medicare transmittal 956 cr 5124 may 19 2006
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Medicare Transmittal 956 CR 5124 May 19, 2006. NOPR Billing Instruction Clarification Physician Offices/IDTF use QR Modifier Hospitals use QR and V70.7 MLM CMS Educational Article MM5124 Published May 31, 2006. CMS Effective: January 28, 2005 NOPR Opened May 8, 2006

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medicare transmittal 956 cr 5124 may 19 2006
Medicare Transmittal 956 CR 5124 May 19, 2006
  • NOPR Billing Instruction Clarification
    • Physician Offices/IDTF use QR Modifier
    • Hospitals use QR and V70.7
  • MLM CMS Educational Article MM5124
    • Published May 31, 2006

CMS Effective: January 28, 2005

NOPR Opened May 8, 2006

NOPR Patients DOS Effective: May 8, 2006

Implemented by Medicare Contractors:

June 19th 2006

Noridian & Empire QR modifier system errors corrected!

timeline
Timeline

No Waiting Period

Hold claims until all data entered into the Registry

Providers Bill Medicare

Using Appropriate

Claim Form & Codes

Hospitals Use

UB/1450 Claim Form

Technical Only

Non-Hospitals Use

1500 Claim Form

Professional/Technical/Global

for carriers on 1500 claim form use modifier
For Carriers on 1500 Claim Form Use Modifier

Modifier Use by Providers to Identify NOPR Claims

Use only with procedure, not necessary with the radiopharmaceutical billed on the same DOS as the procedure.

hospitals only on 1450 claim form ub
Hospitals ONLY on 1450 Claim Form (UB)

V70.7 Use in the Second Diagnosis Position FL 68

From Current CMS policy CR 3741

slide7

Case 1

A 72-year-old woman with diffuse large cell non-Hodgkin\'s lymphoma is undergoing chemotherapy with R-CHOP. PET/CT (skull-base to mid thigh) is requested after the second cycle of treatment for monitoring of therapy.

use of pet for treatment monitoring under nopr
Use of PET for Treatment Monitoring under NOPR
  • One potential problem may be “collision” of NOPR intent with individual carrier frequency limits for PET studies
  • Could lead to rejection of claim (or refusal of Medicare Advantage plan to pre-authorize study)
  • Please notify NOPR staff is this occurs!
slide9

Case 2

A 67-year-old man has a history of glioblastoma multiforme of left parietal lobe treated with surgery, radiation therapy, and temazolamide. Follow-up MRI demonstrates a new 8 mm focus of contrast enhancement adjacent to the original tumor bed. Brain PET is requested for restaging, to distinguish recurrent tumor for radiation necrosis.

slide10

Case 3

A 68-year-old woman has newly diagnosed dermatomyositis and progressive weight loss. CT of the chest, abdomen, and pelvis demonstrated no evidence of malignancy. Whole-body PET/CT is requested to detect an occult malignancy as the cause of her paraneoplastic syndrome.

advance beneficiary notice abn
Advance Beneficiary Notice (ABN)
  • A PET facility can ask registry patients to sign an ABN. This decision is left up to each PET facility. However, an ABN should not be necessary. If patient eligibility is carefully checked before the patient is entered into the registry and before the PET scan is performed, and if the facility works closely with its referring physicians to obtain the required paperwork in a timely fashion, there should be no need for ABNs.
medigap insurance for co payments
Medigap Insurance for Co-Payments
  • Medigap insurance should cover the co-payment for a registry PET scan, as for any other Medicare covered service.

Managed Medicare Plans – Medicare Advantage

  • Managed Medicare plans such as Medicare Advantage should pay any claims that would be covered by Medicare.
    • Follow Pre-Authorization as required by the plan
will non medicare insurers reimburse for patients entered in the registry
Will non-Medicare insurers reimburse for patients entered in the Registry?
  • No, there are no non-Medicare insurers who have elected to reimburse for patients entered in the registry. Patients with insurance coverage other than Medicare, including Medicaid, are not eligible to participate in the NOPR.
does nopr apply to inpatients
Does NOPR Apply to Inpatients?
  • Yes.
  • The technical charge for a PET study on a Medicare inpatient is not billed directly, but is considered to be covered by the Diagnostic Related Grouping (DRG) payment to the hospital for that patient.
  • Inclusion of the patient in the NOPR is necessary, however, for professional component reimbursement for the PET study.
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