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NOTE: Should you have landed here as a result of a search engine (or
other) link, be advised that these files contain material that is copyrighted
by the American Medical Association. You are forbidden to download
the files unless you read, agree to, and abide by the provisions of the
copyright statement. Read the copyright statement now and you will
be linked back to here.
RAILROAD MEDICARE ADVISORY
Latest Part B News for Railroad Medicare
What’s Inside...
Administration
CMS Quarterly Provider Update ............................................................................................3
Provider Customer Service Center Training & Closure Dates
Limiting the Scope of Review on Redeterminations and Reconsiderations of Certain
...............................................4
Updates to Pub. 100-04, Chapters 1 and 16 to Correct Remittance Advice Messages ..........5
Claims .................................................................................................................................7
Revisions to Private Contracting/Opt-out Manual Sections Due to the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) ..................................................................9
Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)
2016 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common
Procedure Coding System (HCPCS) Code Jurisdiction List ...........................................11
Drugs and Biologicals
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code
Changes - July 2016 Update .............................................................................................12
Medicare Policy Clarified for Prolonged Drug and Biological Infusions Started Incident to a
Physician’s Service Using an External Pump ...................................................................13
JW Modifier: Drug Amount Discarded/Not Administered to any Patient ...........................15
Education
Education Now Available......................................................................................................16
Get Your Railroad Medicare News Electronically ................................................................17
Medicine
Medicare Coverage of Substance Abuse Services ...............................................................18
Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing—National
Coverage Determination (NCD) 210.2.1 ..........................................................................23
Update to Internet-Only-Manual Publication 100-04, Chapter 18, Section 30.6 ................26
Stem Cell Transplantation for Multiple Myeloma, Myelofibrosis, and Sickle Cell Disease,
and Myelodysplastic Syndromes ......................................................................................27
Continued >>
palmettogba.com/rr
The Medicare Advisory contains coverage, billing and other information for Railroad Medicare. This information is
not intended to constitute legal advice. It is our ofϐicial notice to those we serve concerning their responsibilities
and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no
cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow
the guidelines. The Railroad Medicare Advisory includes information provided by the Centers for Medicare &
Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any
time. This bulletin should be shared with all health care practitioners and managerial members of the provider
staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/rr.
CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part
of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code
on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2015
American Dental Association (ADA). All rights reserved.
June 2016
Volume 2016, Issue 6
Coding Revisions to National Coverage Determinations ............................................................................................ 31
Coding Revisions to National Coverage Determinations (NCDs) .............................................................................. 33
Cardiology
Percutaneous Left Atrial Appendage Closure (LAAC) ............................................................................................... 35
Laboratory
System Specific Enhancements 2014: Move PAP Smear Risk Indicator (PAPRI) and Technical (TECH)/Professional
(PROF) Dates to Screening Auxiliary File ............................................................................................................... 39
Etcetera
CMS e-News................................................................................................................................................................. 41
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
2 6/2016
CMS Quarterly Provider Update
The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid
Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare
including program memoranda, manual changes and any other instructions that could affect providers.
Regulations and instructions published in the previous quarter are also included in the update. The purpose of
the Quarterly Provider Update is to:
• Inform providers about new developments in the Medicare program
• Assist providers in understanding CMS programs and complying with Medicare regulations and instructions
• Ensure that providers have time to react and prepare for new requirements
• Announce new or changing Medicare requirements on a predictable schedule
• Communicate the specific days that CMS business will be published in the ‘Federal Register’
To receive notification when regulations and program instructions are added throughout the quarter, sign up
for the Quarterly Provider Update listserv (electronic mailing list) at
https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.
We encourage you to bookmark the Quarterly Provider Update Web site at
www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. html
and visit it often for this valuable information.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3 6/2016
Provider Customer Service Center Training &
Closure Dates
The Centers for Medicare & Medicaid Services (CMS) has approved allowing Medicare
provider service centers to close up to eight hours per month for provider Customer
Service Advocates (CSAs) training and/or staff development. The goal is to help CSAs
improve the consistency and accuracy of their responses to provider questions; enhance
their awareness and understanding of Medicare policies and issues; and facilitate CSAs’
retention of the facts of their training by increasing its frequency.
When our CSAs participate in training and developmental sessions on Thursdays of
each month, you may use our online provider portal called eServices. eServices provides
claim status, duplicate remittances, patient eligibility and much more. Register now
at www.PalmettoGBA.com/eServices. Please refer to the training schedule below for
specific closure dates and times.
Date Phones Closed
May 30, 2016 Office closed/ Memorial Day
June 9, 2016 PCC closed from 2:15-4:45 for training
July 4, 2016 Office closed/ Independence Day
September 5, 2016 Office closed/ Labor Day
October 10, 2016 PCC closed/ Columbus Day
November 11, 2016 PCC closed/ Veteran’s Day
November 24-25, 2016 Offi ce closed/ Thanksgiving
December 23, 2016 Office closed/Christmas Eve
December 26, 2016 Office closed/Christmas Day
January 2, 2017 Office closed/ New Year’s Day
Please note that we will attempt to provide advance notice of any changes to the above training schedule via
the website, IVR features and automatic email notices.
If you have not already done so, we encourage you to sign up for automatic email notices of updates to our
website. Subscribing to our Email Updates is the fastest way to find out about Medicare changes that may affect
you. There is no charge for the service, and we will not share your email address with others. To register, go to Email
Updates on our website at http://www.palmettogba.com/registration.nsf/Push+Mail+Archive+Home?OpenForm.
If you have any questions, please contact our provider service center at our toll-free number at 888-355-9165.
For information regarding claims status or eligibility, please call the Interactive Voice Response (IVR) at 877­
288-7600 or use the Palmetto GBA eServices tool, located at
http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4 6/2016
Updates to Pub. 100-04, Chapters 1 and 16 to Correct
Remittance Advice Messages
MLN Matters® Number: MM9578
Related Change Request (CR) #: CR 9578
Related CR Release Date: April 29, 2016
Effective Date: October 1, 2016
Related CR Transmittal #: R3510CP
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
If Change Request (CR) 9578 updates Chapter 1 and Chapter 16 of the “Medicare Claims Processing Manual”
to reflect the standard format and to correct any non-compliant remittance advice code combinations. Make
sure that your billing staffs are aware of the corrected code combinations.
Background
Section 1171 of the Social Security Act requires a standard set of operating rules to regulate the health
insurance industry’s use of Electronic Data Interchange (EDI) transactions. Operating Rule 360: Uniform Use
of CARCs and RARCs, regulates the way in which group codes, Claims Adjustment Reason Codes (CARCs),
and Remittance Advice Remark Codes (RARCs) may be 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
by the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information
Exchange (CORE).
Medicare and all other payers must comply with the CAQH CORE-developed code combinations. The business
scenario for each payment adjustment must be defined, if applicable, and a valid code combination selected
for all remittance advice messages.
CR9578 makes the following code revisions:
• When a MAC rejects an out of jurisdiction professional claim as unprocessable, the following codes are used:
• Group Code of CO
• CARC 109, and
• RARC N104
• When a MAC rejects misdirected Railroad Retirement Board claims as unprocessable, the following codes
are used:
• Group Code of CO
• CARC 109, and
• RARC N105
• When a MAC rejects misdirected United Mine Workers Association claims as unprocessable, the following
codes are used:
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5 6/2016
• Group Code CO
• CARC 109, and
• RARC N127
• In the above 3 situations, RARC MA130 was used previously, but will no longer be used in these situations.
Additional Information
The official instruction, CR9578 issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3510CP.pdf. The revised
manual Chapters 1 and 16 are attached to CR9578.
eServices Eligibility
eServices, by Palmetto GBA, allows you to search for patient eligibility,
which is a functionality of HETS. HETS requires you to enter beneficiary
last name and HICN, in addition to either the birth date or first name. See
options below:
• HICN, Last Name, First Name, Birth Date
• HICN, Last Name, Birth Date
• HICN, Last Name, First Name
For more information about eServices and the many services it offers, please visit our website at
http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6 6/2016
Limiting the Scope of Review on Redeterminations and
Reconsiderations of Certain Claims
MLN Matters® Number: SE1521
Revised Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Note: This article was revised on May 9, 2016, to provide updated information regarding redetermination
requests received by Medicare Administrative Contractors (MACs) or Qualified Independent Contractors
(QICs) on or after April 18, 2016.
Provider Types Affected
This MLN Matters® Special Edition Article is intended for physicians, providers, and suppliers who submit
claims to MACs for services provided to Medicare beneficiaries.
What You Need to Know
This Special Edition article is being published by the Centers for Medicare & Medicaid Services (CMS) to
inform providers of the clarification CMS has given to the MACs and QICs regarding the scope of review
for redeterminations (Technical Direction Letter-160305, which rescinds and replaces Technical Direction
Letter-150407). This updated instruction applies to redetermination requests received by a MAC or QIC on or
after April 18, 2016, and will not be applied retroactively.
Background
CMS recently provided direction to MACs and QICs regarding the applicable scope of review for redeterminations
and reconsiderations for certain claims. Generally, MACs and QICs have 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 appeal decision for a different reason.
For redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex
post-payment review, or an automated post-payment review by a contractor, CMS has instructed MACs and
QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Prepayment
reviews occur prior to Medicare payment, when a contractor conducts a review of the claim and/or supporting
documentation to make an initial determination. Post-payment review or audit refers to claims that were
initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity
Contractor (ZPIC), Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) 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. If an appeal involves a claim or line item denied on an automated
pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion and
may issue unfavorable decisions for reasons other than those specified in the initial determination.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7 6/2016
Please note that contractors will continue to follow existing procedures regarding claim adjustments resulting
from favorable appeal decisions. These adjustments will process through CMS systems and may suspend
due to system edits. Claim adjustments that do not process to payment because of additional system imposed
payment limitations, conditions or restrictions (for example, frequency limits or Correct Coding Initiative
edits) may result in new denials with full appeal rights. In addition, if a MAC or QIC conducts an appeal of a
claim or line item that was denied on pre- or post-payment review because a provider, supplier, or beneficiary
failed to submit requested documentation, the contractor will review all applicable coverage and payment
requirements for the item or service at issue, including whether the item or service was medically reasonable
and necessary. As a result, claims initially denied for insufficient documentation may be denied on appeal if
additional documentation is submitted and it does not support medical necessity.
This clarification and instruction applies to redetermination and reconsideration requests received by a MAC or
QIC on or after April 18, 2016. It will not be applied retroactively. 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 of review. CMS encourages providers and suppliers to include any audit or review results letters
with their appeal request. This will help alert contractors to appeals where this instruction applies.
Additional Information
You can find 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 (Overview)) at https://www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c29.pdf on the CMS website.
You can also find out more about 1) conducting a redeterminations in 42 CFR 405.948, at
http://www.ecfr.gov/cgi-bin/text-idx?SID=06584dd6a5fc15094e7633ff5f6cb359&mc=true&node=pt42.2.4
05&rgn=div5&wb48617274=6B50C328#se42.2.405_1948; and 2) conducting a reconsideration in 42 CFR
405.968 at http://www.ecfr.gov/cgi-bin/text-idx?SID=06584dd6a5fc15094e7633ff5f6cb359&mc=true&node
=pt42.2.405&rgn=div5#se42.2.405_1968 on the Internet.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8 6/2016
Revisions to Private Contracting/Opt-out Manual Sections
Due to the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA)
MLN Matters® Number: MM9616
Related Change Request (CR) #: CR 9616
Related CR Release Date: May 13, 2016
Effective Date: August 15, 2016
Related CR Transmittal #: R222BP
Implementation Date: August 15, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians and practitioners who are planning to opt-out of Medicare
or who have already opted out of Medicare.
Provider Action Needed
Change Request (CR) 9616 alerts physicians and practitioners who signed a valid opt-out affidavit on or
after June 16, 2015, that it will automatically renew every 2 years. CR9616 revises the “Medicare Benefit
Policy Manual” to be consistent with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
amendments. If physicians and practitioners who fi led affidavits effective on or after June 16, 2015, do not
want their opt-out to automatically renew at the end of a 2 year opt-out period, they may cancel the renewal
by notifying all MACs with which they filed an affidavit in writing at least 30 days prior to the start of the
next opt-out period.
Be aware that valid opt-out affidavits signed before June 16, 2015, will expire 2 years after the effective date
of the opt out. If physicians and practitioners that fi led affidavits effective before June 16, 2015, want to extend
their opt out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all
contractors with which they would have filed claims absent the opt-out.
Background
MACRA amended the private contracting/opt out provisions at Section 1802(b) of the Social Security Act. Prior
to the MACRA amendments, the law specified that physicians and practitioners may opt out for a 2-year period.
Individuals that wished to renew their opt-out at the end of a 2-year opt-out period were required to fi le new
affidavits with their MAC. Section 106(a) of the MACRA amended section 1802(b)(3) of the Social Security
Act to require that opt-out affidavits entered into on or after June 16, 2015, automatically renew every 2 years.
Other Key Points
• Medicare will make payment for covered, medically necessary services that are ordered or certified by a
physician/practitioner who has opted out of Medicare if the ordering or certifying physician/practitioner
has acquired a National Provider Identifier (NPI), reports his/her Social Security Number, has a valid opt
out affi davit on file with his or her MAC, is of a specialty that is eligible to order and certify and provided
that the services are not furnished by another physician/practitioner who has also opted out. For example,
if an opt-out physician/practitioner admits a beneficiary to a hospital, Medicare will reimburse the hospital
for medically necessary care.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9 6/2016
• In order for a private contract with a beneficiary to be effective, the physician/practitioner must be opted
out of Medicare. The physician/practitioner’s initial 2-year opt-out period begins the date the affidavit
meeting Medicare requirements is signed, provided the affi davit is filed within 10 days after the physician/
practitioner signs his or her first private contract with a Medicare benefi ciary.
• When a 2-year opt-out period ends, the physician/practitioner must enter into new private contracts with
each beneficiary for the new 2-year period. The new private contracts must state the expected or known
effective date and the expected or known expiration date of the current 2-year opt-out period.
• These points and other information are identified in the revised Chapter 15, Section 40 of the “Medicare
Benefit Policy Manual,” which is attached to CR9616.
Additional Information
The official instruction, CR9616, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R222BP.pdf.
Denial Resolution Tool
The Palmetto GBA Denial Resolution tool, located on the home page under Forms/Tools, includes resources
for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you
pick up the phone.
• Access denial reasons in plain language
• Scroll through the titles to locate your procedure
• Use the Palmetto GBA search engine to search by remark code
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10 6/2016
2016 Durable Medical Equipment Prosthetics, Orthotics, and
Supplies Healthcare Common Procedure Coding System
(HCPCS) Code Jurisdiction List
MLN Matters® Number: MM9481
Revised Related Change Request (CR) #: CR9481
Related CR Release Date: May 10, 2016
Effective Date: January 1, 2016
Related CR Transmittal #: R3520CP
Implementation Date: February 1, 2016
Note: This article was revised on May 10, 2016, due to a revised Change Request (CR). The CR revised the
jurisdiction for HCPCS E0781 to DME MAC only and omitted the local carrier jurisdiction for this code in
the attachment to the CR. The CR release date, transmittal number and link to the CR also chang ed. All other
information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative
Contractors (MACs), including Durable Medical Equipment MACs for DMEPOS services provided to Medicare
beneficiaries.
Provider Action Needed
CR9481 notifies suppliers that the spreadsheet containing an updated jurisdiction list of Healthcare Common
Procedure Coding System (HCPCS) codes is updated annually to reflect codes that have been added or
discontinued (deleted) each year. Changes in Chapter 23, Section 20.3 of the “Medicare Claims Processing
Manual” are reflected in the recurring update notification. The spreadsheet for the 2016 DMEPOS Jurisdiction
List is an Excel® spreadsheet and is available under the Coding Category at
http://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html and is also attached
to CR9481.
Additional Information
The official instruction, CR9481, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3520CP.pdf.
Document History
Date of Change Description
May 10, 2016 The article was revised due to a revised Change Request (CR). The CR revised
the jurisdiction for HCPCS E0781 to DME MAC only and omitted the local carrier
jurisdiction for this code in the attachment to the CR. The CR release date, transmittal
number and link to the CR also changed.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11 6/2016
Quarterly Healthcare Common Procedure Coding System
(HCPCS) Drug/Biological Code Changes - July 2016 Update
MLN Matters® Number: MM9636
Related Change Request (CR) #: CR 9636
Related CR Release Date: May 6, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3518CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs) and Home
Health & Hospice (HH&H) MACs for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9636 informs Medicare providers and suppliers that effective for claims with dates of
service on or after July 1, 20 16, new Healthcare Common Procedure Coding System (HCPCS) codes Q9981
(rolapitant, oral, 1mg); Q9982 (flutemetamol f18 diagnostic); and Q9983 (florbetaben f18 diagnostic) will be
payable for Medicare. In addition, the HCPCS code set will contain code Q5102 (Inj., infl iximab biosimilar),
which is effective for dates of service on or after April 5, 2016. Claims for Q5102 must also have the modifier
ZB (Pfizer/hospira). Make sure that your billing staffs are aware of these changes.
Background
The HCPCS code set is updated on a quarterly basis and CR9636 provides that effective July 1, 2016, the
HCPCS codes contained in the following table will be established:
HCPCS Code Short Description Long Description Type of Service
(TOS) Code
Q9981 rolapitant, oral, 1mg Rolapitant, oral, 1 mg 1
Q9982 fl utemetamol f18
diagnostic
Flutemetamol F18,
diagnostic, per
study dose, up to 5
millicuries
4
Q9983 fl orbetaben f18
diagnostic
Florbetaben f18,
diagnostic, per
study dose, up to 8.1
millicuries
4
Also, as of July 1, the HCPCS code set will contain code Q5102 (short descriptor – Inj., infl iximab biosimilar
– and long descriptor – Injection, Infliximab, 10 mg). Code Q5102 will be effective for dates of service on
or after April 5, 2016, and will have TOS codes of 1 and P. In addition, claims for Q5102 must also have the
modifier ZB (Pfizer/hospira).
Additional Information
The official instruction, CR9636, issued to your MAC regarding this change, is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3518CP.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12 6/2016
Medicare Policy Clarified for Prolonged Drug and Biological
Infusions Started Incident to a Physician’s Service Using an
External Pump
MLN Matters® Number: SE1609
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Special Edition article is intended for all physicians and hospital outpatient departments
submitting claims to Medicare Administrative Contractors (MACs) for prolonged drug and biological infusions
started incident to a physician’s service using an external pump. Note that this article does not apply to suppliers’
claims submitted to Durable Medical Equipment MACs (DME MACs).
What You Need to Know
Medicare pays for drugs and biologicals which are not usually self-administered by the patient and furnished
“incident to” physicians’ services rendered to patients while in the physician’s office or the hospital outpatient
department.
In some situations, a hospital outpatient department or physician offi ce may:
purchase a drug for a medically reasonable and necessary prolonged drug infusion,
begin the drug infusion in the care setting using an external pump,
send the patient home for a portion of the infusion, and
have the patient return at the end of the infusion period.
In this case, the drug or biological, the administration, and the external infusion pump is billed to your MAC.
However, because prolonged drug and biological infusions started incident to a physician’s service using an
external pump should be treated as an incident to service, it cannot be billed on suppliers’ claims to DME MACs.
Background
Under section 1861(s)(2)(A) of the Social Security Act (the Act), Medicare will pay for drugs and biologicals
which are furnished “incident to” a physician’s professional service. Under section 1861(s)(2)(B) of the Act,
Medicare will pay for drugs and biologicals which are not usually self-administered by the patient furnished as
“incident to” physicians’ services rendered to outpatients. In order for Medicare to pay for a drug or biological
under section 1861(s)(2)(A) or (B) of the Act, the physician or hospital (respectively) must incur a cost for
the drug or biological. Generally, the administration of drugs or biologicals covered by Medicare under the
“incident to” benefit (1861(s)(2)(A) and (B)) will start and end while the patient is in the physician’s offi ce or
the hospital outpatient department under the supervision of a physician.
However, in some situations a hospital or office may purchase a drug for a medically reasonable and necessary
prolonged drug infusion, then begin the drug infusion in the care setting using an external pump, send the
Continued >>
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13 6/2016
patient home for a portion of the infusion duration, and have the patient return at the end of the infusion period.
In this case, the drug or biological continues to be covered under section 1861(s)(2)(A) and (B) of the Act
and is billable to the MAC even though the entire administration of the drug or biological did not occur in
the physician’s office or the hospital outpatient department. Also, the drug or biological continues to meet the
requirements for the “incident to” benefit as the physician or hospital incurred a cost for the drug or biological
and the administration of the drug began in a physician’s office or hospital “incident to” a physician’s service.
For the administration of the drug, the physician supervision rules under 42 CFR §410.26(b)(5) (http://www.
ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42cfr410_main_02.tpl&wb48617274=0DD72478) and 42
CFR §410.27 (a)(1)(iv) and CMS Publication 100-02, chapter 15, section 50.3
(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf) apply only
while the patient is present in the physician’s office or hospital outpatient department. CMS does not provide
specific coding guidance; however, appropriate drug administration codes for this situation would describe the
services that are provided by the physician or hospital (for example, intravenous infusion, patient monitoring)
while the patient is in the office or the outpatient setting.
Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment
for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin
administration of the drug or biological that the patient takes home to complete the infusion, is not separately
billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B)
incident to benefit. The MAC may direct use of a code described by CPT or an otherwise applicable HCPCS
code for the drug administration service. If necessary, the MAC may direct use of a miscellaneous code for
the drug administration if there is no specified code that describes the drug administration service that also
accounts for the cost of equipment that the patient takes home to complete the infusion that they later return
to the physician or hospital.
Medicare Physician Fees Lookup Tool
Use the Medicare Physician Fee Lookup Tool, located on our home page. The Physician Fee Schedule tool
saves our customers time and money by providing a ‘one stop shop’! Customers can locate fees for the 2013
through 2016 throughout the United States. The tool can search up to five codes and each code shows the
allowance, all of the indicator rules such as the Global Surgery modifiers and Multiple Surgery rules. This
tool helps customers research more than a fee; they can determine if the wrong modifier was appended to a
service, or if the service was subject to multiple surgery rules. The fees and indicator files are downloadable
and customers can easily save the data to their systems for future use.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
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contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14 6/2016
JW Modifier: Drug Amount Discarded/Not Administered to
any Patient
MLN Matters® Number: MM9603
Related Change Request (CR) #: CR 9603
Related CR Release Date: April 29, 2016
Effective Date: July 1, 2016
Related CR Transmittal #: R3508CP
Implementation Date: July 5, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for drugs or biologicals administered to Medicare beneficiaries.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9603 to alert MACs and
providers of the change in policy regarding the use of the JW modifier for discarded Part B drugs and biologicals.
Effective July 1, 2016, providers are required to:
Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages
that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for
Part B drugs and biologicals) and
Document the discarded drug or biological in the patient’s medical record when submitting claims with unused
Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded
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
The “Medicare Claims Processing Manual,” Chapter 17, Section 40 provides policy detailing the use of the JW
modifier for discarded Part B drugs and biologicals. The current policy allows MACs the discretion to determine
whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specifi c details
regarding how the discarded drug or biological information should be documented.
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 for all claims with
discarded Part B drugs and biologicals.
Additional Information
The official instruction, CR9603, issued to your MAC regarding this change is available at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3508CP.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
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15 6/2016
Education Now Available
The “Understanding the Railroad Medicare Medical Review Program Webcast” recording covers
the basics of the Medical Review program. It discusses why we conduct reviews, the different
types of review we conduct, and your rol in the medical review process. We also share helpful
resources and answer frequently asked questions. Please view at http://tinyurl.com/h6llo7t.
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16 6/2016
Get Your Railroad Medicare News Electronically
The Railroad Medicare listserv is a wonderful communication tool that offers its members the opportunity to
stay informed about:
• Medicare incentive programs • Fee Schedule changes
• New legislation concerning Medicare • And so much more!
What is needed to receive updates?
• Internet access and an e-mail address
• Completion of the form below
• Railroad Medicare will enter the information you provide into the online registration
• This information will not be shared with any mailing list
Note: Once the registration information is entered, you will receive a confirmation/welcome message informing
you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within 3 days
of your registration.
Fax the completed form to (803) 264-9844
User Name
(E-mail address cannot be used for user name or password)
Print First and Last Name
Password S3cret*1
(Your confirmation e-mail will instruct you on how to change this
password later.)
Your E-mail Address
Topics (mark those you’re interested in staying informed about)
Ambulance Federally Qualified Health Center Physical/Occupational Therapy
Ambulatory Surgical Center General - Railroad Medicare Physician
Anesthesia/Pain Management Gynecology Podiatry
Cardiovascular Hematology/Oncology Primary Care
Chiropractic Independent Diagnostic Testing Facility Psychology/Psychiatry
Community Mental Health Center Nephrology Radiology
Diagnostic Tests Non-Physician Practitioners Surgery
Drugs/Biologicals Ophthalmology/Optometry
Electronic Date Interchange (EDI) Pathology & Laboratory
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17 6/2016
Medicare Coverage of Substance Abuse Services
MLN Matters® Number: SE1604
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This MLN Matters® Special Edition article is intended for physicians, other providers, and suppliers who
submit claims to Medicare Administrative Contractors (MACs) for substance abuse services provided to
Medicare beneficiaries.
What You Need to Know
While there is no distinct Medicare benefit category for substance abuse treatment, such services are covered
by Medicare when reasonable and necessary. The Centers for Medicare & Medicaid Services (CMS) provides a
full range of services, including those services provided for substance abuse disorders. This article summarizes
the available services and provides reference links to other online Medicare information with further details
about these services.
Background
Services for substance abuse disorders are available under Medicare, as long as those services are reasonable
and necessary. These services include:
Inpatient Treatment
• Inpatient treatment would be covered if reasonable and necessary.
• Professional services provided during that care would be paid either:
• as part of the inpatient stay (for professional services provided by clinicians not recognized for separate
billing, for instance peer counselors), or
• separately, to the professional billing for the provided services if they are recognized under Part B
and considered separate from the inpatient stay (for instance, physicians, and NPPs within their state
scopes of practice).
• Any medication provided as part of inpatient treatment would be bundled into the inpatient payment and
not paid separately.
Outpatient Treatment
• Similar to inpatient treatment, coverage of outpatient treatment would depend on the provider of the services.
• 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
may provide (either directly, or incident to a physician’s service).
• Coverage and payment would be on a service by service basis for those services that are recognized by
Medicare. For instance, Medicare could pay for counseling by an enrolled licensed clinical social worker,
psychologist or psychiatrist.
• Some services could be provided by auxiliary personnel incident to a physician’s services.
Continued >>
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18 6/2016
• Medications used in an outpatient setting that are not usually self-administered may be covered under Part
B if they meet all Part B requirements.
Partial Hospitalization Program (PHP)
The PHP is an intensive outpatient psychiatric day treatment 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 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 evidenced by their plan of care. PHPs may be available in your local hospital
outpatient department and Medicare certified Community Mental Health Center (CMHCs). PHP services include:
• Individual or group psychotherapy with physicians, psychologists, or other mental health professionals
authorized or licensed by the State in which they practice (for example, licensed clinical social workers,
clinical nurse specialists, certified alcohol and drug counselors);
• Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if
required, must be a component of the physicians treatment plan for the individual;
• Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric
patients;
• Drugs and biologicals that cannot be self-administered and are furnished for therapeutic purposes (subject
to limitations specified in 42 CFR 410.29 (http://www.ecfr.gov/cgi-bin/text-idx?SID=56276e89573496d6
7077d4ea0e27b17c&mc=true&node=pt42.2.410&rgn=div5&wb48617274=0DD72478#se42.2.410_129));
• 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;
• Family counseling services for which the primary purpose is the treatment of the patient’s condition;
• Patient training and education, to the extent the training and educational activities are closely and clearly
related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
• Medically necessary diagnostic services related to mental health treatment.
Similar to inpatient and individual outpatient treatment, coverage of PHP services would depend on the provider
of the services.
MLN Matters® Special Edition article SE1512 (https://www.cms.gov/Outreach-and-Education/Medicare­
Learning-Network-MLN/MLNMattersArticles/downloads/SE1512.pdf) titled “Partial Hospitalization Program
(PHP) Claims Coding & CY2015 per Diem Payment Rates” is intended for hospitals and Community Mental
Health Centers (CMHCs) that submit claims to MACs for PHP services provided to Medicare beneficiaries.
In SE1512, CMS reminds hospitals and CMHCs that provide PHP services to follow existing claims coding
requirements given in the “Medicare Claims Processing Manual” (Chapter 4, Section 260) at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf on the CMS
website.
Coverage and payment would be for those PHP services that are recognized by Medicare. For instance, Medicare
could pay for psychotherapy by an enrolled licensed clinical psychologist or psychiatrist.
Substance Abuse Treatment by Suppliers of Services
There are individuals under the Medicare Part B program who are authorized as suppliers of services that are
Continued >>
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19 6/2016
eligible to furnish substance abuse treatment services providing the services are reasonable and necessary and
fall under their State scope of practice.
These suppliers of services include:
• Physicians (medical doctor or doctor of osteopathy);
• Clinical psychologists;
• Clinical social workers;
• Nurse practitioners;
• Clinical nurse specialists;
• Physician assistants; and,
• Certifi ed nurse-midwives.
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 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 use disorder.
SBIRT services aim to prevent the unhealthy consequences of alcohol and drug use among those who may not
reach the diagnostic level of a substance use disorder, and helping those with the disease of addiction enter and
stay with treatment. You may easily use SBIRT 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 may cause or complicate their ability to successfully handle health, work, or family issues. For more
information on the Medicare’s SBIRT services, refer to Medicare’s fact sheet, “Screening, Brief Intervention,
and Referral to Treatment (SBIRT) Services” at https://www.cms.gov/Outreach-and-Education/Medicare­
Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf on the CMS website.
SBIRT consists of three major components:
1. Structured Assessment (Medicare) or Screening (Medicaid): Assessing or screening a patient for risky
substance use behaviors using standardized assessment or screening tools;
2. Brief Intervention: Engaging a patient showing risky substance use behaviors in a short conversation,
providing feedback and advice; and
3. Referral to Treatment: Providing a referral to brief therapy or additional treatment to patients whose
assessment or screening shows a need for additional services.
The first component to the SBIRT process is assessment or screening which uses tools including the World
Health Organization’s Alcohol Use Disorders Identification Test (AUDIT) Manual and the Drug Abuse Screening
Test (DAST). For more information on SBIRT assessment and screening tools, as well as examples of tools,
visit http://www.integration.samhsa.gov/clinical-practice/sbirt/screening on the Internet.
Medicare covers only reasonable and necessary SBIRT services that meet the requirements of diagnosis or
treatment of illness or injury (that is, when the service is provided to evaluate and/or treat patients with signs/
symptoms of illness or injury) per the Social Security Act (Section 1862(a)(1)(A); see
https://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet).
Continued >>
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Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20 6/2016
Medicare pays for medically reasonable and necessary SBIRT services furnished in physicians’ offi ces (by
physicians and non-physician practitioners) and outpatient hospitals. In these settings, you assess for and identify
individuals with, or at-risk for, substance use-related problems and furnish limited interventions/treatment. To
bill Medicare, suppliers of SBIRT services must be:
• Licensed or certified to perform mental health services by the State in which they perform the services;
• Qualified to perform the specific mental health services rendered; and
• Working within their State Scope of Practice Act.
Medicare pays for these services under the Medicare Physician Fee Schedule (PFS) and the hospital Outpatient
Prospective Payment System (OPPS). For more information on Medicare’s payment for SBIRT services, refer
to the “Medicare Claims Processing Manual” (Chapter 4, Section 200.6) at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf on the CMS
website.
Drugs Used to Treat Opioid Dependence
Medicare Part D sponsors must include coverage for Part D drugs, either by formulary inclusion or via an
exception, when medically necessary for the treatment of opioid dependence. Coverage is not limited to single
entity products such as Subutex®, but must include combination products when medically necessary (for
example, Suboxone®). For any new enrollees, CMS requires sponsors to have a transition policy to prevent any
unintended interruptions in pharmacologic treatment with Part D drugs during their transition into the benefit.
This transition policy, along with CMS› non-formulary exceptions/appeals requirements, should ensure that all
Medicare enrollees have timely access to their medically necessary Part D drug therapies for opioid dependence.
A Part D drug is defined, in part, as “a drug that may be 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. (NOTE: Methadone is a Part D drug when indicated
for pain). State Medicaid 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.
See the “Medicare Prescription Drug Benefit Manual” (Chapter 6, Section 10.8 (Drugs Used to Treat Opioid
Dependence)) at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/
downloads/chapter6.pdf on the CMS website.
Note: Medicare covers diagnostic clinical laboratory services that are reasonable and necessary for the diagnosis
or treatment of an illness or injury. For beneficiaries being treated for substance abuse, testing for drugs of
abuse when reasonable and necessary can help manage their treatment. Information on the clinical laboratory
fee schedule is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/Clinical-Laboratory-Fee-Schedule-Fact-Sheet-ICN006818.pdf on the CMS website.
Additional Information
Providers may want to review the following resources:
• “Mental Health Services” Booklet: see https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNProducts/Downloads/Mental-Health-Services-Booklet-ICN903195.pdf on the CMS
website.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
21 6/2016
• “Summary of Medicare Reporting and Payment of Services for Alcohol and/or Substance (Other than
Tobacco) Abuse Structured Assessment and Brief Intervention (SBIRT) Services;” see https://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1013.
pdf on the CMS website.
• National Coverage Determinations (NCDs): Inpatient Hospital Stays for the Treatment of Alcoholism
(130.1); Outpatient Hospital Services for Treatment of Alcoholism (130.2); Chemical & Electrical
Aversion Therapy for Treatment of Alcoholism (130.3, 130.4); Treatment of Alcoholism and Drug Abuse
in a Freestanding Clinic (130.5); Treatment of Drug Abuse (Chemical Dependency) (130.6); Withdrawal
Treatments for Narcotic Addictions (130.7): See
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf on
the CMS website.
• “Medicaid Program Integrity What Is a Prescriber’s Role in Preventing the Diversion of Prescription
Drugs?” Fact Sheet: See https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/Drug-Diversion-ICN901010.pdf on the CMS website.
• “Effective Strategies for Addressing Overutilization and Abuse of Prescription Drugs in Medicare Part D”:
See https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/
AHIP_Overutilization_Strategies_CMS_-10192015.pdf on the CMS website.
• “New Medicare Part D Opioid Drug Mapping Tool Available”: See https://www.cms.gov/Newsroom/
MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-11-03.html on the CMS website.
• “Prescription Drug Monitoring Programs: A Resource to Help Address Prescription Drug Abuse
and Diversion”: See https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/
mlnmattersarticles/downloads/se1250.pdf on the CMS website.
• “Calendar Year (CY) 2016 Clinical Laboratory Fee Schedule (CLFS) Final Determinations” (includes CY
2016 coding and policy information for drugs of abuse): See https://www.cms.gov/Medicare/Medicare­
Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2016-CLFS-Codes-Final-Determinations.
pdf on the CMS website.
• MLN Matters® Number: SE1105 (Medicare Drug Screen Testing): See https://www.cms.gov/Outreach­
and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1105.pdf on the
CMS website.
• The Prescription Opioid Epidemic (CCSQ Grand Rounds Webinar); see https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/The-Prescription-Opioid­
Epidemic.pdf on the CMS website.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
22 6/2016
Screening for Cervical Cancer with Human Papillomavirus
(HPV) Testing—National Coverage Determination (NCD)
210.2.1
MLN Matters® Number: MM9434
Revised Related Change Request (CR) #: CR 9434
Related CR Release Date: February 5, 2016
Effective Date: July 9, 2015 Implementation Date: July 5, 2016 (CWF analysis and design), October 3, 2016
(CWF Coding, Testing and Implementation, MCS and FISS implementation; January 3, 2017 (requirement
9434-04.8.2), March 7, 2016 (non-shared MAC edits)
Related CR Transmittal #: R189NCD and R3460CP
Note: this article was revised on April 22, 2016, to correct the G code in two places on pages 2 and 3. The
correct code is G0476. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9434 announces that the Centers for Medicare & Medicaid Services (CMS) has determined
that, effective for dates of service on or after July 9, 2015, evidence is sufficient to add Human Papillomavirus
(HPV) testing under specified conditions. Make sure that your billing staffs are aware of this change.
Background
Medicare covers a screening pelvic examination and Pap test for all female beneficiaries at 12- or 24-month
intervals, based on specific risk factors; however, current Medicare coverage does not include the HPV testing.
Section 1861(ddd) of the Social Security Act (the Act) (see
http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) states that CMS may add coverage of “additional
preventive services” through the National Coverage Determination (NCD) process. The preventive services
must meet all of the following criteria:
• Reasonable and necessary for the prevention or early detection of illness or disability;
• Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF); and,
• Appropriate for individuals entitled to benefits under Part A or enrolled under Part B.
CMS has reviewed the USPSTF recommendations and supporting evidence for screening for cervical cancer
with HPV co-testing, and has determined that the criteria were met. Therefore, effective for claims with dates
of service on or after July 9, 2015, CMS will cover screening for cervical cancer with HPV co-testing under
the following conditions:
CMS has determined that the evidence is sufficient to add HPV testing once every 5 years as an
additional preventive service benefit under the Medicare program, for asymptomatic beneficiaries
aged 30 to 65 years in conjunction with the Pap smear test. CMS will cover screening for cervical
Continued >>
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23 6/2016
cancer with the appropriate U.S. Food and Drug Administration (FDA)-approved/cleared laboratory
tests, used consistent with FDA-approved labeling, and in compliance with the Clinical Laboratory
Improvement Act (CLIA) regulations.
A new Healthcare Common Procedure Coding System (HCPCS) code, G0476 (HPV combo assay, CA screen),
Type of Service (TOS) 5 (diagnostic lab), has been created for this benefit. This code will:
• Be effective retroactive back to the effective date of July 9, 2015;
• Be included in the January 2016, Integrated Outpatient Code Editor, Outpatient Prospective Payment
System, and Medicare Physician Fee Schedule Database;
• Be MAC-priced from July 9, 2015, through December 31, 2016, and during this period code G0476 is
paid only when it is billed by a laboratory entity; and,
• Beginning January 1, 2017, this will be priced and paid according to the Clinical Laboratory Fee Schedule
(CLFS).
In addition, you should be aware of the following:
1. Your MACs will not apply beneficiary coinsurance and deductibles to claim lines containing HCPCS G0476,
HPV screening;
2. Part B MACs shall only accept claims with a Place of Service Code equal to ‘81’, Independent Lab or ‘11’,
Office; and
3. Effective for claims with dates of service on or after July 9, 2015, your MACs will deny line-items on claims
containing HCPCS G0476, HPV screening, when reported more than once in a 5-year period [at least 4 years
and 11 months (59 months total) must elapse from the date of the last screening]. The next eligible dates for
this service are shown on all Common Working File (CWF) provider query screens (HUQA, HIQA, HIQH,
ELGA, ELGH, and PRVN).
When denying a line-item on a claim for this requirement they will use the following messages:
• Claim Adjustment Reason Code (CARC) 119 – “Benefit maximum for this time period or occurrence has
been reached;”
• Remittance Advice Remark Code (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 www.cms.gov/mcd/search.asp. If you do not have
web access, you may contact the contractor to request a copy of the NCD;”
• Group Code “CO” if the claim contains a GZ modifier to denote a signed Advance Benefi ciary Notice
(ABN) is not on file or with Group Code “PR” (Patient Responsibility) if the claim has a GA modifi er to
show a signed ABN is on file.
4. HCPCS Code G0476 will be paid only for institutional claims submitted on Type of Bill codes (TOB)
12X, 13X, 14X, 22X, 23X, and 85X. Institutional claims on other TOBs will be returned to the provider.
5. Effective for claims with dates of service on or after July 9, 2015, your MACs will deny line-items on claims
containing HCPCS G0476, HPV screening, when the beneficiary is less than 30 years of age or older than 65
years of age.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
24 6/2016
When denying a line-item on claims for this requirement, they will use the following messages:
• CARC 6 – “The procedure/revenue code is inconsistent with the patient’s age. Note: Refer to the 835
Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present;”
• RARC N129 – “Not eligible due to the patient’s age;”
• Group Code “CO” if the claim contains a GZ modifier to denote a signed Advance Benefi ciary Notice
(ABN) is not on file or with Group Code “PR” (Patient Responsibility) if the claim has a GA modifi er to
show a signed ABN is on file.
6. Effective for claims with dates of service on or after July 9, 2015, you must report the following diagnosis
codes when submitting claims for HCPCS G0476:
• ICD-9 (for dates of service prior to October 1, 2015): V73.81, special screening exam, HPV (as primary),
and V72.31, routine gynecological exam (as secondary)
• ICD-10: Z11.51, encounter for screening for HPV, and Z01.411, encounter for gynecological exam (general)
(routine) with abnormal findings, OR Z01.419, encounter for gynecological exam (general)(routine) without
abnormal findings.
Effective on this date, your MACs will deny line-items on claims containing HCPCS Code G0476, HPV
screening, when the claim does not contain these codes.
When denying a line-item on claim for this requirement, they will use the following messages:
• CARC 167 – “This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment Information 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 www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor
to request a copy of the NCD;” and
• Group Code CO.
7. This NCD does not change current policy as it relates to screening for pap smears and pelvic exams as
described in the Medicare NCD Manual, section 210.2, or in the Medicare Claims Processing Manual, chapter
18, section 30, which you can fi nd at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf on the
CMS website.
Additional Information
The official instruction, CR 9434, was issued to your MAC via two transmittals. The first updates the NCD
Manual and is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R189NCD.pdf and the
second transmittal updates the “Medicare Claims Processing Manual” and it is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3460CP.pdf on the CMS
website.
Document History
• This article was revised on April 22, 2016, to correct the reference to G0476 in two places on pages 2 and
3. The original article mentioned G4076, which is incorrect. All references should have shown G0476.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
25 6/2016
Update to Internet-Only-Manual Publication 100-04, Chapter
18, Section 30.6
MLN Matters® Number: MM9606
Related Change Request (CR) #: CR 9606
Related CR Release Date: May 13, 2016
Effective Date: June 14, 2016
Related CR Transmittal #: R3522CP
Implementation Date: June 14, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for cervical cancer screening services provided to Medicare beneficiaries.
Provider Action Needed
CR9606 advises the MACs of an update to the “Medicare Claims Processing Manual,” Chapter 18, Section
30.6. CR9606 updates the manual by replacing an incorrect diagnosis code for screening of cervical cancer
with HPV testing. The manual shows an incorrect ICD-10 code of Z12.92 and the correct ICD-10 code is
Z12.72 (encounter for screening for malignant neoplasm of the vagina). Make sure that your billing staffs are
aware of this change.
Additional Information
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.pdf. The updated
manual section is attached to the CR.
A list of current system-related claims payment issues is
available on our website. These issues were reported to the
Centers for Medicare & Medicaid Services (CMS) and/or the
Multi-Carrier System (MCS). Please check often for updates
before contacting the provider contact center. The issues are identified by stand alone articles and will be updated
as needed. Be sure to sign-up to receive updates using the “Article Update Notifi cation” feature.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
26 6/2016
Stem Cell Transplantation for Multiple Myeloma,
Myelofibrosis, and Sickle Cell Disease, and Myelodysplastic
Syndromes
MLN Matters® Number: MM9620
Related Change Request (CR) #: CR 9620
Related CR Release Date: April 29, 2016
Effective Date: January 27, 2016
Related CR Transmittal #: R191NCD and R3509CP
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians and providers submitting stem cell transplantation claims
to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9620, from which this article was developed, notifies providers that effective for
claims with dates of service on and after January 27, 2016, for the use of allogeneic Hematopoietic Stem Cell
Transplantation (HSCT) for treatment of Multiple Myeloma, Myelofibrosis, and Sickle Cell Disease is covered
by Medicare, but only if provided in the context of a Medicare-approved clinical study meeting specifi c criteria
under the Coverage with Evidence Development (CED) paradigm.
CR9620 also clarifies the ICD-9 and ICD-10 diagnosis codes for allogeneic HSCT for treatment of
Myelodysplastic Syndromes (MDS) in the context of a Medicare-approved, prospective clinical study under
CED. Specifically, for dates of service on or after August 4, 2010, through September 30, 2015, the ICD-9-CM
diagnosis codes are 238.72, 238.73, 238.74, or 238.75 AND clinical trial ICD-9-CM diagnosis code V70.7.
For dates of service on or after October 1, 2015, the ICD-10-CM diagnosis codes are D46.A, D46.B, D46.C,
D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, or D46.Z AND clinical trial ICD-10-CM diagnosis
code Z00.6. Make sure your billing staff is aware of these determinations.
Background
HSCT is a process that 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) or a donor (allogeneic) and subsequently administered by
intravenous infusion to the patient.
Multiple myeloma is a neoplastic plasma-cell disorder. Myelofibrosis is a stem cell-derived hematologic
disorder. Sickle cell disease is a group of inherited red blood cell disorders created by the presence of abnormal
hemoglobin genes. On April 30, 2015, the Centers for Medicare & Medicaid Services (CMS) accepted a formal
request from the American Society for Blood and Marrow Transplantation (ASBMT) to reconsider its policy
and expand coverage of allogeneic HSCT for sickle cell disease, Myelofibrosis, multiple myeloma and rare
diseases.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
27 6/2016
Myelodysplastic Syndrome (MDS) refers to a group of diverse blood disorders in which the bone marrow does
not produce enough healthy, functioning blood cells. On August 4, 2010, CMS issued a final decision stating
that allogeneic HSCT for MDS is covered by Medicare only if provided pursuant to a Medicare-approved
clinical study under CED. CR 7137 (see the article, MM7137 at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7137.pdf) provides specifi c ICD-9
related coding and claims processing requirements regarding this particular coverage decision, and CRs 8197
and 8691 (see MM8197 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/Downloads/MM8197.pdf and MM8691 at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8691.pdf) provide ICD-10 related
coding requirements. On November 30, 2015, 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 treatment of MDS in the context of a Medicare-approved clinical study under CED.
On January 27, 2016, CMS issued a final decision to expand national coverage of items and services necessary
for research in an approved clinical study via Coverage with Evidence Development (CED) under Section
1862(a)(1)(E) of the Social Security Act (the Act) for allogeneic HSCT for the following indications:
• Multiple Myeloma
• Myelofibrosis
• Sickle Cell Disease
Refer to the following Medicare manual sections for more information regarding this NCD and further billing
instructions specific to this NCD and the business requirements specific to CR9620:
• Chapter 1, Section 110.23, of the “Medicare NCD Manual,” which is attached to the CR9620 NCD transmittal
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R191NCD.pdf
• Chapter 1, Section 310.1, of the “Medicare NCD Manual,” available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf,
and
• Chapter 32, Sections 69 and 90, of the “Medicare Claims Processing Manual,” available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf.
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
For claims submitted on type of bill 11X for discharges on or after January 27, 2016, for HSCT for the treatment
of Multiple Myeloma, Myelofibrosis, or Sickle Cell Disease, the claim must show:
• An ICD-10-PCS procedure code of 30230G1, 30230Y1, 30233G1, 30233Y1, 30240G1, 30240Y1, 30243G1,
30243Y1, 30250G1,30250Y1, 30253G1, 30253Y1, 30260G1, 30260Y1, 30263G1, or 30263Y1 AND
• The clinical trial ICD-10-CM code of Z00.6 AND
• Condition code 30, denoting qualifying clinical trial AND
• Value code D4 showing the Clinical Trial Number (assigned by NLM/NIH with an 8-digit clinicaltrials.
gov identifier number listed on the CMS website) along with the appropriate ICD-10-diagnosis code of:
• Multiple Myeloma-ICD-10-CM diagnosis code C90.00, C90.01, or C90.02 OR
• Myelofibros is-ICD-10-CM diagnosis code C94.40, C94.41, C94.42, D47.4, or D75.81 OR
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
28 6/2016
• Sickle Cell Disease-ICD-10-CM diagnosis code D57.00, D57.01, D57.02, D57.1, D57.20, D57.211,
D57.212, D57.219, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, or D57.819
Outpatient Claims
For claims submitted on type of bill 13X or 85X for dates of service on or after January 27, 2016, for HSCT
for the treatment of Multiple Myeloma, Myelofibrosis, or Sickle Cell Disease, the claim must show:
• 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 code D4 showing the Clinical Trial Number (assigned by NLM/NIH with an 8-digit clinicaltrials.
gov identifier number listed on the CMS website) along with the appropriate ICD-10-diagnosis code of:
• Multiple Myeloma-ICD-10-CM diagnosis code C90.00, C90.01, or C90.02 OR
• Myelofibrosis-ICD-10-CM diagnosis code C94.40, C94.41, C94.42, D47.4, or D75.81 OR
• Sickle Cell Disease-ICD-10-CM diagnosis code D57.00, D57.01, D57.02, D57.1, D57.20, D57.211,
D57.212, D57.219, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, or D57.819
Method II Critical Access Hospital (CAH) Claims
For claims submitted on type of bill 85X with Revenue Codes 96X, 97X, or 98X for dates of service on or after
January 27, 2016, for HSCT for the treatment of Multiple Myeloma, Myelofibrosis, or Sickle Cell Disease,
the claim must show:
• 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 code D4 showing the Clinical Trial Number (assigned by NLM/NIH with an 8-digit clinicaltrials.
gov identifier number listed on the CMS website) along with the appropriate ICD-10-diagnosis code of:
• Multiple Myeloma-ICD-10-CM diagnosis code C90.00, C90.01, or C90.02 OR
• Myelofibrosis-ICD-10-CM diagnosis code C94.40, C94.41, C94.42, D47.4, or D75.81 OR
• Sickle Cell Disease-ICD-10-CM diagnosis code D57.00, D57.01, D57.02, D57.1, D57.20, D57.211,
D57.212, D57.219, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, or D57.819
Professional Claims
For professional claims submitted on type of bill 85X with Revenue Codes 96X, 97X, or 98X for dates of
service on or after January 27, 2016, for HSCT for the treatment of Multiple Myeloma, Myelofibrosis, or Sickle
Cell Disease, the claim must show:
• An HSCT CPT code of 38240 AND
• The clinical trial ICD-10-CM code of Z00.6 AND
• The Q0 modifi er AND
• A Place of Service Code of 19, 21, or 22 along with the appropriate ICD-10-CM diagnosis code of:
• o Multiple Myeloma-ICD-10-CM diagnosis code C90.00, C90.01, or C90.02 OR
• Myelofibrosis-ICD-10-CM diagnosis code C94.40, C94.41, C94.42, D47.4, or D75.81 OR
• Sickle Cell Disease-ICD-10-CM diagnosis code D57.00, D57.01, D57.02, D57.1, D57.20, D57.211,
D57.212, D57.219, D57.40, D57.411, D57.412, D57.419, D57.80, D57.811, D57.812, or D57.819
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
29 6/2016
b b For all of the above claims types submitted without the requisite coding, MACs will deny the claims using the
following messages:
• Claim Adjustment Reason Code (CARC) 50 - These are non-covered services because this is not deemed
a ‘medical necessity’ by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present.
• Remittance Advice Remarks Code (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 http://www.cms.hhs.gov/mcd/search.asp. If you do
not have web access, you may contact the contractor to request a copy of the NCD.
• Group Code - Patient Responsibility (PR) if an Advance Beneficiary Notice (ABN)/Hospital Notice on
Non-Coverage (HINN), otherwise Contractual Obligation (CO)
For claims 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 their MAC.
Additional Information
The official instruction, CR9620, consists of two transmittals. The first updates the “Medicare Claims Processing
Manual” at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3509CP.pdf.
The second transmittal updates the “Medicare NCD Manual” at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R191NCD.pdf.
eServices: Claim Status
To check on a particular claim status, please enter the HICN and other required
eneficiary information, as well as the date(s) of service. Should you not know
the exact date of service, you are able to enter a span or range of up to 45
days. Please keep in mind, retrieving claims older than six months takes a little
longer than something more current. Claims older than three years may not
e searchable. For more information about eServices and the many services
it offers, please visit our website at http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
30 6/2016
Coding Revisions to National Coverage Determinations
MLN Matters® Number: MM9540
Related Change Request (CR) #: CR 9540
Related CR Release Date: April 29, 2016
Effective Date: July 1, 2016
Related C R Transmittal #: R1658OTN
Implementation Date: July 5, 2016, unless otherwise noted
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
What You Need to Know
Change Request (CR) 9540 is the 7th maintenance update of the International Statistical Classifi cation of
Diseases and Related Health Problems 10th Revision (ICD-10) conversions and other coding updates specifi c to
National Coverage Determinations (NCDs). Edits to 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.
Background
The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CRs,
specifically, CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. You may review the corresponding
MLN Matters® Articles MM7818 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNMattersArticles/downloads/MM7818.pdf), MM8109 (https://www.cms.gov/Outreach­
and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8109.pdf), MM8197
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
downloads/MM8197.pdf), MM8691 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNMattersArticles/downloads/MM8691.pdf), MM9087 (https://www.cms.gov/Outreach-and­
Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8907.pdf), and MM9252
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
downloads/MM9252.pdf) for these CRs on the Centers for Medicare & Medicaid Services (CMS) website.
Some are the result of revisions required to other NCD-related CRs released separately.
Updated NCD coding spreadsheets related to CR9540 are available at
http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9540.zip. CR9540 updates the
following 14 NCDs:
1. NCD20.29 - Hyperbaric Oxygen Therapy
2. NCD90.1 - Pharmacogenomic Testing for Warfarin Response
3. NCD110.18 - Aprepitant for Chemotherapy-Induced Emesis
4. NCD150.3 - Bone Mineral Density Studies
5. NCD160.18 - Vagus Nerve Stimulation for Treatment of Seizures
6. NCD160.24 - Deep Brain Stimulation for Essential Tremor
7. NCD210.3 - Colorectal Cancer Screening Tests
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
31 6/2016
b 8. NCD210.14 - Screening for Lung Cancer with Low-Dose CT (CR9246)
9. NCD230.18 - Sacral Nerve Stimulation for Urinary Incontinence
10. NCD260.1 - Adult Liver Transplantation (CR9252, CR8109)
11. NCD110.4 - Extracorporeal Photopheresis
12. NCD20.33 - Transcatheter Mitral Valve Repair (CR9002, TDL150341, policyeffective August 7, 2014
13. NCD220.13 - Percutaneous Image-Guided Breast Biospy
14. NCD220.4 - Mammograms
MACs will adjust any claims already processed, if erroneously impacted by the above changes, if you bring
such claims to their attention.
Additional Information
The official instruction, CR9540, issued to your MAC regarding this change is available for download at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1658OTN.pdf.
Review and Print Electronic Remittances –
via eRemits
Palmetto GBA is pleased to offer eRemits through our eServices, a free, webased, provider self-service tool. You can view or print remittances, which are
available for approximately one year. In addition, eServices will let you store
remittances and utilize search features to fi nd specific information on the notices. eRemits are available to be
accessed every day between the hours of 8 a.m. and 7 p.m. ET.
To use eServices, you must have an Electronic Data Interchange (EDI) Agreement on file with Palmetto GBA.
If you are already submitting claims electronically, you do not have to submit a new EDI Enrollment Agreement.
For more information on EDI, please visit our website at www.PalmettoGBA.com/EDI.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
32 6/2016
Coding Revisions to National Coverage Determinations
(NCDs)
MLN Matters® Number: MM9631
Related Change Request (CR) #: CR 9631
Effective Date: October 1, 2016 - unless noted differently in CR9631
Related CR Release Date: May 13, 2016
Related CR Transmittal #: R1665OTN
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare
Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
CR9631 is the 8th maintenance update of International Classification of Diseases, Tenth Revision (ICD-10)
conversions and other coding updates specifi c to national coverage determinations (NCDs). The majority of
the NCDs included are a result of feedback received from previous ICD-10 NCD CRs, specifi cally CR7818,
CR8109, CR8197, CR8691, CR9087, CR9252, and CR9540, while others are th e result of revisions required
to other NCD-related CRs released separately. Review MLN Matters® Articles CR7818 (https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/
MM7818.pdf), CR8109 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM8109.pdf), MM8197 (https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8197.pdf), MM8691 (https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/
MM8691.pdf), MM9087 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/MM9087.pdf), MM9252 (https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9252.pdf), and MM9540 (https://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/
MM9540.pdf) for information pertaining to these CR’s.
Background
The translations from ICD-9 to ICD-10 are not consistent one-to-one matches, nor are all ICD-10 codes
appearing in a complete General Equivalence Mappings (GEMS) guide or other mapping guides appropriate
when reviewed against individual NCD policies. In addition, for those policies that expressly allow MAC
discretion, there may be changes to those NCDs based on current review of those NCDs against ICD-10 coding.
For these reasons, there may be certain ICD-9 codes that were once considered appropriate prior to ICD-10
implementation that are no longer considered acceptable.
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. Updated NCD coding spreadsheets related to CR9631
are available at https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9631.zip.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
33 6/2016
Edits to 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.
To be specific, CR9631 makes adjustments to the following NCDs:
• NCD 20.4 -Implantable Automatic Defibrillators
• NCD 20.7 -Percutaneous Transluminal Angioplasty (PTA)
• NCD 20.9 - Artificial Hearts
• NCD 20.29 - Hyperbaric Oxygen Therapy
• NCD 50.3 - Cochlear Implants
• NCD 110.18 - Aprepitant
• NCD 210.3 - Colorectal Cancer Screening
• NCD 220.4 - Mammography
• NCD 230.9 - Cryosurgery of Prostate
• NCD 260.9 - Heart Transplants
• NCD 210.4 - Smoking/Tobacco-Use Cessation Counseling
• NCD 210.4.1 - Counseling to Prevent Tobacco Use
Additional Information
The official instruction, CR 9631, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1665OTN.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
34 6/2016
Percutaneous Left Atrial Appendage Closure (LAAC)
MLN Matters® Number: MM9638
Related Change R equest (CR) #: CR 9638
Related CR Release Date: May 6, 2016
Effective Date: February 8, 2016
Related CR Transmittal #: R192NCD and R3515CP
Implementation Date: October 3, 2016
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 9638 informs MACs that the Centers for Medicare & Medicaid Services (CMS) issued a
National Coverage Determination (NCD) covering percutaneous Left Atrial Appendage Closure (LAAC) through
Coverage with Evidence Development (CED) when LAAC is furnished in patients with Non-Valvular Atrial
Fibrillation (NVAF) and the device has received Food and Drug Administration (FDA) Premarket Approval
(PMA) for that device’s FDA-approved indication and meets all the specified conditions. Make sure that your
billing staffs are aware of these changes.
Background
LAAC is a strategy to reduce the risk of stroke by closing the Left Atrial Appendage (LAA) in patients with
NVAF. Patients with NVAF, an abnormally rapid, irregular heartbeat, are at an increased risk of stroke. Some
evidence suggests that many of the strokes attributed to NVAF 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
NVAF to reduce cardioembolic stroke risk as a potential alternative to oral anticoagulation.
On February 8, 2016, CMS issued an NCD covering percutaneous LAAC through CED when LAAC is furnished
in patients with NVAF and the device has received FDA PMA for that device’s FDA-approved indication and
meets all the specified conditions. Coverage requires that patients must have:
• A CHADS2 score = 2 (Congestive heart failure, Hypertension, Age >75, Diabetes, Stroke/transient ischemia
attack/thromboembolism) or CHA2DS2-VASc score = 3 (Congestive heart failure, Hypertension, Age =
65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category)
• A formal shared decision making interaction with an independent non-interventional physician using an
evidence-based decision tool on oral anticoagulation in patients with NVAF prior 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 as a second line therapy to oral
anticoagulants
The NCD lists the criteria for the physician and facility criteria and includes a requirement for a multidisciplinary
team to be engaged in patient care.
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
35 6/2016
The patient must be enrolled in, and the multidisciplinary team (MDT) and hospital must participate in a
prospective, national, audited registry that: 1) consecutively enrolls LAAC patients and 2) tracks the specified
annual outcomes for each patient for a period of at least four years from the time of the LAAC. The registry
must address pre-specified research questions, adhere to standards of scientific integrity, and be approved by
CMS. Approved registries will be posted at
https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/LAAC.html. The process
for submitting a registry to Medicare is outlined in the NCD.
For devices and indications that are not approved by FDA, patients must be enrolled in a qualifying FDAapproved Randomized Controlled Trial (RCT). The clinical study must address pre-specified research questions,
adhere to standards of scientific integrity, and be approved by CMS. Approved studies will be posted at
https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/LAAC.html. The process
for submitting a clinical research study to Medicare is outlined in the NCD. LAAC claims with dates of
service on or after February 8, 2016, will be billed with temporary level III CPT code 0281T (percutaneous
transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture,
catheter placement(s) left atrial angiography, left atrial appendage angiography, radiological supervision and
interpretation) and will be MAC-priced. CMS will issue further instructions, once a permanent CPT level 1
replaces the temporary code.
LAAC is non-covered for the treatment of NVAF when not furnished under CED according to the criteria
outlined in the NCD, which is at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R192NCD.pdf.
Additional Billing Instructions
On institutional claims (type of bill 11X), hospitals should show:
• ICD-10 procedure code of 02L73DK (Occlusion of Left Atrial Appendage with Intraluminal Device,
Percutaneous Approach )
• A primary diagnosis code of one of the following: o I48.0 – Paroxysmal atrial fibrillation
• I48.1 – Persistent atrial fibrillation
• I48.2 – Chronic atrial fibrillation
• I48.91 – Unspecifi ed atrial fibrillation
• A secondary ICD-10 diagnosis code of Z00.6 – Encounter for examination for normal comparison and
control in clinical research program
• Condition Code 30 (Qualifying Clinical Trial), and
• Value Code D4 - Clinical Trial Number (assigned by NLM/NIH with an 8-digit clinicaltrials.gov identifier
number listed on the CMS website)
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 following messages:
• Claim Adjustment Reason Code (CARC) 50: These are non-covered services because this is not deemed
a “medical necessity” by the payer.
• Remittance Advice Remarks Code (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 http://www.cms.hhs.gov/mcd/search.asp. If you do
not have web access, you may contact the contractor to request a copy of the NCD.
• Group Code - Contractual Obligation (CO)
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
36 6/2016
Professional claims with dates of service on or after February 8, 2016, for LAAC under CED will be paid only
when billed with the following codes:
• CPT 0281T
• Primary ICD-10 diagnosis code (one of the following): o I48.0 – Paroxysmal atrial fibrillation, o I48.1 –
Persistent atrial fibrillation,
• I48.2 – Chronic atrial fibrillation,
• I48.91 – Unspecifi ed atrial fibrillation
• Place of Service code of 21 (inpatient hospital)
• Secondary diagnosis code Z00.6
• Modifi er Q0
• Clinical trial number in item 23 of the CMS-1500 form or electronic equivalent
MACs will deny LAAC claims when billed without the appropriate diagnosis codes, with the following messages:
• CARC 50 - These are non-covered services because this is not deemed a “medical necessity” by the payer.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
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 http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the
contractor to request a copy of the NCD.
• Group Code – Contractual Obligation (CO).
MACs will deny claims for LAAC with 0281T with a POS code other than 21 using the following messages:
• CARC 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place
of service. Note: Refer to the 835 Healthcare Policy Identifi cation Segment (loop 2110 Service Payment
Information 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 http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the
contractor to request a copy of the NCD.”
• Group Code – Contractual Obligation (CO).
MACs will return claim lines on professional claims for 0281T as unprocessable when the Q0 modifier is not
present using messages:
• CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.”
• Group Code – Contractual Obligation (CO)
MACs will return claim lines with 0281T as unprocessable when billed without secondary diagnosis code
Z00.6 using the following messages:
• CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code
must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.)”
• RARC M76: “Missing/incomplete/invalid diagnosis or condition.”
• Group Code – Contractual Obligation (CO)
Continued >>
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
37 6/2016
Finally, failure to include the clinical trial number will result in MACs returning claim lines as unprocessable
using the following messages:
• CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code
must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice
Remark Code that is not an ALERT.)”
• RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial
number.
• Group Code – Contractual Obligation (CO)
Note that MACs will not search their files for claims for LAAC with dates of service on or after February 8,
2016, that were processed prior to implementation of CR9638. However, they will adjust such claims that you
bring to their attention.
Additional Information
The official instruction, CR9638, consists of two transmittals. The first contains the actual NCD and is available
at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R192NCD.pdf. The
second provides the claims processing instructions and it is at available at
http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3515CP.pdf.
Appeals Calculator Self Service Tool
Providers may appeal claims that are partially or fully denied, as long as the claim has ‘appeal rights’. Different
levels of appeals have different timelines in which the appeal rights are valid. Access the Appeals Calculator
tool under Forms/Tools on the home page to calculate the your claims appeal deadlines.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
38 6/2016
System Specific Enhancements 2014: Move PAP Smear Risk
Indicator (PAPRI) and Technical (TECH)/Professional (PROF)
Dates to Screening Auxiliary File
MLN Matters® Number: MM9188
Related Change Request (CR) #: CR 9188
Related CR Release Date: November 5, 2015
Related CR Transmittal #: R1551OTN
Effective Date: April 4, 2016
Implementation Date: April 4, 2016
Provider Types Affected
This MLN Matters® Article is intended for institutional providers and Home Health Agencies (HHAs) submitting
inquiries to Medicare Administrative Contractors (MACs) for information on PAP smear services provided to
Medicare beneficiaries.
What You Need to Know
CR9188 announces changes to Medicare systems regarding the placement of PAP smear data on Medicare’s
internal files. The PAP smear data is displayed on the following provider inquiry screens:
• HIQA - Healthcare inquiry for part A for online transactions
• HIQH - Healthcare inquiry for Home Health for online transactions
• ELGA - Eligibility for part A
• ELGH - Eligibility for Home Health
• HUQA - Healthcare Update Inquiry for part A
The Healthcare Common Procedure Coding System (HCPCS) codes for PAP screening displayed on these
screens are P3000, G0123, G0143, G0144, G0145, G0147 and G0148, and the screens can show up to three
occurrences per HCPCS.
The other significant change for providers is that on the unformatted provider inquiry, HUQA, PAP information
will now be carried in screening data location 4053-4612, instead of 780-784.
Additional Information
The official instruction, CR9188, issued to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1551OTN.pdf.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
39 6/2016
Interactive
Tools
These guides provide instruction
on how to complete or interpret the
following forms. They are available
on the home page, under Forms/Tools.
Remittance Advice
EDI Agreement
EDI Application
EDI Provider
Authorization
CMS 1500 Claim Form
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
40 6/2016
_______________________________________
CMS e-News
e-News contains a week’s worth of Medicare-related messages instead
of many different messages being sent to you throughout the week.
This notification process ensures planned, coordinated messages are
delivered timely about Medicare-related topics.
MLN Connects™ Provider eNews
MLN Connects™ Provider eNews for April 28, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-04-28-eNews.pdf
MLN Connects™ Provider eNews for May 5, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-05-eNews.pdf
MLN Connects™ Provider eNews for May 12, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-12-eNews.pdf
MLN Connects™ Provider eNews for May 19, 2016
https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2016-05-19-eNews.pdf
Receive ADRs Electronically:
Go Green via eServices
Providers can now opt to receive Additional Documentation Requests (ADRs)
through eServices. If your claim is selected for review, you can receive your
request as it is generated – instead of by mail (which decreases the amount of
time you have to respond).
This new process is free, secure and easy to use. Our messaging function in eServices will send an inbox
message to let users know that an ‘eLetter’ is now available. This new process delivers the electronic document
as a link within the secure message once you sign into eServices.
For more information about eServices and the many services it offers, please visit our website at
www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
41 6/2016
CMS Offers FREE Medicare Training for Providers
CMS Web Training
The Centers for Medicare & Medicaid Services (CMS) has launched a series of education and training
programs designed to leverage emerging Internet and satellite technologies to offer just-in-time training
to Medicare providers and suppliers throughout the United States. Many of these programs include free,
downloadable computer/Web based training courses. These courses are also available on CD-ROM.
http://www.cms.gov/MLNGenInfo
Railroad Medicare Customer Information and Outreach
Palmetto GBA
Railroad Medicare
P.O. Box 10066
Augusta, GA 30999-0001
www.PalmettoGBA.com/RR
Important Telephone Numbers
Provider Contact Center
888-355-9165
Interactive Voice Response (IVR) System
877-288-7600
Telephone Reopenings
888-355-9165
Electronic Data Interchange (EDI)
Technical Support
888-355-9165
Beneficiary Contact Center
800-833-4455
TTY 877-566-3572
Attention: Billing Manager
42 6/2016

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