Knowledge Base Article

MEDICARE TRANSMITTALS – RECURRING UPDATES

April 2019 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11151.pdf

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

NCD coding changes as the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11134.pdf

Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11121.pdf

OTHER MEDICARE TRANSMITTALS

Processing Veterans Administration (VA) Inpatient Claims Exempt from Present on Admission (POA) Reporting

The HAC-POA payment provision required by the Deficit Reduction Act of 2005 (DRA) applies only to Inpatient Prospective Payment System (IPPS) hospitals. Therefore, VA hospitals are exempt from reporting POA and End of POA Indicators.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11053.pdf

Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

Updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent policy revisions including: (a) the repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and, (b) the discontinuation of the functional reporting requirements.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11120.pdf

Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation

To prevent potential overpayments, Medicare’s Fiscal Intermediary Shared System (FISS) will deduct organ acquisition charges billed with revenue codes 081X from the total covered charges prior to sending an inpatient Type of Bill (TOB) 11X claim to the IPPS pricer for any date of service processed on or after July 1, 2019.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11087.pdf

Revising the Remittance Advice Messaging for the 20-Hour Weekly Minimum for Partial Hospitalization Program Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11066.pdf

Common Working File (CWF) Provider Queries National Provider Identifier (NPI) Verification

The Common Working File (CWF) will require verification of the NPI similar to the HETS when Medicare Part A providers request Medicare beneficiary eligibility and entitlement data via the CWF provider inquiry screens.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10983.pdf

Processing Instructions to Update the Standard Paper Remit (SPR)

Instructs MACs to update their systems to ensure that SPRs mailed after July 1, 2019, mask the Health Insurance Claim Number (HICN), so the Social Security Number (SSN) does not show.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11112.pdf

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

Makes the changes required to send Additional Documentation Request (ADR) letters to participating providers via the (esMD) system. A CR to effectuate the exchange of ADR letters to registered providers via the esMD system will be released at a later date.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11003.pdf

Update to Mammography Editing

Modifies existing editing to ensure only revenue codes 0401, 0403, 0520, 0521, 096, 097, or 098 are billed on claims containing mammography codes 77065, 77066, or 77067.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4225CP.pdf

Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)

Effectuates changes to the SNF Prospective Payment System (PPS) that were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11152.pdf

Local Coverage Determinations (LCDs) – REVISED

Multiple revisions of this transmittal that changes the LCD process.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes

Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11168.pdf

Update to the Internet-Only-Manual (IOM) Publication (Pub.) 100-04, Chapter 32, Section 12.1

Removes diagnosis codes from and adds diagnosis codes to the list of valid diagnosis codes for Counseling to Prevent Tobacco Use.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4237CP.pdf

MEDICARE COVERAGE

Update to Intensive Cardiac Rehabilitation (ICR) Programs

Effective February 9, 2018, coverage in an ICR is expanded to include stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35 percent or less and New York Heart Association (NYHA) Class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11117.pdf

Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)—Clarification of Payment Rules and Expansion of International Classification of Diseases Tenth Edition (ICD-10) Diagnosis Codes

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11022.pdf

CMS proposes Coverage with Evidence Development for Chimeric Antigen Receptor (CAR) T-cell Therapy

https://www.cms.gov/newsroom/press-releases/cms-proposes-coverage-evidence-development-chimeric-antigen-receptor-car-t-cell-therapy

Decision Memo for Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) (CAG-00313R2)

CMS will cover FDA approved vagus nerve stimulation (VNS) devices for treatment resistant depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year with the possibility of extending the study to a prospective longitudinal study when the CMS approved, double-blind, randomized placebo-controlled trial has completed enrollment, and there are positive interim findings.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=292&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs) – REVISED

Implementation date changed from February 26, 2019 to March 26, 2019.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R213NCD.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Medicare Hospital Claims: Avoid Coding Errors
• DME Proof of Delivery Documentation Requirements

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

New App Displays What Original Medicare Covers

Allows people with Original Medicare, caregivers and others to quickly see whether Medicare covers a specific medical item or service.

https://www.cms.gov/newsroom/press-releases/new-app-displays-what-original-medicare-covers

Emergency Triage, Treat, and Transport (ET3) Model

A voluntary, five-year payment model that will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.

https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model