Submitted by Mark Yeh, MD (Alternate CAC Representative)
CMS contractor jurisdictions and updates:
In 2008, CMS created 15 jurisdictions and awarded carrier contractors for 5 year contracts. California was grouped with Nevada, Hawaii, Guam, American Samoa, and Northern Mariana Islands in Jurisdiction 1. This year, with the 5 year contracts expiring, CMS will reduce the number of Jurisdictions from 15 to 10. Although California's current jurisdiction will remain unchanged in its make-up, it will be renamed Jurisdiction E. In anticipation for the conversion to Jurisdiction E, contractor bids went out in 2012 and Noridian was awarded the new Jurisdiction E contract in September of 2012. Our current Jurisdiction 1 contractor, Palmetto GBA, along with another competing contractor filed a protest to CMS and in January of 2013, the Jurisdiction E contract was re-awarded to Noridian. Pametto GBA subsequently filed a second protest to the Federal courts and, at the time of the CAC meeting, final judgment was pending on this second protest.
In the meantime, Noridian has already created a new website (www.noridianmedicare.com/je) for the transition from Palmetto GBA. The transition dates to Jurisdiction E are 8/26/2013 for Part A and 9/16/2013 for Part B. We were advised to check either the new Noridian website or the current Palmetto GBA website (www.palmettogba.com/medicare) for details of the transition process. Palmetto GBA has pledged to make the transition process a smooth one if Noridian prevails as the new contractor without the hiccups that were experienced during the last carrier transition from NHIC to Palmetto GBA.
Sequestration:
As a result of the so-called Sequestration, effective 4/1/2013, CMS will pay 2% less on all Medicare reimbursements. Although a new fee schedule will not be formally issued, providers should expect 2% less than what is currently on the fee schedule from CMS. Providers CANNOT collect the 2% difference from patients. However, providers can continue to collect the regular co-payments from their patients who are Medicare beneficiaries. The Sequestration only affects what the federal government pays out and does not affect direct payments from patients. If a provider is out of network (i.e. has opted out of participation in Medicare), the provider can continue to bill the patient for the full payment without the 2% discount. However, patients should be advised that their reimbursement from Medicare for seeing the out of network provider will be reduced by 2%.
MRI of Patients with MRI compatible pacemakers:
To be paid for and not be audited by the Recovery Auditor, when performing an MRI on a patient with MRI compatible cardiac pacemaker that is approved by the FDA, it is necessary to include the following three items in the Medicare claim:
1) Appropriate MRI code
2) KX modifier
3) ICD-9 code V45.01 (cardiac pacemaker)
Inclusion of the KX modifier on the claim lines means that the provider attests that documentation is on file verifying that FDA-approved labeling requirements are met. For such claims without the KX modifier, Medicare will deny the claim.
Source: MLN MattersŪ Number: MM 7441.
PECOS (Provider Enrollment, Chain and Ownership System) advice:
Non-Medicare providers ordering laboratory or imaging studies on Medicare beneficiaries should fill out form 855 O. This way, the non-Medicare provider will be recognized in the system so that laboratory or imaging studies ordered by the non-Medicare provider will get paid.
We were all reminded that studies ordered by providers not enrolled in PECOS that previously resulted in warning messages in Phase I of this program will now turn into denials in Phase II of the program beginning 5/1/2013.
For further details, see:
MLN MattersŪ Number: SE1305
Related Change Request (CR) #: 6421, 6417, 6696, 6856.
