Questions and Updates: Nathan Kennedy and Medical Review Director Carolyn Cunningham, M.D., responded to these questions from previous sessions:

• What is the correct usage of modifier 51 vs. modifier 59?
• What is the difference between modifiers 52 and 53?

Get his response>>

Cardiac pacemakers: The National Coverage Determination (NCD) policy for cardiac pacemakers indicates the service cannot be reported unless performed by a physician with the “expertise and/or training” to do so. If the physician with the appropriate level of expertise and/or training is not in the office, there is no Medicare coverage.

The policy clearly states this requirement must be met. In a situation wherein the trained physician is not in the office, medical offices may not bill Medicare for the service.

Customer Care updates: Customer Care is the new name for the Customer Service/Provider Assistance line at (866) 250-5665. Matt Meyer, director of the Customer Care departments with National Government Services (NGS), provided an update on current changes. Read his comments>>

Medicare Customer Service: Three contact centers are available for Part A and B, and two contact centers for Durable Medical Equipment. Meyer explained the tier levels and how each operates:

• Tier I handles incoming calls.
• Tier II handles callback, research of claims issues and financial responses.
• Provider Relations Research Specialist (PRRS) handles issues Tier I and Tier II are unable to handle.

Part B updates: All physicians are encouraged to participate in the ACT calls when offered. These calls serve as an additional outlet for physicians to obtain current information concerning specific topics, as well as to obtain answers to any questions. Session handouts covered the current listservs — from May 9 to July 17.

Physicians had questions regarding response time once contacted by CERT. A 75-day response time is allowed; any provider needing additional time to prepare requested documentation should refer to the contact information provided in the initial CERT letter.

Handouts regarding current information on the Physician Quality Reporting Initiative (PQRI) and articles from Med Learn Matters (MLN) regarding National Provider Identifier (NPI) were issued. All physicians are encouraged to review the information; address questions or concerns.

Enrollment: Charity Bright, team lead with Provider Enrollment, said the inventory for Indiana has been decreased by a little over 2,000 applications. She also stated within 15 calendar days the application must be “pre-screened” to ensure all required data elements are on the application and all supporting documentation is included.

If information is missing, a letter will be sent by fax or mail. If requested information is not furnished within 60 days, the application will be rejected.

EDI: Julie McBee, team lead for DME MAC EDI Help Desk, advised that the EDI help desk is experiencing an increase in call volume. Therefore, physicians should have the following information available when calling the help desk in order to reduce wait time:

• Sender ID/Login ID
• Name, contact number and provider number
• Transmission date and dollar amount of claim for claims tracking
• Modem information for communication issues
• Software program, versions of software and detail summary of error codes

Express Plus software is available to physicians with no annual fee. It may be downloaded. If you are unable to download the software and need a disk, a $25 fee will apply.

Physicians experiencing problems with National Provider Identifier (NPI) rejection or front-end edits can respond to (866) 250-5665.

Passwords reset requests: A large percentage of calls routed to the EDI Help Desk pertain to password resets. Effective Aug. 1, 2007, the EDI Help Desk will no longer accept password resets via telephone calls. Reset your password online or request a Password Fax Request form.

Password resets should be completed within two business days or sooner. The top five phone inquiries were discussed and pertinent handouts were provided. Physicians were concerned with payment slowdowns due to NPI issues.

McBee advised there has been more traffic routed to the phone lines with the merger of the Empire and UGS Help Desk calls, which are now routed into the NGS call flow.

National Provider Identifier (NPI): If you are receiving claim rejections due to NPI, please take the following steps:

1. Review the NPI notification received from the enumerator to verify that the NPI number submitted electronically is correct.
2. If information listed on the claim is correct, visit the NPPES Web site or call (800) 456-3203 to determine how your information is registered.

If the number on the NPI notification and electronic claim is not correct, change the NPI number in the rejected electronic claims and resubmit them.

You may contact provider assistance at (866) 250-5665.

Jeri Biedenkopf, R.N., ISMA practice advisor, noted physician Proposal Rules are available in the July 12, 2007, Federal Register, and anyone with questions or comments may contact her.

See correction to this edition at the bottom of the next issue>>

EDS: Mona Green, EDS representative, opened the meeting with discussion on the National Drug Code (NDC) claim form requirement. Green advised that claims submitted on or after Aug. 1 should include the NDC information.

Tawanna Davis, EDS representative, said the qualifier reported and the HCPCS code reported must match in order for a claim to be paid. A qualifier is needed to report to EDS the correct units given. For information on qualifiers and more details on the NDC requirement, please refer to Medicaid bulletin BT200713 on the Medicaid Web site.

Davis advised that if physician-administered drugs are mixed, only NDC information for one drug should be reported on the CMS1500 claim form. Green also discussed Early Periodic Screening and Diagnostic Testing (EPSDT) services. Because many physicians are not aware of how to bill accurately for these services, EDS is teaming up with the various managed care organizations (MCOs) to provide education on the importance of providing and reporting these services.

Green provided an update on a lasting problem with incorrect denials for reporting of multiple surgeries. She advised that EDS has corrected the payment system to now pay these claims correctly, instead of issuing the provider a denial for the second surgical procedure. If a physician received a denial when billing for a second surgical procedure on the same date of service, the physician should re-file the previously denied claim, advised Green.

If your practice is uncertain about what services are covered, contact either the MCO with which you are contracted or Mona Green at EDS.

Note that EDS is now taking registration for quarterly workshops to be held at various locations across the state.

OMPP: Katie Holeman-Shipp from the Family and Social Services Administration (FSSA) confirmed that contracts to deliver care management services to the aged, blind and disabled Medicaid population were awarded to MDwise and Advantage. Both MCOs will deliver care coordination, prior authorization and disease management services statewide.

The new program will roll out in October in central Indiana. Physicians in this region will begin receiving communication from the MCO, as well as the state, throughout August.

Anthem: Shelley Evans represented Anthem and discussed various forms available in the state-sponsored business area of Anthem’s Web site. Please look here to find prior authorization processes and forms, pre-service review forms, and request for claim follow-up forms.

Evans provided a new Anthem contact for physicians, Connie Menale, who will be available to assist you at (317) 287-6043 or via e-mail.

If physicians need to update information with Anthem, a provider change form must be completed. Physicians also can write directly to Anthem; however, the correspondence must come from the physician’s office on letterhead and must be sent to Provider Contracting at Anthem.

MHS: Angela Jackson explained that prior authorizations can now be requested via the MHS Web site. By the end of the year, physicians will have the ability to submit claims, as well as any claim corrections.

Effective Jan. 1, physicians will be required to send only their National Provider Identifier (NPI) numbers to MHS. Currently, MHS can process NPIs, but physicians are not required to submit NPIs until 2008. However, MHS strongly recommends physicians continue submitting their NPI information once they initially report it.

To assist physicians, MHS is providing information edits on the remittance advice (RAs). Watch your RAs to find any additional information on NPI requirements.

MHS has created a monthly provider newsletter to communicate with contracted providers. This communication also can be found on the MHS Web site.

Jackson said EFT and 835 transactions are available. Find further details and forms on the MHS Web site.

MDwise: Chris Kerns was available for physician questions and concerns.