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Podiatrists and Optometrists Billing for Nursing Facility Assessments |
9/27/2004 |
Podiatrists and optometrists cannot be reimbursed for comprehensive nursing facility assessment CPT codes 99301-99303. These codes require an evaluation and management of a new or established patient. According to the Centers for Medicare & Medicaid Services (CMS), only a doctor of medicine or osteopathy legally authorized to practice medicine or surgery in the state may serve as a physician as described in regulation 42 CFR 483.40 (b)(1). This CFR regulation requires the physician to review the nursing facility resident’s total program of care, which includes areas of assessment which are outside the scope of a podiatrist’s or optometrist’s practice. The nursing facility resident’s attending or admitting physician must perform a full assessment. Podiatrists or optometrists may bill subsequent nursing facility care CPT codes 99311-99313 which include new or established patients. (Refer to the CPT 2000 for a full description of the CPT codes in this article.) |
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Service Specific Audit - Procedure Code 11721 |
9/27/2004 |
Data Analysis shows the AR Consortium with a standard deviation in Carrier to Nation ratio greater than 3.0 in allowed services per beneficiary for procedure code 11721. In addition, the data indicates providers are billing debridement codes (11720, 11721) when actually performing routine foot care, billing Evaluation and Management code with Modifier 25 on the same date of service as debridement when no separate identifiable service was documented, no documentation for the extent of debridement, and billing modifier 59 and another procedure code on the same date of service as debridement, with no documentation to support a distinct procedural service. Based on medical review findings and data analysis a prepay medical review audit is being established on procedure code 11721. Requirements to comply with request for additional documentation are below. |
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Nail Debridement Procedure Code 11721 |
9/27/2004 |
This is an informational article on the plan to implement a service specific audit on procedure code 11721. Any billing of this procedure code should meet the guidelines set forth in the Consortium policy AC-03-003. |
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Billing the -22 Modifier (Unusual Circumstances) |
9/2/2004 |
The role of the -22 modifier is to reflect additional work that is not typically part of a particular procedure but does not qualify for its own procedure code. Surgeries for which services performed are significantly greater than usually required may be billed for additional reimbursement with the -22 modifier added to the CPT code for the procedure. Billing of the -22 modifier will generate an ADR (additional documentation request) and the claim will be referred to Medical Review. In response to the ADR, providers should submit the following. |
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Part B Local Coverage Determination |
8/31/2004 |
The following Part B Medical Policies have been revised: INDEPENDENT DIAGNOSTIC TESTING FACILITIES, AC-03-007 -
The CPT/HCPCS listing in the Indications and Limitations contained a typographical error listing "&TC" instead of two CPT codes. This has been corrected and "&TC" in the HCPCS column has been replaced with CPT codes 73222 and 74251. |
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Part B Local Coverage Determination |
8/22/2004 |
The following Part B Medical Policies have been revised: INDEPENDENT DIAGNOSTIC TESTING FACILITIES, AC-03-007 -
The one-year period from the policy effective date for the certification/licensure requirements in Indication and Limitation #5 was clarified to note this grace period applies to existing IDTFs (unless previous local medical review policies had set the same requirements) and not new enrolling IDTFs. Existing IDTFs have through midnight on August 14, 2005 to meet the requirements specified in AC-03-007, where as new enrolling IDTFs must meet these requirements before approval is granted.
Under the Technician Qualifications listing in the Indication and Limitation section, BRPT did not have a number assigned to the qualification. Therefore, #7 was assigned to it and the rest were renumbered. |
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Part B Local Coverage Determination |
8/9/2004 |
The following Part B Medical Policies have been revised: Wet Mounts, AC-03-055 - Policy was revised to allow ICD-9-CM code 112.84 for candidal esophagitis, retroactive to effective date of the policy which was April 15, 2004. TTE, AC-02-014 - This policy has been reformatted from a LMRP (Local Medical Review Policy) to new LCD (Local Coverage Determination) format. Policy was revised to allow ICD-9-CM code V58.1 to allow for pre-chemotherapy assessment as outlined in Indication and Limitation #4. |
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Part B Local Coverage Determination |
8/2/2004 |
The following Part B Medical Policy has been revised: LEUPROLIDE ACETATE/GOSERELIN (GONADOTROPIN RELEASING HORMONE ANALOGS), AC-01-019 - The latest revision of policy AC-01-019 contained an incorrect effective date. The effective date for New Mexico's least costly alternative (LCA) provision was incorrectly listed as October 1, 2001 and has been changed to the correct date of September 30, 2001. The September 30, 2001 date coincides with the Revision Effective Date specified in the local policy titled "Leuprolide Acetate & Goserelin Acetate or Leuprolide Acetate Implant (Viadur), #96-030" that was in effect in 2001. |
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Coding For MOHS Micrographic Surgery (Part B) |
8/1/2004 |
Multiple issues have been identified in the past year related to the reimbursement and coding of CPT 17304-17310. Initially, there was an error in the 2003 Medicare Physician’s Fee Schedule Data Base (MPFSDB), which was corrected. The information on the 2004 MPFSDB remains correct meaning these codes have a “0” Indicator, which indicates multiple surgery rules do not apply to these codes.
Coding guidelines were found to be either unclear or open to interpretation among the various resources (“CPT 2004”, “CPT Assistant” and LMRP). As a result, appropriate coding has been reviewed extensively by the Carrier Medical Directors, PrePay Medical Review, Dermatological Consultants and the technical support staff.
The following guidelines have been developed and test claims completed to ensure consistency and accuracy. |
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Part B Local Coverage Determination |
8/1/2004 |
The following Part B Medical Policy has been revised: MOHS' MICROGRAPHIC SURGERY, AC-02-029 - This policy has been reformatted from a LMRP (Local Medical Review Policy) to new LCD (Local Coverage Determination) format. Indication and Limitation #4, "The following ICD-9-CM codes and CPT procedures must be documented in order to support the necessity of the Mohs' procedure" has been deleted. Also deleted was Documentation Requirement #2 regarding modifier 59. Please refer to the article "Coding for Mohs Micrographic Surgery" published in the July 2004 Medicare Providers' News, #MCB 2004-07, for coding guidance and clarification. |
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Medicare Local Coverage Determination Open Meetings |
7/28/2004 |
The Carrier's Open Forum Meeting for discussion of draft policies that was scheduled for November 30, 2004 has been canceled due to a schedule change. The next scheduled meeting is January 2005. Please view the Draft LCD Section of the web site for specific dates and times. |
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Medicare Local Coverage Determination Open Meetings |
7/28/2004 |
In order to ensure that the development of LCDs occurs through a public and open process, Arkansas Medicare Services invites submission of information from members of the general public. Medicare Services permits interested parties to submit scientific, evidence-based information, professional consensus opinions, or any other relevant information regarding Draft LCDs. Open meetings will be held prior to the presentation of these policies at the Contractor Advisory Committee (CAC) meeting. The 2005 schedule for the Open Meeting has been set. The dates are January 4, 2005, May 3, 2005, and September 6, 2005. |
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Part B Local Medical Review Policy |
7/15/2004 |
The following Part B Medical Policy has been revised: LEUPROLIDE ACETATE/GOSERELIN (GONADOTROPIN RELEASING HORMONE ANALOGS), AC-01-019 - A typographical error was corrected on CPT code 11981 in the HCPCS section. When the policy converted to LCD, the "*" designating 11981 to be used only for the insertion, removal or removal with reinsertion of the Viadur implant was inadvertently omitted on CPT code 11981. This has been corrected. |
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Prepay Medicare Review Part B
Documentation Requirements |
7/13/2004 |
This web page has been specifically designed by Prepay Medical Review, Part B, for providers to offer assistance regarding the documentation requirements Medicare needs to adjudicate your claims. The intent is to provide education and information on the medical review process and to explain why the carrier may request copies of medical documentation from providers in carrying out medical review activities. A link to all PrePay audits implemented by the carrier (except provider specific audits) are listed on this web page. |
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Part B Local Medical Review Policy |
7/6/2004 |
The following Part B Medical Policies have been revised: AICD AC-02-001, Flow Cytoemtry AC-02-022, Insertable Loop Recorder AC-99-529, Leuprolide Acetate/Goserelin (Gonadotropin Releasing Hormone Analogs) AC-01-019, Non-Invasive Vascular Studies AC-02-055, Serum Magnesium AC-03-050. |
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July 2004 Part B Policy Notice Newsletter |
6/27/2004 |
Part B Policy Notice Newsletter |
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Part B Local Medical Review Policy |
5/18/2004 |
The following Part B Medical Policies have been revised: Allergy Patch Test(S), Ambulatory Blood Pressure Monitoring, Debridement Of Toenails, Electrical Bioimpedance Monitoring For Cardiac Output, Epo For Treatment Of Anemia Associated With Chronic Renal Failure, Low Osmolar Contrast Media, Pachymetry, Physical Medicine And Rehabilitation |
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Part B Local Medical Review Policy |
4/5/2004 |
The following Part B Medical Policies have been revised: Colonoscopy Diagnostic Therapuetic and Screening AC-02-020, Pachymetry AC-03-011, Pulmonary Function Testing AC-03-012, Sandostatin Depot (Octreotide Acetate for Injectable Suspension) AC-00-011. |
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Part B Local Medical Review Policy |
3/2/2004 |
The following Part B Medical Policies have been revised: AICD (Automatic Implantable Cardiac Defibrillator), Bilaminate Skin Substitutes, Debridement Of Toenails, Ibritumomab Tiuxetan (Zevalin), Local Injections For Trigger Points, Magnetic Resonance Angiography (Mra), Noninvasive Vascular Studies, Pamidronate (Aredia), Physical Medicine And Rehabilitation,. |
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Part B Local Medical Review Policy |
3/2/2004 |
Effective March 1, 2004, the following Medicare Part B policies have been retired: Diabetes Outpatient Self-Management Services and Left Heart Catheterization. |
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Part B Local Medical Review Policy |
1/30/2004 |
The following Part B Medical Policy has been updated: EPO FOR TREATMENT OF ANEMIA ASSOCIATED WITH CHRONIC RENAL FAILURE, AC-02-048 - Effective with date of service January 1, 2004, HCPCS code Q4055 replaced Q9920-Q9940 for ESRD patients on dialysis. Effective with date of service January 1, 2004, HCPCS code Q0136 should be used for ESRD patients not on dialysis. "Coding Guidelines" 1.g. (Special Note) and 2.b. were revised and #8 was added to reflect these changes. Revised "Coding Guideline" 1.a to note "coding diagnoses" means both 285.21 and 585. "Sources" was revised to include Transmittals #18 and #39, as well as Chapter 8, section 60.4 of the Medicare Claims Processing Manual. |
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Medicare Local Medical Review Policy Open Meetings |
1/23/2004 |
In order to ensure that the development of LMRP occurs through a public and open process, Oklahoma/New Mexico Medicare Services invites submission of information from members of the general public. Oklahoma/New Mexico Medicare Services permits interested parties to submit scientific, evidence-based information, professional consensus opinions, or any other relevant information regarding Draft LMRPs. Open meetings will be held prior to the presentation of these policies at the Contractor Advisory Committee (CAC) meeting. The 2004 schedule for the Open Meeting has been set. The dates are March 30, 2004, July 27, 2004, and November 30, 2004. We will continue to post a list of the anticipated draft policies by the first of the month and the draft by the comment period begin date which is the seventeenth. |
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Part B Local Medical Review Policy |
1/23/2004 |
The following Part B Medical Policy has been updated: EPO FOR TREATMENT OF ANEMIA ASSOCIATED WITH CHRONIC RENAL FAILURE, AC-02-048 - Added HCPCS code Q4055 which replaced Q9920-Q9940 effective with date of service January 01, 2004. Revised the 'special Note' under "Coding Guideline" #1 and "Coding Guideline" #2.b to reflect these changes. |
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Part B Local Medical Review Policy |
12/9/2003 |
The following Part B Medical Policies have been updated: Ablation Of Hepatic Tumors, Ambulatory Blood Pressure Monitoring, Anoscopy/Proctoscopy/Sigmoidoscopy (Diagnostic, Therapeutic, And Screening)/Fecal Occult Blood, Audiology Services, Bilaminate Skin Substitutes, Biofeedback Therapy, Bladder Scan, Chiropractic Service (Manual Spinal Manipulation), Coronary Angiography, Critical Care, Deep Brain Stimulation, Electrical Bioimpedance Monitoring For Cardiac Output, Endovascular Repair Of Infrarenal Abdominal Aortic Aneurysm, Granulocyte Colony-Stimulating Factors, Holter Monitor - Long Term Ekg Monitoring, Immune Globulin, Intravenous, Interventional Cardiology, Left Heart Catheterization, Low Osmolar Contrast Media, Magnetic Resonance Angiography (Mra), Mohs' Micrographic Surgery, Monitored Anesthesia Care (Mac), Myocardial Perfusion Testing, Noninvasive Vascular Studies, Office Injectables, Ophthalmoscopy, Extended, Pachymetry, Percutaneous Transluminal Angioplasty With Or Without Stenting For Abdominal Aortic Stenosis Or Chronic Total Occlusion And Lower Extremity Claudication, Percutaneous Renal Artery Angioplasty With Or Without Stenting, Physical Medicine And Rehabilitation, Pulmonary Function Testing, Sandostatin® Depot (Octreotide Acetate For Injectable Suspension), Small Intestinal Imaging, Steroid Injections, Thermotherapies (Minimally Invasive Surgical Techniques (Mists) For Benign Prostatic Hyperplasia (Bphs), Therapeutic Apheresis, Transjugular Intrahepatic Portosystemic Shunt (Tips), Transtelephonic (Home) Spirometry, Transmyocardial Revascularization (Tmr) For Treatment Of Severe Angina, Transesophageal Echocardiography, Transthoracic Echocardiography (Tte), Upper Gastrointestinal Endoscopy (Diagnostic And Therapeutic), Urinalysis, Urolumetm Endoprosthesis, Vitamin B-12 |
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Outpatient Sleep Studies, AC-03-030 LMRP (Part A and B) |
12/5/2003 |
Outpatient Sleep Studies, AC-03-030: The Description and Documentation Requirements sections of the policy that was published in our November 2003 Providers' News contained certification/accreditation requirements that were effective with the implementation date of December 15, 2003. However, the Carrier received comments during the notice period regarding the timeframe required for certification. Therefore, we are postponing implementation of the certification/accreditation requirements until we can establish an appropriate timeframe.
This postponement applies only to the certification/accreditation requirements. All other aspects of policy AC-03-030 remain effective with date of service December 15, 2003. |
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