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Medicare/Medicaid Coaltion Report
Medicare/Medicaid Coaltion Report
Jan. 14, 2011 meeting
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Medicare Medicaid

DMEPOS competitive bidding
Find information on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) competitive bidding program here.

On the left side of this Web page is a drop-down menu. Use it to select a Competitive Bidding Area (CBA). Enter a zip code or select:

  • A state
  • A CBA
  • The service/item (mail-order diabetic or non-mail order)

For questions, call (877) 577-5331, Monday through Friday from 9 a.m. to 5 p.m. Or send via certified mail to:

Palmetto GBA
Competitive Bidding Contractor
2743 Perimeter Pkwy. Ste. 200-400
Augusta, GA 30909-6499

Beneficiaries who have questions about the Competitive Bidding Program should call 1-800-MEDICARE (1-800-633-4227).

Annual Wellness Visit
The Affordable Care Act (ACA) allows for a preventive physical exam called the Annual Wellness Visit (AWV) beginning Jan. 1, 2011. This visit includes Personal Prevention Plan Services (PPPS).

Medicare will pay for an AWV for a patient who is no longer within the first 12 months of the Part B eligibility or has not received either an Initial Preventive Physical Exam (IPPE) or an AWV within the past 12 months. The deductible and co-insurance are waived for AWVs.

The two new HCPCS codes are:

  • G0438 – First Annual Wellness Visit
  • G0439 – Subsequent Annual Wellness Visit

For greater detail refer to MLN Matters MM7079 here.

Common AWV questions

  1. Can G0101 and Q0091 be billed in addition to the AWV? YES
  2. Can a problem oriented visit be billed in addition to the AWV.
    YES. When there is a significant, separately identifiable medically necessary evaluation and management (E/M) service in addition to the AWV, CPT codes 99201-99215 may be reported and Modifier 25 should be appended to the E/M service.

Note: Some components of a medically necessary E/M service may have been part of the AWV and should not be included when determining the most appropriate level of E/M service to be billed.

At the time of this writing, the Centers for Medicare & Medicaid Services (CMS) had not provided instructions indicating any of these services are required to be carved out.

Medicare wellness visit claims reprocessed
National Government Services (NGS) advised that diagnosis code V70.0 (routine general medical examination at a health care facility) has been issuing denials in the system. The amounts have been transferred to patient responsibility in error.

NGS is reprocessing the claims. You need not take any action at this time.

Waiver of deductible
The Part B deductible is waived for colorectal cancer screening tests that become diagnostic. Effective Jan. 1,
2011, modifier PT must be appended to at least one CPT code in the surgical range of 10000 to 69999 on the claim for services in this scenario.

Refer to MLN Matters MM7012 here.

2011 Fee Schedule
A payment cut was prevented for 2011. While the physician fee schedule update will be zero percent, other changes to the relative value units (RVUs) used to calculate the fee schedule rates must be budget neutral. To make those changes budget neutral, the conversion factor must be adjusted for 2011 (Revised conversion factor 33.9764). Also, changes will be made to some HCPCS code payment indicators to reflect the appropriate payment policy.
See MM7300 here.

Revisions to claims processing
All claims processed on or after Jan.1, 2011, payable under Medicare Physician Fee for Service and also anesthesia services with the home as place of service (POS) – or any POS considered home – must be submitted with the service facility location in item 32 of the CMS 1500 claim form or electronic equivalent. The address is not complete unless the zip code is included.

For more information see MedLearn Matters article 6947 here.

Counseling on tobacco use
Effective for claims with dates of service on and after Aug. 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries who:

  • Use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease
  • Are competent and alert at the time counseling is provided
  • Have counseling furnished by a qualified physician or other Medicare-recognized practitioner

The diagnosis codes that should be reported for these individuals are ICD-9 codes 305.1, dependent tobacco use disorder, or V15.82, history of tobacco use.

Two new G codes were added to bill for tobacco cessation counseling services to prevent tobacco use. These are in addition to CPT codes 99406 and 99407 currently used for tobacco cessation counseling for symptomatic individuals.

They will appear in the quarterly coding updates for January 2011; the TOS code is 1.

  • G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
  • Short Descriptor: Tobacco-use counsel 3-10 minutes
  • G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes
  • Short Descriptor: Tobacco-use counsel >10 minutes

CMS will allow two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with a total benefit covering up to eight sessions per year per Medicare beneficiary who uses tobacco. Practitioner and patient have the flexibility to choose between intermediate (more than three minutes but less than 10 minutes), or intensive (more than 10 minutes) cessation counseling sessions for each attempt.

The Part B Medicare co-insurance and deductible will be waived.

Billing for observation care
If an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.


Mona Green, Provider Relations consultant, gave updates on therapy service limitations and reductions in reimbursement for transportation, podiatry and chiropractic services. Green also provided information about the Preferred Diabetic Supply List and Universal Prior Authorization Form. The new form must be used as the old form will be returned, except on claims for mental health entities.

Green indicated the new CPT codes are currently being loaded into the system, and the fee schedule may not be updated at the end of the month. You are encouraged to monitor this closely. If you experience problems, contact your representative immediately.

Chris Kern, Provider Relations manager, announced the quick reference information is now on their website. You can view claims online but you still cannot submit online.

Kern advised the MCOs are now responsible for primary medical provider (PMP) assignments, and Hoosier Alliance has closed its specialty network.

Advantage Health Solutions
Kelvin Orr, director of Network Development and Contracting, announced that effective Jan. 1, 2011, there is no certification code requirement. He also advised the administrative fee has been reduced for PMPs to $6.

Regional Network Manager Nancy Robinson discussed their upgraded system, new features, secure portal and requirement to use Explorer 7 to submit both institutional and professional claims. A claim-editing tool for National Correct Coding Initiative is available. If it doesn't match, notify MHS. On Feb. 1, 2011, the MHS prior authorization list was updated.

Anthem's new Atlanta, Georgia, address is posted on this website.

This address also will be used for Hoosier Health Wise HIP paper claims.
Pam Staub, program manager, stated the old address is still operational and can be used for 18 months. The new address will apply to all Anthem plans, but more communication on this will be coming to you. The Indianapolis post office box will continue to be used for filing disputes, medical records and correspondence.

Staub also discussed the claims denied for “Member Not Found.” Anthem will reprocess these claims because this was a system-logic issue and is not related to the filing address.

Anthem is pleased to announce behavioral health claims will now be handled in-house by Anthem staff.

HEDIS audits will begin in February, and you will receive faxes requesting medical records.

Anthem HIP
Senior Network Relations Consultant Maribel Mullen discussed an issue regarding EDI claims being rejected on the front end for new 2011 codes. This was identified and fixed on Jan. 7, 2011. If you experienced this problem, you will need to resubmit claims.

The next Medicaid Coalition meeting, March 4, will be held at the Government Center South Conference Room B. The meeting begins at 1 p.m. and will conclude at 3 p.m.

Gloria Kirkham, ISMA's practice advisor, will leave the ISMA office at 12:30 p.m. to attend this meeting, and she will be happy to escort anyone who would like to attend. Consider bringing your lunch if you plan to attend both portions of the Medicare/Medicaid Coalition meeting.

Maps will be available for those who would like to walk from the ISMA to the Government Center South. This is a unique opportunity to meet some of the Office of Medicaid Policy and Planning staff. Hope to see you there.





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