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Instructions and guideline for CMS 1500 claim form and UB 04 form. Tips and updates. Detailed review of all the fields and box in CMS 1500 claim form and UB 04 form and ADA form. HCFA 1500 and UB 92 form instruction.

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    Bill Type Codes:
    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    N/A

    Revenue Codes:
    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

    032X Radiology - Diagnostic - General Classification
    033X Radiology - Therapeutic and/or Chemotherapy Administration - General Classification
    034X Nuclear Medicine - General Classification
    035X CT Scan - General Classification
    040X Other Imaging Services - General Classification
    061X Magnetic Resonance Technology (MRT) - General Classification
    CPT/HCPCS Codes

    Group 1 Paragraph:
    This policy does not take precedence over the Correct Coding Initiative (CCI). Consult current correct coding guidelines for applicable specific code combinations or reductions in payment due to specific codes billed.

    The following short descriptors are in accordance with the AMA copyright. Please refer to the current CPT book for full descriptions.

    Group 1 Codes:
    36200Place catheter in aorta
    36245Ins cath abd/l-ext art 1st
    36246Ins cath abd/l-ext art 2nd
    36247Ins cath abd/l-ext art 3rd
    36248Ins cath abd/l-ext art addl
    36251Ins cath ren art 1st unilat
    36252Ins cath ren art 1st bilat
    36253Ins cath ren art 2nd+ unilat
    36254Ins cath ren art 2nd+ bilat
    75625Contrast exam abdominl aorta
    75630X-ray aorta leg arteries
    75726Artery x-rays abdomen
    G0278Iliac art angio,cardiac cath

    ICD-9 Codes that Support Medical Necessity

    Group 1 Paragraph: N/A

    Group 1 Codes:
    152.0 - 152.9
    MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
    155.0 - 155.2
    MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY
    156.0MALIGNANT NEOPLASM OF GALLBLADDER
    156.1MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS
    156.8MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS
    159.0 - 159.9
    MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM
    189.0MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
    189.1MALIGNANT NEOPLASM OF RENAL PELVIS
    197.7MALIGNANT NEOPLASM OF LIVER SECONDARY
    198.0SECONDARY MALIGNANT NEOPLASM OF KIDNEY
    209.72SECONDARY NEUROENDOCRINE TUMOR OF LIVER
    223.0BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS
    223.1BENIGN NEOPLASM OF RENAL PELVIS
    233.9CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS
    239.0NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM
    401.0MALIGNANT ESSENTIAL HYPERTENSION
    403.00HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
    403.01HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
    404.01HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
    404.02HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
    404.03HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
    405.01MALIGNANT RENOVASCULAR HYPERTENSION
    405.11BENIGN RENOVASCULAR HYPERTENSION
    405.91UNSPECIFIED RENOVASCULAR HYPERTENSION
    440.0ATHEROSCLEROSIS OF AORTA
    440.1ATHEROSCLEROSIS OF RENAL ARTERY
    440.20 - 440.32*
    ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES
    441.00 - 441.9
    DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE
    442.1ANEURYSM OF RENAL ARTERY
    442.2ANEURYSM OF ILIAC ARTERY
    442.83ANEURYSM OF SPLENIC ARTERY
    442.84ANEURYSM OF OTHER VISCERAL ARTERY
    443.22DISSECTION OF ILIAC ARTERY
    443.23DISSECTION OF RENAL ARTERY
    443.9*PERIPHERAL VASCULAR DISEASE UNSPECIFIED
    444.01SADDLE EMBOLUS OF ABDOMINAL AORTA
    444.09OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA
    444.22*ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY
    444.81EMBOLISM AND THROMBOSIS OF ILIAC ARTERY
    445.02ATHEROEMBOLISM OF LOWER EXTREMITY
    445.81ATHEROEMBOLISM OF KIDNEY
    447.3HYPERPLASIA OF RENAL ARTERY
    447.6ARTERITIS UNSPECIFIED
    518.4ACUTE EDEMA OF LUNG UNSPECIFIED
    557.0ACUTE VASCULAR INSUFFICIENCY OF INTESTINE
    557.1CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE
    557.9UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE
    572.3PORTAL HYPERTENSION
    578.0HEMATEMESIS
    578.1BLOOD IN STOOL
    578.9HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED
    593.81VASCULAR DISORDERS OF KIDNEY
    593.9UNSPECIFIED DISORDER OF KIDNEY AND URETER
    599.70 - 599.72
    HEMATURIA, UNSPECIFIED - MICROSCOPIC HEMATURIA
    747.62RENAL VESSEL ANOMALY
    785.9OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM
    794.4NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY
    863.0 - 863.99
    INJURY TO STOMACH WITHOUT OPEN WOUND INTO CAVITY - INJURY TO OTHER AND UNSPECIFIED GASTROINTESTINAL SITES WITH OPEN WOUND INTO CAVITY
    864.00 - 864.19
    UNSPECIFIED INJURY TO LIVER WITHOUT OPEN WOUND INTO CAVITY - OTHER INJURY TO LIVER WITH OPEN WOUND INTO CAVITY
    865.00 - 865.19
    UNSPECIFIED INJURY TO SPLEEN WITHOUT OPEN WOUND INTO CAVITY - OTHER INJURY TO SPLEEN WITH OPEN WOUND INTO CAVITY
    868.00 - 868.19
    INJURY TO UNSPECIFIED INTRA-ABDOMINAL ORGAN WITHOUT OPEN WOUND INTO CAVITY - INJURY TO OTHER AND MULTIPLE INTRA-ABDOMINAL ORGANS WITH OPEN WOUND INTO CAVITY
    902.40INJURY TO RENAL VESSEL(S) UNSPECIFIED
    959.12OTHER INJURY OF ABDOMEN
    959.8OTHER AND UNSPECIFIED INJURY TO OTHER SPECIFIED SITES INCLUDING MULTIPLE
    996.1MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT
    996.81COMPLICATIONS OF TRANSPLANTED KIDNEY
    998.11HEMORRHAGE COMPLICATING A PROCEDURE
    V42.0KIDNEY REPLACED BY TRANSPLANT
    V42.7LIVER REPLACED BY TRANSPLANT
    V42.83PANCREAS REPLACED BY TRANSPLANT
    V58.44AFTERCARE FOLLOWING ORGAN TRANSPLANT
    Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation:
    ** apply to abdominal aortography only.

    ICD-9 Codes that DO NOT Support Medical Necessity


    N/A

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    The National Uniform Claim Committee (NUCC) recently revised the CMS-1500 claim form to align the paper claim form with changes in the 5010 837P and accommodate ICD-10 reporting needs. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised paper claim form, CMS-1500 (version 02/12). The Centers for Medicare & Medicaid Services (CMS) adopted form CMS-1500 (02/12), which replaced the older CMS-1500 claim form (08/05), effective with claims received on and after April 1, 2014.

    • Medicare began accepting claims on the revised form, (02/12), on January 6, 2014;
    • As of April 1, 2014, Medicare only accepts paper claims on the revised CMS-1500 claim form, (02/12); and
    • As of April 1, 2014, Medicare no longer accepts claims on the old claim form CMS-1500 (08/05)

    The grace period for providers and suppliers to transition to the new form expired on April 1, 2014.

    When completing the claim form, ensure to use all capital typeface.
    The revised form has a number of changes. The two most prevalent changes are new indicators to differentiate between ICD-9 and ICD-10 codes and new qualifiers to identify the role of the provider entered in item 17.

    • The NUCC created a presentation that reviews the changes in detail. Click here external pdf file to view the NUCC presentation on the CMS-1500 (02/12) paper claim form.

    Item 17 qualifiers
    The qualifiers appropriate for identifying an ordering, referring, or supervising role are as follows:
    • DN -- referring provider
    • DK -- ordering provider
    • DQ -- supervising provider

    Providers should enter the qualifier to the left of the dotted vertical line on item 17.

    • Note: Claims submitted with a national provider identifier (NPI) and without one of the qualifiers notated above or an invalid qualifier will be returned as an unprocessable claim (RUC).

    Item 21 and 24E diagnosis changes
    The revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.
    Item 21
    • For version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set), up to 12 diagnosis codes.
    • Enter up to 12 diagnosis codes. Note: this information appears opposite lines with letters A-L. Relate lines A- L to lines of service in 24E by the letter of the line. Use the highest level of specificity.
    • Do not provide narrative description in this field.
    • Do not insert a period in the ICD-9-CM or ICD-10-CM code.
    • The "ICD Indicator" identifies the ICD code set being reported. Enter the applicable ICD indicator as a single digit between the vertical, dotted lines.
    • Indicator code set
    • 9 -- ICD-9-CM diagnosis
    • 0 -- ICD-10-CM diagnosis
    Reminder: Regardless of the paper claim form version in effect, providers cannot submit ICD-10 codes for claims with dates of service prior to October 1, 2015.
    Item 24E
    • For version 02/12, the reference will be a letter from A-L.
    • When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L".


    Additional changes
    The following additional changes are also included in the revised form:

    Item 8
    • Form version 02/12: Leave blank.
    Item 9b
    • Form version 02/12: Leave blank.
    Item 11b
    • Form version 02/12: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Provide this information to the right of the vertical dotted line.
    Item 14
    • Form version 02/12: Although this version of the form includes space for a qualifier, Medicare does not use this information; do not enter a qualifier in item 14.


    ASCA reminder
    Only providers that meet the Administrative Simplification Compliance Act (ASCA) exception requirements are permitted to submit their claims to Medicare on paper, which must be submitted on a valid CMS-1500 claim form. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper.

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    This billing software only works for submitting FFS claims to Medicare. It is intended to provide submitters with an ICD-10 compliant claims submission format; it does not provide coding assistance.

    Information about the free billing software is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission Alternatives Web Pages on the CMS website.

    Please note that submitting electronic claims to Medicare using the free billing software does not change the requirement for ICD-10 compliant claims to be submitted for FROM dates of service on or after October 1, 2015. Any claims
    containing ICD-9 codes for FROM dates of service on or after October 1, 2015, will be rejected by Medicare.



    In some cases, you may be able to use your MAC’s provider internet portal to submit ICD-10 compliant professional claims. All MACs offer the portals, and a subset of these MAC portals offer claims submission. Provider portal internet claim submission is not available for institutional or supplier claims.


    Information about registering for access to provider internet portals is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission Alternatives Web Pages on the CMS website.

    Please note that claims submitted via our provider portal must contain ICD-10 codes for FROM dates of service on or after October 1, 2015. Those submitted containing ICD-9 codes for FROM dates of service on or after October 1, 2015, will be
    rejected through normal claims editing processes. ICD-9 codes will still be accepted for FROM dates prior to October 1, 2015.


    DDE

    Providers that bill institutional claims are also permitted to submit claims electronically via DDE screens. DDE requires a connectivity service provided by an external company to establish the connection.

    Information about registering to submit claims via DDE and lists of DDE service vendors is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission

    Alternatives Web Pages on the CMS website.
    Please note that claims submitted via DDE must contain ICD-10 codes for dates of DISCHARGE/THROUGH dates on or after October 1, 2015. Those submitted containing ICD-9 codes for dates of DISCHARGE/THROUGH dates on or after
    October 1, 2015, will be Returned to Provider (RTP).

    PAPER CLAIMS
    In limited situations, you may submit paper claims with ICD-10 codes to Medicare. To find more information on when you may submit paper claims, visit http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWaiver.html
    on the CMS website. Please note that to submit paper claims, you must meet the requirements to qualify for a waiver of the Administrative Simplification Compliance Act (ASCA) provisions.


    Information about submitting paper claims and ordering claim forms is available on each of the CMS Contractor websites. Please refer to the document that provides web page access to all Contractors titled Contractors’ ICD-10 Claims Submission Alternatives Web Pages on the CMS website.


    Information and Resources

    Visit the following web pages to find information and resources that will assist you in submitting ICD-10 codes to Medicare:

    • General ICD-10-CM/PCS information:
    http://www.cms.gov/Medicare/Coding/ICD10/index.html;

    • ICD-10 Fee-For-Service provider resources including claims processing and billing, coding, unspecified ICD-10-CM codes, home health provider information, NCDs and LCDs, testing and results, features and benefits, and calls and background:
    https://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-ServiceProvider-Resources.html;

    • General Equivalence Mappings:
    http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-andGEMs.html;
    and

    • ICD-10 National Coverage Determinations:
    http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html on the CMS website.

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    Coverage Guidance

    Coverage Indications, Limitations, and/or Medical Necessity
    1. The indications for renal arteriography adapted from the American College of Radiology (1999) include the following:

    Severe and/or difficult to control renal vascular hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

    Recent onset of severe or relatively severe hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

    Sudden need to increase medications to control hypertension (uncontrolled hypertension with a systolic blood pressure greater than or equal to 160 mmHg or a diastolic blood pressure greater than or equal to 100 mmHg on at least two anti-hypertensive drugs);

    Deterioration of renal function; and

    Abnormal radionuclide renogram.

    2. Renal arteriography is indicated for those patients with recurrent acute pulmonary edema who are status post-op renal transplantation or patients with recurrent (flash) pulmonary edema.

    3. Renal arteriography is indicated for those patients having primary or secondary, benign or malignant neoplasm of the kidney.

    4. Abdominal aortography and/or renal arteriography may be indicated for those patients with known/suspected aneurysm, dissection, or trauma involving the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

    5. Abdominal aortography and/or renal arteriography may be indicated for those patients having mid-abdominal bruits or known/suspected vascular diseases of the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

    6. In addition to the initial procedure, an appropriate frequency of repeat procedures can be allowed as long as medical necessity is clearly
    established and documented, e.g., there is a reason for performing the procedure. It is expected that important diagnostic information will be obtained from the angiography, which will assist in the patient’s management and treatment. Repeat angiography can be acceptable if there is an appearance of new and incapacitating symptoms or an exacerbation or chronic symptoms, even following an interventional procedure, such as PTA and/or renal stenting.

    Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

    a. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, or

    b. A prior study is available, but as documented in the medical record:

    The patient’s condition with respect to the clinical indication has changed since the prior study; OR

    There is inadequate visualization of the anatomy and/or pathology; OR

    There is a clinical change during the procedure that requires new evaluation outside the target area of intervention

    7. Appropriate non-invasive tests should be performed prior to the repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient has not responded to an adequate trial of medical management or is deemed unstable and in need of some type of surgical intervention. In all instances, documentation must be submitted upon request justifying the repeat procedure and establishing medical necessity.

    8. These services may be performed in a hospital, a hospital outpatient area, or an approved independent catheterization laboratory.

    9. Aortography (from ACR Guideline: Quality Improvement Guidelines for Diagnostic Arteriography, September 2003):

    Intrinsic abnormalities, including transection, dissection, aneurysm, occlusive disease, aortitis, and congenital anomaly;

    Evaluation of aorta and its branches prior to selective catheterization and performance of therapeutic interventional procedures; or

    Before interventional procedures.

    10. Renal Arteriography (from ACR guideline: Practice Guideline for the Performance of Diagnostic Arteriography in Adults, Res. 25, Amended 2004):

    Renovascular occlusive disease (e.g., for hypertension or progressive
    renal insufficiency);

    Renal vascular trauma;

    Primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis;

    Renal tumors;

    Hematuria of unknown cause (following inconclusive noninvasive testing [not included in ACR]);

    Pre- and postoperative evaluation for renal transplantation; or

    Evaluation prior to performance of therapeutic interventional procedures.



    CMS issued HCPCS code G0278 for femoral and/or iliac angiography when done at the time of coronary angiography. Medicare would not expect to see a high percentage of femoral and/or iliac angiography done at the same time of coronary studies and such billing could be subject to review.

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    Important instructions for paper claim form CMS-1500 (version 02/12)

    Recently, First Coast Service Options (First Coast) has noticed a reoccurring issue for several claims when they go through the optical character recognition (OCR) process. To avoid these issues, we wanted to reiterate some important instructions for our paper claim submitters:

    • All paper claims are required to be submitted using the CMS-1500 (02/12) form.
    • When completing the claim form, ensure to use all capital typeface. This is especially important when indicating letter "I" and "L" in Item 24E.
    • Claims submitted with a national provider identifier (NPI) and without one of the Item 17 qualifiers or an invalid qualifier will be returned as an unprocessable claim (RUC).
    • Reminder: Providers cannot submit ICD-10 codes for claims with dates of service prior to October 1, 2015.


    ASCA reminder

    Only providers that meet the Administrative Simplification Compliance Act (ASCA) exception requirements are permitted to submit their claims to Medicare on paper, which must be submitted on a valid CMS-1500 claim form. Providers meeting these exceptions are permitted to submit their claims to Medicare on paper.

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    Entities submitting roster claims to A/B MACs (B) must complete the following blocks on a single modified Form CMS-1500, which serves as the cover document for the roster for each facility where services are furnished. In order for A/B MACs (B) to reimburse by correct payment locality, a separate Form CMS-1500 must be used for each different facility or physical location where services are furnished.

    Item # Instruction

    Item # Instruction Item 1: An X in the Medicare block

    Item 2: (Patient's Name): "SEE ATTACHED ROSTER"

    Item 11: (Insured's Policy Group or FECA Number): "NONE"

    Item 20: (Outside Lab?): An "X" in the NO block

    Item 21: (Diagnosis or Nature of Illness): Line A: Choose appropriate diagnosis code from §10.2.1 ICD Ind. Block: Enter 9 if ICD-9-CM or 0 if ICD-10-CM is applicable. Enter the indicator as a single digit between the vertical dotted lines.

    Item 24B: (Place of Service (POS)): Line 1: "60" Line 2: "60" NOTE: POS Code “60" must be used for roster billing.

    Item 24D: (Procedures, Services or Supplies): Line 1: Pneumococcal vaccine: "90732" or Influenza Virus vaccine: “Select appropriate influenza virus vaccine code” Line 2: Pneumococcal vaccine Administration: "G0009" or Influenza Virus Vaccine Administration: "G0008"

    Item 24E: (Diagnosis Pointer): Lines 1 and 2: "A"

    Item 24F: ($ Charges): The entity must enter the charge for each listed service. If the entity is not charging for the vaccine or its administration, it should enter 0.00 or "NC" (no charge) on the appropriate line for that item. If your system is unable to accept a line item charge of 0.00 for an immunization service, do not key the line item. Likewise, electronic media claim (EMC) billers should submit line items for free immunization services on EMC pneumococcal or influenza virus vaccine claims only if your system is able to accept them.

    Item 27: (Accept Assignment): An "X" in the YES block.

    Item 29: (Amount Paid): "$0.00" Item 31: (Signature of Physician or Supplier): The entity's representative must sign the modified Form CMS-1500.

    Item 32: Enter the name, address, and ZIP code of the location where the service was provided (including centralized billers).

    Item32a: Enter the NPI of the service facility.

    Item 33: (Physician's, Supplier's Billing Name): The entity must complete this item to include the Provider Identification Number (not the Unique Physician Identification Number) or NPI when required.

    Item 33a: Effective May 23, 2007, and later, enter the NPI of the billing provider or group.

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    Bill Type Codes: 
    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
    012xHospital Inpatient (Medicare Part B only)
    013xHospital Outpatient
    018xHospital - Swing Beds
    021xSkilled Nursing - Inpatient (Including Medicare Part A)
    022xSkilled Nursing - Inpatient (Medicare Part B only)
    023xSkilled Nursing - Outpatient
    028xSkilled Nursing - Swing Beds
    071xClinic - Rural Health
    077xClinic - Federally Qualified Health Center (FQHC)
    083xAmbulatory Surgery Center
    085xCritical Access Hospital

    Revenue Codes:
    Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
    Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
    0250 Pharmacy - General Classification
    0258 Pharmacy - IV Solutions
    0260 IV Therapy - General Classification
    0263 IV Therapy - IV Therapy/Drug/Supply Delivery
    045X Emergency Room - General Classification
    076X Specialty Services - General Classification
    CPT/HCPCS Codes

    Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
    Group 1 Codes:
    96360Hydration iv infusion init
    96361Hydrate iv infusion add-on
    J7030Normal saline solution infus
    J7040Normal saline solution infus
    J70425% dextrose/normal saline
    J7050Normal saline solution infus
    J70605% dextrose/water
    J7070D5w infusion
    J7120Ringers lactate infusion

    ICD-9 Codes that Support Medical Necessity 

    Group 1 Paragraph: Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

    The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

    Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:

    Covered for:

    Group 1 Codes:
    250.80DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
    275.42HYPERCALCEMIA
    276.0HYPEROSMOLALITY AND/OR HYPERNATREMIA
    276.50VOLUME DEPLETION, UNSPECIFIED
    276.51DEHYDRATION
    276.52HYPOVOLEMIA
    458.9HYPOTENSION UNSPECIFIED
    535.00 - 535.01ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - ACUTE GASTRITIS WITH HEMORRHAGE
    535.10 - 535.11ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE
    535.20 - 535.21GASTRIC MUCOSAL HYPERTROPHY (WITHOUT HEMORRHAGE) - GASTRIC MUCOSAL HYPERTROPHY WITH HEMORRHAGE
    535.30 - 535.31ALCOHOLIC GASTRITIS (WITHOUT HEMORRHAGE) - ALCOHOLIC GASTRITIS WITH HEMORRHAGE
    535.40 - 535.41OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) - OTHER SPECIFIED GASTRITIS WITH HEMORRHAGE
    535.50 - 535.51UNSPECIFIED GASTRITIS AND GASTRODUODENITIS (WITHOUT HEMORRHAGE) - UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITH HEMORRHAGE
    535.60 - 535.61DUODENITIS (WITHOUT HEMORRHAGE) - DUODENITIS WITH HEMORRHAGE
    535.70 - 535.71EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF HEMORRHAGE - EOSINOPHILIC GASTRITIS, WITH HEMORRHAGE
    536.2PERSISTENT VOMITING
    558.9OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS
    578.0HEMATEMESIS
    643.10HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE UNSPECIFIED AS TO EPISODE OF CARE
    643.13HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE ANTEPARTUM
    643.20LATE VOMITING OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
    643.23LATE VOMITING OF PREGNANCY ANTEPARTUM
    643.80OTHER VOMITING COMPLICATING PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
    643.83OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM
    780.2SYNCOPE AND COLLAPSE
    780.4DIZZINESS AND GIDDINESS
    780.97ALTERED MENTAL STATUS
    787.01NAUSEA WITH VOMITING
    787.03VOMITING ALONE
    787.91DIARRHEA
    V58.11ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY

    Group 2 Paragraph: Report an encounter for radio-contrast dye(s), when hydration is needed in conjunction with angiography and/or CT scan with contrast, with the primary diagnosis of V15.89(other specified personal history presenting hazards to health) and one of the secondary diagnoses from the list below.

    Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:

    Covered for:

    Group 2 Codes:
    585.3CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
    585.4CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
    585.5CHRONIC KIDNEY DISEASE, STAGE V

    ICD-9 Codes that DO NOT Support Medical Necessity
    Paragraph: NA
    General Information
    Associated Information
    Documentation Requirements
    Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
    Hospital, outpatient, nursing facility or office records should clearly document the reason(s) and medical necessity for hydration therapy. The volume of hydration therapy and the doses of non-chemotherapy drugs administered should be documented in the medical record.


    CPT Codes 96360 and 96361 are time-based codes and must be documented with start and stop times. No other service may be billed concurrently with the time represented by these codes.

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  • 10/14/15--09:13: BOX 24D, how to put NDC CODE
  • 24d Procedure Code- Unshaded area NDC unit measurement-Shaded area

    Unshaded area: Enter the 5-digit CPT-4 or HCPCS procedure code that describes the procedure performed. If service provided requires modifier(s), enter up to 3 modifiers in the column(s) provided following the CPT-4 or HCPCS code. If more than 3 modifiers apply, enter modifier 99 first. Shaded area: Enter the NDC unit of measurement and numeric quantity administered to the patient. Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may precede the decimal point and three numbers may follow the decimal. The unit of measurement codes are: F2 -International Unit GR-Gram ML-Milliliter UN- Unit


    24e Diagnosis Code Enter the diagnosis code reference numbers from form locator 21 (maximum 4). Only specific reference numbers (1, 2, 3, 4) will be accepted. Now its a, b, c, d

    24f Charges Enter the total charge for the procedure performed.

    24g Unit(s) Enter the number of times the procedure for which you are billing was performed. (Please note: decimal points are not allowed when billing CPT codes or HCPCS codes)

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     The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease (CAD), and urinary incontinence:

     Measure #2 (LDL-C) with QDC 3048F + diabetes line-item diagnosis (24E points to DX 250.00 in Item 21);

     Measure #3 (BP in Diabetes) with QDCs 3074F + 3078F + diabetes line-item diagnosis (24E points to Dx 250.00 in Item 21);

     Measure #6 (CAD) with QDC 4011F + CAD line-item diagnosis (24E points to Dx 414.00 in Item 21); and

     Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRS, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter.

     Note: All diagnoses listed in Item 21 will be used for PQRS analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21.

     NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing.

     If billing software limits the line items on a claim, you may add a nominal line-item charge of a penny to one of the QDC line items on that second claim. PQRS analysis will subsequently join both claims based on the same beneficiary, for the same date-of-service, for the same TIN/NPI and analyze as one claim.

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    Hepatitis C Virus (HCV) is an infection that attacks the liver and is a major cause of chronic liver disease. Inflammation over long periods of time (usually decades) can cause scarring, called cirrhosis. A cirrhotic liver fails to perform the normal functions of the liver which leads to liver failure. Cirrhotic livers are more prone to become cancerous and liver failure leads to serious complications, even death. HCV is reported to be the leading cause of chronic hepatitis, cirrhosis, and liver cancer, and a primary indication for liver transplant in the Western World. Prior to June 2, 2014, CMS did not cover screening for HCV in adults. Pursuant to §1861(ddd) of the Social Security Act, CMS may add coverage of “additional preventive services” through the National Coverage Determination (NCD) process.

    Effective June 2, 2014, CMS will cover screening for HCV with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory test (used consistently with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations) and point-of-care tests (such as rapid anti-body tests that are performed in outpatient clinics and physician offices) when ordered by the beneficiary’s primary care physician or practitioner within the context of a primary care setting, and performed by an eligible Medicare provider for these services, for beneficiaries who meet either of the following conditions:

    1.Adults at high risk for HCV infection. “High risk” is defined as persons with a current or past history of illicit injection drug use, and persons who have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.

    2.Adults who do not meet the high risk definition as defined above, but who were born from 1945 through 1965. A single, once-in-a-lifetime screening test is covered for these individuals. The determination of “high risk for HCV” is identified by the primary care physician or practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan. The medical record should be a reflection of the service provided.

    General Claims Processing Requirements for Claims with Dates of Service on and After June 2, 2014:
    1. New HCPCS G0472, short descriptor - Hep C screen high risk/other and long descriptor- Hepatitis C antibody screening for individual at high risk and other covered indication(s), will be used. HCPCS G0472 will appear in the January 2016 recurring updates of the Clinical Laboratory Fee Schedule (CLFS) and the Integrated Outpatient Code Editor (IOCE) with a June 2, 2014, effective date. MACs shall apply contractor pricing to claims with dates of service June 2, 2014, through December 31, 015, that contain HCPCS G0472. MACs will not automatically adjust claims that may be processed in error, but will adjust such claims that you bring to their attention.
    2.Beneficiary coinsurance and deductibles do not apply to HCPCS G0472.
    3.For services provided to beneficiaries born between the years 1945 and 1965 who are not considered high risk, HCV screening is limited to once per lifetime, claims shall be submitted with:
    •HCPCS G0472.
    4.For those determined to be high-risk initially, claims must be submitted with:
    •HCPCS G0472; and
    •ICD-9 diagnosis code V69.8, other problems related to life style/ICD-10 diagnosis code Z72.89, other problems related to lifestyle (once ICD-10 is implemented).
    5.Screening may occur on an annual basis if appropriate, as defined in the policy. Claims for adults at high risk who have had continued illicit injection drug use since the prior negative screening shall be submitted with:
    •HCPCS G0472;
    •ICD diagnosis code V69.8/Z72.89; and
    •ICD diagnosis code 304.91, unspecified drug dependence, continuous/F19.20, other psychoactive substance abuse, uncomplicated (once ICD-10 is implemented).
    NOTE: Annual is defined as 11 full months must pass following the month of the last negative HCV screening.

    Institutional Billing Requirements
    Effective for claims with dates of service on and after June 2, 2014, institutional providers may use types of bill (TOB) 13X, 71X, 77X, and 85X when submitting claims for HCV screening, HCPCS G0472. Medicare will deny G0472 service line-items on other TOBs using the following messages:
    •Claim Adjustment Reason Code (CARC) 170 -Payment denied when performed/billed  by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
    •Remittance Advice Remarks Code (RARC) N95 - This provider type/provider specialty may not bill this service.
    •Group Code CO (contractual obligation) – If claim received without a GZ modifier. The service is paid on the following basis:
    •Outpatient hospitals – TOB 13X - based on the Outpatient Prospective Payment System.
    •Rural Health Clinics (RHCs)- TOB 71X - and Federally Qualified Health Centers (FQHCs) - 77X - For RHCs and FQHCs that are authorized to bill under the All-Inclusive Rate (AIR) system, payment for the professional component is included in the AIR. For FQHCs authorized to bill under the FQHC Prospective Payment System (PPS), payment for the professional component is included in the FQHC PPS rate. HCV screening is not a stand-alone payable visit for RHCs and FQHCs.
    •Critical Access Hospitals (CAHs) - TOB 85X – based on reasonable cost; and
    •CAH Method II – TOB 85X - based on 115 percent of the lesser of the MPFS amount or actual charge as applicable with revenue codes 096X, 097X, or 098X.

    Note: Separate guidance shall be issued for FQHCs that are authorized to bill under the prospective payment system.

    Professional Billing Requirements
    For professional claims with dates of service on or after June 2, 2014, CMS will allow coverage for HCPCS G0472, only when services are submitted by the following provider specialties found on the provider’s enrollment record:
    01 - General Practice
    08 - Family Practice
    11 - Internal Medicine
    16 - Obstetrics/Gynecology
    37 - Pediatric Medicine
    38 - Geriatric Medicine
    42 - Certified Nurse Midwife
    50 - Nurse Practitioner
    89 - Certified Clinical Nurse Specialist
    97 - Physician Assistant
    Medicare will deny claims submitted for these services by providers other than the specialty types noted above. When denying such claims, Medicare will use the following messages:
    •CARC 184 - The prescribing/ordering provider is not eligible to prescribe/order the service.
    NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
    •RARC N574 - Our records indicate the ordering/referring provider is of a type/specialty that cannot order/refer. Please verify that the claim ordering/referring information is accurate or contact the ordering/referring provider.
    •Group Code CO if claim received without GZ modifier.

    For professional claims with dates of service on or after June 2, 2014, CMS will allow coverage for HCV screening, HCPCS G0472, only when submitted with one of the following place of service (POS) codes:
    11 - Physician’s Office
    22 - Outpatient Hospital
    49 - Independent Clinic
    71 - State or Local Public Health Clinic
    81 - Independent Laboratory
    Medicare will deny claims submitted without one of the POS codes noted above with the following messages:
    •CARC 171 - Payment denied when performed by this type of provider in this type of facility.
    Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
    •RARC N428 - Not covered when performed in this place of service.
    •Group Code – CO if claim received without GZ modifier.

    Other Billing Information for Both Professional and Institutional Claims
    On both institutional and professional claims, Medicare will deny claims line-items for HCPCS G0472 with dates of service on or after June 2, 2014, where it is reported more than once-in-a-lifetime for beneficiaries born from1945 through 1965 and who are not high risk. Medicare will also line-item deny when more than one HCV screening is billed for the same high-risk beneficiary prior to their annual eligibility criteria being met. In denying these claims, Medicare will use:
    •CARC 119 - Benefit maximum for this time period or occurrence has been reached.
    •RARC N386 - This decision was based on a National Coverage Determination (NCD).
    An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.
    •Group Code - CO if claim received without GZ modifier.

    When applying the annual frequency limitation, MACs will allow both a claim for a professional service and a claim for a facility fee.

    In addition, remember that the initial HCV screening for beneficiaries at high risk must also contain ICD-9 diagnosis code V69.8 (ICD-10 code Z72.89 once ICD-10 is implemented).

    Then, for the subsequent annual screenings for high risk beneficiaries, you must include ICD-9 code V69.8 and 304.91 (ICD-10 of Z72.89 and F19.20 once ICD-10 is implemented). Failure to include the diagnosis code(s) for high risk beneficiaries will result in denial of the line item. In denying thes
    e payments, Medicare will use the following:
    •CARC 119 - Benefit maximum for this time period or occurrence has been reached. (for initial high risk screening), or,
    •CARC 167 - This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (for subsequent annual high risk screening)
    •RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.
    •Group Code CO if claim received without GZ modifier.



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    The Centers for Medicare & Medicaid Services (CMS) today strengthened the FiveStar Quality Rating System for Nursing Homes on the Nursing Home Compare website to give families more precise and meaningful information on quality when they consider facilities for themselves or a loved one. Today’s announcement also marks an important milestone to achieving the goal of implementing further improvements to the Five Star system in 2015, as the Administration announced last October.

    Star ratings allow users to see important differences in quality among nursing homes to help them make better care decisions. CMS rates nursing homes on three categories: results from onsite inspections by trained surveyors, performance on certain quality measures, and levels of staffing. CMS uses these three categories to offer an overall star rating, but consumers can see and focus on any of the three individual categories.

    Beginning today, nursing home star ratings will:

    Include use of antipsychotics in calculation of the star ratings. These medications are often used for diagnoses that do not warrant them. The two existing quality measures – for short stay and long stay patients – will now be part of the calculation for the quality measures star rating.
    Have improved calculations for staffing levels. Research indicates that staffing is important to overall quality in a nursing home.
    Reflect higher standards for nursing homes to achieve a high rating on the quality measure dimension on the website.
    “CMS is committed to improving Nursing Home Compare and the FiveStar Quality Rating System to ensure they are the most trusted and easy-to-use resources we can provide,” said Patrick Conway, M.D., CMS Deputy Administrator for Innovation and Quality and Chief Medical Officer for CMS. “Consumers can feel confident that Nursing Home Compare’s star ratings include measures that matter most to nursing home residents and their families and challenge nursing homes to continuously improve care.”
    Since CMS standards for performance on quality measures are increasing, many nursing homes will see a decline in their quality measures star rating. By making this change, Nursing Home Compare will include more meaningful distinctions in performance for consumers and focus nursing homes on continuously improving care focused on residents, families, and their caregivers. About two thirds of nursing homes will see a decline in their quality measures rating and about one third of nursing homes will experience a decline in their Overall Five Star Rating.

    For example, before the recalibration, about 80 percent of nursing homes received either a 4 or 5-star rating on their quality measures. Now, about 49 percent of nursing homes will receive a 4 or 5 stars on their quality measure rating. Also, the number of nursing homes receiving one star for their quality measures has increased from 8.5 percent to 13 percent after the recalibration.

    CMS is also focusing changes in areas identified by consumers and other stakeholders as important. For example, by the end of 2013 nursing homes achieved a 15 percent reduction in the use of anti-psychotics compared to 2011 levels. As part of the National Partnership to Improve Dementia Care, CMS is working with the nursing home community, patients, families and other important stakeholdersto achieve a 30 percent reduction by the end of CY2016.

    The Nursing Home Compare website was launched in 1998, and CMS added the FiveStar Quality Rating System (“NH Compare 2.0”) in 2008. Nursing Home Compare gets approximately 1.4 million visits per year and users report high satisfaction with the site. More than 85 percent of users have indicated that they found the information they were seeking. CMS recommends that consumers rely on multiple factors – including star ratings, visits and community reputation -- when selecting a nursing home.



    To achieve better care, smarter spending and healthier people, the Department of Health and Human Services is focused on sharing information more broadly to providers, consumers, and others to support better decisions while enforcing patient privacy. The Five Star Quality Rating System for Nursing Homes is part of an administration-wide effort to increase the availability and accessibility of information on quality, utilization and costs for effective, informed decision-making by consumers.

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    Important Change:
    The Sleep Study Authorization program implementation date , previously scheduled for April 1, 2015 and earlier, has been changed to May 1, 2015.Please disregard all previous communications indicating earlier implementation dates.

    Effective May1, 2015, Florida Blue and Florida Blue HMO (Health Options, Inc.)will implement the mandatory preservice review/prior authorization program for sleep and titration studies. The Sleep Study Authorization program applies to the following networks:
    NetworkBlue (BlueOptionsSM), Health Options, Inc. (BlueCare®HMO) and Blue Select.

    Florida Blue and Florida Blue HMO (Health Options, Inc.) have contracted with Sleep Management Solutions to manage the Sleep Study Authorization Program. The program is designed to maximize patient care in the most appropriate and affordable manner based on clinically accepted standards.

    Providers Participating in the Sleep Study Authorization Program

    Effective May1, 2015, providers who are subject to the Sleep Study Authorization Program must submit all sleep study procedures (as set forth on Appendix A) to Sleep Management Solutions for preservice review/prior authorization. Failure to seek a preservice review/authorization will result in a denial of the claim and the provider will not be entitled to compensation from Florida Blue or Florida Blue HMO or from the member for any such services rendered. The authorization requirement is applicable to all Florida Blue and Florida Blue HMO (Health Options, Inc.) products in which contracted providers participate
    . This program will not apply to members who are covered through self-insured administrative services only (ASO) plans nor will it apply to any members of other Blue
    Plans who may access the above networks through BlueCard®.

    How to Obtain Prior Authorization through Sleep Management Solutions 
    • Access the Sleep Management Solutions website at www.sleepsms.com.
    • You may also access the Sleep Management Solutions website through a link on Availity®1at availity.com ; select Payer Resources and then Florida Blue.

    Important:
    • Effective May 1, 2015, you must refer to the Prior Authorization Program section of the Florida Blue Manual for Physicians and Providers for a list of sleep study procedures that require prior authorization. You can access the provider manual at providermanual.bcbsfl.com on our home page at www.floridablue.com/authorization.
    • Appendix A on the following page also provides a list procedures included in the program.
    If you have any questions or require any additional information about this information, please call the Provider Contact Center at (800) 727-2227

    Appendix A
    Sleep Study Procedures (Procedure list is subject to change.)

    95782 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

    95783 - Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

    95800 - Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis(e.g., by air flow or peripheral arterial tone), and sleep time

    95801 - Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)

    95805 - Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

    95806 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist

    95807 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist

    95808 - Polysomnography; any age, sleep staging with 1 –3 additional parameters of sleep, attended by a technologist

    95810 - Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

    95811 - Polysomnography; age 6 or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by technologist

    G0398 - Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation

    G0399 - Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen
    G0400 - Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels

    Note: The list above is not all-inclusive.



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    Change Request 8901, implemented on March 18, 2015, incorporated several provider enrollment policies into Chapter 15 of the Medicare Program Integrity Manual.  One of the changes is associated with the reactivation of Medicare billing privileges.  In summary, when the Medicare Administrative Contractor (MAC) approves a Part B non-certified provider’s/supplier’s reactivation request, the effective date of the reactivation is now the date the MAC received the reactivation request (i.e., the reactivation application or the Reactivation Certification Package[RCP]).  The effective date referenced is the effective date of Medicare billing privileges.  Additionally, the Part B non-certified provider/supplier will be issued a new Provider Transaction Access Number (PTAN) in conjunction with the reactivation.

    Note:  A Part B non-certified provider/supplier is a provider/supplier type other than an Ambulatory Surgical Center (ASC) or a Portable X-ray supplier.

    Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs.

    • If a MAC approves a provider’s or supplier’s Form CMS-855 reactivation application or Reactivation Certification Package (RCP) for a Part B non-certified supplier, the reactivation effective date will be the date the MAC received the application or RCP that was processed to completion. Also, upon reactivating billing privileges for a Part B non-certified supplier, the MAC will issue a new Provider Transaction Access Number (PTAN).

    • CMS may deny a physician’s or eligible professional’s Form CMS-855 enrollment
    application under § 424.530(a)(11) if:
    • The physician’s or eligible professional's Drug Enforcement Administration (DEA) Certificate of Registration to dispense a controlled substance is currently suspended or revoked; or
    • The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked the physician’s or eligible professional's ability to prescribe drugs, and such suspension or revocation is in effect on the date the physician or eligible professional submits his or her enrollment application to the Medicare contractor.
    • CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(13) if:
    • The physician’s or eligible professional's DEA Certificate of Registration is suspended or revoked; or
    • The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked the physician’s or eligible professional's ability to prescribe drugs.
    • CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(14) if CMS determines that the physician or eligible professional has a pattern or practice of prescribing Part D drugs that falls into one of the following categories:
    • The pattern or practice is abusive or represents a threat to the health and safety of Medicare beneficiaries or both.


    • The pattern or practice of prescribing fails to meet Medicare requirements.

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    24h EPSDT/Family Planning (For providers participating in EPSDT and Family Planning programs only)
    Valid values include: Spaces = not applicable Y = EPSDT N = Non-EPSDT


    24i ID Qualifier
    Shaded area: Enter ZZ when entering the taxonomy code for the servicing provider in block 24j If the rendering provider is a One to Many provider, (one NPI to more than one legacy number), enter the provider’s taxonomy code in 24j along with the qualifier ZZ in block 24i if applicable.


    24j Rendering provider’s NPI in unshaded area
    Unshaded area: Enter in the rendering provider’s NPI number Entry is required if the provider is a physician, CNP, therapist; a person and the payment/remit is going to a group or “pay-to” location documented in block 33 Shaded area: If the rendering provider is a One to Many provider, (one NPI to more than one legacy number), enter the provider’s taxonomy code in 24j along with the qualifier ZZ in block 24i if applicable.

    25 Fed Tax ID
    Enter in Tax ID #


    26 Patient Account Number or Name
    Alphanumeric characters may be used (maximum of 20). The account number or name will be printed on the remittance advice.


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    Outpatient observation services defined:

    “The use of a bed for physician periodic monitoring and active monitoring by the hospital's nursing or other ancillary staff, for the patient care which are reasonable and necessary to evaluate an outpatient's condition or determine the need for an inpatient admission. ” - Novitas, Local Coverage Determination (LCD) L27548

    Observation services must be patient specific and not part of the facility’s standard operating procedures. For example, post-procedural recovery and monitoring would not be billable as observation. In certain instances, specific clinical situations may arise and additional outpatient services, or an inpatient admission, may be medically necessary. However, this would have to be outside the standard recovery and monitoring periods for the procedure rendered.

    Observation services are not considered medically necessary when the patient’s current medical condition does not warrant observation, or when there is not an expectation of significant deterioration in the patient’s medical condition in the near future.

    Observation services generally are not expected to exceed 48 hours in duration. Observation services greater than 48 hours in duration are seen as rare and exceptional cases. If medically necessary, Medicare will cover up to 72 hours of observation services. Observation services rendered beyond 72 hours is considered medically unlikely and will be denied as such. The appeals process must be followed to have observation services exceeding 72 hours to be considered for payment. A patient in observation status is either:

    Admitted as an inpatient based on the patient’s condition or; 
    An outpatient and released when the physician determines observation is no longer medically necessary
    A physician’s order is required when placing a patient in observation. Lack of documentation can lead to claim errors and payment retractions. A lack of documentation for an inpatient admission does not warrant retroactive observation billing. An order to admit the patient as an inpatient is also required when billing for an inpatient stay. Again, lack of documentation that clearly indicates the order for admission is grounds for a claim error and payment retraction. For example, and order simply documented as “admit” will be treated as an inpatient admission. A clearly worded order such as “inpatient admission” or “place patient in outpatient observation” will ensure appropriate patient care and prevent hospital billing errors. It is imperative that there is a continued focus on lowering the CERT rate and facility involvement is a key component to this goal.

    Observation Service Billing Requirements

    As discussed; observation services are outpatient services Therefore when the facility is billing for observation services, an outpatient claim will be submitted under a 13X or 85X Type of Bill (TOB). Observation is reported with revenue code 0762 and HCPCS code G0378.
    Because observation may span multiple calendar dates you might be wondering how is this billed following line item billing guidelines? Observation is not split by calendar days per line item. Observation is billed on one line including the total accumulation of observation time with the date that observation care began.
    Institutions are to follow typical billing requirements, reporting all appropriate and applicable ancillary revenue codes and HCPCS / CPT codes along with all applicable diagnosis codes associated with the outpatient service.



    In conclusion, providers are reminded that observation services are provided on an outpatient basis and should be billed according to observation billing guidelines; which state that all hours of observation should be submitted on a single line with the date of service being the date the order for observation was written. Orders for observation services are not considered to be valid inpatient admission levels of care orders. When billing observation services, Novitas Solutions expects the charges associated with those services to be billed as outpatient level of care services. Providers are encouraged to participate in educational opportunities offered by Provider Outreach and Education (POE). Training and educational materials are focused on addressing topics that assist providers in understanding Medicare policies.

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    Compounded drugs are drugs not reconstituted as labeled in order to create a combination of drugs or vary the concentration/volume. As such, compounded medications do not have a National Drug Code (NDC) number, an average sales price (ASP) or an average wholesale price (AWP).

    Compounded drugs are contractor priced. 

    The use of compounded drugs has been especially prevalent in the filling of implantable infusion pumps. The following methods are appropriate when billing for drugs used in implantable infusion pumps:
    1. When submitting a claim for compounded drug(s) for a single agent or a combination of agents, providers must use NOC HCPCS code J7799KD. Even though the compound is similar to or includes a drug with a specific HCPCS code (e.g. HCPCS code J2275 for preservative free morphine), providers must use HCPCS code J7799KD (unclassified drug) for reimbursement of the compounded drug. The KD modifier must be appended to indicate the drug will be administered through a DME.
    2. When a non-compounded drug is used (a true ‘off –the –shelf’ product without compounding), the specific HCPCS code for the drug may be used (see examples below). Payment for these drugs is reimbursed differently and is not subject to the fee schedule below.
    Note: Any drug, compounded or non-compounded, that is administered through an infusion pump must be reported with the KD modifier.

    Medicare will consider implantable infusion pumps and associated services (such as the drugs discussed here) medically reasonable and necessary for the conditions listed in the Medicare National Coverage Determination Manual Pub.100-03, Chapter 1, Section, 280.14.

    This article does not define the medical necessity for use of these drugs but directs the proper billing. Refer to the applicable Local Coverage Determination (LCD), Implantable Infusion Pump, for coverage indications and medical necessity information.

    Please Note: HCPCS code J7799 has a status indicator of N in Part A, bundled no separate payment.

    The billing guidance in this Article is specific to Part B.

    Coding Guidelines:
    1. When billing for compounded drugs, report HCPCS code J7799 with the KD modifier on a single claim line.
    2. Place quantity = ‘1’ on the line billed for J7799KD.
    3. Enter the name and total dose (in mg or mcg) of each drug of the refill in Box 19 of the CMS 1500 or the appropriate comment loop of electronic claims (see examples below).
    4. Covered compounded single or combination drugs should be billed on a single detail line with the exceptions noted below in the examples.
    5. The ICD-9-CM code used on each detailed line must represent the condition treated by the drug(s) billed on that detail line.
    6. Drug doses used in narrative description must be in mgs or mcgs only. Do not report ugs.
    Billing examples of drugs for implanted infusion pumps:
    Non-compounded Baclofen
    Non-compounded Baclofen (J0475KD) is routinely used as a single drug therapy for spasticity. It is not routinely used with other intrathecal combinations for pain management. Medicare does not provide reimbursement for non-compounded baclofen combined with any other intrathecal drugs.
    As baclofen is indicated for use in the treatment of spasticity, refer to the list of covered diagnoses in the associated LCD, Implantable Infusion Pumps.

    Compounded Baclofen
    Baclofen (J7799KD) and pain management drugs do not have the same coverage requirements. Baclofen is indicated for use in the treatment of spasticity. The list of covered diagnoses is part of the associated LCD as noted above. Pain management drugs and baclofen may have different diagnoses based on the LCD coverage.

    The compounded Baclofen is reported on a separate line item from the pain management drug in the compounded mixture. Report separately, as indicated in the examples below.
    Example of compounded mixture: Morphine 20mg/ Bupivacaine 6mg/ Baclofen 4000mcg:
    Report Baclofen 4000mcg (J7799KD) on one claim line, and report Morphine20mg/Bupivacaine 6 mg (J7799KD) on a second claim line.

    If compounded Baclofen (J7799KD), when used as part of compounded drug combination in an implantable infusion pump, is not listed on a separate claim line and the claim does not meet the diagnosis requirements per the LCD; the total compounded drug line will be denied.

    Compounded drug reporting
    Do not list the drug separately from the dosage, such as morphine bupivacaine baclofen sufentanil 20mg 6mg 4mcg 5mcg. This format will be denied.


    List each drug with the applicable dosing amount, for example morphine 20mg, bupivacaine 6 mg, baclofen 4 mcg, sufentanil 5 mcg.

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    31 Signature Signature of person authorized to certify this claim. By signing the BMS Provider Enrollment Agreement providers have certified that all information listed on a claim for reimbursement from Medicaid is true, accurate and complete. Therefore, claims may be endorsed with a computer-generated, manual or stamped signature.

    date Enter the claim submission date.


    32 Service Facility Location Information
    Enter name and address of rendering site, if patient was seen in institutional setting. (Hospital, Nursing Home, etc.)

    32 A&B Servicing Facility NPI
    A. Enter in the Servicing Facilities NPI
    B. Non applicable


    33 Billing Provider Info and Phone number
    Enter required information as followed: Phone Name Address City, State & 9 digit zip code


    33A NPI number of Physician or Supplier 
    Enter the NPI of the servicing or rendering provider or group or pay-to. If the servicing /rendering is in 24j then enter in the servicing providers group number.

    33B Taxonomy code of Physician or Supplier
    Enter ZZ (qualifier) if you are entering in a taxonomy code for the pay-to No spaces between qualifier and value.

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    Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

    Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

    INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY
    Gender Reassignment Surgery

    Gender Identity Disorder (GID) is the formal diagnosis used to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender). Although it is a psychiatric classification, GID is not medically classified as a mental illness.

    In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) are met. The criteria are:
    A.A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
    1.A marked incongruence between one’s experienced/expressed gender and primary and/or sex characteristics; OR
    2.A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender; OR
    3.A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
    4.A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR
    5.A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR
    6.A strong conviction that one has the typical feelings and reactions of the other gender or some alternative gender different from one’s assigned gender; AND

    B.The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    Gender reassignment surgery (GRS) is one treatment option for extreme cases of gender dysphoria or GID, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in his or her own gender. People with gender dysphoria often report a feeling of being born the wrong sex. GRS is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful psychological, behavioral, functional and medical outcomes. Before undertaking gender reassignment surgery, candidates need to undergo important medical and psychological evaluations, begin medical therapies and behavioral trials to confirm that surgery is the appropriate treatment choice.

    Prior to March 27, 2014, GRS was specifically excluded from coverage and reimbursement by The Center for Medicare and Medicaid Services. After May 30, 2014 procedures for GRS may be covered and reimbursable by Medicare when specific criteria outlined below are present and documented in the patient record.



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    What steps can we take to avoid return to provider (RTP) reason code 34931?

    A: One or more present on admission (POA) indicator(s) is/are missing, invalid or incorrectly submitted with the reported diagnosis code(s). It is recommended that you review each diagnosis code and POA indicator to ensure they are correct, prior to submitting your claim.

    • POA is defined as being present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department and/or observation services, or outpatient surgery, are considered POA.

    • Claims for inpatient admission to acute care inpatient prospective payment system (IPPS) hospitals must include the appropriate POA indicator for the principal and all secondary diagnoses, unless the code is exempt.

    • It is important to review the POA exempt list to ensure you are submitting your claims correctly. Refer to downloads on the CMS website, at Hospital Acquired Conditions (Present on Admission) - Coding external link.

    Note: The 2015 ICD-9-CM and ICD-10-CM POA exempt lists are identical to the 2014 ICD-9-CM and ICD-10-CM POA exempt lists. There were no changes.

    • The CMS Hospital-acquired conditions (HAC) and present on admission (POA) indicator reporting provision external pdf file fact sheet provides background information, additional resources and general reporting requirements.
    The following hospitals are exempt from this provision:
    • Critical access hospitals
    • Long term care hospitals
    • Cancer hospitals
    • Children’s inpatient facilities
    • Religious non-medical health care institutions
    • Inpatient psychiatric hospitals
    • Inpatient rehabilitation facilities
    • Veteran’s administration/department of defense hospitals

    Valid values for POA indicators are:

    Code Reason for code

    Y Diagnosis was present at time of inpatient admission.
    N Diagnosis was not present at time inpatient admission.
    U Documentation insufficient to determine if the condition was present at the time of inpatient admission.
    W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

    ‘Blank’ Unreported/not used. Exempt for POA reporting.


    Note: Blank is used on UB-04 claim form and the equivalent 5010 electronic claim version.






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    GRS may be considered medically reasonable and necessary when all the following candidate criteria are met and supporting provider documentation is submitted.

    Candidate Criteria:
    The candidate is at least 18 years of age; and
    Has been diagnosed with GID, including meeting all of the following indications:

    oThe desire to live and be accepted as a member of the opposite sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment; and
    oThe desire for alternate gender identity has been present for at least 5 years; and
    oThe GID is not a symptom of another mental disorder, hormonal aberration or chromosomal variation; and
    oThe GID causes clinical distress or impairment in social, occupational, or other important areas of functioning.

    For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is:

    oRecommended by a mental health professional and
    oProvided under the supervision of a physician; and
    othe supervising physician indicates that the patient has taken the hormones as directed.

    When the initial requested surgery is solely a mastectomy for candidates requesting female to male surgery, the treating physician may indicate that no hormonal treatment (as described above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy are met.
    The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to the original gender. This requirement must be demonstrated by living in their new gender while:

    oMaintaining part- or full-time employment; or
    oFunctioning as a student in an academic setting; or
    oFunctioning in a community-based volunteer activity as applicable.

    If the candidate does not meet the 12 month time frame criteria as noted above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria.
    Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) are required.
    The individual contemplating or undergoing GRS shall have documentation of regular therapy sessions with a qualified mental health professional for two (2) years prior and expectantly, two (2) years following GRS or therapy made available to the Medicare carrier upon request.

    If the individual has significant medical or mental health issues present, they must be well controlled. If the individual is diagnosed with severe psychiatric disorders with impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder, paranoid state or equivalent debilitative disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.

    Failure to control and maintain a lifestyle devoid of psychotic behavior and ideations for a period of 24 months prior to planned surgical intervention renders the individual ineligible for surgical gender reassignment under the Medicare program due to the unacceptably high suicide risk and disastrous sequella seen in individuals psychologically unsuitable for this therapy.

    * At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D, D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

    Primary Gender Reassignment Surgery (GRS-1) may consist of any combination of hysterectomy, salpingo-oophorectomy, mastectomy or orchiectomy, considered medically necessary when all of the above criteria are met.



    Individuals having undergone (or in concert with) any combination of the above primary gender reassignment surgical procedures (GRS-1), may elect to pursue secondary genital reconstructive surgery (GRS-2) consisting of any combination of metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, reduction mammoplasty or mastectomy, or placement of testicular prostheses, Medical Necessity is established only when all criteria for Gender Reassignment Surgery are met.

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