In This Issue... Disclosure of Itemized Statement Providers Must Furnish an Itemmized Statement when Requested in Writing by the Beneficiary .................................................................................................... 6 Prospective Payment System The Outpatient Code Editor Software Has Been Modified in Preparation for the Implementation of Outpatient Prospective Payment System ........................... 8 Reclassification of Certain Urban Hospitals Certain Urban Hospitals in the State of Florida May Be Permitted to Be Reclassified as Rural Hospitals................................................................................ 13 ulletin Final Medical Review Policies 33216, 53850, 70541, 82108, 83735, 87621, 93303, 94010, 95004, A0320, J0207, J2430, J2792, J3240, J7190, and J9999 .......................................... 15 B Payment of Skilled Nursing Facility Claims Involving a Terminating Medicare+Choice Plan Payment of Skilled Nursing Facility Care for Beneficiaries Involuntarily Disenrolling from M+C plans Who Have Not Met the 3-Day Stay Requirement ........................................................................................... 67 Features From the Medical Director 3 Administrative 4 lease share the Medicare A roviders PBulletin with appropriate General Information 5 members of your organization. Outpatient Prospective Payment System 7 Routing Suggestions: General Coverage 12 o Medicare Manager Hospital Services 13 o Reimbursement Director Local and Focused Medical Policies 15 o Chief Financial Officer Skilled Nursing Facilities 67 edicare Part edicare A P End Stage Renal Disease 68 o Compliance Officer Fraud and Abuse 69 o DRG Coordinator Educational Resources 70 o ________________ Index 77 o ________________ o ________________ o ________________ sletter sletter for M Florida FIRST COAST ew Health Care Financing Administration SERVICE OPTIONS, INC. N Medicare A A HCFA Contracted Carrier & Intermediary A June/July 2000 Volume 2, Number 3 TABLE OF CONTENTS Table of Contents Medicare A In This Issue.............................................. 1 70541: Magnetic Resonance Angiography (MRA)................................................. 21 Bulletin From the Intermediary Medical Director 82108: Aluminum ..................................... 25 A Physicians Focus 83735: Magnesium .................................. 27 Vol. 2, No. 3 Improving Claim Error Rate - An Effort by 87621: Human Papillomavirus DNA June/July Multiple Stakeholders .......................... 3 Assay, Amplified Probe Technique ... 30 2000 Administrative 93303: Transthoracic and Doppler Publications About the Medicare A Bulletin .................... 4 Echocardiography and Doppler Staff Color Flow Velocity Mapping ............. 32 General Information 94010: Spirometry.................................... 37 Millie C. Pérez Frequency of Billing for Outpatient 95004: Allergy Skin Tests ........................ 41 Cynthia Moore Services ............................................... 5 A0320: Ground Ambulance Services....... 43 Pauline Crutcher New Web Site for Prompt Payment J0207: Amifostine .................................... 47 Shari Bailey Interest Rate ........................................ 5 J2430: Pamidronate (Aredia®, APD) ....... 49 Bill Angel Claim Expanasion and Line Item J2792: Rho (D) Immune Globulin The Medicare A Bulletin Processing Implementation ................. 5 Intravenous ........................................ 51 is published bimonthly Overpayment Interest Rate ......................... 6 J3240: Thyrotropin Alfa (Thyrogen ®) ..... 53 by the Medicare Disclosure of Itemized Statement to an J7190: Hemophilia Clotting Factors ......... 55 Publications Individual for Items of Services J9999: Antineoplastic Drugs .................... 57 Department, to provide Provided ............................................... 6 timely and useful Reporting of Noncovered Charges and Medicare Noncovered Services - Investigational Status information to Related Revenue Codes - Change Medicare Part A in Implementation Date ........................ 6 62263: Percutaneous Lysis of Epidural Adhesions .......................................... 65 providers in Florida. Prospective Payment System A9270: Arthroscopic Laser Arthrodesis ... 65 HCFA Announces New Medicare Hospital Questions concerning Outpatient Payment System ............... 7 Skilled Nursing Facilities this publication or its Outpatient Code Editor Modifications for Payment of Skilled Nursing Facility contents may be the Outpatient Prospective Payment Claims for Beneficiaries Disenrolling directed in writing to: System ................................................. 8 from Terminating Medicare+Choice Medicare Part A Description of OCE Edits/Claim (M+C) Plans Who Have Not Met Publications Reasons ............................................. 10 the 3-Day Stay Requirement ............. 67 P.O. Box 2078 General Coverage End Stage Renal Disease Jacksonville, FL 32231-0048 Coverage Revision to Pneumococcal ESRD Facilities - Billing for Iron Dextran .. 68 Pneumonia Vaccine ........................... 12 Fraud And Abuse CPT five-digit codes, 20974: Osteogenic Stimulator for descriptions, and Caveat Emptor - Let the Buyer Beware .... 69 Fracture Healing ................................ 12 other data only are 48554: Revision to Pancreas Educational Resources copyrighted by Transplantation Coverage ................ 12 Medicare Provider Education and American Medical Training Events for Year 2000 ........... 70 Association. All Hospital Services Medical Specialty Seminar Schedule ....... 71 Rights Reserved. No Hospital Information fee schedules, basic Lets Talk with Medicare - Part B Permitting Reclassification of Certain units, relative values Session .............................................. 72 Urban Hospital as Rural Hospital - or related listings are Lets Talk with Medicare - Part A Application Procedures ...................... 13 included in CPT. Session .............................................. 73 AMA does not Outpatient Hospital Services Provider Education and Training Advisory directly or indirectly Hospital Outpatient Radiology Service Meeting - Registration Form .............. 74 practice medicine or Fee Schedule..................................... 14 Two New Computer Based Training dispense medical Courses Available .................................. 75 services. AMA Local and Focused Medical Review Medicare Provider Web Site Replaces assumes no liability Policies BBS ................................................... 75 for data contained or General Information About Order Form - 2000 Part A Materials ......... 76 not contained herein. Medical Policies .............................. 15 Medical Policy Table of Contents ............. 15 Other Information ICD-9-CM codes Index to Medicare A Bulletin .................. 77 and their descriptions Final Medical Policies used in this Important Adresses, Telephone 33216: Implantation of Automatic publication are Numbers, and Websites ..... Back Cover Defibrillators ....................................... 16 copyrightÓ 1998 53850: Prostate Treatments .................... 18 under the Uniform Copyright Convention. All rights reserved. 2 The Florida Medicare A Bulletin June/July 2000 FROM THE INTERMEDIARY MEDICAL DIRECTOR A PHYSICIANS FOCUS Improving Claim Payment Error RateAn Effort by Multiple Stakeholders he Medicare program pays more than $200 billion to one million Thealth care providers for services provided to 39 million seniors and disabled Americans annually. Promoting the integrity of the Medicare and Medicaid programs is a top priority of the Health Care Financing Administration (HCFA). HCFA states its program integrity goal as being straightforward to pay the right amount, to a legitimate provider, for covered, reasonable, and necessary services, provided to an eligible beneficiary. HCFA has set goals for reducing the claim payment error rate. A claim payment error rate incorporates both over-and underpayment. It is a general measure that reflects aspects of coding, medicalD necessity, eligibility, benefits, and record keeping. Accurate claim adjudication depends on proper input from multiple stakeholders and proper process, sometimes by multiple stakeholders. This ultimately leads to the outcome of a correct claim payment. Patients, providers, HCFA, and HCFA contractors are the general stakeholders supported by multiple health care professionals. As a fiscal intermediary (Medicare Part A HCFA contractor), First Coast Service Options, Inc. administers payment of five billion dollars to 1,300 health care providers for services to over two million seniors and disabled Americans in Florida and in other states. Approximately five and a half million claims are processed annually. Intermediaries and other HCFA contractors are implementing programs to improve their claims payment error rates and medical review. These programs supplement the ongoing education programs to help providers document and file claims correctly. Medicare Peer Review Organizations (PROs), as part of their new scope of work from HCFA, are working with hospitals to analyze, correct, and prevent the billing of inpatient claims that are miscoded, inadequately documented, and unnecessary services. The Florida PROFlorida Medical Quality Assurance, Inc. (FMQAI)has expanded its quality improvement activities and initiated this program known as the Payment Error Prevention Program (PEPP). Through PEPP, the FMQAI and all PROs across