Corporate Compliance

Transmittals and MLN Matters articles: CMS posts RAC articles, issues condition code 44 language, suspends automatic -GA denials, and more

Medicare Insider, September 28, 2010

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CMS approves ICR programs

On September 24, CMS issued a transmittal to include the Ornish Program for Reversing Heart Disease and the Pritikin Program on the list of approved intensive cardiac rehabilitation (ICR) programs. Effective for claims with dates of service on and after August 12, 2010, these two ICR programs will be covered under Part B.

Effective date: August 12, 2010
Implementation date: October 25, 2010

View the transmittal.

CMS to amend FDG PET language

On September 24, CMS issued a transmittal to modify Section 220.6.17 of the National Coverage Determinations Manual to remove the restriction of only one FDG PET scan to determine the location and/or extent of the tumor for therapeutic purposes related to initial treatment strategy. CMS will allow local Medicare contractors discretion to cover (or not cover) any additional FDG PET scans for therapeutic purposes related to initial treatment strategy.

Effective date: August 4, 2010
Implementation date: October 25, 2010

View the transmittal.

CMS clarifies status indicator change date

On September 24, CMS issued a one-time notification to clarify that the effective date for the change of the status indicator to I (“Not valid for Medicare purposes, Medicare recognizes another code”) for CPT codes 80101 and 80101QW has been set to January 1, 2010. For claims with a date of service on or after January 1, 2010, clinical laboratories shall submit claims with the new test HCPCS code G0431 or G0431QW.

Effective date: October 26, 2010
Implementation date: October 26, 2010

View the transmittal.

CMS posts RAC articles on inpatient hospital vulnerabilities

On September 23, CMS posted two special edition MLN Matters articles on inpatient hospital vulnerabilities related to high-risk DRGs from a coding perspective and medical necessity difficulties. The articles provide information garnered from the previous RAC demonstration project.

View the article on coding vulnerabilities.

View the article on medical necessity vulnerabilities.

CMS suspends automatic denials of -GA modifier

On September 17, CMS issued a transmittal instructing contractors to suspend denial of line items submitted with the -GA modifier (waiver of liability statement issued as required by payer policy). The transmittal indicates that provider feedback is the cause of the suspension, and that CMS is reviewing further instructions.

Effective date: April 1, 2010
Implementation date: October 17, 2010

View the transmittal.

View a related MLN Matters article.

CMS updates OPPS, issues condition code 44 guidance

On September 17, CMS issued its quarterly OPPS update instructions, which includes additional manual language related to reporting observation services in condition code 44 situations. The new language states that:

On the outpatient claim on an uncoded line with revenue code 0762, the hospital could bill for the 12 hours of monitoring and nursing care that were provided prior to the change in status and the physician order for observation services, in addition to billing HCPCS code G0378 for the observation services that followed the change in status and physician order for observation services.

Effective date: October 1, 2010
Implementation date: October 4, 2010

View the transmittal.

View a related MLN Matters article.

CMS updates IPPS, LTCH PPS, and IPF PPS

On September 17, CMS issued a transmittal to make annual updates to the FY 2011 IPPS, LTCH PPS, and IPF PPS. The transmittal addresses the FY 2011 update to MS-DRGs and ICD-9-CM coding.

Effective date: October 1, 2010
Implementation date: October 4, 2010

View the transmittal.

View a related MLN Matters article.

CMS issues transmittal on enrollment for ordering/referring providers

On September 17, CMS issued a transmittal on enrollment for ordering/referring providers. CMS is aware of physicians or practitioners who have unique enrollment issues and will need to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries (e.g., physician employed by the Department of Veterans Affairs). CMS is modifying the enrollment process for these providers.

Effective date: October 18, 2010
Implementation date: October 18, 2010

View the transmittal.

View a related MLN Matters article.

CMS updates MPFS

CMS has posted its quarterly update to the Medicare physician fee schedule (MPFS) database.

Effective date: January 1, 2010 (unless otherwise stated in the transmittal)
Implementation date: October 4, 2010

View the transmittal.

View a related MLN Matters article.

CMS replaces transmittals

CMS issued two transmittals to rescind and replace several previous transmittals.

MLN Matters article

CMS issued an MLN Matters article related to a transmittal previously outlined in Medicare Weekly Update.



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