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MIR-2006-7AB, July 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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July Update to the 2006 Medicare Physician Fee Schedule Database
Provider Types Affected
Physicians, providers, suppliers submitting claims to carriers or fiscal intermediaries (FIs) for services paid under the Medicare Physician Fee Schedule (MPFS) provided to Medicare beneficiaries
Impact on Providers
This article is based on Change Request (CR) 5102, which amends payment files issued to your carrier/intermediary that were based on the November 21, 2005, MPFS Final Rule. Attach-ment 1 of CR5102 also includes new Category II and Category III codes.
Background
The Social Security Act (Section 1848(c)(4); http://www.ssa.gov/OP_Home/ssact/title18/1848.htm  ) authorizes the Centers for Medicare & Medicaid Services (CMS) to establish ancillary policies necessary to implement relative values for physicians’ services.
Change Request (CR) 5102:
- Amends payment files issued to your carrier/intermediary based upon the November 21, 2005, Medicare Physician Fee Schedule (MPFS) Final Rule; and
- Includes new Category II and Category III codes.
CR5102 also instructs that your carrier/intermediary should:
- Give providers 30 days notice before implementing the revised payment amounts identified in CR 5102 (Attachment 1) in accordance with the Medicare Claims Processing Manual (Pub 100-4, Chapter 23, Section 30.1; http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf). Note that unless otherwise stated in CR5102, changes will be retroactive to January 1, 2006;
- Not search their files to either retract payment for claims already paid or to retroactively pay claims; and
- Adjust claims brought to their attention.
Changes included in the July Update to the 2006 MPFS Database (CR5102 (Attachment 1)) are as follows:
CPT/ HCPCS Code |
ACTION |
95991 |
Non-Facility RVU = 1.50 |
G0978 |
Effective for services performed on or after January 1, 2006, the long descriptor is: Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell type; t2 or t3a† gleason 8-10 or psa > 20 at diagnosis with no evidence of disease progression, recurrence, or metastases |
G9125 |
Effective for services performed on or after January 1, 2006, the long descriptor is: Oncology; disease status; chronic myelogenous leukemia, limited to philadelphia chromosome positive and /or bcr-abl positive; blast phase not† in hematologic, cytogenetic, or molecular remission |
G9127 |
Effective for services performed on or after January 1, 2006, the long descriptor is: Oncology; disease status; chronic myelogenous leukemia, limited to philadelphia chromosome positive and /or bcr-abl positive; extent of disease unknown, under evaluation, not listed (for use in a Medicare-approved
demonstration project) |
In addition, effective July 1, 2006, a number of Category II codes will be added to the MPFSDB with a status indicator of “M.” Rather than repeat all those Category II codes in this article, we refer you to Attachment 1 of CR5102, which contains the codes and their descriptors. CR5102 is available at http://www.cms.hhs.gov/Transmittals/downloads/R963CP.pdf  on the CMS Web site
The long descriptor for Category II code 1000F has been revised. The new descriptor is effective for services performed on or after January 1, 2005 (date code was implemented).
Category II Code 1000F
Long Descriptor: Tobacco use assessed (CAD1, CAP1, COPD1, DM4, PV1)
The descriptors for Category II code 4015F have been revised. The new descriptors are effective forservices performed on or after January 1, 2006(date code was implemented).
Category II Code 4015F
Long Descriptor (Revised): Persistent asthma, preferred long term control medication or acceptable alternative treatment, prescribed (Asthma1)
Short Descriptor: Persist asthma medicine ctrl
Also, note that G code (G8085) was inadvertently not included in the April update. G8085 is added with a status indicator of “M” and is effective for services on or after January 1, 2006. The long descriptor for G8085 is “End-stage renal disease patient requiring hemodialysis vascular access was not an eligible candidate for autogenous AV fistula.”
Effective July 1, 2006, the Category III codes of 0155T-0161T will be added to the MPFSDB. The descriptors and other indicators for these codes may also be found in Attachment 1 of CR5102.
Implementation
The implementation date for CR5102 is July 3, 2006.
Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R963CP.pdf on the CMS Web site.
MLN Matters Number: MM5102 Related Change Request Number: 5102
If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5102
Pub. 100-4, Transmittal# R963CP, CR# 5102
Related CR Release Date: May 26, 2006
Effective Date: January 1, 2006
Implementation Date: July 3, 2006
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.
Additional Information Provided by Empire Medicare Services
Please refer to the following pages for all carrier-specific pricing updates:
NJ: www.empiremedicare.com/partbnj/partbnj_fees.htm
NY: www.empiremedicare.com/partbny/partbny_fees.htm
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