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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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December 2008 Medicare Part B Policy Notice Newsletter
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Friday, December 19, 2008
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The December 2008 Medicare Part B Policy Notice Newsletter has been posted online.
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Part B Local Coverage Determination Update
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Friday, December 19, 2008
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The Part B LCD Section of our website has been updated to include the December 2008 Policy Notice (AC PN 2008-02), policies and the comment/response document. This update includes the policies that were open for comment September 1, 2008 through October 31, 2008.
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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 B)
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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 B Carrier for Arkansas, Louisiana and 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 closure dates and times for December 2008 and January 2009.
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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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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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Intravenous Immune Globulin (IVIG) Advisory for Part B Prescribing Providers in Part A Facilities
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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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Part B Local Coverage Determination Update
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Wednesday, November 12, 2008
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The following Part B LCD has been revised: Nerve Conduction Studies (NCS)/Electromyography (EMG) AC-02-009.
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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 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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Reporting National Provider Identifiers (NPI) on claims for Out-of-Jurisdiction Purchased Mammography Preventive Screening and Diagnostic Services
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Wednesday, November 05, 2008
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CR 6237, from which this article is taken provides billing instructions for using the NPI on paper, or electronically-submitted, Medicare claims for purchased mammography screening and diagnostic services when the service is performed outside of the carrier’s or A/B MAC’s claims processing jurisdiction. In this situation, billing providers should report their own NPI as the performing provider and also provide the name, address, and zip code of the performing physician/supplier.
You should be aware that carriers and AB MACs will return your out-of-jurisdiction, purchased mammography screening or diagnostic service claims as unprocessable if you submit them without the billing provider’s NPI; and the name, address, and ZIP code of the performing physician/supplier.
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Documentation of Physical Examination in Evaluation and Management (E/M) Services
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Tuesday, November 04, 2008
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Pinnacle Business Solutions, Inc. (PBSI) is committed to decreasing the Comprehensive Error Rate Testing (CERT) error rate. Our goal is to assist providers, through education, to reduce billing errors, and enable providers to have their claims paid correctly.
The appropriate level of an evaluation and management service within a range of codes can only be determined based on the documentation in the medical record. As reviewed in a separate article, the complexity of medical decision making is used as the primary indicator of the appropriate level of service. Documentation for E/M codes must contain the specified number of key components in the CPT definition of the code, based on the condition of the patient.
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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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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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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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The ICD-10 Clinical Modification/Procedure Coding System (CM/PCS) - The Next Generation of Coding
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Tuesday, October 14, 2008
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Note: This article was revised on October 9, 2008, to update the website addresses and other information in the "Additional Information" section of this article. All other information remains the same. This Special Edition article (SE0832) outlines general information for providers detailing the International Classification of Diseases, 10th Edition (ICD-10) classification system. Compared to the current ICD-9 classification system, ICD-10 offers more detailed information and the ability to expand specificity and clinical information in order to capture advancements in clinical medicine. Providers may want to become familiar with the new coding system.
The system is not yet implemented in Medicare’s fee-for-service (FFS) claims processes so no action is needed at this time.
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Non-acceptance of Legacy Provider Numbers on Incoming Medicare Claims
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Monday, October 13, 2008
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With the implementation of the National Provider Identifier (NPI) on May 23, 2008, Medicare ceased accepting legacy provider numbers, qualified by 1C and 1G within the secondary provider REF segments, on incoming Medicare American National Standards Institute (ANSI) X12N 837 4010A1 claims. Effective October 6, 2008, providers should note that, with one qualified exception, as highlighted below, Medicare will reject all incoming Medicare X12N 837 4010A1 claims that contain legacy identifiers. The following qualifiers within the secondary provider REF loops are acceptable:
For 837 institutional claims, the Employer Identification Number (EIN)/Federal Tax ID, qualified by "EI" or "TJ," will be accepted; and
For 837 professional claims, the provider’s EIN/Tax ID, qualified by "EI" or "TJ," or social security number, as qualified by "SY," will be accepted.
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Medical Review Documentation Request System Error Led To the Delay of Records Being Received By the MR Department
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Friday, October 10, 2008
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Documentation requested by Medical Review (MR) and received via mail for services in Rhode Island, encountered a system error which led to the delay of these records being received by the MR department. When the time allotted for receipt of these records expired, they were denied as "no response to request for records" and an EOB to that effect was sent to these providers. These records are now appearing in MR. If your records were already denied as "no response to request for records" and MR does have those records, a letter will be sent to you within the next two weeks explaining that MR will reopen those claims and review the records. If you receive a letter, please do not submit these claims for appeal until you receive a new EOB message for that beneficiary and date of service. If you are not notified by letter that MR is reopening your claim(s), denied for "no response to request for records," please wait until after 10/23/08 before requesting a reopening. If your 120 day appeal rights expire on claims denied for "no response to request for records" during 10/9/08 – 10/23/08, MR will extend this 120 day limit to 11/30/08. We apologize for problems caused by this error.
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Part B Local Coverage Determination Updates
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Thursday, October 09, 2008
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The following policies have been retired effective for services performed starting October 1, 2008: Ablation of Hepatic Tumors, Allergy Patch Test(s), Anoscopy/Proctoscopy/Sigmoidoscopy (Diagnostic, Therapeutic, and Screening)/Fecal Occult Blood, Atriobiventricular Pacemakers, Biofeedback Therapy, Bladder Scan, Deep Brain Stimulation, Electrophysiologic Studies, Intracardiac, Endovascular Repair for Descending Thoracic Aneurysm, FEESS/FEESST, Indocyanine Green Angiography, Insertable Loop Recorder (ILR), Intracoronary Brachytherapy, Monitored Anesthesia Care (MAC), Motion Analysis Studies, Oprelvekin (Neumega), Pachymetry, Percutaneous Renal Artery Angioplasty with or w/o Stenting, Percutaneous Transluminal Angioplasty with or Without Stenting for Abdominal Aortic Stenosis or Chronic Total Occlusion and Lower Extremity Claudication, Recombinant Human Thyrotropin for Radionucleotide Scanning, Routine Foot Care, Sacral Nerve Stimulation, and Vitamin B-12.
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Part B Local Coverage Determination Updates
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Thursday, October 09, 2008
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The following Part B LCD has been revised: EPO/Darbepoetin Alfa for Treatment Of Anemia Associated With Chronic Renal Failure, AC-05-007.
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