Contents
Up Front

Promoting Influenza and Pneumococcal Vaccinations

Changes to HCPCS for Influenza Virus, Pneumonia and Hepatitis B Vaccines

Hospitals Cannot Charge for Records Requested for Review

How to Adjust or Cancel A Claim

Adjustment/Cancellation Reason Codes

Coding for Adequacy of Hemodialysis

Patient Is A Member of an HMO

Fraud and Abuse Corner

Sanctioned Providers Quick Reference

Medicare Audit and Reimbursement Fraud and Abuse

New Waived Tests

Pancreas Transplants

Implantation of Automatic Defibrillators

Screening PAP Smears

Holiday Schedule

Type of Bill 22X or 23X – When Do I Bill

Positron Emission Tomography

Prostate Cancer Screening Tests – Covered

Magnetic Resonance Angiography

Transmyocardial Revascularization for Treatment of Severe Angina

Hyperbaric Oxygen Therapy

HCFA Form 838 Credit Balance Report

GAVEL GRAVEL: The Medicare Docket

Standard Provider Level Adjustment Reason Codes

Leave of Absence

Timely Filing

Limited Medicare Coverage and Billing Instructions for Enhanced Counterpulsation

Vagus Nerve Stimulation for Treatment of Seizures

Disclosing Non-Medicare Activities on Cost Reports

Form HCFA 339 Filing Requirements

Prospective Payment System-Billing

Helpful Hints for Providers

Appeals Process for Part B Services

Cryosurgery of the Prostate Gland

Provider Addresses and Phone Numbers

Provider Relations Phone Number
410-561-0541

EMTALA SERVICES

Under the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital with an emergency department must provide, upon request and within the capabilities of the hospital, an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual’s eligibility for Medicare.

The general classification of revenue code 450 should not be used in conjunction with any subcategory. The sum of revenue codes 451 and 452 is equivalent to code 450.

Stand alone usage of revenue code 451 is acceptable when no services beyond an initial screening/assessment is rendered.

Stand alone usage of revenue code 452 is not acceptable.

Combining revenue codes 450, 451, and 452 on the same claim are also not acceptable.

For more information regarding revenue codes and other billing requirements, hospital providers can reference the Hospital Manual, Transmittal #738 which is in Section 460.

PROVIDER MANUALS

The Health Care Financing Administration (HCFA) manuals provide regulations for the processing and payment of Medicare claims, preparing reimbursement forms and billing procedures. As procedures change, HCFA issues updates for the manuals. It is imperative that providers maintain an updated manual.

Different provider manuals are available through the National Technical Information Service (NTIS). Some of these manuals are:

Medicare Coverage Issues (HCFA Pub. 6)
Medicare CORF/OPT Manual (HCFA Pub. 9)
Medicare Hospital Manual (HCFA Pub. 10)
Medicare Skilled Nursing Facility Manual (HCFA Pub. 12)
Medicare Intermediary Manual (HCFA Pub. 13-3)
Medicare Renal Dialysis Manual (HCFA Pub. 29)

If you would like to purchase a manual, please call NTIS at 1-800-553-6847. We suggest that all providers maintain their manual by properly inserting transmittals when they are issued.

Standing orders are one example of an effective strategy that a hospital, public health clinic, or nursing home can use to increase immunization rates. For example, a physician could write a standing order in the hospital inpatient setting requiring the assessment and vaccination of all Medicare patients. A missed opportunity in the inpatient hospital setting occurs when a beneficiary is discharged without being offered and receiving an influenza and/or pneumococcal vaccination. Missed opportunities can often result in a beneficiary being readmitted to a hospital for influenza and related illnesses, like pneumonia. Unfortunately, missed vaccination opportunities occur in all settings. Strategies aimed at modifying systems for delivering care, such as standing orders, are one way of reducing missed opportunities. Please note that a standing order is not required for Medicare coverage of influenza immunizations, but it is required for coverage of pneumococcal vaccinations.

Other strategies are also effective in reducing missed vaccination opportunities. Physicians and their office personnel can promote influenza and pneumococcal vaccinations by hanging posters on the clinic walls to function as reminders for both the provider and his/her patients, and using wall charts to track immunizations. Most importantly, physicians can make influenza and pneumococcal vaccinations available in their office or refer patients to other health care providers for these vaccinations. Postcards and phone calls to patients to remind them to get vaccinated are also effective strategies.

The most effective strategies for increasing influenza and pneumococcal immunizations involve the health care provider. Simply put, Medicare beneficiaries are most likely to get immunized when their physician specifically recommends vaccination. We ask that providers realize their significant roles and discuss and promote influenza and pneumococcal vaccinations with their patients.
Please remember that while influenza immunizations are seasonal and should be given every year in the fall, pneumococcal vaccinations can be given at any time of the year. Generally, one pneumococcal vaccination after the age of 65 is all that a person needs to protect himself/herself for a lifetime. However, persons who are considered at highest risk, such as persons with chronic illnesses, like diabetes, and cardiovascular or pulmonary disease, and people with compromised immune systems, like chronic renal failure, should ask their doctor if a booster pneumococcal vaccination is necessary. If any person 65 and over is unsure of his/her pneumococcal vaccination status, revaccination is recommended and will be covered by Medicare Part B.

Your Medicare contractor can provide you with brochures and posters free-of-charge to display in your offices to promote both influenza and pneumococcal vaccinations. To request these materials or for instructions on how to bill Medicare for influenza and pneumococcal vaccinations, please call your contractor.

Thank you for your help in bringing this important preventive health care benefit to Medicare beneficiaries.

CHANGES TO HCPCS FOR INFLUENZA VIRUS, PNEUMONIA AND HEPATITIS B VACCINES

The following is a reprint from the Provider Bulletin dated March 29, 1999. The only change is adding type of bill 721 for ESRD providers. Please use this as a guide when billing for the flu, PPV, or hepatitis B vaccines.

The October 1998, Intermediary News, provided 1998 billing instructions for the pneumococcal vaccine (PPV) and the influenza virus vaccine (Flu).

The Intermediary Manual, Section 3660.7 states that effective January 1, 1999, the HCPCS, 90724 for the flu vaccine is deleted and the HCPCS, 90732 for the PPV vaccine is revised. The billing instructions are also revised but there is a three month grace period until March 31, 1999 for providers to continue submitting claims with 90724 and 90732. The revenue code and HCPCS for the administration remains the same. These new billing instructions supercede all previous instructions.

Claims received on or after April 1, 1999, must contain the new flu and PPV HCPCS. The attached chart will provide the necessary billing information.

When the PPV and flu vaccines are given to inpatients of a hospital, and the hospital wants to submit an individual bill for each patient, then the hospital must submit a bill using bill type 13X. The submitted bill must show the discharge date of the hospital stay as the date of service to prevent the claim from editing within the system. However, if the hospital prefers to roster bill for the inpatients, follow the previous roster billing instructions and show the actual date of the vaccination as the date of service.

To qualify for roster billing, immunizations of at least five beneficiaries on the same date is required. The provider can access the electronic roster billing screen from the Fiscal Intermediary Standard System (FISS) by first selecting 02 (claims/attachments) and then selecting 87 (roster bill entry). At the vaccine roster for mass immunizers screen, the provider must enter the following information: date of service, type of bill, revenue codes, HCPCS and the charge per each revenue code/HCPC combination.

The following are defaults that will be used on the claim:

It is important for providers to note that if the provider knows that a particular group health plan covers the flu and PPV and all other Medicare Secondary Payer (MSP) requirements for the Medicare beneficiary are met, the primary payer must be billed.

Therefore, Maryland Medicare will not reimburse any provider or company for invoices submitted.
Please remember that failure to submit copies of the requested medical records will result in denial of the claim.

A paid claim can be adjusted to add late charges, reduce charges, change a patient status, correct a revenue code, correct a HCPC, make an MSP correction and for other reasons.

A claim can be cancelled when the provider wants the entire payment to be withdrawn.

A claim must be in a paid status location such as PB9997 in order to request an adjustment or cancellation of a claim.

The following instructions are being provided to assist providers with adjustments or cancellations:

1) From the main menu of the Florida Shared System (FSS), type 03 and enter.
2) From the correction menu to adjustment, select 30 for an inpatient claim, select 31 for an outpatient claim or select 32 for a SNF claim and enter. To cancel, select 50, 51or 52 then enter.
3) Enter the beneficiary’s Medicare number. Type of bill (TOB) will default to 11, 13 or 21. If the TOB is other than one of those, then tab to the TOB field and enter the correct TOB such as a 14, 83, or 22.
4) The claim will appear as long as it is paid. Make the necessary changes to the claim and type a comment in the remarks field to explain why the adjustment is being done.
5) Put a claim change reason code in the condition code field. The codes are D0-E0 and are defined in the following resources: SNF manual, section 560; FSS manual, pg. 367; this issue of the Intermediary News; Hospital Manual, section 460; and the OPT/CORF Manual, section 416. To cancel a claim, only D5 or D6 can be used.
6) Put another adjustment or cancellation reason code on page 3 of the screen. The second code can be found by accessing 01 from the main menu and then 16 for adjustment reason codes. Or use the schortcut (SC) method by typing 16 in the SC field  located in the upper left hand corner of the screen. The SC method can be used with any other selections from the menus. For example, the second code could be CC for “charge change” and the condition code on page one be D1 for “change to charges”. If an adjustment or cancellation reason code cannot be determined, then and only then can the OT for “other” be used. A written remark must accompany all requests.
7) After making the changes, adding two reason codes, and typing a comment in the remarks field, then F9 to store the claim. If using PCACE, use ESC9 to store the claim.
8) Claims correction instructions are also written in the FSS manual beginning on page 341.

The condition codes shown here were previously written in the December 1998 Intermediary News.

D0 change to service dates
D1 change to charges
D2 change to revenue codes/HCPCS
D3 second or subsequent interim PPS bill
D4 change in grouper input
D5 cancel to correct HICN or provider ID
D6 cancel only to repay overpayment
D7 change to make Medicare the secondary payer
D8 change to make Medicare the primary payer
D9 any other change
E0 change in patient status

G1 Most recent URR of less than 60%
G2 Most recent URR of 60%-64.9%
G3 Most recent URR of 65%-69.9%
G4 Most recent URR of 70%-74.9%
G5 Most recent URR of 75% or greater

For patients that have received dialysis six days or less in a month, use the following modifier:

G6 ESRD patient for whom less than seven dialysis sessions have been provided in a month

Billing Requirements
Claims for dialysis treatments must include the adequacy of dialysis data as measured by URR. Dialysis facilities must monitor the adequacy of dialysis treatments monthly for facility patients. Home dialysis and peritoneal dialysis patients may be monitored less frequently, but not less than quarterly.

HCPCS code 90999 (unlisted procedure, inpatient or outpatient) must be reported in field location 44 for all bill types 72X. Attach the appropriate G-modifier in field location 44 (HCPCS/RATES) for patients that received seven or more dialysis treatments in a month. Continue to report revenue codes 820, 821, 825, and 829 in field location 43.

The techniques to be used to draw the pre-and post-dialysis Blood Urea Nitrogen (BUN) samples are listed in the National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Hemodialysis Adequacy, Guideline 8, Acceptable Methods for BUN sampling, New York, National Kidney Foundation, 1997, pp 53-60.

• Whether the provider is included in PPS, and
• The date of the enrollment.

If the patient changes HMO status during an inpatient hospitalization in a PPS hospital, the beneficiary status at admission determines liability. If the beneficiary was enrolled in the HMO before admission, the HMO is responsible regardless of whether the patient dis-enrolled before discharge. If the beneficiary was not an HMO enrollee upon admission, later enrolls before discharge, the HMO is not responsible for payment.

Where the facility is a non-PPS hospital or unit, SNF, HHA, etc., the HMO is responsible for payment for services on and after the day of enrollment up through the day dis-enrollment is effective.

The above information is in the Intermediary Manual, section 3654.2 and the Hospital Manual, section 408.
As a reminder, providers are asked to use the HIQA screen to verify a beneficiary’s entitlement and possible HMO enrollment. If an HMO identification number is present along with an option code, please see below for a definition of the option codes:

Unrestricted
1 Intermediary to process all Part A & Part B provider bills.
2 HMO to process bill for directly provided services and for services from providers with effective    arrangements. Intermediary to process all other bills.

Restricted
A Intermediary to process all Part A & Part B provider bills.
B HMO to process bills only for directly provided services.
C HMO to process all bills.

NOTE: Regardless of option, the intermediary will process all bills for dialysis and related services provided through an approved dialysis facility.

Abosede Adedapo, R.N.
1471 Hadwick Drive
Baltimore, Maryland 21221
Effective Date: May 20, 1999
Period of Sanction: 5 years

Antonino H. Calon, M.D.
611 South Union Avenue
Havre de Grace, Maryland 21078-3409
Effective Date: May 20, 1999
Period of Sanction: Indefinite

Gene Patrick Carpenter, R.N.
7328 Church Hill Road
Chestertown, Maryland 21620
Effective Date: May 20, 1999
Period of Sanction: 10 years

Tonya Walker, R.N.
A/k/a Tonya Walker-Lucas
3416 Brinkley Road
Suite 402
Temple Hills, Maryland 20748
Effective Date: May 20, 1999
Period of Sanction: 5 years
Lois E. Wehren, M.D.
4098 Fragile Sail Way
Ellicott City, Maryland 21042
Effective Date: June 17, 1999
Period of Sanction: Not provided

Joyce Keel Smith, R.N.
26 Dowling Circle
Suite T-2
Baltimore, Maryland 21234
Effective Date: June 17, 1999
Period of Sanction: Not provided

Tammara Smith, R.N.
6466 Roots Drive
Glen Burnie, Maryland 21061
Effective Date: June 17, 1999
Period of Sanction: Not provided

Silverrene P. Roundtree, M.D.
106 West Market Street
Snow Hill, Maryland 21863
Effective Date: June 17, 1999
Period of Sanction: Not provided

Tuoc Kim Nguyen, D.D.S.
8003 Hastings Hunt Court
Severn, Maryland 21144
Effective Date: June 17, 1999
Period of Sanction: Not provided
Linh Hong Duong, D.D.S.
8003 Hastings Hunt Court
Severn, Maryland 21144
Effective Date: June 17, 1999
Period of Sanction: Not provided

Pietr Hitzig, M.D.
15 Charles Plaza
Suite 101
Baltimore, Maryland 21201
Effective Date: June 17, 1999
Period of Sanction: Not provided

Richard W. Holland, M.D.
1370 Ivywood Lane
Silver Spring, Maryland 20904
Effective Date: June 17, 1999
Period of Sanction: Not provided

Craig R. Lane, DPM
C/O 911 North Carey Street
Baltimore, Maryland 21217
Effective Date: July 20, 1999
Period of Sanction: Not provided

Jermany & Associates
Medical Practice
P.O. Box 2505
Baltimore, Maryland 21214-0001
Effective Date: July 20, 1999
Period of Sanction: Not provided

Robert Dawson
Employee (non-gov’t)
1422 Fernhill Court
Forestville, Maryland 20747
Effective Date: July 20, 1999
Period of Sanction: Not provided

Elmer E. Cook, D.D.S.
2300 Paper Mill Road
Phoenix, Maryland 21131-1330
Effective Date: July 20, 1999
Period of Sanction: Not provided

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 reinstatement action and one stayed action involving providers who were previously sanctioned, as follows:

Michael P. Hiotis
Pharmacist
1612 Gray Haven Court
Baltimore, Maryland 21222
Reinstatement Date: June 22, 1999
Vallerie B. Kee, D.D.S.
6328 Towncrest Court
Frederick, Maryland 21703
Stay Date: July 1, 1999

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

FIGHTING HEALTH CARE FRAUD IN MARYLAND
The United States Attorney’s office for the District of Maryland has established a Health Care Fraud Hotline, 1-800-377-5879, which can be used to report suspected fraud in the practice of health care across the State in the areas of Medicare, Medicaid, CHAMPUS etc.

The United States Attorney advises that her office is committed to fighting health care fraud in Maryland. They have prosecuted a number of criminal health care cases and recovered millions of dollars in civil settlements under the False Claims Act. They have engaged in prevention efforts, educating health care providers and beneficiaries about fraudulent schemes etc.

Since 1994, the U.S. Attorney’s Office in Maryland has recovered over $32 million dollars in fines and damages from health care fraud and abuse.

U. S. Attorney Lynne A. Battaglia stressed that many of her Office’s health care cases are developed from complaints brought by beneficiaries or persons working for health care providers who bring the false or fraudulent conduct to the attention of her office or the health care contractors.

http://www.dhhs.gov/progorg/oig/cumsan/index.htm

Medicare has had a policy of not covering pancreas transplantation for many years as the safety and effectiveness of the procedure had not been demonstrated. The Office of Health Technology Assessment performed an assessment on pancreas kidney transplantation in 1994. They found reasonable graft survival outcomes for patients receiving either simultaneous pancreas-kidney transplantation or pancreas after kidney transplantation.

Per the Coverage Issues Manual, section 35-82, and Program Memorandum A-99-16, effective July 1, 1999, Medicare will cover whole organ pancreas transplantation (ICD-9 CM procedure code 52.80 or 52.83, HCPC 48554) only when it is performed simultaneously with or after a Medicare covered kidney transplant (ICD-9 procedure code 55.69, HCPC 50360 or 50365).

There are no special provisions related to managed care participants. Managed care plans are required to provide all Medicare covered services.

Medicare does not restrict which hospitals or physicians may perform pancreas transplantation.

Hospital Billing Instructions

• Revenue Codes/ICD-9 CM Procedure Codes

Revenue Code 360-Operating Room Services

Revenue Code 81X Organ Acquisition (X=1-4)
Acquisition cost will be in this revenue center for pancreas and kidney transplants. The intermediary will override any claims suspended due to repetition of revenue code 81X on the same claim. The intermediary will pay for both kidney and pancreas organs. The intermediary will not pay for more than two organ acquisitions on a single claim.

The transplant procedure and revenue code for the operating room are paid under these codes. Procedures must be reported using the current ICD-9- CM procedure codes for pancreas and kidney transplants. Providers must place at least one of the following transplant procedure codes on the claim:

52.80-transplant of pancreas (with date of procedure)
52.83-heterotransplant of pancreas (with date of procedure)

• HCPCS Code

48554-transplantation of pancreatic allograft

• Conditions of Coverage/ICD-9 CM Diagnosis Codes

One or more of the following diagnosis codes must be present:

250.00-diabetes mellitus without mention of complication, type II (non-insulin dependent) (NIDDM) (adult onset) or unspecified type, not stated as uncontrolled.

250.01-diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), not stated as uncontrolled.

250.02-diabetes mellitus without mention of complication, type II (non-insulin dependent) (NDDM) (adult onset) or unspecified type, uncontrolled.

250.03-diabetes mellitus without mention of complication, type I (insulin dependent) (IDDM) (juvenile), uncontrolled.

*NOTE: X=0-3
*250.1X-diabetes with ketoacidosis
*250.2X-diabetes with hyperosmolarity
*250.3X-diabetes with coma *250.4X-diabetes with renal manifestations
*250.5X-diabetes with opthalmic manifestations
*250.6X-diabtes with neurological manifestations
*250.7X-diabets with peripheral circulatory disorders
*250.8X-diabetes with other specified manifestations
*250.9X-diabetes with unspecified complication

Also include ICD-9-CM diagnosis code 585, chronic renal failure, unless one of the following codes is present:

V42.0     organ or tissue replaced by transplant kidney
V43.89   organ tissue replaced by other means, kidney or pancreas

If the pancreas transplant occurs after the kidney transplant, the 36 month period of entitlement to immunosuppressive therapy will begin with the date of discharge from the stay for pancreas transplant.

The Common Working File (CWF) will edit to ensure that a claim for kidney transplant (ICD-9-CM procedure code 55.69) has been received prior to pancreas transplantation.

Pancreas transplantation for diabetic patients who have not experienced end stage renal failure secondary to diabetes continues to be excluded from Medicare coverage. Medicare also excludes coverage of transplantation of partial pancreatic tissue or islet cells. There is not sufficient evidence at this time to support a determination that these procedures are reasonable and necessary.

Effective for services performed on or after July 1, 1991, the implantation of an automatic defibrillator is a covered service for patients who have had a documented episode of life-threatening ventricular tachyarrhythmia or cardiac arrest not associated with myocardial infarction.

Effective for services performed on or after July 1, 1999, the implantation of an automatic defibrillator is also a covered service for patients with the following conditions:

* A documented episode of cardiac arrest due to ventricular fibrillation not due to a transient or reversible cause;

* Ventricular tachyarrhythmia, either spontaneous or induced, not due to a transient or reversible cause; or,

* Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy.

• HCPCS coding only reported by physicians has not been included;

• Reference to payment under the Medicare Physician Fee Schedule for pelvic examinations has been corrected to payment on a reasonable cost basis.

In addition, the following information has been included:

• Revenue code 770 “Preventive Care Services - General Classification” has been added as the appropriate revenue code to bill for screening pelvic examinations; and

• New HCPCS codes G0123, G0143, G0144, G0145, G0147, and G0l48 have been added for billing of screening Pap smears.

Screening Pap Smears and Screening Pelvic Examinations
A. Screening Pap Smear—Section 4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33) amends ß1861 (nn) of the Social Security Act (the Act) (42 USC 1395X(nn) to include coverage every 3 years for a screening Pap smear or more frequent coverage for women (1) at high risk for cervical or vaginal cancer, or (2) of childbearing age who have had a Pap smear during any of the preceding 3 years indicating the presence of cervical or vaginal cancer or other abnormality.

1. Coverage—Screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy (as defined in ß1861(r)(l) of the Act), or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under State law to perform the examination) under one of the following conditions:

• The beneficiary has not had a screening Pap smear test during the preceding 3 years (use ICD-9-CM code V76.2, special screening for malignant neoplasm, cervix); or

• There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding 3 years; or that she is at high risk of developing cervical or vaginal cancer (use ICD-9-CM code V15.89, other specified personal history presenting hazards to health). The high risk factors for cervical and vaginal cancer are:

Cervical Cancer High Risk Factors:

- Early onset of sexual activity (under 16 years of
age);

- Multiple sexual partners (five or more in a life time);

- History of a sexually transmitted disease (including
HIV infection); and

- Fewer than three negative Pap smears within the
previous 7 years.

- Vaginal Cancer High Risk Factors:

- DES (diethylstilbestrol) - exposed daughters of
women who took DES during pregnancy.

The term “woman of childbearing age” means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings. Payment is not made for a screening Pap smear for women at high risk or who qualify for coverage under the childbearing provision more frequently than once every 11 months after the month that the last screening Pap smear covered by Medicare was performed.

2. HCPCS Coding—The following HCPCS codes are used for screening Pap smears:

• P3000—Screening papanicolaou smear, cervical or vaginal, up to three smears, by a technician under the physician supervision.

• G0123—Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, evaluation by cytotechnologist under physician supervision.

• G0143—Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluation and reevaluation by cytotechnologist under physician supervision.

• G0144—Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluation and computer-assisted reevaluation by cytotechnologist under physician supervision.

• G0145—Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual evaluation and computer-assisted reevaluation using cell selection and review under physician supervision

• G0147—Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision.

• G0148—Screening cytopathology smears, cervical or vaginal, performed by automated system with manual reevaluation.

3. Payment—Screening Pap smears are paid under the clinical diagnostic laboratory fee schedule. Deductible and coinsurance do not apply.

4. Billing Requirements—The applicable bill types for screening Pap smears are 13X (hospital outpatient), 14X (hospital other, diagnostic clinical laboratory services to “nonpatients”), 23X (SNF outpatient), 24X (SNF other), or 71X (Rural Health Clinic). The applicable revenue code is 311.

B. Screening Pelvic Examinations—Section 4102 of the BBA of 1997 (P.L. 105-33) amends ß1861 (nn) of the Act (42 USC 1395X(nn)) to include coverage of a screening pelvic examination for all female beneficiaries, effective January 1, 1998. A screening pelvic examination should include at least 7 of the following 11 elements:

• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;

• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;

Pelvic examination (with or without specimen collection for smears and culture) including:

• External genitalia (for example, general appearance, hair distribution, or lesions);

• Urethral (for example, masses, tenderness, or scarring);

• Bladder (for example, fullness, masses, or tenderness);

• Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);

• Cervix (for example, general appearance, lesions or discharge);

• Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support);

• Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); and

• Anus and perineum.

1. Coverage—Medicare Part B pays for a screening pelvic examination if it is performed by a doctor of medicine or osteopathy (as defined in ß1861(r)(1) of the Act), or by a certified nurse midwife (as defined in ß1861 (gg) of the Act), or a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in ß1861 (aa) of the Act) who is authorized under State law to perform the examination. This examination does not have to be ordered by a physician or other authorized practitioner.

• Payment may be made for a screening pelvic examination performed on an asymptomatic woman only if the individual has not had a screening pelvic examination paid for by Medicare during the preceding 35 months following the month in which the last Medicare covered screening pelvic examination was performed (use ICD-9-CM code V76.2, special screening for malignant neoplasm, cervix) except as follows:

• Payment may be made for a screening pelvic examination performed more frequently than once every 36 months if the test is performed by a physician or other practitioner and there is evidence that the woman is at high risk (on the basis of her medical history or other findings) of developing cervical cancer, or vaginal cancer. (Use ICD-9-CM code V15.89, other specified personal history presenting hazards to health.) The high risk factors for cervical and vaginal cancer are:

Cervical Cancer High Risk Factors:

- Early onset of sexual activity (under 16 years of age);

- Multiple sexual partners (five or more in a lifetime);
- History of a sexually transmitted disease (including HIV infection); and

- Fewer than three negative Pap smears within the previous 7 years.

Vaginal Cancer High Risk Factors:

- DES (diethylstilbestrol) - exposed daughters of women who took DES during pregnancy.

• Payment may also be made for a screening pelvic examination performed more frequently than once every 36 months if the examination is performed by a physician or other practitioner, for a woman of childbearing age, who has had such an examination that indicated the presence of cervical or vaginal cancer or other abnormality during any of the preceding 3 years. The term “women of childbearing age” means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings. Payment is not made for a screening pelvic examination for women at high risk or who qualify for coverage under the childbearing provision more frequently than once every 11 months after the month that the last screening pelvic examination covered by Medicare was performed.

2. HCPCS Coding—The following HCPCS code is used for screening pelvic examinations:

• G0101—Cervical or vaginal cancer screening pelvic and clinical breast examination.

3. Payment—Screening pelvic examinations are paid on a reasonable cost basis. The Part B deductible for screening pelvic examinations is waived effective January 1, 1998. Coinsurance applies.

4. Billing Requirements—The applicable bill types for screening pelvic examination (including breast examination) are 13X (hospital outpatient, 14X (hospital other, diagnostic clinical laboratory services to “nonpatients”), 23X (SNF outpatient), 24X (SNF other), or 71X (Rural Health Clinic). The applicable revenue code is 770.

C. Screening Pap Smears and Screening Pelvic Examinations—

1. CWF Edits—CWF will edit for screening Pap smear and/or screening pelvic examination performed more than once in 3 years and high risk factors are not present.

2. Medicare Summary Notices (MSN) and Explanation of Your Medicare Benefits (EOMB) Messages-(This is for the beneficiary)-If a screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more than once in 3 years and no high risk factors are present, the following MSN or EOMB message will be used:

“Medicare pays for screening Pap smear and/or screening pelvic examination only once every 3 years unless high risk factors are present.” (MSN Message 18-17, EOMB Message 18.26.)

3. Remittance Advice Notices—(This is for the provider)-If the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more than once in 3 years and no high risk factors are present, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 119, “Benefit maximum for this time period has been reached” at the line level, along with line level remark code M83, “service is not covered unless the beneficiary is classified as at high risk.”

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

Thanksgiving     Thursday, November 25, 1999 and Friday, November 26, 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

For services rendered after the PPS effective date, the provider should bill a TOB 23X whenever the patient is a non resident of the skilled nursing facility. This means that the patient does not reside in the facility. A 22X TOB should be used when the patient is a resident of the facility and inpatient benefits are exhausted, the level of care changes to non-skilled care or if the patient was never skilled.

Providers should not bill a TOB 23X and a TOB 22X for the same dates of service or overlapping dates of service.

There are three new HCPCS codes for PET scans when performed on or after July 1, 1999. The new HCPCS codes are:

• G0163—Positron Emission Tomography (PET), whole body, for recurrence of colorectal or colorectal metastatic cancer.

• G0164—Positron Emission Tomography (PET), whole body, for staging and characterization of lymphoma.

• G0165— Positron Emission Tomography (PET), whole body, for recurrence of melanoma or melanoma metastic cancer.

These codes represent the technical component costs associated with these procedures when furnished to hospital outpatients (bill type 13X) and are payable on a reasonable cost basis. They are reported with revenue code 404 (Positron Emission Tomography).

Hospitals can bill for the above PET scans performed on or after July 1, 1999, provided all the terms and conditions set forth in the coverage guidelines for PET are met. The above new “G” codes will be added to the outpatient code editor effective July 1, 1999.

Postpayment Review

As with any claim, but particularly in view of the limitations on this coverage, Medicare may decide to conduct post-payment reviews to determine that the use of PET scans is consistent with coverage instructions. Positron Emission Tomography scan facilities must keep patient record information on file for each Medicare patient for whom a PET scan claim is made. These medical records will be used in any post-payment reviews and must include the information necessary to substantiate the need for the PET scan. These records must include standard information (e.g., age, sex, and height) along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed. Such information must include, but is not limited to, the date, place and results of previous diagnostic tests (e.g., cytopathology and surgical pathology reports, CT, etc.), as well as the results and reports of the PET scan(s) performed at the center. If available, such records should include the prognosis derived from the PET scan, together with information regarding the physician or institution to which the patient proceeded following the scan for treatment or evaluation. The ordering physician is responsible for forwarding appropriate clinical data to the PET scan facility.

• Screening digital rectal examination; and
• Screening prostate specific antigen blood test.

Screening Digital Rectal Examinations —Screening digital rectal examinations (HCPCS code G0102) are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening digital rectal examination was performed). Screening digital rectal examination means a clinical examination of an individual’s prostate for nodules or other abnormalities of the prostate. This screening must be performed by a doctor of medicine or osteopathy (as defined in ß1861(r)(1) of the Act), or by a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (as defined in ß1861(aa) and ß1861(gg) of the Act) who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary’s medical condition, and would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.

Screening Prostate Specific Antigen Tests —Screening prostate specific antigen tests (code G0103) are covered at a frequency of once every 12 months for men who have attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered screening prostate specific antigen test was performed). Screening prostate specific antigen tests (PSA) means a test to detect the marker for adenocarcinoma of prostate. Prostate specific antigen test is a reliable immunocytochemical marker for primary and metastatic adenocarcinoma of prostate. This screening must be ordered by the beneficiary’s physician or by the beneficiary’s physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (the term “attending physician” is defined in ß1861(r)(1) of the Act to mean a doctor of medicine or osteopathy and the terms “physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife” are defined in ß1861(aa) and ß1861(gg) of the Act) who is fully knowledgeable about the beneficiary’s medical condition, and who would be responsible for using the results of any examination (test) performed in the overall management of the beneficiary’s specific medical problem.

MAGNETIC RESONANCE ANGIOGRAPHY

Section 1861(s)(2)(C) of the Social Security Act provides for coverage of diagnostic testing. Effective for claims with dates of service on or after July 1, 1999, Medicare provides limited coverage for Magnetic Resonance Angiography (MRA) of the abdomen and chest as described in the Medicare Coverage Issues Manual, ß50-14, “Magnetic Resonance Angiography”. Coverage is provided only under the medical indications set forth in that instruction for MRA. Previously, MRA of peripheral vessels of the lower extremities and of the head and neck had been covered. Those coverages continue in effect. Magnetic Resonance Angiography is covered for these diagnostic applications only as a substitute for contrast angiography, except when it is medically necessary to do both tests. All other uses of MRA are not covered. These instructions apply to all covered uses of MRA.

Billing Requirements
Follow the general bill review instructions in Section 3604 of the Medicare Intermediary Manual, Part 3 or Section 460 of the Hospital Manual. The provider bills on Form HCFA-1450 (UB92) or the electronic equivalent.

Applicable Bill Types
The appropriate bill types are 12X, 13X, 14X, 22X, 23X, 34X, 71X (Provider-based and independent), 72X, 73X (Provider-based and freestanding), 83X and 85X.

Providers utilizing the UB-92 flat file use record type 40 to report the bill type. Record type (Field
No. 1), Sequence Number (Field No. 2), Patient Control Number (Field No. 3), and Type of Bill (field No. 4) are required.

Providers utilizing the hard copy UB-92 (HCFA-1450) report the applicable bill type in Form Locator (FL) 4 “Type of Bill”.

Coding Requirements
Providers must report HCPCS codes when submitting claims for MRA of the chest, abdomen, head, neck or peripheral vessels of lower extremities along with an appropriate revenue code. The following HCPCS codes should be used to report these services:

Payment Requirements
Part B deductible and coinsurance apply.

Providers must report component services with the -26 (professional component) or -TC (technical component) modifier when appropriate. Physicians performing both the professional and the technical components for such services must bill without the modifier unless the service is provided in a Health Professional Shortage Area.

The precise workings of this technique are not certain. The original theory, upon which the technique was based, that the open channels would result in increased perfusion of the myocardium, does not appear to be the major or only action at work. Several theories have been proposed, including partial denervation of the myocardium, or the triggering of the cascade of biological reactions which encourage increased development of blood vessels.

However, research at several facilities indicates that, despite this uncertainty, the technique does offer relief of angina symptoms for a period of time in patients for whom no other medical treatment offering relief is available. Studies indicate that both reduction in pain and reduction in hospitalizations are significant for most patients treated. Consequently, we have concluded that, for patients with severe angina (Class III or IV, Canadian Cardiovascular Society, or similar classification system) for whom all other medical therapies have been tried or evaluated and found insufficient, such therapy offers sufficient evidence of its medical effectiveness to treat the symptomatology. It is important to note that this technique does not provide for increased life expectancy, nor is it proven to affect the underlying cause of the angina. However, it appears effective in treating the symptoms of angina, and reducing hospitalizations and allowing patients to resume some of their normal activities of daily living.

Program Memorandum AB-99-22 and Coverage Issues Manual, section 35-94, provides coverage of TMR as a late or last resort for patients with severe (Canadian Cardiovascular Society Classification Classes III or IV) angina (stable or unstable) for claims with dates of service furnished on or after July 1, 1999, which has been found refractory to standard medical therapy, including drug therapy at the maximum tolerated or maximum safe dosages in a hospital inpatient setting. In addition, the angina symptoms must be caused by areas of the heart not amenable to surgical therapies such as percutaneous transluminal coronary angioplasty, stenting, coronary atherectomy, or coronary bypass. Coverage is further limited to those uses of the laser used in performing the procedure which have been approved by the Food and Drug Administration for the purpose for which they are being used.

Patients have to meet the following additional selection guidelines:

1. An ejection fraction of 25% or greater;

2. Have areas of viable ischemic myocardium (as demonstrated by diagnostic study) which are not capable of being revascularized by direct coronary intervention; and,

3. Have been stabilized, or have had maximal efforts to stabilize acute conditions such as severe ventricular arrhythmias, decompensated congestive heart failure or acute myocardial infarction.

Coverage is limited to physicians who have been properly trained in the procedure. Providers of this service must also document that all ancillary personnel, including physicians, nurses, operating room personnel, and technicians, are trained in the procedure and the proper use of the equipment involved. Coverage is further limited to providers which have dedicated cardiac care units, including the diagnostic and support services necessary for care of patients undergoing this therapy. In addition, these providers must conform to the standards for laser safety set by the American National Standards Institute, ANSIZ1363. (See the Coverage Issues Manual, section 35-94, for more information on the coverage criteria.)

Intermediary Billing and Payment Instructions

Follow the general bill review instructions in ß3604 of the Medicare Intermediary Manual, Part 3. Hospitals bill using Form HCFA-1450 or its electronic equivalent using bill type 11X. The ICD-9-CM procedure code must be 36.31 (open chest TMR) for this service to be covered. This procedure code is currently grouped to DRG 108.

A. Covered Conditions-Program reimbursement for HBO therapy will be limited to that which is administered in a chamber (including the one man unit) and is limited to the following conditions:

l. Acute carbon monoxide intoxication, (ICD-9 - CM diagnosis 986).

2. Decompression illness, (ICD-9-CM diagnosis 993.2, 993.3).

3. Gas embolism, (ICD-9-CM diagnosis 958.0, 999.1).

4. Gas gangrene, (ICD-9-CM diagnosis 040.0).

5. Acute traumatic peripheral ischemia. Hyperbaric oxygen therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 902.53, 903.01, 903.1, 904.0, 904.41.)

6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened. (ICD-9-CM diagnosis 927.00- 927.03, 927.09-927.11, 927.20-927.21, 927.8-927.9, 928.00-928.01, 928.10-928.11, 928.20-928.21, 928.3, 928.8-928.9, 929.0, 929.9, 996.90- 996.99.)

7. Progressive necrotizing infections (necrotizing fasciitis), (ICD-9-CM diagnosis 728.86).

8. Acute peripheral arterial insufficiency, (ICD-9- CM diagnosis 444.21, 444.22, 444.81).

9. Treatment of compromised skin grafts, (ICD- 9CM diagnosis 996.52; excludes artificial skin graft).

10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management, (ICD-9-CM diagnosis 730.10-730.19).

11. Osteoradionecrosis as an adjunct to conventional treatment, (ICD-9-CM diagnosis 526.89).

12. Soft tissue radionecrosis as an adjunct to con- ventional treatment, (ICD-9-CM diagnosis 990).

13. Cyanide poisoning, (ICD-9-CM diagnosis 987.7, 989.0).

14. Actinomycosis, only as an adjunct to conven- tional therapy when the disease process is refractory to antibiotics and surgical treatment, (ICD-9-CM diagnosis 039.0-039.4, 039.8, 039.9).

No program payment may be made for any conditions other than those listed above.

B. Topical Application of Oxygen-This method of administering oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.

C. Physician Supervision Requirement-For HBO therapy to be covered under the Medicare program, the physician must be in constant attendance during the entire treatment. This is a professional activity that cannot be delegated in that it requires independent medical judgement by the physician. The physician must be present, carefully monitoring the patient during the hyperbaric oxygen therapy session and be immediately available should a complication occur. This requirement applies in all settings: no payment will be made under Part A or Part B, unless the physician is in constant attendance during the HBO therapy procedure.

D. Credentials-A physician qualified in HBO therapy treatment is defined by Medicare for this purpose to be credentialed by the hospital in which HBO therapy is being performed specifically in hyperbaric medicine and the management of acute cardiopulmonary emergencies, including placement of chest tube. Credentialing includes, at a minimun, the following:

• Training, experience and privileges within the institution to manage acute cardiopulmonary emergencies, including advanced cardiac life support, and emergency myringotomy;
• Completion of a recognized hyperbaric medicine training program as established by either the American College of Hyperbaric Medicine or the Undersea and Hyperbaric Medical Society (UHMS) with a minimum of 60 hours of training and documented by a certificate of completion or an equivalent program; and
• Continuing medical education in hyperbaric medicine of a minimum of 16 hours every 2 years after initial credentialing.

An additional requirement that must be met for Medicare's payment for hyperbaric medical therapy is that a cardiopulmonary resuscitation team coverage must be immediately available during the hours of the hyperbaric chamber operation.

Physician credentialing documentation must be kept in the patient's medical/file record.

Intermediary Billing Instructions

The provider bills using Form HCFA-1450 or its electronic equivalent using bill type 13X. Providers must report HBO therapy under revenue code 413 using existing HCPCS 99183 for physician attendance and supervision of hyperbaric oxygen therapy, per session. Hospital inpatient claims use ICD-9 procedure code 93.95.

If a HCFA FORM 838 is not received in a timely fashion, that is, 30 days following the end of a calendar quarter, your Medicare interim payments will be suspended until you have submitted the report.

For quarter ending September 30, 1999, the credit balance report must be postmarked on or before October 30, 1999.

For your convenience, below is a chart indicating the due dates for the quarterly Medicare credit balance reports (HCFA Form 838) for the year 2000:

GAVEL GRAVEL: THE MEDICARE DOCKET

By: Michael Berkey

May an intermediary deny a reopening request without fear of any further appeal by a provider, even if the intermediary's action is arbitrary, capricious, or just plain wrong? In a unanimous decision, the U.S. Supreme Court resoundingly said Yes!

A home health agency in Tennessee learned that its previous fiscal intermediary had improperly calculated allowable owner's compensation in 1987. Because the new fiscal intermediary, based in South Carolina, had used the 1987 allowed amount in its calculations of allowable owner's compensation for 1989, the provider believed the settlement of the 1989 cost report was in error. By the time of the discovery, the 180-day appeal period had run from the notice of program reimbursement ("NPR") for the 1989 cost report, but the 3-year period for reopenings had not. Citing the Provider Reimbursement Manual provision that provides for reopenings where "new and material evidence" is shown, the provider timely requested a reopening to allow the intermediary to correct the mistake. The intermediary denied the reopening request, and the home health agency appealed. The Provider Reimbursement Review Board and the lower courts refused to hear the appeal, citing a lack of jurisdiction.

The provider's main argument was that the system was unfair if intermediaries could reopen cost reports on their own motion to take money away from providers, but providers could only "request" reopening to obtain additional reimbursement. The Supreme Court disposed of this argument by weighing the burden of the two groups:

"[W]e would not be shocked by a system in which underpayments could never be the basis for reopening. The few dozen fiscal intermediaries often need three years within which to discover overpayments in the tens of thousands of NPRs that they issue, while each of the tens of thousands of sophisticated Medicare-provider recipients of these NPRs is generally capable of identifying an underpayment in its own NPR within the 180-day time period." (Emphasis added.)

The court also pointed out that reopenings are regulatory, not statutory, and that the Medicare program can regulate them as it wishes, including failing to grant an appeal right for denials. Moreover, if appeals were granted from reopening denials, then the 180-day appeal period from NPRs might effectively become a 3-year appeal period through the reopening process. In short, a provider can only rely on its 180-day appeal rights, and can not expect to use the reopening process to score a Home run. (Your Home Visiting Nurse Services, Inc. v. Shalala, U.S. Supreme Court, No. 97-1489, Feb. 23, 1999.)

• If a skilled resident goes on a leave of absence on Friday evening and returns on Sunday evening, is this considered a discharge and readmission?
• The day the patient begins a leave of absence is treated as a day of discharge and is not counted as an inpatient day unless they return to the facility by midnight of the same day.
• The day the patient returns to the facility from a leave of absence is treated as a day of admission and is counted as an inpatient day if they are present at midnight of that day.
• If the absence exceeds 30 consecutive days, the 3-day qualifying hospital stay and the 30-day transfer requirements must again be met to establish re-entitlement to extended care benefits.
• Charges for the days that the patient is on the leave of absence should not be shown on the beneficiary's bill, nor can you bill the beneficiary for these charges.

What affect does the leave of absence have on the Minimum Data Set (MDS) schedule?

• The assessment schedule is not altered by leave of absence days. Any benefit days not utilized during the course of a stay could be billed based on the last assessment for that beneficiary.
• Another event that would generally end a beneficiary's "resident" status for SNF consolidated billing purposes would be a beneficiary's formal discharge from the SNF, or a departure from the SNF without a formal discharge unless followed within 24 consecutive hours by a readmission to that or another SNF.

The Intermediary manual, section 3307, states that Medicare cannot make payment for claims filed after the timely filing limit.

Coverage is further limited to those enhanced external counterpulsation systems that have sufficiently demonstrated their medical effectiveness in treating patients with severe angina in well-designed clinical trials. Note that a 510(k) clearance by the Food and Drug Administration does not, by itself, satisfy this requirement.

A full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, (usually 5 days per week). The patient is placed on a treatment table where their lower extremities are wrapped in a series of three compressive air cuffs which inflate and deflate in synchronization with the patient's cardiac cycle.

This service should be billed using HCPC code 97016 (Application of a modality to one or more areas; vasopneumatic devices), and must be performed under the direct supervision of a physician.

Intermediary Billing and Payment Instructions

Follow the general bill review instructions in section 3604 of the Medicare Intermediary Manual, Part 3. Providers submit using Form HCFA-1450 or the electronic equivalent using bill type 12X, 13X, 22X, 23X, 74X, 75X, or 83X. The applicable revenue codes for reporting this procedure are 42X or 43X. Until a specific code for the EECP procedure is developed, providers must report HCPC code 97016. In addition, one of the following modifiers must be reported:

GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy Plan of Care; or,

GP Service delivered personally by a physical thera-
pist or under an outpatient physical therapy Plan of Care.

NOTE: For purposes of the EECP procedure, if other than a therapist provides the service the GP modifier should be reported.

Since this procedure is an outpatient rehabilitation service, payment is made under the Medicare Physician Fee Schedule (refer to Provider Bulletin dated 1/4/1999 for additional payment information).

Deductible and coinsurance apply. Coinsurance for this service is made at 20 percent of the lower of the actual charge or the fee schedule amount.

In the past 10 years, there have been significant advances in surgical treatment for epilepsy and in medical treatment of epilepsy with newly developed and approved medications. Despite these advances, 25-50 percent of patients with epilepsy experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs.

The vagus nerve is a mixed nerve carrying both somatic and visceral afferent and efferent signals. The majority of vagal nerve fibers are visceral afferents with wide distribution. The basic premise of vagus nerve stimulation in the treatment of epilepsy is that vagal visceral afferents have a diffuse central nervous system projection and the activation of these pathways has a widespread effect upon neuronal excitability. Besides activation of well-defined reflexes, vagal stimulation produces evoked potentials recorded from the cerebral cortex, the hippocampus, the thalamus, and the cerebellum.

The vagus nerve stimulation system is comprised of an implantable pulse generator and lead, and an external programming system used to change stimulation settings. Clinical evidence has shown that vagus nerve stimulation is a safe and effective treatment for patients with medically refractory partial onset seizures, for whom surgery is not recommended or for whom surgery has failed. Vagus nerve stimulation is not covered for patients with other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed.

A partial onset seizure has a focal onset in one area of the brain and may or may not involve a loss of motor control or alteration of consciousness. Partial onset seizures may be simple, complex, or complex partial seizures, secondarily generalized.

The neurostimulator pulse generator is implanted subcutaneously below the left clavicle and the lead is attached to the vagus nerve in the neck. The procedure is performed in the hospital and usually requires an overnight stay. The procedure is usually coded using HCPC codes 64573 (lead placement), and 64590 (generator implantation).

The ICD-9-CM procedure code for implantation of a neurostimulator into the vagus nerve is 04.92. The diagnosis codes for intractable epilepsy are 345.01, 345.11, 345.41, 345.51, and 345.91. Infrequently, contractors might see the diagnosis code for convulsions, 780.3, used to identify eligible patients.

The regulations at 42 CFR 413.20(a) require that a provider begin the cost report process with the "data available from the institution's basic accounts," and that requires that no allocations be made prior to entering the information from those basic accounts onto the cost report. Failing to disclose all the appropriate costs on the cost report, for whatever reason, could subject a provider to rejection of the cost report, delayed reimbursement and penalties, and/or a costly fraud and abuse investigation.

As always, providers should ensure that key provider personnel as well as any cost report preparation consultants are fully aware of proper cost reporting practices and procedures. If you have any cost report preparation problems or if you have questions about proposed alternative cost reporting methods or allocation situations, please contact the auditor or supervisor responsible for your facility.

Who Should File Form HCFA 339

HCFA Pub. 15-II, Section 1100 requires all providers filing a full Medicare cost report to submit a properly completed Form HCFA 339 with the cost report filing. This includes not only hospitals, SNFs, CORFs, and OPTs, but also ESRDs, Home Offices, etc. There has been some question lately as to whether or not ESRD facilities must complete the HCFA 339, because this facility type is not specifically listed on the first page of Exhibit 1. Not every cost report form is listed. Instead, a line for "Other" cost reports is included on the first page.

Failure to submit a properly completed Form HCFA 339 will result in rejection of the cost report being filed. In the case of a home office, besides rejection of the cost report, all home office costs will be eliminated from the related provider cost reports.

Expansion of Services and/or Business
All providers should have completed and attached a questionnaire regarding expansion of services to the front of their Form HCFA 339. This was effective for cost reporting periods ending on or after June 30, 1998.

If you have not done so, and have any questions, please contact your assigned Medicare Auditor.

Owner's/Management Personnel Compensation

PPS Hospitals are not required to complete Exhibit 6 of Form HCFA 339. However, any cost based units attached to the PPS hospital are now required to complete Exhibit 6, effective for cost reporting periods ending on or after June 30, 1998.

Compensation must be reported for not more than the top 10 management personnel. The exhibit for owners and relatives is not limited to 10 individuals. All owners and relatives must be included in the report. This is in addition to the manager's exhibit.

If you have any questions regarding the above or any other issues regarding filing Form HCFA 339, please contact your assigned Medicare Auditor.

Under the Prospective Payment System (PPS), residents are assessed on a mandated schedule and each assessment predetermines (in advance) the number of Part A days that can be billed. The number of days paid are specific days of the 100 day benefit period.

• 5 day assessment provides the billing code for days 1-14
• 14 day assessment provides the billing code for days 15-30
• 30 day assessment provides the billing code for days 31-60
• 60 day assessment provides the billing code for days 61-90
• 90 day assessment provides the billing code for days 91-100

EXAMPLE: (For 1 month's bill) Admission on July 1; Billing Period is July 1-31

• The 5 day assessment rugged at SSB will pay for July 1-14 (14 days)
  
• The 14 day assessment rugged at SSC will pay for July 15-30 (16 days)
  
• The 30 day assessment rugged at SSB will pay for July 31 (1 day )

For a resident remaining in the SNF, on the August bill, you will see SSB02 for 29 days and the 60 day RUG for the remaining 2 days of the month. The August claim cannot be submitted until the July claim is processed, therefore, the SNF billing office must store data until it can be used to prepare the August claim.

HELPFUL HINTS FOR PROVIDERS

• Please share all Intermediary News and Provider Bulletins with your staff. We have received many inquiries that could have been answered by reading one of our published articles.
• Make sure that the beneficiary's name and Medicare number are verified by accessing HIQA through the Florida Shared System (FSS).
• Maintain a copy of each beneficiary's Medicare card.
• Share Medicare claims knowledge with other staff members.
• Providers should be prepared when calling Provider Relations. Please have the Medicare number, date of service, provider number and writing material ready when you call.
• Providers submitting claims using the UB92 can call Provider Relations at 410-561-0541.
• Providers submitting claims using the HCFA 1500 can call Trailblazer at 410-771-6111 to speak with a representative or 1-800-862-8162 to use an automated service.
• Record in the beneficiary's chart where the beneficiary is being transferred to or from where the beneficiary came. This helps with claims processing when the claim is properly coded,

When requesting an appeal, please follow the procedures outlined below:

• Submit a written request for an appeal,
  
• Submit a hard copy of the UB92 claim,
  
• Submit all records and an itemized bill to support the appeal,
  
• Submit a copy of the denial letter and/or the remittance notice displaying the denial code.

Send all appeal requests to:

Maryland Medicare Part A
APPEALS-Medical Review
1946 Greenspring Drive
Timonium, MD 21093-4141

RECONSIDERATION PROCESS FOR PART A SERVICES

If a provider disagrees with the Intermediary's initial decision for Part A services, the provider has sixty (60) days from the date of receipt of the initial denial to request a reconsideration.

When requesting a reconsideration, please follow the procedures outlined below:

• Submit a written request for a second reconsideration,
  
• Submit a hard copy of the UB92 billing from,
  
• Submit all records and an itemized bill to support the reconsideration,
  
• Submit a copy of the denial letter and/or the remittance notice displaying the denial code.

Please submit the reconsideration request timely to avoid dismissal of the reconsideration.

Send all reconsideration request to:

Maryland Medicare Part A
RECONSIDERATION-Medical Review
1946 Greenspring Drive
Timonium, MD 21093-4141

The evidence is not yet sufficient to demonstrate the effectiveness of this procedure as salvage therapy for local failures after radical prostatectomy, external beam irradiation, and brachytherapy. Therefore, cryosurgery of the prostate as salvage therapy is not covered under Medicare.

This procedure should only be rendered in an outpatient hospital setting (bill types 13x and 83x).

Billing and Payment Requirements

Claims for cryosurgery of the prostate gland are to be submitted on the Form HCFA-1450 or electronic equivalent. Follow the instructions in ß3604 of the Medicare Intermediary Manual.

The HCPCS codes which will indicate that the procedure was rendered are:

G0160 - Cryosurgical ablation of localized prostate cancer, primary treatment only (postoperative irrigations and aspiration of sloughing tissue included).

This service may be paid only for patients with clinically localized prostate cancer, Stages T1-T3.

G0161 - Ultrasonic guidance for interstitial cryosurgical probe placement.

This service may be paid only for patients with clinically localized prostate cancer, Stages T1-T3; and when a claim for G0160 on the same date of service and for the same beneficiary has been approved for payment.

Maryland Medicare Provider Relations
Address Update
1946 Greenspring Drive
Timonium, MD 21093-4141

OR FAX to 410-561-7951

Your help will be greatly appreciated.

Send all literature, seminar notices, record requests, etc. to:

Provider #: _________________________________________________________________________
Provider Name: _____________________________________________________________________
Your Name & Title: __________________________________________________________________
Provider Address: ___________________________________________________________________

Is the above address, a central mailing address? YES___ NO___
If a central address, please list all provider numbers.
Is the remittance mailed to the same address as above? YES___ NO___

If no, please provide mailing address for remittance

Provider #: _________________________________________________________________________
Provider Name: _____________________________________________________________________
Your Name & Title: __________________________________________________________________

Do you receive the payment through electronic funds transfer (EFT)?
YES____ NO___

Do you receive the remittance electronically (ERA)?
YES____ NO___