Provider Information: Part A Medical Review - Articles By The Medical Review Department

Publications


Part A Medical Review
	What Is Medical Review?
	Articles
	CMS Manuals
	CMS Program Transmittals
	Documentation Requirements
	Documentation Tips
	Frequently Asked Questions
	How To Be Proactive?
	ICD-9 codes for Anti-Cancer Drugs
	Inpatient Rehabilitation Facility
	Medical Policy
	Prepayment Review Edits
	Probe Review
	Progressive Corrective Action Process
	Self Administered Drugs
	Skilled Nursing Facility

Tools

Medical Review Home > Part A Medical Review > Articles

Part A Medical Review Articles

This section of our web site contains information written about subjects of Part A Medical Review and Part A Local Medical Review Policies. Please visit the Medical Review Part A Archived Updates Section for updates published before October 1, 2004.

Displaying Medical Review Part A Articles 1 to 25 of 49

Topic	Date	Description
Part A Draft Local Coverage Determination Update	Wednesday, August 27, 2008	Outpatient Sleep Studies, ARA-03-030: This policy has been reopened for comment beginning September 1, 2008. The entire policy, excluding the date requirements for certification, is open for comment.
ICD-9 for Anti-Cancer Drugs Update: August 2008	Friday, August 22, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as for documentation requirements. The Compendia List can be found on the CMS website at: http://www.cms.hhs.gov/CoverageGenInfo/02_compendia.asp The following revisions have been made to the allowable diagnoses for the specified drugs, effective January 1, 2008 or as otherwise specified:
Sacral Nerve Stimulation	Friday, August 22, 2008	Sacral nerve stimulation is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder function. This treatment is one of several alternative modalities for patients with urge urinary incontinence who have not responded to more conservative treatment for at least six months. Such measures might include behavioral and pharmacological treatments that were ineffective or not well tolerated.
Implementation of New Provider Authentication Requirements for Medicare Contractor Provider Telephone and Written Inquiries	Friday, August 15, 2008	CR 6139, from which this article is taken, addresses the necessary provider authentication requirements to complete IVR transactions and calls with a Customer Service Representative (CSR). Effective March 1, 2009, when you call either the IVR system, or a CSR, the Centers for Medicare & Medicaid Services (CMS) will require you to provide three data elements for authentication: 1) Your National Provider Identifier (NPI); 2) Your Provider Transaction Access Number (PTAN), and 3) The last 5-digits of your tax identification number (TIN). Make sure that your staffs are aware of this requirement for provider authentication.
Call Center Closing Times (Part A)	Friday, August 15, 2008	To better serve the provider community, the Centers for Medicare and Medicaid Services (CMS) is allowing Provider Contact Centers across the nation to conduct customer service training during normal business hours. The Medicare Program is very complex with continuous changes and this initiative will help prepare Provider Customer Service Representatives (CSR's) to give quality answers to substantive Medicare related questions or inquiries. Pinnacle Business Solutions, Inc. the Medicare Part A Intermediary for the State of Arkansas, will be participating in this program. We have developed a comprehensive training plan that includes closing our Provider Contact Center for up to eight hours each month. The following closure dates are scheduled for August 2008 and September 2008.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE FIRST IN A SERIES OF ARTICLES	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. These articles will help providers to register for access to CMS online computer services when directed to do so by CMS. This article contains: 11 questions and answers to get you started and Overview of the registration process for IACS-PC defined provider/supplier organization users.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE SECOND IN A SERIES OF ARTICLES ON THE IACS	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. This article contains: 3 questions and answers about the registration process for provider organizations. (See NOTE below.) Links to the Quick Reference Guides for completing the registration process for provider organizations. (See NOTE below.) Note: For purposes of the IACS-PC, "Provider Organizations" include individual practitioners who will delegate IACS-PC work to staff as well as their staff using IACS-PC.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE THIRD IN A SERIES OF ARTICLES ON THE IACS-PC	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. This article describes the 3 steps providers must take to access a CMS Enterprise Provider Application including how to request a provider application role in IACS-PC (See step 2). CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC). Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice.
Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)	Monday, August 04, 2008	This article is based on Change Request (CR) 6107 and reminds the Medicare contractors and providers that the annual ICD-9-CM update will be effective for dates of service on and after October 1, 2008 (for institutional providers, effective for discharges on or after October 1, 2008). You can see the new, revised, and discontinued ICD-9-CM diagnosis codes on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage, or at the National Center for Health Statistics (NCHS) website at http://www.cdc.gov/nchs/icd9.htm in June of each year.
Medicare Coverage of Bioengineered Skin Substitutes (Revised for Clarification and Explanation)	Thursday, July 31, 2008	The following article is written to clarify the articles previously published on August 27, 2007 and November 5, 2007. To be covered by Medicare, any metabolically active product used in ulcer treatment must be billed under the appropriate code and used according to the FDA labeling instructions. Documentation of criteria, frequency, and duration must be included in the medical record. The medical record must clearly document that conservative pre-treatment wound management has been tried and failed to induce healing. Compliance with the FDA approved labeling provisions is subject to monitoring by pre-payment medical review and post payment data analysis with subsequent medical review. Additional utilization guidelines beyond the FDA labeling, and information based on Medical Review results of prior claim review, are included in this article for provider use. This article provides information for coverage of bioengineered skin substitutes and their application. The short descriptors for the codes are in accordance with the AMA copyright agreement. Please refer to the current CPT book for full descriptions. Please remember that the HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits that limits their use with certain CPT codes and global periods. Providers are also reminded that the use must be consistent with State licensure and scope of practice limitations. Documentation should be readily available and submitted to the Contractor upon request.
ICD-9 for Anti-Cancer Drugs Update: July 2008	Thursday, July 24, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as for documentation requirements.
Important Information on the New Medicare Law – The Medicare Improvements for Patients and Providers Act of 2008	Tuesday, July 22, 2008	This article contains a compilation of messages that were issued on July 16, 2008. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008. This legislation alters a number of Medicare policies, which have been the subject of a number of change requests (CRs) and MLN Matters articles published in recent months. The Centers for Medicare & Medicaid Services (CMS) is in the process of revising these previously issued CRs and MLN Matters articles as a result of this legislation. However, CMS feels it is important that physicians, providers and suppliers be aware of five critical issues immediately. These five issues are: New 2008 Medicare Physician Fee Schedule (MPFS) payment rates effective for dates of service July 1, 2008 through December 31, 2008; Extension of the exceptions process for the therapy caps; A delay in the Medicare durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) competitive bidding program; Reinstatement of the moratorium that allows independent laboratories to bill for the technical component (TC) of physician pathology services furnished to hospital patients; and Extension of the payment rule for Brachytherapy and Therapeutic Radiopharmaceuticals. Be sure your billing staff is aware of these changes.
Documentation Guidelines for Group Psychotherapy	Thursday, July 10, 2008	Providers are advised that correct billing and coding are expected on all claims so it is incumbent on all providers to stay apprised of changes. The purpose of this review is to identify the medical necessity of the billing of group psychotherapy services and identify areas of educational need. All providers are encouraged to become familiar with the Indications and Limitations of Coverage, Medical Necessity, and LCD policy revisions.
ICD-9 for Anti-Cancer Drugs Update: New Compendia	Wednesday, July 09, 2008	The Centers for Medicare & Medicaid Services (CMS) will now recognize the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium as an additional source of information in determining which drugs should be covered under Medicare Part B when used to treat patients undergoing cancer treatment through chemotherapy. CMS will no longer use the now obsolete American Medical Association Drug Evaluations (AMA-DE) compendium as a source for making these decisions. Both of these changes will be reflected in CMS’ Medicare Benefit Policy Manual.
Documentation Requirements - Erythropoiesis Stimulating Agents - Non ESRD	Thursday, June 19, 2008	Erythropoietin (EPO) and Darbepoetin Alfa (Aranesp) are ESAs that stimulate the bone marrow to increase red blood cell production and are FDA approved for use in reducing the need for blood transfusion in patients with specific clinical indications. The FDA issued alerts and warnings in 2007 for ESAs administered for a number of clinical conditions due to increased mortality, serious cardiovascular and thromboembolic events, as well as tumor progression. There are published studies available on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.hhs.gov as well as a National Coverage Determination (NCD), #110.21, which was posted 4/8/08. It is incumbent on providers to stay apprised of this information. Providers are required to maintain documentation for services rendered and to submit that documentation to the Fiscal Intermediary when requested. The following documentation will be expected in response to an Additional Documentation Request (ADR) for ESA services. Please note, this is not an all inclusive list nor will all elements apply to every service, so providers are expected to submit any additional documentation that may support the services billed. In addition, accurate coding and billing are expected and a claim may be denied in part or full if there are technical errors.
ICD-9 for Anti-Cancer Drugs Update: J0894 (Decitabine)	Thursday, June 19, 2008	Please note that effective June 1, 2008, J0894 (Decitabine) will be removed from the audit for Anti-Cancer Drugs (Medicare Part B Local Coverage Determination AC-01-024). Decitabine will then be adjudicated on the basis of Medicare Part B Local Coverage Determination (LCD) AC-01-023 Office Injectables.
ICD-9 for Anti-Cancer Drugs Update - June 2008	Wednesday, June 11, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information) and/or AHFS (American Hospital Formulary Service Drug Information) providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as documentation requirements. The following revisions have been made to the allowable diagnoses for the specified drugs, effective January 1, 2008 or as otherwise specified.
Instructions for Institutional Providers and Suppliers Billing Self-Referred Mammography Claims Regarding the Attending/Referring Physician National Provider Identifier (NPI)	Tuesday, June 10, 2008	This article is based on Change Request (CR) 6023 which provides National Provider Identifier (NPI) instructions for institutional providers and suppliers billing for self-referred mammography services. Do not use the surrogate unique physician identification number (UPIN) of "SLF000" on claims effective May 23, 2008. Providers of mammography services are instructed to report their own facility NPI in the attending physician NPI field in cases where the service is self-referred by the patient (beneficiary) and no attending/referring physician NPI is available. See the Background and Additional Information Sections of this article for further details regarding these changes.
July 2008 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files	Tuesday, June 10, 2008	CR 6049, from which this article is taken, instructs Medicare contractors to download and implement the July 2008 Average Sales Price (ASP) drug pricing file for Medicare Part B drugs; and if released by CMS, also the revised April 2008, January 2008, January 2007, April 2007, July 2007, and October 2007 files.
ICD-9 for Anti-Cancer Drugs Update: May 2008	Thursday, May 22, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information) and/or AHFS (American Hospital Formulary Service Drug Information) providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as documentation requirements. The following revisions have been made to the allowable diagnoses for the specified drugs, effective January 1, 2008 or as otherwise specified:
Pinnacle Business Solutions, Inc. Holiday	Monday, May 19, 2008	Pinnacle Business Solutions, Inc. will be closed on Monday, May 26, 2008 in observance of the Memorial Day holiday. EDI Technical Support and Customer Service Representatives will not be available. The EDI Gateway will be available for transmissions and report retrieval. No Medicare checks or Electronic Remits will be generated on these dates.
Assignment of Providers to Medicare Administrative Contractors	Friday, May 16, 2008	This "One Time Notice" CR describes the Centers for Medicare & Medicaid Services (CMS) approach for assigning providers to MACs and discusses the process of moving providers to MACs.
Part A Local Coverage Determination Updates	Wednesday, May 14, 2008	The following Part A LCDs have been revised: Anti-Cancer Drugs ARA-01-024, Audiology Services ARA-02-027, Chronic Wound Care ARA-02-025.
Provider Authentication by Medicare Provider Contact Centers	Monday, May 05, 2008	SE0814 covers the implementation of the National Provider Identifier (NPI) and the Provider Transaction Access Number (PTAN), effective May 23, 2008, as the provider authentication elements used when providers make telephone or written inquiries to the Medicare fee-for-service contractor provider contact centers. Note: For providers enrolled in Medicare before May 23, 2008, their PTAN initially will be their legacy provider number. New providers enrolling in Medicare on or after May 23, 2008, will be assigned a PTAN as part of the Medicare enrollment process.
New HCPCS Codes for the April 2008 Update	Tuesday, April 22, 2008	This article is based on Change Request (CR) 5981, which instructs Medicare Contractors to implement Healthcare Common Procedure Coding System (HCPCS) code changes effective April 1, 2008. Make sure that your billing staffs are aware of these changes.
Previous Next

Home \| Site Search \| FAQ's \| Contact Us \| Locate Us \| Subscribe \| Help \| Hurricane Updates	Skip Navigation Bar