Tufts Health Plan Medicare Preferred
Recent Medicare Determinations

As a Medicare Advantage Organization, Tufts Medicare Preferred must follow Medicare coverage guidelines. Network providers should be aware of the following recent Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), which can be accessed online at the Centers for Medicare & Medicaid Services (CMS) Web site, cms.hhs.gov.

Erroneous Surgery
Retroactive to an effective date of January 15, 2009, CMS does not cover a surgical or other invasive procedure to treat a medical condition when the practitioner performs 1) a different procedure altogether; 2) the correct procedure on the wrong body part; or 3) the correct procedure on the wrong patient. CMS released detailed coding instructions available in Transmittal R1778CP.

For further information, refer to the following NCDs and Transmittal:

• NCD 140.6: Wrong Surgical or Other Invasive Procedure Performed on a Patient
• NCD 140.7: Surgical or Other Invasive Procedure Performed on the Wrong Body Part
• NCD 140.8: Surgical or Other Invasive Procedure Performed on the Wrong Patient
• Transmittal R1778CP

Pharmacogenomic Testing for Warfarin Response
On August 3, 2009, CMS stated in a final decision memo that pharmacogenomic testing to predict warfarin responsiveness is not reasonable and necessary. CMS proposes pharmacogenomic testing to predict warfarin responsiveness be covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin, and only then in the context of a prospective, randomized, controlled Medicare qualifying clinical study. 

Additional information is available in Decision Memo for Pharmacogenomic Testing for Warfarin Response (CAG-00400N).

Wheelchair Seating
Effective December 1, 2009, CMS has added several diagnoses that are indicated for types of wheelchair seating. For details, refer to LCD for Wheelchair Seating (L15845).

KX, GA, GZ and GY Modifiers
CMS has made changes in the definitions of these modifiers required for accurate billing in several LCDs. Details are available in article A49303 regarding KX, GA, GZ and GY modifiers.

November 1, 2009