MLN Matters Number: MM6046
Related Change Request (CR) #: 6046
Related CR Release Date: June 6, 2008
Effective Date: March 17, 2005
Related CR Transmittal #: R349OTN
Implementation Date: July 7, 2008

Inappropriate Denials of Claims for Percutaneous Transluminal Angioplasty (PTA) of Carotid Arteries Concurrent with Stenting Based on Facility Recertification Due Dates

Provider Types Affected
Physicians and hospitals who submit claims to Medicare carriers, fiscal intermediaries (FI) and Part A/B Medicare Administrative Contractors (A/B MAC) for PTA services provided to Medicare beneficiaries

What Providers Need to Know
Be aware that the Centers for Medicare & Medicaid Services (CMS) using Change Request (CR) 6046 reminds providers and Medicare contractors that certifying and recertifying facilities for Medicare payment is solely under CMS jurisdiction. When CMS certifies a facility, the facility name and effective date appear on a list of approved facilities located at http://www.cms.hhs.gov/MedicareApprovedFacilitie/CASF/list.asp on the CMS Web site. If CMS disapproves a facility at any time, that facility is placed on a separate list of formerly approved facilities indicating the time period during which the facility was certified (also accessible on the above-noted Web site). Therefore, as long as a facility appears on the
approved list, it is considered certified by CMS whether or not recertification is in pending status. Your Medicare contractors are expected to consult the two facility lists in determining certification status and they should not deny claims based on any other certification factors such as erroneously applied expiration date edits.

All requirements contained in CR 3811 and CR 5660 remain in effect. You may review related articles MM5660, which clarifies the national coverage determination (NCD) policy for PTA at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5660.pdf on the CMS Web site, and MM3811, which outlines the initial NCD policy for PTA at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf on the CMS Web site.

Background
This article is based on CR 6046 and in this article CMS states that it has come to their attention that some contractors are misapplying the initial certification and recertification requirements contained in CR 3811 and CR 5660, respectively, thereby inappropriately denying claims when a facility is not immediately recertified at the end of a two-year period.

Effective March 17, 2005, CMS revised the NCD for PTA of the carotid artery concurrent with placement of an FDA-approved carotid stent for certain beneficiaries at high risk for carotid endarterectomy. On April 22, 2005, CMS issued change request (CR) 3811 to implement NCD 20.7, which included detailed steps facilities must follow to become certified by CMS to perform this procedure.

On April 30, 2007, as a result of a request for reconsideration of NCD 20.7, CMS posted a final decision that the current coverage policy would remain unchanged. CR 5660 was subsequently released on September 12, 2007, reiterating its decision. CR 5660 also made clarifying revisions to NCD 20.7 which included additional, detailed recertification steps a facility must follow every two years in order to maintain Medicare coverage of carotid artery stenting (CAS) procedures.

Additional Information
If you have questions, please contact your Medicare carrier, FI, or A/B MAC, at their toll-free number which may be found at:

http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

You may see the official instruction (CR6046) issued to your Medicare carrier, FI, or A/B MAC, by going to http://www.cms.hhs.gov/Transmittals/downloads/R349OTN.pdf on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.