Medicare Bulletin KENTUCKY & OHIO PART a Jurisdiction 15

KENTUCKY & OHIO PART A

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Jurisdiction 15 Bulletin Medicare JULY 2016 JULY Medicare Bulletin KENTUCKY & OHIO PART A Jurisdiction 15

CONTENTS Fee Schedule MM9633: Quarterly Update to the Medicare Physician Administration Fee Schedule Database (MPFSDB) - July Calendar 2016 Provider Contact Center (PCC) Training 3 Year (CY) 2016 Update 28 Contact Information for CGS Medicare Part A 3 Hospital MLN Connects™ Provider eNews 4 MM9599: System Changes to Implement Section 231 of the Consolidated Appropriations Act, 2016, Temporary MM9550: Claim Status Category Exception for Certain Severe Wound Discharges From and Claim Status Codes Update 4 Certain Long-Term Care Hospitals (LTCHs) 30 MM9568: Shared Savings Program (SSP) Accountable MM9601: Phase 2 of Updating the Fiscal Intermediary Care Organization (ACO) Qualifying Stay Edits 5 Shared System (FISS) to Make Payment for Drugs and MM9578: Updates to Pub. 100-04, Chapters 1 Biologicals Services for Outpatient Prospective Payment and 16 to Correct Remittance Advice Messages 6 System (OPPS) Providers 33 MM9606: Update to Internet-Only-Manual MM9658: July 2016 Update of the Hospital Publication 100-04, Chapter 18, Section 30.6 8 Outpatient Prospective Payment System (OPPS) 35 myCGS Password Requirements 8 MM9661: July 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.2 41 Appeals SE1521 (Revised): Limiting the Scope of Review on Inpatient Psychiatric Facilities (IPF) Redeterminations and Reconsiderations of Certain Claims 9 MM9522: Clarification of Inpatient Psychiatric Facilities (IPF) Requirements for Certification, Recertification and Delayed/ Coverage Lapsed Certification and Recertification 43 MM9540: Coding Revisions to National Coverage Determinations 11 Preventative Services MM9188: System Specific Enhancements 2014: Move MM9620: Stem Cell Transplantation for Multiple PAP Smear Risk Indicator (PAPRI) and Technical (TECH)/ Myeloma, Myelofibrosis, and Sickle Cell Disease, Professional (PROF) Dates to Screening Auxiliary File 45 and Myelodysplastic Syndromes 12 MM9631: Coding Revisions to National Provider Enrollment Revalidation Coverage Determinations (NCDs) 16 Provider Enrollment Revalidations: Things You Should Know 45 MM9638: Percutaneous Left Atrial Appendage Closure (LAAC) 18 Rural Health Clinics SE1604: Medicare Coverage of Substance SE1611: Rural Health Clinics (RHCs) Healthcare Abuse Services 21 Common Procedure Coding System (HCPCS) Reporting Requirement and Billing Updates 47 Drugs and Biologicals MM9603: JW Modifier: Drug Amount Skilled Nursing Facility (SNF) Discarded/Not Administered to any Patient 26 Skilled Nursing Facility (SNF) Billing Reference 49 MM9636: Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2016 Update 27

Expanding Possibilities with myCGS! Are you missing out on a fast and secure system my that provides Medicare information with a click of a mouse? Visit the myCGS website at http://www. cgsmedicare.com/parta/myCGS/index.html to check out the many portal features and learn how to register if you are a new user. Save time and http://go.cms.gov/MLNGenInfo resources - take advantage of this Web-based resource today!

Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2016-07 JULY 2016 2 KENTUCKY & OHIO PART A 3

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and click the “myCGS” button http://www.cgsmedicare.com/ A Valuable Educational Resource! Educational Valuable A

: http://www.cgsmedicare.com/parta/ ® and subscribe to the ) is available for assistance available is obtaining ) in PCC Training/Closures PCC Office Closed a.m. Eastern9:00 Time a.m. – 11:00 1.866.289.6501 on the CGS website. In addition, CGS’ Internet portal, (MLN), offered the by Centersfor Medicare ® GR 2016-07 ) will be closed for CSR training and staff development.

1.866.590.6703 and choose Option additional For 1. contact information, please access http://www.cgsmedicare.com/parta/index.html http://www.cgsmedicare.com/parta/cs/2016_holiday_schedule.pdf at MedicareLearning Network MLNProducts/Downloads/MailingLists_FactSheet.pdf CMS electronic mailing lists. Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNGenInfo/index.html The MedicareThe Network Learning & Medicaid Services includes (CMS), a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and muchstay informed more. To about all of the CMS MLN products, refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ 1.866.590.6703 Thursday, July 2016 14, Thursday, July 28, 2016 Date Monday, July 4, 2016 MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com parta/cs/contact_info.html Response system, (IVR) as well as telephone numbers, fax numbers, and mailing addresses for departments. CGS other To contact a CGSTo Customer Service Representative, call the CGS Provider Contact Center at the Kentucky & Ohio Part A “Contact Information” page Web at Contact Information for CGS Medicare Part Medicare CGS A for Contact Information list of PCC closures. Administration For yourFor reference, access the Schedule” myCGS, is available to access eligibility information through the Internet. additional For information, go to on the left side of the page. Web patient eligibilitypatient information, claim deductible and information, general and information. For information about the IVR, access the IVR User Guide at cs/cgs_j15_parta_ivr_user_guide.pdf The Interactive Voice Response ( (IVR) Medicare & Medicaid Services allows (CMS) the provider contact centers the opportunity to offer training to our customer service representatives The list below (CSRs). indicates when the CGS Part A PCC ( Medicare is continuously a changing program, and it is important that provide we correct and accurate answers better to your questions. serve To the provider community, the Centers for Administration Administration Training Contact (PCC) Center Provider 2016 KENTUCKY & OHIO PART A 4

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CR 9550 October 3, 2016 3, October LearnResource-L@

October 1, 2016 1, October

Medicare Learning Learning Medicare

Change Request #: (CR) Effective Date: Implementation Date:

GR 2016-07

• May 20, 2016 May 20, 2016 R3527CP MM9550 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/ https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/ https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/ https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/ Article is intended for physicians, other providers, and suppliers submitting - - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ - ® Claim Status Category Status Claim - Number: Number: ® . (MLN) Matters ® June 2, 2016 Downloads/2016-06-02-eNews.pdf June 2016 9, Downloads/2016-06-09-eNews.pdf May 19, 2016 May 19, Downloads/2016-05-19-eNews.pdf May 26, 2016 Downloads/2016-05-26-eNews.pdf • • • • • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com trimester meeting (January/February, June, and September/October) and makes decisions about additions of new codes, as well as modifications and retirement of existing codes. The submitted Proprietary claim(s). codes 276/277 transactions not may be used in the ASC X12 to report claim status. The National Code Maintenance Committee meets at the beginning of each ASC X12 National Code Maintenance Committee 276/277 Health in Care the Claim ASC X12 Status Request and Response transaction standards adopted under HIPAA for electronically submitting health care claims status requests and responses. These codes explain the status of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved the by Change 9550 Request (CR) informs MACs about the changes to Claim Status Category Codes and Claim Status Codes. Make sure that your billing staffs are aware of these changes. Background beneficiaries. Needed Action Provider This MLN Matters claims to Medicare Administrative Contractors for services (MACs) provided to Medicare Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN MM9550: Update Codes Status Claim and Administration Administration If you wishto receive the listserv directly from CMS, please contact CMS at cms.hhs.gov messages issued the by Centers of Medicare Medicaid & Services These (CMS). messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The followingprovides access to the weekly messages. Please share with appropriate staff. MLN Connects™ Provider eNews eNews Provider MLN Connects™ The MLN Provider Connects™ eNews contains a weeks worth of Medicare-related Administration Administration KENTUCKY & OHIO PART A 5

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CR 9568 CR January 2017 3,

January 1, 2017 January 1,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

1.866.590.6703 GR 2016-07

• http://www.wpc-edi.com/reference/codelists/healthcare/claim- http://www.wpc-edi.com/reference/codelists/healthcare/claim- May 6, 2016 R166OTN MM9568 . © 2016 Copyright, CGS Administrators, LLC. and article. This MLN Matters article and other CMS articles can be found on Article is intended for Hospitals and Skilled Nursing Facilities (SNFs) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Shared Savings Program (SSP) Accountable Accountable (SSP) Program Savings Shared Number: Number: ® . (MLN) Matters ® the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com become known as the SNF 3-day rule. requiring skilled nursing and/or rehabilitation care. Pursuant of the to Section Social 1861(i) Security Act beneficiaries Act), (the a prior must have inpatient hospital stay of no fewer than 3 consecutive in days order to be eligible for Medicare coverage of inpatient SNF care. This has Background The Medicare SNF benefit is for beneficiaries who require a short-term intensive stay in a SNF, 3-day hospital stay requirement for certain designated SNFs that a relationship have with an participatingACO Make sure that your SNF in the is clear SSP. on whether or not it is eligible to participate in this initiative and that your billing staffs are aware of these changes. Provider Action Needed Action Provider Change 9568 Request (CR) allows the processing of SNF claims without having to meet the working with Accountable CareOrganizations participating (ACOs) in the Medicare Shared Savings Program and submitting (SSP) claims to Medicare Administrative Contractors (MACs) beneficiaries. Medicare services to for provided Provider Types Affected Types Provider This MLN Matters MLN MattersMLN Related CR Release Date: Related CR Transmittal #: MM9568: Edits Qualifying Stay (ACO) Organization Care the CGS Provider Contact Center at Administration The official instruction, CR9550 issued to your MAC regarding this change is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3527CP.pdf questions, any If you have please contact a CGS Customer Service Representative calling by ASC X12 277 transactionsASC X12 issued on and after the date of implementation of CR9550. InformationAdditional The Centers for Medicare & Medicaid Services will issue (CMS) future CRs regarding the need for future updates to these codes. These code changes are to be used in editing of all ASC X12 transactions276 processed on or after the date of implementation and to be reflected in the All code changes approvedduring the committee June 2016 meeting will be posted on the above mentioned websites on or about 2016. July 1, status-codes/ Included in the code lists are specific details, including the date when a code was added, deleted. or changed, The codes sets are available at status-category-codes/ Committeehas decided to allow the industry months 6 for implementation of newly added or changed codes. KENTUCKY & OHIO PART A 6

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CR 9578 October 3, 2016 3, October

. To learn more about. To the October 1, 2016 1, October

Medicare Learning Learning Medicare https://www.cms.gov/Medicare/ Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1. http://www.gpo.gov/fdsys/pkg/FR-2015-06-09/

1.866.590.6703 GR 2016-07

• April 29, 2016 R3510CP MM9578 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on ) a waiver of the prior 3-day inpatient hospitalization requirement in order Article is intended for physicians, providers, and suppliers submitting claims https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Updates to Pub. 100-04, Chapters 1 1 100-04, Chapters Pub. to Updates . Number: Number: ® (MLN) Matters ® https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com This MLN Matters beneficiaries. Medicare services to for provided (MACs) Contractors Administrative Medicare to Related CR Transmittal #: Affected Types Provider MLN MattersMLN Related CR Release Date: and 16 to Correct Remittance Advice Messages Remittance Correct to 16 and Advice Administration Administration MM9578: You can learnYou more about the SSP visiting by our website at Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html SNF 3-Day visit the SSP Waiver, page Web and click on Statutes/Regulations/Guidance. If you have any questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at The official instruction, CR9568, issued to your MAC regarding this change, is available at R1660OTN.pdf beneficiaries that are prospectively assigned 3 ACO. to the Track InformationAdditional affiliates) eligible to participate in the SNF 3-Day with Waiver the ACO. CMS will reimburse designated SNFs (specifically, SNF affiliates participating 3 SSP in Track for the MedicareACOs), SNF benefit without the required 3-day in-patient hospitalization for prospective assignment list close to the start of each performance year. identifyTo the SNFs eligible to use the SNF 3-Day ACOs designate SNF SNFs Waiver, (as SNF benefit. identifyTo the beneficiaries eligible to receive the SNF 3-Day CMS provides Waiver, ACOs with a prospective beneficiary assignment list for the performance ACOs will receive year. the for 3 that SSP demonstrate ACOs in Track the capacity and infrastructure to identify and manage patients who would be eitherdirectly admitted to a SNF or admitted to a SNF after an inpatient hospital stay of fewer than for 3 days, services otherwise covered under the Medicare to provide Medicare SNF coverage when certain beneficiaries assigned to SSP ACOs in Track 3 are admitted to designated SNF affiliates either directly from an inpatient hospital stay or after fewer than 3 inpatient hospital starting days, The waiver will be available in January 2017. may bemay necessary to carry out theprovisions of this section.” As a result, CMS proposed and finalized through rulemaking (80 32692 FR at pdf/2015-14005.pdf Section 3022of the Affordable Care Act amended Title XVIII of the Act adding by new a Section 1899 to establishthe under Medicare Section SSP. 1899(f), the Secretary of Health and Human Services is permitted to waive “such requirements of . . . title XVIII ofthis Act as care and/or rehabilitation services provided inSNF a without prior hospitalization or with an inpatient hospital length of stay of less than 3 days. The Centersfor Medicare & Medicaid Services understands(CMS) that, in certain circumstances, it couldbe medically appropriate for some patients to receive skilled nursing KENTUCKY & OHIO PART A 7

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and choose Option 1. 1.866.590.6703 GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. Group Code CO CARC and 109, RARC N127 Group Code of CO CARC and 109, RARC N105 Group Code of CO CARC and 109, RARC N104 ------In the 3 situations, above RARC was used but previously, will no longer MA130 be used in these situations. When a MAC rejects misdirected United Mine Workers Association claims as unprocessable, the following codes used: are - - - When a MAC rejects misdirected Railroad Retirement Board claims as unprocessable, the following codes used: are - - - When a MAC rejects an out of jurisdiction professional claim as unprocessable, the following codes used: are - - -

4. 3. 2. 1. MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com revised manual Chapters are 1 and attached 16 to CR9578. questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at The official instruction, CR9578 issued to your MAC regarding this change is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3510CP.pdf Additional InformationAdditional CR9578 makes the following code revisions: combinations. The business scenario defined, be must adjustment for each payment code applicable,if valid a and combination selected remittancefor all advice messages. for Affordable Quality Healthcare Committee (CAQH) on Operating Rules for Information Exchange (CORE). Medicare and all other payers must comply with the CAQH CORE-developed code Adjustment Reason Codes and Remittance (CARCs), Advice Remark Codes (RARCs) be may used. The rule requires specific codes which are to be used in combination with one another if one of the named business scenarios applies. This rule is authored the by Council Section 1171 of the Social SecuritySection Act 1171 requires a standard set of operating rules to regulate the health insurance industry’s use of Electronic Data Interchange transactions. (EDI) Operating Rule 360: Uniform Use of CARCs and RARCs, regulates the in which way group codes, Claims corrected code combinations. Background If Change 9578 Request updates (CR) Chapter1 and of the Chapter “Medicare16 Claims Processing Manual” to reflect the standard format and to correct non-compliantany remittance advice code combinations. Make sure that your billing staffs are aware of the Provider Action Needed Action Provider KENTUCKY & OHIO PART A 8

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CR 9606 CR June 14, 2016 June 14,

June 14, 2016 June 14,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

Must contain an upper-case letter Must contain a lower-case letter Must contain least at one special character $) as #, @, (such Must contain numbers (0-9) and letters (A-Z, a-z) Must begin with a letter Cannot use leading portion of first or last name Cannot contain spaces Cannot use same password as the previous thirteen passwords Case sensitive Case 1.866.590.6703 • • • • • • • • • GR 2016-07 • • • • • • • • •

• password upon log in. Must be changed every 60 days Must contain least at 4 different characters than the previous password. When the password expires, user will be prompted to create a new At least 8 characters May 13, 2016 2016 May 13, R3522CP MM9606 MM9606 . © 2016 Copyright, CGS Administrators, LLC. article. ThisMLN Matters article and other CMS articles can be found on Article is intended for physicians, providers, and suppliers submitting claims https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Update to Internet-Only-Manual to Internet-Only-Manual Update Number: Number: ® (MLN) Matters ® . The updated manual section is attached to the CR. MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network the CMS website at: Password Expiration Period Expiration Password Password Requirements Password Length of Password MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com information, it is necessary for each myCGS user a uniqueto have User ID and password. As please a reminder, review the following guidelines for creating or updating your password. myCGS Password Requirements ensure a MedicareTo beneficiary’s health information is secure, as well as your provider Administration Administration pdf questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at Additional InformationAdditional The official instruction, CR9606, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3522CP. Z12.92 and the correctZ12.92 (encounter for screening code ICD-10 is for Z12.72 malignant neoplasm Make sureof the that vagina). your billing staffs are aware of this change. CR9606 advises the MACs of an update to the “Medicare Claims Processing Chapter Manual,” Section18, 30.6. CR9606 updates the manual replacing by an incorrect diagnosis code for screening of cervical cancer with HPV testing. The manual showsan incorrect code ICD-10 of to Medicareto beneficiaries. Needed Action Provider Provider Types Affected Types Provider This MLN Matters to Medicare Administrative Contractors for cervical (MACs) cancer screening services provided Related CR Release Date: Related CR Transmittal #: MLN MattersMLN MM9606: Section 18, 30.6 100-04, Chapter Publication Administration Administration KENTUCKY & OHIO PART A 9

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N/A

Special Edition Medicare Medicare Edition Special Change Request #: (CR) Effective Date: Implementation Date:

GR 2016-07

Revised Revised • Password canbe changed once in a 24-hour period. If user forgets password, access the Password selecting by Reset Tool the ‘Forgot your password?’ link on the Log In screen; or the ‘Forgot or Change Password’ linkYour on the Welcome screen. Limiting the Scope Review of article. This MLN Matters article and other CMS articles can be found N/A N/A SE1521 . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Special Edition Article is intended for physicians, providers, and suppliers ® (MLN) Matters ® Number: Number: ® This article was revised to provide on May 2016, 9, updated information regarding redetermination requests myCGS Password Quick Reference Guide - http://www.cgsmedicare.com/pdf/mycgs_passwordquickrefguide.pdf myCGS User Guide, Overview myCGS Chapter 1: of myCGS - http://www.cgsmedicare.com/pdf/mycgs/chapter1.pdf must write down the password, it keep in a secure, locked location. Do not the leave myCGS system accessible on your computer when you are away. Log off and close your browser every time you exit the system. number, or streetnumber, address. Don’t use letters or numbers that appear on the keyboard nextor to each are in other, logicalhjkl, sequence abcd, or 12345) (e.g., Never share your password with anyone. Don’t write down your password and it leave ina place where others can access it. If you Don’t use easily identifiable information such as your birthday, child’s birthday, phone • • • • • • • • • • • • • • • • The Centers for Medicare & Medicaid Services has revised (CMS) the following Network Learning on the CMS website at: MLNMattersArticles/2015-MLN-Matters-Articles.html April 2016. 18, Note: received Medicare by Administrative Contractors or (MACs) Qualified Independent Contractors on or (QICs) after Password Reset Frequencyof Password Change MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Services to inform (CMS) providers of the clarification CMS has given to the MACs and QICs regarding the scope of review for redeterminations (Technical Direction Letter- 160305, which What You NeedWhat to Know You This Special Edition article is being published the by Centers for Medicare & Medicaid This MLN Matters who submit claims to MACs for services provided to Medicare beneficiaries. Provider Types Affected Types Provider Related CR Transmittal #: MLN MattersMLN Related CR Release Date: Certain Claims SE1521 (Revised): of Reconsiderations and on Redeterminations Appeals Please share this information with your appropriate staff. additional For information, tips and reminders about passwords, refer to the following CGS resources. For moreFor secure passwords, usephrases and/or non-dictionary words, combined with obscure character substitutions. Below are just a few guidelinesthat will help protect your password and your information: KENTUCKY & OHIO PART A 10

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on the CMS website. . It will not be applied retroactively. https://www.cms.gov/Regulations-and- ; and 2) conducting; and 2) a reconsideration CFR in 405.968 42 at GR 2016-07

• on or after April 2016 18, . © 2016 Copyright, CGS Administrators, LLC. MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com .2.405&rgn=div5#se42.2.405_1948 Guidance/Guidance/Manuals/Downloads/clm104c29.pdf can also findYou out conducting more about 1) a redeterminations CFR in 405.948, 42 at www.ecfr.gov/cgi-bin/text-idx?SID=06584dd6a5fc15094e7633ff5f6cb359&mc=true&node=pt42 You can findYou out more about appealing claims decisions in the “Medicare Claims Processing Manual” (Publication 100-04, Chapter 29 (Appeals of Claims Decisions), Section 310.4.C.1. (Conducting the Redetermination at (Overview)) appeal request. This will help alert contractors to appeals where this instruction applies. InformationAdditional Appellants will not be entitled to request a reopening of a previously issued redetermination or reconsideration for the purpose of applying this clarification on the scope CMS of review. encourages providers and suppliers to include audit any or review results letters with their This clarification and instruction applies to redetermination and reconsideration requests received a MAC or by QIC was medicallywas reasonable necessary. and result, As claims a initially denied insufficient for documentation be may denied on appeal if additional documentation is submitted and it does not support medical necessity. was denied on pre- or post-payment review because or beneficiary supplier, a provider, failed to submit requested documentation, the contractor will review all applicable coverage and payment requirements forthe item or service at issue, including whether the item or service payment because of additional system imposed payment limitations, conditions or restrictions example,(for frequency limits or Correct Coding Initiative result may edits) in new denials with full appeal rights. In addition, if a MAC or QIC conducts an appeal of a claim or line item that Please note that contractors will continue to follow existing procedures regarding claim adjustments resulting appeal from decisions. favorable These adjustments will process through CMS systems and suspend may due to system edits. Claim adjustments that do not process to If an appeal involves a claim or line item denied on an automated pre-payment basis, MACs and QICs continue may to develop new issues and evidencetheir at discretion and issue may unfavorable decisions for reasons other than those specified in the initial determination. contractor, and revised to deny coverage, change coding, or reduce payment. Complex reviews require a manual review of the supporting medical records to determine whether there is an improper payment. Automated reviews use claims data analysis to identify improper payments. initial determination. Post-payment review or audit refers to claims that were initially paid by Medicare and subsequently reopened for example, a Zone and reviewed Program by, Integrity Contractor Recovery (ZPIC), MAC, or Comprehensive Auditor, Error (CERT) Rate Testing CMS has instructed MACs and QICs tolimit their thereview claim to the reason(s) or line item at issue was initially denied. Prepayment reviews occur prior to Medicare payment, when a contractor conducts review a of the claim and/or supporting documentation an to make appeal decision for a different reason. different a for decision appeal redeterminationsFor and reconsiderations of claims denied following a complex prepayment a complexreview, post-payment or an automated review, post-payment review a contractor, by discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item. As a result, in some cases where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable CMS recently provided direction to MACs and QICs regarding the applicablescope of review for redeterminations and reconsiderationsfor certain claims. Generally, MACs and QICs have applied retroactively. applied Background rescinds and replaces Direction Technical This updated Letter-150407). instruction applies to redetermination requests received a MAC or by QIC on or after April and will 2016, not be 18, KENTUCKY & OHIO PART A 11

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http://www.cms.gov/ July 5, 2016, unlessJuly 5, 2016,

. Medicare Learning Learning Medicare July 1, 2016 July 1,

Effective Date: Effective Date: Implementation Date: otherwise noted

on the Internet.

GR 2016-07

Articles for these CRs on the Centers for Medicare & Medicaid • ® April 29, 2016 R1658OTN R1658OTN CR 9540 MM9540 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for physicians, providers, and suppliers submitting claims Coding Revisions to to Coding Revisions https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Number: Number: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® (MLN) Matters ® MM9087, MM9087, MLNMattersArticles/downloads/MM9087.pdf MM9252, MLNMattersArticles/downloads/MM9252.pdf MLNMattersArticles/downloads/MM8109.pdf MM8197, MLNMattersArticles/downloads/MM8197.pdf MM8691, MLNMattersArticles/downloads/MM8691.pdf MM7818, MM7818, MLNMattersArticles/downloads/MM7818.pdf MM8109, • • • • • • • • • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com CR9540 updates the following NCDs: 14 Updated NCD coding spreadsheets related to CR9540 are available at Medicare/Coverage/DeterminationProcess/downloads/CR9540.zip released separately. released CRs, specifically, CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. You may review may and CR9252. CR8691, CR9087, You CRs, specifically, CR8197, CR8109, CR7818, the corresponding MLN Matters Services website. Some (CMS) are the result of revisions required to other NCD-related CRs Background The majority of the NCDs included are a result of feedback received from previous NCD ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. Change 9540 Request (CR) is the 7th maintenance update of the International Statistical Classification of Diseases and Related Health Problems 10th conversions Revision (ICD-10) and other coding updates specific to National Coverage Determinations Edits to ICD-10 (NCDs). to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Medicare servicesto for provided (MACs) Contractors Administrative Medicare to NeedWhat to Know You Provider Types Affected Types Provider This MLN Matters Related CR Release Date: Related CR Transmittal #: Change Request #: (CR) MLN MattersMLN MM9540: Determinations Coverage National Coverage http://www.ecfr.gov/cgi-bin/text-idx?SID=06584dd6a5fc15094e7633ff5f6cb359&mc=true&node =pt42.2.405&rgn=div5#se42.2.405_1968 KENTUCKY & OHIO PART A 12

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CR 9620 October 3, 2016 3, October

January 27, 2016 January 27,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

1.866.590.6703 GR 2016-07

• April 29, 2016 R191NCD and R3509CR191NCD MM9620 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for physicians and providers submitting stem cell https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Stem Cell Transplantation for Multiple Multiple for Transplantation Cell Stem . Number: Number: ® http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ (MLN) Matters ® NCD20.33 policy Mitral effective - Transcatheter Repair (CR9002, Valve TDL150341, 2014 August 7, - PercutaneousNCD220.13 Image-Guided Breast Biopsy NCD220.4 Mammograms - NCD210.14 - Screening for Lung CancerNCD210.14 with Low-Dose (CR9246) CT Sacral - Nerve Stimulation Urinary for NCD230.18 Incontinence - Adult LiverNCD260.1 Transplantation (CR9252, CR8109) - Extracorporeal NCD110.4 Photopheresis NCD110.18 - Aprepitant for Chemotherapy-Induced Aprepitant for - Emesis NCD110.18 NCD150.3 - Bone Mineral Density Studies Nerve - Vagus Stimulation of Seizures forNCD160.18 Treatment NCD160.24 - Deep Brain Stimulation for Essential Tremor - ColorectalNCD210.3 Cancer Screening Tests NCD20.29 - Hyperbaric Oxygen Therapy Hyperbaric Oxygen NCD20.29 - Pharmacogenomic - NCD90.1 for Warfarin Testing Response

13. 14. 11. 12. 9. 10. 7. 8. 4. 5. 6. 2. 3. 1. The Centers for Medicare & Medicaid Services has issued (CMS) the following Network the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Provider Action Needed Action Provider This MLN Matters transplantation claims to Medicare Administrative Contractors for services (MACs) to Medicare beneficiaries. Related CR Transmittal #: Affected Types Provider MLN MattersMLN Related CR Release Date: and Myelodysplastic Syndromes MM9620: Disease, Cell and Sickle Myelofibrosis, Myeloma, the CGS Provider Contact Center at Coverage download at R1658OTN.pdf questions, any If you have please contact a CGS Customer Service Representative calling by Additional InformationAdditional The official instruction, CR9540, issued to your MAC regarding this change is available for MACs will adjust claims any already processed, if erroneously impacted the by changes, above if you bring such claims to their attention. KENTUCKY & OHIO PART A 13

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http://www.

Sickle Cell Disease • • and MM8691 at ) provides specific ICD-9 related coding and Myelofibrosis GR 2016-07 •

• • http://www.cms.gov/Outreach-and-Education/Medicare-Learning- ) provide related ICD-10 coding requirements. On November 30, 2015, http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ . © 2016 Copyright, CGS Administrators, LLC. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Chapter 1, Section of theChapter “Medicare 1, 110.23, NCD which Manual,” is attached to the CR9620 NCD transmittal at Multiple Myeloma Multiple • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com to CR9620: to Refer to the following Medicare manual sections for more information regarding this NCD and further billing instructionsspecific to this NCD and the business requirements specific Development (CED) under Section 1862(a)(1)(E) of the Social SecurityDevelopment under Section (CED) Act for Act) 1862(a)(1)(E) (the allogeneic for the following HSCT indications: treatment of MDS in the context of a Medicare-approved clinical study under CED. CMS 2016, issuedOn January a final decision 27, to expand national coverage of items and services necessary for research in an approved clinical study via Coverage with Evidence Downloads/MM8691.pdf CMS accepted a formal request from the National Marrow Donor Program (NMDP) to clarify the list of ICD-9-CM and ICD-10-CM diagnosis codes covered for allogeneic HSCT for the and at 8691 MM8197 (see Network-MLN/MLNMattersArticles/Downloads/MM8197.pdf cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ MM7137 at MM7137 MLNMattersArticles/Downloads/MM7137.pdf claims processing requirements regarding this particular coverage decision, and CRs 8197 marrow does not produce enough functioning healthy, blood cells. On CMS August 2010, 4, issued a final decision stating that allogeneic HSCT for MDS is covered Medicare by only if provided pursuant to a Medicare-approved the clinical (see article, study under CR CED. 7137 HSCT for sickle cell disease, Myelofibrosis, multiple myeloma and rare diseases. Myelodysplastic Syndrome refers (MDS) to a group of diverse blood disorders in which the bone by theby presence of abnormal hemoglobin genes. On April the Centers 30, 2015, for Medicare & Medicaid Services accepted (CMS) a formal request from the American Society for Blood and Marrow Transplantation (ASBMT) to reconsider its policy and expand coverage of allogeneic or a donor and (allogeneic) subsequently administered intravenous by infusion to the patient. Multiple myeloma is a neoplastic plasma-cell Myelofibrosis disorder. is a stem cell-derived hematologic Sickle disorder. cell disease is a group of inherited red blood cell disorders created HSCT is a processthat includes mobilization, harvesting, and transplant of stem cells and the administration of high-dose chemotherapy and/or radiotherapy prior to the actual transplant. During the process stem cells are harvested from either the patient (autologous) Make sure your billing staff is aware of these determinations. Background AND clinical trial ICD-9-CM dates For diagnosis of service code V70.7. on or after October the ICD-10-CM 2015, 1, diagnosis codes are D46.A, D46.B, D46.20, D46.C, D46.0, D46.1, D46.21, D46.22, D46.4, D46.9, or D46.Z AND clinical trial ICD-10- CM diagnosis code Z00.6. of Myelodysplastic Syndromes (MDS) in the context of a Medicare-approved, prospective prospective Medicare-approved, a of context the in (MDS) Syndromes Myelodysplastic of clinical study under Specifically, CED. for dates of service on or after throughAugust 2010, 4, September the ICD-9-CM 30, 2015, diagnosis codes or are 238.75 238.72, 238.73, 238.74, context ofa Medicare-approved clinical study meeting specific criteria under the Coverage with paradigm. (CED) Development Evidence CR9620 also clarifies the ICD-9 and diagnosis ICD-10 codes for allogeneic HSCT for treatment allogeneic Hematopoietic Stem Cell Transplantation (HSCT) fortreatment of Multiple Myeloma, Myelofibrosis, and Sickle Cell Disease is covered Medicare, by but only if provided in the Change Request (CR) 9620, from which this article was developed, notifies providers notifies providers article developed, this which from 9620, was (CR) Request Change that effective for claims with dates of service on and for afterthe 2016, use of January 27, KENTUCKY & OHIO PART A 14

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, and

https://www.cms.gov/

GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. . https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ or D75.81 OR or D75.81 D57.20, Sickle Cell Disease-ICD-10-CM D57.1, D57.02, diagnosis D57.811, D57.01, code D57.80, D57.00, D57.419, D57.412, D57.411, D57.40, D57.219, D57.212, D57.211, or D57.819 D57.812, Multiple Myeloma-ICD-10-CM diagnosis code C90.00, or C90.01, C90.02 OR Myelofibrosis-ICD-10-CM diagnosis code C94.40, C94.42, D47.4, C94.41, Sickle Cell Disease-ICD-10-CM diagnosis code D57.00, D57.01, D57.02, D57.1, D57.20, D57.20, Sickle Cell Disease-ICD-10-CM D57.1, D57.02, diagnosis D57.811, D57.01, code D57.80, D57.00, D57.419, D57.412, D57.411, D57.40, D57.219, D57.212, D57.211, or D57.819 D57.812, Multiple Myeloma-ICD-10-CM diagnosis code C90.00, or C90.01, C90.02 OR Myelofibrosis-ICD-10-CM diagnosis OR or D75.81 code C94.40, C94.42, D47.4, C94.41, Value codeValue D4 showing the Clinical Number (assigned Trial NLM/NIH by with an 8-digit clinicaltrials.gov identifier number listed on the CMS along website) with the appropriate ICD-10-diagnosis code of: An HSCT CPT code of 38240 AND The clinical trial ICD-10-CM code of Z00.6 AND Condition code 30, denoting qualifying clinical trial AND Value codeValue D4 showing the Clinical Number (assigned Trial NLM/NIH by with an 8-digit clinicaltrials.gov identifier number listed on the CMS along website) with the appropriate ICD-10-diagnosis code of: 30240Y1, 30243G1, 30243Y1, 30250G1,30250Y1, 30253G1, AND or30263G1, 30263Y1 30253Y1, 30260G1, 30260Y1, The clinical trial ICD-10-CM code of Z00.6 AND Condition code 30, denoting qualifying clinical trial AND An ICD-10-PCS procedure 30240G1, code 30233Y1, 30233G1, of 30230G1, 30230Y1, Chapter 32, Sections 69 and 90, of the“Medicare Claims Processing availableManual,” at clm104c32.pdf Downloads/R191NCD.pdf of the “Medicare Section NCDChapter available Manual,” 1, at 310.1, Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Method II Critical Access Hospital Claims (CAH) claimsFor submitted on type of bill 85X with Codes Revenue 96X, 97X, or 98X for dates For claimsFor submitted on type or 85X of bill for dates 13X of service on or after 2016, January 27, for HSCT for the treatment of Multiple Myeloma, Myelofibrosis, or Sickle Cell Disease, the claim show: must Outpatient Claims claim must show: claim must For claimsFor submitted for discharges on type on of bill or for after 11X 2016, January 27, HSCT for the treatment of Multiple Myeloma, Myelofibrosis, or Sickle Cell Disease, the In addition to the diagnosis codes detailed at the beginning of this article, providers need to be aware of the other billing requirements, as follows: Inpatient Claims KENTUCKY & OHIO PART A 15

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. If you do Web not have

GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. Multiple Myeloma-ICD-10-CM diagnosis code C90.00, or C90.01, C90.02 OR Myelofibrosis-ICD-10-CM diagnosis OR or D75.81 code C94.40, C94.42, D47.4, C94.41, D57.20, Sickle Cell Disease-ICD-10-CM D57.1, D57.02, diagnosis D57.811, D57.01, code D57.80, D57.00, D57.419, D57.412, D57.411, D57.40, D57.219, D57.212, D57.211, or D57.819 D57.812, D57.812, or D57.819 D57.812, Multiple Myeloma-ICD-10-CM diagnosis code C90.00, or C90.01, C90.02 OR Myelofibrosis-ICD-10-CM diagnosis OR or D75.81 code C94.40, C94.42, D47.4, C94.41, D57.20, Sickle Cell Disease-ICD-10-CM D57.1, D57.02, diagnosis D57.811, D57.01, codeD57.80, D57.00, D57.419, D57.412, D57.411, D57.40, D57.219, D57.212, D57.211, Group Code - Patient Responsibility if an Advance (PR) Beneficiary Notice (ABN)/Hospital Notice on Non-Coverage (HINN), otherwise Contractual Obligation (CO) Remittance Advice Remarks Code (RARC) N386 - This decision was based on a National Coverage Determination An (NCD). NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at gov/medicare-coverage-database/overview-and-quick-search.aspx access, contact you may the contractor to request a copy of the NCD. Claim Adjustment Reason Code 50 - These (CARC) are non-covered services because this is not deemed a ‘medical necessity’ Refer Note: to the 835 the Healthcare by payer. Policy Identification Service Segment (loop Payment Information 2110 REF), if present. An HSCT CPT code of 38240 AND The clinical trial ICD-10-CM code of Z00.6 AND The Q0 modifier AND A Place of Service or 22 along Code 21, with the of 19, appropriate ICD-10-CM diagnosis code of: The clinical trial ICD-10-CMcode of Z00.6 AND Condition code30, denoting qualifying clinical trial AND codeValue D4 showing the Clinical Number (assigned Trial NLM/NIH by with an 8-digit clinicaltrials.gov identifier number listed on the CMS along website) with the appropriate ICD-10-diagnosis code of: An HSCT CPT code of 38240AND • • • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com The official instruction, CR9620, consists of two transmittals. The first updates the “Medicare their MAC. their InformationAdditional For claimsFor with dates of service prior to the implementation date of CR9620, MACs shall perform necessary adjustments only when the provider brings such claims to the attention of claims the using following messages: For allFor of the above claims types submitted without the requisite coding, MACs will deny the Myelofibrosis, or Sickle Cell Disease, the claim must show: Professional Claims Professional professionalFor claims submitted on type of bill 85X with Codes Revenue 96X, 97X, or 98X for dates of service on or for after HSCT 2016, for the January treatment of Multiple 27, Myeloma, ofservice onor forafter HSCT2016, forthe January treatmentof Multiple 27, Myeloma, Myelofibrosis, or Sickle Cell Disease, the claim must show: KENTUCKY & OHIO PART A 16

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October 3, 2016 3, October

October 1, 2016 - unlessOctober 2016 1,

Medicare Learning Learning Medicare Articles for information pertaining to

® Effective Date: Effective Date: noted differently in CR9631 Implementation Date: and choose Option 1.

. The second transmittal updates the “Medicare NCD 1.866.590.6703 GR 2016-07

• http://www.cms.gov/Regulations-and-Guidance/Guidance/ May 13, 2016 2016 May 13, R1665OTN CR 9631 MM9631 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for physicians and other providers submitting claims to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Coding Revisions to to Coding Revisions Number: Number: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® . http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ (MLN) Matters ® MLNMattersArticles/downloads/MM9087.pdf MM9252, MLNMattersArticles/downloads/MM9252.pdf MM9540, MLN/MLNMattersArticles/Downloads/MM9540.pdf MM8197, MLNMattersArticles/downloads/MM8197.pdf MM8691, MLNMattersArticles/downloads/MM8691.pdf MM9087, MM7818, MM7818, MLNMattersArticles/downloads/MM7818.pdf MM8109, MLNMattersArticles/downloads/MM8109.pdf • • • • • • • • • • • • • • Network the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com The translations from ICD-9 are to ICD-10 not consistent one-to-one matches, nor are all Background related CRs released Review separately. MLN Matters these CR’s. coverage determinations The (NCDs). majority of the NCDs included are a result of feedback received from CR8691, previous NCD ICD-10 CRs, specifically CR8197, CR8109, CR7818, CR9252,CR9087, and CR9540, while others are the result of revisions required to other NCD- Provider Action Needed Action Provider CR9631 is the 8th maintenance update of International Classification of Diseases, conversions Revision (ICD-10) Tenth and other coding updates specific to national This MLN Matters beneficiaries. Medicare services to for provided (MACs) Contractors Administrative Medicare Change Request #: (CR) Affected Types Provider MLN MattersMLN Related CR Release Date: Related CR Transmittal #: National Coverage Determinations (NCDs) Determinations Coverage National Coverage MM9631: If you have any questions, any If you have please contact a CGS Customer ServiceRepresentative calling by theCGS Provider Contact Center at Manual” at R191NCD.pdf Claims ProcessingClaims Manual” at Transmittals/Downloads/R3509CP.pdf KENTUCKY & OHIO PART A 17

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• . © 2016 Copyright, CGS Administrators, LLC. . NCD 230.9 - Cryosurgery of Prostate NCD 260.9 - Heart Transplants - Smoking/Tobacco-UseNCD 210.4 Cessation Counseling - Counseling Use Tobacco to Prevent NCD 210.4.1 NCD 20.29 - Hyperbaric Oxygen Therapy NCD 50.3 - Cochlear Implants – Aprepitant NCD 110.18 - ColorectalNCD 210.3 Cancer Screening NCD 220.4 – Mammography NCD 20.4 -Implantable Automatic Defibrillators Angioplasty -Percutaneous(PTA) NCD 20.7 Transluminal NCD 20.9 - Artificial Hearts • • • • • • • • • • • • https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com If you have any questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at The official instruction, issued CR 9631, to your MAC regarding this change is available at R1665OTN.pdf Additional InformationAdditional NCD process. be specific,To CR9631 makes adjustments to the following NCDs: Edits and to ICD-10 other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCDs continue to be implemented via the current, long-standing NCD process. Updated NCD coding spreadsheets related to CR9631 are available at Coverage/DeterminationProcess/downloads/CR9631.zip certain ICD-9 codes that were once considered appropriate prior implementation to ICD-10 that acceptable. considered longer no are No policy-related changes are included with these updates. Any policy-related changes to those policies thatexpressly allow MAC discretion, there be may changes to those NCDs based on current review of those NCDs against coding. ICD-10 these For reasons, there be may ICD-10 codesICD-10 appearing in a completeGeneral Equivalence Mappings guide (GEMS) or other mapping guides appropriate when reviewedagainst individual NCD policies. In addition, for KENTUCKY & OHIO PART A 18

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CR 9638 October 3, 2016 3, October

February 8, 2016

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date:

GR 2016-07

• May 6, 2016 R192NCD andR192NCD R3515CP MM9638 . © 2016 Copyright, CGS Administrators, LLC. article. ThisMLN Matters article and other CMS articles can be found on Article is intended for physicians, other providers, and suppliers https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Percutaneous Left Percutaneous Number: Number: ® (MLN) Matters ® physician using an evidence-based decision tool on oral anticoagulation in patients with prior NVAF to LAAC. Additionally, the shared decision making interaction must be documented in the medical record A suitability for short-term warfarin but deemed unable to take long term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered assecond a line therapy to oral anticoagulants A CHADS2 score ≥ 2 (Congestive heart failure, Hypertension, Diabetes, Stroke/ Age >75, transient ischemia attack/thromboembolism) or CHA2DS2-VASc score ≥ 3 (Congestive heart failure, Hypertension, Age ≥ 65, Diabetes, Stroke/transient ischemia attack/ thromboembolism, Vascular disease, category) Sex formalA shared decision making interaction with independent an non-interventional • • • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com for a multidisciplinary team to be engaged in patient care. The NCD lists the criteria for the physician and facility criteria and includes a requirement must have: must On February CMS 8, 2016, issued an NCD covering percutaneous LAAC through CED when LAAC is furnished in patients with and NVAF the device has received PMA FDA for that device’s FDA-approved indication and meets all the specified conditions. Coverage requires that patients originate from the LAA. The LAA is a tubular structure that opens into the left atrium of the heart. LAAC with a percutaneously implanted device could be used in patients with to NVAF reduce cardioembolic stroke risk as a potential alternative tooral anticoagulation. LAAC is a strategy to reduce the risk of stroke closing by the Left Atrial Appendage (LAA) in an abnormally Patientspatients with rapid, NVAF, irregular with NVAF. heartbeat, are at an increased risk of stroke. Some evidence suggests that of many the strokes attributed to NVAF staffs are aware of these changes. Background whenLAAC is furnished in patients with Non-Valvular Atrial Fibrillation (NVAF) and the device has received Food and Drug Administration Premarket Approval (FDA) (PMA) for that device’s FDA-approved indication and meets all the specified conditions. Make sure that your billing Change 9638 Request (CR) informs MACs that the Centers for Medicare & Medicaid Services issued (CMS) a National Coverage Determination covering (NCD) percutaneous Left Atrial Appendage Closure (LAAC) through Coverage with Evidence Development (CED) to Medicareto beneficiaries. Needed Action Provider This MLN Matters submitting claims to Medicare Administrative Contractors for services (MACs) provided Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN MM9638: MM9638: (LAAC) Appendage Closure Atrial Coverage KENTUCKY & OHIO PART A 19

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. If you do Web not have

. https://www.cms.gov/Regulations-and-Guidance/ https://www.cms.gov/Medicare/Coverage/Coverage- . The process for submitting a clinical research study to GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/ . The process for submitting a registry to Medicare is outlined in the NCD. 48.2 – Chronic atrial fibrillation Unspecified fibrillation – atrial I48.91 I48.0 – Paroxysmal atrial fibrillation – Persistent atrialI48.1 fibrillation gov/medicare-coverage-database/overview-and-quick-search.aspx access, contact you may the contractor to request a copy of the NCD. Group Code - Contractual Obligation (CO) Claim Adjustment Reason Code 50: These (CARC) are non-covered services because this is not deemed a “medical necessity” the by payer. Remittance Advice Remarks Code (RARC) N386: This decision was based on a National Coverage Determination An (NCD). NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at Value CodeValue D4 - Clinical Number (assigned Trial NLM/NIH by withan 8-digit clinicaltrials. gov identifier number listed on the CMS website) A secondary diagnosis ICD-10 code of Z00.6 – Encounter for examination for normal comparison control and clinical in research program and Condition Code 30 (Qualifying Clinical Trial), Device, PercutaneousApproach ) A primary diagnosis code of one of the following: ICD-10 procedureICD-10 code of 02L73DK (Occlusion of Left Atrial Appendage with Intraluminal • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com following messages: following MACs will fully reject inpatient claims for LAAC with discharges on or after February 8, 2016, when billed without the appropriate procedure, diagnosis, or clinical trial codes, with the Guidance/Transmittals/Downloads/R192NCD.pdf Instructions Billing Additional hospitals should show: On institutional 11X), claims bill (type of LAAC is non-covered for the treatment when of NVAF not furnished under CED according to the criteria outlined in the NCD, which is at angiography, left atrial appendage angiography, radiological leftatrial supervision appendage angiography, and angiography, interpretation) and will be MAC-priced. CMS will issue further instructions, once a permanent CPT 1 replaces level the temporary code. LAAC claims with dates of service on or after February will 8, be 2016, billed with temporary IIIlevel CPT (percutaneous code 0281T transcatheter closure ofthe left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter left placement(s) atrial CMS. Approved studies will be posted at with-Evidence-Development/LAAC.html Medicare is outlined in the NCD. For devicesFor and indications that arenot approved FDA, by patients must be enrolled in a The clinical addressqualifying (RCT). must study FDA-approved Randomized Controlled Trial pre-specified research questions, adhere to standards of scientific integrity, and be approved by adhere to standards of scientific integrity, and be approved CMS. by Approved registries will be posted at LAAC.html patients tracks and 2) thespecified annual outcomes for each patient forperiod a of at least four years from the time of the LAAC. The registry must address pre-specified research questions, The patient must be enrolled in, and the enrolled be and multidisciplinary must Thein, patient hospital and (MDT) team must participate in a prospective, national, audited registry consecutively that: 1) enrolls LAAC KENTUCKY & OHIO PART A 20

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https://www.cms.gov/medicare-coverage- https://www.cms.gov/medicare-coverage- . If access, you do Web not have you may . If access, you do Web not have you may GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. I48.91 – Unspecified fibrillation – atrial I48.91 I48.0 – Paroxysmal atrial fibrillation, – Persistent atrialI48.1 fibrillation, I48.2 – Chronic atrial fibrillation, CARC 16: “Claim/serviceCARC 16: lacks information which is needed for adjudication. At least one Remark Code must be provided be comprised (may of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)” is missing. Refer Note: to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.” Group Code – Contractual Obligation (CO) contact the contractor to request a copy of the NCD.” Group Code – Contractual Obligation (CO). “TheCARC 4: procedure code is inconsistent with the modifier used or a required modifier (loop 2110 Service(loop Payment Information 2110 REF), if present.” RARC N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at database/overview-and-quick-search.aspx Group Code – Contractual Obligation (CO). CARC was 58: deemed “Treatment the been by to have payer rendered in an inappropriate or invalid place of service. Refer Note: to the 835 Healthcare Policy Identification Segment (loop 2110 Service(loop Payment Information 2110 REF), if present. RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at database/overview-and-quick-search.aspx contact the contractor to request a copy of the NCD. Clinical trial number in item 23of the CMS-1500 form or electronic equivalent CARC 50 - These are non-covered services because this is not deemed a “medical necessity” Refer Note: to the 835 the Healthcareby payer. Policy Identification Segment Place of Service code (inpatient of 21 hospital) Secondary code diagnosis Z00.6 Modifier Q0 Primary diagnosis ICD-10 code of the following): (one CPT 0281T CPT • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com MACs will return claim as unprocessable lines with 0281T when billed without secondary diagnosis code Z00.6 the using following messages: MACs will return claim lines on professional as unprocessable claims for 0281T when the Q0 modifier is not present using messages: MACs will deny claims for LAAC witha POS with code 0281T other than using 21 the messages: following MACs will deny LAACclaims when billed without the appropriate diagnosis codes, messages: following the with Professional claims with dates of serviceon or after February for LAAC 8, 2016, under CED will be paid only when billed with thefollowing codes: KENTUCKY & OHIO PART A 21

JULY 2016 JULY RETURN TO TABLE OF CONTENTSTABLE N/A N/A

N/A

Special Edition Medicare Medicare Edition Special Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

1.866.590.6703 GR 2016-07

• article. This MLN Matters article and other CMS articles can be found N/A N/A . The second provides the claims processing instructions and it is at SE1604 . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Special Edition article is intended for physicians, other providers, and https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ ® (MLN) Matters ® Medicare Coverage Coverage Medicare Number: Number: ® . http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or number. Clinical Trial GroupCode – Contractual Obligation (CO) CARC 16: “Claim/serviceCARC 16: lacks informationwhich is needed for adjudication. At least one Remark Code mustbe provided be comprised (may of eitherthe NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not anALERT.)” RARC “Missing/incomplete/invalidM76: diagnosis or condition.” Group Code – Contractual Obligation (CO) • • • • • • • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network Learning on the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Services for substance abuse disorders are available under Medicare, as long as those services services These necessary. and reasonable are include: reference links to other online Medicare information with further details about these services. Background services are covered Medicare by when reasonable and necessary. The Centers for Medicare & Medicaid Services provides (CMS) a full range of services, including those services provided for substance abuse disorders. This article summarizes the available services and provides What You NeedWhat to Know You While there is no distinct Medicare benefit category for substance abuse treatment, such This MLN Matters suppliers who submit claimsto Medicare Administrative Contractors for substance (MACs) beneficiaries. Medicare services to abuse provided Related CR Transmittal #: Affected Types Provider MLN MattersMLN Related CR Release Date: of Substanceof Services Abuse Coverage SE1604: If you have any questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at Downloads/R192NCD.pdf available at R3515CP.pdf Additional InformationAdditional The official instruction, CR9638, consists of two transmittals. The first contains the actual NCD and is available at February that were 8, 2016, processed prior to implementation of CR9638. they will However, adjust such claims that you bring to theirattention. Note that MACs will not search their files for claims for LAAC with dates of service on or after unprocessable theusing following messages: Finally, failureFinally, to include the clinical trial number will result in MACs returning claim lines as KENTUCKY & OHIO PART A 22

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http://www.ecfr.gov/cgi-bin/ GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. ; as part of the inpatient stay professional (for servicesprovided clinicians by not recognized for separate billing, for instance peer counselors), or to theseparately, professional billing for the provided services if they are recognized under Part B and considered separate from the inpatient stay instance, (for physicians, and NPPs within their state scopes of practice). Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals; Services of other staff (social workers, psychiatric nurses, and trained others) to work with psychiatric patients; Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes (subject to limitations specified - CFR in 410.29) 42 text-idx?SID=56276e89573496d67077d4ea0e27b17c&mc=true&node=pt42.2.410&rgn=div 5#se42.2.410_129 example, licensed clinical social workers, clinical nurse specialists, certified alcohol drug counselors); and Occupational requiring therapy qualified a the skills of occupational therapist. Occupational if required, therapy, must be a component of the physicians treatment the for plan individual; Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed the by State in which they practice (for recognized Medicare. by instance, For Medicare could for pay counseling an enrolled by licensed clinical social psychologist worker, or psychiatrist. Some services could be provided auxiliary by personnel incident services. physician’s to a Medications used in an outpatient setting that are not usually self-administered be may covered under Part B if they meet all Part B requirements. Pursuant to the Social Security Act, Medicare does not recognize substance abuse treatment facilities as an independent provider type, nor is there an integrated payment for the bundle of services those providers provide may (either directly, or incident to a service). physician’s Coverage and payment would be on a service service by basis for those services that are Any medication provided as part of inpatient treatment would be bundled into the inpatient payment and not paid separately. Similar to inpatient treatment, coverage of outpatient treatment would depend on the provider of the services. Professional services provided during that care would be paid either: Inpatienttreatment would be covered if reasonable and necessary. • • • • • • • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com outpatient department and Medicare certified Community Mental Health Center (CMHCs). servicesPHP include: admitted to a PHP must be under the care of a physician who certifies and re-certifies the need for partial hospitalization and require a minimum of 20 hours per week of PHP therapeutic services, as evidencedtheir by plan of care. PHPs be may available in your local hospital The PHP is an intensive outpatient psychiatric treatment day program that is furnished as an alternative to inpatient psychiatric hospitalization. This means that without the PHP services, the person would otherwise be receiving inpatient psychiatric treatment. Patients Partial Hospitalization Program (PHP) Partial Program Hospitalization Outpatient Treatment Inpatient Treatment KENTUCKY & OHIO PART A 23

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on the CMS website. http://www.cms.gov/

https://www.cms.gov/Outreach- https://www.cms.gov/Outreach-and- GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. on the CMS website. Special titled Edition “Partial article Hospitalization SE1512 Program (PHP) ® Clinical nurse specialists; Physician assistants; and, Certified nurse-midwives. Physicians (medical doctor or doctor of osteopathy); Clinical psychologists; Clinical social workers; practitioners; Nurse closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and Medically necessary diagnosticservices related to mental health treatment. Family counseling services for which the primary purpose is thetreatment of the patient’s condition; Patient training and education, to the extent the training and educational activities are • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ ICN904084.pdf or complicate their ability to successfully handle health, work, or family issues. more For information on the Medicare’s SBIRT services,refer to Medicare’s fact sheet, “Screening, Brief Intervention, and Referral (SBIRT) Services” to Treatment at with the disease of addiction enter and stay with easily may treatment. use SBIRT You services in primary care settings, enabling you to systematically screen and assist people who may not be seeking help for a substance use problem, but whose drinking or drug use cause may SBIRT services aim to prevent the unhealthy consequences of alcohol and drug use among those who not may reach the diagnostic of a substance level use and disorder, helping those specialized treatment. This approach differs from the primary focus of specialized treatment of individuals with more severe substance use, or those who meet the criteria for diagnosis of a substance disorder. use Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services SBIRT is an early intervention approach that targets individuals with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or These suppliers of services of These suppliers include: There are individuals under the Medicare Part B program who are authorized as suppliers of services that are eligible to furnish substance abuse treatment services providing the services are reasonable and necessary and fall under their State scope of practice. or psychiatrist. Substance Abuse Treatment Suppliers by of Services Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf Coverage and payment would be for those PHP services that are recognized Medicare. by instance,For Medicare could for pay psychotherapy an enrolled by licensed clinical psychologist MACs for PHP services provided to Medicare CMS beneficiaries. reminds hospitals In SE1512, and CMHCs that provide PHP services to follow existing claims coding requirements given in the “Medicare Claims Processing Manual” Section (Chapter 4, 260) at Claims per Diem Coding Payment Rates” & CY2015 at Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1512.pdf intended for hospitals and Community Mental Health Centers that (CMHCs) submit claims to Similar to inpatient and individual outpatient treatment, coverage of PHP services would depend on the provider ofthe services. MLN Matters KENTUCKY & OHIO PART A 24

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on the Internet).

http://www.integration. , but must include must combination but , ® ). For any new enrollees, any For ). ® on the Internet. GR 2016-07

• on the CMS website. . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ https://www.ssa.gov/OP_Home/ssact/title18/1862.htm tools; BriefIntervention: Engaging a patient showing risky substance use behaviors in a short conversation, providing feedback and advice; and Referral Providing to Treatment: a referral to brief therapy or additional treatment to patients whose assessment or screening shows a need for additional services. Structured Assessment (Medicare) or Screening (Medicaid): Assessing or screening a risky for patient substance behaviors use standardizedusing assessment screening or Qualified perform to specific the services health mental and rendered; Working within their State Scope of Practice Act. Licensed or certified to perform mental health services the by State in which they perform services;the

• • • • • • 3. 2. 1. MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com (NOTE: Methadone(NOTE: is a Part D drug when indicated State for Medicaid pain). Programs may continue to include the costs of methadone in their bundled payment to qualified drug treatment clinics or hospitals that dispense methadone for opioid dependence. A Part D drug is defined, in part, as “a drug that be may dispensed only upon a prescription.” Consequently, methadone is not a Part D drug when used for treatment of opioid dependence because it cannot be dispensed for this purpose upon a prescription at a retail pharmacy. Medicare enrollees timely have access to their medically necessary Part D drug therapies for opioid dependence. CMS requires sponsors a transition to have policy unintended to prevent any interruptions in pharmacologic treatment with Part D drugs during their transition into the benefit. This transition alongpolicy, with CMS’ non-formulary exceptions/appeals requirements, should ensure that all or via an exception, when medically necessary for the treatment of opioid dependence. Coverage is not limited to single entity products such as Subutex products when medically necessary example, (for Suboxone Drugs Used Opioid to Treat Dependence Medicare Part sponsors D include must for Part coverage formulary drugs, D either by inclusion payment for SBIRT services, refer to the “Medicare Claims Processing Manual” (Chapter Section4, 200.6) at Downloads/clm104c04.pdf Medicare for pays these services under the Medicare Physician Schedule Fee and the (PFS) hospital Outpatient Prospective more For Payment System information (OPPS). on Medicare’s problems and furnish limited interventions/treatment. bill Medicare, To suppliers of SBIRT services must be: Medicare for pays medically reasonable and necessary SBIRT services furnished in physicians’ offices physicians (by and non-physician practitioners) and outpatient hospitals. In these settings, you assess for and identify individuals with, or at-risk substance for, use-related or treat patients with signs/symptoms of illness or injury) per the Social Security Act (Section see 1862(a)(1)(A); samhsa.gov/clinical-practice/sbirt/screening Medicare covers only reasonable and necessary SBIRT servicesthat meet the requirements of diagnosis or treatment of illness or injury is, (that when the service is provided and/ toevaluate including the World Health Organization’s Alcohol Use Disorders Identification (AUDIT) Test Manual and the Drug Abuse Screening (DAST). more For information Test on SBIRT assessment and screening tools, as well as examples of tools, visit The first component to the SBIRT process is assessment or screening which uses tools SBIRT consists of three major components: KENTUCKY & OHIO PART A 25

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https://www. https://www. https://www.cms.

on the CMS website. https://www.cms.

on the CMS website. on the CMS website. on the CMS website. on the CMS website. on the CMS website. https://www.cms.gov/Outreach-and-Education/ https://www.cms.gov/Outreach-and-Education/ https://www.cms.gov/Outreach-and-Education/ GR 2016-07

• https://www.cms.gov/Medicare/Prescription-Drug-Coverage/ https://www.cms.gov/outreach-and-education/medicare- https://www.cms.gov/Medicare/Prescription-Drug-Coverage/ https://www.cms.gov/Regulations-and-Guidance/Guidance/ on the CMS website. on the CMS website. on the CMS website. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ . © 2016 Copyright, CGS Administrators, LLC. Number: SE1105 (Medicare See Number: Drug Screen SE1105 Testing): ® on the CMS website. on the CMS website. Medicare covers diagnostic clinical laboratoryMedicare diagnostic covers necessary services and reasonable are diagnosis the for that The Prescription Opioid Epidemic (CCSQ Grand Rounds Webinar); see see Webinar); Grand Rounds PrescriptionThe (CCSQ Opioid Epidemic cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/ Downloads/The-Prescription-Opioid-Epidemic.pdf (includes coding 2016 CY and policy information for drugs See of abuse): cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/ CY2016-CLFS-Codes-Final-Determinations.pdf MLN Matters gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ downloads/SE1105.pdf items/2015-11-03.html “Prescription Drug Monitoring Programs: A Resource to Help Address Prescription Drug Abuse and Diversion”: See learning-network-mln/mlnmattersarticles/downloads/se1250.pdf Clinical 2016 (CY) “CalendarLaboratory Year Schedule Fee Final Determinations” (CLFS) in Medicare Part See D”: PrescriptionDrugCovContra/Downloads/AHIP_Overutilization_Strategies_CMS_-10192015. pdf “New Medicare Part D Opioid Drug See Available”: Mapping Tool gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases- Manuals/Downloads/ncd103c1_Part2.pdf “Medicaid Program Integrity What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs?” Sheet: Fact See Medicare-Learning-Network-MLN/MLNProducts/Downloads/Drug-Diversion-ICN901010. pdf “Effective Strategies for Addressing Overutilization and Abuse of Prescription Drugs National Coverage Determinations Inpatient (NCDs): Hospital Stays for the Treatment Outpatient Hospital Servicesof Alcoholism of Alcoholism (130.1); for Treatment (130.2); Chemical & Electrical Aversion Therapy of Alcoholism for Treatment 130.4); (130.3, of AlcoholismTreatment and Drug Abuse Treatment in a Freestanding Clinic (130.5); of Drug Abuse Withdrawal (Chemical for Narcotic Treatments Dependency) (130.6); See Addictions (130.7): “Summary of Medicare Reporting and Payment of Services for Alcohol and/or Substance Abuse (Other Structured than Tobacco) Assessment and Brief Intervention (SBIRT) Services;” see Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1013.pdf the CMS website. “Mental Health Services” Booklet: see Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mental-Health-Services- Booklet-ICN903195.pdf • • • • • • • • • • • • • • • • • • • • MLNProducts/Downloads/Clinical-Laboratory-Fee-Schedule-Fact-Sheet-ICN006818.pdf or treatment ofan illness or injury. For beneficiaries being treated forsubstance abuse, testing for drugs of clinical necessary the laboratory Information on and reasonable treatment. when their abuse manage can help fee schedule is available at Note: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Providers want to review may the following resources: Additional InformationAdditional PrescriptionDrugCovContra/downloads/chapter6.pdf See the “Medicare Prescription Drug Benefit Manual” (Chapter6, Section (Drugs10.8 Used Opioid Dependence)) at to Treat KENTUCKY & OHIO PART A 26

JULY 2016 JULY RETURN TO . http:// TABLE OF CONTENTSTABLE CR 9603 July 5, 2016 July 5,

July 1, 2016 July 1,

Special Edition Medicare Medicare Edition Special

Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1. 1.866.590.6703 GR 2016-07

• article. ThisMLN Matters article and other CMS articles can be found April 29, 2016 R3508CP MM9603 . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Article is intended for physicians, providers, and suppliers submitting ® JW Modifier: JW Drug Amount (MLN) Matters ® Number: Number: ® Document the discarded drug or biological in the patient’s medical record when submitting claims with unused Part drugs B or biologicals from single use vials or single use packages that are appropriately discarded Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded those (except provided under the Competitive Acquisition Program for Part (CAP) B drugs and biologicals)and • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network Learning on the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3508CP.pdf questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at Additional InformationAdditional The official instruction, CR9603, issued to your MAC regarding this change is available at Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier claims for all with discarded Part drugs B biologicals. and allows MACs the discretion to determine whether to require the JW modifier for claims any with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented. The “Medicare Section Claims Processing 40 provides policy Chapter Manual,” 17, detailing the use of the JW modifier for discarded Part B drugs and biologicals. The current policy Make sure that your billing staffs are aware of these changes. Remember that the JW modifier is not used on claims for CAP drugs and biologicals. Background Effective providers 2016, July are 1, required to: The Centers for MedicareMedicaid & Services issued (CMS) Change 9603 Request (CR) to alert MACs and providers of the change in policy regarding the use ofthe JW modifier for discarded Part B drugs and biologicals. Medicare beneficiaries. Needed Action Provider This MLN Matters claims to Medicare Administrative Contractors for drugs (MACs) or biologicals administered to Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN MM9603: Patient to any Administered Discarded/Not Drugs Biologicals and KENTUCKY & OHIO PART A 27

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CR 9636 July 5, 2016 July 5,

Type of ServiceType (TOS) Code 1 4 4 January 1, 2016 January 1,

Medicare Learning Learning Medicare , and will codes TOS have of 1 Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

, new Healthcare Common Procedure Coding . Claims for Q5102 must also. Claims the have modifier for Q5102 April 5, 2016 1.866.590.6703 GR 2016-07

Long Description Long Rolapitant, oral, 1 mg Flutemetamol diagnostic, F18, per study millicuries 5 to up dose, Florbetaben diagnostic, f18, per study millicuries 8.1 to up dose, • July 2016 1, April 5, 2016 May 6, 2016 R3518CP MM9636 MM9636 . © 2016 Copyright, CGS Administrators, LLC. article. ThisMLN Matters article and other CMS articles can be found on Article is intended for physicians, providers, and suppliers submitting https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Quarterly Healthcare Common Procedure Quarterly Procedure Common Healthcare Number: Number: diagnostic Short Description 1mg oral, rolapitant, flutemetamol f18 diagnostic florbetaben f18 ® . (MLN) Matters ® https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ Network the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Q9983 Q9981 Q9982 HCPCS Code MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com If you have any questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at The official instruction, CR9636, issued to your MAC regarding this change, is available at R3518CP.pdf and P. In addition, must claims also the have modifier forand Q5102 P. ZB (Pfizer/hospira). InformationAdditional Also, the as HCPCS of July 1, code set will contain (short code descriptor Q5102 – Inj., infliximab biosimilar – and long descriptor – Injection, will Infliximab, Code Q5102 mg). 10 be effective for dates of service on or after The HCPCS code set is updated on a quarterly basis and CR9636 provides that effective the HCPCS 2016, July 1, codes contained in the following tablewill be established: ZB (Pfizer/hospira). Make sure that your billing staffs are aware of these changes. Background Q9983 (florbetaben diagnostic) will f18 be payable for Medicare.In addition, the HCPCS code set will contain infliximab (Inj., code Q5102 biosimilar), which is effective for dates of service on or after Change 9636 Request (CR) informs Medicare providers and suppliers that effective for claims with dates of service on or after System(HCPCS) codes Q9981 Q9982 (rolapitant, oral, (flutemetamol 1mg); diagnostic); and f18 Medicare beneficiaries. Needed Action Provider This MLN Matters claims to Medicare Administrative Contractors including (MACs), Durable Medical Equipment MACs (DME and Home MACs) Health & Hospice (HH&H) MACs for services provided to Provider Types Affected Types Provider MLN MattersMLN Related CR Release Date: Related CR Transmittal #: Changes - July 2016 Update 2016 - July Changes MM9636: MM9636: Code Drug/Biological CodingSystem (HCPCS) Drugs Biologicals and KENTUCKY & OHIO PART A 28

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4-5-16 7-1-16 7-1-16 7-1-16 Effective Date CR 9633 July 5, 2016 July 5,

January 1, 2016 January 1,

no RVUs no RVUs no RVUs no RVUs RVU Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: Procedure Status Procedure E E E E

GR 2016-07

• May 20, 2016 May 20,2016 R3528CP MM9633 . © 2016 Copyright, CGS Administrators, LLC. article. ThisMLN Matters article and other CMS articles can be found on Short Descriptor infliximab biosimilarInj., 1mg oral, rolapitant, flutemetamol diagnostic f18 florbetaben diagnostic f18 Article is intended for physicians, other providers, and suppliers who submit Bilateral Indicator = 1 PC/TC indicator = 3 Action Multiple Surgery Diagnostic = 0; Imaging Family Indicator = 99 Procedure Status = C (Effective for services on or after 7-1-2016.) Multiple Surgery Indicator = 0 Multiple Surgery Indicator = 0 Endo Base Code = 45330 Multiple Surgery Indicator = 0 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Quarterly to the Update Physician Medicare Number: Number: ® (MLN) Matters ® Network the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Q9982 Q9983 CPT/HCPCS Code Q5102 Q9981 69209 45346 61651 65855 10036 37188 CPT/HCPCS G0296 G9678 MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com The following new codes in CR9636 have also been added to the MPFSDB. effective for dates of service on and after January 2016. 1, The changes key for the July update, effective as of January are 2016, as 1, follows. Key ChangesKey in CR9633 Unless otherwise stated, the changes included in the July update MPFSDB to the 2016 are Background of the SocialSection Security 1848(c)(4) Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services. paymentfiles are to be effective for services furnished between Januaryand December2016, 1, Make sure your billing 2016. staff31, is aware of these changes. Provider Action Needed Action Provider Change 9633 Request (CR) amends payment files that were issued to your MAC based upon MPFS Final Rulethe 2016 published CY in theFederal Register These on November 2015. 16, claims to Medicare Administrative Contractors for services (MACs) provided to Medicare beneficiaries. Provider Types Affected Types Provider This MLN Matters MLN MattersMLN Related CR Release Date: Related CR Transmittal #: Year (CY) 2016 Update (CY) 2016 Year MM9633: MM9633: Calendar - July (MPFSDB) Database Schedule Fee Fee Schedule KENTUCKY & OHIO PART A 29

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and choose Option 1. . 1.866.590.6703 GR 2016-07

• including fitting, insertion, training, and bilateral or unilateral Subsequent placement of a drug-eluting ocular insert under one or more including insert, re-training, existing eyelids, of or unilateral removal and bilateral Myocardial contrast perfusion echocardiography; rest at or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code primary for procedure) Ablation, percutaneous, cryoablation, includes upper guidance; imaging extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes lower guidance; imaging extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes nerve guidance; imaging plexus or other truncal nerve brachial (eg, plexus, pudendal nerve) Real time spectral analysis of prostate tissue fluorescence by spectroscopy Initial placement of a drug-eluting ocular insert under one or more eyelids, Long Descriptor Long Implantation of non-biologic or syntheticimplant polypropylene) (eg, for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure) biodegradable peri-prostatic placement of material, (via Transperineal includes single multiple, or image guidance needle), . . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- R-t spctrl alys prst8 tiss plmt drug1st elut oc ins Sbsqt plmt drugelut oc ins Abltj perc uxtr/perph nrv Abltj perc lxtr/perph nrv Abltj perc plex/trncl nrv abdl wal plmt Tprnl biodegrdabl matrl Myocrd contrast prfuj echo Short Descriptor Impltj synth rnfcmt http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ Note: MACs will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims brought to their attention. 0445T 0444T 0442T 0443T 0441T 0439T 0440T 0438T 0437T CPT Code MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Downloads/R3528CP.pdf questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at The official instruction, CR9633 issued to your MAC regarding this change is available at Additional InformationAdditional Diagnostic Procedures = 09, and Diagnostic Imaging Family = 99. The Global Surgery for Days and 0443T 0439T, 0437T, = ZZZ; the rest are YYY. There are no RVUs for these codes, and the following payment policy indicators are the same for each code: Procedure Status Multiple = C, Surgery Bilateral = 0, Surgery Assistant = 0, at Surgery Co-Surgeons = 0, Surgeons PC/TC = 0, Team = 0, Physician = 0, Supervision of The new CPT Category III codes listed below been have added to the MPFSDB effective for dates of service on and after 2016. July 1, MLN/MLNMattersArticles/Downloads/MM9636.pdf CPT Codeseffective on or after July 2016 1, For moreFor informationon the codes in CR9636, want you review to may therelated MLN Matters Article MM9636 at KENTUCKY & OHIO PART A 30

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CR 9599 October 3, 2016 3, October

April 21, 2016 April 21,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date:

GR 2016-07

• April 29, 2016 R1654OTN MM9599 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article submitting is Care intended Hospitals for claims Long-Term (LTCHs) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® System Changes to Implement Section 231 of Section to Implement of SystemChanges 231 Number: Number: ® (MLN) Matters ® diagnosis; or diagnosis; beenHave admitted directly from an IPPS hospital discharge and is the LTCH assigned to an MS-LTC-DRG based on the receipt of ventilator services of at least 96 hours, but must a principal not have of a psychiatricdiagnosis or in the LTCH rehabilitation diagnosis. Have beenHave admitted directly from an IPPS hospital during which at least were 3 days spent in an Intensive Care Unitor (ICU) Coronary Care but the Unit discharge (CCU), must a principal not have of a psychiatric diagnosis or in rehabilitation the LTCH

2. 1. MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com a “severe wound.” Thea “severe final wound.” payment for discharges that meet the statutory provider-level and prior to January 1, 2017, from LTCHs “identified of from LTCHs the by amendmentprior made Section to January by 2017, 4417(a) 1, the Balanced Budget Act of 1997” and “located in a rural area” or “treated as being so located” pursuant to Section of the Social 1886(d)(8)(E) Security Act when the individual discharged had from the site neutral payment rate for certain patients discharged from certain before LTCHs 2017. January 1, As implemented, this exception applies to discharges occurring on or after and 2016, April 21, Section of the Consolidated 231 Appropriations Act, establishes 2016, a temporary exception LTCH discharge either: must LTCH Payment System (IPPS)-comparable” payment amount or 100 percent of the estimated cost of case). the In general, PPS in standard order to be paid Federal at the rate payment LTCH amount, an categories patients cases upon discharge. for meeting LTCH specific LTCH clinical criteria are PPS standardpaid Federal the rate payment LTCH and those cases not meeting specific clinical criteria are paid the site neutral rate payment is, (that the lesser of an “Inpatient Prospective Under the LTCH Prospective Payment System (PPS), for LTCH discharges ProspectiveUnder in for cost Payment the LTCH System LTCH (PPS), reporting periods beginning on or after Medicare October 2015, established 1, two separate payment discharges from the site neutral payment rate for certain Make sure your billing staffs LTCHs. are aware of this exception. Background Provider Action Needed Action Provider Change 9599 Request (CR) implements a temporary exception for certain wound care This MLN Matters beneficiaries. Medicare servicesto for provided (MACs) Contractors Administrative Medicare to Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN Exception for Certain Severe Wound Discharges From From Discharges Certain for Exception Wound Severe Hospitals Care (LTCHs) Certain Long-Term MM9599: Temporary 2016, Act, Appropriations the Consolidated Hospital KENTUCKY & OHIO PART A 31

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GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com HwH LTCHs (defined above) to apply to their (defined above) CMSHwH Regional LTCHs Office for treatment as being located in a rural area for the sole purpose of qualifying for this temporary exclusion from the application of the site neutral payment rate. 1886(d)(8)(E) of the Act for1886(d)(8)(E) the temporary statutory exclusion for certain discharges LTCH from the site neutral payment rate, CMS revised its regulations to “borrow” the existing rural reclassification process and to allow grandfathered for urban IPPS hospitals under § 412.103 on CMS’ policies for IPPS hospitals located in urban areas and that apply for reclassification as can PPS final be found rule in the IPPS/ FY (76 51595).) FR LTCH 2012 rural under § 412.103 theFor purpose of implementing the phrase “treated as being so located” pursuant to Section Section of the Act provides 1886(d)(8)(E) for an urban IPPS hospital that is located in an urban area to be reclassified as a rural hospital if it submits an application in accordance with CMS’ established criteria and meets certain (Additional information conditions Section (see 412.103). (Information on the current labor market area geographic classifications used under the LTCH PPS is PPS available final in the IPPS/LTCH FY rule 2015 (79 through 50180 FR 50185)). “located in a rural that are currently area” refers to LTCHs located in a rural area as defined is, (that locatedunder § 412.503 area in any outside an urban area, which is an area within a Metropolitan Statistical Area defined (as the by Office of Management and Budget)). The temporary statutory exclusion for certain discharges from the site neutral payment rate is further limited to grandfathered that are “located HwH LTCHs in a rural area” or “treated as being so located” pursuant to Section of the Act. 1886(d)(8)(E) purposes For of this provision, 412.22(f) can be412.22(f) found in the following IPPS rules: FY IPPS 1997 final FY rule 46012); FR (62 2004 IPPS final rule (68 45463); FR PPS interim May 22, 2008 final rule LTCH with comment PPS final 43980). FR periodrule and (74 FY IPPS/RY LTCH (73 29703); FR 2010 2010 temporary exception from the site neutral payment rate for certain wound care discharges. This process will likely direct involve in order outreach to verify to LTCHs the required information. Additional information on the requirement that grandfathered HwHs meet the criteria in § examples are not intended to be an exhaustive not may meet list the of the reasons an LTCH criteria in MACs Section must described verify 412.22(f)). that an in LTCH Section 412.23(e)(2) currently(i) meets the criteria in Section to be eligible in order 412.22(f) for for the this LTCH of beds. There are several may reasons described for which an in LTCH Section 412.23(e)(2)(i) not currently meet the criteria more have may than in Section example, For the LTCH 412.22(f). one location, or the HwH increased have may beds after September 30, 2003 (CMS notes these requirements of Section 412.22(f). of requirements Section requires 412.22(f) that, in order to maintain grandfathered status, an HwH must continue to operate under the same terms and conditions including but not limited to the number by anotherby hospital or on the campus of another hospital). Therefore, in order to be eligible for this temporary participated must have exception, an LTCH and in Medicare have as an LTCH been co-located with another hospital as of September 30, 1995, and must currently meet the meet the criteria of Section which commonly are 412.22(f), a group referred of LTCHs to as “grandfathered hospitals-within-hospitals” grandfathered (or An Note: HwH HwHs). is defined in as a hospitalthe which regulations occupies CFR 412.22(e) at 42 space in a building also used paymentrate is that applicable is “identified to an LTCH the by amendment made Section by As discussed of the Balancedin the CMS Budget IFC, has Actinterpreted of 1997.” 4417(a) the phrase to mean hospitals which that are described CFR in Section 42 412.23(e)(2)(i) Provider-Level Criteria: Provider-Level The statute specifies that the temporary exclusion for certain discharges from the site neutral from the site neutral payment rate was implemented in an interim finalrule with comment period (published (IFC) inthe Federal Register on 2016). April 21, discharge-level criteria as implemented the by Centers for Medicare Medicaid & Services (CMS) PPS standardis based Federal on the payment LTCH rate. This temporary statutory exception KENTUCKY & OHIO PART A 32

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• . © 2016 Copyright, CGS Administrators, LLC. . Under the CMS definition of wound, the ICD-10 diagnosis codes used to identify severe wounds in the This policy only allowsgrandfathered to applyfor HwH this LTCHs reclassification, and the rural treatment Note: osteomyelitis category are also part of the ICD-10 diagnosis codes used to identify severe wounds in the fistula category so no separate identification of ICD-10 codes for osteomyelitis is necessary. rate, and reclassifying grandfathered will not be treated HwH LTCH as rural PPS for other any under the LTCH reason including, but not limited the to, 25 percent policy and Any wage rural index). treatment under the provisions for a grandfathered will expire the at HwH same LTCH timeof § 412.103 as this temporary provision is, (that December 2016). 31, Note: only extends to this statutory temporary exception for certain wound care discharges from the site neutral payment MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com diagnosis codes listed on the CMS website mentioned is above present. The claims shall be MACs will reprocess claims with a through date interim (for or a discharge claims) date (for final on or claims) after through when 2016 April December the 2016, Temporary Relief 21, 31, onIndicator the Provider Specific for an LTCH File (PSF) equals ‘Y’ and one of the ICD-10 reclassified rural) grandfathered will generate HwH a standard LTCHs Federal payment rate payment for the claim is, (that exclusion from the site neutral consistent payment rate) with this statutory PPS Pricer provision and in the claims LTCH processing system. will then place the payer-only condition code “M4” on the claim for processing. The presence of that designated payer-only condition code on the claim for qualifying rural (or “infected wound” as “a wound with infection requiring complex, continuing care including local wound care occurring has a discharge meeting If an LTCH multiple this definition times day.” a of “wound with morbid obesity” or “infected will inform wound” its the MAC, LTCH and the MAC by usingby specified “payer-only” condition codes. the For purposes of this provision, CMS has defined a “wound with morbid obesity” as “a wound in those with morbid obesity that require complex, continuing care including local wound care occurring multiple times a day” and an The remaining two statutory categories included in the definition of “severe wound” (infected wound and wound with morbid obesity) lack diagnosis ICD-10 codes with sufficient specificity to identify the presence of a “severe” wound, so claims containing such wounds willbe identified https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/ download.html For sixFor of the eight statutory categories included in the definition of “severe wound” (stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, fistula, and CMSosteomyelitis), is using the list diagnosis of ICD-10 codes found on the CMS website at the claim where diagnosis ICD-10 codes contain sufficient specificity for this purpose or through the use of a payer-specific condition code where the diagnosis ICD-10 codes lack sufficient specificity purpose. this for To implement this statutoryTo definition, CMS has defined wound as “an injury, usually involving division of tissue or rupture of the integument or mucous membrane with exposure to the implementexternal this environment.” definition, To CMS is using diagnosis ICD-10 codes on wound” as, “a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, infected wound, fistula,osteomyelitis, or wound with morbid obesity as identified in the claim from the long-term care hospital.” As implemented, the statutory temporary exclusion for certain discharges from the site neutral payment rate for certain is applicable LTCHs to discharges occurring on or after 2016, April 21, and on or before that The had December 2016, a “severe statute wound.” defines 31, a “severe Discharge-Level Criteria: Discharge-Level (that is,(that as of the filing date ofthe application as specified in § 412.103). reclassify theexception as rural from theunder site the neutral provisions payment of § 412.103, rate forqualifying discharges is effective beginning the effective date of the rural reclassification For grandfatheredFor that qualify HwH LTCHs for thistemporary exception for certain wound care discharges from the site neutral payment applying rate by for and satisfying the criteria to KENTUCKY & OHIO PART A 33

JULY 2016 JULY RETURN TO

. TABLE OF CONTENTSTABLE http://

CR 9601 October 3, 2016 3, October

January 1, 2016 January 1,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

1.866.590.6703 GR 2016-07

• April 28, 2016 R1649OTN MM9601 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for physicians, other providers, and suppliers submitting https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Phase 2 of Updating the 2 of Phase Fiscal Intermediary Number: Number: ® (MLN) Matters ® the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com 2015. The ASP2015. rates for drugs furnished on or after were April not available 2016, until mid- 1, March The ASP 2016. rates for drugs furnished on or after will not 2016, be available July 1, complexity, volume of data, and the number of drugs affected, approximately 6 weeks are required to process, validate, and issue final ASPs for a given quarter. As a result, the ASP rates for drugs furnished on or after January were not available 2016, until mid-December 1, Average Sales Price methodology. (ASP) The schedule for submission of all ASP pricing is statutory of the Medicare per Section Modernization 621(a) Act. Drug manufacturers are required to submit drug ASPs within 30 of the days close of their fiscal quarter. Given the Background The Centers for Medicare & Medicaid Services for pays all outpatient (CMS) drugs using the changes necessary to the Fiscal Intermediary Shared and System Integrated (FISS) Outpatient Code Editor (IOCE) which are necessary payment to make for drugs and biologicals to OPPS providers. Makesure that your billing staffs are aware of these changes. Provider Action Needed Action Provider Change 9601 Request (CR) informs MACs about the implementation of phase 2 of system claims to Medicare Administrative Contractors including (MACs), HomeHealth & Hospice MACs and Durable Medical Equipment MACs (DME for services MACs) provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS). Provider Types Affected Types Provider This MLN Matters MLN MattersMLN Related CR Release Date: Related CR Transmittal #: Biologicals Services Outpatient for Prospective Payment Providers System (OPPS) MM9601: Drugs and for Payment Make to (FISS) System Shared the CGS Provider Contact Center at Hospital The official instruction, CR9599 issued to your MAC regarding this change is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1654OTN.pdf questions, any If you have please contact a CGS Customer Service Representative calling by after the effective date of the rural reclassification. InformationAdditional qualifying LTCH. which ClaimsNote: are treated for LTCHs as rural for the purposes of this provision will be reprocessed with a through date interim (for or a discharge claims) date final (for on or claims) date final(for on or claims) after through processed2016, April December 2016, 21, prior 31, to implementation of CR9599 or after when brought the to attention of the a MAC by reprocessed within60 from days the implementation dateof this change request.MACs will inpatientadjustclaims impactedwith LTCH a through dateinterim (for or a discharge claims) KENTUCKY & OHIO PART A 34

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• . © 2016 Copyright, CGS Administrators, LLC. MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com of the cap on the drug lines. $1,588.00 is greater than $1,288.00. The OPPS Pricer will cap the coinsurance amount to be applied on the highest wage adjusted national coinsurance procedure line prior to application DrugLine D has a fee of $500.00, a payment of $400.00 and coinsurance of $100.00. Highest wage adjusted national coinsurance amount for a procedure line is $1,588.00. The Inpatient Part A deductible is $1,288.00 for 2016 DrugLine B has a fee of $1,000.00, a payment of $800.00, and coinsurance of $200.00. DrugLine C has a fee of $500.00, a payment of $400.00 and coinsurance of $100.00. DrugLine A has a fee of $2,000.00, a payment of $1,600.00, and coinsurance of $400.00. Example 2 of inpatient deductible capped amount: DrugLine C has a final payment of $450.00, and coinsurance of $50.00. DrugLine D has a final payment of $450.00, and coinsurance of $50.00. 50% back into the payment amount. Drug Line A has a final payment of $1,800.00, and coinsurance of $200.00. Drug Line B has a final payment of $900.00, and coinsurance of $100.00. due to inpatient deductible cap Apply 50% reduction of the coinsurance amounts for each line and add the remaining Drug Lines A-D coinsurance is $800.00. $400.00 cap remaining/$800.00 coinsurance drug line(s) = 50% reduction to coinsurance The Inpatient Part A deductible is $1,288.00 for 2016 $1,288.00 - $888.00 = $400.00 remaining coinsurance to be applied toward inpatient deductible cap. Drug Line D has a fee of $500.00, a payment of $400.00 and coinsurance of $100.00. Highest wage adjusted national coinsurance amount for a procedure line is $888.00. Drug Line B has a fee of $1,000.00, a payment of $800.00, and coinsurance of $200.00. Drug Line C has a fee of $500.00, a payment of $400.00 and coinsurance of $100.00. amount: Example 1 of inpatient deductible capped amount: Drug Line A has a fee of $2,000.00, a payment of $1,600.00, and coinsurance of $400.00. deductible amount for each calendar year and to insure the rural floor is applied. The following examples are part of CR9601 to demonstrate the capped inpatient deductible fee schedule amount will be used FISS by to price covered outpatient drugs, and drugs and biologicals with pass-through status under the OPPS. Phase 2 includes logic for FISS to cap the coinsurance amounts for procedures (which include blood and drug services) to the inpatient hospital setting). Starting on drug October 2016, HCPCS 1, on OPPS claims will no longer be priced the by Outpatient PPS Pricer. The feeschedule amount from the ASP drug file or future any drug were an exception to this process. Payment for OPPS claims were based on tables provided to the OPPS Pricer to account for some of the special processing rules that are unique to OPPS providers as, pass-through (such status necessary and drugs provided solely in the CMS supplies MACs with theASP drug pricingfiles for Medicare Partdrugs B on a quarterly basis and this file is used for payment to most institutional providers FISS. by OPPS claims until mid-Juneand the ASP2016 rates for drugs furnished on or after willOctober not 2016, 1, respectively. mid-September 2016 until available be KENTUCKY & OHIO PART A 35

JULY 2016 JULY RETURN TO . TABLE OF CONTENTSTABLE http://

CR 9658 July 5, 2016 July 5,

July 1, 2016 July 1,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1.

1.866.590.6703 GR 2016-07

• May 13, 2016 May 13, R3523CP MM9658 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for providers and suppliers who submit claims to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® July 2016 Update of the Hospital of Update 2016 July Number: Number: ® (MLN) Matters ® the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Hospital OPPS (CR9549), replace the instructions discussed OPPS in the final 2016 rule at 80 70401-70402 FR and in the January Update of the 2016 Hospital Outpatient Prospective (CR9486).Payment System The (OPPS) effective date of these instructions is January 2016. 1, The revised Intensity Modulated Radiation Therapy (IMRT) planning billing instructions (in the paragraph, that below), were also included in the April Update of the 2016 Key changesKey to and billing instructions for various payment policies implemented in the July OPPS updates2016 are as follows: InstructionsBilling IMRT for Planning staffs are aware of these changes. PointsKey of CR9658 Procedure Coding System (HCPCS), Ambulatory Payment Classification HCPCS (APC), Modifier, and Code Revenue additions, changes, and deletions that are reflected in the July Integrated2016 Outpatient Code Editor (I/OCE) and OPPS Pricer. Make sure that your billing Provider Action Needed Action Provider 9658 describes (CR) variousChange Request payment instructions billing and changes to, for, policies implemented in the OPPS July update. 2016 It identifies the Healthcare Common MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient (OPPS). System Payment Prospective Provider Types Affected Types Provider This MLN Matters Medicare Administrative Contractors including (MACs), Home Health and Hospice (HH&H) Related CR Release Date: Related CR Transmittal #: MLN MattersMLN MM9658: System (OPPS) Outpatient Prospective Payment the CGS Provider Contact Center at Hospital www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1649OTN.pdf questions, any If you have please contact a CGS Customer Service Representative calling by Additional InformationAdditional The official instruction, CR9601 issued to your MAC regarding this change is available at Drug LineB has a final paymentof $1,000.00, and no coinsurance. Drug LineC has a final payment of $500.00, and no coinsurance. Drug LineD has a final payment of $500.00, and no coinsurance. $0 cap remaining / $800.00 = 100% reduction to coinsurance due to inpatient deductible cap Drug Line A has final a payment of $2,000.00, and no coinsurance. Drug Lines A-D coinsurance is $800.00. KENTUCKY & OHIO PART A 36

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https://www.cms.gov/

, respectively. , GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- , and Using an Advance Beneficiary Notice of Noncoverage for a service that would be bundled into another service if billed to Medicare In the rare that event a blepharoplasty is performed on and one a blepharoptosis eye repair is performed on the other the services eye, must each be billed with the appropriate RT or modifier. LT Billing for two procedures when two surgeons divide the work of a blepharoplasty performed with blepharoptosis a repair Using modifier 59 to unbundle the blepharoplasty from the ptosis repair on the claim form; this applies to both physicians and facilities medicallyTreating necessary surgery as cosmetic for the purpose of charging the beneficiary for a cosmetic surgery Performing a blepharoplasty on a different date of service than the blepharoptosis procedure for the purpose of unbundling the blepharoplasty or charging the beneficiary for surgery cosmetic a Performing blepharoplasty as a staged procedure, either one by or more surgeons (note that under certain circumstances a blepharoptosis procedure could be a staged procedure) eyelid surgery eyelid Charging the beneficiary cosmetic additional for a an amount blepharoplasty when a performed is repair blepharoptosis Charging the beneficiary orbital additional for removing an amount when a fat performed repaiis blepharoptosis a or blepharoplasty Operating on the left and right on eyes different when days the standard of care is bilateral • • • • • • • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com other services) in the update. July 2016 (CytopathThe SI for CPTc/v code interpret) 88141 will change from SI=Q4 to SI=N in the July update. 2016 The SI for CPT code 85396 (Clotting assay whole blood) will change from SI=Q4 (Conditionally packaged laboratory to SI=N tests) (Paid under OPPS; payment is packaged into payment for Revised Status Indicators for (SIs) Pathology CPT Codes for a cosmetic procedure regardless of the amount of upper eyelid skin that is removed on a patient receiving a blepharoptosis repair because of upperamount) eyelid removal skin of (any is part of the blepharoptosis In addition, repair. the following are not permitted: Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is surgery. blepharoptosis part the a considered of A blepharoplasty cannot be billed to Medicare and the beneficiary cannot be separately charged The Centers for Medicare & Medicaid Services payment policy (CMS) does not allow separate payment for a blepharoplasty procedure (CPT codes in addition 15822, 15823) to blepharoptosis a procedure (CPT codes 67901-67908) on the ipsilateral upper eyelid. MLN/MLNMattersArticles/Downloads/MM9486.pdf BlepharoplastyRepair Blepharoptosis and Eyelid Upper The MLN Matters articles related to CRs 9549 and 9486 are available at Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/ MM9549.pdf payment for CPTcode should 77301 notreport (IMRT You planning). these codes in addition to CPT code when 77301, provided prior or to, as part the of, developmentof theIMRT plan. These instruction state that payment for the services identified CPTby 77280, codes 77014, 77285, 77290, 77295, 77306 and are 77370 included through 77331, in the 77321, APC KENTUCKY & OHIO PART A 37

JULY 2016 JULY SI N N Q4 Q4 RETURN TO )

TABLE OF CONTENTSTABLE

https://www.cms.gov/Medicare/ GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. https://www.federalregister.gov/articles/2015/11/13/2015-27943/medicare- or review, under physician supervision physician under review, or any pharmacologic additive(s), as indicated, including as interpretation written and report, pharmacologicany per day additive(s), Cytopathology, cervical reporting or vaginal (any requiring system), interpretation physician by Cytopathology, cervical reporting or vaginal (any collected system), in preservative fluid, supervision physician under system, automated screening by preparation; layer thin automated Cytopathology, cervical reporting or vaginal (any collected system), in preservative fluid, automated thin layer preparation; with screening automated by system and manual rescreening Long Descriptor Long Coagulation/fibrinolysis whole assay, blood viscoelastic (eg, clot assessment), including use of . 88175 88141 88174 HCPCS Code 85396 Table 1 – PathologyTable CPT Codes with Revised SIs MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com since it will be replaced with Category III CPT code 0438T effective CPT code 2016. July 1, 0438T will be assigned to the same SI and APC assignment as its predecessor HCPCS code effectiveC9743 2016. July 1, Updates.html Please note that HCPCS will be (Also code deleted 2) listed June C9743 in 30, Table 2016, for these codes 2. Payment are rates shown for in these Table services are available in Addendum B of the OPPS July Update 2016 that is posted at Medicare-Fee-For-Service-Payment/HospitalOutpatientpps/Addendum-A-and-Addendum-B- following July, and in July, for implementation for the For beginning the following January. July, in and following July, update,July CMS 2016 is implementing in the OPPS nine Category III CPT codes that the AMA released in January for implementation 2016 The SIs 2016. and on July APCs 1, Category III CPT Codes Effective July 2016 1, The American Medical Association (AMA) releases Category III Current Procedural Terminology (CPT) codes twice per year: in January, for implementation beginning the instead should be reported with Code Revenue 0940 (Other Therapeutic Services). The SI for this revenue code will be changed from SI=B to SI=N, indicating that the payment for these services will be packaged into the C-APC payment. on the same claim as a comprehensive APC procedure. Non-therapy outpatient department services that are adjunctive or J2 procedures toJ1 should be reported without a CPT code and (SI = J2), should not = J2), be reported(SI with therapy CPT codes. This includes services described namely outpatient physicalat 1833(a)(8), outpatient therapy, speech-language pathology and non-therapists or therapists included furnishedand by occupational either therapy outpatient 80 70326 FR at program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment or the specific combination of services assigned to the Observation Comprehensive APC 8011 Effective for claims received on or after with 2016, dates of service July 1, on orafter January non-therapy 2015, 1, outpatient department services are (that similar to therapy services) that are adjunctive to a comprehensive APC procedure procedure) indicator (status (see = J1 (SI) Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (“Non-Therapy Outpatient Department Services”) That AreAdjunctive to Procedures APC Comprehensive These codes, their Descriptors, and Status Indicators are listed in table 1. The SI for (Cytopath CPT code c/v88175 auto fluid will change redo) from SI=N to SI=Q4 in the update.July 2016 The SI for CPT code 88174 (CytopathThe SI forCPT c/v code auto in fluid) 88174 will changefrom SI=N to SI=Q4 in the update.July 2016 KENTUCKY & OHIO PART A 38

5374 July 2016 APC OPPS N/A 5374 N/A 5361 5361 5361 5373 N/A N/A JULY 2016 JULY RETURN TO

T July 2016 OPPS SI N T N J1 J1 J1 T N N TABLE OF CONTENTSTABLE

06/30/2016 Term Date

10/01/2015 Add Date 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016 07/01/2016

. https://www.cms.gov/Medicare/Medicare- . GR 2016-07 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

• . © 2016 Copyright, CGS Administrators, LLC. eyelids, including insert, re-training, existing eyelids, of unilateral removal and bilateral or Injection/implantation of bulking or spacer material type) with (any or without image guidance to be used (not if a more specific code applies) Ablation, percutaneous, cryoablation, includes nerve guidance; imaging plexus or other truncal nerve brachial (eg, plexus, pudendal nerve) Real time spectral analysis of prostate tissue fluorescence by spectroscopy Initial placement of a drug-eluting ocular insert under one or more including fitting,eyelids, insertion, training, and bilateral or unilateral Subsequent placement of a drug-eluting ocular insert under one or more for assessment of myocardial ischemia or viability (List separately in primary to addition procedure) Ablation, percutaneous, cryoablation, includes upper guidance; imaging extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes lower guidance; imaging extremity distal/peripheral nerve Implantation of non-biologic or synthetic implant polypropylene) (eg, for fascialaddition in reinforcement separately to the (List abdominal of wall primary procedure) biodegradable peri-prostatic placement of material, (via Transperineal includes single multiple, or image guidance needle), Myocardial contrast perfusionechocardiography; rest at or with stress, Long Descriptor Long payment files. payment Drugs and Biologicals with OPPS Pass-Through Status Effective July 2016 1, drugsFive and biologicals been have granted OPPS pass-through status, effective These 2016. items,July along 1, with their descriptors and APC assignments, are identified 3. in Table Some drugs and biologicals paid based on the ASP methodology will payment have rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected payments rates will be accessible on the first date of the quarter at Payment/HospitalOutpatientPPS/index.html resubmit may claimsYou that were impacted adjustments by to previous quarter’s basis, as later quarter ASP submissions become available. Updated payment rates effective and drug 2016, July price 1, restatements are available in the update July 2016 of the OPPS Addendum A and Addendum B at Fee-for-Service-Payment/HospitalOutpatientPPS/index.html Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective July 2016 1, payment for 2016, both CY For nonpass-through, and pass-through, drugs, biologicals and therapeutic radiopharmaceuticals is made at a single rate of ASP + 6 percent, which provides payment for both the acquisition cost and pharmacy overhead costs of these items. Payments for drugs and biologicals based on ASPs will be updated on a quarterly C9743 0445T 0443T 0444T 0441T 0442T 0440T 0439T 0437T 0438T CPT Code Table 2 - Category 2 Table III CPT Codes Effective July 2016 1, MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com c. b. Drugs, Biologicals, and Radiopharmaceuticals and Drugs, Biologicals, a. KENTUCKY & OHIO PART A 39

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RETURN TO

APC 1761 TABLE OF CONTENTSTABLE APC 9476 9477 9478 9479 9480

Modifier Modifier Effective Date 01/01/2016 04/01/2016 SI K

SI G G G G G

Low/High Cost Status Cost Low/High High

Modifier ZA-Novartis/ Sandoz ZB – Pfizer/ Hospira , was approved ®

HCPCS Code Effective Date 03/06/2015 04/05/2016 Status Indicator N Long Descriptor Long Rolapitant, oral, 1 mg APC 1822 1761 SI G K GR 2016-07 Each vial of C9479 contains 60 doses. mg, or 10 If one single

• Long Descriptor Long Filgrastim Injection, (G-CSF), Biosimilar, microgram Infliximab, Injection, mg 10 Biosimilar, . © 2016 Copyright, CGS Administrators, LLC. Short Descriptor Helicoll, per square cm Short Descriptor 1mg oral, rolapitant, Instillation, ciprofloxacin otic suspension, 6 mg Injection, trabectedin, mg 0.1 Long Descriptor Long mg Injection, 10 daratumumab, mg 1 elotuzumab, Injection, mg 1 alfa, sebelipase Injection, biosimilar Short Descriptor Inj filgrastim g-csf biosim infliximab Inj., use vial is used for both patient’s ears with the remainder of the drug in the vial unused, then two units of C9479 should be reported as administered to the patient; discarded any amount should be reported with theJW modifier according to the “Medicare Claims Processing - Drugs Chapter Manual,” and 17 Biologicals, Section 40 - Discarded Drugs Biologicals.and Note on reporting C9479: reporting on Note C9479: Table 6 – ReassignmentTable of Skin Substitute Product from the Low Cost Group to the High Cost Group Effective July 2016 1, HCPCS Code Q4164 Q5102 Table 5 – BiosimilarTable Biological Product Payment and Required Modifiers HCPCS Code Q5101 HCPCS Code Q9981 Table 4 – NewTable Drug HCPCS Codes Effective July 2016 1, C9477 C9478 C9479* C9480 Table 3 – Drugs 3 Table and Biologicals with OPPS Pass-ThroughStatus Effective July 2016 1, HCPCS Code C9476 Other Changes HCPCS 2016 to Codes CY for Certain Drugs, Biologicals, Radiopharmaceuticalsand product 6. is listed in Table Reassignment of Skin Substitute Product from the Low Cost Group to the High Cost Group One existing skin substitute product has been reassigned from the low cost skin substitute group to the high cost skin substitute group based on updated pricing information. This product. The modifier does not affect payment determination, but is used to distinguish between biosimilar products that appear in the same HCPCS code but are made by different manufacturers. On April the second 5, 2016, biosimilar biological product, Inflectra 5 lists theby the FDA. biosimilar Table HCPCS codes and required modifiers. Biosimilar Biological Product Payment and Required Modifiers Required and Payment Product Biological Biosimilar AsOPPS a reminder, claims for separately paid biosimilar biological products are required to include a modifier that identifies the manufacturer of the specific New Drug HCPCS Code Effective one new HCPCS 2016, July 1, code has been created for reporting drugs and biologicals in the hospital outpatient setting, where there not previously have been specific codes available. This new code 4. is listed in Table

MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com g. f. e. d. KENTUCKY & OHIO PART A 40

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Termination Termination Date 06/30/2016 06/30/2016

Added Date 01/01/2016 07/01/2016 01/01/2016 07/01/2016

APC 9459 9459 9458 9458 Status Status Indicator G G G G GR 2016-07

• Florbetaben f18, diagnostic, per per diagnostic, f18, Florbetaben millicuries 8.1 to up dose, study Long Descriptor Long Flutemetamol diagnostic, f18, per millicuries 5 to up dose, study Flutemetamol diagnostic, F18, per millicuries 5 to up dose, study per diagnostic, f18, Florbetaben millicuries 8.1 to up dose, study

. © 2016 Copyright, CGS Administrators, LLC. f18 diagnosticf18 Florbetaben f18 florbetaben diagnosticf18 Short Descriptor Flutemetamol f18 flutemetamol http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ C9458 Q9983 Radiopharmaceuticals Effective July 1, 2016 Radiopharmaceuticals 1, Effective July HCPCS Code C9459 Q9982 Table 7 – OtherTable Changes HCPCS 2016 to CY Codes for Certain Drugs, Biologicals, and payment the by wage-adjusted offset for theAPC with the highest offset amount when the radiopharmaceutical or contrast agent with pass-through appears on a claim with a nuclear procedure. The offset will cease to apply when the diagnostic radiopharmaceutical or contrast agent expires from pass-through status. The offset amounts for diagnostic radiopharmaceuticals and contrast agents are the “policy-packaged” portions of the CY APC payments2016 for nuclear medicine procedures and are on the CMS website. Effective there 2016, will July be four 1, diagnostic radiopharmaceuticals with (2 new Q-codes replacing the previously used C-codes described (as above in the immediately precedingand one contrast section agent g.)) receiving pass-through payment in the OPPS Pricer logic. APCs For containing nuclear medicine procedures, Pricer will reduce the amount of the pass-through diagnostic radiopharmaceutical or contrast agent Changes to OPPS Pricer Logic Effective HCPCS 2016, July code 1, Q9983, florbetaben diagnostic, f18 will replace HCPCS code C9458, Florbetaben The SI f18. will remain G, “Pass-Through Drugs Biologicals.”and 7 describesTable the HCPCS codes changes and effective dates. Effective HCPCS 2016, July code 1, Q9982,flutemetamol diagnostic, f18 will replace HCPCS code C9459, Flutemetamol The SI f18. will remain G, “Pass-Through Drugs Biologicals.” and MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com available at Downloads/R3523CP.pdf Additional InformationAdditional The official instruction, CR9658, issued to your MAC regarding this change, is beneficiary’s condition and whetherit is excluded from payment. Please note that your MACs will adjust, as appropriate, claims brought to their attention with any retroactive changes thatwere received prior to implementation OPPS of July Pricer. 2016 only how the product, procedure, or service be may paid if covered the by program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. example, For MACs determine that it is reasonable and necessary to treat the Coverage Determinations Coverage The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage the by Medicare program, but indicates devices allowed for the device intensive procedure edit in the release, July 2016 and will itmake retroactive to January 2016. Procedure Edit Procedure (Anchor/screw forCMS opposing will be adding bone-to-bone C1713 or soft tissue-to- (Septal defect implant system, intracardiac)bone and to the C1817 (implantable)) list of Addition of C1713 and C1817 to the List of and DevicesAddition C1817 Allowed of C1713 for the Device Intensive h. KENTUCKY & OHIO PART A 41

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CR 9661 July 5, 2016 July 5,

January 1, 2016 January 1,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date: and choose Option 1. A PHP claim and From Through date spans 4 or more days, but less than 8 An interim PHP claim (bill type with 763 or 133 condition and From code 41) A PHP claim and From Through date spans more than 7 days.

Edit 95: Partial hospitalization claim span is equal to or more than 4 days with insufficient number of hours of service (RTP) Criteria: days, and there are less than 20 hours of services present. Edit 96: Partial hospitalization interim claim and From Through dates must span more than 4 days (RTP) Criteria: Through date spans less than 5 days. PartialEdit 97: hospitalization services are required to be billed weekly (RTP) Criteria: • • • • • • See special processing logic under OPPS (page Appendix 7), C of CR9661-a (Weekly PHP flowchart) and (OPPS edits Appendix applied F(a) bill by type). Modification Implement new edits under the partial hospitalization program logic for weekly hours of service requirements: 1.866.590.6703 GR 2016-07

• May 13, 2016 May 13, R3524CP 95, 96, 97 Edits Affected MM9661 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Articleis intended for providers submitting claims to Medicare Administrative https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® July 2016 Integrated Outpatient Integrated 2016 July 7/1/2016 Date Effective Number: Number: ® (MLN) Matters ® MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following Network the CMS website at: Logic Type MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com The modifications release are of the summarized I/OCE for in the the v17.2 July 2016 following table. CR9661 informs the Part A/B MACs, the HHH MACs, and the Fiscal Intermediary Shared that Systemthe (FISS) I/OCE is being The updated I/OCE 2016. for July routes 1, all institutional outpatient claims (which includes non-OPPS hospital through claims) a single integrated OCE. your billing staffs are aware of these changes. Background Provider Action Needed Action Provider Change 9661 Request (CR) provides the Integrated Outpatient Code Editor (I/OCE) instructions and specifications. Please sure make your billing staff is aware of these updates. Make sure that Agency (HHA) not under the Home Health or claims PPS (HH PPS) for services to a hospice patient for the treatment of a non-terminal illness. the Outpatient Prospective and Payment for System outpatient (OPPS) claims from non-any OPPS provider not paid under the OPPS. It is also intended for claims for limited services when provided in a Home Health Provider Types Affected Types Provider This MLN Matters Contractors for outpatient (MACs) services provided to Medicare beneficiaries and paid under Related CR Release Date: Related CR Transmittal #: MLN MattersMLN MM9661: 17.2 Version Specifications (I/OCE) Code Editor Hospital If you have any questions,any If you have please contactCGS a CustomerService Representative callingby the CGS Provider Contact Center at KENTUCKY & OHIO PART A 42

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and choose Option 1. of the modified NCCI (as for applicable outpatient institutional 22.2 1.866.590.6703 A pass-through device, drug orbiological HCPCS code is present without an value changed to N if reported with a blank HCPCS code. Update the following lists for the release quarterly (see data files): -Questionable covered service revenue code -Valid list list -Revised 12) (edit files for pass-through offset conditions 98) (edit -Device and device-procedure lists -Skin 92) (edit substitute product lists 87) (edit Make all HCPCS/APC/SI changes as specified CMS by (quarterly data files). versionImplement providers). logic under OPPS, 5). page 9 and Table procedure inpatient the under APC processing) (Comprehensive Appendix L Update where the patient expired logic to note non-covered SI values are returned as excluded from packaging under comprehensive APCs, but associated any edits are not returned (documentation no change only, to program logic). Update the reference on page 8 to indicate the change made for edit 45 to include SI = J1 procedures (documentation is retroactive no change only, to 1/1/2015 to program logic). 2 withUpdate reference Table information for the reporting of modifiers. Updated special processing logic on page 9 to include reference to the use of the when amount credit device for look-up the complexity-adjusted APC as comprehensive condition code 49, 50, or 53 are present (documentation no change only, to program logic). Add modifier ZB (Pfizer/Hospira) to the list of valid modifiers. Modify the valid revenue list for revenue code 940 (Other therapeutic services) SI to have See special processing logic underAppendix OPPS (page 13), P (flowchart) and Appendix F(a). Add program logic to exclude certain blood products (packed red cells and whole blood) from packagingif reported on a comprehensive APC claim special (see processing logic under OPPS, page and 9 Appendix L). Apply mid-quarter approval FDA date for HCPCS code Q5102. Apply the edit if new biosimilar HCPCS is code reported Q5102 without the associated new modifier ZB. Updates to the skin substitute list (Appendix from move Q4164 O: low cost to high cost). Updates to the device and device procedure lists. Change the program logic to provide unique Code Value Payer QU when a condition for device credit is present, reported with condition code 49, 50, or 53 special (see processing Modification Implement new edit 98: Claim with pass-through device, drug orbiological lacks required (RTP). procedure Criteria: procedure. required associated, GR 2016-07

• 20, 40 45 22 67 94 87 92 Edits Affected 98 . . © 2016 Copyright, CGS Administrators, LLC. 7/1/2016 7/1/2016 7/1/2016 4/1/2016 1/1/2015 1/1/2015 7/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2016 1/1/2015 4/5/2016 4/1/2016 7/1/2016 1/1/2016 Effective Date https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ Content Content Content Content Content Documentation Documentation Documentation Documentation Logic and Field Definition Logic Logic Logic Logic Logic Logic Type MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com If you have any questions, any If you have please contact a CGS Customer Service Representative callingby the CGS Provider Contact Center at The official instruction, CR9661 issued to your MAC regarding this change is available at Downloads/R3524CP.pdf Additional InformationAdditional KENTUCKY & OHIO PART A 43

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TABLE OF CONTENTSTABLE

CR 9522

August 15, 2016 August 15,

August 15, 2016 2016 August 15,

Medicare Learning Learning Medicare Change Request #: (CR) Effective Date: Implementation Date:

GR 2016-07

• May 13, 2016 2016 May 13, R223BP R98GI and MM9522 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for physicians and other specified providers submitting https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® Clarification Inpatient of Psychiatric Number: Number: ® (MLN) Matters ® were met. MAC will allow providersYour to adopt method any that permits verification of all the elements require IPFs to continue treatment. No specific procedures or forms are required Your MAC will use theYour beneficiary’s IPF medical record, if the statement “that the patient continues to need, on a daily basis, active treatment furnished directly or requiring by the supervision of inpatient psychiatric facility personnel” is not present in the physician’s recertification documentation, to determine if all the required elements for recertification • • • • MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com either: (1) treatment whicheither: could (1) reasonably be expected to improve the patient’s condition, diagnosticor (2) study. PointsKey of CR9522 There is also a difference in the content of the certification and recertification. In certification the physician is required to document that the IPF admission was medically necessary for recertification with respect to IPF services in the “Medicare General Information, Eligibility and Entitlement Chapter Manual,” Section 4, and in 10.9 the “Medicare Benefit Policy Manual,” Chapter 2, Section 30.2.1. all the necessary requirements to continue care were being denied because they did not use “the statement.” certification,CR9522 clarifies physician recertification certification delayed/lapsed and and Background Currently, the IPFProspective requires Payment System (PPS) facilities to provide “the statement” for recertification. As a result, payments to providers whose documentation validates is present that validates (without using particular any that the words) patient continues to need care. Inpatient Psychiatric Facility (IPF) providers that do not use “the statement” that “the patient continues to need, on a daily basis, active treatment furnished directly or requiring by the supervision of inpatient psychiatric facility personnel” for recertification when documentation A physician or other specified providers need to certify the medical necessity of inpatient services. This is required at admission, and if the service is needed for an extended period of time, a recertification is necessary. CR9522 clarifies that your MAC will cease denials of necessity of inpatient psychiatric services provided to Medicare beneficiaries. NeedWhat to Know You This MLN Matters claims to Medicare Administrative Contractors to certify (MACs) and recertify the medical Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN Recertification and Delayed/Lapsed Certification Recertification Delayed/Lapsed and and Recertification MM9522: Certification, for (IPF) Requirements Facilities Inpatient PsychiatricFacilities (IPF) KENTUCKY & OHIO PART A 44

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and choose Option 1. 1.866.590.6703 . The second updates the “Medicare Benefit Policy Manual” GR 2016-07

• https://www.cms.gov/Regulations-and-Guidance/Guidance/ . The revised manual section is attached to each transmittal. . © 2016 Copyright, CGS Administrators, LLC. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ be if timely certification and recertification had been completed. all For IPF services, a delayed certification not may extend past discharge. An IPF certification or recertification statement only may be signed a physician. by other evidence the IPF considers relevant for purposes of explaining the delay. MACs will allow the IPF to determine the format of delayed certification and recertification statements, and the method which by they are obtained. A delayed certification be may included with one or more recertifications on a single signed statement. Separate signed statements for eachdelayed certification and recertification are not required, as they would MACs will allow the reopening of technical denial decisions (initiated the by provider contractor). or MACs will reverse delayed/lapsed any certification or recertification denials where the provider later produced a legitimate reason for the delay. certification delayed recertification. for and explanations/reasons provider review will MACs The submission of documents must include an explanation for the delay and medical any or Your MAC will deny IPF claimsYour that do timely not have certifications and recertifications. delayed certificationsHowever, and recertifications will be honored where, for instance, there has been an oversight or lapse, and there is a legitimate reason Denial for the delay. of payment for lack of therequired certification and recertificationis considered a technical denial, which means statutory a requirement has not been met. forcertification and recertification. The recertification be may entered on provider generated forms, in progress notes, or in the records (relating to the stay in question) and must be signed physician. a by • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Downloads/R223BP.pdf questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at Manual” and it is available at Transmittals/Downloads/R98GI.pdf and it is available at The official instruction, CR9522, was issued to your MAC regarding this change via two transmittals. The first updates the “Medicare General Information, Eligibility and Entitlement Additional InformationAdditional KENTUCKY & OHIO PART A 45

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CR 9188 CR 9188 April 2016 4,

article, “Provider ®

April 2016 4,

Medicare Learning Learning Medicare and choose Option 1.

Change Request #: (CR) Effective Date: Implementation Date: 1.866.590.6703 https://www.cms.gov/Outreach-and-Education/ GR 2016-07

• November 5, 2015 R1551OTN MM9188 . © 2016 Copyright, CGS Administrators, LLC. article. This MLN Matters article and other CMS articles can be found on Article is intended for institutional providers and Home Health https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ ® System Specific Enhancements 2014: 2014: SystemSpecific Enhancements Number: Number: . ® (MLN) Matters ® HIQH Healthcare - inquiry for Home Health transactions for online - EligibilityELGA for Part A - EligibilityELGH for Home Health HUQA - Healthcare Update Inquiry for Part A HIQA Healthcare - inquiry for Part transactions online for A • • • • • https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ • • • • • MLNMattersArticles/2015-MLN-Matters-Articles.html The Centers for Medicare Medicaid & Services has issued (CMS) the following Network the CMS website at: MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com The Centers for Medicare & Medicaid Services issued (CMS) MLN Matters Enrollment Revalidation ( – Cycle SE1605 2,” Things You Should Know You Things Provider Enrollment Revalidation Enrollment Provider Revalidations: Enrollment Provider If you have any questions, any If you have please contact a CGS Customer Service Representative callingby the CGS Provider Contact Center at The official instruction, CR9188, issued to your MAC regarding this change is available at R1551OTN.pdf PAP informationPAP will now be carried in screening data location 4053-4612, instead of 780-784. InformationAdditional the screens can show up to three occurrences per HCPCS. The other significant change for providers is that on the unformatted provider inquiry, HUQA, The Healthcare Common Procedure Coding System (HCPCS) codes screening for PAP displayed on these screens and are and G0148, P3000, G0147 G0145, G0144, G0143, G0123, CR9188 announcesCR9188 changes to Medicare systems regarding the placement smear of PAP data on Medicare’s internal files. smear The PAP data is displayed on the following provider inquiry screens: for information smear on PAP services provided to Medicare beneficiaries. NeedWhat to Know You This MLN Matters Agencies (HHAs) submitting inquiries to Medicare Administrative Contractors (MACs) Related CR Release Date: Related CR Transmittal #: Affected Types Provider MLN MattersMLN Technical (TECH)/Professional (PROF) (TECH)/Professional Dates Technical File Auxiliary to Screening MM9188: and (PAPRI) Indicator Risk Smear PAP Move Preventative Services KENTUCKY & OHIO PART A 46

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) informing) .

on the CMS website.

https://pecos. and submit payment

http://www.cgsmedicare.com/img/articles/ on the CMS website. https://data.cms.gov/revalidation https://www.cms.gov/Medicare/Provider-Enrollment-and- GR 2016-07 to all development requests from CGS to avoid a hold on your

• ), the), fastest and most efficient to submit way your . © 2016 Copyright, CGS Administrators, LLC. once the full enrollment application is received, your enrollment will be reactivated with your ). https://data.cms.gov/revalidation Respond timely submit an enrollment revalidation more than six months in advance of the due https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do If your enrollment is deactivated, you will be required to submit a new full and complete application to submitted for processing.submitted for For Part A, original effective date. Any claims for services provided during the deactivation period will need to be CGS Jurisdiction Part 15 A Revalidation Application Checklist - http://www.cgsmedicare.com/parta/enrollment/revalidation_checklist.pdf • • - as directed. The fee be may submitted debit, ACH by or your pay application credit card. To fee, go to Refer to the CGS checklist to ensure the enrollment application is complete. - date. Ifdate. you submit a revalidation application, and your due date is listed as “TBD” the application will be returned. Due dates will be posted monthly at least to have 6 months available. CGS encourages providers to check this at least each month. Due dates are listed up to months 6 in advance. Revalidations are due the last of the day month. NOT DO Due dates assigned not yet will indicate “TBD” be determined). (to NOTE: privileges. billing and enrollment your reactivate Institutional providers are required to submit application the 2016 fee of $544.00. An institutional provider is defined as a provider or supplier submitting an application using the CMS-855A, CMS-855B physician (except and non-physician practitioner organizations), or CMS-855S forms. information. Medicare payments and possible deactivation of Medicare billing privileges. revalidation information. Complete the appropriate CMS-855 application. Applications are available on the “Enrollment Applications” page at Certification/MedicareProviderSupEnroll/EnrollmentApplications.html If a revalidation application is received but is incomplete, CGS will develop for the missing cope32609.jpg If you are within 2 months of the listed due date and not received have a notice fromCGS, you are encouraged to proceed with submitting your revalidation application the by due date indicated in the CMS lookup tool at Submit the revalidation application through Internet-based PECOS ( cms.hhs.gov/pecos/login.do CGS will issue revalidation notices in addition to the CMS lookup tool. Notices will be mailed 2-3 months before the established office due Your date. personnelshould be aware that the notice will be sent inyellow a envelope ( CMS has established revalidation due dates. Revalidation due dates can be found on the lookup tool at • • • • • • • • • • • • • • MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com cycle 2 revalidation process. regular revalidations reduce cycles. provider/supplier To burden, CMS has implemented revalidation process improvements. The following provides things you should know about the Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1605.pdf providers that the initial round of revalidationshas been completed and CMS has resumed KENTUCKY & OHIO PART A 47

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N/A

October 3, 2016 3, October

https://www.cms. October 1, 2016 1, October

https://pecos.cms.hhs.gov/ Special Edition Medicare Medicare Edition Special

http://www.cgsmedicare.com/parta/ Change Request #: (CR) Effective Date: Implementation Date: https://www.cms.gov/center/provider-type/rural- . The RHC Qualifying can Visit be List (QVL) and select option 3. https://www.cms.gov/Medicare/Provider-Enrollment-and- GR 2016-07

• article. This MLN Matters article and other CMS articles can be found N/A N/A

1.866.590.6703

Special Edition Article is intended for Rural Health Clinics (RHCs) ® (MLN) Matters ® Number: Number: ® Rural Health Clinics (RHCs) Healthcare pecos/login.do CGS Provider Enrollment Revalidation page Web - enrollment/index.html Downloads/SE1605.pdf Revalidations – CMS website - Certification/MedicareProviderSupEnroll/Revalidations.html CMS - Lookup Tool Provider Enrollment, Chain and Ownership - System (PECOS) “Provider Enrollment Revalidation Cycle – 2” MLN SE1605 article - gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ • • • • • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ • • • • • on the CMS website at: MLNMattersArticles/2016-MLN-Matters-Articles.html The Centers for Medicare & Medicaid Services has issued (CMS) the following Network Learning MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com In April CMS 2016, instructed RHCs to hold claims only for a billable visit shown in red on the RHC QVL until Upon October 2016. billing these 1, claims and/or for claim adjustments MLNMattersArticles/Downloads/MM9269.pdf accessed on the RHC Center Page located at health-clinics-center.html preventive services, using revenue code 052x for medical services and/or revenue code 0900 for mental health services. This guidance is available in MLN Matters Article MM9269 at From April 1, 2016, through AprilFrom 2016, September 1, all 30, charges 2016, for a visit will continue to be reported on the service line with the qualifying visit HCPCS code, minus charges any for effective for dates of service on or after Make sure April your billing 2016. staff 1, is aware of instructions. these Background This article provides information to assist RHCs in meeting the requirements to report the HCPCS code for each service furnished along with the revenue code on claims to Medicare submitting claims to Medicare Administrative Contractors for services (MACs) provided Medicareto beneficiaries. Needed Action Provider Provider Types Affected Types Provider This MLN Matters Related CR Release Date: Related CR Transmittal #: MLN MattersMLN Common Procedure Coding System (HCPCS) Coding System (HCPCS) Common Procedure Reporting and Billing Updates Requirement Rural Health Clinics SE1611: Please share this information with your appropriate staff to ensure a successful provider revalidation process for your facility. questions, If you have please contact the CGS Provider staffEnrollment calling by Resources: KENTUCKY & OHIO PART A 48

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and choose Option 1. 1.866.590.6703 GR 2016-07

• . © 2016 Copyright, CGS Administrators, LLC. Obtaining screen smear pap Initial preventive exam Initial preventive min 3-10 counsel Tobacco-use >10 counsel Tobacco-use initial visitPpps, visit subseq Ppps, Annual alcohol min screen 15 counsel alcohol misuse Brief Depression screen annual High inten beh couns std 30 min Intens behave ther cardio dx min obesity counsel 15 Behavior Short Descriptor pelvic/breast exam screen; Ca Visit to determ LDCT elig G0446 G0447 Q0091 G0444 G0445 G0439 G0442 G0443 G0436 G0437 G0438 G0101 G0296 G0402 Table 1: Approved 1: Table Preventive Health Services with Coinsurance and Deductible Waived HCPCS Code MEDICARE BULLETIN BULLETIN MEDICARE This newsletter should be shared with all health care practitioners and managerial members members practitioners managerial and care health all with shared be newsletter should This of the provider/supplier staff. Newsletters are available at no cost from ourwebsite at http://www.cgsmedicare.com Additional InformationAdditional questions, any If you have please contact a CGS Customer Service Representative calling by the CGS Provider Contact Center at Finally, note that theFinally, HCPCS reporting requirements no impact have in the that way telehealth chronicor care management services reimbursed. are furnished When on the modifier same day. 59 or modifier 25 is reported, RHCs will receive the AIR for an additional visit. This is the only circumstance in which modifier 59 or modifier 25 used. be should diagnosis or treatment the on subsequent the same day, medical service should be billed using revenue code 052x and modifier 59. Beginning on RHCs October 2016, can 1, also report modifier 25 to indicate the subsequent visit was distinct or independent from an earlier visit which do not receive the AIR. When the patient, subsequent to the first visit, suffers an illness or injury that requires additional Each additional service furnished during the visit should be reported with the most appropriate revenue code and charges greater to The or equal additional to $0.01. service lines are for MACs willinformational continue package/bundle to purposes the additional service only. lines, 1. When preventive a 1. health service isthe primary service for the visit, RHCs should report modifier CG on the revenue code 052x service line with the preventive health service. Medicare will 100% pay of the AIR for the preventive health service. will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG. RHCs will continue to be paid an all-inclusive rate per (AIR) visit. Coinsurance anddeductible are waived for the approved preventive health services in Table adjustments. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service whichline includes per day, all charges subject to coinsurance and deductiblefor the visit. For RHCs, the coinsurance is 20 percent of the charges. Therefore, coinsurance and deductible modifierfurther. CG Beginning on the October MACs 2016, will accept 1, modifier CG on RHC claims and claim beginning on RHCs October 2016, shall add 1, modifierCG (policy criteria applied) to theline with the charges all subject coinsurance to deductible. and paragraph The subsequent explains KENTUCKY & OHIO PART A 49

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GR 2016-07 https://www.cms.gov/Outreach-and-Education/Medicare-