Knowledge Base Article

Welcome to this month’s MAC Talk article. Before diving into updates from the MACs, there are two issues I want to alert readers about. First, a reminder about the updated ABN form. Second, CMS’ indication that Medicare Contractor can resume medical reviews as of August 3, 2020.

New Fee-For-Service (FFS) Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131

On June 24th the FFS ABN CMS webpage was modified to add the following statement:

“The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal.  The use of the renewed form with the expiration date of 06/30/2023 will be mandatory on 8/31/2020.  The ABN form and instructions may be found in the download section.”

Link to webpage: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN

Medical Review during the COVID-19 Public Health Emergency

On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews.

Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) for the COVID-19 pandemic?

A. On March 30 CMS suspended most Medicare Fee-For-Service (FFS) medical review because of the COVID-19 pandemic. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). As states reopen, and given the importance of medical review activities to CMS’ program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency. If selected for review, providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness. CMS notes that all reviews will be conducted in accordance with statutory and regulatory provisions, as well as related billing and coding requirements. Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied.

Link to document: https://www.cms.gov/files/document/provider-burden-relief-faqs.pdf

July MAC Talk: The Local Scene

June 16, 2020: Palmetto GBA Article: Botulinum Toxin Injections

In this article, Palmetto provides detail from their Local Coverage Determination (L33458) including dosage and frequency of botulinum toxin injections, documentation expectations for coverage of the services provided, and a checklist to ensure documentation requirements are in the medical record.

This was timely information in advance of the July 1, 2020 implementation date for the Prior Authorization Program for Certain Hospital Outpatient Department (OPD) Services.

June 29, 2020: CGS J15

CGS posted the following information to their website on June 29th:

On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment (CMS-1744-IFC) instructing the DME MACs to suspend or not enforce various requirements found in local coverage determinations and related policy articles. On May 8, 2020, CMS published CMS-5531-IFC extending non-enforcement of the clinical indications for coverage to therapeutic continuous glucose monitors (CGMs). These changes are effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE). Please see the full details regarding DME MAC implementation of CMS-1744-IFC and CMS-5531-IFC in the article here.”

July 2, 2020: Noridian JF Article: The Difference Between and Appeal and a Rebuttal

“When a provider does not agree with an overpayment determination, they may appeal the decision. An appeal disputes the overpayment and provides documentation to show medical necessity for the procedures in question. The limitation on recoupment provision mandates that no recoupment begins when a valid and timely request for a first level or second level appeal is received.

A rebuttal does not dispute the amount of the overpayment, nor does it dispute the overpayment determination. A rebuttal permits the provider a vehicle to indicate why the proposed recoupment should not be taken at the designated time. This allows providers to submit a statement advising if the recoupment occurs, it will cause financial hardship for their facility. The contractor, based on the rebuttal statement, determines whether to delay or begin recoupment. The rebuttal process is not an appeal and does not change anything regarding the debt owed.”

Internet Only Manual, (IOM), Publication 100-06, Chapter 3, Section 200.1.4: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/fin106c03.pdf 

Link to Noridian JF webpage: https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/the-difference-between-an-appeal-and-a-rebuttal

July 6, 2020: WPS GHA eNews - Prior Authorization (PA) for Hospital Outpatient Department Services Facts

Effective June 17, 2020, providers billing on a 13x Type of Bill (TOB) should submit a PA request to their MAC before providing the following services:

• Blepharoplasty

• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein Ablation 

Providers should note the following:

• Prior authorization requests for botulinum toxin injections are only for injection CPT codes 64612 and 64615

• Prior authorization requests for botulinum toxin injections must include both the administration site and drug CPT codes
• Units of service for botulinum toxin injections should include the expected units of waste
• Each date of service requires its own prior authorization request
• CPT code 21235 no longer requires a prior authorization request
• Prior authorization is for dates of service July 1, 2020, and after
• Expedited requests must include justification that the standard review time for making a decision would seriously risk the health of the beneficiary
• Requests are not valid if they do not have the facility PTAN and NPI for the Hospital Outpatient Department 

For additional information, see Prior Authorization for Hospital Outpatient Department Services (HOPD) Overview. Please note, you need to select J5A or J8A to see the entire article.

July 6, 2020: Noridian JF to Host ABN Webinar – August 6, 2020

Noridian announced they will be hosting an ABN webinar on August 6th at 11 a.m. CT. This event includes:

• The new ABN form
• ABN Basics
• ABN Completion
• ABN Tips
• ABN Resources
• Noteworthy information

The Noridian announcement provides a link to sign up for this webinar.

July 9, 2020: New and Improved ST PEPPER Format for Short-Term (ST) Acute Care Hospital PEPPER

The PEPPER Team sent a notice about a “new and improved” format for the PEPPER Report. Hospitals will notice changes with the release of the Q1FY20 report scheduled to be available on July 15th.

The PEPPER Team noted in the announcement that “while all of the data and information that you are used to seeing in your PEPPER will still be available, the new format will include the following improvements:

• Greater accessibility
• Cleaner presentation
• Improved readability.

To help introduce Providers to the new format of PEPPER, the PEPPER Team prepared a recorded webinar demonstration of the new PEPPER, which is available on the PEPPER website.

July 13, 2020: First Coast JN Prior Authorization for Certain Hospital Outpatient Department Services Tips and Reminders

First Coast has posted the following information on their website regarding this program:

The PA team has been receiving and processing prior authorization requests (PAR) for certain hospital OPD services. View the following reminders prior to submitting your request:

• Providers are reminded that the PAR must include a PAR coversheet along with appropriate documentation. 
• Providers are asked to make sure the PAR hospital outpatient procedures Medicare fax/mail coversheet is being used and that all fields on the PAR coversheet are completed.
• Remember that PA is only required for procedures on the CMS list

• The PA is only required for the hospital outpatient department (OPD) who will be billing on the type of bill (TOB) 13X
• PA for hospital OPD does not apply to Ambulatory Surgical Centers (ASCs)

• PAR resubmissions must include the following:
• A copy of the initial PAR cover sheet and all documentation from the initial submission
• Any additional information/documentation

Click here to view additional information related to the prior authorization program.