code does not exist for the predominant component, HCPCS code A4649 is used.

y Products where no single material comprises greater than 50% (by weight) of the composition are coded as A4649.

Composite and multi-component products may not be unbundled and billed as the separate components of the dressing.

[Emphasis added]

Correct coding for dressings that contain multiple materials such as composite and multi-component dressings (not all-inclusive) is based upon the composition and combination of the clinically relevant materials. Basic construction elements such as backing material, adhesives used in borders (including full-surface adhesives), binders, preservatives, etc. are not necessary for the coding analysis. These basic construction materials do not need to be included in the compositional analysis reported as part of the PDAC HCPCS Code Verification Application. Manufacturers should only report those materials that contribute to the clinical function of the product. Inclusion of these basic construction materials as part of the composition analysis may result in a delay in coding and/or an incorrect HCPCS code assignment.

Manufacturers should note that these basic construction elements may need to be discussed elsewhere in the coding application. Some dressing types have requirements for adhesive borders, bacterial barriers, etc. Demonstrating compliance with these criteria often requires the inclusion of basic construction components.

Refer to the Surgical Dressings LCD (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ContrID=140), related Policy Article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54563&ContrID=140), and Standard Documentation Article (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55426&ContrID=140) for additional information regarding coverage coding and documentation for these items.

Suppliers are reminded to access the PDACs Durable Medical Equipment Coding System (DMECS) https://www.dmepdac.com/dmecs/index.html for any questions regarding the correct coding of products or call the PDAC Contact Center at 877-735-1326 between the hours of 8:30 a.m. and 4:00 p.m. CT.

Publication HistoryOriginal Publication Date: September 7, 2017

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ContrID=140


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54563&ContrID=140




https://www.dmepdac.com/dmecs/index.html


Local Coverage Determination (LCD) Revision Summary for September 7, 2017


Outlined below are the principal changes to the DME MAC Knee Orthoses Local Coverage Determination (LCD) that has been revised and posted. Please review the entire LCD and related PA for complete information.

Knee Orthoses

LCDhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33318&ContrID=140

Revision Effective Date: 10/16/2017COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:• Updated: References to ICD 10 code lists to reflect accurate title of the listICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Added: ICD 10 codes S76.111 (A,D,S), S76.112 (A,D,S), S76.121 (A,D,S) and S76.122 (A,D,S) to

Group 2 and Group 4 codes POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Updated: language under to add “justify”DATE (09/07/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Note: The information contained in this article is only a summary of revisions to the LCDs and Policy Articles. For complete information on any topic, you must review the LCDs and/or Policy Articles.

Policy Article (PA) Revision Summary for October 12, 2017


Outlined below are the principal changes to the DME MAC Oral Anticancer Drugs Policy Article (PA) that has been revised and posted. Please review the entire LCD and related PA for complete information.

Oral Anticancer Drugs

PAhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52479

Revision Effective Date: 10/01/2017:Covered ICD-10 Codes• Deleted: Non-valid ICD-10 code C96.2 from group 1, 3, 4, 5 and 7










LCD Revision Summary for October 19, 2017


Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) for Wheelchair Seating that has been revised and posted. Please review the entire LCD and related PA for complete information.

Wheelchair Seating

LCDhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33312

Revision Effective Date: 10/01/2017ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Added: New ICD-10 codes G12.23, G12.24, G12.25 to Group 2 and Group 4 10/01/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.


LCD and Policy Article Revisions Summary for October 26, 2017


Outlined below are the principal changes to the DME MAC Mechanical In-exsufflation Devices and Nebulizers Local Coverage Determinations (LCD) and Policy (PA) that have been revised and posted. Please review the entire LCDs and related PAs for complete information.

Mechanical In-exsufflation Devices


Revision Effective Date: 10/01/2017ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Added: New ICD-10 codesPOLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Clarified: Verbiage in Policy Specific Documentation Requirements








10/26/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Nebulizers


Revision Effective Date: 10/01/2017COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:• Update: References to ICD-10 Codes that Support Medical NecessityICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Added: New ICD-10 codes to Groups 11, 12, 13• Deleted: Non-valid ICD-10 codes from Group 11, 12, 13• Revised: ICD-10 code descriptions in Groups 2, 3, 7, 12, 13POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Update: Language to add “justify”, for Medicare reimbursement 10/26/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

PA https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52466

Revision Effective Date: 01/01/2017NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:• Added: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PERSUANT TO 42 CFR 410.38(g),

previously in the Policy Specific Documentation Requirements section

Note: The information contained in this article is only a summary of revisions to the LCDs and PAs. For complete information on any topic, you must review the LCDs and/or PAs.

Policy Article Revisions Summary for November 16, 2017


Outlined below are the principal changes to the DME MAC Standard Documentation Requirements for All Claims Submitted to the DME MACs Policy Article (PA) that has been revised and posted. Please review the entire PA for complete information.

Standard Documentation Requirements for All Claims Submitted to the DME MACs


Revision Effective Date: 11/20/2017DETAILED WRITTEN ORDERS:• Revised: Description of all items orderedGENERAL:






• Added: Seven (7) year documentation retention direction PROOF OF DELIVERY:• Revised: POD shipping date definition for Method 2PROOF OF DELIVERY REQUIREMENTS FOR RECENTLY ELIGIBLE MEDICARE FFS:• Revised: Supplier record information to an “and” from an “or”REPLACEMENT:• Revised: updated word “entire” to “entirely” 11/16/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and PAs. For complete information on any topic, you must review the LCDs and/or PAs.

T WO VANTAGE WAY | NASHVILLE, TN 37228 -150 4 | CGSMEDICARE.COM

© 2018, CGS Administrators, LLC CGS Administrators, LLC is a Medicare Part A, B, Home Health and Hospice, and DME Medicare Administrative Contractor for the Centers for Medicare & Medicaid Services.

We IMPACT Lives.NOVEMBER 2017 ORIGINALLY PUBLISHED JULY 2013

RE: GLUCOSE MONITORS

Dear Physician:

Home blood glucose monitor (BGM) supplies have consistently been one of the highest sources of errors in medical reviews performed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Comprehensive Error Rate Testing (CERT) contractor. We know that ordering physicians do work to document the medical necessity for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). The following information is intended to provide you with guidance on Medicare’s coverage and documentation requirements for BGMs and testing supplies.

COVERAGE

Glucose monitors and related supplies are covered for patients with diabetes if they or their caregiver can be trained to use the prescribed device appropriately.

The Glucose Monitors Local Coverage Determinations (LCDs) of the DME MACs define the quantity of test strips and lancets that are covered, if the basic criterion above is met.

Treatment regimenBasic coverage

Test strips and lancets

Insulin treated 300 per 3 months

Non-insulin treated 100 per 3 months

Additional quantities of test strips can be considered for coverage if they are documented to be medically necessary – see following section. Coverage is also provided for a lancing device, calibration solution, and replacement batteries.

MEDICAL NECESSITY DOCUMENTATION

CMS expects that physician records will reflect the care provided to the patient including evidence of the medical necessity for the prescribed frequency of testing. Physicians are not required to fill out additional forms from suppliers or to provide additional information to suppliers unless specifically requested of the supplier by the DME MAC.

As noted below in the Orders section, standard BGMs (HCPCS code E0607) require a written order prior to delivery and a face-to-face examination. The face-to-face examination must document that the patient was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. Both the written order and the face-to-face examination must be provided to the supplier before they can dispense the glucose monitor to the patient.

There are several critical issues to address in the patient’s medical record related to medical necessity for glucose testing supplies:

• Basic coverage criteria for the BGM and any related supplies; and,

• If ordering quantities of test strips and lancets that exceed the quantities specified in the LCD:

▪ Justification for testing frequency; and

▪ Evidence of the patient’s use at this frequency

To satisfy the requirements for the basic coverage criteria, the patient’s medical record should provide information about the following:

• Diagnosis

• Treatment regimen (insulin treated versus non-insulin treated)

To support coverage for quantities of supplies that exceed the limits specified in the LCD, there must be:

• Documentation by the physician in the patient’s medical record of the necessity for the higher frequency of testing. This may include some of the following elements:

▪ Names, dosages, and timing of administration of medications used to treat the diabetes;

▪ Frequency and severity of symptoms related to hyperglycemia and/or hypoglycemia;

▪ Review of patient-maintained log of glucose testing values;

▪ Changes in the patient’s treatment regimen as a result of glucose testing results review;

▪ Dosage adjustments that the patient should make on their own based on self-testing results;

▪ Laboratory tests indicating level of glycemic control (e.g., hemoglobin A1C);

▪ Other therapeutic interventions and results.

Not every patient’s medical record will contain all of these elements; however, there must be enough information in the patient’s medical record to support the medical necessity for the quantity of item(s) ordered and dispensed.

• Documentation by the patient of the actual frequency of testing.

▪ Logs of self-testing values including the date, time, and results

▪ Information about medication dosage adjustments related to the results is also helpful

ORDERS

For initial dispensing of a standard BGM (code E0607), the supplier must receive a written order prior to delivery of the item to the patient. In addition, you must conduct a face-to-face examination within six (6) months prior to the date of the written order. Both of these documents must be received by the supplier prior to dispensing the item to your patient. This detailed written order must contain, at a minimum, the following elements:

1. Patient’s name

2. Item of DME ordered - this may be general – e.g., “hospital bed”– or may be more specific.

3. The prescribing practitioner’s National Provider Identifier (NPI)

4. The signature of the ordering practitioner

5. Date of the Order

Note that testing supplies (e.g., lancets, test strips, control solutions, batteries) are not subject to the written order prior to delivery and face-to-face requirements. For testing supplies, the written order must contain the following elements:

1. Patient’s name

2. Prescribing physician’s name

3. Item(s) to be dispensed

4. Frequency of testing (“as needed” is not acceptable)

5. Quantity to be dispensed

6. Number of refills


8. Signature date

9. Date of the order and the start date

A new order for diabetic testing supplies is required only if there is a change in the frequency of testing, when replacing a BGM, or there is a change in supplier.

If the supplier provides you with a prepared “written order” for your signature and date, you should inspect this document carefully. Suppliers must not add unrelated items to the detailed written order, whether requested by the patient or not, in the absence of your explicit approval.

Medicare now covers certain continuous glucose monitors (CGM) and related supplies. The coverage, coding and documentation requirements are included in the Glucose Monitors LCD, related Policy Article and Standard Documentation Requirements article linked below. There is a separate “Dear Physician” letter specifically for therapeutic CGM devices [insert link].

This article is only intended to be a general summary. It is not intended to take the place of the written law, regulations, national or local coverage determinations. The LCD for Glucose Monitors can be found in the Medicare Coverage Database on the CMS web site at https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33822&ContrID=140

Sincerely,

Wilfred Mamuya, MD, PhD Medical Director, DME MAC, Jurisdiction A Noridian Healthcare Solutions

Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C CGS Administrators, LLC


Peter J. Gurk, MD, CPE, CHCQM Medical Director, DME MAC, Jurisdiction D Noridian Healthcare Solutions



T WO VANTAGE WAY | NASHVILLE, TN 37228 -150 4 | CGSMEDICARE.COM

© 2018, CGS Administrators, LLC CGS Administrators, LLC is a Medicare Part A, B, Home Health and Hospice, and DME Medicare Administrative Contractor for the Centers for Medicare & Medicaid Services.

We IMPACT Lives.NOVEMBER 2017 RE: CONTINUOUS GLUCOSE MONITORS

Dear Physician,

As of January 12, 2017, Medicare covers continuous glucose monitor (CGM) devices that are classified by CMS as “therapeutic CGMs.” Note that not all products marketed as CGM devices are considered therapeutic CGMs by Medicare. A therapeutic CGM is one that meets the definition of durable medical equipment (DME) and is labeled by the Food & Drug Administration (FDA) for non-adjunctive use (i.e., it can be used to make treatment decisions without the need for a stand-alone home blood glucose monitor to confirm testing results).

COVERAGE

Therapeutic CGMs and related supplies are covered by Medicare when all of the following coverage criteria (1-6) are met:

1. The beneficiary has diabetes mellitus; and,

2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and,

3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump; and,

4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,

5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and,

6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

When a therapeutic CGM is covered, the related supply allowance for sensors, transmitters, batteries, and calibration supplies are also covered.

Therapeutic CGM devices replace a standard home blood glucose monitor (BGM) and related supplies. Once billing starts for a CGM and the associated supply allowance, Medicare will no longer pay separately for a standard BGM and related supplies.

MEDICAL NECESSITY DOCUMENTATION

For the in-person treating practitioner visit that is required as part of the initial provision of a therapeutic CGM, there must be sufficient information in the beneficiary’s medical record to determine that the beneficiary has diabetes mellitus (criterion 1), requires frequent testing (criterion 2), frequent dosing of their insulin (criterion 3) and frequent adjustment of their diabetes treatment regimen (criterion 4).

For the in-person treating practitioner visit that is required as part of the ongoing provision of a therapeutic CGM, there must be sufficient information in the beneficiary’s medical record to determine that the beneficiary continues to adhere to their diabetes treatment regimen and use of the CGM device on a daily basis.

ORDERS

Continuous glucose monitors and the related supply allowance require a detailed written order. The written order must include, at a minimum, the following elements:

1. Patient’s name

2. Prescribing physician’s name

3. Item(s) to be dispensed

4. Frequency of testing (“as needed” is not acceptable)

5. Quantity to be dispensed

6. Number of refills


8. Signature date

9. Date of the order and the start date

A new order for continuous glucose monitors is required only if replacing a therapeutic CGM device or there is a change in supplier.

If the supplier provides you with a prepared “written order” for your signature and date, you should inspect this document carefully. Suppliers must not add unrelated items to the detailed written order, whether requested by the patient or not, in the absence of your explicit approval.

MISCELLANEOUS

The supply allowance for supplies used with a therapeutic CGM system encompasses all items necessary for the use of the device and includes, but is not limited to: CGM sensor, CGM transmitter, home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries.

There is no Medicare benefit for supplies used with equipment that is not classified as DME. Coverage of CGM system supplies is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data. If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supplies shall be denied as non-covered by Medicare.

This article is only intended to be a general summary. It is not intended to take the place of the written law, regulations, national or local coverage determinations. Coverage, coding and documentation requirements for CGM devices may be found in the LCD for Glucose Monitors in the Medicare Coverage Database on the CMS web site at https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33822&ContrID=140

Sincerely,

Wilfred Mamuya, MD, PhD Medical Director, DME MAC, Jurisdiction A Noridian Healthcare Solutions

Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C CGS Administrators, LLC


Peter J. Gurk, MD, CPE, CHCQM Medical Director, DME MAC, Jurisdiction D Noridian Healthcare Solutions




APPEALS

Notification of the 2018 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review

Please be aware that there is a change to the amounts that must remain in controversy for Administrative Law Judge (ALJ) hearing requests and Federal District Court review requests filed on or after January 1, 2018. The new amounts are reflected in the chart below.

Appeal Level Time Limit for Filing Monetary ThresholdRedetermination 120 days from the date of issuance of the initial

determination or overpayment demand letter None

Reconsideration 180 days from the date of receipt of the Medicare Redetermination Notice

None

Administrative Law Judge (ALJ)

60 days from the date of receipt of the Reconsideration notice

For requests filed on or after January 1, 2017, at least $160 remains in controversy.

Departmental Appeals Board (DAB) Review

60 days from the date of receipt of the ALJ decision/dismissal

None

Federal Court (Judicial) Review

60 days from the date of the DAB decision or declination of review by the DAB

For requests filed on or before December 31, 2017, at least $1,560 remains in controversy.

For requests filed on or after January 1, 2018, at least $1,600 remains in controversy.

http://go.cms.gov/MLNGenInfo


MISCELLANEOUS

Revision to Publication 100.06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment


MLN Matters® Number: MM9815 RevisedRelated CR Release Date: September 14, 2017 Related CR Transmittal #: R293FM

Related Change Request (CR) #: CR 9815Effective Date: April 2, 2018Implementation Date: April 2, 2018

Revised: This article was revised on September 15, 2017, to reflect an updated Change Request that corrected format errors in the manual instructions. In the article, the CR release date, transmittal number, and link to the transmittal changed. All other information remains the same.

Provider Types AffectedThis 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 NeededChange Request (CR) 9815 updates the Centers for Medicare & Medicaid Services (CMS) “Medicare Financial Management Manual,” Chapter 3, Sections 200-200.2.1, Limitation on Recoupment Overpayments. CR9815 is the first of four CRs that are forthcoming and incorporated into this manual. Make sure your billing staffs are aware of these updates that relate to the limitation on recovery of certain overpayments.

BackgroundSection 1893(f)(2)(a) of the Social Security Act and the provision in the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) prohibits recouping Medicare overpayments from a provider or supplier that seeks a reconsideration from a Qualified Independent Contractor (QIC). This provision changed how interest is to be paid to a provider or supplier whose overpayment is reversed at subsequent administrative or judicial levels of appeal. The final rule defines the overpayments to which the limitation applies, how the limitation works in concert with the appeals process, and the change in our obligation to pay interest to a provider or supplier whose appeal is successful at levels above the QIC. This section also limits recoupment of Medicare overpayments when a provider or supplier seeks a redetermination until a redetermination decision is rendered.

The MAC will cease recoupment or not begin recoupment when the MAC receives a valid redetermination or reconsideration request timely on an overpayment subject to these limitations The provider has until the appeal deadline to file an appeal (refer to the “Medicare Claims Processing Manual,” Chapter 29 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf). If a provider wants to delay recoupment, it must submit the redetermination appeal request within 30 days of the demand letter date. To continue the delayed recoupment, the provider will have 60 days from the redetermination decision to submit a reconsideration request. If the request is received before the appeal deadline but after recoupment has started, the MAC will stop the recoupment. The MAC shall not refund any



https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf



monies collected back to the provider, unless otherwise directed by the Centers for Medicare & Medicaid Services (CMS). The MAC will be accountable to ensure the debts continue to age and accrue interest until the debt is paid in full.

After the first two levels of appeal are completed, the MAC shall resume recoupment and normal debt collection processes. Whether or not the provider subsequently appeals the overpayment to the Administrative Law Judge (ALJ), or subsequent levels (Department Appeals Board (DAB), or Federal court), the MAC shall initiate recoupment at 100% until the debt is satisfied in full, unless an Extended Repayment Schedule (ERS) is established. If the debt was referred to Treasury and the provider files for an appeal, the MAC shall recall the debt from Treasury while in an appeal status. If the appeal decision is unfavorable to the provider, any outstanding debt will be referred back to Treasury, unless an approved Extended Repayment Schedule (ERS) is established or the provider pays the debt in full.

Additional InformationThe official instruction, CR9815, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R293FM.pdf.

Chapter 29 of the “Medicare Claims Processing Manual” is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf.


Document History

DATE OF CHANGE DESCRIPTIONSeptember 15, 2017 The article was revised to reflect an updated CR that corrected format errors in the

manual instructions. In the article, the CR release date, transmittal number, and link to the transmittal changed.

September 1, 2017 Initial article issued

Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2016 American Medical Association. All rights reserved.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R293FM.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R293FM.pdf






New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs)


MLN Matters® Number: MM9893 RescindedRelated CR Release Date: N/A Related CR Transmittal #: N/A

Related Change Request (CR) #: CR 9893Effective Date: October 1, 2017Implementation Date: October 2, 2017

This article was rescinded.


Guidance on Implementing System Edits for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)


MLN Matters® Number: MM9904 RevisedRelated CR Release Date: September 28, 2017 Related CR Transmittal #: R1925OTN

Related Change Request (CR) #: CR 9904Effective Date: July 1, 2017Implementation Date: October 2, 2017

Note: This article was revised on September 28, 2017, to reflect an updated CR9904. In the article, the CR Release Date, transmittal number, and the Web address of the CR were revised. All other information remains the same.

Provider Types AffectedThis MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME/MACs), for services provided to Medicare beneficiaries.

Provider Action NeededCR9904 updates CR7333 and CR9371 and informs MACs about changes related to Section 302 of the Medicare Modernization Act of 2003 (MMA). Section 302 added a new paragraph to the Social Security Act (the Act), Section 1834(a)(20) requiring the Secretary to establish and implement quality standards for suppliers of DMEPOS.

All DMEPOS suppliers that furnish such items or services required in the new paragraph, as the






Secretary determines appropriate, must comply with the quality standards in order to receive Medicare Part B payments and to retain a supplier billing number. The covered items and services are defined in the Act.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) added a new subparagraph for implementing quality standards which state the Secretary shall require suppliers furnishing items and services on or after October 1, 2009, directly or as a subcontractor for another entity, to have submitted evidence of accreditation by an accreditation organization designated by the Secretary. Make sure that your billing staffs are aware of these changes.

BackgroundPursuant to subparagraph 1834(a)(20)(D) of the Act, the covered items and services are defined in Section 1834(a)(13), Section 1834(h)(4), and Section 1842(s)(2) of the Act. The covered items include:

y DME

y Medical supplies

y Home dialysis supplies and equipment

y Therapeutic shoes

y Parenteral and enteral nutrient, equipment and supplies

y Transfusion medicine

y Devices, prosthetics, and orthotics

Section 154(b) of MIPPA added a new subparagraph (F) to Section 1834(a)(20) of the Act. In implementing quality standards under this paragraph, the Secretary shall require suppliers furnishing items and services on or after October 1, 2009, directly or as a subcontractor for another entity, to have submitted evidence of accreditation by an accreditation organization designated by the Secretary. This subparagraph states that eligible professionals and other persons (defined below) are exempt from meeting the September 30, 2009, accreditation deadline unless the Centers for Medicare & Medicaid Services (CMS) determines that the quality standards are specifically designed to apply to such professionals and persons. The eligible professionals who are exempt from meeting the September 30, 2009, accreditation deadline (as defined in Section 1848(k)(3)(B)) include the following practitioners:

y Physicians (as defined in Section 1861(r) of the Act)

y Physical Therapists

y Occupational Therapists

y Qualified Speech-Language Pathologists

y Physician Assistants

y Clinical Nurse Specialists

y Certified Registered Nurse Anesthetists

y Certified Nurse-Midwives

y Clinical Social Workers

y Clinical Psychologists

y Registered Dietitians

y Nutritional professionals

Section 154(b) of MIPPA allows the Secretary to specify “other persons” that are exempt from meeting the accreditation deadline unless CMS determines that the quality standards are specifically designed to apply to such other persons. At this time, “such other persons” are


specifically defined as the following practitioners:

y Orthotists

y Prosthetists

y Opticians

y Audiologists

All supplier types (except those listed above) who furnish items and services requiring accreditation, directly or as a subcontractor for another entity, must have submitted evidence of accreditation by an accreditation organization designated by the Secretary on or after October 1, 2009.

Medicare systems will have edits to check for accreditation on claims with HCPCS codes in the product categories designated by MIPPA as requiring accreditation. The edits will deny claims for these codes unless the DMEPOS supplier has been identified as accredited and verified on their CMS-855S or the DMEPOS supplier is currently exempt from meeting the accreditation requirements.

Denied ClaimsMACs will use Claim Adjustment Reason Code (CARC) B7 and Remittance Advice Remark Code (RARC) N211 and RARC N790 for denial:

y CARC B7 - This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

y RARC N211 - Alert: You may not appeal this decision.

y RARC N790 - Provider/supplier not accredited for product/service

y Group Code: CO - Contractual Obligation

Additional InformationThe official instruction, CR9904, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1925OTN.pdf.


Document History

DATE OF CHANGE DESCRIPTIONSeptember 28, 2017 This article was revised to reflect an updated CR. In the article, the CR Release Date,

transmittal number, and the Web address of the CR were revised. All other information remains the same.

August 18, 2017 This article was revised to reflect an updated CR. The CR changed the July analysis implementation date and revised the codes used for denied claims. The CR Release Date, transmittal number and link to the CR also changed.

February 17, 2017 Initial article released


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1925OTN.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1925OTN.pdf




IVIG Demonstration: Payment Update for 2018


MLN Matters® Number: MM10343Related CR Release Date: November 3, 2017 Related CR Transmittal #: R185DEMO

Related Change Request (CR) Number: CR 10343Effective Date: October 1, 2017Implementation Date: January 2, 2018

Note: This article was revised on September 24, 2015, to change the link to the list of providers authorized to order a PMD on page 5. That link wa

Provider Type AffectedThis MLN Matters Article is intended for suppliers billing Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Intravenous Immune Globulin (IVIG) services provided to Medicare beneficiaries under the IVIG Demonstration.

Provider Action NeededChange Request (CR) 10343 specifies the payment rate for 2018 and allows for continued payments from October 1, 2017 - December 31, 2017, at the current 2017 payment rate. The original demonstration end date was September 30, 2017. The IVIG demonstration was extended by law through December 31, 2020.

y The payment rate for Q2052: “Services, Supplies and Accessories Used in the Home under the Medicare IVIG Demonstration” for October 1, 2017 - December 31, 2017 shall be $354.60. This same rate was paid for services rendered January 1, 2017 - September 31, 2017.

y The payment rate for services rendered January 1, 2018 - December 31, 2018, shall be $358.50.

Be sure your billing staff is aware of these changes.

BackgroundThe “Medicare Intravenous Immune Globulin (IVIG) Access and Strengthening Medicare and Repaying Taxpayers Act of 2012” authorizes a 3-year demonstration under Part B of Title XVIII of the Social Security Act to evaluate the benefits of providing payment for items and services needed for the in-home administration of IVIG for the treatment of Primary Immunodeficiency Disease (PIDD).

In accordance with the original legislation, the demonstration was scheduled to end on September 30, 2017 and CR 9746 specified that claims for services after that date should not be paid. However, on September 28, 2017, Congress passed the Disaster Tax Relief and Airport and Airway Extension Act of 2017. Title III, section 302 of this legislation extended the IVIG demonstration through December 31, 2020. CR 10343 authorizes the continued payment of claims for the remainder of 2017 at the current payment rate and specifies a new payment rate for services rendered in 2018.

Additional InformationThe official instruction, CR10343, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R185DEMO.pdf.



https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R185DEMO.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R185DEMO.pdf



Document History

DATE OF CHANGE DESCRIPTIONNovember 3, 2017 Initial article released




Accepting Payment from Patients with a Medicare Set-Aside Arrangement


MLN Matters® Number: SE17019 ReissuedArticle Release Date: November 8, 2017Related CR Transmittal #: N/A


Note: This article was reissued on November 8, 2017, to clarify information. The title of the article was also changed to better reflect the information.

Provider Type AffectedThis MLN Matters® Article is intended for providers, physicians, and other suppliers who are told by patients that they must pay the bill themselves because they have a Medicare Set-Aside Arrangement (MSA).

What You Need to KnowThis article is based on information received from Medicare beneficiaries, their legal counsel,







and other entities that assist these individuals, indicating that physicians, providers, and other suppliers are often reluctant to accept payment directly from Medicare beneficiaries who state they have a MSA and must pay for their services themselves. This article explains what a MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA.

Please review your billing practices to be sure they are in line with the information provided.

BackgroundMedicare is always a secondary payer to liability insurance (including self-insurance), no-fault insurance, and workers’ compensation benefits. The law precludes Medicare payment for services to the extent that payment has been made, or can reasonably be expected to be made promptly. When future medical care is claimed, or a settlement, judgment, award, or other payment releases (or has the effect of releasing) claims for future medical care, it can reasonably be expected that the monies from the settlement, judgment, award, or other payment are available to pay for future medical items and services which are otherwise covered and reimbursable by Medicare.

Medicare should not be billed for future medical services until those funds are exhausted by payments to providers for services that would otherwise be covered and reimbursable by Medicare.

A MSA is a financial arrangement that allocates a portion of a settlement, judgment, award, or other payment to pay for future medical services. The law mandates protection of the Medicare trust funds but does not mandate a MSA as the vehicle used for that purpose. MSAs are the most frequently used formal method of preserving those funds for the Medicare beneficiary to pay for future items or services which are otherwise covered and reimbursable by Medicare and which are related to what was claimed or the settlement, judgment, award, or other payment had the effect of releasing. These funds must be exhausted before Medicare will pay for treatment related to the claimed injury, illness, or disease.

Medicare beneficiaries are advised that before receiving treatment for services to be paid by their MSA, they should advise their health care provider about the existence of the MSA. They are also notified that their health care providers should bill them directly, and that they should pay those charges out of the MSA if:

y The treatment or prescription is related to what was claimed or the settlement, judgment, award, or other payment had the effect of releasing AND

y The treatment or prescription is something Medicare would cover.

The obligation to protect the Medicare trust funds exists regardless of whether or not there is a formal CMS approved MSA amount. A Medicare beneficiary may or may not have documentation they can provide the physician, provider, or supplier from Medicare approving a Medicare Set-Aside amount.

Provider Action NeededWhere a patient who is a Medicare beneficiary states that he/she is required to use funds from the settlement, judgment, award, or other payment to pay for the items or services related to what was claimed or which the settlement, judgment, award, or other payment, it is appropriate for you to document your records with that information and accept payment directly from the patient for such services.

Additional InformationIf you have any questions, please contact your Medicare Administrative Contractor (MAC) at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.





Document History

DATE OF CHANGE DESCRIPTIONNovember 8, 2017 The article was reissued to clarify information in the initial release. The title of the article

was also changed to better reflect the information.October 3, 2017 Rescinded

September 19, 2017 Initial article issued




Hurricane Maria and Medicare Disaster Related United States Virgin Islands and Commonwealth of Puerto Rico Claims


MLN Matters® Number: SE17028 RevisedRelated CR Release Date: October 2, 2017 Related CR Transmittal Number: N/A


Note: The article was updated on October 2, 2017, to include the section on Applicability of Reporting Requirements for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Ambulatory Surgical Centers, and Renal Dialysis Facilities Affected by Hurricane Maria. All other information remains the same.

Provider Type AffectedThis MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries in the United States Virgin Islands and the Commonwealth of Puerto Rico who were affected by Hurricane Maria.



Provider Information AvailableOn September 18, 2017, pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of Hurricane Maria, an emergency exists in the United States Virgin Islands and the Commonwealth of Puerto Rico. Also on September 19, 2017, Secretary Price of the Department of Health & Human Services declared that a public health emergency exists in the United States Virgin Islands and the Commonwealth of Puerto Rico and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to September 16, 2017, for the United States Virgin Islands and retroactive to September 17, 2017, for the Commonwealth of Puerto Rico.

On September 19, 2017, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under Section 1812(f) of the Social Security Act for the United States Virgin Islands and the Commonwealth of Puerto Rico, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Hurricane Maria in 2017.

Under Section 1135 or 1812(f) of the Social Security Act, the CMS has issued several blanket waivers in the impacted geographical areas of the United States Virgin Islands and the Commonwealth of Puerto Rico. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency. Providers do not need to apply for an individual waiver if a blanket waiver has been issued. Providers can request an individual Section 1135 waiver, if there is no blanket waiver, by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.

The most current waiver information can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Hurricanes.html. See the Background section of this article for more details.

BackgroundSection 1135 and Section 1812(f) Waivers As a result of the aforementioned declaration, CMS has instructed the MACs as follows:

1. Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to items and services furnished to Medicare beneficiaries within the United States Virgin Islands from September 16, 2017, and the Commonwealth of Puerto Rico from September 17, 2017, for the duration of the emergency. In accordance with CR6451, use of the “DR” condition code and the “CR” modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presencea “formal waiver” including, but not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act. of

2. The most current information can be found at https://www.cms.gov/emergency. Medicare FFS Questions & Answers (Q&As) posted in the downloads section at the bottom of the Emergency Response and Recovery webpage and also referenced below are applicable for items and services furnished to Medicare beneficiaries within the United States Virgin Islands and the Commonwealth of Puerto Rico. These Q&As are displayed in two files:

y One file addresses policies and procedures that are applicable without any Section 1135 or other formal waiver. These policies are always applicable in any kind of emergency or disaster, including the current emergency in the United States Virgin Islands and the Commonwealth of Puerto Rico.

y Another file addresses policies and procedures that are applicable only with approved Section 1135 waivers or, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved Section 1135 blanket waivers and approved individual 1135 waivers requested by providers and are effective September 16, 2017, for the United States Virgin Islands and September 17, 2017, for the Commonwealth of

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf



https://www.cms.gov/About-CMS/Agency-Information/Emergency/Hurricanes.html


https://www.cms.gov/emergency


Puerto Rico.

In both cases, the links below will open the most current document. The date included in the document filename will change as new information is added, or existing information is revised.

a. Q&As applicable without any Section 1135 or other formal waiver are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf.

b. Q&As applicable only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver, are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf.

Blanket Waivers Issued by CMSUnder the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS has issued blanket waivers in the affected area of the United States Virgin Islands and Commonwealth of Puerto Rico. Individual facilities do not need to apply for the following approved blanket waivers:

Skilled Nursing Facilities y Section 1812(f): Waiver of the requirement for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Hurricane Maria in the United States Virgin Islands and the Commonwealth of Puerto Rico in 2017. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period. (Blanket waiver for all impacted facilities)

y 42 CFR 483.20: Waiver provides relief to Skilled Nursing Facilities on the timeframe requirements for Minimum Data Set assessments and transmission. (Blanket waiver for all impacted facilities)

Home Health Agencies y 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission. (Blanket waiver for all impacted agencies)

Critical Access HospitalsThis action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours. (Blanket waiver for all impacted hospitals)

Housing Acute Care Patients In Excluded Distinct Part UnitsCMS has determined it is appropriate to issue a blanket waiver to IPPS hospitals that, as a result of Hurricane Maria, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to Hurricane Maria. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the hurricane.)

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of Hurricane Maria, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf


https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf



bed because of capacity or other exigent circumstances related to the hurricane. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient Rehabilitation units that, as a result of Hurricane Maria, need to relocate inpatients from the excluded distinct part Rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the hurricane. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients and such patients continue to receive intensive rehabilitation services.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or DisasterAs a result of Hurricane Maria, CMS has determined it is appropriate to issue a blanket waiver to suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) where DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable. Under this waiver, the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required for replacement. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the hurricane.

For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Appeal Administrative Relief for Areas Affected by Hurricane MariaIf you were affected by Hurricane Maria and are unable to file an appeal within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination or will have an extended period of non-receipt of remittance advices that will impact your ability to file an appeal, please contact your Medicare Administrative Contractor.

Replacement Prescription FillsMedicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the emergency.

Applicability of Reporting Requirements for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Ambulatory Surgical Centers, and Renal Dialysis Facilities Affected by Hurricane Maria – This information added on October 2, 2017.

CMS is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, renal dialysis facilities, and ambulatory surgical centers located in areas affected by Hurricane Maria due to the devastating impact of the storm. These providers will be granted exceptions without having to submit an Extraordinary

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf




Circumstances Exceptions (ECE) request if they are located in one of the 78 Puerto Rico municipios or one of the three U.S. Virgin Islands county-equivalents, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster municipio or county-equivalent.

The scope and duration of the exception under each Medicare quality reporting program is described in the memorandum that CMS posted on September 25, 2017, however, all of the exceptions are being granted to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.

Requesting an 1135 Waiver Information for requesting an 1135 waiver, when a blanket waiver hasn’t been approved, can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.


The Centers for Disease Control and Prevention released ICD-10-CM coding advice to report healthcare encounters in the hurricane aftermath.

Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html.

Document History

DATE OF CHANGE DESCRIPTIONOctober 2, 2017 The article was updated to include the section on Applicability of Reporting Requirements

for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Ambulatory Surgical Centers, and Renal Dialysis Facilities Affected by Hurricane Maria. All other information remains the same.

September 21, 2017 Initial article released.




https://www.fema.gov/

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Memo-Requirements-Facilities-Maria.pdf





https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html



Updates to Medicare’s Cost Report Worksheet S-10 to Capture Uncompensated Care Data


MLN Matters® Number: SE17031Article Release Date: September 29, 2017 Related CR Transmittal Number: N/A


Provider Type AffectedThis MLN Matters® Special Edition article is intended for all 1886(d) hospitals, including 1886(d) Puerto Rico hospitals, eligible to receive uncompensated care payments.

What You Need to KnowThis article is intended to provide additional guidance to 1886(d) hospitals by summarizing revisions and clarifications to the instructions for the Worksheet S-10 of the Medicare cost report. The Worksheet S-10 data is used in the computation of Factor 3 in the calculation of the uncompensated care payment for 1886(d) hospitals under the Social Security Act (SSA) eligible to receive such payments. The revisions and clarifications to the Worksheet S-10 are provided to ensure appropriate reporting of uncompensated care costs and to achieve proper Medicare reimbursement. Examples are also provided in this article as additional guidance.

The Centers for Medicare & Medicaid Services (CMS) provided an extension to allow all Inpatient Prospective Payment Systems (IPPS) hospitals to submit an amended cost report with revised Worksheet S-10 data for Fiscal Year (FY) 14 and FY 15 by October 31, 2017. The resubmission of data is not required; providers may choose to resubmit if they have additional data for lines 20, 22, 25 and 26.

BackgroundSection 1886(r) of the Act, as added by Section 3133 of the Affordable Care Act, requires that, for FY 2014 and each subsequent fiscal year, subsection (d) hospitals that would otherwise have received a Disproportionate Share Hospital (DSH) payment made under Section 1886(d)(5)(F) of the Act will receive two separate payments, a DSH payment and a payment for the hospital’s proportion of uncompensated care.

In the 2018 Medicare IPPS final rule (82 Fed. Reg. 37990, August 14, 2017), CMS indicated that it would begin to incorporate data from Worksheet S-10 in the computation of Factor 3 for the calculation of hospitals’ share of uncompensated care payments for fiscal year 2018. As part of CMS’ continued desire to work with its stakeholders regarding the reporting of uncompensated care and to achieve greater clarity of the data needed to compute Factor 3, CMS has clarified the instructions and line item descriptions on the Worksheet S-10.

In Transmittal 10, CMS clarified that hospitals may include discounts given to uninsured patients who meet the hospital’s charity care criteria. In Transmittal 11, CMS further clarified that full or partial discounts given to uninsured patients who meet the hospital’s charity care policy or financial assistance policy/uninsured discount policy (hereinafter referred to as Financial Assistance Policy or FAP) may be included on line 20, column 1 of the Worksheet S-10. These clarifications apply to cost reporting periods beginning on or after October 1, 2013.

CMS also modified the application of the cost-to-charge-ratio (CCR). The CCR will not be applied to the deductible and coinsurance amounts for insured patients approved for charity care and non-reimbursed Medicare bad debt. The CCR will be applied to uninsured patients approved for charity care or an uninsured discount, non-Medicare bad debt, and charges for




non-covered days exceeding a length of stay limit imposed on patients covered by Medicaid or other indigent care programs.

Summary of Modifications to the Worksheet S-10 and ExamplesThe following were implemented for Worksheet S-10: 1) a revision to the instructions for Electronic Health Records (EHR) incentive payments to apply to subsection (d) Puerto Rico hospitals for cost reporting periods beginning on or after October 1, 2016; and effective for cost reporting periods beginning on or after October 1, 2013: 2) a clarification of the definition of charity care that includes the addition of uninsured discounts reported on line 20; 3) a clarification that Medicare and non-Medicare hospital bad debt reported on line 26 must be net of recoveries; 4) the addition of line 27.01, Medicare allowable bad debts for the hospital, that will be used to compute the non-Medicare bad debt separately from the non-reimbursed Medicare bad debt; 5) modifications to the calculation of costs for both insured charity care charges not subject to the CCR, and insured non-covered days beyond a length-of-stay limit subject to the CCR; and, 6) modifications to the calculation of non-Medicare bad debt subject to the CCR and non-reimbursed Medicare bad debt (deductible and coinsurance) not subject to the CCR. The modifications to the calculations will be applied to all cost reports, however providers will not be required to amend their cost report in order to benefit from these modifications.

Examples for the Worksheet S-10, Uncompensated and Indigent Care DataFor examples 1 through 3 only, assume the following facts: A hospital has a charity care policy which determines charity care on a “sliding scale” basis and may forgive anywhere from 25% to 100% of the patient’s liability. An insured patient owes the hospital $100.00 for a deductible on an allowable hospital service. The insured patient applies for charity care and the hospital determines that he qualifies for charity care at 25%. The cost reporting period is on or after October 1, 2016.

Example 1: Unpaid Insured Patient’s Liability

The hospital deems $25.00 of the patient’s $100.00 liability as charity care and records this $25.00 on line 20, column 2. The remaining $75.00 is a patient liability. The $75.00 remaining patient liability may subsequently be determined by the hospital to be classified as charity care or a hospital bad debt, but not both. (It is generally assumed that insured persons are not eligible for charity care, however an insured person can qualify for charity care for the portion of the charges that represents the patient liability pursuant to the hospital’s charity care policy).

Example 2: Partial Payment of Insured Patient’s Liability

The hospital deems $25.00 of the patient’s $100.00 liability as charity care and records this $25.00 on line 20, column 2. The patient pays $35.00 of the $75.00 patient liability. The hospital can determine the remaining $40.00 patient liability to qualify as charity care or a bad debt, but not both. If the $40.00 is determined to be charity care, it is recorded on line 20, column 2. If it is determined to be a bad debt, it is recorded on line 26 as a hospital bad debt.

Example 3: Partial Payment of Insured Patient’s Liability, a Medicare Beneficiary

The hospital deems $25.00 of the patient’s $100.00 liability as charity care and records this $25.00 on line 20, column 2. The hospital makes reasonable collection efforts to collect the remaining $75.00 patient liability. The patient pays $35.00 of the $75.00 patient liability. The hospital determines the unpaid $40.00 patient liability to be a Medicare bad debt. The $40.00 unpaid patient liability would be recorded on line 26 as a hospital bad debt and be reflected on line 27.01 as the Medicare allowable bad debt. The Medicare reimbursable bad debt, $26.00, would be reflected on line 27 (assuming a 65% bad debt limitation pursuant to 42 CFR 413.89(h)).

Example 4: Uninsured Patient, Sliding Scale Charity Care, Partial Payment of Patient Liability with Remaining Amount of Patient Liability Unpaid, Cost Reporting Periods


Beginning on or After October 1, 2016

A hospital has a charity care policy which determines charity care on a “sliding scale” basis and may forgive anywhere from 25% to 100% of the patient’s liability. An uninsured patient owes the hospital $1,000.00 for an allowable hospital service. The patient applies for charity care, and the hospital determines that the uninsured patient qualifies for charity care at 60%. The hospital records the $600.00 charity care amount on line 20, column 1. The remaining $400.00 is the patient’s liability. The uninsured patient pays $100.00 toward his liability. If the patient does not pay the remaining $300.00 and the hospital determines the unpaid patient liability to be a bad debt, the hospital would record the $300.00 on line 26 as a hospital bad debt. The $100.00 payment made by the patient does not get recorded anywhere on the Worksheet S-10 because it was not a payment toward the amount deemed charity care; it was a payment toward the non-charity care patient liability.

Example 5: Uninsured Patient, Sliding Scale Charity Care, Partial Payment of Patient Liability with Remaining Amount of Patient Liability Unpaid, Cost Reporting Periods Beginning Prior to October 1, 2016

A hospital has a charity care policy which determines charity care on a “sliding scale” basis and may forgive anywhere from 25% to 100% of the patient’s liability. An uninsured patient owes the hospital $1,000.00 for an allowable hospital service. The patient applies for charity care, and the hospital determines that the uninsured patient qualifies for charity care at 60%. The hospital records the entire $1,000.00 charge as charity care on line 20, column 1. The remaining $400.00 is the patient’s liability and must be recorded on line 22 as this is a patient liability for which the hospital expects to receive payment. The uninsured patient pays $100.00 toward his $400.00 liability. The $100.00 patient payment does not get recorded on Worksheet S-10 because the $400.00 full patient liability was already recorded as an expected payment on line 22. If the $300.00 balance remains unpaid and the hospital determines it to be a bad debt, it can be recorded as a hospital bad debt on line 26.

Example 6: Uninsured Patient, Sliding Scale Charity Care, Partial Payment of Patient Liability with Remaining Amount of Patient Liability Unpaid, Cost Reporting Periods Beginning Prior to October 1, 2016 with Patient Liability Payment Made in a Cost Reporting Period that Began on or After October 1, 2016

A hospital has a charity care policy which determines charity care on a “sliding scale” basis and may forgive anywhere from 25% to 100% of the patient’s liability. In a cost reporting period that began prior to October 1, 2016, an uninsured patient owes the hospital $1,000.00 for an allowable hospital service. The patient applies for charity care, and the hospital determines that the uninsured patient qualifies for charity care at 60%. The hospital records the entire $1,000.00 charge as charity care on line 20, column 1. The remaining $400.00 is the patient’s liability, however the provider did not record the payment/expected payment on line 22 as required. Several months later, in a cost reporting period that began on or after October 1, 2016, the uninsured patient made a payment of $100.00. This $100.00 payment must be recorded on line 22 as a reduction of an amount previously deemed charity care.

Example 7: Uninsured Patient Qualifies to Receive an Uninsured Patient Discount Pursuant to Hospital’s FAP, Cost Reporting Periods Beginning on or After October 1, 2016

An uninsured patient owes the hospital $100.00 for an allowable hospital service. The uninsured patient does not qualify for charity care. The hospital has a FAP which automatically gives a 30% discount to all uninsured patients who meet the hospital’s FAP. The uninsured patient meets the hospital’s FAP and the hospital writes off $30.00 as an uninsured discount on line 20, column 1. The remaining $70.00 is a patient liability. If the $70.00 patient liability remains uncollected and the hospital determines it to be a bad debt, it is recorded on line 26 as a hospital bad debt. (If the cost reporting period began prior to October 1, 2016 using the same


scenario above, the full charges of $100.00 would be written off on line 20, column 1. The hospital would record $70.00 on line 22 as an expected payment. If the $70.00 patient liability remains uncollected and the hospital determines it to be a bad debt, it is recorded on line 26 as a hospital bad debt).

Example 8: Calculating the Cost of Insured Patients Approved for Charity Care When Line 20, Column 2 Includes Charges for Patient Days Beyond the Length-Of-Stay Limit for Medicaid or Another Indigent Care Program

Charges for patient days beyond the length of the stay limit are recorded on line 20, column 2. At the end of the fiscal year when preparing its cost report, a hospital, whose CCR is 0.31, has accrued charges for patient days beyond the length-of-stay limit imposed on patients covered by Medicaid in the amount of $10,000 and is reported on line 20, column 2. The hospital also has $550,000 in charity care charges for deductible and co-insurance amounts on line 20, column 2. The net amount reported on line 20, column 2 is $560,000, ($550,000 + $10,000). The hospital answers “yes” to line 24 and reports $10,000 on line 25. When calculating the cost of insured patients approved for charity care on line 21, column 2, the hospital must multiply line 25, $10,000, by the CCR, 0.31 on line 1 and add it to the result of line 20, column 2, $560,000 minus line 25, $10,000.

($560,000 - $10,000) + ($10,000 x 0.31)$550,000 + $3,100

= $553,100 line 21, column 2

Additional InformationAdditional information regarding uncompensated care and the Worksheet S-10 can be found in the 2018 IPPS Final Rule at 82 Fed. Reg. 37990 (August 14, 2017). The following resources are available to find additional information regarding instructions to the Worksheet S-10 for uncompensated care, see “Provider Reimbursement Manual” Transmittal 11 containing updates to CMS Pub. 15-2, Chapter 40, Section 4012.


Document History


Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R11p240.pdf




Hurricane Nate and Medicare Disaster Related Alabama, Florida, Louisiana and Mississippi Claims


MLN Matters® Number: SE17034Related CR Release Date: October 11, 2017Related CR Transmittal Number: N/A


Provider Types AffectedThis MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries in the States of Alabama, Florida, Louisiana, and Mississippi, who were affected by Hurricane Nate.

Provider Information AvailablePursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of Hurricane Nate, an emergency exists in Alabama, Florida, Louisiana and Mississippi.

On October 8, 2017, Acting Secretary Wright of the Department of Health & Human Services declared that a public health emergency exists in the States of Louisiana retroactive to October 5, 2017; Mississippi, and Alabama retroactive to October 6, 2017; and Florida retroactive to October 7, 2017, and authorized waivers and modifications under §1135 of the Social Security Act.

On October 10, 2017, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under §1812(f) of the Social Security Act for the States of Louisiana retroactive to October 5, 2017; Mississippi, and Alabama retroactive to October 6, 2017; and Florida retroactive to October 7, 2017 for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Hurricane Nate in 2017. These waivers will prevent gaps in access to care for beneficiaries impacted by the emergency. Providers do not need to apply for an individual waiver if a blanket waiver has been issued. Providers can request an individual Section 1135 waiver, if there is no blanket waiver, by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.

The most current waiver information can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Hurricanes.html. See the Background section of this article for more details.

BackgroundSection 1135 and Section 1812(f) WaiversAs a result of the aforementioned declaration, CMS has instructed the MACs as follows:

Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to items and services furnished to Medicare beneficiaries within Alabama, Florida, Louisiana and Mississippi for the duration of the emergency. In accordance with CR6451, use of the “DR” condition code and the “CR” modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a “formal waiver” including, but








not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act.

The most current information can be found at https://www.cms.gov/emergency posted in the downloads section at the bottom of the Emergency Response and Recovery webpage.

Also referenced below are Q&As that are applicable for items and services furnished to Medicare beneficiaries within the Alabama, Florida, Louisiana and Mississippi. These Q&As are displayed in two files:

y One file addresses policies and procedures that are applicable without any Section 1135 or other formal waiver. These policies are always applicable in any kind of emergency or disaster, including the current emergency in Alabama, Florida, Louisiana and Mississippi

y Another file addresses policies and procedures that are applicable only with approved Section 1135 waivers or, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved Section 1135 blanket waivers and approved individual 1135 waivers requested by providers for Alabama, Florida, Louisiana and Mississippi.




Blanket Waivers for Alabama, Florida, Louisiana and MississippiUnder the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS has issued the following blanket waivers in the affected areas of Alabama, Florida, Louisiana and Mississippi. Individual facilities do not need to apply for the following approved blanket waivers.

Skilled Nursing Facilities y 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a skilled nursing facility stay provides temporary emergency coverage of Skilled Nursing Facility (SNF) services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of Hurricane Nate in Alabama, Florida, Louisiana and Mississippi in 2017. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

y 42 CFR 483.20: This waiver provides relief to Skilled Nursing Facilities on the timeframe requirements for Minimum Data Set assessments and transmission (Blanket waiver for all impacted facilities).

Home Health Agencies42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Blanket waiver for all impacted agencies).

Critical Access HospitalsThis action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours (Blanket waiver for all impacted hospitals).

Housing Acute Care Patients in Excluded Distinct Part UnitsCMS has determined it is appropriate to issue a blanket waiver to IPPS hospitals that, as a result of Hurricane Nate, need to house acute care inpatients in excluded distinct part units,

https://www.cms.gov/emergency






where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the hurricane. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the hurricane.)

Durable Medical Equipment y As a result of Hurricane Nate, CMS has determined it is appropriate to issue a blanket waiver to suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) where DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable. Under this waiver, the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required for replacement. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the hurricane.

y As a result of Hurricane Nate, CMS is temporarily extending the 10 business day deadline to provide notification of any subcontracting arrangements. During the temporary extension period, affected contract suppliers will have 30 business days to provide notice to the Competitive Bidding Implementation Contractor of any subcontracting arrangements. CMS will notify DMEPOS Competitive Bidding contract suppliers via e-mail when this temporary extension expires. All other competitive bidding program requirements remain in force. Note: CMS will provide notice of any changes to reporting timeframes for future events.

y For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Replacement Prescription FillsMedicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the emergency.

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of Hurricane Nate, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the hurricane. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient Rehabilitation units that, as a result of Hurricane Nate, need to relocate inpatients from the excluded distinct part Rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for such patients and annotate




the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the hurricane. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients and such patients continue to receive intensive rehabilitation services.

These temporary emergency policies would apply to the timeframes specified in the waiver(s) issued under Section 1135 of the Act in connection with the effect of Hurricane Nate in Alabama, Florida, Louisiana and Mississippi. More information is available in the 1135 Waiver Letter, which is posted in the Downloads section at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Hurricanes.html.

Requesting an 1135 WaiverInformation for requesting an 1135 waiver, when a blanket waiver hasn’t been approved, can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.


The Centers for Disease Control and Prevention released ICD-10-CM coding advice to report healthcare encounters in the hurricane aftermath.

Document History











https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdf



Medicare Fee-for-Service (FFS) Response to the 2017 California Wildfires


MLN Matters® Number: SE17035 RevisedRelated CR Release Date: November 1, 2017 Related CR Transmittal Number: N/A


Note: This article was revised on November 1, 2017, to add information regarding the exceptions granted for certain Medicare quality reporting and value-based purchasing programs. All other information is unchanged.

Provider Types AffectedThis MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries, who were affected by the 2017 wildfires in the State of California.

Provider Information AvailablePursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of the 2017 Wildfires, a major disaster exists in the State of California.

On October 15, 2017, Acting Secretary Hargan of the Department of Health & Human Services declared that a public health emergency exists in the State of California retroactive to October 8, 2017, and authorized waivers and modifications under §1135 of the Social Security Act.

On October 17, 2017, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under §1812(f) of the Social Security Act for the State of California retroactive to October 8, 2017 for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of wildfires. Providers can request an individual Section 1135 waiver by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.

BackgroundSection 1135 and Section 1812(f) WaiversAs a result of the aforementioned declaration, CMS has instructed MACs as follows:

Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to items and services furnished to Medicare beneficiaries within the State of California retroactive to October 8, 2017, for the duration of the emergency. In accordance with CR6451, use of the “DR” condition code and the “CR” modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a “formal waiver” including, but not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act.

The most current information can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.

Also referenced below are Q&As that are applicable for items and services furnished to Medicare beneficiaries within the State of California. These Q&As are displayed in two files:

y One file addresses policies and procedures that are applicable without any Section 1135





https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html



or other formal waiver. These policies are always applicable in any kind of emergency or disaster, including the current emergency.

y Another file addresses policies and procedures that are applicable only with approved Section 1135 waivers or, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved individual 1135 waivers requested by providers for California.




Waiver for CaliforniaUnder the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS has issued the following waiver in the affected areas of California. Individual facilities do not need to apply for the following approved waiver.

Skilled Nursing Facilities y 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a Skilled Nursing Facility stay provides temporary emergency coverage of Skilled Nursing Facility (SNF) services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of the wildfires. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

y In addition, the waiver provides temporary emergency coverage of SNF services that are not post-hospital SNF services under the authority in §1812(f) of the Social Security Act (the Act), for those people who are evacuated, transferred, or otherwise dislocated as a result of the effects in the State of California, in October 2017. In addition, this waiver provides authority under §1812(f) of the Act to provide coverage for extended care services which will not require a new spell of illness in order to renew provision of services by a SNF. These temporary emergency policies would apply to the timeframes specified in the waiver(s) issued under §1135 of the Act in connection with the effects of the wildfires in the State of California in October 2017. Accordingly, both the effective date and expiration date for these temporary emergency policies are the same as those specified pursuant to the §1135 waivers. Further, unlike the policies authorized directly under the §1135 waiver authority itself, the two policies described above would not be limited to beneficiaries who have been relocated within areas that have been designated as emergency areas. Instead, the policies would apply to all beneficiaries who were evacuated from an emergency area as a result of the effects of the wildfires in California in October 2017, regardless of where the “host” SNF providing post-disaster care is located.

Administrative ReliefAppeal Administrative Relief for Areas Affected by California Wildfires

If you were affected by the California wildfires and are unable to file an appeal within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination or will have an extended period of non-receipt of remittance advices that will impact your ability to file an appeal, please contact your Medicare Administrative Contractor.






Requesting an 1135 WaiverInformation for requesting an 1135 waiver can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.

More information is available in the 1135 Waiver Letter, which is posted in the Downloads section at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.

Medicare Quality Reporting and Value-based Purchasing Programs CMS is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, renal dialysis facilities, and ambulatory surgical centers located in areas affected by the devastating impacts of the Northern California wildfires since October 8, 2017, in and around counties in Northern California. For complete details of these exceptions, see the document posted at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Memo-Requirements-Facilities-CA-Wildfires.pdf.


Document History

DATE OF CHANGE DESCRIPTIONNovember 1, 2017 This article was revised to add information regarding the exceptions granted for certain

Medicare quality reporting and value-based purchasing programs.October 18, 2017 Initial article released.


Copyright © 2017, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials,please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected]






https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Memo-Requirements-Facilities-CA-Wildfires.pdf

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Memo-Requirements-Facilities-CA-Wildfires.pdf





FEES & PRICING

October Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule


MLN Matters® Number: MM10248 Related CR Release Date: September 8, 2017 Related CR Transmittal #: R3859CP

Related Change Request (CR) Number: CR 10248Effective Date: October 1, 2017Implementation Date: October 2, 2017

Provider Type AffectedThis MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services paid under the DMEPOS fee schedule.

Provider Action NeededChange Request (CR) 10248 provides instructions regarding the October quarterly update for the 2017 DMEPOS and parenteral and enteral nutrition (PEN) fee schedules and the October 2017 DMEPOS Rural ZIP code file containing the Quarter 4, 2017 Rural ZIP code changes. It includes information, when necessary, to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes.

BackgroundThe DMEPOS fee schedule is updated on a quarterly basis, when necessary, to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes, and the quarterly update process for the DMEPOS fee schedule is covered in the Medicare Claims Processing Manual, Chapter 23, Section 60 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf

Payment on a fee schedule basis is required for DMEPOS and surgical dressings by the Social Security Act, Section 1834(a), (h), and (i) at https://www.ssa.gov/OP_Home/ssact/title18/1834.htm. Also, payment on a fee schedule basis is a regulatory requirement at 42 CFR §414.102 for PEN, splints and casts, and intraocular lenses (IOLs) inserted in a physician’s office.

Additionally, the Social Security Act (Section 1834(a)(1)(F)(ii)) mandates adjustments to the fee schedule amounts for certain items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs (CBPs) for DME. The Social Security Act (Section 1842(s)(3)(B)) provides authority for making adjustments to the fee schedule amount for enteral nutrients, equipment and supplies (enteral nutrition) based on information from CBPs. Also, the adjusted fees apply a rural payment rule. The DMEPOS and PEN fee schedule files contain HCPCS codes that are subject to the adjustments as well as codes that are not subject to the fee schedule adjustments. Additional information on adjustments to the fee schedule amounts based on information from CBPs is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9642.pdf., Transmittal 3551, dated June 23, 2016.

The ZIP code associated with the address used for pricing a DMEPOS claim determines the



https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf



https://www.ecfr.gov/cgi-bin/text-idx?SID=666a01aa3d15b73356485c262fcc280a&mc=true&node=pt42.3.414&rgn=div5#se42.3.414_1102





rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. ZIP codes for non-continental Metropolitan Statistical Areas (MSA) are not included in the DMEPOS Rural ZIP code file. The DMEPOS Rural ZIP code file is updated on a quarterly basis as necessary.

Effective with the October update, code K0861 RR KF is removed from the fee schedule file.

The October 2017 DMEPOS Rural ZIP code file public use files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the data files at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched.


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-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/

Document History

DATE OF CHANGE DESCRIPTIONSeptember 12, 2017 Initial article released


January 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files


MLN Matters® Number: MM10320Related CR Release Date: October 6, 2017 Related CR Transmittal Number: R3878CP

Related Change Request (CR) Number: CR 10320Effective Date: January 1, 2018Implementation Date: January 2, 2018

Provider Type AffectedThis MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries.

What You Need to KnowChange Request (CR) 10320 instructs MACs to download and implement the January 2018

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched








and, if released, the revised October 2017, July 2017, April 2017, and January 2017, ASP drug pricing files for Medicare Part B drugs via the Centers for Medicare & Medicaid Services (CMS) Data Center (CDC). 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 January 2, 2018, with dates of service January 1, 2018, through March 31, 2018. Make sure your billing staffs are aware of these changes.

BackgroundThe Average Sales Price (ASP) methodology is based on quarterly data that manufacturers submit to the CMS. CMS supplies the MACs 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 Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are in Chapter 4, Section 50 of the “Internet Only Manual” (IOM) which is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf.

y File: January 2018 ASP and ASP NOC --Effective for Dates of Service: January 1, 2018, through March 31, 2018

y File: October 2017 ASP and ASP NOC --Effective for Dates of Service: October 1, 2017, through December 31, 2017

y File: July 2017 ASP and ASP NOC --Effective for Dates of Service: July 1, 2017, through September 30, 2017

y File: April 2017 ASP and ASP NOC --Effective for Dates of Service: April 1, 2017, through June 30, 2017

y File: January 2017 ASP and ASP NOC --Effective for Dates of Service: January 1, 2017, through March 31, 2017

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-and-Guidance/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, MACs will 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.



Document History












HCPCS UPDATES

The 2018 HCPCS Updates – New, Revised, and Discontinued HCPCS Codes


The 2018 Healthcare Common Procedure Coding System (HCPCS) File has been published. There are several additions, revisions, and discontinued HCPCS codes. The changes are effective January 1, 2018. Please keep in mind, the appearance of a HCPCS code is not an indication of coverage by the DME MAC.

The first listing contains the added HCPCS Codes that will take effect on January 01, 2018.

HCPCS DESCRIPTIONE0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware,

eachE0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each footJ0565 Injection, bezlotoxumab, 10 mgJ0606 Injection, etelcalcetide, 0.1 mgJ1428 Injection, eteplirsen, 10 mgJ1555 Injection, immune globulin (cuvitru), 100 mgJ1627 Injection, granisetron, extended-release, 0.1 mgJ1726 Injection, hydroxyprogesterone caproate, (makena), 10 mgJ1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mgJ2326 Injection, nusinersen, 0.1 mgJ2350 Injection, ocrelizumab, 1 mgJ3358 Ustekinumab, for intravenous injection, 1 mgJ9022 Injection, atezolizumab, 10 mgJ9023 Injection, avelumab, 10 mgJ9203 Injection, gemtuzumab ozogamicin, 0.1 mgJ9285 Injection, olaratumab, 10 mgL3761 Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelfL7700 Gasket or seal, for use with prosthetic socket insert, any type, each

The listing of HCPCS Codes with description/verbiage changes that will take effect January 01, 2018 is as follows:

HCPCS DESCRIPTION

L3760 Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise


The last listing contains discontinued HCPCS Codes along with the cross-walked HCPCS Code (if applicable). However, not all discontinued HCPCS Codes will have a cross-walked HCPCS Code. The list is as follows:

HCPCS DISCONTINUE DATE CROSSWALK HCPCS CODE

J9300 12/31/2017

Q9985 12/31/2017 J1729

Q9986 12/31/2017 J1726

Q9989 12/31/2017 J3358

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2017 Update


MLN Matters® Number: MM10234Related CR Release Date: August 25, 2017 Related CR Transmittal Number: R3850CP

Related Change Request (CR) Number: CR 10234Effective Date: July 24, 2017Implementation Date: October 2, 2017

Provider Types AffectedThis MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

What You Need to KnowThe Healthcare Common Procedure Coding System (HCPCS) code set is updated on a quarterly basis. The October 2017 HCPCS file includes a new HCPCS modifier. CR10234 informs MACs about the new modifier, ZC, Merck/Samsung Bioepis. The ZC modifier will become effective for claims submitted beginning October 1, 2017, and applies retroactively to dates of service on or after July 24, 2017.

MACs shall add the following modifier to the required modifiers that must be used when HCPCS code Q5102 is billed on a claim:

y HCPCS Modifier: ZC

y Short Description: Merck/Samsung Bioepis

y Long Description: Merck/Samsung Bioepis

A second biosimilar version of infliximab was marketed on July 24, 2017, creating a situation where products from two manufacturers may appear on claims. To allow the identification of the manufacturer of the specific biosimilar biological product that was administered to a patient, either existing HCPCS modifier ZB, or new modifier ZC is required when HCPCS code Q5102 is billed on a claim that is submitted after October 1, 2017.








Document History



2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update


MLN Matters® Number: MM10262Related CR Release Date: September 8, 2017 Related CR Transmittal Number: R3857CP

Related Change Request (CR) Number: 10262Effective Date: January 1, 2018Implementation Date: January 2, 2018

Provider Types Affected

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and Durable Medical Equipment (DME) MACs, for services provided to Medicare beneficiaries who are in a Part A covered Skilled Nursing Facility (SNF) stay.

Provider Action NeededChange Request (CR) 10262 makes changes to Healthcare Common Procedure Coding System (HCPCS) codes and Medicare Physician Fee Schedule designations that will be used to revise Common Working File (CWF) edits to allow A/B MACs to make appropriate payments in accordance with policy for SNF CB in Chapter 6, Section 110.4.1 and Chapter 6, Section 20.6 in the “Medicare Claims Processing Manual.”

BackgroundThe Common Working File (CWF) currently has edits in place for claims received for beneficiaries in a Part A covered SNF stay as well as for beneficiaries in a non-covered stay.

These edits allow only those services that are excluded from consolidated billing to be separately paid. Barring any delay in the Medicare Physician Fee Schedule, the new code files will be provided to CWF by November 1, 2017.




By the first week in December 2017, new code files will be posted at http://www.cms.gov/SNFConsolidatedBilling/. The files will be applicable to claims with dates of service on or after January 1, 2018, through December 31, 2018. It is important and necessary for the provider/contractor community to view the “General Explanation of the Major Categories” file located at the bottom of each year’s update in order to understand the Major Categories including additional exclusions not driven by HCPCS codes.

Additional Information The official instruction, CR10262, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3857CP.pdf.


Document History



eNEWS

Archived MLN Connects® May 24, 2015 through August 22, 2016November 9, 2017 MLN Connects for November 09, 2017

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-11-09-eNews.html

November 2, 2017 MLN Connects for November 02, 2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-11-02-eNews.html

November 2, 2017 CMS Finalizes 4 Rules Affecting CY18 Payment & Quality Programs https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-11-02-enews-SE.html

October 26, 2017 MLN Connects for October 26, 2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-10-26-eNews.html



http://www.cms.gov/SNFConsolidatedBilling/

http://www.cms.gov/SNFConsolidatedBilling/









https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-11-02-enews-SE.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-11-02-enews-SE.html









September 28, 2017 MLN Connects for September 28,2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-28-eNews.html

September 21, 2017 MLN Connects for September 21,2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-20-enews.html

September 21, 2017 Hurricane Maria: Medicare Disaster Related US Virgin Islands and Commonwealth of Puerto Rico Claims Article https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-21-eNews-SE.html

September 14, 2017 MLN Connects for September 14,2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-14-enews.html

September 11, 2017 Hurricane Irma and Medicare Disaster Related Claims MLN Matters Article https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-11-eNews-SE.html

September 11, 2017 Hurricane Irma and Medicare Disaster Related South Carolina and Georgia Claims MLN Matters Article — New https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-11-eNews-SE2.html

September 7, 2017 MLN Connects for September 07,2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-07-eNews.html

September 7, 2017 Emergency DMEPOS for Medicare Beneficiaries Impacted by Hurricane Harvey https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-07-eNews-SE.html

September 5, 2017 Hurricane Harvey: Additional Updates to Two MLN Matters Special Edition Articles on Medicare Disaster Related Claims https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-05-eNews-SE.html

September 1, 2017 Updated: Two MLN Matters Special Edition Articles on Hurricane Harvey and Medicare Disaster Related Claims https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-01-eNews-SE.html

August 31, 2017 MLN Connects for August 31,2017 https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-08-31-eNews.html

August 31, 2017 CMS Helping Texas and Louisiana with Hurricane Harvey Recovery https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-08-31-eNews-SE.html

For more Archived MLN Connects® visit: https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive.html





https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-20-enews.html


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-21-eNews-SE.html






https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-11-eNews-SE2.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-09-11-eNews-SE2.html














Contact for: Contact Information:EDI – Electronic Claim Submission; Electronic Remittance Notices

Jurisdiction B CEDI website: http://www.ngscedi.com E-mail: [email protected]

Jurisdiction B CEDI (toll-free): 1.866.311.9184 Mon - Fri, 8:00 a.m. - 6:00 p.m. CT

Paper Claim Submission Address: CGS - Jursidiction B PO Box 20013 Nashville, TN 37202

Provider Customer Service Calls IVR (Interactive Voice Response): 1.877.299.7900 Mon - Fri, 6:00 a.m. - 8:00 p.m. CT; Sat, 6:00 a.m. - 4:00 p.m. CT

Customer Service: 1.866.590.6727 Mon - Fri, 7:00 a.m. - 5:00 p.m. CT

Hearing Impaired: 1.888.897.7534 Mon - Fri, 7:00 a.m. - 5:00 p.m. CT

Beneficiary Customer Service Calls Phone: 1.800.Medicare

Written Inquiries Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Claim Reopenings (Adjustments) Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Fax (for underpayments): 1.615.660.5978 Fax (for overpayments): 1.615.782.4508

Telephone requests for Reopenings: 1.866.240.7490 Mon - Fri, 7:00 a.m. - 5:00 p.m. CT

Claim Status Inquiry Security Access Issues/Password Reset, E-mail: [email protected]

Enrollment Status: 1.866.270.4909

Appeals – Redetermination Requests

Address: CGS - Jurisdiction B PO Box 23070 Nashville, TN 37202

Fax: 1.615.660.5976

Electronic Funds Transfer Address: CGS Attn: EFT-DME PO Box 20013 Nashville, TN 37202

Refunds Address: CGS DME MAC Jurisdiction B PO Box 953479 St. Louis, MO 63195-3479

Overnight or Special Shipping Address: CGS DME MAC Jurisdiction B Two Vantage Way Nashville, TN 37228

DME MAC Jurisdiction B Website Website: https://www.cgsmedicare.com/jb/index.htmlAdvance Determination of Medicare Coverage (ADMC) - Requests

Address: CGS - Jurisdiction B Attn: ADMC PO Box 20007 Nashville, TN 37202

Fax: 1.615.660.5988

Prior Authorization Address: CGS Medical Review - Prior Authorization PO Box 23110 Nashville, TN 37202

Fax: 1.615.660.5992

Supplier Enrollment Address: National Supplier Clearinghouse Palmetto GBA * AG-495 PO Box 100142 Columbia, SC 29202-3142

Phone: 1.866.238.9652

https://www.cgsmedicare.com/jb/index.html

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