ACT Questions and Answers - January 16, 2019

The following questions and answers (Q&As) are cumulative from the Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

Medicare Program Updates

  1. NMP Portal Enhancements: You spoke and we listened! The most recent Noridian Medicare Portal (NMP) enhancements now offer expanded denial details. View this information under the Related Inquiries section of the Claim Status Inquiry feature.
  2. SMRC Website is Now Available: Noridian launched the Supplemental Medical Review Contractor (SMRC) website in November 2018. Go to for more information.
  3. E/M Documentation Made Easier: Change Request (CR) 11063, effective January 7, 2019, removes potential for duplicative requirements by streamlining documentation requirements and reducing provider burden.
  4. DDE User Guide Updated: The Direct Data Entry (DDE) User Guide has been updated with current screen-prints and includes information on how to search by and for the Document Control Number (DCN). DDE is a real-time (Fiscal Intermediary Shared System) FISS system that gives providers interactive access for inquiries, claims entry and correction purposes.
  5. January is Annual Wellness Visit (AWV) Awareness Month: The initial AWV is provided to a beneficiary who is no longer within their first 12 months of Medicare Part B coverage and has not received an initial preventive physical examination (IPPE). Medicare Part B covers one initial AWV in a lifetime and subsequent AWVs every 12 months. No deductible or copayment/coinsurance applies.
  6. SNF ABN: Change Request (CR) 10567 has revised the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055. With this revision, CMS is discontinuing the five SNF Denial Letters (namely, the Intermediary Determination of Noncoverage, the UR Committee Determination of Admission, the UR Committee Determination on Continued Stay, the SNF Determination on Admission and the SNF Determination on Continued Stay), and the Notice of Exclusion from Medicare Benefits (NEMB-SNF), Form CMS-20014. Please note that the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123 is not being discontinued with this revised SNF ABN.
  7. Coverage of FDA Approved Biosimilars: Effective immediately, the Food and Drug Administration (FDA) approved use of biosimilars for FDA approved drugs, has increased recently. Noridian will accept a biosimilar drug on the same criteria as the drug to which it is a biosimilar unless an article is published to the contrary. These biosimilars remain subject to FDA restrictions, if any, that do not apply to the original drug.

Questions and Answers

Q1. Similar to the Transcatheter Aortic Valve Replacement (TAVR) procedure, the Transcatheter Mitral Valve Replacement (TMVR) is performed for many of the same diagnoses but in relation to the Mitral valve. Currently, there are Medicare edits in place reducing the selection of diagnoses to either mitral valve regurgitation or mitral valve prolapse. The FDA approved the use of valve- in-valve replacement for TMVR in June of 2017 which opens up even more diagnoses that could be treated with this procedure (e.g. initial valve replacement complication or failure). If a diagnosis that is not regurgitation or prolapse is billed, are we going to assume a denial and then request an appeal? If the diagnosis list will be expanded, will this be retroactive to the FDA's approval?
A1. Change Request (CR) 9002, updated the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual Chapter 32, Section 340, and provides guidance that International Classification of Diseases (ICD)-10 diagnoses codes I34.0, "Nonrheumatic mitral (valve) insufficiency," and I34.8, "Other nonrheumatic mitral valve disorders" are the only approved primary diagnoses codes, presently. Should this list be updated, CMS will issue guidance on proper claims processing to the Medicare Administrative Contractors (MACs); at that time, it would be determined if there would, or would not, be a retroactive adjustment of claims, either initiated by the MAC or the provider.

Q2. If a provider is reviewing the beneficiary's intake form/health questionnaire for the review of systems (ROS), is it mandatory that he/she sign and date the intake form/health questionnaire to receive credit in the ROS, or can the provider state in the electronic medical record (EMR) note, "patient intake form has been reviewed and scanned into the chart by me, and all other systems were reviewed and negative; except for what was mentioned in the History of Present Illness (HPI)," and still receive credit for the ROS, without having to sign and date the intake form?
A2. Assuming this is a form that is used to gather data for a component of the Evaluation and Management (E/M) visit: if providers are using this information and referencing its content in the medical record, it must have a signature identifying the person who assessed the data; chart notes would have to be signed. The intake form, if it's completed by the beneficiary, would not require a signature; however, if it's administered and entered by a practitioner, then a signature would be required.

Q3. Are clinical trials sponsored by pharmaceutical companies considered qualified clinical trials for payment of routine services, complications, etc.?

Effective September 19, 2000, clinical trials that are deemed to be automatically qualified are:

1. Trials funded by [National Institutes of Health] NIH, [Centers for Disease Control and Prevention] CDC, [Agency for Healthcare Research and Quality] AHRQ, CMS, [Department of Defense] DOD, and [Department of Veterans Affairs] VA;

2. Trials supported by centers or cooperative groups that are funded by the NIH, CDC, AHRQ, CMS, DOD, and VA;

3. Trials conducted under an investigational new drug application (IND) reviewed by the FDA; and

4. Drug trials that are exempt from having an IND under 21 [Code of Federal Regulations] CFR 312.2(b)(1) will be deemed automatically qualified until the qualifying criteria are developed and the certification process is in place. At that time the principal investigators of these trials must certify that the trials meet the qualifying criteria to maintain Medicare coverage of routine costs. This certification process will only affect the future status of the trial and will not be used to retroactively change the earlier deemed status.

A3. The questioner has pointed to a passage found in Medicare Coverage ~ Clinical Trials, Final National Coverage Decision which explains when a trial is automatically qualified; however, there is another process, just previous to this section, which explains the criteria needed to qualify a clinical trial, and how it should be loaded into a Medicare registry, which is found at the NIH National Library of Medicine (NLM) website. There is no guidance indicating which entities are approved or disallowed.

Q4. We are asking when we are treating the two stable chronic conditions that are included in the plan of care and are addressed for 30 minutes in the month, can we also count the time for the review of unrelated conditions such as a cold or flu using time and Medical Decision Making (MDM) toward billing the Complex Chronic Care Management (CCM)?
A4. Per the January 18, 2017 Frequently Asked Questions about Physician Billing for Chronic Care Management Services:

"2. Do the times listed for the work of the billing practitioner mean that the billing practitioner must spend that amount of time each month, in addition to the clinical staff time in the code descriptors, in order to bill CCM? No, these times should be considered like the typical times for evaluation & management (E/M) office visits. They are assumed times, established through physician survey by the American Medical Association when the codes were created and valued, for how much time the billing practitioner spends himself or herself each month, but are not exact times. The billing practitioner's time could be spent in activities such as directing clinical staff; personally performing clinical staff activities; or in the case of complex CCM, performing moderate to high complexity medical decision making."

Q5. When a beneficiary is in a covered Part A SNF stay, how should a general acute hospital bill the technical component (TC) of Current Procedural Terminology (CPT) 77333?
A5. In reviewing the SNF Consolidated Billing (CB) Files:

  • Part B MAC Update
    • File 1, Part A Stay - Physician, does not include CPT code 77333; however, this file is for "physician professional services (other than interpretation of diagnostic tests)."
    • File 2, Part A Stay - Professional, does indicate that the professional component of CPT code 77333 is billed to the Part B MAC."
  • Part A MAC Update
    • CPT code 77333 is listed as a Major Category 1 code with a subcategory "D."
    • This indicates the radiology code is excluded from SNF CB and its TC should be billed by the rendering facility to the Part A MAC.

Q6. Please explain the Deficit Act, or summarize it? We have a beneficiary that Medicare was billed and paid, but we found out another payer was primary, and we cancelled the Medicare claim. The other payer still refuses to pay us, citing the deficit act. The other payer states they paid Medicare and that we need to find their payment from Medicare.
A6. Please contact the Provider Contact Center (PCC) with your claim example. They can further assist with the issue at hand. We cannot speak to the denial of another primary insurance. If the beneficiary has a Medicare Secondary Payer (MSP) file with the other payer, they would need to discuss this with them.

Q7. Why are the vendor donated drugs being paid at their normal rate when billed with the nominal fee of one cent ($0.01)? Per billing regulations, we are only requesting to be reimbursed for the administration code, and not the drug, since it is donated.
A7. This is a known system issue that we are currently researching. Currently, these drugs are being reimbursed incorrectly.


            Last Updated Mon, 28 Jan 2019 13:40:09 +0000