The Edge Blast E-Newsletter
posted 10/17/2007
Electronic news for October 2007
Read the EdgeBlast and Earn CEUs Toward Your Annual Renewal
Earn continuing education units (CEUs) by reading the EdgeBlast. Simply answer the five questions found in the EdgeBlast Test Yourself at the end and submit your answers at the time of your renewal, using the same process you follow monthly for the Test Yourself in the AAPC Cutting Edge. Each EdgeBlast (there are two issued each month) will feature five questions that are worth .5 CEUs, for a total of 12 CEUs annually.

Time is Running Out to Claim Your Share of BCBS Settlement

In a recent class action suit against Blue Cross Blue Shield (BCBS), physicians, physician groups, and physician organizations across the nation won a $131 million settlement. The American Medical Association (AMA) urges physicians who provided covered services to anyone enrolled in a BCBS plan between May 22, 1999 and May 31, 2007 to claim what is rightfully theirs!

But don't delay. The deadline to claim your fair share of this settlement is Oct. 19, 2007.

For full details and the claim form, go to the AMA website at

Get a Sneak Peek at What the OIG Will Be Up to in 2008

It looks like it will be a busy year for the Office of Inspector General (OIG). In the OIG 2008 Work Plan, under the Medicare heading Medicare Physicians and Other Health Professionals, the OIG says it will investigate place of service errors, evaluation and management services during global surgery periods, payments for psychiatric and selected physician services, payments for polysomnography services … and the list goes on.

In direct line of sight are chiropractic treatments. In the Work Plan, the OIG states, “ … prior OIG work found that 40 percent of chiropractic services were for maintenance therapy and thus did not meet Medicare coverage criteria, potentially costing the program and its beneficiaries approximately $186 million in improper payments.”

Medicare medical equipment and supplies will also receive a fair amount of attention in 2008. In particular, the OIG says that, in regards to Medicare payments for durable medical equipment claims with modifiers, “We will review the appropriateness of Medicare payments to DME suppliers that submitted claims with modifiers … Reviews of supplies conducted by several of CMS’s DME regional carriers found that suppliers had little or no documentation to support their claims.”

To read the complete OIG 2008 Work Plan, go to

No National Determination Coverage for Pulmonary Rehabilitation

The Centers for Medicare and Medicaid Services (CMS) has determined that a national coverage determination (NCD) for Pulmonary Rehabilitation (PR) isn’t necessary at this time. In the Decision Memo for Pulmonary Rehabilitation (CAG-00356N), CMS states that "… the Social Security Act (SSA) does not expressly define a comprehensive Pulmonary Rehabilitation Program as a Part B benefit."

Respiratory therapy services are identified as covered services under the CORF benefit memorandum. On December 27, 2006, CMS initiated the NCD process, but later found that "… the evidence is not adequate to draw conclusion about the frequency or duration of these CORF services."

"Decisions pursuant to § 1862(a)(1)(A) should be made by local contractors through the local coverage determination process or by case-by-case adjudication," says CMS in the memo.

You can read the complete decision memo online at

2008 Payment Limits for Splints and Casts Increase by 2.7%

The 2008 payment limits for splints and casts will be based on the 2007 limits, with an increase of 2.7 percent. The increase is in keeping with the percent of change in the consumer price index for all urban consumers for the 12-month period ending June 30, 2007.

Payment will continue to be made on a reasonable charge basis for splints, casts, dialysis supplies, dialysis equipment, and intraocular lenses. Payment is only made on a reasonable charge basis for lenses implanted in a physician’s office.

For splints and cast, continue to use Q codes when supplies are indicated for cast and splint purposes. This payment is in addition to the payment made under the physician fee schedule for the procedure of applying the splint or cast.

For specific instructions and 2008 payment limits for splints and casts, refer to the CMS transmittal at

CMS Revises 2008 Payment System for Ambulatory Surgical Centers

Submitting claims for Ambulatory Surgical Center (ASC) services won’t be business as usual with the start of the new year. In accordance with the Modernization Act of 2003 (MMA), the Centers for Medicare and Medicaid Services (CMS) is implementing significant revisions to the payment system for ASC services rendered on or after Jan. 1, 2008.

The revised ASC payment system uses the Outpatient Prospective Payment System (OPPS) relative payment weights as a guide, and provides a 3-year transition to the new rates through payments that are based on a variable percentage of new and old rates. HCPCS codes newly payable in the ASC setting beginning in 2008 will not be subject to this blended transitional payment methodology.

For prompt and accurate payments, you should be aware of the revised ASC payment system and coding requirements.

The final rule limits payments for procedures performed in physicians’ offices to the amount that would be paid to a non-facility practice expense (PE) under the Medicare Physician Fee Schedule (MPFS). “Payment rates for surgical procedures that are commonly performed in physicians’ offices and for the technical component of covered ancillary radiology procedures cannot exceed the MPFS non-facility PE amount,” states CMS in the final rule.

The rule also expands the types of procedures that are eligible for Medicare payment when performed in the ASC setting. CMS will pay separately for certain covered ancillary items and services, such as drugs and biological, brachytherapy sources, radiological procedures, and pass-through devices, that are integral to covered surgical procedures in ASCs.

For correct payment, make sure to report separately payable ancillary services with an accurate number of units. Under or over payment could result if you don’t pay attention to the units included in the HCPCS code descriptors when reporting units.

For further guidance, you can read the final rule at For payment rates and other rate-setting information, go to

Transition of the Medigap Crossover Process to the COBC is Complete

Effective Oct. 1, 2007, the Centers for Medicare and Medicaid Services (CMS) completed the transition of the Medigap crossover process to the Coordination of Benefits Contractor (COBC). How does this affect you?

Participating providers should now enter COBA Medigap claim-based identifiers (ID) within the NM109 portion of the 2330B loop of the incoming HIPAA ANSI X12-N 837 professional claim form. Providers granted a billing exception under the Administrative Simplification Compliance Act (ASCA) should enter the COBA Medigap claim-based ID within block 9-D of the incoming CMS-1500 claim.

Providers should only include the new 5-byte ID for the purpose of triggering crossovers to those Medigap insurers that have been assigned a COBA Medigap claim-based ID between 55000-59999 on the Medigap Billing ID spreadsheet, which providers can find at on the CMS website.

If a provider or its billing vendor files a Medicare claim with a COBA ID other than the COBA Medigap IDs on the Medigap Billing ID list, Medicare will generate an MA-19 message on the provider’s 835 electronic remittance advice (ERA), stating “Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.”

For complete details, read MLN Matters article SE0743 at

Looking for Kudos!

Have you performed your 100th prospective claims audit at your practice? Did you trek across Africa on safari? Have you recently filed appeals that brought in an extra $50,000 in revenue for your facility? We’d love to hear about it! Please submit your Kudos to our editors at

EdgeBlast Test Yourself

By answering the following questions, you can earn .5 continuing education units to apply toward your annual AAPC CEU renewal every two years. Simply answer the questions and send in a copy of your work when submitting your CEU package. Do put the number of each EdgeBlast included in your submission. The number is available at the top of the page.

Answers to the questions are not always found directly (word for word) in the EdgeBlast in which they appear. While often related to the EdgeBlast content, they require additional resources, such as your ICD-9-CM, CPT® and HCPCS manuals.

1. Providers should only include the new 5-byte ID for the purpose of triggering crossovers to those Medigap insurers that have been assigned a COBA Medigap claim-based ID between what range?



2. In addition to the procedure code for a splint or cast, which type of code should you submit for splint or cast supplies?



3. Respiratory therapy services are identified as covered services under which benefit memorandum?



4. The physician indicates a 100 mg dosage of the drug Dolasetron Mesylate by injection. The HCPCS code is J1260. Under the revised ASC payment system, how many units should you report to receive proper payment?



5. According to the OIG 2008 Work Plan, what percentage of chiropractic services didn’t meet Medicare coverage criteria and why?



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CPT® is a trademark of the AMA.
No fee schedules, basic units, relative values or related listings are included in CPT®.
The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.