May 2020 MAC Talk

on Tuesday, 19 May 2020. All News Items | Case Management | Documentation | Coding

Telehealth, Who Can Certify Home Health Plans and The Local Scene

Welcome to the fifth edition of our monthly MAC Talk article. This month before diving into updates from the MACs there are a couple of updates that have come about due to the current COVID-19 Public Health Emergency (PHE) that I wanted to share. Specifically, an NGS update about telehealth and an MLN Connects announcement regarding who can certify a home health plan of care.


Medicare Telehealth versus Telemedicine

On April 22, 2020 NGS included the following post in their Latest COVID-19 News:

“We have received many questions that have indicated confusion between telehealth and telemedicine, and which rules apply to which services within these two benefit categories. While there is a perceived relation between these types of services they are distinctly different.

Telemedicine refers to a group of services that may be provided to a patient without any physical patient contact. Services may be provided via a telephone (audio) connection, or via some type of online communication such as a patient/provider portal or via email interactions between the patient and practitioner. Typically, most telemedicine services are non-covered by Medicare. However, CMS has opened some of the codes for coverage during the COVID-19 public health emergency (PHE).

Telehealth refers to a distinct level of established services that have traditionally been performed via a face-to-face interaction between the patient and practitioner. This group of services has been grouped together in a distinct policy that allows this limited amount of traditional face-to-face services to be performed via an audio and video connection as a replacement to the in person, face-to-face interaction. Telehealth allows the interaction to still occur face-to-face; however, it can be achieved via the audio and video connection.

This benefit was set apart as a specific addition to Medicare policy in SSA 1834(m). The criteria requires real time communication between the patient and practitioner (audio and video), the patient geographic location is in a rural or non-metropolitan statistical area (based on ZIP Code eligibility), and patient consent is required. 

The site where the patient is located is considered the originating site and may bill Q3014 to cover the cost of a professional to set up the audio and video communication system and assist with the service provided, if required. The site where the practitioner is rendering the telehealth service is known as the distant site. The practitioner will bill for the service s/he provides based on the list of approved telehealth services. All telehealth services in the benefit are professional services.

CMS issued the MLN Telehealth Booklet which explains the coverage criteria, provides a listing of eligible originating sites, and eligible distant site practitioners that may perform services via telehealth. The booklet also contains a listing of applicable procedure codes that are allowed to be performed via telehealth and information on the appropriate geographic location of the patient that is allowed for telehealth services. During the PHE, the list of services allowed to be performed via telehealth have been temporarily expanded. The MLN Telehealth Booklet includes the complete list of codes, with those that are temporarily identified as such.”


May 7, 2020: MLNConnects Home Health Plans of Care: NPs, CNSs and PAs Allowed to Certify

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act to allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This is a permanent change that will continue after the Public Health Emergency.

Effective for claims with dates of service on or after March 1, 2020, these non-physician practitioners may bill the following codes:

  • G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care
  • G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care
  • G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans

The descriptors of the three codes will be revised at a later date to include the non-physician practitioner specialties.


May MAC Talk: The Local Scene


April 22, 2020: Palmetto GBA JJ Posts TPE Progress Updates

In last month’s MAC Talk article, we included TPE Progress Updates that had been posted by Palmetto GBA for Jurisdiction M and J. Since then Palmetto GBA has posted additional articles. Following is a list of specific TPE articles released to date by Palmetto GBA JJ:

  • March 25, 2020: HBO Therapy G0277,
  • March 25, 2020: JJ Part A Skilled Nursing Facility (SNF),
  • March 25, 2020: Therapeutic Exercise 97110,
  • April 3, 2020: DRG 885 Psychoses; and
  • April 3, 2020: DRG 470 Major Joint Replacement,
  • April 10, 2020: Manual Therapy 97140,
  • April 10, 2020: Inpatient Rehabilitation Facility (IRF) Ao604-D0604
  • April 10, 2020: Pegfilgrastim J205,
  • April 10, 2020: DRGs 291 and 292: Heart Failure and Shock with MCC and with CC,
  • April 11, 202: Rituximab J9310,
  • April 11, 2020: Infliximab J1745,
  • April 11, 2020: Denosumab J0897,
  • April 11, 2020: Bevacizumab J9035, and
  • April 20, 2020: DRGs 682/683 – Renal Failure.

Links to all of the articles can be found on Palmetto GBA’s JJ Target Probe and Educate webpage.


April 24, 2020: Palmetto GBA Daily Newsletter: Provider Contact Center FAQs and Reminder of Suspended Sequestration


April 23, 2020: Palmetto GBA Daily Newsletter: Clarification of Negative Reimbursement

Palmetto GBA’s April 23rd Daily Newsletter included an article about negative reimbursement. The article opens with the following: “Negative reimbursement happens when the beneficiary cost sharing, such as coinsurance and/or deductible, exceeds the reimbursement due to the provider. Medicare Administrative Contractors (MACs) are instructed to withhold payments if the Medicare deductible/coinsurance is more than the reimbursement rate. For example, if the set deductible for an inpatient stay is $100 and the reimbursement for the stay is $95, Medicare will show a negative $5 for the reimbursement amount. Further examples are provided in this article.”


April 28, 2020: Noridian Announcement: Outpatient Therapy A/B Physical, Occupational, and Speech Language Pathology Webinar – May 28, 2020

The Noridian Provider Outreach and Education (POE) staff announced they are hosting this webinar on May 28, 2020. This webinar includes:

  • Certification and Re-certification,
  • Coding and Billing,
  • Maintenance Services,
  • CMS and Noridian Resources.

They advise providers that you can sign up for this webinar and other events of interest by visiting the Noridian Schedule of Events.


April 29, 2020: WPS GHA Medicare eNews: June 9, 2020 Hospital Notices of Non-Coverage Webinar

WPS announced they will be hosting this webinar that will cover the different notices of non-coverage issued by hospitals and clarifies when to issue each. The following notices will be covered during this presentation:

  • Hospital-Issued Notices of Noncoverage (HINNs) 1, 10, 11, and 12
  • Important Message from Medicare (IM) and the Detailed Notice of Discharge (DND) (CMS-R-193 and CMS-10066)
  • Medicare Outpatient Observation Notice (MOON) (CMS-10611)
  • Advance Beneficiary Notice of Noncoverage (ABN) (CMS-R-131)

You can sign up for this course through the WPS Learning Center.


May 4, 2020: WPS GHA eNews: Procedure Code 94762 – Are You Billing Correctly?

In their May 4th eNews, WPS noted that procedure code 94762 represents a continuous overnight pulse oximetry service. Further, they have recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. WPS encourages all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) - Evaluate Use.


May 4, 2020: Palmetto GBA Daily eNewsletter: CERT Task Force Education Material

Palmetto GBA reminds provider that the Medicare A/B Contractor CERT Task Force is a joint effort of the Part A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. They also encourage providers to review the CERT Task Force Educational Material available on their website and share with your staff.


May 5, 2020: Palmetto GBA Daily eNewsletter: Spring Virtual Tour

Palmetto GBA announced they will be presenting their first ever Medicare Part A Spring Virtual Tour for Jurisdictions J and M. There will be two days of sessions with presenters from the following:

  • The Provider Outreach and Education (POE) Team,
  • The Appeals Department,
  • Medical Review, Audit and Reimbursement,
  • MCG Health, and
  • C2C Solutions.

You can read more about this event and select sessions you would like to register for on the JJ/JM Part A Springing into Summer Virtual Tour 2020: June 8-9, 2020 webpage.


May 8, 2020: Noridian JF: Sleep Lab Credentialing: Polysomnography and Other Sleep Studies Retirement – Effective May 14, 2020

Noridian provided the following Notice in their daily eNewsletter. Even though they are retiring this article (A57698), Noridian cautions against a change in your current practice.

This coverage article has been retired under contractor numbers: 02101 (AK), 02201 (ID), 02301 (OR), 02401 (WA), 03101 (AZ), 03201 (MT), 03301 (ND), 03401 (SD), 03501 (UT), and 03601 (WY).

Effective Date: May 14, 2020
Summary: Coverage articles may be retired due to lack of evidence of current problems or CMS may have issued guidance regarding national coverage. The Noridian guidance in the retired article may still be helpful in assessing medical necessity. Where providers have adjusted their billing and coding practices to correspond to the guidance in a coverage article, they will want to be very careful in departing from these practices just because the article is retired. Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is a coverage article in place.

Note: Noridian JE also announced the retirement of their Polysomnography and Other Sleep Studies Article (A57697) effective May 14, 2020.


May 15, 2020: Palmetto GBA Daily Newsletter: Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Webcast

Palmetto will be hosting this webcast on June 1, 2020. Their Medical Review subject matter experts will be available to discuss and answer questions about the current TPE model. This announcement includes a link for you to register for this event.


May 15, 2020: Palmetto GBA Daily Newsletter: Appeals and Clerical Error Reopenings Module 

Palmetto notes this “updated module provides education on correcting incomplete and/or invalid submissions, correcting claims with medically denied lines, clerical error reopening, and redetermination requests. There is also a further explanation on the submission of documentation for a clerical error reopening (bilateral procedure) and on adding late charges during the appeal process. A new section, Correcting Inpatient Discharge Status, was added to the module. Please review the updated module and share it with your staff.”


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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