CMS, DHHS/MediCal, & Palmetto/J1MAC News

The following information has been received by ANCO.


****CMS NEWS****
The Centers for Medicare & Medicaid Services (CMS) has posted the July 2009 ASP pricing files and crosswalks, which are available for download at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a1_2009aspfiles.asp


SE0910 – Clarification for Billing Part B versus Part D for the Anti-emetic Aprepitant (Emend®)
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0910.pdf


The written and audio transcripts of the ICD-10-CM/PCS Implementation and General Equivalence Mappings (Crosswalks) National Provider Conference Call, which was conducted by the Centers for Medicare & Medicaid Services on May 19, 2009, are now available in the Downloads Section at http://www.cms.hhs.gov/ICD10/06a_2009_CMS_Sponsored_Calls.asp .


The Centers for Medicare & Medicaid Services (CMS) must announce that the 2007 Physician Quality Reporting Initiative (PQRI) feedback reports that have been posted since July 2008 on www.qualitynet.org/pqri will be archived effective June 30, 2009 and will no longer be available to eligible professionals (EPs) who participated in the 2007 PQRI.

Archiving is required to create server space for new feedback reports related to the 2008 PQRI and the 2007 PQRI re-run participation. Only those EPs who previously did not qualify by submitting at least one quality data code successfully, but are newly qualified following the back-end system analysis and re-run of 2007 PQRI data, will receive a 2007 PQRI re-run feedback report.

All eligible professionals who successfully submitted at least one quality data code for the 2008 PQRI will receive a feedback report. These reports should be available in October 2009.

The 2008 PQRI incentive payment will be distributed by the Carrier and/or A/B MAC in October 2009. The 2007 PQRI re-run incentive payments will be distributed by the Carrier and/or A/BMAC in November 2009.

Additional information about the 2007 PQRI feedback reports can be found in the “2007 PQRI Program” section page at http://www.cms.hhs.gov/pqri on the CMS website.


It is not too late to start participating in the 2009 Physician Quality Reporting Initiative (PQRI) and potentially qualify to receive incentive payments. A new half-year reporting period begins on July 1. If you have not yet started, you can begin by reporting either:

· Three individual 2009 PQRI measures for at least 80% of applicable Medicare Part B FFS patients seen between July 1, 2009 and December 31, 2009 through a qualified 2009 PQRI registry. To qualify for a half-year incentive (some registries may allow an eligible professional to submit data to them from the start of 2009 thus being able to report for the entire year); or

· A measures group through claims or a qualified 2009 PQRI registry.; depending on the sample method selected for a measures group, you could qualify for:
o A half-year incentive by reporting the measures group on 80% of applicable Medicare Part B FFS patients seen between July 1, 2009 and December 31, 2009 or
o A full-year incentive by reporting the measures group on 30-consecutive patients.

A list of qualified registries for the 2009 PQRI can be found on the CMS PQRI “Reporting” section page at http://www.cms.hhs.gov/PQRI on the CMS website.

Eligible professionals do not need to sign-up or pre-register to participate in the 2009 PQRI. Submission of quality data codes for individual PQRI measures to CMS through a qualified registry or for a measures group through claims or a qualified registry will indicate intent to participate.

Although there is no requirement to register prior to submitting the data, there are some preparatory steps that professionals should take prior to undertaking PQRI reporting. CMS has created a tip sheet titled, “Satisfactorily Reporting 2009 PQRI Measures,” that provides information about how to get started with PQRI reporting. To access this tip sheet and all available educational resources on the 2009 PQRI please visit http://www.cms.hhs.gov/PQRI/ on the CMS website. Eligible professionals are encouraged to visit the PQRI webpage often for the latest information and downloads on PQRI.


The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the availability of Qualified Registries for 2009 Physician Quality Reporting Initiative (PQRI) Reporting.

A list of qualified registries can be accessed under the “Reporting” section page on the CMS website at http://www.cms.hhs.gov/PQRI. Each of the registries listed has gone through a vetting process. CMS believes that it is highly likely each of these registries will be successful in their data submission for the PQRI program.

Eligible professionals who wish to participate in the 2009 PQRI using one of the registry-based options may contact the registries for additional details on participation options.

All publicly available information on the CMS Physician Quality Reporting Initiative can be found at http://www.cms.hhs.gov/PQRI on the CMS website.


A new website is now available from the Centers for Medicare & Medicaid Services (CMS) concerning Health Information Technology as provided for in the American Recovery and Reinvestment Act of 2009. On this website, you can find information pertaining to the Medicare and Medicaid incentives for electronic health records adoption and important links to related websites at the Department of Health and Human Services.

Posted now are:
· A CMS fact sheet and questions/answers pertaining to the incentive programs
· Link to press release pertaining to the process of defining meaningful use (Comments are due June 26, 2009.)
· Resources on Health IT and privacy & security (HIPAA)

Bookmark http://www.cms.hhs.gov/Recovery/11_HealthIT.asp today to find the latest on Health Information Technology.


****DHHS/MediCal NEWS****
Medi-Cal is receiving increased volumes of claims with NDCs. Please keep in mind that, claims with dates of service on or after April 1, 2009 that do not meet the NDC reporting requirements to include a valid NDC with a HCPCS Level I, II or III code, will be denied. As a result, Medi-Cal would like to note the findings related to claim denials. Below are common questions/errors, based on claim reporting and provider contact, to be shared with your membership.

Medi-Cal has seen an increase in denied claims resulting from, but not limited to, the following issues:

Providers report they are unaware that NDCs are required
Provider's software is not ready yet
Provider didn't think NDC was required for this particular code
Provider was unaware of correct NDC format
Resources

The Medi-Cal Web site has a page devoted to NDC Reporting Requirements that contains reporting requirements details, frequently asked questions (FAQs), definitions, claim examples/formats, NDC presentation and information on Section 340B of the Public Health Service Act. Click here to access: http://files.medi-cal.ca.gov/pubsdoco/ndc/ndc.asp


The ASC X12N Version 4010A1 Companion Guides have been updated and are available on the Medi-Cal Web site at http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaaspecs_home.asp . These guides will enable technical staff or software vendors to update your software to include the NDC requirements on the 837 electronic transactions.

Additionally, the Part 2 provider bulletins (General Medicine, Obstetrics and Outpatient) include NDC information, physician-administered drug definitions, billing descriptions and examples for CMS 1500 and UB-04 paper claim forms, as well as both 837 Institutional and Professional electronic formats, and Section 340B information. These bulletins can be viewed on the Medi-Cal Web site at http://files.medi-cal.ca.gov/pubsdoco/Bulletins_menu.asp .

Finally, the CMS 1500 and UB-04 claim form tutorials on the Medi-Cal Web site have been updated to include instructions on how to bill HCPCS and NDCs and can be viewed at http://files.medi-cal.ca.gov/pubsdoco/eo/elearning.asp .

Should you have any questions or need additional information, please call the Telephone Service Center (TSC) at 1-800-541-5555 and choose the appropriate prompt or visit the Medi-Cal Web site at the address listed above.


Additional information has been posted to the Medi-Cal Web site this week regarding Optional Benefits Reductions. A new link has been added to the home page (http://www.medi-cal.ca.gov/), Newsroom, section entitled: Medi-Cal Beneficiary Optional Benefits Reduction Notice. The link connects users to the DHCS Web page and beneficiary notices provided in the thirteen threshold languages.

In addition, the applicable provider manual sections have been refreshed and pages updated to reflect the most current information. The provider manuals can be accessed from the following link: http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp.


****PALMETTO/J1MAC NEWS****
July 2009 J1 A/B MAC Medicare Advisory
The July 2009 J1 A/B MAC Medicare Advisory is now available on the Palmetto
GBA Web site. It contains the latest updates and useful information
regarding Medicare. Please share this information with your staff.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7TCRHU0154?opendocument


MammaPrint Test – Breast Cancer Prognosis Draft LCD J1B-09-0002
Palmetto GBA Part B has developed a new Local Coverage Determination (LCD)
for a new diagnostic test. The Draft LCD MammaPrint Test – Breast Cancer
Prognosis which will be open for comment on July 16, 2009.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7TANRA2065?opendocument


Part B LCD Update
The following J1 Part B LCDs have been revised.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7TANL83761?opendocument


Part B LCD Update
The following J1 Part B LCDs will begin their notice period on June 25,
2009.The revisions made during the comment period will become effective
August 10, 2009.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7TAN6V8370?opendocument


Advance Payments to Providers of Part B Services: Updated Summary of the
Requirements
The requirements for advance payment for Part B providers who are
experiencing financial hardship due to claims that are unable to process
within established time limits have been updated.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7TBQYM3512?opendocument


Erythropoietin Stimulating Agents (ESAs) for the Treatment of Anemia
Unrelated to Dialysis Therapy: Rounding Error Revised
From April 1, 2009, through May 9, 2009, there was an error in the EDI
system, which may have caused claims submitted with a Hematocrit (HCT)
and/or Hemoglobin (HGB) level, to process incorrectly. Previously, you were
told these claims could be corrected via a telephone reopening. However,
due to the complex nature of these services, the reopening should be
requested in writing.
http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7SAL6P2226?opendocument


Fraud Alert: Be Aware of Fraudulent Requests for Provider Enrollment
Information by Fax or Mail
Fraud Alert: Please be aware of a recent scam that asks providers to
complete an enrollment application within 48 hours or risk payment
interruption.
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/7SXNUX1831?opendocument