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Highlights In This Issue… A Physician’s Focus FCSO Office of the Medical Director Announces the Appointment of New Medical Directors .......................................................................................................... 3 Claims, Appeals, and Hearings Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 11.2, Effective July 1, 2005 .................................................................................................... 10 Billing Partial Month ESRD Related Visits .......................................................... 10 Health Professional Shortage Area Listing .......................................................... 19 Updated Place of Service Code Set to Add Code for Pharmacy ............................ 20 Coverage/Reimbursement Payment to Ambulatory Surgical Center for New CPT Code 66711 ........................ 23 pdate Abarelix for the Treatment of Prostate Cancer .................................................... 27 New HCPCS Drug Codes ................................................................................. 35 New CLIA Waived Tests .................................................................................. 45 Cochlear Implant ............................................................................................. 53 HIPAA–The Health Insurance Portability and Accountability Act U ASCA Enforcement of Mandatory Electronic Submission of Medicare Claim .......... 67 Access Process for Beneficiary Eligibility Inquiries/Replies .................................. 68 General Information Office of Inspector General Reports Progress Against Waste, Abuse, and Fraud ... 71 Distribution of the Annual Fee Schedule and 2006 Participation Packages ............ 71 CMS Announces the National Provider Identifier Enumerator Contractor and Information on Obtaining NPIs .......................................................................... 72 Do Not Forward Initiative - Reminder .................................................................. 74 Prescription Drug Coverage .............................................................................. 89 Features Connecticut and Florida Connecticut Only About the Update! .............. 4 Medical Review .................. 93 he Medicare B Update! Claims ................................. 6 should be shared with all Florida Only T Coverage/Reimbursement .. 21 Medical Review .................. 100 health care practitioners and HIPAA and EMC ..................67 managerial members of the General Information ............ 71 provider/supplier staff. Publica- Index ................................... 111 Educational Resources ...... 110 tions issued beginning in 1997 are available at no cost from our provider education websites: http://www.connecticutmedicare.com To receive quick, automatic notification when new publications and other and http://www.floridamedicare.com. items of interest are posted to our provider education websites, subscribe to our FCSO eNews mailing list. It’s very easy to do; go to http://www.connecticutmedicare.com or http://www.floridamedicare.com, Routing Suggestions: click on the eNews” link on the navigational menu and follow the prompts. Physician/Provider Office Manager Billing/Vendor Nursing Staff Other _________ A CMS Contracted Intermediary & Carrier _________ Medicare B A Newsletter for Connecticut and Florida Medicare Part B Providers Fourth Quar ter 2005 Volume 3 Number 4 efvi2yp2gyxix Highlights In This Issue… ......................................... 1 Preventive Services Diagnosis for Screening Mammography.............. 52 A Physician’s Focus Surgery Medicare B FCSO Office of the Medical Director Announces the Addition of CLIA Edits to MOHS Surgery Codes .. 53 Appointment of New Medical Directors...............3 Cochlear Implant .................................................. 53 Update! About the Connecticut and Florida Expansion of Coverage for PTA ............................ 56 Medicare B Update! .............................................4 Updated Requirements for Autologous Vol. 3, No. 4 Advance Beneficiary Notices (ABNs) ....................... 5 Stem Cell Transplantation for Amyloidosis .... 58 Fourth Quarter 2005 Claims Therapeutic Services Billing for Air Ambulance Mileage ..........................6 Continuous Positive Airway Pressure Therapy for Publications Obstructive Sleep Apnea .............................. 59 2005 ASC HCPCS Adds, Deletes, Master Listing .... 6 Staff 2005 HCPCS for ASC - Supplement to MM3905 ... 8 Outpatient Rehabilitation Therapy Services........ 60 Medicare Contractor ICD-9-CM Modifications.........8 General Coverage Terri Drury Billing Partial Month ESRD Related Visits ............. 9 Medicare Advantage Organizations for NCD Kimberly McCaw Services not Previously Included in the CCI Update, Version 11.2 ...................................... 10 Millie C. Pérez Procedures Denied as Secondary, Medicare Advantage’s Capitated Rates ............ 62 Primary not Present .......................................... 10 Smoking and Tobacco Use Cessation Counseling 62 List of Medicare Telehealth Services ................... 65 The Medicare B Update! PPV, Hepatitis and Flu Vaccines ........................... 10 is published quarterly by Re-review of Previously Denied Claims HIPAA and EMC Prohibited-CR3622 ........................................... 15 the Medicare ASCA Enforcement of Mandatory Electronic Communication and Revision to HPSA/PSA Area Payment Rules ....... 15 Submission of Medicare Claims ....................... 67 Override of HPSA/PSA Bonus Education department of Correction to Use of Group Codes for First Coast Service Payments for Globally Billed Services ........... 16 Enforcement of Mandatory Electronic Temporary Instruction to Forego HPSA/PSA Submission of Medicare Claims ........................... 68 Options, Inc. (FCSO), to Incentive Payment for ....................................... 17 Access Process for Bene Eligibility provide timely and useful New HPSA Modifier ............................................... 18 Inquiries/Replies (HIPAA 270/271 information to Medicare Payment Issue with HPSA Bonus Payments ........ 18 Transactions) ................................................... 68 Part B providers in HPSA Listing .......................................................... 19 Update to the National Council for Rx Drug Connecticut and Florida. Update to POS Code Set to Add a Code for Program Batch Standard 1.1 Billing Pharmacy ........................................................ 20 Request Companion Document ...................... 70 Questions concerning this Removal of Special Edition Article SE0516 ........ 20 publication or its contents Coverage/Reimbursement General Information may be directed in writing to: Fraud Ambulance Medicare Part B Medical Review of Rural Air Ambulance Service 21 CMS Efforts to Identify Medicare and Medicaid Medicare Billing Rules for Ambulance Service Improper Payments ...................................... 71 MCE-Publications Rendered to Patient During an Inpatient OIG Reports Progress Against Waste, Abuse P.O. Box 45270 Hospital Stay .................................................... 22 and Fraud ...................................................... 71 Jacksonville, FL 32232-5270 Ambulatory Surgical Centers Medicare Physician Fee Schedule Payments to ASC for New CPT Code 66711........ 23 Distribution of Annual Fee Schedule and 2006 CPT codes, descriptors, Participation Packages................................. 71 and other data only are Consolidated Billing CWF SNF CB Edits for Ambulance Transports Provider Enrollment copyright 2004 to or from a Diagnostic or Therapeutic Site .... 24 CMS Announces the NPI Enumerator Contractor American Medical July Update to 2005 Annual Update of HCPCS and Information on Obtaining NPIs ................ 72 Association (or such for SNF CB ...................................................... 24 NPI Reminder........................................................ 73 other date of publication Diabetic Services Medicare Fee-for-Service Transition to NPI ......... 74 of CPT). All Rights Infusion Pumps: C-Peptide Levels as A Criterion Do Not Forward Initiative - Reminder ................... 74 Reserved. Applicable for Use .................................................................... 26 General Information FARS/DFARS apply. No Drugs and Biologicals New Remittance Advice Message for Referred fee schedules, basic units, Abarelix for Treatment of Prostate Cancer ........... 27 Clinical Diagnostic/Purchased Diagnostic relative values, or related Coverage of Aprepitant for Chemo-Induced Service Duplicate Claims................................. 74 listings are included in Emesis ............................................................ 28 New Educational Guide on Remittance CPT. AMA does not Q0136 - Pricing Revision ...................................... 29 Advice Notices ................................................. 76 directly or indirectly Anti-Cancer Chemo for Colorectal Cancer ........... 30 Understanding the Remittance Advice Guide ...... 77 practice medicine or Drug and Administration Redetermination Standard Paper Remittance Advice ..................... 77 Administrative Law Judge Hearing Requests ....... 77 dispense medical Requests no Longer Acceptable services. AMA assumes via Telephone................................................... 32 Remittance Advice Remark Code and April 2005 ASP Pricing File/Revisions to Claim Adjustment