The Centers for Medicare & Medicaid Services (CMS) is changing the payment status indicator for CPT® code 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use from “E” (not paid under the Outpatient Prospective Payment System (OPPS)) to “L” (not paid under OPPS; paid at reasonable cost; not subject to deductible or co-insurance) in the October 2010 Integrated Outpatient Code Editor (IOCE).

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Effective Nov. 6, physicians separately can report implantable tissue markers (HCPCS Level II A4648 Tissue marker, implantable, any type, each) and implantable radiation dosimeters (A4650 Implantable radiation dosimeter, each) in Medicare Part B claims.

To receive payment for these miscellaneous supplies, codes A4648 and A4650 must be billed in conjunction with one of the following CPT^® codes:

19499 Unlisted procedure, breast

32553 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-thoracic, single or multiple

49411 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple

55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple

If one of the above CPT® codes is not paid on the same claim (or in history) with the same date of service, payment will be denied.

No policy change has been made for hospitals paid under the Outpatient Prospective Payment System (OPPS), Inpatient Prospective Payment System (IPPS), or ambulatory surgical centers (ASCs) paid under the ASC Payment System. Current Medicare policy continues to instruct Medicare contractors not to separately reimburse claims for HCPCS Level II codes A4648 or A4650 to hospitals and ASCs paid under these payment systems.

Refer to the Centers for Medicare & Medicaid Services (CMS) Transmittal 745, Change Request (CR) 6968, issued Aug. 6, for further clarification of this physician payment policy in Pub. 100-20 of the Medicare Claims Processing Manual.

Palmetto GBA recently amended its Cataract Surgery Local Coverage Determinations (LCDs) to reflect a focus on the adult patient and a more complete description of functional status.

In response to comments the J1 Part A/B Medicare administrative contractor (MAC) received, the title of the final policy was amended to appropriately reflect the adult patient population. Palmetto GBA also removed the specific Snellen visual acuity threshold from the final LCD. The reporting requirement of the “best corrected” Snellen visual acuity remains, however. As does the expectation that the medical records supporting the cataract extraction identify the activity limitations (e.g., in self-care and mobility) and participation restrictions (e.g., in interpersonal interactions and relationships and community, social and civic life) are also reported.

These terms may be new to physicians, hospitals, and ambulatory surgical centers (ASCs) providing cataract surgery but are reflective of long-standing concepts included in such well-established instruments like the National Eye Institute’s Visual Functioning Questionnaire – 25 (VFQ – 25).

To provide guidance to physicians, hospitals, and ASCs on how best to communicate functional status for patients requiring cataract extraction, Palmetto GBA has incorporated the concepts of the International Classification of Functioning, Disability and Health (ICF) taxonomy into the final version of the LCD.

Below is a case scenario demonstrating the value of going beyond diagnosis by using the concepts of the ICF. Please note that while Palmetto GBA is encouraging physicians and hospitals providing cataract surgery to consider the conceptual framework of the ICF, Medicare does not require the reporting of the ICF codes. Read more »

Twenty-one U.S. senators sent a letter dated Aug. 5 to the Centers for Medicare & Medicaid Services’ (CMS) Administrator Donald Berwick, M.D., asking for the agency “to use its existing discretionary authority to make an important modification to the ASC payment system.”

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The Centers for Medicare & Medicaid Services (CMS) issued a final rule that changes how physicians are paid for furnishing dialysis services for patients with end stage renal disease (ESRD) from partial bundled composite rates to a new partial payment system (PPS). The rule also establishes a quality incentive program (QIP) linking a facility’s payments to performance standards. This is the first time a QIP is part of a PPS.

Facilities failing to meet or exceed specified total performance scores will receive reduced reimbursement for dialysis services furnished on or after Jan. 1, 2012.

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The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as health reform) has required the Centers for Medicare & Medicaid Services (CMS) to revise its final 2010 payment system rules in the past few months. As if keeping up with annual changes to the various payment systems isn’t enough, mid year changes can be overwhelming. To simplify matters, CMS has conveniently compiled all the changes made to the various payment systems due to health reform into one document.

Transmittal 726, Change Request (CR) 7029, issued July 8, outlines all the changes to the 2010 Inpatient Prospective Payment System (IPPS), Long Term Care Hospital Prospective Payment System (LTCH PPS), Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and Outpatient Prospective Payment System (OPPS) as a result of health reform.

The policy changes reflected in the transmittal are also available in various Federal Register notices for IPPS/LTCH PPS, OPPS and IRF PPS.

The 2011 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) payment system proposed rule, released July 2 by the Centers for Medicare & Medicaid Services (CMS), proposes payment system changes and 2011 payment rates. The proposed rule also would implement several health care reform law provisions, including some pertaining to certain inpatient hospital services, graduate medical education costs, and physician self-referral rates, which did not make it into the 2011 Inpatient Prospective Payment System (IPPS) proposed rule, published May 4. Read more »

The July 2010 update to the Ambulatory Surgical Center (ASC) payment system adds seven new ancillary service codes and eight new surgical procedure codes. ASC staff also should note that the payment rates for three codes were incorrect in the April 2010 ASC DRUG file.

New Ancillary Service Codes

Seven new HCPCS Level II codes have been created for drugs that are payable as covered ancillary services for dates of service on or after July 1. The following new separately payable drug and biological codes and their payment rates are included in the July 2010 ASC DRUG file.

*C9262 is discontinued after June 30 and replaced by Q2025 effective July 1.

CPT® Code Payment Indicator Change

Effective April 1, the payment for CPT® code 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use will change from ASC PI=Y5 (non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made) to ASC PI=K2 (drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on Outpatient Prospective Payment System (OPPS) rate). The payment rate effective April 1 is: $106.70. Suppliers who think they may have received an incorrect payment determination between April 1 and June 30 should request contractor adjustment of previously processed claims.

New Surgical Procedure Codes

Seven new Category III CPT® codes have been created for surgical procedures that are payable for dates of service on or after July 1. and one new HCPCS Level II surgical procedure code has been created and is payable for dates of service on or after March 23.

The following new separately payable codes and their payment rates are included in the July 2010 ASC Fee Schedule (ASCFS) file.

*Temporary office-based status

Updated Payment Rates

The corrected payment rates that follow appear in the revised April 2010 ASC DRUG file effective for services furnished on April 1 through implementation of the July 2010 update (July 6).

Medicare contractors will adjust claims for these three HCPCS Level II codes that have dates of service on or after April 1 through July 1, and were originally processed prior to the installation of the revised April 2010 ASC DRUG File, only if brought to their attention.

MLN Matters MM7008 notifies providers submitting claims payable under the ASC payment system to Medicare of these important changes.

The Medicare manual and previous guidance stipulates that physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives who operate within the scope of practice under state law may order and perform diagnostic tests. That much was clear, but then the 2010 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule implemented a few changes to this policy. New guidance from the Centers for Medicare & Medicaid Services (CMS) helps clarify any misconceptions providers may have about Medicare’s current policy for physician supervision of diagnostic and therapeutic services provided to hospital outpatients.

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Effective for dates on or after May 25, claims submitted for a collagen meniscus implant procedure will be denied by Medicare. The Centers for Medicare & Medicaid Services (CMS) completed a National Coverage Determination (NCD) for collagen meniscus implants in May, rendering the procedure non-covered for Medicare beneficiaries.

Effective with the July 2010 updates of the Medicare Physician Fee Schedule Database (MPFSDB) and the Integrated Outpatient Code Editor (I/OCE), new HCPCS Level II code G0428 Collagen or other tissue engineered meniscus knee implant procedure for filling meniscal defects (e.g., collagen scaffold, Menaflex) should be used to report non-covered collagen meniscus implant claims with service dates on and after May 25.

As is custom, notifying the Medicare patient of his or her responsibility to pay for this non-covered service and asking the patient to sign an Advanced Beneficiary Notice (ABN) would be appropriate.

NOTE:  This NCD does not include cadaver meniscus transplants, for which you would report CPT® code 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral.

Source: CMS Transmittal 1977, CR 6903, issued May 28.