Medical Oncology Association of Southern California

MODIFIER -25 - Update Definition

Modifier -25 is to be used when a Significant, Separately Identifiable Evaluation and Management (E/M) Service that is above and beyond the usual pre- and post-operative work of the procedure. is rendered by the Same Physician (or same qualified nonphysician practitioner) on the Same Day of the Procedure or Other Service with a global fee period or identified as “bundled” (under National Correct Coding Initiative (NCCI) edits). Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

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Unprocessable or Rejected Claims

CMS defines an unprocessable claim as a claim that is incomplete due to missing or invalid required information. NHIC’s editing process “returns” claims to the provider as unprocessable or rejected through the Remittance Advice process if the claim contains incomplete or invalid information. CMS has determined that no appeal rights are afforded to these claims because no “initial determination” could be made; the claim was “unprocessable”.

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29 June 2006

CMS has issued notification on a new Current Procedural Terminology (CPT) code for tetanus and diphtheria toxoids. (CR 4222)
Effective January 1, 2006, providers do not have to include a Clinical Laboratory Improvement Amendments (CLIA) number on claims submitted for HCPCS code 89049 [Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report]. (CR 5113)
CMS has noted that on or after May 1,2006, the QV modifier is no longer valid for islet cell transplantation and routine followup services related to the islet cell transplantation. The QR modifier (item or service provided in a Medicare-specified study) will replace the QV modifier. (CR 5140)
Medicare Learning Network Products for Physicians

The Facilitator's Guide, which provides facilitators with everything needed to prepare for and conduct a Medicare Program training course and is a companion to the Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals, is now available in downloadable format on the MLN Publication Page located at http://www.cms.hhs.gov/MLNProducts/MPUB/list.asp on the Centers for Medicare & Medicaid Services (CMS) website.

The Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals in CD-ROM format is available free of charge from the MLN Product Ordering Page located at http://www.cms.hhs.gov/mlngeninfo/ on the CMS website. (CMS Message 200606-12)

23 June 2006

CMS has issued an Update to the Healthcare Provider Taxonomy Codes (HPTC) Version 5.1 (CR 4072).
The July Quarterly Update for 2006 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule Article has been revised (CR 5017).
CMS announces proposed changes to the Physician Fee Schedule methodology (Message 200606-11)

22 June 2006

Do you want up-to-date information from CMS? Then you should review the CMS Mailing Lists Fact Sheet available from the MLN Matters website. The fact sheet can be obtained by downloading it from the following url:
http://www.cms.hhs.gov/MLNProducts/downloads/MailingLists_FactSheet.pdf
Hardcopies can also be ordered by going to the MLN Products Ordering Page at:
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 and then click on the first item under ‘Informational Resource s'. NHIC encourages providers to distribute the mailing lists at all association meetings and events. (JSM 06504)
CMS has made modifications to the online Medicare Secondary Payer (MSP) questionnaire . (CR 5087)

15 June 2006

In conjunction with National Men’s Health Week and in commemoration of Father’s Day (June 18), the Centers for Medicare & Medicaid Services (CMS) would like to invite you to join with us as we strive to heighten the awareness of prevention and encourage early detection and treatment of disease. (CMS Message 200606-06)
The Centers for Medicare & Medicaid Services (CMS) has announced an extension of the election period for physician enrollment in the CAP for Part B Drugs and Biologicals. The physician election period has been extended until June 30, 2006.(SE0639)

08 June 2006

CMS has posted the quarterly update to Correct Coding Initiative (CCI) Edits, Version 12.2,effective July 1, 2006. (CR 5064)
Changes to the laboratory National Coverage Determination (NCD) edit softwarefor July 2006 are available. (CR 5108)
Collection of fee-for-service payments made during periods of managed care enrollment.(CR 5105)
Visit http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp#TopOfPage and scroll to the bottom of the page to download the Beneficiary Fact Sheet for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals. Physicians who elect to participate in the CAP are required to provide the CAP Beneficiary Fact Sheet to Medicare beneficiaries who are receiving certain Part B physician-administered drugs. ( JSM 06475)
Medicare Policy regarding collection of fee-for-service payments made during periods of managed care enrollment . (SE0638)
This article has been revised: Medicare contractors will print and mail No-Pay Medicare Summary Notices (MSNs) on a quarterly schedule (rather than the current monthly schedule). (CR 5062)
This article provides specific information regarding the interim G codes for drug administration coding that were adopted in 2005 and operational until 2006 when the new Current Procedural Terminology (CPT) codes become operational. (CR 5028)
Medicare Part B Drug Competitive Acquisition Program (CAP) Ask the Contractor Teleconference -- Monday, June 12th (CMS Message 200606-04)
The Clinical Laboratory Improvement Amendments (CLIA) Brochure has been updated and is now available. (CMS Message 200606-05)
MEDICARE POSTS HOSPITAL PAYMENT INFORMATION - Important Step Toward Transparency in Health Care Costs and Quality (CMS Message 200606-03)

02 June 2006

CMS has posted the July update to the 2006 Medicare Physician Fee Schedule Database. (CR 5102)
On June 1, 2006, CMS announced an extension to the physician election period for the Medicare Part B Drug Competitive Acquisition Program (CAP). The CAP is a voluntary program that offers physicians an option to acquire many drugs they use in their practice from approved CAP vendors. Rather than purchasing these drugs from distributors and being reimbursed by Medicare, the physician would order the drug from an approved vendor and administer it to the beneficiary, but the vendor would be responsible for billing Medicare for the drug and collecting the coinsurance from the beneficiary.

The CAP physician election period’s extension will begin on June 3, 2006 and continue through June 30, 2006. Physicians must return their completed election forms to their local carrier by mail. Physicians whose completed physician election forms are postmarked on or after June 3, but no later than June 30, 2006, will begin participation in the CAP starting on August 1, 2006.

Initial CAP implementation is still scheduled for July 1, 2006. Physicians whose completed CAP election forms are postmarked on or before June 2, 2006 will begin participation in the CAP starting on July 1, 2006.

Please see the Medicare Part B Drug CAP Website’s Information for Physicians page (http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp) for additional information about CAP physician election. The physician election form may be downloaded from this page. Completed forms must be returned by mail to the physician’s local carrier.

Please note that participation in the CAP is voluntary and that no action is required from physicians who do not wish to participate.(JSM/TDL-06478)

01 June 2006

CMS article on payment for Evaluation and Management services provided during global period of surgery. (CR 5025)
This article provides additional information and instructions for the implementation of the CAP pertaining to CAP drug categories and fee schedule. (CR 5079)
Medicare covers whole organ pancreas transplantation when it is performed in conjunction with or after kidney transplantation. However, Medicare does not cover PA in diabetes patients without end-stage renal failure because of a lack of sufficient evidence. (CR 5093)
Effective January 28, 2005, for certain FDG PET indications, rather than the QV modifier previously required, you must use the QR modifier on all carrier claims to identify that this service is provided in a Medicare-specified study. (CR 5124)
Per Transmittal R914CP (CR 4361) dated April 21, 2006, effective for dates of service on and after February 27, 2006, through February 26, 2011, Medicare will pay an additional $50 to ambulatory surgical centers (ASCs) for new technology intraocular lenses (NTIOLs) that CMS recognizes as belonging to NTIOL Category 3(Reduced Spherical Aberration). Information regarding the lenses that are classified in NTIOL Category 3 is posted at http://www.cms.hhs.gov/CoverageGenInfo/09_NTIOLs.asp. Additional information about NTIOLs is posted at http://www.cms.hhs.gov/center/coverage.asp.Or, refer to Pub 100-04, Medicare Claims Processing, Chapter 14, Section 40.3, which can be accessed on the following webpage: http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage. (CMS Message 200605-25)
Since December of 2005 we have been holding weekly Part D Providers conference calls to address issues physicians and other health care providers were having with Part D. We have seen a gradual decline in the participation on those calls and this past week, we only had one question on the call. To that effect, we held the final weekly Part D Providers call on May 30th at 2pm EST. We continue to remain committed to fixing your Part D issues and we are confident that between your email access to us (PRIT@cms.hhs.gov) and our participation in the Open Door Forums (ODF) you will not feel abandoned. We are asking that physicians and other health care providers take their Part D issues to their respective ODF calls. If you do not currently participate in the ODFs, you are encouraged to sign up to receive the ODF announcements by going to: http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=4 or http://www.cms.hhs.gov/opendoorforums/ The next Skilled Nursing Facilities/Long-Term Care ODFs is June 6th (1-800-837-1935, Reference ID: 8266876) and the next Physician ODF is June 27th. Both will start at 2pm EST. (CMS Message 200605-24)
Countdown has begun; do you have your NPI? Don’t risk disruption to your cash flow – Get your NPI now! National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every healthcare provider needs to get an NPI! Learn more about NPI and how to apply by visiting www.cms.hhs.gov/NationalProvIdentStand/ on the CMS website.

This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A Countdown Clock is now available on this page to remind health care providers of the number of days left before the compliance date; bookmark this page as new information and resources will continue to be posted.

For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative website at http://www.wedi.org/npioi/index.shtml on the web.(JSM 06468)