In This Issue... From the Intermediary Medical Director Medical Review Progressive Corrective Action ......................................................................... 3 General Information Medical Review Process Revision to Medical Record Requests ................................................ 5 General Coverage New CLIA Waived Tests ............................................................................................................. 8 Outpatient Hospital Services Correction to the Outpatient Services Fee Schedule ................................................................. 9 Skilled Nursing Facility Services Fee Schedule and Consolidated Billing for Skilled Nursing Facility (SNF) Services ............. 12 Fraud and Abuse Justice Recovers Record $1.5 Billion in Fraud Payments - Highest Ever for One Year Period ........................................................................................... 20 Bulletin Medical Policies Use of the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Codes on Contractors’ Web Sites ................................................................................. 21 Outpatient Prospective Payment System January 2001 Update: Coding Information for Hospital Outpatient Prospective Payment System (OPPS) ......................................................................................................................... 93 he Medicare A Bulletin Providers Will Be Asked to Register Tshould be shared with all to Receive Medicare Bulletins and health care practitioners and Newsletters managerial members of the provider/supplier staff. During this fiscal year, Medicare contractors will Publications issued after be required to register providers/suppliers to receive October 1, 1997, are available hard copy bulletins and newsletters. First Coast at no-cost from our provider Service Options, Inc. is developing a process in Web site at accordance with the guidelines issued by the Health www.floridamedicare.com. Care Financing Administration. At this time there is no need to contact your Routing Suggestions: Medicare contractor, you will be notified regarding ! Medicare Manager this new registration requirement in the near future. ! Reimbursement Director ! Chief Financial Officer ! Compliance Officer ! DRG Coordinator FIRST COAST ! ________________ Medicare A Health Care Financing Administration SERVICE OPTIONS, INC. A Newsletter for Florida Medicare Part Providers A HCFA Contracted Carrier & Intermediary Second Quarter 2001 Volume 3, Number 2 TABLE OF CONTENTS Table of Contents Medicare A In This Issue ................................................. 1 70551: Magnetic Resonance Imaging of the Bulletin From the Intermediary Medical Director Brain .................................................. 31 72192: Computed Tomography of the Pelvis .... 33 Vol. 3, No. 2 A Physician’s Focus 80100: Qualitative Drug Screen ................... 38 Second Quarter Medical Review Progressive Corrective Action ... 3 82105: Tumor Markers ................................ 40 2001 Administrative 82310: Total Calcium .................................. 43 Publications Staff About The Medicare A Bulletin ....................... 4 82435: Chloride .......................................... 46 84152: Complexed and Free Prostate Specific Millie C. Pérez General Information Antigen ................................................ 48 Pauline Crutcher Medical Review Process Revision to 93000: Electrocardiography ......................... 50 Shari Bailey Medical Record Requests ........................ 5 93312: Transesophageal Echocardiogram ... 53 Bill Angel Medicare Appeals Workloads in FY 2001 ....... 5 93724: Electronic Analysis of Pacemaker System Mandatory Assignment Now Required for The Medicare A Bulletin is and Pacer Cardioverter-Defibrillator ......... 56 published bimonthly by the Drugs and Biologicals .............................. 5 93990: Duplex Scan of Hemodialysis Access .. 59 Medicare Publications Coordination of Benefits Trading Partners ....... 6 95115: Allergen Immunotherapy .................. 61 Department, to provide General Coverage 95900: Nerve Conduction Studies ................ 63 timely and useful A0426: Ground Ambulance Services ............ 66 information to Medicare Intravenous Iron Therapy ............................... 7 C1203: Ocular Photodynamic Therapy (OPT) Part A providers in Florida. Replacement of Prosthetic Devices and Parts ....7 with Verteporfin ..................................... 70 New CLIA Waived Tests ................................ 8 Questions concerning this DYSPHRT: Dysphagia/Swallowing Diagnosis publication or its contents Outpatient Hospital Services and Therapy ......................................... 72 may be directed in writing Correction to the Outpatient Services J9999: Antineoplastic Drugs ........................ 73 to: Fee Schedule ........................................ 9 PHPPROG: Psychiatric Partial Hospitalization Program .............................................. 83 Medicare Part A 2001 Clinical Laboratory Fee Schedule— Publications Additions and Revisions ......................... 9 Additions and Revisions to Previously P.O. Box 2078 Inpatient Hospital Services Published Medical Policy Jacksonville, FL 32231-0048 Payment for Method II Home Dialysis Supplies .. 9 44388: Colonoscopy—Addition to Policy ...... 91 Intestinal Transplatation ............................... 10 82108: Aluminum—Addition to Policy ........... 91 CPT five-digit codes, Changes in Payment of Swing-Bed J1950: Leuprolide Acetate—Addition to Policy . 92 descriptions, and other data Facility Services ................................... 11 93965: Non-Invasive Evaluation of Extremity only are copyright 1999 by Veins—Addition to Policy ...................... 92 American Medical Skilled Nursing Facility Services G0108: Diabetes Outpatient Self-Management Association (or such other Fee Schedule and Consolidated Billing for Training—Revision to Policy ................. 92 date of publication of CPT). Skilled Nursing Facility (SNF) Services ... 12 J7190: Hemophilia Clotting Factors— All Rights Reserved. Addition to Policy ................................... 92 Applicable FARS/DFARS Comprehensive Outpatient Percutaneous Transluminal Angioplasty and apply. No fee schedules, Rehabilitation Facility Services basic units, relative values or Carotid Stents ...................................... 92 related listings are included Payment of Drugs, Biologicals and Supplies in Outpatient Prospective Payment System in CPT. AMA does not a Comprehensive Outpatient Rehabilitation directly or indirectly Facility ................................................. 19 January 2001 Update: Coding Information for practice medicine or Hospital Outpatient Prospective Payment dispense medical services. Fraud and Abuse System (OPPS) ................................... 93 AMA assumes no liability for Justice Recovers Record Technical Corrections to the January 2001 data contained or not $1.5 Billion in Fraud Payments Update: Coding Information for Hospital contained herein. Highest Ever for One Year Period ............ 20 Outpatient Prospective Payment System .. 101 ICD-9-CM codes and their Hospital Outpatient Prospective Payment System Medical Policies descriptions used in this Pass-Through Payment Corrections for Two publication are copyright General Information About Medical Policies .. 21 Radiopharmaceuticals .......................... 103 Medical Policy Table of Contents ................. 21 1998 under the Uniform Copyright Convention. All Use of the American Medical Association’s Educational Resources rights reserved. (AMA’s) Current Procedural Terminology www.floridamedicare.com—Florida Medicare’s (CPT) Codes on Contractors’ Web Sites .. 21 Provider Web Site ................................ 104 Third-party websites. This Order Form - Part A Materials .................... 105 document contains Final Medical Policies references to sites operated 33216: Implantation of Automatic Defibrillators . 22 Other Information by third parties. Such 55873: Cryosurgical Ablation of the Prostate .... 24 Index to Medicare A Bulletin ....................... 106 references are provided for 62263: Percutaneous Lysis of Epidural your convenience only. Addresses, Medicare Websites, BCBSF and/or FCSO do not Adhesions ........................................... 26 and Phone Numbers ........................... 111 70544: Magnetic Resonance Angiography control such sites and are not responsible for their content. (MRA) ................................................... 28 The inclusion of these references within this document does not suggest any endorsement of the material on such sites or any association with their operators. 2 The Florida Medicare A Bulletin Second Quarter 2001 FROM THE INTERMEDIARY MEDICAL DIRECTOR A PHYSICIAN’S FOCUS Medical Review Progressive Corrective Action o matter what your politics, the recent presidential election in NFlorida gave citizens an opportunity to gain a better understanding of data collection and its possible uses. All processes produce outcomes that vary. This is true of processes from making parts in a factory to counting votes in an election. It is also true of billing a CPT code on a health care claim. Data synthesis allows one to evaluate variation in outcomes and consider types of variation. A common cause type of variation can generally be attributed to random error. A special cause type of variation is generally attributed to something