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AHRQ Study Shows Families Could Save More Than $1,000 on Average if States Expanded Medicaid


A new AHRQ study published in Health Affairs estimated that low income, uninsured adults could have saved, on average, more than $1,000 per year in family out-of-pocket health care costs if they were able to enroll in Medicaid, according to the analysis by AHRQ researcher Steven Hill, Ph.D. The study measured family out-of-pocket health care spending in 2005-2010 among uninsured, low-income adults who gained eligibility for Health Insurance Marketplace coverage because they lived in states that had not yet expanded Medicaid under the Affordable Care Act. It then compared those data with the following simulated scenarios for these adults: coverage in a Marketplace silver plan with financial assistance and enrolling in expanded Medicaid. Findings revealed under a Marketplace silver plan, average out-of-pocket health care spending would have been $1,948 per year, while under Medicaid, out-of-pocket health care spending would have been $938 a year. Thus, enrolling in Medicaid would have saved these adults’ families approximately $1,000 per year, on average, compared with a Marketplace silver plan.


Prompt payment interest rate revision


Medicare must pay interest on clean claims if payment is not made within the applicable number of calendar days (i.e., 30 days) after the date of receipt. The applicable number of days is also known as the payment ceiling. For example, a clean claim received March 1, 2014, must be paid before the end of business March 31, 2014.

The interest rate is determined by the applicable rate on the day of payment. This rate is determined by the Treasury Department on a six-month basis, effective every January and July 1. Providers may access the Treasury Department Web page http://fms.treas.gov/prompt/rates.html external link for the correct rate. The interest period begins on the day after payment is due and ends on the day of payment.

The new rate of 2.125 percent is in effect through June 30, 2015.

Interest is not paid on:

• Claims requiring external investigation or development by the Medicare contractor
• Claims on which no payment is due
• Claims denied in full
• Claims for which the provider is receiving periodic interim payment
• Claims requesting anticipated payments under the home health prospective payment system.

Note: The Medicare contractor reports the amount of interest on each claim on the remittance advice to the provider when interest payments are applicable.

Reference: http://medicare.fcso.com/Billing_news/209233.asp

Proper use of ‘Medicare Treatment Authorization’ field


Starting January 5, 2015, the “Medicare Treatment Authorization” field must contain blanks or valid Medicare data in the first 14 bytes of the treatment authorization field for direct data entry (DDE) and hardcopy claims and at the loop 2300 REF02 (REF01=G1) segment for the ASC X12 837 claim.

Institutional claims submitted without blanks or valid data (see list below) will be returned to the provider with reason code 30729 for correction. Providers should work with their system representatives or vendors to ensure the field complies with these instructions.

Valid data for the ‘Medicare Treatment Authorization’ field

The following list represents the current valid data used in the “Medicare Treatment Authorization field”; any other data (other than blanks or the valid data values listed below) will be returned to the provider (RTP) with reason code 30729.

Valid data in the loop 2300 REF02 (REF01=G1) segment for the ASC X12 837 claim may be any of the following values:

• Unique Tracking Number (UTN)=FIRST TWO POSITIONS OF UTN MUST BE ALPHA-NUMERIC AND NOT CONTAIN SPACES, THIRD POSITION OF UTN IS AN A OR H, LAST 11 POSITIONS OF UTN MUST BE NUMERIC AND NOT CONTAIN SPACES.
• TRIAL 49
• SPN66
• 64
• 56
• A/B REBILLING
• 54
• SPN65
• 07
• 08
• Valid 18-byte OASIS Treatment Number for Home Health claims

Routine ABN Prohibition Exceptions


ABNs may be routinely given to beneficiaries and considered to be effective notices which will protect notifiers in the following exceptional circumstances:

A. Services Which Are Always Denied for Medical Necessity 

In any case where a national coverage decision provides that a particular service is never covered, under any circumstances, as not reasonable and necessary under §1862(a)(1) of the Act (e.g., at present, all acupuncture services by physicians are denied as not reasonable and necessary), an ABN that gives as the reason for expecting denial that: “Medicare never pays for this item/service” may be routinely given to beneficiaries, and no claim need be submitted to Medicare. If the beneficiary demands that a claim be submitted to Medicare, the notifier should submit the claim as a demand bill.

B. Experimental Items and Services 

When any item or service which Medicare considers to be experimental (e.g., “Research Use Only” and “Investigational Use Only” laboratory tests) is to be furnished, since all such services are denied as not reasonable and necessary under §1862(a)(1) of the Act because they are not proven safe and effective, the beneficiary may be given an ABN that gives as the reason for expecting denial that: “Medicare does not pay for services which it considers to be experimental or for research use.” Alternative, more specific, language with respect to Medicare coverage for clinical trials may be substituted as necessary as the ABN’s reason for expecting denial.

C. Frequency Limited Items and Services 

When any item or service is to be furnished for which Medicare has established a statutory or regulatory frequency limitation on coverage, or a frequency limitation on coverage on the basis of a national coverage decision or on the basis of the contractor’s local medical review policy (LMRP), because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances, the notifier may routinely give ABNs to beneficiaries. In any such routine ABN, the notifier must state the frequency limitation as the ABN’s reason for expecting denial (e.g., “Medicare does not pay for this item or service more often than frequency limit”).

D. Medical Equipment and Supplies Denied Because the Supplier Had No Supplier Number or the Supplier Made an Unsolicited Telephone Contact

Given that Medicare denials of payment under §1834(j)(1) of the Act on the basis of a supplier’s lack of a supplier number, and under §1834(a)(17)(B) of the Act, the prohibition on unsolicited telephone contacts, apply to all varieties of medical equipment and supplies and to all Medicare beneficiaries equally, the usual prohibition on provision of routine notices to all beneficiaries does not apply in these cases.

NOTE: A routine ABN, like any other ABN, is effective only for the reason for expecting denial that is specified on the ABN. Such a routine ABN will not be effective notice, that is, will not shift liability to the beneficiary, in the case of any Medicare denial of the claim for any reason other than that specified on the ABN.

Reference: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

NCD for Transcatheter Mitral Valve Repair (TMVR)


Effective for claims with dates of service furnished on or after August 7, 2014, the Centers for Medicare & Medicaid Services (CMS) will reimburse claims for TMVR for Mitral Regurgitation (MR) when furnished under Coverage with Evidence Development (CED).

TMVR is non-covered for the treatment of MR when not furnished under CED according to the above-noted criteria. TMVR used for the treatment of any non-MR indications are non-covered by Medicare.

Coding Requirements for TMVR for MR Claims Furnished on or After August 7, 2014

The Current Procedural Terminology (CPT) Codes for TMVR for MR Claims are:

• 0343T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis. (Note: 0343T will be replaced by CPT code 33418 effective January 1, 2015.)

• 0344T - Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure). (Note: 0344T will be replaced by CPT code 33419 effective January 1, 2015.)

• 0345T - Transcatheter mitral valve repair percutaneous approach via the coronary sinus

• 33418 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. (Note: CPT code 33418 is effective January 1, 2015.)

• 33419 - Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session. (List separately in addition to code for primary procedure.) (Note: CPT code 33419 is effective January 1, 2015.)

ICD-9/ICD-10 Codes for TMVR for MR Claims

• ICD-9 Procedure Code - 35.97 - Percutaneous mitral valve repair with implant - and ICD-10 procedure code is 02UG3JZ – Supplement mitral valve with synthetic substitute, percutaneous approach

• ICD-9 Diagnosis Code for TMVR for MR Claims is - 424.0 – Mitral valve disorder and ICD-10 diagnosis codes are I34.0 – Nonrheumatic mitral (valve) insufficiency or I34.8 – Other nonrheumatic mitral valve disorders

Professional Claims Place of Service (POS) Codes for TMVR for MR Claims

Effective for claims with dates of service on and after August 7, 2014, place of service (POS) code 21 is valid for use for TMVR for MR services. All other POS codes will be denied. MACs will supply the following messages when MACs denying TMVR for MR claims for invalid POS:

• Claim Adjustment Reason Code (CARC) 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed Advance Beneficiary Notice (ABN) is on file.)

Professional Claims Modifiers for TMVR for MR Claims

Effective for claims with dates of service on or after August 7, 2014, MACs will pay TMVR for MR claim lines billed with CPT codes 0343T, 0344T, and 00345T when billed for two surgeons/co-surgeons only when the claim includes modifier -62. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.) Claim lines for two surgeons/co-surgeons billed without modifier -62 shall be returned as unprocessable.

Effective for claims with dates of service on or after August 7, 2014, MACs will pay claim lines for TMVR for MR billed with CPT codes 0343T, 0344T, and 0345T in a clinical trial when billed with modifier -Q0. (Effective January 1, 2015, CPT codes 33418 and 33419 replace CPT codes 0343T and 0344T, respectively.) TMVR for MR claim lines in a clinical trial billed without modifier -Q0 will be returned as unprocessable. 

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9002.pdf

Medicare Claims will be on hold till January 14, 2015


On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2015 services paid under the MPFS for the first 14 calendar days of January 2015 (i.e., Thursday January 1 through Wednesday January 14). The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MPFS claims for services rendered on or before Wednesday Dec 31, 2014 are unaffected by the 2015 claims hold and will be processed and paid under normal procedures and time frames.

2015 CPT Book - New definition for Colonoscopy procedures


The definition of a colonoscopy examination is now specifically described in CPT as the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

When performing a diagnostic or screening procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.

If a therapeutic examination colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

New codes for the colonoscopy family include endoscopic mucosal resection (EMR), band ligation and decompression for pathologic distention. Revised codes address appropriate reporting of ablation and stent placement. 

Colonoscopy through Stoma

Colonoscopy through stoma has been specifically defined in CPT as the examination of the colon, from the colostomy stoma to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. 

When performing a diagnostic or screening colonoscopy through stoma on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 44388 with modifier 53 and provide appropriate documentation.

If a therapeutic colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy through stoma code with modifier 52 and provide appropriate documentation.

New codes for the colonoscopy through stoma family include endoscopic mucosal resection, submucosal injection, balloon dilation, EUS, EUS with FNA, and decompression for pathologic distention. Revised codes address appropriate reporting of ablation and stent placement. 

Enteroscopy

A new definition and instructions for reporting antegrade transoral small intestine endoscopy (i.e., enteroscopy) have been added to the section guidelines. Enteroscopy is defined by the most distal segment of small intestine that is examined; coding does not reflect the technology used to perform the examination.

Codes in the 44360 family for enteroscopy, not including ileum (44360–44373), are endoscopic procedures to visualize the esophagus through the jejunum using an antegrade approach. Codes in the 44376 family for enteroscopy, including ileum (44376–44379), are endoscopic procedures to visualize the esophagus through the ileum using an antegrade approach. 

If an endoscope cannot be advanced at least 50 cm beyond the pylorus, see the appropriate code in the EGD family (43233, 43235–43259, 43266, 43270). If an endoscope can be passed at least 50 cm beyond pylorus, but only into jejunum, see the appropriate code in the enteroscopy, not including ileum family (44360–44373). 

To report retrograde examination of small intestine via anus or colon stoma, use 44799, Unlisted procedure, small intestine.

There were no changes to the language of the individual CPT codes.

Unlisted Procedures

A new code has been developed and one revised to distinguish unlisted procedure of the colon from unlisted procedure of the small intestine and unlisted procedure of the rectum.

See also complete list of 2015 CPT Changes

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