December Medicare Transmittals and Other Updates

on Tuesday, 05 January 2021. All News Items | Outpatient Services | Miscellaneous | Medicare Coverage | Coding | Billing



Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2021 – Recurring File Update

  • Article Release Date: December 4, 2020
  • What You Need to Know: Since 2017 CMS has updated the FQHC PPS rate annually. Based on historical data through the second quarter of 2020, the FQHC market basket for CY 2021 is 1.7 percent increasing the FQHC PPS base payment of $173.50 in 2020 to $176.45 for 2021.
  • MLN MM12046:

Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2021

  • Article Release Date: December 4, 2020
  • What You Need to Know: This article provides the CY 2021 payment limit for RHCs. The CY 2021 amount has increased from $86.31 in 2020 to $87.52 effective January 1, 2021. The related Change Request (CR) 12035 was released on October 29, 2020.
  • MLN MM12035:

Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction list, and Preventive Services List

  • Article Release Date: December 4, 2020
  • What You Need to Know: CR 12071 provides a summary of policies in the CY 2021 MPFS Final Rule and makes other policy changes that apply to Medicare Part B. This MLN article is a supplement to the CR.
  • MLN MM12071:

2021 Annual Update of Per-Beneficiary Threshold Amounts

  • Article Release Date: December 7, 2020
  • What You Need to Know: The related Change Request (CR) 12014 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2021.
  • MLN MM12014:

CY 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

  • Article Release Date: December 7, 2020
  • What You Need to Know: Information on the data files, update factors, and other information related to the CY 2021 update to the fee schedule can be found in this article.
  • MLN MM12063:

Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

  • Article Release Date: December 18, 2020
  • What You Need to Know: Information provided in this article is related to CR 12080 and intended for clinical diagnostic laboratories. CR 12080 provided instructions for CY 2021 CLFS, mapping for new codes for clinical laboratory tests, and an update for laboratory costs subject to reasonable charge payment.
  • MLN MM12080:

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.1, Effective April 1, 2021

  • Article Release Date: December 23, 2020
  • What You Need to Know: This article provides a background on NCCI Edits and refers to CR 12110, which provides quarterly updates to the NCCI PTP edits.
  • MLN MM12110:

Updating Calendar Year (CY) 2021 Medicare Diabetes Prevention Program (MDPP) Payment Rates

  • Article Release Date: December 23, 2020
  • What You Need to Know: For organizations enrolled as MDDP suppliers, this article includes a link to the accompanying CR 12030, which contained instructions for MACs and the Railroad Specialty MAC to update the MDPP Expanded Model payment rates for CY 2021.
  • MLN MM12030:

Quarterly Update to Home Health (HH) Grouper

  • Article Release Date: December 30, 2020
  • What You Need to Know: This article provides information regarding the January 2021 update to the HH Grouper software to reflect new COVID-19-related diagnosis code changes.
  • MLN MM12047:

2021 Annual Update to the Therapy Code List




Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes (A-04-18-04067)

  • Article Release Date: December 1, 2020
  • What You Need to Know: An OIG audit report released August 2020 (report No. A-04-18-04067) identified Medicare overpayments to hospitals that did not comply with Medicare’s post-acute-care transfer policy. This MLN Special Edition article was published to remind hospitals of proper coding of the patient discharge status code and the use of condition codes 42 and 43.
  • MLN SE20025:

FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients




Changed to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020

  • Article Release Date: July 31, 2020 – Revised November 30, 2020
  • What You Need to Know: This article was revised to reflect changes made to CR 11889 issued on August 14th. CR 11889 was revised to update the codes for NCD 190.15.
  • MLN MM11889:

Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021

  • Article Release Date: November 9, 2020 – Revised December 2, 2020
  • What You Need to Know: This is the second time that CMS has updated this MLN article. The December 2nd revisions added information for reporting the use of cinacalcet by ESRD facilities. “Beginning January 1, 2021, cinacalcet is an oral drug eligible for consideration as an ESRD outlier service. ESRD facilities should report revenue code 250 with the drug’s NDC.
  • MLN MM12011:

New & Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE

  • Article Releases Date: April 17, 2020 – Revised December 3, 2020
  • What You Need to Know: Revisions to this article includes additional guidance on telehealth services that have cost-sharing and cost-sharing waived and language changes for clarity that did not alter the substance of the article.
  • MLN MMSE20016:

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – April 2021

  • Article Release Date: November 4, 2020 – Revised December 10, 2020
  • What You Need to Know: This article was revised due to a revised CR 12027. Revisions made did not impact the substance of this article.
  • MLN MM12027:

Medicare Claims Processing Transmittal 10521: New Medicare Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs

  • Transmittal 10266 Release Date: August 6, 2020
    • Transmittal 10521 Release Date: December 16, 2020
  • What You Need to Know: Transmittal 10266 was rescinded and replaced by Transmittal 10266 to add the Provider Type "34", note that CAH's are paid via the OTP fee schedule, and clarification on the 2020 OTP fee schedule file (attachment 1) versus the 2021 OTP fee schedule file (new attachment 3). This correction revises business requirement 1856-4.1 and only impacts publication 100-04. All other information remains the same.
  • Transmittal 10521:
    • Effective Date: January 1, 2021 for claims received on or after 1/1/2021

Note, a related Medicare Financial Management Transmittal 10521 revises business requirement 1856-4.1 and only impacts publication 100-04. (

Transmittal 10525: Implementation of the New Ambulatory Surgical Center (ASC) Payment Indicator “K5”

  • Transmittal 10245 Release Date: July 30, 2020
    • Transmittal 10525 Release Date: December 17, 2020
  • What You Need to Know: Transmittal 10245 was rescinded and replaced by Transmittal 10525 to remove the word “DRAFT” from Attachment A. CMS created “a new ASC payment indicator, specifically, “K5” to identify codes that describe items, procedures, and services for which pricing information and claims data are not available, and consequently, no ASC payment will be made. This new payment indicator, effective January 1, 2021, provides the assignment, definition, and detail needed for this subset of HCPCS codes.”
  • Transmittal 10525:

Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) – Implementation

  • Article Release Date: August 10, 2020 – Revised December 22, 2020
  • What You Need to Know: Revisions were made due to a revised CR 11870 with updates to some denial edits.
  • MLN MM11870:




December 1, 2020: CMS Updates Coverage Policies for Artificial Hearts and Ventricular Access Devices (VADs)

CMS released Decision Memo CAG-00453N on December 1st updating coverage requirements for artificial hearts and VADs. Specifically,

  • Artificial Hearts: “CMS is removing the NCD at § 20.9, ending coverage with evidence development for artificial hearts and permitting Medicare coverage determinations for artificial hearts to be made by the Medicare Administrative Contractors (MACs) under § 1862(a)(1)(A) of the Social Security Act.”
  • VADs: CMS notes in a related Press Release that “The final national coverage determination, which is effective today, also provides updated coverage criteria for VADs that better aligns with current medical practice and that we believe will expand coverage to a greater number of candidates who are likely to benefit from this technology. Specifically, the updated patient criteria in the NCD aligns with the inclusion criteria derived from recent large randomized controlled trials, which demonstrated improved patient outcomes.”

December 21, 2020: Proposed Updates to Coverage Policy for Autologous Blood-Derived Products from Chronic Non-Healing Wounds

CMS proposed to “update coverage of Platelet Rich Plasma (PRP) for the treatment of chronic non-healing diabetic, venous, and pressure wounds. PRP is a blood-derived product prepared from the patient’s own blood to be used as a wound covering in the management of chronic wounds. PRP is currently covered under the Coverage with Evidence Development (CED) pathway for the treatment of chronic, non-healing diabetic, venous, and pressure wounds when beneficiaries are enrolled in a clinical study. This proposed National Coverage Determination would eliminate the CED requirement and nationally cover PRP for the treatment of chronic non-healing diabetic wounds. The proposal also would provide for coverage determinations for PRP for all other chronic non-healing wounds to be made by local Medicare Administrative Contractors.”

CMS is seeking comments on the proposed national coverage determination.






December 10, 2020: MLN Call – Physician Fee Schedule Final Rule: Understanding 4 Key Concepts

CMS hosted a Medicare Learning Event to provide information about the following four key concepts in the 2021 PFS Final Rule:

  • Extending Telehealth & Licensing Flexibilities,
  • Evaluation and Management (E/M) Visits and Analogous Services,
  • Quality Payment Program Updates, and
  • Opioid Use Disorder/Substance Use Disorder Provisions.

You can access the Presentation on the 2020-12-10 Physician Fee Schedule webpage

KEPRO Case Review Connections: Acute Care Edition Winter 2020

KEPRO has released their Winter 2020 Edition of their Case Review Connections e-newsletter for Acute Care. Examples of what’s in this newsletter are the Medical Director’s Corner, a notice about them now accepting Medical Records electronically and an immediate advocacy success story.

MLN Educational Tool Medicare Preventive Services Updated in December

CMS has revised this Medicare Learning Network educational too. The tool provides information about coding, coverage and the beneficiary’s copayment/coinsurance and deductible.




December 1, 2020: CMS Releases 2021 Medicare Physician Fee Schedule (PFS) Final Rule

The following list highlights several of the changes found in the PFS Final Rule for 2021:

  • Within the Final Rule, CMS issued two interim final rules with comment period.
    • The first interim final rule is “to establish coding and payment for virtual check-in services to support the continued need for coding and payment to reflect the provisions of lengthier audio-only services outside of the PHE for COVID,19, if not as substitutes for in-person services.”
    • The second interim final rule is “to establish coding and payments for PPE as a bundled service and certain supply pricing increases in recognition of the increased market-based costs for certain types of PPE.”
  • Payments have been Increased to physicians and other practitioners for additional time spent with patients providing chronic disease management,
  • Sixty additional services have been added to the telehealth list that will continue to be covered beyond the COVID-19 public health emergency (PHE),
  • CMS established on an interim final basis a new HCPCS G-code describing 11-20 minutes of medical discussion to determine the necessity of an inpatient visit.”
  • CMS commissioned a study of its telehealth flexibilities during the COVID-19 PHE,
  • The increase in payment rates for office/outpatient face-to-face evaluation and management (E/M) visits finalized in 2020 goes into effect in 2021. According to a related CMS Press Release, the payment increases “support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home,”
  • Simplified coding and documentation changes for Medicare billing for E/M office visits goes into effect January 1, 2021 modernizing guidelines developed in the 1990’s,
  • CMS Finalized the following workforce flexibilities that have been provided during the COVID-19 PHE:
    • “Certain non-physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
    • Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
    • Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.”
  • CMS notes in a related Fact Sheet that “direct supervision may be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the PHE ends or December 31, 2021.”
  • CMS finalized the elimination of six older National Coverage Determinations (NCDs) and noted in the final rule “that if the previous NCD barred coverage for an item or service under title XVIII (that is, national noncoverage NCD), a MAC would now be able to cover the item or service if the MAC determined that such action was appropriate under the statue…proactively removing obsolete broad non-coverage NCDs removes barriers to innovation and reduces burden for stakeholders and CMS.” The effective date for removal of the following six NCDs is on the date of the final rule:
    • NCD 20.5 – Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
    • NCD 30.4 – Electrosleep Therapy,
    • NCD 100.9 – Implantation of Gastrointestinal Devices,
    • NCD 110.19 – Abarelix for the Treatment of Prostate Cancer
    • NCD 220.2.1 – Magnetic Resonance Spectroscopy, and
    • NCD 220.6.16 - FDG PET for Inflammation and Infection.

December 2, 2020: OIG Fall 2020 Semiannual Report to Congress

The OIG Semiannual Report reflects work performed from April 1, 2020 through September 30, 2020. Following are some of the high-level findings from the report by the numbers:

  • 97 – the number of audit reports completed
  • 27 – the number of evaluation reports completed
  • $337 million – the amount identified in expected recoveries,
  • $446 million – costs questions by the OIG because of an alleged violations, costs not supported by adequate documentation, or the expenditure of funds where the intended purpose is unnecessary or unreasonable,
  • $2 billion – potential savings identified for HHS; and
  • 416 – The number of new audit and evaluation recommendations made by the OIG.

December 7, 2020: 2021 IPPS Final Rule Correction Notice Published in Federal Register

This document corrects technical and typographical errors in the September 18, 2020 issue of the FY 2021 IPPS Final Rule.

December 10, 2020: CMS Proposed Modifications to the HIPAA Privacy Rule

HHS notes in their announcement the proposed changes will “support individuals’ engagement in their care, remove barriers to coordinated care, and reduce regulatory burdens on the health care industry.” The Summary statement in the Proposed Rule indicates that “these modifications address standards that may impede the transition to value-based health care by limiting or discouraging care coordination and case management communications among individuals and covered entities (including hospitals, physicians, and other health care providers, payors, and insurers) or posing other unnecessary burdens. The proposals in this NPRM address these burdens while continuing to protect the privacy and security of individuals’ protected health information.”

December 10, 2020: CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers

CMS released the following information in a December 12, 2020 Special Edition of MLNConnects:

On December 10, under President Trump’s leadership, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care. For More Information:

December 16, 2020: CMS Report – National Healthcare Spending in 2019

“The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. The data are presented by type of service, sources of funding, and type of sponsor.

U.S. health care spending grew 4.6 percent in 2019, reaching $3.8 trillion or $11,582 per person.  As a share of the nation's Gross Domestic Product, health spending accounted for 17.7 percent.”

You can download the entire report on the CMS National Health Expenditure Data Historical webpage.

December 18, 2020: Special Edition MLNConnects: Monitoring for Hospital Price Transparency

CMS indicated in this Special Edition MLNConnects that they plan “to audit a sample of hospitals for compliance starting in January, in addition to investigating complaints that are submitted to CMS and reviewing analyses of non-compliance, and hospitals may face civil monetary penalties for noncompliance.” CMS also reminds providers of their Hospital Price Transparency website where they have provided several resources for hospitals as they work towards compliance with Hospital Price Transparency. 

December 31, 2020: Palmetto GBA offers Introduction to 2021 E&M Changes

Palmetto GBA included the following information in their December 31st Daily Newsletter:

“Effective January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented a new coding, prefatory language, and interpretive guidance framework that the American Medical Association Current Procedural Terminology Editorial Panel issued for office and outpatient E/M visits. Please review the information in this job aid and share it with your staff.” You can access this introduction education material at:

January 1, 2021: CMS Releases MLN Guide Titled Evaluation and Management (E/M) Services

CMS has released publication ICN: 006764 that serves as a guide to learning the principles of documentation, common sets of codes used to bill for services, and other considerations.


Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

 In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

 This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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