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Archive for the ‘MEDICARE UPDATES’ Category
« Older Entries |Unavailability of Internet-Based PECOS Monday, March 29 – Monday, April 5
Wednesday, March 10th, 2010
Due to scheduled maintenance, Internet-based Provider Enrollment, Chain and Ownership System (PECOS) will be unavailable from Monday, March 29, 2010 through Monday, April 5, 2010. Internet-based PECOS allows physicians, non-physician practitioners, providers, and other suppliers (except suppliers of durable medical equipment, prosthetics, orthotics, and supplies [DMEPOS]) to enroll or make a change to their existing Medicare enrollment information over the Internet.
If you would like to enroll or make a change to your existing Medicare enrollment record, you can do either of the following:
* Use Internet-based PECOS prior to March 29, 2010 or after April 5, 2010.
* Complete and submit the paper Medicare provider enrollment applications(s) (CMS-855) along with any required supporting documentation and mail the application(s) to the appropriate Medicare carrier, fiscal intermediary, or A/B MAC. The CMS-855 forms are downloadable from the CMS forms page: www.cms.hhs.gov/cmsforms.
If you need assistance or have questions, contact the Medicare fee-for-service contractor serving your State.
Posted in MEDICARE UPDATES | No Comments »
CMS Lifts 10-day Freeze on Claim Payments with DOS of March 1st.
Wednesday, March 3rd, 2010
Subject: The “Temporary Extension Act of 2010″ Extends the Zero Percent Medicare Physician Fee Schedule Update and the Therapy Cap Exception Process
March 2, 2010, President Obama signed into law the “Temporary Extension Act of 2010.” Among other things, this law extends through March 31, 2010, the zero percent update to the Medicare Physician Fee Schedule that was in effect for claims with dates of service January 1, 2010, through February 28, 2010. Consequently, effective immediately, claims with dates of service March 1 and later which were being held by Medicare contractors will be released for processing and payment. Please keep in mind that the statutory payment floors still apply and, therefore, clean electronic claims cannot be paid before 14 calendar days after the date they are received by Medicare contractors (29 calendar days for clean paper claims). In addition, the new law extends through March 31, 2010, the exception process for therapy claims reaching the annual cap, retroactive to January 1, 2010. Affected providers may submit claims for exceptions to the annual therapy caps, with dates of service January 1 through March 31, 2010, using the KX modifier, following the pre-January 1, 2010, requirements for therapy cap exceptions. Please watch your listserv and contractors website for more information about the new legislation.
Posted in MEDICARE UPDATES | No Comments »
Healthcare Provider Taxonomy Codes April 2010 Update
Wednesday, February 24th, 2010
The Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities comply with the requirements in the electronic transaction format implementation guides adopted as national standards. The X12 837 Professional and Institutional Implementation Guides require the use of valid codes contained in the Healthcare Provider Taxonomy Codes (HPTC) set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.
The HPTC set is maintained by the National Uniform Claim Committee (NUCC) for standardized classification of health care providers. The NUCC updates the code set twice a year with changes effective April 1 and October 1.
Valid HPTCs are those codes approved by the NUCC for current use. Terminated codes are not approved for use after a specific date and newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears. Although the NUCC generally posts their updates on the Washington Publishing Company (WPC) Web site three months prior to the effective date, changes are not effective until April 1 or October 1 as indicated in each update. Specialty and/or provider type codes issued by any entity other than the NUCC are not valid and Medicare would be guilty of noncompliance with HIPAA if Medicare contractors accepted claims that contain invalid HPTCs.
The taxonomy code is not required for processing Medicare claims. However, if a taxonomy code is submitted, it must be valid according to the HPTC code set. The HPTC code set is named in the 837 professional and institutional implementation guides, thus EDI must validate the inbound taxonomy codes against this HPTC maintained code source.
The April 2010 HPTC changes are available on the WPC Web site at http://www.wpc-edi.com/codes/taxonomy, then select New Codes for a listing of new HPTCs or Modifications for a listing of modified HPTCs.
Posted in MEDICARE UPDATES | No Comments »
CLAIMS NOT AUTOMATICALLY CROSSING OVER TO SUPPLIMENTAL PAYERS
Monday, February 22nd, 2010
The Centers for Medicare & Medicaid Services (CMS) has identified a problem where claims were not automatically crossing over to supplemental payers even though the provider remittance advice indicated otherwise. This problem began January 5, 2010. Part A institutional claims and Part B professional claims, with the exception of supplier claims processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs), were impacted by this problem. Claims processed by DME MACs were not impacted.
Part B Professional Claims
Action is required on behalf of Part B professional providers where a remittance advice with an issue date between January 5, 2010, and February 12, 2010, has two or more service lines for a beneficiary where both of the following apply:
- One service line is 100 percent reimbursable (i.e., the approved amount and amount to be paid are equal,) AND
- One service line where part of or the entire Medicare approved amount is applied to the Part B deductible and/or carries co-insurance amounts.
CMS is not able to forward these beneficiary claims to supplemental payers even though the remittance advice may indicate otherwise. Providers will need to identify these claims by reviewing their remittance advice with an issue date between January 5, 2010, and February 12, 2010, that contain the criteria noted above. Once identified, providers will need to take action to balance bill the beneficiary’s supplemental payer. As of February 12, 2010, this system problem was fixed and all claims are crossing over to supplemental payers as indicated on the provider remittance advice.
The CMS has already notified supplemental payers of these issues. We regret any inconvenience you may experience related to this Medicare claim supplemental payer crossover problem.
Valerie A. Haugen, Director
Division of Provider Information Planning & Development
Provider Communications Group, CMS
(410) 786-6690
valerie.haugen@cms.hhs.gov
Posted in MEDICARE UPDATES, Uncategorized | No Comments »
PECOS and Consultation
Monday, February 22nd, 2010
Unlike Medicare, other health plans will continue to recognize consultation codes. Although Medicare now considers the consult codes invalid for Medicare billing purposes, consultation services might still be necessary. There may be times when a physician needs the advice or opinion of another physician in order to continue the treatment of the patient. Whether or not the physician needs to put his/her advice/opinion in written form is the physician’s call when Medicare is involved since Medicare will need to be billed using the E&M visit codes, only.
However, just because Medicare will not recognize the codes for billing purposes does not mean that consultation services are no longer needed.
In addition, you must remember that Medicare is NOT is only health plan around. If a physician is performing a consultation for a health plan other than Medicare or for WC or NFA, a written report is required if the physician is billing with the consult codes.
PECOS is the provider enrollment system for the Centers for Medicare and Medicaid Services (CMS). PECOS stands for Provider Enrollment Chain Organization System. CMS created PECOS so the government could know who is enrolled in the Medicare Program. The PECOS system is a central computer system for CMS and was not made to be compatible with the provider enrollment systems of the existing Medicare contractors’ enrollment systems. Again, PECOS is the government’s provider enrollment system.
The name and NPI of the referring physician, on the Medicare claim submission, is not only needed for consultations. The name and NPI of the referring or ordering physician is required for laboratory services, medical diagnostic testing, including x-rays and for durable medical equipment (DME). The PECOS website can be found here: https://pecos.cms.hhs.gov/pecos/login.do
If claims are submitted for lab or medical diagnostic testing, the Medicare carrier (NGS in NYS) will review PECOS and their claim system (MCS) to verify that the referring or ordering physician is in their (NGS’) system. The NGS website can be found here: www.NGSMedicare.com <http://www.ngsmedicare.com/>
If a physician has ordered DME for his/her patient, the DME contractor (NHIC for NYS DME) can only search PECOS (since it does not have access to the Medicare Part B claim files of NGS). If the ordering physician is not in PECOS, NHIC will be required to deny the DME claim for benefits. The NHIC website can be found here: http://www.medicarenhic.com/dme
CMS has made a file available that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment web site: www.cms.hhs.gov/MedicareProviderSupEnroll : click on “Ordering/Referring File” on the left-hand side. Next, scroll down to the DOWNLOAD section and click on the report link. Note, the report is over 13 thousand pages long. So, it is NOT meant to be printed.
This .pdf file contains approximately 800,000 records. A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be viewed online. In addition, it can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file. (5) If a user is unsure of a physician or non-physician practitioner’s NPI, he or she can look it up in the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do).
Also note, the NPI file is not the same as the PECOS file.
Regina McNally, VP
Division of Socio-Medical Economics
Medical Society of the State of New York
Posted in MEDICARE UPDATES | No Comments »
Scope on Claims Editing
Thursday, February 11th, 2010
It is a requirement that claims submitted to the Medicare Part B carrier, the Medicare administrative contractor (A/B MAC) or the durable medical equipment (DME) MAC that are the result of an order or referral must include the National Provider Identifier (NPI) and the name of the ordering or referring provider. Physician and nonphysician practitioners who are eligible to order/refer must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
Medicare is expanding the current scope of editing for claims processed that require an ordering or referring provider. There are two phases to this implementation.
Phase 1 extends through April 4, 2010.
Claims Submitted to the DME MAC During Phase 1
During this phase, claims processing edits are in place to verify the ordering/referring provider is in PECOS and is eligible to order or refer under Medicare guidelines. If the provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process. The DMEPOS supplier will receive a warning message for claims submitted electronically. The supplier will not receive a warning message for paper claims.
Claims Submitted to the Medicare Part B Carrier or A/B MAC During Phase 1
During this phase claims processing edits are in place to verify the ordering/referring provider is in PECOS and is eligible to order or refer under Medicare guidelines. If the provider is not in PECOS the contractor will search the claims processing system for the ordering/referring provider. If the provider is not in PECOS or the claims processing system, the claim will continue to process. The provider submitting the claim will receive a warning message on the remittance advice.
Phase 2 begins April 5, 2010 and continues thereafter.
Claims Submitted to the DME MAC During Phase 2
If you order/refer items for a beneficiary that will be billed to the DME MAC by a supplier of durable medical equipment, prosthetics, orthotics or supplies and you are not eligible to order/refer under Medicare guidelines OR you are not in PECOS as of April 5, 2010 the beneficiary’s claims submitted to Medicare by the supplier will not be paid. The DME MAC processing system does not contain the ordering/referring physicians’ eligibility records and cannot verify the information if it is not in PECOS.
Claims Submitted to the Medicare Part B Carrier or A/B MAC During Phase 2
If the NPI and the name of the ordering/referring provider are on the claim the contractor will verify the provider is in PECOS and eligible to order or refer. If the provider is not in PECOS the contractor will search the claims processing system for the ordering/referring provider. A referring or ordering physician that is not enrolled with the Medicare contractor that is processing the claim will not be in the contractor’s claims processing system. Those claims that include the NPI and name of ordering/referring providers that cannot be found in PECOS OR found in the claims processing system will be rejected and not paid.
To ensure your reimbursement is not affected and your patients’ DME claims are paid, follow these steps:
- Log on to www.cms.hhs.gov/MedicareProviderSupEnroll. In the box on the left, under Medicare Provider Supplier Enrollment, select the Ordering Referring Report. Search for your National Provider Identifier (NPI) in the Medicare Ordering Referring File found in the Downloads section. If your NPI and name are on the list you are in the Provider Enrollment Chain of Ownership System (PECOS). You do not need to enroll in PECOS. If your NPI is not on the list or you want to confirm and review your enrollment in PECOS, go to step 2.
- Providers that are already in PECOS do not need to revalidate, enroll or submit an 855 application to the contractor at this time unless you receive a request from the contractor. If you are not in PECOS or want to review your enrollment information you may do so by visiting the PECOS Web site at https://pecos.cms.hhs.gov/pecos/login.do. You will need to create a User ID and Password if you have not accessed PECOS previously. For helpful guidance on PECOS please use this link http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage.
Two recommended documents to get you started with enrollment in PECOS are:
- Internet Based PECOS – Getting Started Guide for Physicians and Nonphysician Practitioners
- Internet Based PECOS – Enrollment Example
Tips for revalidating or enrolling:
- If revalidating a Group Member, the CMS 855I and the CMS 855R must be submitted.
- If revalidating an Individual, the CMS 855I application must be submitted.
- If revalidating a Group or Organization, the CMS 855B application must be submitted.
Services that require an ordering/referring provider can be found in the CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section 10.4 at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
The Medicare Learning Network Matters articles released on this implementation are:
- MM6417: Revised Final – Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)
- MM6421: Final – Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplier (DMEPOS) Suppliers Claims Process by Durable Medical Equipment Medicare Administrative Contractors (DMEMACs)
Thank you,
National Government Services, Inc.
Corporate Communications
Posted in MEDICARE UPDATES | No Comments »
Attention Part B Providers Billing for Ozurdex™ with Unlisted Code J3490
Monday, February 8th, 2010
Ozurdex was approved for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) on June 17, 2009. Claims with dates of service prior to 6/17/2009 will be denied as noncovered.
Claims with dates of service after 6/17/2009 are payable if the drug was administered to treat macular edema (reported with ICD-9 code 362.83 (retinal edema)). Claims submitted for other indications will be denied as not medically necessary as there are no other FDA-accepted uses for the drug.
For example: Claims containing ICD-9 codes 362.35 (central retinal vein occlusion) or 362.36 {venous tributary (branch) occlusion of retina} as the only diagnosis codes will be denied as Ozurdex is indicated for the treatment of the macular edema caused by the occlusion; not the treatment of the occlusion.
Claims that were incorrectly coded and contain a covered diagnosis of retinal edema (362.83) in the medical records, or suspected of being incorrectly denied despite the presence of the 362.83 code on the submitted claim, must be appealed, as no automated system adjustments will be done for them. Please access the Appeals section of www.NGSMedicare.com for instruction on filing a timely appeal.
Thank you,
National Government Services, Inc.
Corporate Communications
Posted in MEDICARE UPDATES | No Comments »
Medicare Physician Fee Schedule Fact Sheet – Feb.2010
Friday, February 5th, 2010
The Medicare Physician Fee Schedule Fact Sheet (February 2010) has been revised to include information about the two month zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) effective only for dates of service January 1, 2010 through February 28, 2010. This fact sheet, which also provides information about MPFS payment rates and the MPFS payment rates formula, is available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/MedcrePhysFeeSchedfctsht.pdf .
Special Open Door Forum: Medicare Provider & Supplier Enrollment
Centers for Medicare & Medicaid Services
Special Open Door Forum:
Medicare Provider & Supplier Enrollment
February 17, 2010
2:00 PM – 3:30 PM ET
Conference Call Only
The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:
• Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners and provider and supplier organizations
• Provider and supplier reporting responsibilities
• Medicare ordering and referring Issues
• Revalidation efforts
Afterwards, there will be an opportunity for the public to ask questions.
We look forward to your participation.
Open Door Forum Instructions:
**Capacity is limited so dial in early. You may begin dialing into this forum as early as 1:45 PM ET.**
Dial: 1-800-837-1935
Reference Conference ID 52537484
Posted in MEDICARE UPDATES | No Comments »
Helpful Hints for Completing Electronic Data Interchange Online Enrollment Forms
Thursday, February 4th, 2010
Attention All Electronic Data Interchange Trading Partners, Providers, Billing Services, Clearinghouses, and Vendors
National Government Services has developed the following helpful hints regarding the online electronic data interchange (EDI) enrollment process for providers that are new or providers that need to add, change, or remove their EDI status. If you are currently setup with EDI function you don’t need to do anything. If you are not setup for EDI functions please take a moment to read these EDI online forms helpful hints.
All EDI enrollment requests must be submitted online at www.NGSMedicare.com and then printed, signed, dated, and faxed to National Government Services’ EDI Enrollment Department at 502-423-2356.
A record identification number (RID#) is shown on the bottom right-hand side of each printed EDI enrollment form. If the EDI Enrollment Department does not receive the signed, dated, and faxed enrollment form that contains the RID# at the bottom right-hand side and/or any information is handwritten (except the signature), the request(s) will be returned to the submitter.
All EDI enrollment form(s) returned for invalid or missing information will need to be re-entered online at www.NGSMedicare.com and faxed with a new signature. Corrections to the previous form(s) should not be handwritten and/or refaxed.
Screen prints of the online form(s) will be rejected/returned. Complete the online form, select the “Submit” button, then print, sign, and fax the completed form(s) to 502-423-2356.
It is not necessary to submit EDI enrollment forms for providers that are part of a group that is already setup for EDI. If a new provider is added to the group then they are automatically setup. There is no need to submit new EDI Enrollment forms unless you are making changes or switching to a new submitter ID. Please do not submit the same form(s) repeatedly. Each additional form will be rejected as duplicates and can cause delays in the processing time.
You will receive e-mail notification when your request has been received. You will also receive an e-mail when your request has been ‘completed’ or ‘rejected.’
Confirmation and rejection letters/notices are sent via e-mail. Please make sure that a valid e-mail address is provided on the form(s).
For more information, please contact the National Government Services EDI Enrollment Department at ngs.edi.setups@wellpoint.com or the EDI Help Desk at 877-273-4334.
Posted in MEDICARE UPDATES | No Comments »
ATTENTION: PAPER CLAIMS SUBMITTERS:
Friday, January 29th, 2010
Currently, paper claims that are received where the health insurance claim number (HICN) and the beneficiary name do not match, are returned to the provider with a development letter advising the provider to correct the problem and submit as a new claim.
The Centers for Medicare and Medicaid Services (CMS) is now directing contractors to follow the current electronic rejection process with all claims, electronic and paper.
These paper claims will now be rejected and returned to the provider with a rejection letter specifying the reason the claims were returned. The effective date of this change is tentatively scheduled for February 26, 2010.
As always, thank you for your assistance.
Jim
James D. Bavoso
Provider Outreach & Education
National Government Services
50 Broadway, Suite 103
Hawthorne, NY 10532
Posted in MEDICARE UPDATES | No Comments »
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