Medicare Updates You May Have Missed

More Medicare updates and changes are rolling in for 2015, including a new time frame for response to additional documentation requests, and revised local coverage determinations.

New time frame for response to additional documentation requests  Effective April 1, 2015, you'll have 45 days to respond to a request for additional documentation from Novitas or the Medicare zone program integrity contractor. The Centers for Medicare & Medicaid Services (CMS) has instructed these reviewers not to grant extensions to practices that need more time to comply with the request and to deny claims for which they don't receive the requested documentation by day 46. (See MLN Matters No. MM8535 [PDF].)

New info for claims for percutaneous image-guided lumbar decompression for lumbar spinal stenosis  Since Jan. 9, 2014, Medicare has allowed coverage with evidence development for percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) for beneficiaries enrolled in an approved clinical trial. Recent follow-up from CMS says that beginning with PILD for LSS claims with dates of service on and after Jan. 1, 2015, you should bill using one of two distinct procedure codes: G0276 for clinical trials that are blinded, randomized, and controlled, and contain a placebo procedure control arm (see MLN Matters No. MM8954 [PDF] for claims processing instructions), and 0275T for all other clinical trials (see MLN Matters No. MM8757 [PDF] for claims processing instructions).

Comparative billing report on modifiers 24 and 25: specialty surgeons  CMS reported it would issue in February 2015 a national provider Comparative Billing Report (CBR) on specialty surgeons' use of modifiers 24 and 25. The CBR focuses on specialty surgeons (excluding general and orthopedic surgeons) who bill evaluation and management (E&M) services 99211-99215 during the global period of a procedure and receive payment by appending modifier 24 and/or modifier 25 to the E&M service.

The reports are meant to be a tool that helps these physicians better understand applicable Medicare billing rules. The CBR contains data-driven tables with an explanation of findings comparing these surgeons' billing and payment patterns to those of their peers within their specialty. These reports are only accessible to the physicians who receive them; they are not publicly available.

CMS contractor eGlobalTech will fax reports to the fax number a physician has in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), so if you expect a report, be sure your fax number is up to date in PECOS. If you want to get your CBR in the mail, call (800) 771-4430 or email CBRsupport[at]eglobaltech[dot]com.

Medical Policy Updates

Effective Jan. 1, 2015  Novitas Solutions has revised these JH local coverage determinations (LCDs) to reflect the annual CPT/HCPCS code updates:

  • Bioengineered Skin Substitutes L32622
  • Biomarkers for Oncology L34796*
  • Cardiac Rhythm Device Evaluation L30529
  • Cardiovascular Nuclear Medicine L32635
  • Glaucoma Treatment with Aqueous Drainage Device L32733
  • Hemophilia Factor Products L32735
  • Hyaluronan Acid Therapies for Osteoarthritis of the Knee L32237
  • Hyperbaric Oxygen (HBO) Therapy L32739
  • Independent Diagnostic Testing Facility (IDTF) L34792
  • Non-Coronary Vascular Stents L32641
  • Psychiatric Codes L32766
  • Qualitative Drug Testing L34352
  • Services That Are Not Reasonable and Necessary L31686
  • Spinal Cord Stimulation (Dorsal Column Stimulation) L34705
  • Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) L34745
  • Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous L32685
  • Wound Care L32687 
*Also has been revised as a result of a reconsideration request.

Effective April 9, 2015  These JH LCDs have been posted for notice: 

  • Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds L27549
  • Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) L27475
  • Co-Management of Surgical Procedures L27481
  • Coverage of Services and Procedures in Nursing Facilities L27485
  • Diagnostic Abdominal Aortography and Renal Angiography L32709
  • Evaluation and Management Services Provided in a Nursing Facility L27496
  • Hemophilia Factor Products L33658
  • Hydration Therapy L32738
  • Lower Extremity Major Joint Replacement (Hip and Knee) L35594
  • Monitored Anesthesia Care L32628
  • Non-Coronary Vascular Stents L32641
  • Speech-Language Pathology (SLP) Services: Communication Disorders L27531
  • Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy L27537
  • Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography L32673

The JH draft LCD Gender Reassignment Surgery (DL35573) will not be finalized at this time.  

 Local coverage article updates — Novitas has revised these JH local coverage articles to reflect the annual CPT/HCPCS code updates effective Jan. 1, 2015: 

Looking for a past Medicare-related etip, or want to peruse the collection? Visit theTMA Practice e-Tips on Medicare page. Visit the Medicare Resource Center for additional practice help. 

Published Feb. 26, 2015

TMA Practice E-Tips main page

Last Updated On

May 13, 2016

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