July Medicare Transmittals and Other Updates

on Tuesday, 28 July 2020. All News Items | Outpatient Services | Miscellaneous | Medicare Coverage | Coding | Billing



Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.3, Effective October 1, 2020

  • Article Release Date: June 23, 2020
  • What You Need to Know: Change Request (CR) 11840 providers the quarterly updates to the NCCI PTP edits.
  • MLN MM11603: undefined

Quarterly Update to the End Stage Renal Disease Prospective Payment System (ERSD PPS)

  • Article Release Date: June 29, 2020
  • What You Need to Know: CR 11835 informs providers about the twenty new diagnosis codes eligible for the ESRD PPS comorbidity payment adjustment effective October 1, 2020.
  • MLN MM11835: undefined

October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

  • Article Release Date: July 2, 2020
  • What You Need to Know: This article updates the Quarterly ASP Medicare Part B Files and informs providers of revisions to prior quarterly filing prices.
  • MLN MM11854: undefined

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021

  • Article Release Date: July 2, 2020
  • What You Need to Know: This article provides FY 2020 Updates to the SNF PPS payment rates, as required by statue.
  • MLN MM11859: undefined

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2020 Update

  • Article Release Date: July 6, 2020
  • What You Need to Know: Change Request (CR) 11769 released on June 23, 2020 updates the HCPCS code set for codes related to drugs and biologicals effective July 1, 2020. The related MLN article MM11769 provides links to the updated quarterly HCPCS complete code set.
  • MLN MM11769: undefined

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

  • Article Release Date: July 10, 2020
  • What You Need to Know: This article announced changes included in the October 2020 quarterly release of the edit module for clinical diagnostic laboratory services.
  • MLN MM11889: undefined

Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season

  • Article Release Date: July 10, 2020
  • What You Need to Know: This article informs you of the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 each year.
  • MLN MM11882: undefined




Revising Chapters 3 and 5 of Publication (Pub.) 100-08, to Reflect the Recent Final Rule CMS-1713-F

  • Article Release Date: July 1, 2020
  • What You Need to Know: CR 11599, released June 19, 2020, revises the Medicare Program Integrity Manual, Chapters 3 (Verifying Potential Errors and Taking Corrective Actions) and 5 (Items and Services Having Special DMEPOS Review Considerations) to include finalized regulatory updates, including those related to face-to-face encounter and written order requirements.
  • MLN Matters MM11599: undefined

Change to the Payment of Allogeneic Stem Cell Acquisition Services

  • Article Release Date: July 13, 2020
  • What You Need to Know: Currently payment for this service is included in the MS-DRG payment for allogeneic hematopoietic stem cell transplants when transplants occurred in the inpatient setting. Change Request (CR) Transmittal R10218CP provides instructions to pay inpatient hospital Allogeneic Stem Cell Acquisition services on a reasonable cost basis.
  • MLN Matters MM11729: undefined




International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2020 Update

  • Article Release Date: February 25, 2020 – Revised June 22, 2020
  • What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11655 in which CMS removed the CPT code 0048U from the business requirement for NCD 90.2 Next Generation Sequencing (NGS) and corresponding removals of CPT 0048U and its associated diagnosis codes from the NCD 90.2 NGS spreadsheet. Changes were made due to the CPT code not meeting the policy criteria in NCD 90.2 for NGS.
  • MLN MM11655: undefined

July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) Revised

  • Article Release Date: June 8, 2020 – Revised July 2, 2020
  • What You Need to Know: This article was revised to reflect updates in the related CR R10207CP. Updates include the following:
    • Added CPT code 99458 with status indicator "B".
    • "New Separately Payable Procedure Codes – Surgical Procedures" has been updated with corrected APC assignment for HCPCS code C9760.
    • "OPPS PRICER Logic and Data Changes for the July 2020 Update" has been removed. There is also a new, "Inadvertent Deletion of CPT code 0126T" added.
    • Therefore, the existing section 16 "Changes to the Wage Index" has become section 15. Table 1 has been updated by adding a new PLA COVID-19 code, 0202U.
    • Table 2 has been updated by adding CPT code 99458 with status indicator "B".
    • Table 21 has been updated by changing APC number for HCPCS code C9760 from APC 1591 to APC 1589. We also changed the CR release date, transmittal number and link to the transmittal. All other information is unchanged.
  • MLN MM11814: undefined

July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

  • Article Release Date: June 24, 2020 – Revised July 2, 2020
  • What You Need to Know: This article describes changes to and billing instructions for various payment policies implemented in the July 2020 ASC payment system update. This notification also includes HCPCS updates. The July 2nd revision was made to correct the last section in Section 6.e, on page 10. CMS notes it should have stated, “C9058 is replaced by Q5120 effective July 1, 2020.”
  • MLN MM11842: undefined

Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model

  • Article Release Date: May 4, 2015 – Revised July 24, 2020
  • What You Need to Know: This article was revised to provide information on transportation information for beneficiaries in the Additional Information section of this article.
  • MLN SE1514: undefined

Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

  • Article Release Date: May 1, 2020 – Revised July 21, 2020
  • What You Need to Know: This article was revised to reflect revisions in Change Request (CR) 11850 also issued on July 21, 2020. This CR reflects additional sections to the Medicare Claims Procession Manual – Chapter 32 – Billing Requirements for Special Services. Section 66.2 of the chapter identifies CAR-T as having significant costs for Medicare Advantage. Due to the significant cost Providers may bill the A/B MAC for this NCD service provided to a MA beneficiary.
  • MLN MM11580: undefined




MLN Booklet: How to Use the Medicare Coverage Database (MCD)

  • Booklet Release Date: June 2020
  • What You Need to Know: This MLN education booklet provides information on what the MCD is, why you would use it, a background about Medicare coverage and coverage determinations, how up-to-date is the MCD and how to search the MCD.
  • ICN MLN901347 June 2020: undefined

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS) MLN Article Revised

  • MLN Article Revised: June 23, 2020
  • What You Need to Know: This article was revised to reflect the revised CR11461 issued on June 23, 2020. The revised CR clarifies instructions for the MACs and changed the implementation date to July 22, 2020.
  • MLN MM11461: undefined

Medicare Compliance Tips


MLN Booklet: How to Use the Medicare National Correct Coding Initiative (NCCI) Tools

  • Booklet Release Date: June 2020
  • What You Need to Know: This MLN education booklet provides information on what is the Medicare NCCI, why would you use it, how up to date are the NCCI tables and manual, how to locate the NCCI tables and manual and using the NCCI tools.
  • ICN 901346 June 2020: undefined

Medicare Quarterly Provider Compliance Newsletter

  • Newsletter Release Date: July 2020
  • What You Need to Know: This newsletter is released on a quarterly basis to share Medicare Contractor Audit Findings and provide information on how to address and avoid top issues in a particular quarter. The July 2020 edition includes information from the following three RAC Auditor Reviews:
    • New Issue #0099 – Skilled Nursing Facility Consolidated Billing: Outpatient Facility – Not Separately Payable Services: Unbundling,
    • New Issue #0129 – Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements, and
    • New Issue #0103 – Urological Supplies: Medical Necessity and Documentation Requirements.
  • ICN MLN5829840 July 2020: undefined




CMS Announces the Creation of the Office of Burden Reduction and Health Informatics

In a June 23rd Press Release, CMS announced a new Office of Burden Reduction and Health Information meant “to unify the agency’s efforts to reduce regulatory and administrative burden and to further the goal of putting patients first.” CMS Administrator Seema Verma said in the announcement that “The Office of Burden Reduction and Health Informatics will ensure the agency’s commitment to reduce administrative costs and enact meaningful and lasting change in our nation’s health care system…Specifically, the work of this new office will be targeted to help reduce unnecessary burden, increase efficiencies, continue administrative simplification, increase the use of health informatics, and improve the beneficiary experience.”

June 25, 2020: CMS Issues Home Health PPS Proposed Rule [CMS-1730-P] CY 2021

In addition to updating payment rates and wage index for calendar year 2021, “this proposed rule proposes to permanently finalize the changes to §409.43(a) as finalized in the first COVID-19 PHE IFC (85 FR 19230), to state that the plan of care must include any provision of remote patient monitoring and other services furnished via a telecommunications system and describe how the use of such technology is tied to the patient-specific needs as identified in the comprehensive assessment and will help to achieve the goals outlined on the plan of care.”

June 26, 2020: HHS Submits Status Report on Medicare Appeals Backlog at the ALJ Level

In this June 26th report, HHS indicated that they have reduced that “By the end of the second quarter of 2020, a total of 242,995 appeals remain pending at OMHA, which is a 43% reduction from the starting number of appeals identified in the Court’s order (426,594 appeals).”


AHA Announcement: undefined

July 6, 2020: CMS Issues End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Calendar Year (CY) 2021 Proposed Rule (CMS-1732-P)

In addition to proposed updates to payment policies and rates, this rule is also proposing updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and proposes changes to the ESRD Quality Incentive Program (QIP).

July 15, 2020: OIG Report: Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims

This is not the first time the OIG has focused on malnutrition diagnosis codes and based on their findings I do not anticipate this will be the last time. The parameters of the OIG audit included:

  • Focusing on Diagnosis Codes E41 (Nutritional marasmus) and E43 (Unspecified severe protein calorie malnutrition), and
  • Auditing a random sample of 200 claims with a discharge date in Fiscal Year 2016 or 2017.

OIG Findings:

  • 173 of the 200 records reviewed were not correctly billed by the hospitals
  • 9 of the 173 incorrectly coded claims the removal of the malnutrition code did not impact DRG assignment or payment.
  • The 164 claims that were incorrectly coded results in net overpayments of $914, 128
  • The OIG extrapolated their sample and estimated that hospitals received overpayments of$1 billion for FYs 2016 and 2017.

Based on OIG recommendations, “CMS stated that it will instruct its contractors to review a sample of claims in the sampling frame to determine whether they were billed correctly. Based on the findings of the sample review, CMS will determine the appropriate course of action. CMS will recover, as appropriate, any identified overpayments associated with the reviews consistent with agency policy and procedures.” You can read the entire report at undefined.

July 15, 2020: Contract Award for A/B MAC Jurisdiction 6

CMS posted the following information on the CMS MAC What’s New webpage:

“On July 15, 2020, the Centers for Medicare & Medicaid Services (CMS) awarded National Government Services, Inc. (NGS) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims for Illinois, Minnesota, and Wisconsin (Jurisdiction 6). This contract will also administer Medicare Home Health and Hospice (HH+H) FFS claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington. As NGS is the incumbent contractor for this A/B MAC jurisdiction, CMS anticipates that implementation of the new contract will go smoothly, with few, if any, service issues for Medicare beneficiaries and providers. Learn more about this at A/B MAC Jurisdiction 6 Award Fact Sheet (PDF).”

July 17, 2020: The Joint Commission’s (TJC’s) Continued Approval of its Hospital Accreditation Program Limited to 2 Years

CMS published their decision to approve TJC for continued recognition as a national accrediting organization for hospitals participating in the Medicare and Medicaid Programs in the Federal Register on July 17, 2020. CMS can approve an accrediting agency for up to 6 years. However, the Final Notice indicated the TJCs continued approval is effective for only two years from July 15, 2020 through July 15, 2022. The following excerpt from the Federal Register outlines CMS reasons for this shorter term of approval:

“This shorter term of approval is based on our concerns related to the comparability of TJC’s survey processes to those of CMS, as well as what CMS has observed of TJC’s performance on the survey observation. Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC’s processes surrounding its staff interview practices. Additionally, we are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment condition of participation. Based on these observations and review of TJC’s processes as discussed at section V.A. (Differences Between TJC’s Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements), we remain concerned about the thoroughness of review conducted within the facilities. While TJC has taken action based on the findings annotated in section V.A., as authorized under §488.8, we will continue ongoing review of TJC’s survey processes across all their approved accrediting programs to ensure that all our recommended changes have been implemented. In keeping with CMS’s initiative to increase AO oversight, and ensure that our requested revisions by TJC are complied with, CMS expects more frequent review of TJC’s activities to avoid any continued inconsistencies.”

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