Intermediaries were also instructed to take steps to intensify their medical review of partial hospitalization services, beginning Oct. 1, 1999. In preparation for this review, and to assist providers in greater understanding of the benefit requirements, we would like to bring attention to a revision in the regulations communicated in the October 1st, bulletin. On pages 5 and 6 of the bulletin, under the category entitled "Reasons for Denial", it is stated in bold print that benefit category denials made under §1861(ff) or §1835 (a)(2)(F) and coverage denials made under §1861(ff) are not appealable by the provider and the Limitation of Liability provision does not apply (HCFA Ruling 97-1).

The following are benefit catagories and coverage denials that cannot be appealed and the Limitation of Liability provision does not apply:

• Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
• Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; and
• Patients who are otherwise psychiatrically stable or require medication management only.

Excluded services such as:

• Services to hospital inpatients;
• Meals, self-administered medications, transportation; and
• Vocational training.

Coverage denials such as:

• Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a partial hospitalization program;
• Treatment of chronic conditions without acute exacerbation of symptoms which place the individual at risk of relapse or hospitalization; and
• Services to a skilled nursing facility resident that should be expected to be provided by the nursing facility staff.

It is not enough that a patient qualify under the benefit category requirements §1835(a)(2)(F) unless he/she also has the need for the active treatment provided by the program of services defined in §1861(ff).

Reasonable and necessary denials based on §1862(a)(1)(A) remain appealable and the Limitation of Liability provision still applies.

Effective Date: January 1, 2000
Implementation date for the new screening limit will be January 17, 2000

Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added ß1834(c) of the Act to provide for Part B coverage of mammography screening performed on or after January 1, 1991. The term "screening mammography" means a radiologic procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes a physician's interpretation of the results of the procedure. Unlike diagnostic mammographies, there does not need to be signs, symptoms, or history of breast disease in order for the exam to be covered.

There is no requirement that the screening mammography examination be prescribed by a physician for an eligible beneficiary to be covered. Payment may be made for a screening mammography furnished to a woman at her direct request.

Prior to October 1, 1994, providers that perform screening mammographies must request and be recommended for certification by the State certification agency and approved by HCFA before payment is made. Effective October 1, 1994, providers that perform mammography services (diagnostic and screening) must be issued a certificate from the Food and Drug Administration (FDA) before payment is made. (See §3660.15 of the Intermediary Manual for more detailed instructions.) A provider that arranges for another entity to perform a screening mammography for one of its patients must assure, prior to October 1, 1994, that the entity is certified to perform the screening. On or after October 1, 1994, the provider must assure that the entity has been issued a certificate by the FDA. If the entity that performed the screening mammography is not certified, the claim will be denied.

Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over 39 and waives the Part B deductible. Coverage applies as follows:

• No payment may be made for a screening mammography performed on a woman under 35 years of age;
• Pay for only one screening mammography performed on a woman between her 35th and 40th birthday (ages 35 thru 39); or
• For a woman over 39, pay for a screening mammography performed after 11 full months have passed following the month in which the last screening mammography was performed.

1. Determining 11 Month Period.--To determine the 11 month period, start your count beginning with the month after the month in which a previous screening mammography was performed.

EXAMPLE:      The beneficiary received a screening mammography in January 1991. Start your count beginning with February 1991. The beneficiary is eligible to receive another screening mammography in January 1992 (the month after 11 full months have elapsed).

2. Payment Limitations.--There is no Part B deductible. However, coinsurance is applicable. Following are three categories of billing for mammography services:

• Professional component of mammography services (that is, for the physician's interpretation of the results of the examination),
• Technical component (all other services), or
• Both professional and technical components (global). However, global billing is not permitted for services furnished in provider outpatient departments.

When the technical and professional components of the screening mammography are billed separately, the payment limit is adjusted to reflect either the professional or technical component only. That is, the limitation ($62.10 in calendar year 1996, $63.34 in calendar year 1997, $64.73 in calendar year 1998, $66.22 in calendar year 1999 and $67.81 in calendar year 2000) applicable to global billing for screening is allocated between the professional and technical components as set forth by regulations. For example, in calendar year 2000, 32 percent of the $67.81 limit, or $21.69, is used in determining payment for the professional component and 68 percent of the $67.81 limit, or $46.12 is used in determining payment for the technical component.

Payment for the technical component equals 80 percent of the least of the:

• Actual charge for the technical component of the service;
• Amount determined for the technical component of a bilateral diagnostic mammogram (HCPCS code 76091) for the service under the radiology fee schedule in 1991; or for services furnished on or after January 1, 1992, under the Medicare physicians' fee schedule; or
• Technical portion of the screening mammography limit. This is an amount determined by multiplying the screening mammography limit ($59.63 in calendar year 1994 by 63 percent, $60.88 in calendar year 1995, $62.10 in calendar year 1996, $63.34 in calendar year 1997, $64.73 in calendar year 1998 $66.22 in calendar year 1999, and $67.81 in calendar year 2000) by 68 percent.

On January 1 of each subsequent year, the overall limit is updated by the percentage increase in the Medicare Economic Index.

Providers bill the Intermediary using Form HCFA-1450 for the technical component portion of the screening mammography and their carrier on Form HCFA-1500 for the professional component portion.

3. Billing Requirements.--Providers bill for the technical component portion of the screening mammography on Form HCFA-1450 under bill type 14X, 22X, 23X, 71X (provider number ranges, 3400-3499, 3975-3999 and 8500-8899), or 85X, using revenue code 403 and HCPCS code 76092. Separate bills are required. Providers include on the bill only charges for the mammography screening.

Provider-based RHCs and FQHCs bill the intermediary for the technical component and their carrier for the professional component of the screening mammography. Provider-based FQHCs utilize bill type 14X or 22X when billing their intermediary for this service (see §3643 ). Independent RHCs and free-standing FQHCs bill their carrier for both the technical and professional components.

On every screening claim with dates of service October 1, 1997 thru December 31, 1997, where the patient is not a high risk individual, the provider enters in FL 67, "Principal Diagnosis Code," the following code:

• V76.12 "Other screening mammography."

If the screening is for a high risk individual, the provider enters in FL 67, "Principal Diagnoses Code," the following code:

• V76.11 "Screening mammogram for high risk patient."

In addition, for high risk individuals, providers also report one of the following applicable codes in FL 68, "Other Diagnoses Codes":

• V10.3 "Personal history - Malignant neo plasm female breast;"
• V16.3 "Family history - Malignant neoplasm breast;" or
• V15.89 "Other specified personal history representing hazards to health."

The following chart indicates the ICD-9 diagnosis codes providers report for each high risk category:

On every screening claim with dates of service on or after January 1, 1998, providers enter in FL 67, "Principal Diagnosis Code," the following code:

• V76.12 "Other screening mammography."

NOTE:      Providers code the ICD-9 diagnosis codes to the appropriate fourth or fifth digit. Omit decimal points for data entry purposes. In addition, due to the BBA of 1997, there is no need for providers to continue to report the high risk diagnosis codes effective January 1, 1998.

4. Actions Required.--The Intermediary will consider the following when determining whether payment may be made:

• Presence of revenue code 403;
• Presence of HCPCS code 76092;
• Date of last screening mammography; and
• Age of beneficiary.

5. Determining Payment Amount For Technical Component.--This provides for the payment calculation of the technical portion of a screening mammography. For services in 2000, the Intermediary will pay the lower of:

• Billed charges for HCPCS code 76092;
• $46.12 limit; or
• The physicians' fee schedule amount for the technical component of HCPCS code 76091.

The screening mammography payment is a final payment, not a payment limit, as are other radiology services, and is not subject to the radiology blend. Therefore, determine the payment in your system before remittance.

Payment is 80 percent of the lower of:

To calculate the payment, select the lower of:

Pay 80 percent of the remainder. It does not apply to the provider's interim rate. This is a final payment to the provider.

In this case:

$46.12 x 80% = $36.90 payment to the provider.

To determine the patient's liability, multiply the actual charge by 20 percent. The result is the patient's liability.

In this case:

$90.00 x 20% = $18.00 (coinsurance).

6. Special Billing Instructions When a Radiologist Interpretation Results in Additional Films.--Radiologists who interpret screening mammographies are allowed to order and interpret additional films based on the results of the screening mammogram while the beneficiary is still at your facility for the screening exam. Where a radiologist interpretation results in additional films, the mammography is no longer considered a screening exam for application of age and frequency standards or for payment purposes. When this occurs, the claim will be paid as a diagnostic mammography instead of a screening mammography. However, since the original intent for the exam was for a screening, for statistical purposes, the claim is considered a screening.

Prepare the claim reflecting the diagnostic revenue code 401 along with HCPCS code 76090 or 76091 and modifier GH for "Diagnostic mammogram on same day". Payment will be made on a cost reimbursement basis. Statistics will be collected based on the presence of modifier GH. A separate claim is not required. Regular billing instructions remain in place for the mammographies that do not fit this situation.

All of the above information has previously been written. The only changes are written in bold.

Please refer to the Intermediary Manual, section 3660.10, the Hospital Manual, section 451 or the Skilled Nursing Facility Manual, section 537 for more information.

1. The Provider Relations department would like to suggest to all providers that at least two staff members of each facility know how to navigate the Fiscal Intermediary Shared System (FISS) and are knowledgeable about the DDE screens. This would allow a back-up system in case the facility experiences a sudden departure in staff and the provider would not be left not knowing how to use the FISS. This is important especially when the provider wants to know what the check amount is for a current week.
2. We would like to request that all providers please refer to their bulletins, Intermediary News and HCFA provider manuals as a reference before calling the Provider Relations department.
3. The September 1999 Intermediary News contained an address update form on the last page. We have only received a few completed forms. Please complete the form and FAX it or mail it to Provider Relations. Even if the information is the same, please complete it. This allows us to maintain a current mailing list to ensure that you are receiving information from Maryland Medicare Part A.
   HOLIDAY SCHEDULE
   

   The Medicare office will be closed for the following Holidays in 1999:

   Christmas	Friday, December 24, 1999 and Monday, December 27, 1999
   New Year's	Thursday, December 30, 1999 closing at 11:30 a.m. and closed all day on Friday, December 31, 1999

   The availability of the FISS (DDE) and the HIQA screen will be as follows:

   Christmas:	Friday, December 24, 1999 system 6:00 a.m. - 12:00 noon Saturday, December 25, 1999 system not available Monday, December 27, 1999 DDE and HIQA available 6:00 a.m.-10:00 p.m. Tuesday, December 28, 1999 business as usual
   New Years's:	Due to Y2K compliance, it will be necessary to alter the system availability as follows:

   Wednesday, December 29, 1999

   • All claims processing will STOP at 3:30 p.m.
   • All EMC files must be submitted by 11:00 a.m.
   • HIQA NOT available
   • DDE available until 3:30 p.m. only

   
   Thursday, December 30, 1999

   • HIQA is available 6:00 a.m. - 6:00 p.m.
   • DDE is NOT available all day
   • Provider Phones NOT available

   
   Friday, December 31, 1999

   • DDE NOT available at all
   • HIQA NOT available at all

   
   Saturday January 1, 2000

   • DDE available 10:00 a.m. - 12:00 noon
   • HIQA available 10:00 a.m. - 5:00 p.m.
   • Any claims related problems, call 410-561-4036 from 10:00 a.m. until noon

   
   PLEASE NOTE that an exception is being made for system availability on Sunday; this is not a normal operational day.
   
   Sunday, January 2, 2000

   • DDE 12:00 noon - 6:00 p.m.
   • HIQA 6:00 a.m. - 6:00 p.m.

   
   Monday, January 3, 2000
   Return to normal schedule

   • DDE available 6:00 a.m. - 10:00 p.m.
   • HIQA available 6:00 a.m. - 10:00 p.m.

   We would like to remind providers that all claims with dates of service beginning with January 1, 2000, will be held for processing from January 1, 2000 through January 17, 2000. Beginning January 17, 2000, claims will be released for processing. Claims will follow the normal processing flow to payment. Providers were previously informed about this in Provider Bulletins dated September 10, 1999 and September 30, 1999. Please refer to those bulletins for detailed information.

   SNF BENEFIT/SPELL OF ILLNESS
   

   We have recently experienced an increased number of inquiries regarding the "Spell of Illness". Please note the following regulations regarding the "Spell of Illness" as it relates to the Skilled Nursing Facility stay:

   The Spell of Illness begins with the first day on which a patient is furnished extended care services by a qualified provider in a month for which the patient is entitled to hospital insurance (not included in a previous benefit period/spell of illness).
   • Posthospital extended care services represent an extension of care for a condition for which the individual received inpatient hospital services.
   • Extended care services are "posthospital" if initiated within 30 days after discharge from a hospital stay which included at least 3 consecutive days of medically necessary inpatient hospital services.
   • The 30 day transfer period begins on the day following discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care. Thus, an individual who is admitted to a SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after discharge, does not meet the 30-day requirement.
   • If an individual whose SNF stay was covered upon admission is thereafter determined not to require a covered level of care for a period of more than 30 days, payment could not be resumed for any extended care services he may subsequently require even though he has remained in the facility. Such services could not be deemed "posthospital" extended care services.
   • If an individual who is receiving covered posthospital extended care leaves a skilled nursing facility and is readmitted to the same or any other participating skilled nursing facility for further covered care within 30 days, the 30-day transfer requirement is considered to be met.
   • Exception to 30 day transfer rule--An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in a SNF within 30 days after hospital discharge, and it is medically predictable at the time of the hospital discharge that he will require covered level of SNF care within a predeterminable time period.
   • Deferred care--When the required care commences within the anticipated time frame the transfer requirement would be considered met even though more than 30 days have elapsed. However, situations may occur where complications necessitate delayed initiation of the required care and treatment beyond the usual anticipated time frame (e.g., skilled rehabilitative services which will enable an amputee patient to use a prosthetic device must be deferred due to an infection in the stump). In such situations, the 30-day transfer requirement may still be met even though care is not started within the usual anticipated time frame, if the care is begun as soon as medically possible and the care at that time is still reasonable and necessary for the treatment of a condition for which the patient received inpatient hospital care.
   • In the infrequent situation where the patient has been discharged from the hospital to his home more than 60 days before he is ready to begin a course of deferred care in an SNF, a new spell of illness begins with the day the beneficiary enters the SNF thereby regenerating another 100 days of extended care benefits. Another qualifying hospital stay would not be required, providing the care furnished is clearly related to the hospital stay in the previous spell of illness and represents care for which the need was predicted at the time of discharge from such hospital stay.
   • A Spell of Illness ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF. To determine the 60 day consecutive period, begin counting with the day the individual was discharged. A beneficiary in a SNF is considered to be an inpatient, for spell of illness purposes, only while receiving a skilled level of care.

   EXAMPLE:
   A beneficiary was hospitalized for a treatment of diverticulitis and later admitted to a skilled nursing facility. Almost a year later, she was transferred to a second skilled nursing facility where she broke her hip, was hospitalized a second time, and readmitted to the same skilled nursing facility. Payment was made on her behalf for the extended care services resulting from her first hospitalization. A claim was then filed for the extended care services furnished because of her second hospitalization. It is held that a new spell of illness did not start when she was readmitted to the hospital for a broken hip since there had not elapsed a period of 60 consecutive days during which time she was not an inpatient of either a hospital or a skilled nursing facility. Her second admission and subsequent readmission to a skilled nursing facility occurred within the initial spell of illness, for which she had already exhausted her entitlement to have payment made. It is not material that the two hospitalizations were for different reasons.

   EXAMPLE:
   A resident goes into the nursing home on Medicare. The skilled services are for a newly placed gastostomy tube. The G-tube is permanent and the resident will be dependant on this G-tube for the rest of her life. The resident uses 100 days of Medicare Part A and then goes to the uncertified section of the nursing facility still receiving skilled services for G-tube feedings. This resident will presumably never again qualify for Medicare Part A SNF services because she did not end the spell of illness since she will remain in the facility with her feeding tube which comprises an uninterrupted skilled level of care. The only way she would qualify again for Medicare Part A is if at some point in the future she would be discharged from the facility (and not be admitted to another facility-hospital or SNF) for at least 60 consecutive days, or if the feeding tube was removed (putting her at a lesser level of care) for at least 60 consecutive days.

   Questions regarding this article may be addressed via E-mail to: diane.baker@carefirst.com OR faxed to: Diane Baker, Medical Review Department (410) 561-7951. Inquiries via telephone may be made to (410) 561-4032.

   ASSISTED SUICIDE FUNDING RESTRICTION ACT OF 1997 (P.L. 105-12)
   

   The purpose of Program Memorandum AB-99-31 is to apprise carriers and intermediaries of the Assisted Suicide Funding Restriction Act of 1997 (Public Law 105-12). This Act prohibits the use of Federal funds to provide or pay for any health care item or service or health benefit coverage for the purpose of causing, or assisting to cause, the death of any individual. The prohibition does not pertain to the withholding or withdrawing of medical treatment or care, nutrition or hydration. In addition, the prohibition does not pertain to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing death. The list of programs to which the prohibition applies includes the Medicare program and §1862 (a) of the Social Security Act (the Act), was amended by adding a new paragraph (16) referencing the Assisted Suicide Funding Restriction Act.

   We do not envision any revisions to existing policy, since Medicare payment for such services is already excluded by §1862 (a) (1) (A) of the Act which states that no payment may be made under Part A or Part B for any expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.

   RETENTION OF HEALTH INSURANCE RECORDS
   

   Maintain health insurance materials related to services rendered under title XVIII for the retention periods outlined below unless State law stipulates a longer period. Keep them available for references by HCFA, intermediary, DHHS audit, or specially designated components for bill review, audit and other references.

   1. Categories of Health Insurance Records to be Retained - If these records are microfilmed, also see subsection B.
      1. Billing Material: Hospital copies of forms HCFA-1450 and any other supporting documents e.g., charge slips, daily patient census records, and other business and accounting records referring to specific claims.
      2. Cost Report Material: All data necessary to support the accuracy of the entries on the annual cost reports, including original invoices, cancelled checks and hospital copies of materials used in preparing them. Also include other similar cost reports, schedules and related worksheets and contracts or records of dealings with outside sources of medical supplies and services or with related organizations.
      3. Medical Record Material: Utilization review committee reports, physicians' certification and recertifications, discharge summaries, clinical and other medical records relating to health insurance claims.
      4. Hospital Physician Materials: Hospital physician agreements upon which Part A-Part B allocations are based.

   After payment of the bill, do not retain administrative and billing work records if the material does not represent critical detail in support of summaries related to these records. These include punch cards, adding machine tapes, internal controls, or other similar material not required for record retention.

   1. Microfilming Records - You may microfilm all health insurance records.

   Billing material and related attachments that you furnished to your intermediary may be microfilmed providing the microfilm accurately reproduces all original documents.

   Retain copies of all other categories of health insurance records in their original form. If you microfilm them, store them in a low cost facility for the retention period.

   1. Retention Period - Maintain a medical record for each inpatient and outpatient. Medical records must be accurately written promptly completed, properly filed and retained and accessible. Use a system of author identification and record maintenance that ensures the integrity of the authentification and protects the security of all record entries.

   Retain medical records in their original or legally reproduced form for a period of at least 5 years.

   (source: Hospital Manual, section 413)

   PHONE CALLS FROM PROVIDERS
   

   When some providers are calling the Provider Relations department, they are asking certain questions that could have been accessed by using the DDE screen from the Fiscal Intermediary System (FISS).

   Examples of some of the questions are:

   • What is my total check amount?
   • How much was paid for a particular claim?
   • Has a claim for a certain date been submitted?
   • What is the status of a claim?
   • How many claims are suspended in TB9997?

   We are requesting that electronic providers please follow the instructions below before calling the Provider Relations department:

   1. Total check amounts can be accessed from the FISS main menu by typing 01, then press enter, then typing FI, then press enter. The last three check amounts with the date and check number will be displayed. A check amount can not be given over the telephone. A check amount inquiry will not be given to a provider who submit hard copy claims.
   2. The paid amount for a particular claim can be accessed from the FISS main menu by typing 01, then press enter, then type 12, then press enter, then type the beneficiary's HIC# and date of service, then press enter. The paid amount is on the claim summary inquiry screen under the column "prov reimb.". The paid amount is also on page 6 of that same screen.
   3. To verify if a claim has been submitted, follow the instructions above for #2. If the claim does not appear (verify the correct HIC# was entered), then submit the claim.
   4. The status of a claim can also be accessed by following the steps in #2. If the claim is in location status TB9997 and it is not suppressed, then the provider is required to correct the claim. If the claim is in location status RB9997, then the claim was rejected. If the claim is in status location PB9997, then the claim is paid (although, not always paid if an HMO or MSP is involved). Please refer to the FISS DDE manual, page 348 for more status location definitions. If the provider does not understand the reason code assigned to the claim, then call Provider Relations.
   5. The total number of claims suspended in TB9997 can be accessed by typing 01, then press enter, then type 56, then press enter. The screen appears with the total claim count of suspended claims. A break-down by type of bill and amount by type of bill is on this screen. A detailed explanation begins on page 132 of the FISS DDE manual.

   If the provider does not submit electronically, then call the Provider Relations department for #3-#5. If a provider would like to inquire about submitting electronically, please call 410-561-4299 or 410-561-4122.

   Vendors need to contact the hospital for claim information. Vendors can request to be set up so they can view FISS screens. If the vendor is requesting information over the telephone, then the vendor needs to contact the Senior VP of a facility for authorization and have the Senior VP of the facility submit written permission to Medicare.

   We are requesting that providers please try to research the information first before calling.

   Fraud and Abuse Corner

   
   SANCTIONED PROVIDER UPDATE
   

   The OIG has notified us of recent administrative sanction actions involving the following providers:

   Michael Anthony Lee, R.N.
   512 Quincy Street, N.W.
   Washington, D.C. 20011-5932
   Effective Date: August 19, 1999

   Cheryl E. Richardson, M.D.
   84 Willis Street
   Westminster, Maryland 21157
   Effective Date: August 19, 1999

   Patricia Faye Thomas, R.N.
   P.O. Box 535
   Jessup, Maryland 20794
   Effective Date: August 19, 1999

   Mary Hui Fang, M.D.
   AKA Mary Chang
   10931 Martingale Court
   Potomac, Maryland 20854
   Effective Date: September 20, 1999

   David William French
   Owner/Operator
   51 Murphy Avenue
   Annapolis, Maryland 21401
   Effective Date: September 20, 1999

   Barbara Hart
   Owner/Operator
   7606 Brightside Avenue
   Baltimore, Maryland 21237
   Effective Date: September 20, 1999

   Delores Jones Marable, R.N.
   2602 Berkley Street
   Temple Hills, Maryland 20748
   Effective Date: September 20, 1999

   Deana McKenzie, R.N.
   19 Marview Drive
   Berlin, Maryland 21811
   Effective Date: September 20, 1999

   Jesse Reid
   Health Care Aide
   2806 Brighton Street
   Baltimore, Maryland 21216
   Effective Date: September 20, 1999

   Derek Shepherd
   Health Care Aide
   2053 Belvedere Avenue
   Baltimore, Maryland 21239
   Effective Date: September 20, 1999

   Henry Maurice Thomas
   Technician
   3426 Edmondson Avenue
   Baltimore, Maryland 21229
   Effective Date: September 20, 1999

   Yolanda C. Gordon, R.N.
   3871 Alabama Avenue, S.E.
   Apartment 203
   Washington, D.C. 20020
   Effective Date: October 20, 1999

   An employer of a sanctioned provider cannot be reimbursed under Medicare or Medicaid for the salary paid to a sanctioned provider, nor can an employer bill either program for services rendered to Medicare and Medicaid beneficiaries by this provider. In addition, a provider which hires a sanctioned individual without making proper inquiries may be subject to Civil Monetary Penalty Law (CMPL) action by the OIG. Direct questions or inquiries to the Maryland Medicare Part A Fraud and Abuse Unit at 410-561-4102 or 410- 561-4111.

   The OIG has also informed us of one stay action involving a provider who was previously sanctioned, as follows:

   Craig R. Lane
   1120 North Carrollton Avenue
   Baltimore, Maryland 21217
   Effective Date: September 3, 1999

   The effect of this stay action is that this provider may now bill the Medicare and Medicaid programs for items and services supplied to beneficiaries. Also, an employer of this individual may now be reimbursed under Medicare and Medicaid for the salary paid to this provider and may bill the programs for services rendered to beneficiaries by this provider.

   MEDICARE AS SECONDARY PAYER- POSSIBLE FALSE CLAIMS ACT SUITS
   

   Section 301 of the Medicare Hospital Manual (revised January, 1999) requires that hospitals determine whether there is a payer primary to Medicare upon each admission and each outpatient encounter. In addition, section 301 also requires that the specific secondary payer questionnaire contained in the Manual (or at a minimum the language from the questionnaire) must be used in soliciting the required information.

   If a provider does not comply with the process set forth in Section 301, it could be accused of submitting false claims for which action could be taken pursuant to the civil False Claims Act (31 USC 3729 et seq). The False Claims Act provides for a penalty of from $5,000 to $10,000 for each false claim filed plus treble damages. If a provider consistently bills Medicare when it could have determined by use of the secondary payer questionnaire that there was a payer primary to Medicare, the OIG could argue that the provider acted in "deliberate ignorance" or "reckless disregard" of the truth or falsity of the information. These terms constitute the standards for liability under the False Claims Act (31 USC 3729 (b) (2) and (3)).

   MEDICARE PROGRAM INTEGRITY MANUAL (PIM) ON THE INTERNET
   

   The Health Care Financing Administration (HCFA) has advised us that they have published the above manual on the Internet. This manual consolidates program integrity instructions from HCFA's Medicare Carrier Manual (MCM), Medicare Intermediary Manual (MIM) and provider manuals, into a single electronic manual.

   The PIM consists of nine separate chapters which contain the program integrity language formerly located in MCM sections 7500 and 14000, MIM section 3900 and provider manuals. In addition, one chapter contains Program Memoranda.

   HCFA will not be sending paper copies of this new manual. The current paper copies are being retired and the PIM is now HCFA's official source of program integrity instructions.

   The website address for the PIM is: http://www.hcfa.gov/pubforms/83_pim/pimtoc.htm.

   MEDICARE TRAVEL ALLOWANCE FEES FOR COLLECTION OF SPECIMENS
   

   This Program Memorandum (PM) AB 99-49, is to clarify payment of travel allowances, either on a per mileage basis (P9603) or on a flat rate basis (P9604).

   Medicare, under Part B, covers a specimen collection fee and travel allowance for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under §1833(h)(3) of the Act and payment is made based on the clinical laboratory fee schedule.

   CURRENT POLICY

   Travel Allowance - The travel codes allow for payment either on a per mileage basis (P9603) or on a flat rate per trip basis (P9604). Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel allowance is intended to cover the estimated travel costs of collecting a specimen including the laboratory technician's salary and travel expenses. Contractor discretion allows the contractor to choose either a mileage basis or a flat rate, and how to set each type of allowance. Because of audit evidence that some laboratories abused the per mileage fee basis by claiming travel mileage in excess of the minimum distance necessary for a laboratory technician to travel for specimen collection, many contractors established local policy to pay based on a flat rate basis only.

   Under either method, when one trip is made for multiple specimen collections (e.g., at a nursing home), the travel payment component is prorated based on the number of specimens collected on that trip, for both Medicare and non-Medicare patients, either at the time the claim is submitted by the laboratory or when the flat rate is set by the contractor.

   NEW POLICY

   Per Mile Travel Allowance (P9603) - There is a minimum of 75 cents a mile. The per mile travel allowance is to be used in situations where the average trip to patients' homes is longer than 20 miles round trip, and is to be pro-rated in situations where specimens are drawn or picked up from non-Medicare patients in the same trip.

   The per mile allowance was computed using the Federal mileage rate of 31 cents a mile plus an additional 44 cents a mile to cover the technician's time and travel costs. Contractors have the option of establishing a higher per mile rate in excess of the minimum of 75 cents a mile if local conditions warrant it. The minimum mileage rate will be reviewed and updated in conjunction with the clinical lab fee schedule as needed. At no time will the laboratory be allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician.

   Example 1: A laboratory technician travels 60 miles round trip from a lab in a city to a remote rural location, and back to the lab to draw a single Medicare patient's blood. The total reimbursement would be $45.00 (60 miles x .75 cents a mile), plus the specimen collection fee of $3.00.

   Example 2: A laboratory technician travels 40 miles from the lab to a Medicare patient's home to draw blood, then trav els an additional 10 miles to a non-Medicare patient's home and then travels 30 miles to return to the lab. The total miles traveled would be 80 miles. The claim submitted would be for one half of the miles traveled or $30.00 (40 x .75), plus the specimen collection fee of $3.00.

   Flat Rate (P9604) - There is a minimum of $7.50 one way. The flat rate travel allowance is to be used in areas where average trips are less than 20 miles round trip. The flat rate travel fee is to be pro-rated for more than one blood drawn at the same address, and for stops at the homes of Medicare and non-Medicare patients. The pro-ration is done by the laboratory when the claim is submitted based on the number of patients seen on that trip. The specimen collection fee will be paid for each patient encounter.

   This rate was based on an assumption that a trip is an average of 15 minutes and up to 10 miles one way. It uses the Federal mileage rate of 31 cents a mile and a laboratory technician's time of $17.66 an hour, including overhead. Contractors have the option of establishing a flat rate in excess of the minimum of $7.50, if local conditions warrant it. The minimum national flat rate will be reviewed and updated in conjunction with the clinical laboratory fee schedule, as necessitated by adjustments in the Federal travel allowance and salaries.

   Example 3: A laboratory technician travels from the laboratory to a single Medicare patient's home and returns to the laboratory without making any other stops. The flat rate would be calculated as follows: 2 x $7.50 for a total trip reimbursement of $15.00, plus the $3.00 specimen collection fee.

   Example 4: A laboratory technician travels from the laboratory to the homes of five patients to draw blood, four of the patients are Medicare patients and one is not. An additional flat rate would be charged to cover the 5 stops and the return trip to the lab (6 x $7.50 =$45.00). Each of the claims submitted would be for $9.00 ($45.00 /5 = $9.00). Since one of the patients is non-Medicare, four claims would be submitted for $9.00 each, plus the $3.00 specimen collection fee.

   Example 5: A laboratory technician travels from a laboratory to a nursing home and draws blood from 5 patients and returns to the laboratory. Four of the patients are on Medicare and one is not. The $7.50 flat rate is multiplied by two to cover the return trip to the laboratory (2 x $7.50 = $15.00) and then divided by five (1/5 of $15.00 = $3.00). Since one of the patients is non-Medicare, four claims would be submitted for $3.00 each, plus the $3.00 specimen collection fee.

   CREDIT BALANCE REASON CODES
   

   Two new reason codes have been developed for processing credit balance reports.

   These new reason codes were developed to notify providers that unless they respond within two weeks, Medicare will cancel the original claim to satisfy the credit balance.

   The two new reason codes are:

   7CMSP	In order to process your credit balance we need additional information concerning the primary payer. Please provide the information requested in REMARKS. If we do not receive a response within two weeks, we will cancel the claim.
   7COTH	In order to process your credit balance we need additional information. Please provide the information requested in REMARKS within two weeks. If we do not receive the information within two weeks, we will cancel the claim.

   As a reminder, all credit balances are to be sent to Veronica Moore at Medicare, and credit balances cannot be dropped off or FAXed. Providers were informed of this policy in a Provider Bulletin dated September 10, 1999.

   The next credit balance report is due January 30, 2000 for the quarter ending December 31, 1999. A complete credit balance report due chart was written in the September 1999 Intermediary News.

   ZEMPLAR (Paricalcitol Injection)
   

   On April 17, 1998 the FDA approved the drug Zemplar (Paricalcitol Injection) for use to prevent and treat high parathyroid levels in patients with chronic kidney failure. Zemplar is administered as an injection during dialysis treatment, no more than every other day. At this time, Zemplar has not yet been assigned a HCPC. The following will apply for billing purposes:

   Revenue Code:	250 (hospitals); 636 (freestanding facilities)
   HCPC:	J3490 (dump code until a code is assigned)
   Primary Diagnostic Code:	585 (Chronic Renal Failure) or 586 (Renal Failure, Unspecified)
   Secondary Diagnostic Code:	588.8 (Secondary Hyperparathyroidism of Renal Origin)
   Reimbursement:	@ 95% of cost

   Volume/Container	Concentration	AWP (Cost)
   1 mL/Fliptop Vial	5 mcg/mL	$26.48 per vial
   2 mL/Fliptop Vial	5 mcg/mL	$52.96 per vial

   Providers using the "dump" code must include the following information in the "Remarks" area of the claim: drug name; drug dose; dates received; medical justification for use of this medication.

   The following coverage criteria will apply for the use of Zemplar:

   • Patients with malabsorption syndrome
   • Status-post radical head and neck surgery when the oral form cannot be tolerated
   • Failure to respond to oral medication by:
     1. demonstrating decreases in PTH levels
     2. developing hypercalcemia
   • Severe symptomatic bone disease when parathyroidectomy is strongly considered
   • High normal serum calcium levels and the oral form would augment the development of hypercalcemia

   Medicare documentation to support medical necessity for the use of Zemplar requires baseline parathyroid levels before oral therapy is initiated. The baseline and subsequent levels serve as documentation of non-response to the oral preparation.

   Example of documentation chronology to justify intravenous Zemplar therapy:

   1.	Baseline laboratory studies prior to therapy: Baseline calcium level ______________ Baseline parathyroid level ______________ Date oral therapy begun ______________	Date of test ______________ Date of test ______________
   2.	Repeat calcium level ______________ (receiving oral form) Repeat parathyroid level ______________	Date of test ______________ Date of test ______________

   When laboratory studies indicate that the patient did not respond to oral therapy, the intravenous route is coverable.

   GAVEL GRAVEL: THE MEDICARE DOCKET
   

   By Michael Berkey

   May a Provider reinstate a case with the Provider Reimbursement Review Board ("PRRB or Board) when a settlement agreement has not been implemented within a year of its signing? Until recently, the answer had always been yes, but a recently decided case now means the answer must be "It depends."

   The Provider in this case had several cost reporting issues in dispute as its hearing date before the PRRB approached. After some negotiations, the Provider and the Intermediary agreed to resolve all but one of the issues. Before the hearing started, the Provider withdrew those issues based on a signed settlement agreement. In keeping with Board procedures, the Provider understood that it could reinstate those issues if the settlement agreement was not fully implemented within one year.

   The PRRB held a hearing on the remaining issue and issued a decision favorable to the Provider within a few months. The Administrator of the Health Care Financing Administration reversed that decision within the required 60-day review period.

   Shortly thereafter, there was a change in intermediaries servicing the Provider, which still had not been paid under the settlement agreement. As the one-year anniversary of the agreement was approaching, the Provider thought it prudent to reinstate the previously settled issues, just in case the new intermediary did not implement the prior intermediary's settlement agreement within that one-year period. The Provider wrote to the PRRB, explained the circumstances, and requested reinstatement by "asserting its ability, pursuant to a Board-established rule, to preserve its appeal rights within a one-year period from the date that the settlement was signed."

   The Board held that it did not have jurisdiction over the reinstatement request, because the Administrator made the last ruling on the case. The Provider requested reconsideration, explaining that it was not the Administrator but the Board that had overseen the withdrawal of the settled issues; therefore only the Board could reinstate them. The Board denied the reinstatement request. The Provider then appealed to the Administrator, who agreed with the Provider that the Board had the discretionary power to reinstate issues withdrawn before a hearing.

   Upon remand, the Board again denied the reinstatement, this time holding that the one-year right of reinstatement only applies when all issues are withdrawn prior to a hearing.

   The Provider then appealed again to the Administrator, who declined to disturb the Board's decision. Thus, it appears that providers that settle some, but not all issues prior to a hearing have no administrative recourse should that agreement not be implemented. Absent some modification of these rulings, perhaps via court action, they are likely to make future settlement negotiations much dicier. Hurley Medical Center, Case No. 94-3278, PRRB Jurisdictional Dec., May 12, 1999.

   PAYMENT FOR BLOOD CLOTTING FACTOR ADMINISTERED TO HEMOPHILIA INPATIENTS
   

   Section 6011 of Public Law (P.L.) 101-239 amended §1886(a)(4) of the Act to provide that prospective payment hospitals receive an additional payment for the costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients. Section 6011(b) of P.L. 101-239 specified that the payment is to be based on a predetermined price per unit of clotting factor multiplied by the number of units provided. This add-on payment originally was effective for blood clotting factor furnished on or after June 19, 1990 and before December 19, 1991. Section 13505 of P.L. 103-66 amended §60ll (d) of P.L. 101-239 to extend the period covered by the add-on payment for blood clotting factors administered to Medicare inpatients with hemophilia through September 30, 1994. Section 4452 of P.L. 105-33 amended §6011(d) of P.L. 101-239 to reinstate the add-on payment for the costs of administering blood clotting factor to Medicare beneficiaries who have hemophilia and who are hospital inpatients for discharges occurring on or after October 1, 1998.

   The add-on payment for FY 1999 was calculated using the same methodology used in the past. The price per unit of clotting factor is established based on the current price listing available from the 1997 Drug Topics Red Book, the publication of pharmaceutical average wholesale prices (AWP).

   1. Billing.--Three separate add-on amounts have been set, one for each of the three basic types of clotting factor--Factor VIII, Factor IX and other factors which are given to the patients with inhibitors to Factors VIII and IX.

   The HCPCS codes which identify the three types of clotting factor along with the price per unit for discharges occurring on or after June 19, 1990, and before October 1, 1991 are:

   J7190	Factor VIII, viral inactivated	- $ .64 per IU
   J7194	Factor IX, complex, heat treated	- .26 per IU
   J7196	Other Hemophilia clotting factors (e.g., anti-clotting inhibitors.)	- 1.00 per IU

   For discharges occurring on or after October 1, 1991, and through September 30, 1992, the codes and changes are:

   J7190	Factor VIII, viral inactivated	- $ .72 per IU
   J7194	Factor IX, complex, heat treated	- .26 per IU
   J7196	Other Hemophilia clotting factors (e.g., anti-clotting inhibitors.)	- 1.11 per IU

   For discharges October 1, 1992, through September 30, 1993, the following prices per unit are in effect:

   J7190	Factor VIII	- $ .76 per IU
   J7194	Factor IX	- .30 per IU
   J7196	Other Hemophilia blood clotting factors	- 1.02 per IU

   For discharges occurring on or after October 1, 1993, through September 30, 1994, the prices are as follows:

   J7190, J7192	Factor VIII	- $ .76 per IU
   J7194	Factor IX	- .33 per IU
   J7196	Other Hemophilia blood clotting factors	- 1.02 per IU

   Effective January 1, 1994, a new Factor VIII code was introduced, J7192 (Antihemophilic recombinant) paid at the same rate as other Factor VIII products ($.76 per unit).

   J7192

   Factor VIII, Anti-Hemophilic, recombinant

   - $ .76 per IU

   For discharges occurring on or after October 1, 1997 through September 30, 1998, the prices are as follows:

   J7190	Factor VIII (Anti-Hemophilic Factor, Human)	- $ .76 per IU
   J7192	Factor VIII	- 1.00 per IU
   J7194	Factor IX Complex	- .32 per IU
   J7196	Other Hemophilia clotting factors (e.g., anti-inhibitors)	- 1.10 per IU

   Effective for services on or after April 1, 1998, two new HCPCS billing codes are established for purified and recombinant Factor IX.

   Q0160	Factor IX (Anti-Hemophilic Factor, purified, non-combinant)	- $ 0.93 per IU
   Q0161	Factor IX (Anti-Hemophilic Factor, purified, Recombinant)	- 1.00 per IU

   For discharges occurring on or after October 1, 1998 through September 30, 1999, the prices are as follows:

   J7190	Factor VIII (Anti-Hemophilic Factor, Human)	- $ .78 per IU
   J7192	Factor VIII (Anti-Hemophilic Factor, Recombinant)	- 1.00 per IU
   J7194	Factor IX, (Complex)	- .38 per IU
   J7196	Other Hemophilia clotting Factor, (anti-inhibitors)	- 1.10 per IU
   Q0160	Factor IX (Anti-Hemophilic Factor, purified, non-recombinant)	- .93 per IU
   Q0161	Factor IX (Anti-HemophilicFactor, purified, recombinant)	- 1.00 per IU

   Report one hundred IUs of any of the clotting factors as one unit (100 IUs - one billing unit). Therefore, the payment for one billed unit of hemophilia clotting Factor VIII furnished December 1, 1993, is $76.00. One billed unit of Factor IX is $33.00. One billed unit of other hemophilia clotting factors is $102.00.

   If the number of units is between even hundreds, round to the nearest hundred. Thus, units of 1 to 49 are rounded down to the prior 100 and units of 50 to 99 are rounded up to the next 100 (i.e., 1,249 units are entered on the bill as 12; 1,250 units are entered as 13).

   In reporting the number of IUs administered, divide the number of IUs administered by 100 and round the answer to the nearest whole number to determine the billing unit. (An answer which includes fractions of .50 to .99 = 1 additional billing unit. An answer which includes fractions of .01 to .49 = no additional billing units). The following examples illustrate the correct billing for the different types of clotting factors:

   EXAMPLE 1: A patient receives 1,200 IUs of Factor VIII (J7190) on December 1, 1993. The hospital divides the number of IUs administered by 100 to obtain the number of billing units. (1,200 divided by 100 = 12 billing units.) Enter 12 in FL 46 of the HCFA-1450. The payment amount is $912 (12 billing units x $76 (100 IUs x $.76)).

   EXAMPLE 2: A patient receives 3,449 IUs of Factor IX (J7194) on January 4, 1994. The hospital divides this number by 100 to obtain the number of billing units. (3,449 divided by 100 = 34.49 billing units.) Round down to the nearest whole number to obtain the billing units, and enters 34 in FL 46. The payment amount is $1,122 (34 billing units x $33 (100 IUs x $.33)).

   EXAMPLE 3: A patient receives 5,250 IUs of anti-inhibitors (J7196) (which are a type of other hemophilia clotting factor) on July 6, 1994. The hospital divides the number of IUs administered by 100 to obtain the number of billing units. (5,250 divided by 100 = 52.50 billing units.) The hospital rounds up to the nearest whole number to obtain the billing units, and enter 53 in FL 46. The payment amount will be $5406 (53 billing units x $102 (100 IUs x $1.02).

   When the number of units of blood clotting factor administered to hemophiliac inpatients exceeds 999,999,949 (report as 9,999,999, report the excess as a second line for revenue code 636 and repeat the HCPCS code. One billion fifty million (1,050,000,000) units are reported on one line as 9,999,999, and another line as 500,001.

   Use Revenue Code 636. This requires HCPCS. Continue to bill other inpatient drugs without HCPCS codes under pharmacy.

   In order to qualify for the add-on payment for hemophilia blood clotting factor, the claim must contain a hemophilia diagnosis code, either as principal or secondary diagnosis. One of the following ICD-9-CM diagnosis codes must be present on the claim.

   Final rule (58 FR 46304) states that payment will be made for blood clotting factor only if there is an ICD-9-CM diagnosis code for hemophilia included on the bill. Since blood clotting factors are only covered for beneficiaries with hemophilia, list one of the following hemophilia diagnosis codes on the bill:

   286.0	Congenital factor VIII disorder
   286.1	Congenital factor IX disorder
   286.2	Congenital factor XI disorder
   286.3	Congenital deficiency of other clotting factors
   286.4	von Willebrands' disease

   
   UPDATE FOR 1999 DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS) FEE SCHEDULE
   

   This Program Memorandum (PM), AB-99-62, provides specific instructions regarding the fourth quarter update for the 1999 DMEPOS fee schedule. General instructions regarding the quarterly update schedule for the 1999 DMEPOS fee schedule were provided in a PM to carriers and intermediaries in October 1998 (AB-98-61). Based on these earlier instructions, the base year fee amounts for the 1999 fourth quarter update were due to HCFA central office by July 16, 1999. Due to concerns regarding contractor and systems workloads as we approach the year 2000, the 1999 fourth quarter DMEPOS update will be limited to the following four items falling under the jurisdiction of the durable medical equipment regional carriers (DMERCs):

   K0531	HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
   K0532	RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACK UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)
   K0533	RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)
   K0534	RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)

   Currently, HCFA central office is reviewing several issues relating to payment for codes K0532, K0533, and K0534. Until these issues are resolved, we will include code K0532 in the fee schedule class for capped rental items and we will use the rental fee schedule amounts for code E0452 in determining the allowed payment amounts for code K0532. In addition, until further notice, we will include codes K0533 and K0534 in the fee schedule class for items requiring frequent and substantial servicing and we will use the rental fee schedule amounts for code E0453 in determining the allowed payment amounts for codes K0533 and K0534.

   Base fee schedule amounts for code K0531 should be gap-filled in accordance with instructions located in §5102.2 of the Medicare Carriers Manual. Do not use the base fee schedule amounts you gap-filled for codes K0532, K0533, and K0534 until final determinations regarding payment for those codes are made. The DMERCs should submit the base year fees for these items in accordance with the instructions provided in the October 1998 PM (AB-98-61), except that these fees were due by July 1, 1999, rather than July 16, 1999.

   The revised 1999 DMEPOS fee schedule file containing the fee schedules for codes K0531, K0532, K0533, and K0534 were transmitted by HCFA central office to the DMERCs and intermediaries by July 22, 1999.

   HCFA issued instructions regarding the addition of these codes to the Common Working File (CWF) in an April 1999 PM (AB-99-21). HCFA added these codes to the CWF in July 1999 and they will be effective on October 1, 1999.

   NEW WAIVED TESTS -- EFFECTIVE DATE OF RECEIPT
   

   Listed below are the latest tests approved by the Center for Disease Control as waived tests under the Clinical Laboratory Improvement Amendments (CLIA). The Current Procedural Terminology (CPT) codes for these new tests must have the modifier QW to be recognized as a waived test. The complete list of waived test is also attached.

   Roche/Boehringer Mannheim CoaguChek System for Professional Use
   Applied Biotech SureStep Mono Test (whole blood)
   Becton Dickinson Link 2 H. pylori Rapid Test (for whole blood)
   Bion Diagnostic Sciences BTA Stat Test (for home use)
   Diatech Diagnostics Uriscreen (for OTC use)
   Lifestream Technologies Cholesterol Monito
   Abbott TestPack Plus H. pylori (for whole blood)
   Jant Accutest Infectious Mononucleosis Test (whole blood)
   Two new waived CPT codes have been assigned:
   

   • 83518QW for the Bion Diagnostics Sciences BTA Stat Test; and
   • 81007QW for the Diatech Diagnostics Uriscreen Test.
   
   

   Dipstick or tablet reagent urinalysis - non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen	Various	81002	Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections
   Fecal occult blood	Various	82270 G0107 (contact your Medicare carrier for payment instructions)	Detection of blood in feces from whatever cause, benign or malignant (colorectal cancer screening)
   Ovulation tests by visual color comparison for human luteinizing hormone	Various	84830	Detection of ovulation (optimal for conception)
   Urine pregnancy tests by visual color comparison	Various	81025	Diagnosis of pregnancy
   Erythrocyte sedimentation rate - non-automated	Various	85651	Nonspecific screening test for inflammatory activity, increased for majority of infections, and most cases of carcinoma and leukemia
   Hemoglobin by copper sulfate - non-automated	Various	83026	Monitors hemoglobin level in blood
   Blood glucose by glucose monitoring devices cleared by the FDA for home use	Various	82962	Monitoring of blood glucose levels
   Blood count; spun microhematocrit	Various	85013	Screen for anemia
   Hemoglobin by single instrument with self-contained or component features to perform specimen/reagentinteraction, providing direct measurement and readout	HemoCue	85018QW (effective 10/1/96)	Monitors hemoglobin level in blood ( HCPCS code Q0116 should be discontinued for this test 9/30/96)
   HemoCue B-Glucose Photometer	HemoCue	82947QW, 82950QW, 82951QW, 82952QW (effective 10/1/96)	Diagnosis and monitoring of blood glucose levels (HCPCS codes G0055, G0056 and G0057 should be discontinued for this test 9/30/96)
   ChemTrak AccuMeter	ChemTrak	82465QW	Cholesterol monitoring
   Advanced Care	Johnson & Johnson	82465QW	Cholesterol monitoring
   Boehringer Mannheim Chemstrip Micral	Boehringer Mannheim	82044QW	Monitors low concentrations of albumin in urine which is helpful for early detection in patients at risk for renal disease
   Cholestech LDX	Cholestech	82465QW, 83718QW, 84478QW, 82947QW, 82950QW, 82951QW, 82952QW, 80061QW,	Measures total cholesterol, HDL cholesterol, triglycerides and glucose levels in whole blood
   Serim Pyloritek Test Kit	Serim	87072QW	Presumptive identification of tissue, Helicobacter pylori in gastric biopsy which has been shown to cause chronic active gastritis (ulcers)
   QuickVue In-Line One-Step Strep A Test	Quidel	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Boehringer Mannheim Accu-Chek InstantPlus Cholesterol	Boehringer Mannheim	82465QW	Cholesterol monitoring
   All qualitative color comparison pH testing - body fluids (other than blood)	Various	83986QW	pH detection (acid-base balance) in body fluids such as semen, amniotic fluid and gastric aspirates
   SmithKline Gastroccult	SmithKline	82273QW	Rapid screening test to detect the presence of gastric occult blood
   QuickVue One-Step H. Pylori Test for Whole Blood	Quide	86318QW	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood.
   Binax NOW Strep A Test	Binax	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Delta West CLOtest	Delta West Tri-Med Specialties	87072QW	Presumptive identification of Helicobacter pylori in gastric biopsy tissue, which has been shown to cause chronic active gastritis (ulcers)
   Wampole STAT-CRIT Hct	Wampole Laboratories	85014QW	Screen for anemia
   SmithKline Diagnostics FlexSure HP Test for IgG Antibodies to H. pylori in Whole Blood	SmithKline Diagnostics, Inc.	86318QW	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood
   Wyntek Diagnostics OSOM Strep A Test	Wyntek Diagnostics, Inc	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   GI Supply HP-FAST	Mycoscience Labs, Inc.	87072QW	Presumptive identification of Helicobacter pylori in gastric biopsy tissue, which has been shown to cause chronic active gastritis (ulcers)
   Abbott FlexPak HP Test for whole blood	Abbott Laboratories	86318QW	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood
   Chemtrak AccuMeter H. pylori Test (for whole blood)	ChemTrak	Pending	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood
   BioStar Acceava Strep A Test (direct specimen only)	Wyntek Diagnostics, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   LXN Fructosamine Test System	LXN Corporation	82985QW	Used to evaluate diabetic control, reflecting diabetic control over a 2-3 week period. Not a useful test for screening diabetes mellitus.
   ITC Protime Microcoagulation System for Prothrombin Time	International Technidyne Corporation (ITC)	85610QW (contact your Medicare carrier for claims instructions)	Aid in screening for congenital deficiencies of Factors II, V, VII, X; screen for deficiency of prothrombin; evaluate heparin effect, coumarin or warfarin effect; screen for Vitamin K deficiency.
   CoaguChek PST for Prothrombin Time	Boehringer Mannheim Corporation	85610QW (contact your Medicare carrier for claims instructions)	Aid in screening for congenital deficiencies of Factors II, V, VII, X; screen for deficiency of prothrombin; evaluate heparin effect, coumarin or warfarin effect; screen for Vitamin K deficiency.
   SmithKline ICON Fx Strep A Test (from throat swab only)	Binax	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Abbott Signify Strep A Test (from throat swab only)	Wyntek Diagnostics, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Bayer Clinitek 50 Urine Chemistry Analyzer - qualitative dipstick for glucose, bilirubin, ketone, specific gravity, blood, pH, protein, urobilinogen, nitrite, leukocytes - automated	Bayer	81003QW	Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections
   Bayer DCA 2000 - glycosylated hemoglobin (Hgb A1c)	Bayer	83036QW	Measures the percent concentration of hemoglobin A1c in blood, which is used in monitoring the long-term care of people with diabetes
   Wampole Mono-Plus WB	Wampole Laboratories	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   LXN Duet Glucose Control Monitoring System	LXN Corporation	82962, 82985QW	Monitoring of blood glucose levels and measures fructosamine which is used to evaluate diabetic control, reflecting diabetic control over a 2-3 week period.
   ENA.C.T Total Cholesterol Test	ActiMed Laboratories, Inc.	82465QW	Cholesterol monitoring
   Genzyme Contrast Mono (for whole blood)	Genzyme Diagnostics	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   Applied Biotech SureStep Strep A (II) (direct from throat swab)	Applied Biotech, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarletfever
   STC Diagnostics Q.E.D. A150 Saliva Alcohol Test	STC Technologies Inc.	Pending	Qualitative determination of alcohol (ethanol) in saliva
   STC Diagnostics Q.E.D. A350 Saliva Alcohol Test	STC Technologies Inc.	Pending	Qualitative determination of alcohol (ethanol) in saliva
   Micro Diagnostics Spuncrit Model DRC-40 Infrared Analyzer for hematocrit	Micro Diagnostics Corporation	Pending	Screen for anemia
   Chemstrip Mini UA - qualitative dipstick for glucose, bilirubin, ketone, specific gravity, blood, pH, protein, urobilinogen, nitrite, leukocytes - automated	Boehringer Mannheim Corporation	81003QW	Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections
   Litmus Concepts FemExam TestCard (from vaginal swab)	Litmus Concepts, Inc.	84999QW	Qualitative test of a vaginal fluid sample for elevated pH (pH greater than or equal to 4.7) and the presence of volatile amines
   Wyntek Diagnostics OSOM Mono Test (for whole blood)	Wyntek Diagnostics, Inc.	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   Meridian Diagnostics ImmunoCard STAT Strep A (direct from throat swab)	Applied Biotech, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Seradyn Color Q Mono (whole blood)	Genzyme Diagnostics	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   Jant Pharmacal AccuStrip Strep A (II) (direct from throat swab)	Applied Biotech, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   BioStar Acceava Mono Test (whole blood)	Wyntek Diagnostics, Inc.	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   LifeSign UniStep Mono Test (whole blood)	Princeton BioMeditech Corp.	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   Becton Dickinson LINK 2 Strep A Rapid Test (direct from throat swab)	Applied Biotech, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   DynaGen NicCheck I Test Strips	Dynagen, Inc.	80101QW (This test may not be covered in all instances. Contact your Medicare carrier.)	Detects nicotine and/or its metabolites in urine, which is used as an aid in indicating the smoking status of an individual and as an aid in the identification of a smoker as a low or high nicotine consumer
   Mainline Confirms Strep A Dots Test (direct from throat swab)	Applied Biotech, Inc.	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   Quidel Cards O.S. Mono (whole blood)	Quidel Corporation	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   Bayer Clinitek 50 Urine Chemistry Analyzer - for HCG, urine	Bayer Corp	84703QW	Diagnosis of pregnancy
   Bayer Clinitek 50 Urine Chemistry Analyzer - for microalbumin, creatinine	Bayer Corp.	82044QW	Detection of patients at risk for developing kidney damage.
   Bayer DCA 2000+ - glycosylated hemoglobin (Hgb A1c)	Bayer Corp.	83036QW	Measures the percent concentration of hemoglobin A1c in blood, which is used in monitoring the long-term care of people with diabetes
   GDS Diagnostics HemoSite Meter - for hemoglobin	GDS Technology, Inc.	85018QW	Measures hemoglobin level in whole blood
   ActiMed Laboratories ENA.C.T. Total Cholesterol Test (PDU)	ActiMed Laboratories, Inc.	82465QW (Contact your Medicare carrier for claims instructions)	Cholesterol monitoring
   Genzyme Contrast Strep A (direct from throat swab)	Genzyme Diagnostics	86588QW	Rapidly detects Group A streptococcal (GAS) antigen from throat swabs and used as an aid in the diagnosis of GAS infection which typically causes strep throat, tonsillitis and scarlet fever
   *Roche/Boehringer Mannheim CoaguChek System for Professional Use	Roche Diagnostics/Boehringer Mannheim Corporation	85610QW (Contact your Medicare carrier for claims instructions)	Aid in screening for congenita deficiencies of Factors II, V, VII, X; screen for deficiency of prothrombin; evaluate heparin effect, coumarin or warfarin effect; screen for Vitamin K deficiency.
   *Applied Biotech SureStep Mono Test (for whole blood)	Applied Biotech, Inc.	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis
   *Becton Dickinson Link 2 H. pylori Rapid Test (for whole blood)	Becton Dickinson Microbiology Systems	86318QW	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood
   *Bion Diagnostic Sciences BTA stat Test (for home use)	Bion Diagnostic Sciences, Inc.	83518QW	Immunoassay for the qualitative detection of bladder tumor associated antigen in urine of persons diagnosed with bladder cancer and used as an aid in the management of bladder cancer patients
   *Diatech Diagnostics Uriscreen (for OTC use)	Savyon/USA	81007QW	Detects catalase in urine which is associated with urinary tract infections (UTIs). White blood cells and some bacteria associated with UTIs are positive for catalase.
   *Lifestream Technologies Cholesterol Monitor	Lifestream Technologies	82465QW	Cholesterol monitoring
   *Abbott TestPack Plus H. pylori (for whole blood)	Abbott Laboratories	86318QW	Immunoassay for rapid, qualitative detection of IgG antibodies specific to Helicobacter pylori in whole blood
   *Jant Accutest Infectious Mononucleosis Test (for whole blood)	Jant Pharmacal Corporation	86308QW	Qualitative screening test for the presence of heterophile antibodies in human whole blood, which is used as an aid in the diagnosis of infectious mononucleosis

   * Newly-added waived test system

   CLINICAL DIAGNOSTIC LABORATORY ORGAN OR DISEASE PANEL CODES BILLING PROCEDURES FOR JANUARY 2000
   

   This Program Memorandum, AB 99-80, provides specific instructions regarding Automated Multi-Channel Chemistry Panel codes.

   New automated multi-channel chemistry panels will be included in the American Medical Association (AMA) Common Procedure Terminology (CPT) for calendar year (CY) 2000. Because of claims processing complications and the Y2K system moratorium, we will be unable to process any claims with these new codes for the first quarter of CY 2000. All providers, including physicians and laboratories, should continue to bill the old panel codes until April 1, 2000.

   The old organ/disease panel codes for CY 1999, which you should continue to use through March 31, 2000, are as follows: 80049, 80054, and 80058.

   The new organ/disease panel codes which you should delay using until April 1, 2000 are: 80048, 80053, 80069, and 80076. Any claim submitted with the new organ/disease panel codes during the period January 1, 2000 through March 31, 2000 will be returned to the submitter as unprocessable.

   Payment based on the CY 2000 fee schedule will not be affected.