Knowledge Base Article

Medicare MLN Articles & Transmittals – Recurring Updates

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 0240U, 0231U and 87637

• Article Release Date: June 11, 2021
• What You Need to Know: The FDA has issued Emergency Use Authorizations (EUAs) for the COVID-19 tests represented by these three HCPCS codes. “For Medicare to recognize these tests performed under a CLIA certificate of waiver or a CLIA certificate for provider-performed microscopy procedures, you must add the modifier QW.”
• MLN MM12318: (link)

July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: June 14, 2021
• What You Need to Know: This article provides a summary of changes to and billing instructions for payment policies to be implemented by CMS on July 1, 2021.
• MLN MM12316: (link)

July 2021 Update of the Ambulatory Surgical Center [ASC] Payment System

• Article Release Date: June 25, 2021
• What You Need to Know: For the July 2021 Update there are 8 new CPT Category III codes, a new device pass through code, new HCPCS codes for drugs and biologicals, a change to a skin substitute HCPCS code from the low to the high-cost skin substitute group and a new technology HCPCS code as been established to describe the technology associated with vaginal colpopexy by sacrospinous ligation fixation.
• MLN MM12341: (link)

Revised Medicare MLN Articles & Transmittals

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update

• Article Release Date: February 23, 2021 – Most recent revision June 3, 2021
• What You Need to Know: In the third iteration of this MLN article, important information about the use of the QW modifier was added in red print on page 10 of this document.
• MLN MM12131: (link)

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

• Article Release Date: May 18, 2021 – Revised June 3, 2021
• What You Need to Know: This article was revised to reflect NCD specific changes made in a revised Change Request (CR) 12124.
• MLN MM12124: (link)

July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: April 27, 2021 – Revised June 8, 2021
• What You Need to Know: This article was revised to reflect a revised CR 12244 which added language about Section 405 of the Consolidated Appropriates Act, 2021.
• MLN MM12244: (link)

Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Amount

• Article Release Date: May 24, 2021 – Revised June 15, 2021
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12885 which included the addition of new codes to the national HCPCS file.
• MLN MM12285: (link)

Medicare Coverage Updates

June 10, 2021: NGS Reminder Regarding General Anesthesia, Conscious Sedation and Facet Joint Interventions

NGS posted a reminder regarding the recent revision to Local Coverage Determination (LCD) (L35936) “Facet Joint Interventions for Pain Management” and Local Coverage Article (LCA) (A57826) “Billing and Coding: Facet Joint Interventions for Pain Management.” As of April 25, 2021, one Limitation of LCD L359356 (link) indicates that “general anesthesia is considered not reasonable and necessary for facet joint interventions.” Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.”

National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs)

• Article Release Date: June 11, 2021
• What You Need to Know: Effective December 1, 2020, CMS covers VADs under certain criteria. Change Request (CR) 12290 revises NCD 20.9 in the Medicare NCD Manual and Chapter 32, Section 320 of the Medicare Claims Processing Manual.
• MLN MM12290: (link)

July 2, 2021: Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches

CMS issued Proposed Decision Memo CAG-00296R2 (link). Two changes being proposed includes:

• Remove NCD 240.2.2 of the Medicare NCD Manual, ending coverage with evidence development, and allow the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for cluster headaches (CH), and
• Modify NCD 240.2 Home Use of Oxygen to expand patient access to oxygen and oxygen equipment in the home, and to permit MACs to cover the use of home oxygen and equipment in order to treat CH and other acute conditions.

You can submit comments through August 1, 2021. The related National Coverage Analysis (NCA) Tracking Sheet for this Decision Memo CAG-00296R2 (link) will enable you to follow the progress of this proposal.