CMS Manual System. Pub Medicare Claims Processing. Change Request 7580

Transcription

1 anual ystem Pub edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2337 Date: October 28, 2011 hange equest 7580 UBJET: New nfluenza Virus Vaccine ode. UY O NGE: This change request provides instructions for payment and W edits to be updated to include influenza virus vaccine code for claims with dates of service on or after ay 9, 2011, processed on or after pril 2, EETVE DTE: ay 9, 2011 PLEENTTON DTE: pril 2, 2012 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED /N/D PTE / ETON / UBETON / TTLE 18/10/10.2.1/ealthcare ommon Procedure oding ystem (P) and Diagnosis odes 18/10/10.4.1/W Edits on /B laims 18/10/10.4.2/W Edits on arrier/b laims 18/10/10.4.3/W /B rossover Edits for /B and arrier/b laims. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractor activities are to be carried out within their operating budgets.

2 or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTENT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

3 ttachment Business equirements Pub Transmittal: 2337 Date: October 28, 2011 hange equest: 7580 UBJET: New nfluenza Virus Vaccine ode Effective Date: ay 9, 2011 mplementation Date: pril 2, GENEL NOTON. Background: This change request () provides instructions for payment and W edits to be updated to include influenza virus vaccine code (influenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 64) for claims with dates of service on or after ay 9, 2011, processed on or after pril 2, P code was added to the 2011 P file effective January 1, owever, didn t become payable by edicare until ay 9, The instructions in this allow for updates to the standard systems that will be effective pril 2, These updates will affect all claims processed on or after pril 2, 2012, with dates of service on or after ay 9, NOTE: hange equest () 7575, Transmittal 2329, - nfluenza Vaccine Payment llowances nnual update for eason, provides instruction regarding reimbursement rates for seasonal influenza vaccine codes for the upcoming flu season. The effective date for 7575 is eptember 1, 2011, so on eptember 1, 2011, edicare has a nationally set reimbursement rate for seasonal influenza virus vaccines, including B. Policy: Effective for claims processed with dates of service on or after ay 9, 2011, influenza virus code will be payable by edicare.. BUNE EQUEENT TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OTE B E aintainers ontractors shall accept code for dates of service on or after ay 9, X X X X X X OE ontractors shall pay for influenza virus vaccine code X X X X to hospitals (12X and 13X), Ns (22X and 23X), (34X), hospital-based Ds (72X), and s (85X) based on reasonable cost ontractors shall pay for influenza virus vaccine code X X X to ospitals (12X, 13X), and s (85X), based on the lower of the actual charge or 95% of the verage Wholesale Price (WP) ontractors shall pay for influenza virus vaccine code X X X E V W

4 Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OTE B E aintainers to Os (75X), and independent Ds (72X), based on the lower of the actual charge or 95% of the WP ontractors shall add influenza virus vaccine code to all W existing influenza virus vaccine edits ontractors shall not search their files to either retract payment for claims already paid or retroactively pay claims. owever, contractors shall adjust claims brought to their attention. X E X X X X V W X. POVDE EDUTON TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers provider education article related to this instruction will be available at shortly after the is released. You will receive notification of the article release via the established LN atters listserv. ontractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in your next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. X E X X X V W

5 V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: N/ hould" denotes a recommendation. X-ef equirement Number ecommendations or other supporting information: ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): Bridgitté Davis (410) , bridgitte.davis@cms.hhs.gov for practitioner claims and Bill uiz (410) , william.ruiz@cms.hhs.gov for institutional claims. Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), arriers, and egional ome ealth ntermediaries (s): No additional funding will be provided by ; contractor activities are to be carried out within their operating budgets. ection B: edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

6 ealthcare ommon Procedure oding ystem (P) and Diagnosis odes (ev. 2337, ssued: , Effective: , mplementation: ) Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only. P Definition nfluenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 64; nfluenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use; nfluenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use; nfluenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use; nfluenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use; nfluenza virus vaccine, live, for intranasal use; nfluenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use; epatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use; epatitis B vaccine, adolescent (2 dose schedule), for intramuscular use; epatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use; epatitis B vaccine, adult dosage, for intramuscular use; and epatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use. The following codes are for reporting administration of the vaccines only. The administration of the vaccines is billed using:

7 P G0008 G0009 Definition dministration of influenza virus vaccine; dministration of pneumococcal vaccine; and *G0010 dministration of hepatitis B vaccine. *90471 mmunization administration. (or OPP hospitals billing for the hepatitis B vaccine administration) *90472 Each additional vaccine. (or OPP hospitals billing for the hepatitis B vaccine administration) * NOTE: or claims with dates of service prior to January 1, 2006, OPP and non-opp hospitals report G0010 for hepatitis B vaccine administration. or claims with dates of service January 1, 2006 and later, OPP hospitals report or for hepatitis B vaccine administration as appropriate in place of G0010. One of the following diagnosis codes must be reported as appropriate. f the sole purpose for the visit is to receive a vaccine or if a vaccine is the only service billed on a claim the applicable following diagnosis code may be used. Diagnosis ode Description V03.82 Pneumococcus V04.81** nfluenza V06.6*** Pneumococcus and nfluenza V05.3 epatitis B **Effective for influenza virus claims with dates of service October 1, 2003 and later. ***Effective October 1, 2006, providers may report diagnosis code V06.6 on claims for pneumococcus and/or influenza virus vaccines when the purpose of the visit was to receive both vaccines. f a diagnosis code for pneumococcus, hepatitis B, or influenza virus vaccination is not reported on a claim, contractors may not enter the diagnosis on the claim. ontractors must follow current resolution processes for claims with missing diagnosis codes. f the diagnosis code and the narrative description are correct, but the P code is incorrect, the carrier or intermediary may correct the P code and pay the claim. or example, if the reported diagnosis code is V04.81 and the narrative description (if annotated on the claim) says "flu shot" but the P code is incorrect, contractors may change the P code and pay for the flu vaccine. Effective October 1, 2006, carriers/b s should follow the instructions in Pub , hapter 1, ection (arrier Data Element equirements) for claims submitted without a P code.

8 laims for hepatitis B vaccinations must report the.d. Number of the referring physician. n addition, if a doctor of medicine or osteopathy does not order the influenza virus vaccine, the intermediary claims require: UPN code L000 to be reported on claims submitted prior to ay 23, 2008, when edicare began accepting NPs, only The provider s own NP to be reported in the NP field for the attending physician on claims submitted on or after ay 23, 2008, when NP requirements were implemented W Edits on /B laims (ev. 2337, ssued: , Effective: , mplementation: ) n order to prevent duplicate payment by the same /B, W edits by line item on the /B number, the beneficiary ealth nsurance laim () number, and the date of service, the influenza virus procedure codes 90654, 90655, 90656, 90657, 90658, 90660, or and the pneumococcal procedure codes 90669, 90670, or 90732, and the administration codes G0008 or G0009. f W receives a claim with either P codes 90654, 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with the same number, same /B number, same date of service, and any one of those P codes, the second claim submitted to W rejects. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, same /B number, same date of service, and the same P code, the second claim submitted to W rejects when all four items match. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with the same number, same /B number, same date of service, and same procedure code, W rejects the second claim submitted when all four items match. W returns to the /B a reject code 7262 for this edit. s/b s must deny the second claim and use the same messages they currently use for the denial of duplicate claims W Edits on arrier/b laims (ev. 2337, ssued: , Effective: , mplementation: ) n order to prevent duplicate payment by the same carrier/b, W will edit by line item on the carrier/b number, the number, the date of service, the influenza virus procedure codes 90654, 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009.

9 f W receives a claim with either P codes 90654, 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with the same number, same carrier/b number, same date of service, and any one of those P codes, the second claim submitted to W will reject. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, same carrier/b number, same date of service, and the same P code, the second claim submitted to W will reject when all four items match. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with the same number, same carrier/b number, same date of service, and same procedure code, W will reject the second claim submitted. W will return to the carrier/b a specific reject code for this edit. arriers/b s must deny the second claim and use the same messages they currently use for the denial of duplicate claims. n order to prevent duplicate payment by the centralized billing contractor and local carrier/b, W will edit by line item for carrier number, same number, same date of service, the influenza virus procedure codes 90654, 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009. f W receives a claim with either P codes 90654, 90655, 90656, 90657, 90658, 90660, or and it already has on record a claim with a different carrier/b number, but same number, same date of service, and any one of those same P codes, the second claim submitted to W will reject. f W receives a claim with P codes 90669, 90670, or and it already has on record a claim with the same number, different carrier/b number, same date of service, and the same P code, the second claim submitted to W will reject. f W receives a claim with P administration codes G0008 or G0009 and it already has on record a claim with a different carrier/b number, but the same number, same date of service, and same procedure code, W will reject the second claim submitted. W will return a specific reject code for this edit. arriers/b s must deny the second claim. or the second edit, the reject code should automatically trigger the following edicare ummary Notice (N) and emittance dvice () messages. N: 7.2 This is a duplicate of a claim processed by another contractor. You should receive a edicare ummary Notice from them. laim adjustment reason code 18 duplicate claim or service

10 W /B rossover Edits for /B and arrier/b laims (ev. 2337, ssued: , Effective: , mplementation: ) When W receives a claim from the carrier/b, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted. W will edit on the beneficiary number; the date of service; the influenza virus procedure codes 90654, 90655, 90656, 90657, 90658, 90660, or 90662; the pneumococcal procedure codes 90669, 90670, or 90732; and the administration code G0008 or G0009. W will return a specific reject code for this edit. ontractors must deny the second claim and use the same messages they currently use for the denial of duplicate claims.