Provider Types Affected
All Medicare providers billing either a Medicare carrier or fiscal intermediary (FI) for ICDs for Medicare beneficiaries who are also members of Medicare Advantage (MA) plans

Provider Action Needed

Impact to You
Be aware that, effective for services provided on and after January 1, 2006, your Medicare carrier or FI will no longer pay Fee-for-Service (FFS) claims for the expanded coverage of ICD services rendered to MA beneficiaries.

What You Need to Know
Related CR 4133 instructs Medicare carriers and FIs to no longer pay FFS claims for the expanded coverage of ICD services (described in CR3604) that you provide to MA beneficiaries. These services are now part of the MA capitation rates.

What You Need to Do
Make sure that your billing staffs are aware of these changes and also the basis for billing Medicare.

Background
In CR3604 (January 27, 2005), Medicare expanded ICD coverage for the following new indications:

• Patients with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI), New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) ≤35 percent;
• Patients with nonischemic dilated cardiomyopathy (NIDCM) > 9 months, NYHA Class II and III heart failure, and measured LVEF ≤35 percent;
• Patients who meet all current Centers for Medicare & Medicaid Services (CMS) coverage requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure; and
• Patients with NIDCM > 3 months, NYHA Class II or III heart failure, and measured LVEF ≤35 percent.

At that time, because this new coverage exceeded the significant cost threshold for managed care organizations, services related to these newly covered indications for Medicare Advantage (MA) beneficiaries were not part of the MA capitation rates, but rather were paid on a FFS basis.

See Medlearn Matters article MM3604 regarding this issue at http://www.cms.hhs.gov/medlearn/ matters/mmarticles/2005/MM3604.pdf on the CMS Web site.

Adjustment in MA Rates
Beginning January 1, 2006, the MA rates are appropriately adjusted to account for the expanded coverage of ICD services, and MA plans are now liable for payment relating directly to providing these services. Thus CR 4133:

• Instructs your carriers and FIs to no longer pay FFS for the expanded coverage of ICD services that you provide to MA beneficiaries, effective for services performed on and after January 1, 2006;
• Requires MA plans to furnish, arrange, and/or make appropriate payment for these services; and
• Notes that MA enrollees are liable for the MA plan’s cost sharing of these services.

Conditions for Denying Claims
CR 4133 provides that Medicare systems will now deny, for beneficiaries in MA plans, claims that meet all of the conditions described in the following categories:

Outpatient Claims Processed by Your FI

• Date(s) of service on or after January 1, 2006; and
• Condition code 78 (New coverage not implemented by HMO); and
• One of the following HCPCS codes: G0297, G0298, G0299, or G0300.

Hospital Inpatient Claims

• Discharge date is on or after January 1, 2006; and
• Condition code 78; and
• ICD-9-CM 37.94.

Professional Part B Claims

• Date(s) of service is/are on or after January 1, 2006; and
• Modifier KZ (New coverage not implemented by managed care); and
• CPT code 33249.

Finally, CR4133 instructs your carriers and FIs, when denying these services, to use:

• Medicare Summary Notice (MSN) 11.3 (Our records show that you are enrolled in a health maintenance organization. Your provider must bill this service to them); and
• Claim adjustment reason code 24 (Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan).

Additional Information
You can find more information about billing for ICD services for MA Plan beneficiaries by going to http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. From that Web page, look for “4133” in the CR NUM column on the right, and click on the file for that CR.

Indications and limitation of coverage for ICDs are located in the Medicare National Coverage Determinations Manual (Pub. 100-03), Chapter 1, Part 1, §20.4 (Implantable Automatic Defibrillators).

Finally, if you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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.

Pub. 100-20, Transmittal# 186, CR# 4133
Medlearn Matters Number: MM 4133
Related CR Release Date: October 28, 2005
Effective Date: January 1, 2006
Implementation Date: January 3, 2006

Posted: 11/15/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.