(information from Palmetto GBA)
Influenza Virus Vaccine Code
Effective Date: August 1, 2017
Implementation Date: January 2, 2018
The influenza virus vaccine code set is updated on a quarterly basis. This update will include one new influenza virus vaccine code: 90756.
Effective for claims processed with dates of service (DOS) on or after January 1, 2018,
influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use) will be payable by Medicare. This new code will be included on the 2018 Medicare Physician Fee Schedule Database file update and the annual Healthcare Common Procedure Coding System (HCPCS) update.
During the interim period of August 1, 2017, through December 31, 2017, Palmetto will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.
The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). Where the vaccine is furnished in the hospital outpatient department, RHC, or FQHC, payment for the vaccine is based on reasonable cost.
The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2017-July 31, 2018:
CPT 90653 Payment allowance is $50.217.
CPT 90655 Payment allowance is pending.
CPT 90656 Payment allowance is $19.247.
CPT 90657 Payment allowance is pending.
The payment allowances for seasonal influenza virus vaccines are updated on August 1 of each year.
Make Sure You Are Using the Correct PO Box Address!
Palmetto GBA has reduced the number of addresses used for submitting provider checks to satisfy Medicare debts. Please immediately begin using the addresses below to submit payment for any Medicare Debts. All other PO Boxes will be closed.
PO Box 100246
Columbia, SC 29202
Please note that the new PO Boxes will be reflected on all forms and letters. This will not affect payments being submitted by eCheck.
Providers are strongly encouraged to submit payment electronically using eCheck via Palmetto GBAs eServices. Providers can electronically submit their payment and PDF attachments online. Once submitted, you will receive a confirmation from Palmetto GBA indicating that the payment has been received.
Email and Faxed Inquiries
CMS requires all providers to utilize the Provider Contact Center (PCC) (855-696-0705) as their point of contact with their Medicare Administrative Contractors. If you submit an unsolicited fax or email inquiry directly to a specific department or individual your inquiry will be routed to the written correspondence area within the PCC for proper logging, tracking, research and response. An escalation process is used for complex issues. Submitting inquires directly to the PCC will assure CMS compliance and allow for the most timely response.
Additional Guidance on Electronic Signatures Is Available
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.
Healthcare Provider Taxonomy Codes (HPTCs) October 2017 Code Set Update
Change Request (CR) 10141 instructs MACs to obtain the most recent Healthcare Provider Taxonomy Code (HPTC) set and to update their internal HPTC tables and/or reference files. Make sure your staff is aware.
Implement Operating Rules -Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule -Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)
Change Request (CR) 10140 instructs MACs and Medicare's Shared System Maintainers (SSMs) to update systems based on the CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule publication. These system updates are based on the CORE Code Combination List to be published on or about October 1, 2017.
Email and Faxed Inquiries
CMS requires all providers to utilize the Provider Contact Center (PCC) (855-696-0705) as their point of contact with their Medicare Administrative Contractors. If you submit an unsolicited fax or email inquiry directly to a specific department or individual your inquiry will be routed to the written correspondence area within the PCC for proper logging, tracking, research and response. An escalation process is used for complex issues. Submitting inquires directly to the PCC will assure CMS compliance and allow for the most timely response.
Medicare Secondary Payer Inquiry Form
As a reminder, A Medicare Secondary Payer Inquiry Form is available in the Medicare Secondary Payer forms section of our website. To ensure timely processing of your request, this form should be used for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.
Palmetto GBA Medic
al R
eviews
The following are the current Medicare reviews being performed by Palmetto GBA:
CPT 99233 E&M
CPT 99233 E&M -
CPT 11042-11047 Outpatient Surgical Debridement in POS 22
CPT 99283, 99284, 99285 Emergency Department E&M
CPT 99291-99292 Critical Care, First Hour Plus
CPT 99309-99310 Subsequent Nursing Facility Care
HCPCS A0425, A0428 Ambulance Service, NonEmergent
HCPCS A0429, A0427, A0425 Ambulance Services, Emergent
E/M Tip
E/M Tip: Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician must satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making, documentation in the medical record must include:
- Documentation stating the stay for hospital treatment or observation care status involves
eight hours but less than 24 hours
- Documentation identifying the billing physician was present and personally performed the services
- Documentation identifying the admission and discharge notes were written by the billing physician
