Claims processing system delay. (December 19, 2000) — The first CY 2001 quarterly release (2001.1) for intermediary claims processing systems is being delayed from Jan. 1, 2001, to Jan. 8, 2001. This delay will give intermediaries more time to test the release. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-121 (Dec. 5, 2000), ¶151,601.

"Do Not Forward" initiative. (December 19, 2000) — The "Do Not Forward" instructions contained in Program Memorandum No. AB-00-6 should not be implemented until further notice. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-93 (Dec. 7, 2000), ¶151,609.

Correct coding edits. (December 19, 2000) — Version 7.1 of the Correct Coding Initiative, effective April 1, 2001, is expected to be available via the HCFA Data Center by Feb. 14, 2001. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-70 (Dec. 8, 2000), ¶151,610.

Pelvic electric stimulators. (December 19, 2000) — Medicare is covering non-implantable pelvic floor electrical stimulators, effective April 1, 2001. The stimulators are covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise training. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-120 (Dec. 7, 2000), ¶151,611.

Coverage appeals. (December 19, 2000) — Intermediaries and carriers should not accept implied requests for Medicare appeals from providers, suppliers, or Medicaid state agencies without a signed written statement expressing disagreement with the initial determination or indicating that a review or a reexamination should be made. HCFA has removed the former requirement that a state agency, or its agent, secure written beneficiary authorization prior to its submitting an appeal request to HCFA or the contractors. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-122 (Dec. 7, 2000), ¶151,612.

2001 clinical laboratory fee schedule. (December 12, 2000) — HCFA has provided instructions for implementing the calendar year 2001 clinical laboratory fee schedule and mapping for 2001 Current Procedural Terminology codes for clinical diagnostic laboratory tests. The HCFA Center for Health Plans and Providers will issue the fee schedule data file via the software package for mainframe-to-mainframe communications. Program Memorandum (Intermediaries / Carriers), HCFA Pub. 60AB, Trans. No. AB-00-109 (Nov. 29, 2000), ¶151,515.

HIPAA transaction standards. (December 12, 2000) — The Health Insurance Portability and Accountability Act of 1996 (PubLNo 104-191) directs HCFA to adopt standards for administrative transactions, code sets, and identifiers. Oct. 16, 2000, begins a two-year implementation period for code sets used in eight administrative transactions. After this period, all other formats and code sets may not be used. Intermediaries will be required to implement five of these standards: health care claim and equivalent encounter; remittance advice; coordination of benefits; eligibility query and response, and claim status query and response. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-89 (Nov. 28, 2000), ¶151,516.

Coding for adequacy of hemodialysis. (December 12, 2000) — Sec. 3644 of the Intermediary Manual states that end-stage renal disease facilities are to report the appropriate G-modifier indicating the patient's urea reduction ratio level for each renal patient on each monthly bill. However, intermediaries should not edit for the G-modifier. Intermediaries should process and pay claims whether the G-modifier is present or not. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-90 (Nov. 29, 2000), ¶151,517.

Consolidated billing for SNF residents. (December 12, 2000) — The Balanced Budget Act of 1997 (PubLNo 105-33) requires consolidated billing for skilled nursing facilities (SNFs). For SNF residents covered under Part A, SNFs may not unbundle services to an outside provider that can submit a separate bill directly to the Medicare carrier. The requirement also includes physical, occupational, and speech therapies in a Part B stay. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-67 (Nov. 27, 2000), ¶151,518.

Blood glucose test strips. (December 12, 2000) — HCFA has advised beneficiaries to report instances of misleading advertising and excessive or non-requested deliveries of test strips to their DMERCs. Carriers should remind suppliers that beneficiaries must specifically request refills of supplies before they are dispensed. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-69 (Nov. 29, 2000), ¶151,519.

Glucose monitoring. (December 12, 2000) — HCFA has clarified the coverage of glucose monitoring for a patient whose stay is not covered by Part A but who is eligible for services under Part B. Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if a beneficiary uses the equipment in the home or in an institution that is used as a home. Program Memorandum (Intermediaries / Carriers), HCFA Pub. 60AB, Trans. No. AB-00-108 (Dec. 1, 2000), ¶151,522.

Inpatient rehabilitation facilities. (December 12, 2000) — Sec. 4421 of the Balanced Budget Act of 1997 (PubLNo 105-33), as amended by Sec. 125 of the Balanced Budget Refinement Act of 1999 (PubLNo 106-113), authorizes implementation of a per-discharge prospective payment system (PPS) for inpatient rehabilitation facilities (IRF). The new IRF PPS will utilize information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-91 (Nov. 30, 2000), ¶151,523.

Inpatient payment amounts. (December 12, 2000) — HCFA has made additional corrections to certain area wage index values used in calculating inpatient payment amounts. HCFA also has corrected errors found in the pre-reclassified wage index reported in Program Memorandum A-00-75. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-92 (Dec. 1, 2000), ¶151,524.

X12N professional flat file. (December 12, 2000) — HCFA has provided an X12N final flat file for carriers and Durable Medical Equipment Regional Carriers for compliant, outbound X12N 837 coordination-of-benefits transactions. The Excel-compatible file is available on HCFA's Website at http://www.hcfa.gov/medicare/edi/hipaadoc.htm. The downloadable file is 4010flat.xls, and descriptions of columns on the spreadsheet are included. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-68 (Nov. 30, 2000), ¶151,525.

Codes for oral anti-cancer drugs. (December 12, 2000) — HCFA has authorized several miscellaneous codes to process claims for oral anti-cancer drugs, while waiting for the establishment of permanent "WW" and National Drug Codes (NDCs). WW codes are only for DMERC internal systems processing, and providers should continue to bill using the appropriate NDC. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-71 (Dec. 1, 2000), ¶151,526.

Payment for drugs and supplies in CORFs. (December 12, 2000) — Payment for drugs and biologicals in a comprehensive outpatient rehabilitation facility (CORF) no longer will be reimbursed on a cost basis. Payment will be made at the lower of the billed charge or 95 percent of the average wholesale price. Also, because supplies are part of a CORF's practice expense, separate payments under the Medicare Physician Fee Schedule should not be made. Program Memorandum (Intermediaries / Carriers), HCFA Pub. 60AB, Trans. No. AB-00-11 (Nov. 30, 2000), ¶151,527.

Ambulance fee schedule. (December 12, 2000) — Payment for ambulance services will be made based on 100 percent of the allowance under current payment rules, not on the basis of the "80 percent current/20 percent fee schedule" blend methodology required by Sec. 4531 of the Balanced Budget Act of 1997 (PubLNo 105-33). Implementation of new HCPCS codes for ambulance services and the requirement to report the ZIP code of the point of pickup continue to be effective, however, with services furnished on or after Jan. 1, 2001. Program Memorandum (Intermediaries / Carriers), HCFA Pub. 60AB, Trans. No. AB-00-118 (Nov. 30, 2000), ¶151,528.

Collection of comprehensive encounter data. (December 12, 2000) — HCFA is conducting Medicare Choices, Department of Defense Subvention, Long-Term Care (Social Health Maintenance Organization), and Dual Eligible Beneficiaries demonstrations to expand the types of managed care plans available to beneficiaries and to test different payment methods. This Program Memorandum contains the requirements for intermediaries and carriers to process demonstration claims for the period after Nov. 30, 2000. Program Memorandum (Intermediaries / Carriers), HCFA Pub. 60AB, Trans. No. AB-00-119 (Dec. 1, 2000), ¶151,529.

Postpayment review. (December 6, 2000) — Carriers may use the Program Integrity Module for Part B and DME (PIMB) to meet HCFA requirements for random medical review. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-64 (Nov. 16, 2000), ¶151,503.

Home health PPS. (December 6, 2000) — Effective April 1, 2001, contractors must cancel and recoup payment for claims submitted during a 60-day episode for nonroutine medical supplies or therapy services that were processed prior to the receipt of a home health agency's Request for Anticipated Payment that would have established a home health PPS episode in the Common Working File (CWF). The CWF will cancel such claims automatically. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-112 (Nov. 16, 2000), ¶151,504.

DMEPOS fee schedule. (December 6, 2000) — The 2001 fee schedule for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) is ready for implementation. The fee schedule file will be released on Dec. 7, 2000. There will be a 0.3 temporary payment increase for DME in 2001 that will not be carried over into future years. There will be no increase for surgical dressings, ostomy supplies, tracheostomy supplies, and urologicals. There will be an increase of one percent for other prosthetics and orthotics. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-113 (Nov. 17, 2000), ¶151,505.

ASC code update. (December 6, 2000) — The following Physicians’ (CPT) codes are covered when furnished in an ambulatory surgical center (ASC), effective Jan. 1, 2000: 62263, 64470, 64472, 64479, 64480, 64483, 64484, 64626, and 64627. In addition, the following codes are added to the ASC coverage list to replace deleted CPT® codes, effective Jan. 1, 2001: 52351, 52352, 52353, 52354, and 52400. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-114 (Nov. 17, 2000), ¶151,506.

AWP payment limit for drugs. (December 6, 2000) — The list containing Average Wholesale Prices (AWPs) for drugs issued by the Department of Justice in Program Memorandum No. AB-00-86 (¸151,399) should not be used as an alternative source for AWP until further notice. HCFA fears congressional action to preclude use of the DOJ's list and has chosen to suspend use of the list to avoid disruption in payment allowances. Program Memorandum (Intermediaries/Carriers), HCFA Pub. 60AB, Trans. No. AB-00-115 (Nov. 17, 2000), ¶151,507.

Physician fee schedule. (December 6, 2000) — Carriers are notified concerning changes in the 2001 physician fee schedule. In addition, clarification is provided that assistants at surgery must be involved in the performance of the procedure, not simply in other ancillary services; therefore, they may not bill for another surgical procedure during the same time period. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-65 (Nov. 21, 2000), ¶151,508.

Oral chemotherapy drugs. (December 6, 2000) — Self-administrable oral chemotherapy drugs Methotrexate and Cyclophosphamide may be used as well in immunosuppressive therapy for patients who have had organ transplants, effective Jan. 1, 2000. Providers must either report a diagnosis of cancer or an occurrence code 36 on their bill. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-87 (Nov. 21, 2000), ¶151,509.

Ultrasonic osteogenic stimulators. (December 6, 2000) — Medicare will cover ultrasonic osteogenic stimulators when there are two sets of radiographs documenting nonunion of a fracture and the patient has failed at least one surgical intervention for the treatment of the fracture. Program Memorandum (Carriers), HCFA Pub. 60B, Trans. No. B-00-66 (Nov. 22, 2000), ¶151,511.

Medicare+Choice nursing and education. (December 6, 2000) — Hospitals that operate approved nursing or allied health education programs and receive Medicare reasonable cost reimbursement for these programs are entitled to receive additional payments for Medicare|math|0Choice enrollees. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-86 (Nov. 22, 2000), ¶151,512.

SNF consolidated billing. (December 6, 2000) — Consolidated billing for nursing homes will apply only to Part B physical, occupational, and speech therapy services until further notice. SNFs may choose to bill for other Part B services themselves or have bills submitted by their suppliers. Billing instructions are provided. Program Memorandum (Intermediaries), HCFA Pub. 60A, Trans. No. A-00-88 (Nov. 22, 2000), ¶151,513.

PET scan coverage. (December 19, 2000) — HCFA is expanding Medicare coverage of positron emission tomography (PET), an innovative imaging technology, to improve the care of patients who have or may have one of six types of cancer. Additional coverage is also provided for some patients with refractory epilepsy or who may be candidates for coronary revascularization. HCFA Press Release, Dec. 15, 2000.

Provider-based facilities. (December 19, 2000) — Three Medicare-certified community mental health centers were not entitled to hearings concerning their Medicare certification status because the determinations HCFA had made previously involved only the classification of the reimbursement status of the providers. Comprehensive Mental Health Center of Baton Rouge, Civil Remedies Division, Dec. No. CR709; Comprehensive Mental Health Center of Alexandria, Civil Remedies Division, Dec. No. CR710; Comprehensive Mental Health Center of Monroe, Civil Remedies Division, Dec. No. CR711, ¶120,201.

Community mental health centers. (December 19, 2000) — HCFA properly denied a Florida provider certification as a community mental health center providing partial hospitalization services under Medicare. Options Center of St. Petersburg, Civil Remedies Division, Dec. No. CR712, ¶120,202.

Hospice certification. A California hospice could not be certified to participate in Medicare before the date on which a state survey agency determined that the provider complied with all applicable Medicare participation requirements. Wells House, Civil Remedies Division, Dec. No. CR714, ¶120,204.

Good cause exception for hearing requests. (December 19, 2000) — A Tennessee skilled nursing facility failed to file a timely request for a hearing to reconsider HCFA's imposition of penalties for Medicare and Medicaid violations subsequent to its reliance on allegedly incorrect filing information provided by a HCFA employee. Hamilton County Nursing Home, Civil Remedies Division, Dec. No. CR716, ¶120,205.

Untimely hearing request. (December 19, 2000) — An Arkansas skilled nursing facility failed to file a timely request for a hearing to reconsider HCFA's imposition of penalties for Medicare violations. Sunchase Nursing Center, Civil Remedies Division, Dec. No. CR717, ¶120,206.

Rescission of remedy. (December 19, 2000) — The administrative law judge properly concluded that a skilled nursing facility was not entitled to an administrative hearing to correct its compliance record because HCFA had rescinded its civil money penalty. The Lutheran Home Caledonia, Appellate Division, Dec. No. 1753, ¶120,207.