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CMS Announces Award of Jurisdiction 14 Medicare Administrative Contractor (MAC) Contract
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Tuesday, January 06, 2009
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On November 19, 2008, CMS announced it has awarded the contract for Jurisdiction 14 (J14) to National Heritage Insurance Corporation (NHIC). NHIC will be responsible for the workload in Maine, Massachusetts, New Hampshire, Rhode Island and Vermont. NHIC's contract also includes the Regional Home Health and Hospice Intermediary (RHHI) workload in Jurisdiction A comprised of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont. As the J14 A/B MAC, NHIC will immediately begin implementation activities to take over the claims payment work now performed by fiscal intermediaries and carriers in the five state jurisdiction.
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Providers Urged to Participate in Annual Medicare Contractor Satisfaction Survey (MCPSS)
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Tuesday, January 06, 2009
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This article alerts providers that the Centers for Medicare & Medicaid Services (CMS) will distribute its annual MCPSS to a new sample of Medicare providers. CMS is sending the 2009 survey, designed to be completed in about 20 minutes, to approximately 30,000 randomly selected providers, including physicians and other health care practitioners, suppliers and institutional facilities that serve Medicare beneficiaries across the country. CMS will begin to notify providers selected to participate in the survey in December 2008. Providers are urged to submit their responses via a secure website, mail, fax, or over the telephone.
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Part A Local Coverage Determination Update
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Wednesday, December 31, 2008
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The following Part A LCDs have been revised: Granulocyte Colony-Stimulating Factors ARA-02-052, EPO/Darbepoetin Alfa Administration for Secondary Anemia ARA-05-004.
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December 2008 Medicare Part A Policy Notice Newsletter
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Friday, December 19, 2008
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The December 2008 Medicare Part A Policy Notice Newsletter has been posted online.
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Positive Airway Pressure (PAP) Devices – Important Information for the Ordering Physician
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Friday, December 19, 2008
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On March 13, 2008, CMS released a revised National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) devices. In September 2008, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) published a revised Local Coverage Determination (LCDs) and a "Dear Physician" letter which reviewed the pertinent coverage criteria for these devices, including bi-level positive airway pressure devices (respiratory assist devices, RADs) when they are use to treat obstructive sleep apnea (OSA).
The DME MAC medical directors have updated the PAP LCD; consequently, we are republishing this important information for ordering physicians. In addition, there are Frequently Asked Questions (FAQs) specifically addressing issues of importance to ordering physicians on the DME MAC web sites.
The major requirements for coverage of a PAP device for OSA that pertain to the ordering physician are:
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Positive Airway Pressure (PAP) Devices – Physician Frequently Asked Questions
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Friday, December 19, 2008
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Based on questions received from the clinical community, the following Frequently Asked Questions will address issues in the Positive Airway Pressure (PAP) Devices local coverage determination (LCD). The complete medical policy may be viewed on the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) individual web sites or in the CMS Medicare Coverage Database. Note that the formal title of the policy is Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. The web address of the Medicare Coverage Database is: http://www.cms.hhs.gov/mcd/search.asp. Additional information may also be found in the "Dear Physician" letter published in December 2008 on the DME MAC web sites.
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Pinnacle Business Solutions, Inc. Holiday
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Wednesday, December 17, 2008
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Pinnacle Business Solutions, Inc. will be closed on Thursday, December 25 and Friday, December 26, 2008 in observance of the Holiday Season. EDI Technical Support and Customer Service Representatives will not be available. The call center will open at our normal operating hours on Monday, December 29. We will be happy to serve you then.
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Call Center Closing Times (Part A)
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Tuesday, December 16, 2008
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To better serve the provider community, the Centers for Medicare and Medicaid Services (CMS) is allowing Provider Contact Centers across the nation to conduct customer service training during normal business hours. The Medicare Program is very complex with continuous changes and this initiative will help prepare Provider Customer Service Representatives (CSR's) to give quality answers to substantive Medicare related questions or inquiries.
Pinnacle Business Solutions, Inc. the Medicare Part A Intermediary for the State of Rhode Island, will be participating in this program. We have developed a comprehensive training plan that includes closing our Provider Contact Center for up to eight hours each month. Using Provider Contact Center call distribution data to determine the least possible impact for our customers, we have selected the following dates in December 2008 and January 2009.
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Required Documentation Advisory
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Friday, December 12, 2008
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There has been a recent increase in untimely responses to Additional Documentation Requests (ADRs) related to the submission of medical records. When a claim suspends for medical review, a letter requesting documentation is mailed to the provider/physician from our Medical Review (MR) Department. The provider must in turn submit the requested documentation within 45 days of the date on the ADR letter. Per Medicare guidelines, the ADR gives instructions in reference to sending specific documentation to the Fiscal Intermediary (FI) within 30 days. However, Medical Review allows an additional 15 days to this request for documentation. If the documentation is not received by Medical Review within 45 days, the claim will automatically be denied by the FISS system with a Medical Review reason code indicating records have not been received or not received timely.
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Influenza Pandemic Emergency - The Medicare Program Prepares
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Tuesday, December 09, 2008
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Note: This article was revised on December 8, 2008, to include a Web link to CR6209, which was recently issued by CMS. All other information remains the same. This article is informational only and is alerting providers that the Centers for Medicare & Medicaid Services (CMS) has begun preparing emergency policies and procedures that may be implemented in the event of a pandemic or national emergency.
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Documentation Requirements for Unna Boot
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Wednesday, December 03, 2008
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Unna boot is a compression dressing which consists of a paste which is applied to the lower extremity and covered with a bandage. It is often used in the treatment of various ulcers and variscosities of the leg, and sometimes as a supportive bandage for sprains and strains of the lower extremity. Unna boot is billed on TOB 13X, Revenue Code 051X. The purpose of this review is to identify the medical necessity for the unna boots and the frequency of application as well as potential areas of educational need.
The Centers for Medicare and Medicaid Services (CMS) requires that all providers have available documentation to support the services they are billing. The documentation requirements for unna boots are detailed below and it is noted that the list is not all inclusive nor will all the elements apply to every service. Providers are encouraged to submit any additional documentation that supports the services billed.
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ICD-9 for Anti-Cancer Drugs Update – November 2008
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Wednesday, November 26, 2008
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Pinnacle Business Solutions, Inc. as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug.
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Documentation Requirements for Intravenous Immune Globulin (IVIG)
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Friday, November 21, 2008
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Providers are advised that correct billing and coding are expected on all claims so it is incumbent on all providers to stay apprised of changes. At the time of this posting, the most recent changes to IVIG codes are noted below for easy reference.
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Intravenous Immune Globulin (IVIG) Advisory for Part A Facilities and Part B Prescribing Providers
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Tuesday, November 18, 2008
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Intravenous Immune Globulin (IVIG) services represent very high dollar services that have been of national and local concern. Rhode Island has a Part A service specific edit in place for the review of IVIG based on data analysis findings and a persistent high denial rate of IVIG claims. In spite of continued educational efforts by Medical Review to Part A facilities, individual provider and overall error rates have not significantly improved. Review findings and communication with the Part A providers indicates that one of the reasons for these continued denials is that the facilities are unable to obtain necessary medical documentation from the prescribing providers, in order to meet medical necessity documentation requirements.
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Coding and Billing of Radiopharmaceuticals with Computerized Tomography (CT Scan) Services and Magnetic Resonance Imaging (MRI)
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Monday, November 17, 2008
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During FY 2007, Medical Review conducted widespread prepay probes in Rhode Island and Arkansas on TOB 13X, Revenue Code 035X, Computerized Tomography (CT scan) services and Magnetic Resonance Imaging (MRI).
During the probe reviews, the documentation related to contrast agents was of concern because of the inconsistencies between documentation, billing and coding. In the probe claims, documentation indicated contrast agents were used in some instances but not billed. In other probe claims, the contrast agents were not mentioned in the interpretive reports but were submitted on the billing.
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Preparing for a Transition from an FI/Carrier to a Medicare Administrative Contractor (MAC)
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Wednesday, November 12, 2008
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This article is intended to assist all providers that will be affected by Medicare Administrative Contractor (MAC) implementations. The Centers for Medicare & Medicaid Services (CMS) is providing this information to make you aware of what to expect as your FI or carrier transitions its work to a MAC. Knowing what to expect and preparing as outlined in this article will minimize disruption in your Medicare business.
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Part A Local Coverage Determination Updates
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Friday, November 07, 2008
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The following Part A LCDs have been revised: Anti-Cancer Drugs ARA-01-024, Chronic Wound Care ARA-02-025, Non-Invasive Vascular Studies ARA-02-055 and Physical Medicine and Rehabilitation ARA-02-059.
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Part B Local Coverage Determination Updates
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Friday, November 07, 2008
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The following Part B LCDs have been revised: Anti-Cancer Drugs AC-01-024, Chronic Wound Care AC-02-025, Magnetic Resonance Imaging of The Brain AC-03-043, Noninvasive Vascular Studies AC-02-055 and Physical Medicine and Rehabilitation, AC-02-059.
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New 2008 Medicare Physician Fee Schedule (MPFS) Payment Rates Effective for Dates of Service July 1, 2008, through December 31, 2008
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Wednesday, October 29, 2008
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This article is based on Change Request (CR) 6212, which announces the new 2008 MPFS payment rates effective for dates of service July 1, 2008, through December 31, 2008. Please note that Medicare contractors have already implemented the actions annotated in this article.
The Centers for Medicare & Medicaid Services (CMS) directed Medicare contractors to revert back to the 0.5 percent payment rates that were previously in place until June 30, 2008, and to use those rates through December 31, 2008. In addition, carriers/Part B MACs are using the same rates as used for January 1 through June 30, 2008, to make payments, where appropriate, to Ambulatory Surgical Centers (ASCs) for services rendered from July 1 through December 31, 2008. This reflects a continuation of the payment policy for brachytherapy services at carrier/Part B MAC-priced amounts and the prospective rates for other ASC services. CMS also provided revised fees for selected mental health codes that had an increase in their fee schedule amounts. The effective date for the increase for the mental health codes was for dates of service on and after July 1, 2008.
See the Background and Additional Information Sections of this article for further details regarding these changes.
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Documentation Requirements for Computed Tomography (CT Scan)
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Tuesday, October 28, 2008
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Computed Tomography (CT scan) is a noninvasive Radiological diagnostic test with or without contrast agents, billed on TOB 13X, Revenue Code 035X.
The Centers for Medicare and Medicaid Services (CMS) requires that all providers have available documentation to support the services they are billing. The documentation requirements for CT Scans are detailed below and it is noted that the list is not all inclusive nor will all the elements apply to every service. Providers are encouraged to submit any additional documentation that supports the services billed.
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Power Wheelchairs and Power Operated Vehicles – Documentation Requirements
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Monday, October 27, 2008
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In order for Medicare to provide reimbursement for a power wheelchair (PWC) or power operated vehicle (POV) (scooter), there are several statutory requirements that must be met:
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ICD-9 for Anti-Cancer Drugs Update
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Monday, October 27, 2008
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Pinnacle Business Solutions, Inc. as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as for documentation requirements.
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Minimum Data Set (MDS) Issues Identified During SNF (Skilled Nursing Facility) Complex Review
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Tuesday, October 21, 2008
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A problem identified during the SNF complex reviews for both Arkansas and Rhode Island is the Minimum Data Set (MDS) not being in the National Repository, resulting in denied services.
All Medicare contractors are instructed by CMS to utilize a software program called the FI Extract tool in the review of SNF claims to verify the MDS is in the Repository and to validate the appropriate RUG level has been assigned. To utilize the FI Extract tool, the contractor enters the HIC number and dates of service being billed for the beneficiary to pull up the MDS.
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National Provider Identifier (NPI) for Secondary Providers
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Tuesday, October 21, 2008
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Note: This article was revised on October 16, 2008, to reflect changes to CR 6093, which CMS revised on October 15, 2008, to include the FISS in the business requirements. The implementation date was changed to October 29, 2008. The CR release date, transmittal number, and the Web address for accessing CR6093 were also revised. All other information remains the same. This article is based on CR 6093 and outlines the need to use NPIs to identify secondary providers in Medicare claims beginning May 23, 2008.
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Status of Complex Review of Skilled Nursing Facilities (SNF) in Arkansas and Rhode Island
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Monday, October 20, 2008
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As a result of Widespread and Provider Specific Probe Reviews that were done in Arkansas and Rhode Island in 2004, 2005, and 2006, a Complex Review edit for 60 and 90-day assessments was initiated and has been on-going since May of 2006 for both states. Medical Review findings initially reflected a failure to transition beneficiaries to lesser RUG levels as progress was made and documented. Additional medical review findings included significant therapy documentation deficits that failed to support the services and RUG levels billed.
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