Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 3285 Date: June 19, 2015

Transcription

1 anual ystem Pub edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 3285 Date: June 19, 2015 hange Request 9200 UBJET: creening for epatitis Virus (V) in Adults Implementation of Additional ommon Working ile (W) and hared ystem aintainer (s) Edits I. UARY O ANGE: This hange Request (R) is a follow-up to R 8871, Transmittal 3215 dated arch 11, 2015, entitled creening for epatitis Virus (V) in Adults. R 9200 addresses the line-item denial of V claims for those born outside the years that do not have a high risk indicator as this population is not eligible for the V screening benefit. R 9200 also clarifies/revises from R 8871, Transmittal 3215 the correct use of N messages & 15.20, removes TOBs/payment instructions/modifies editing for: Rs 71, Qs 77, and A 85 ethod II professional services (with revenue code 096, 097, or 098). EETIVE DATE: June 2, 2014 *Unless otherwise specified, the effective date is the date of service. IPLEENTATION DATE: or I shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, - or non-shared A edits; October 5, or W shared systems edits Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. ANGE IN ANUAL INTRUTION: (N/A if manual is not updated) R=REVIED, N=NEW, D=DELETED R/N/D R R R APTER / ETION / UBETION / TITLE 18/210.1/Institutional Billing Requirements 18/210.3/laim Adjustment Reason odes (ARs), Remittance Advice Remark odes (RARs), Group odes, and edicare ummary Notice (N) essages 18/210.4/ommon Working ile (W) Edits III. UNDING: or edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the A tatement of Work. The contractor is not

2 obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. IV. ATTAENT: Business Requirements anual Instruction

3 Attachment - Business Requirements Pub Transmittal: 3285 Date: June 19, 2015 hange Request: 9200 UBJET: creening for epatitis Virus (V) in Adults Implementation of Additional ommon Working ile (W) and hared ystem aintainer (s) Edits EETIVE DATE: June 2, 2014 *Unless otherwise specified, the effective date is the date of service. IPLEENTATION DATE: or I shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, - or non-shared A edits; October 5, or W shared systems edits I. GENERAL INORATION A. Background: Effective for claims with dates of services performed on or after June 2, 2014, the enters for edicare & edicaid ervices covers screening for hepatitis virus (V) consistent with the grade B recommendations by the United tates Preventive ervices Task orce for the prevention or early detection of an illness or disability, and is appropriate for individuals entitled to benefits under edicare Part A or enrolled under Part B. This policy was implemented in hange Request (R) 8871, Transmittal 3215, dated arch 11, B. Policy: As indicated in R 8871, and replicated here for ease of reference only (for these claims processing instructions see R 8871), covers screening for V with the appropriate U.. ood and Drug Administration (DA) approved/cleared laboratory tests, used consistent with DA-approved labeling and in compliance with the linical Laboratory Improvement Act regulations, when ordered by the beneficiary s primary care physician or practitioner within the context of a primary care setting, and performed by an eligible edicare provider for these services, for beneficiaries who meet either of the following conditions: 1. A screening test is covered for adults at high risk for V infection. igh 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 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. A single screening test is covered for adults who do not meet the high risk definition as defined above, but who were born from 1945 through The determination of high risk for V 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. NOTE: (1) or services provided to beneficiaries born between the years 1945 and 1965 who are not considered high risk as defined in the policy, V screening is limited to once per lifetime. New P code G0472, short descriptor - ep screen high risk/other, and long descriptor- epatitis antibody screening for individual at high risk and other covered indication(s), will be used. (Those born prior to 1945 or after 1965 with no risk factors are not eligible for this benefit, and this is the edit being implemented with this follow-up R to R 8871.) (2) or those beneficiaries determined to be high-risk initially as defined in the policy, regardless of birth year, ID-9 diagnosis code V69.8, other problems related to life style/id-10 diagnosis code Z72.89, other problems

4 related to lifestyle (once ID-10 is implemented) is required in addition to P G0472. (3) overage of a sub-set of the above high risk beneficiaries may occur on an annual basis if appropriate as defined in the policy, regardless of birth year, denoted by the presence of P G0472, ID diagnosis code V69.8/Z72.89, and ID-9 diagnosis code , unspecified drug dependence, continuous/id-10 diagnosis code 19.20, other psychoactive substance abuse, uncomplicated (once ID-10 is implemented). Annual is defined as 11 full months must pass following the month of the last negative V screening. (4) V screening, P code G0472, is a technical service only and there is no professional fee. R 8871, Transmittal 3215, provided claims processing instructions for G0472 when submitted on TOBs 71 (R), 77 (Q), and 85 with revenue code 096, 097, or 098 (As ethod II). This change request removes TOBs 71, 77 and 85 with revenue code 096, 097, or 098 as a valid TOB for V P code G0472. NOTE: Only P G0472 as noted above should be reported for this new V screening benefit. PT code 86803, V rapid antibody test, is not appropriate for reporting screening under this policy. II. BUINE REQUIREENT TABLE "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B A D E hared- ystem aintainers Effective for claims with dates of service on and after June 2, 2014, contractors shall be aware of the following clarification: Where N is indicated in previous V screening R 8871, requirements , and : The following policies ND were used when we made this decision. A B A I V W Other panish Version - Las siguientes políticas ND fueron utilizadas cuando se tomó esta decisión. The following language clarification is added: N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your doctor if you think it could change our decision. all EDIARE ( ) for a copy of the LD. panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación.

5 Number Requirement Responsibility A/B A D E hared- ystem aintainers Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ). A B A I V W Other NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N Effective for claims with dates of service on and after June 2, 2014, contractors shall line-item deny P G0472 screening as a covered service for: - Adult beneficiaries born prior to 1945 and after 1965, who are not high risk (absence of V69.8 or V69.8/ ID-10 diagnosis code Z72.89 and /ID-10 diagnosis code 19.20). NOTE: This edit shall be overridable ontractors shall line-item deny claims for V screening, P G0472, that do not meet requirements in with the following messages: AR 96 - Non-covered charge(s). At least one Remark ode must be provided (may be comprised of either the NPDP Reject Reason [sic] ode, or Remittance Advice Remark ode that is not an ALERT.) Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N386 - This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND. N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your doctor if you think it could

6 Number Requirement Responsibility A/B A D E hared- ystem aintainers change our decision. all EDIARE ( ) for a copy of the LD. A B A I V W Other panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ) (continuation of 2.1) ontractors shall use the following N message in addition to N 15.19, as instructed in , when lineitem denying claims for V screening, P G0472, that do not meet requirements in : N The following policies ND were used when we made this decision panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N. Group ode O assigning financial liability to the provider ontractors shall line-item deny claims for V screening, P G0472, that do not meet requirements in with the following messages: N The following policies ND were used when we made this decision panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision AR 96 - Non-covered charge(s). At least one Remark ode must be provided (may be comprised of either the

7 Number Requirement Responsibility A/B A D E hared- ystem aintainers NPDP Reject Reason [sic] ode, or Remittance Advice Remark ode that is not an ALERT.) Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. A B A I V W Other RAR N386 - This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND. Group code - O assigning financial liability to the provider ontractors shall remove the following types of bill (TOBs) as valid for V screening services, P G0472, as initially indicated as valid TOBs in R 8871: TOB 71 Rural ealth linics (Rs) TOB 77 ederally Qualified ealth enters (Qs) TOB 85 ritical Access ospitals (As) ethod II professional services with revenue code 096, 097, or ontractors shall remove claims processing instructions regarding payment of V screening services, P G0472, as initially indicated in R 8871, for: Rs, Qs, and A ethod II with revenue code 096, 097x, or ontractors shall modify current editing for V screening services, P G0472, as initially indicated in R 8871, by removing TOBs 71, 77, and 85 ethod

8 Number Requirement Responsibility A/B A D E hared- ystem aintainers II professional services with revenue code 096, 097, or 098. A B A I V W Other ontractors shall not search their files for claims that may have been processed in error. owever, contractors may adjust claims that are brought to their attention. III. PROVIDER EDUATION TABLE Number Requirement Responsibility LN Article: A provider education article related to this instruction will be available at Network-LN/LNattersArticles/ shortly after the R is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within 5 business days after receipt of the notification from announcing the availability of the article. In addition, the provider education article shall be included in the contractor's next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. A/B A A B D E A E D I IV. UPPORTING INORATION ection A: Recommendations and supporting information associated with listed requirements: "hould" denotes a recommendation. -Ref Recommendations or other supporting information: Requirement Number R 8871, Transmittal 3215 dated arch 11, 2015.

9 ection B: All other recommendations and supporting information: N/A V. ONTAT Pre-Implementation ontact(s): Wendy Knarr, or (upplier laims), William Ruiz, or (Institutional laims Processing), Bridgitte Davis-awkins, or (Practitioner laims Processing), ichelle Issa, or (overage), Wanda Belle, or (overage), Patricia Brocato-imons, or (overage) Post-Implementation ontact(s): ontact your ontracting Officer's Representative (OR). VI. UNDING ection A: or edicare Administrative ontractors (As): The edicare Administrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the A tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. ATTAENT: 0

10 210.1 Institutional Billing Requirements (Rev. 3285, Issued: , Effective: , Implementation: or I shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, - or non-shared A edits; October 5, or W shared systems) Effective for claims with dates of service on and after June 2, 2014, providers may use the following types of bill (TOBs) when submitting claims for V screening, P G0472: 13 and 85. ervice line-items on other TOBs shall be denied. The service shall be paid on the basis shown below: -Outpatient hospitals TOB 13 - based on Outpatient Prospective Payment ystem (OPP) -ritical Access ospitals (As) - TOB 85 based on reasonable cost NOTE: or outpatient hospital settings, as in any other setting, services covered under this ND must be ordered by a primary care provider within the context of a primary care setting and performed by an eligible edicare provider for these services laim Adjustment Reason odes (ARs), Remittance Advice Remark odes (RARs), Group odes, and edicare ummary Notice (N) essages (Rev. 3285, Issued: , Effective: , Implementation: or I shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, - or non-shared A edits; October 5, or W shared systems) ontractors shall use the appropriate claim adjustment reason codes (ARs), remittance advice remark codes (RARs), group codes, or edicare summary notice (N) messages when denying payment for V screening, P G0472: Denying services submitted on a TOB other than 13 or 85: AR Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N95 This provider type/provider specialty may not bill this service. N 21.25: This service was denied because edicare only covers this service in certain settings. panish Version: El servicio fue denegado porque edicare solamente lo cubre en ciertas situaciones." Group ode O (ontractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N Denying services where previous V screening, P G0472, is paid in history for claims with dates of service on and after June 2, 2014, and the patient is not deemed high risk by the presence of ID-9 diagnosis code V69.8, other problems related to lifestyle/id-10 diagnosis code Z72.89, other problems related to lifestyle (once ID-10 is implemented), and ID-9 diagnosis code , unspecified drug dependence, continuous/id-10 diagnosis code 19.20, other psychoactive substance dependence, uncomplicated (once ID-10 is implemented):

11 AR 119 Benefit maximum for this time period or occurrence has been reached. RAR N386 - This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND. N The following policies ND were used when we made this decision. panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision. N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your doctor if you think it could change our decision. all EDIARE ( ) for a copy of the LD. panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ). NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N. Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N NOTE: This edit shall be overridable. Denying services for V screening, P G0472, for beneficiaries at high risk who have had continued illicit drug use since the prior negative screening test, when claims are not submitted with ID-9 diagnosis code V69.8/ID-10 diagnosis code Z72.89 (once ID-10 is implemented), and ID-9 diagnosis code /ID-10 diagnosis code (once ID-10 is implemented), and/or 11 full months have not passed since the last negative V screening test: AR 167 This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N386 - This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND. N The following policies ND were used when we made this decision. panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision. N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your

12 doctor if you think it could change our decision. all EDIARE ( ) for a copy of the LD. panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ). NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N. Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N NOTE: This edit shall be overridable. Denying services for V screening, P G0472, for beneficiaries who do not meet the definition of high risk, but who were born from 1945 through 1965, when claims are submitted more than once in a lifetime: AR 119: Benefit maximum for this time period or occurrence has been reached. RAR N386: This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND. N The following policies ND were used when we made this decision. panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision. N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your doctor if you think it could change our decision. all EDIARE ( ) for a copy of the LD. panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ). NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N. Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N NOTE: This edit shall be overridable.

13 Denying claim lines for V screening, P G0472, without the appropriate PO code: AR 171 Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N428 - Not covered when performed in certain settings. N This service was denied because edicare only covers this service in certain settings. panish Version: El servicio fue denegado porque edicare solamente lo cubre en ciertas situaciones." Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N Denying claim lines for V screening, P G0472, that are not ordered by an appropriate provider specialty: AR The prescribing/ordering provider is not eligible to prescribe/order the service billed. NOTE: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N574 Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider. N This item or service is not covered when performed or ordered by this provider. Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). NOTE: or modifier GZ, use AR 50 and N Denying claim lines for V screening, P G0472, if beneficiary born prior to 1945 and after 1965 who are not at high risk (absence of V69.8 /ID-10 diagnosis code Z72.89 (once ID-10 is implemented) or / ID-10 diagnosis code (once ID-10 is implemented)): AR 96 - Non-covered charge(s). At least one Remark ode must be provided (may be comprised of either the NPDP Reject Reason [sic] ode, or Remittance Advice Remark ode that is not an ALERT.) Note: Refer to the 835 ealthcare Policy Identification egment (loop 2110 ervice Payment Information RE), if present. RAR N386 - This decision was based on a National overage Determination (ND). An ND provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the ND.

14 N Local overage Determinations (LDs) help edicare decide what is covered. An LD was used for your claim. You can compare your case to the LD, and send information from your doctor if you think it could change our decision. all EDIARE ( ) for a copy of the LD. panish Version - Las Determinaciones Locales de obertura (LDs en inglés) le ayudan a decidir a edicare lo que está cubierto. Un LD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LD, llame al EDIARE ( ). N The following policies ND were used when we made this decision. panish Version Las siguientes politicas ND fueron utilizadas cuando se tomo esta decision. NOTE: Due to system requirement, I has combined messages and so that, when used for the same line item, both messages will appear on the same N. Group ode O assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file) ommon Working ile (W) Edits (Rev. 3285, Issued: , Effective: , Implementation: or I shared system edits, split between October 5, 2015, and January 4, 2016, releases; July 20, 2015, - or non-shared A edits; October 5, or W shared systems) The common working file (W) shall apply the following frequency limitations to V screening, P G0472: One initial V screening, P G0472, for beneficiaries at high risk, when claims are submitted with ID- 9 diagnosis code V69.8/ID-10 diagnosis code Z72.89 (once ID-10 is implemented), Annual V screening, P G0472, when claims are submitted with ID-9 diagnosis code V69.8/ID-10 diagnosis code Z72.89 (once ID-10 is implemented), and ID-9 diagnosis code /ID-10 diagnosis code (once ID-10 is implemented), Once in a lifetime V screening, P G0472, for beneficiaries who are not high risk who were born from 1945 through NOTE: These edits shall be overridable. NOTE: V screening, P G0472 is not a covered service for beneficiaries born prior to 1945 and after 1965 who are not at high risk (absence of V69.8/ID-10 diagnosis code Z72.89 (once ID-10 is implemented) and/or / ID-10 diagnosis code (once ID-10 is implemented)).