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March 2021 Medicare Transmittals and Other Updates

Published on 

Wednesday, March 31, 2021

 | Billing 
 | Coding 
 | Miscellaneous 
 | Medicare Coverage 
 | Outpatient Services 

MEDICARE MLN ARTICLES & TRANSMITTALS – RECURRING UPDATES

April 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1

  • Article Release Date: March 8, 2021
  • What You Need to Know: Included in this MLN article are changes to the April 2021 version of the I/OCE instructions and specifications for the I/OCE that Medicare uses under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, limited services when provided in a home health agency not under the HH PPS, and for a hospice patient for treating a non-terminal illness.
  • MLN MM12187: https://www.cms.gov/files/document/mm12187.pdf

Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens

  • Article Release Date: March 9, 2021
  • What You Need to Know: Changes to CY 2021 travel allowances bill per mileage basis (HCPCS P9603) and on a flat rate basis (HCPCS P9604) are included in this article. Note, “Medicare Part B allows payment for a specimen collection fee and travel allowance, when medically necessary, for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Act. Payment for these services is made based on the Clinical Laboratory Fee Schedule (CLFS).”
  • MLN MM12140: https://www.cms.gov/files/document/mm12140.pdf

April 2021 Update to the Fiscal Year (FY) 2021 Inpatient Prospective Payment System

  • Article Release Date: March 9, 2021
  • What You Need to Know: This MLN Article provides notice of changes that CMS is making for the April 2021 update of the FY 2021 Inpatient Prospective Payment System (IPPS). CMS notes that MACs will be reprocessing certain claims as explained in this article.
  • MLN MM12062: https://www.cms.gov/files/document/mm12062.pdf

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

  • Article Release Date: March 8, 2021
  • What You Need to Know: Related CR 12175 describes changes to and billing instructions for various payment policies implemented in the April 2021 Outpatient Prospective Payment System (OPPS) update. The April 2021 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 12175.
  • MLN MM 12175: https://www.cms.gov/files/document/mm12175.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

  • Article Release Date: March 10, 2021
  • What You Need to Know: Quarterly updates to the Clinical Laboratory Fee Schedule (CLFS) are detailed in this MLN article, including a table of new codes effective April 1, 2021.
  • MLN Article MM12178: https://www.cms.gov/files/document/mm12178.pdf

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

  • Article Release Date: March 10, 2021
  • What You Need to Know: This MLN article provides highlights from Change Request (CR) 12155 which includes April 2021 updates to the 2021 MPFS. CMS notes in the article that “MACs won’t search their files to either retract payment for claims already paid or to retroactively pay claims. However, MACs will adjust claims that you bring to their attention.”
  • MLN MM12155: https://www.cms.gov/files/document/mm12155.pdf

One-Time Transmittal 10599 (Change Request 12089): HIPAA Electronic Data Interchange (EDI) Front End Updates for July 2021

  • Transmittal Release Date: March 11, 2021
  • What You Need to Know: The purpose of this Change Request (CR) is to provide the July 2021 Combined Common Edits/Enhancements Module (CCEM) edits for the Part A and Part B Medicare Administrative Contractors (A/B MACs) and the Common Electronic Data Interchange (CEDI) contractor. Additionally, this CR directs Shared Systems to appropriately update the CCEM.
  • Change Request 12089: https://www.cms.gov/files/document/r10599otn.pdf

April Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) & PC Print Update

  • Article Release Date: March 12, 2021
  • What You Need to Know: This article details updates to the RARC and CARC lists and instructs Medicare’s Shared System Maintainers (SSMs) to update MREP and PC Print.
  • MLN MM12102: https://www.cms.gov/files/document/mm12102.pdf

Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021

  • Article Release Date: March 17, 2021
  • What You Need to Know: Included in this article are the Calendar Year 2021 rate updates and policies for the ESRD PPS. Of note, the January 2021 ESRD PRICER did not apply the network reduction to Intermittent Peritoneal Dialysis (IPD) revenue code 0831 and ultrafiltration revenue code 0881 in error. The revised PRICER is correcting this error.
  • MLN MM12188: https://www.cms.gov/files/document/mm12188.pdf

April 2021 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

  • Article Release Date: March 25, 2021
  • What You Need to Know: Updates to lists of HCPCS codes subject to the consolidated billing provision of the SNF Prospective Payment System (PPS) are provided in this MLN article.
  • MLN MM12212: https://www.cms.gov/files/document/mm12212.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2021

  • Article Release Date: March 23, 2021
  • What You Need to Know: This article and related Change Request (CR) 12171 announced changes in the July 2021 quarterly release of the edit module for clinical diagnostic laboratory services.
  • MLN MM12171: https://www.cms.gov/files/document/mm12171.pdf

OTHER MEDICARE MLN ARTICLES & TRANSMITTALS

Updated Billing Requirements for Home Infusion Therapy (HIT) Services on or after January 1, 2021

  • Article Release Date: March 15, 2021
  • What You Need to Know: Following is an excerpt from this article regarding new changes to Medicare claims processing for HIT services on or after January 1, 2021:
  • “As described in the 21st Century Cures Act, Medicare will make a separate payment for HIT services under the permanent HIT benefit to qualified home infusion suppliers, effective January 1, 2021. Home infusion drugs are assigned to three payment categories, as determined by the HCPCS J-code:
  • Payment Category 1: Includes certain intravenous antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, and chelation drugs
  • Payment Category 2: Includes subcutaneous immunotherapy and other certain subcutaneous infusion drugs
  • Payment Category 3: Includes certain chemotherapy drugs. MLN Matters article MM11880 lists the home infusion therapy service G-codes and corresponding home infusion therapy drug J-codes.
  • MLN MM12108: https://www.cms.gov/files/document/mm12108.pdf

Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update

  • Article Release Date: March 18, 2021
  • What You Need to Know: This article is for physicians, non-physician practitioners, nursing facilities, and other providers submitting telehealth claims to MACs for nursing facility services.
  • MLN MM12068: https://www.cms.gov/files/document/mm12068.pdf

Update to Rural Health Clinic (RHC) Payment Limits

Update to the Manual for Telephone Services, Physician Assistant (PA) Supervision, and Medical Record Documentation for Part B Services

  • Article Release Date: March 24, 2021
  • What You Need to Know: This article serves as notice regarding updates made to Chapter 15 of the Medicare Benefit Policy Manual for Physician Supervision for Physician Assistant (PA) Services and Medical Record Documentation for Part B services.
  • MLN MM11862: https://www.cms.gov/files/document/mm11862.pdf

New Provider Enrollment Administrative Action Authorities

  • Article Release Date: March 24, 2021
  • What You Need to Know: This Special Edition MLN article provides information about the CMS Final Rule titled Program Integrity Enhancement to the Provider Enrollment Process. This Final Rule was issued on September 10, 2019. Included in this MLN article is the following note, “In light of the pandemic and various other factors, we will not begin updating the Form CMS-855 applications with affiliation disclosure for at least another 12 months.”
  • MLN SE21003: https://www.cms.gov/files/document/se21003.pdf

REVISED MEDICARE MLN ARTICLES & TRANSMITTALS

Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes

  • Article Release Date: September 22, 2020 – Revised March 9, 2021
  • What You Need to Know: In CR 11879, CMS changes the 25th percentile wage index value from 0.8465 to 0.8649. This MLN article reflects this change.
  • MLN MM11879: https://www.cms.gov/files/document/mm11879.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

  • Article Release Date: February 23, 2021 – Revised March 9, 2021
  • What You Need to Know: This MLN article was revised to reflect the revised CR 12131, which changed the date CMS added HCPCS code 87428 to the correct date of November 10, 2020.
  • MLN MM12131: https://www.cms.gov/files/document/mm12131.pdf

MEDICARE COVERAGE UPDATES

OIG Reports and Guidance regarding Polysomnography Services

MACs paid providers approximately $885 million for selected polysomnography services provided to Medicare beneficiaries from January 1, 2017 through December 31, 2018. The OIG identified in prior audits payments being made with inappropriate diagnosis codes, without documentation supportive of the services provided and to providers exhibiting questionable billing patterns. These findings in combination with increased spending as noted above prompted the OIG to conduct additional audits. This month, the OIG has released reports for two polysomnography audits.

  • OIG Report: Peninsula Regional Medical Center: Audit of Medicare Payments for Polysomnography
  • 10 of 100 randomly selected beneficiary claims included 12 lines of service that did not comply with Medicare requirements. Based on the net overpayments of $17,499, the OIG estimated that Peninsula received at least $66,647 in overpayments for polysomnography services during the audit period.
  • OIG Report: North Mississippi Medical Center: Audit of Medicare Payments for Polysomnography
  • 12 of 100 randomly selected beneficiary claims included 13 lines of services that did not comply with Medicare requirements. Based on the next overpayments of $7,624, the OIG estimated that North Mississippi received at least $67,038 in overpayments for polysomnography services during the audit period.

CMS included the following additional resources for Providers related to correct billing for Polysomnography services in the March 18, 2021 edition of their weekly eNewsletter, MLN Connects:

Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)

MEDICARE EDUCATIONAL RESOURCES

MLN Booklet: Behavioral Health Integration Services

MLN Booklet: Evaluation and Management Service Guide

January 2021 Medicare Quarterly Compliance Newsletter

CMS Posted a link to this newsletter in the March 18, 2021 MLN Connects eNewsletter. In this quarter’s newsletter you can learn about:

  • Prefabricated and custom-fabricated knee orthoses: medical necessity and documentation requirements, and
  • Ankle-foot orthoses and knee-ankle foot orthoses within the reasonable useful lifetime: excessive units.

March 15, 2021” Medicare Learning Network® (MLN) Provider Compliance Products

CMS published a list of Provider Compliance Education Products. These products provide education on how to avoid common coverage and coding/billing errors (i.e. Complying with Medical Record Documentation Requirements (MLN909160), Complying with Medicare Signature Requirements (MLN905364), and Provider Compliance Tips for Polysomnography (Sleep Studies) (MLN4013531)).

OTHER MEDICARE UPDATES

Happy National Nutrition Month®

CMS included the following information in the March 4th edition of MLN Connects:

“Did you know that Medicare covers the following preventive services for nutrition-related health conditions like diabetes, chronic kidney disease, and obesity?

  • Medical nutrition therapy
  • Diabetes screening
  • Diabetes self-management training
  • Intensive behavioral therapy for obesity
  • Intensive behavioral therapy for cardiovascular disease
  • Annual wellness visit

During National Nutrition Month®, encourage your patients to develop healthy eating patterns and make food choices to meet their individual nutrient needs, goals, backgrounds, and tastes. More Information:

Information for your patients on nutritional therapy services, diabetes screenings, diabetes self-management training, obesity behavioral therapy, cardiovascular behavioral therapy, and yearly “wellness” visits

MLN Fact Sheet: Health Professional Shortage Area Physician Bonus Program

This fact sheet explains how the Medicare Health Professional Shortage Area (HPSA) Physician Bonus Program works. It has information about how to get bonus payments when you deliver Medicare-covered services to patients in a geographic HPSA. Key Takeaways noted in this Fact Sheet includes:

  • HPSAs are geographic areas of populations that lack enough health care providers to meet the health care needs of that population.
  • CMS pays a 10 percent bonus payment when health care providers deliver Medicare-covered services to patients in a geographic HPSA.
  • CMS pays HPSA bonuses quarterly based on the amount paid for professional services.

Link to MLN Fact Sheet (ICN MLN903196) February 2021: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HPSAfctsht.pdf

March 17, 2021: American Hospital Association (AHA) Response to the American Rescue Plan Act of 2021 (ARP)

President Biden signed this $1.9 trillion coronavirus relief plan into law on March 11, 2021. In a related American Hospital Association Legislative Advisory, AHA notes their concern “that the law does not include an extension of relief from Medicare sequester cuts, which will go back into effect at the beginning of next month, and also fails to provide loan forgiveness for Medicare accelerated payments for hospitals.”

You can read more about the ARP Act of 2021 in related HHS and CMS Fact Sheets:

March 12, 2021: CMS Published Lists of Participants for Emergency Triage, Treat and Transport (ET3) Model

Link to Model CMS webpage:
link to Press Release: https://www.cms.gov/newsroom/press-releases/cms-announces-final-participants-emergency-triage-treat-and-transport-et3-model-furthers-commitment

March 18, 2021: MLN Connects Clinical Laboratory Data Reporting Delayed Until 2022 Reminder

CMS included the following information regarding the Protecting Access to Medicare Act of 2014 (PAMA) data collection and reporting periods:

For Clinical Diagnostic Laboratory Tests that are not Advanced Diagnostic Laboratory Tests, the requirement for you to report private payor data between January 1 and March 31, 2020, was delayed 2 years.  You must report data from the original collection period. Reporting will resume on a 3-year cycle beginning in 2025. (Section 3718 of the Coronavirus Aid, Relief, and Economic Security Act). Current timeline:

  • Collect Data for January 1 through June 30, 2019
  • Report data between January 1 and March 31, 2022

For more information, see the PAMA Regulations webpage.

March 17, 2021: Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule Delayed

CMS published an interim final rule in the Federal Register in keeping with the January 20, 2021 “Regulatory Freeze Pending Review” Memorandum. The Final Rule is being delayed until May 15, 2021. CMS is seeking public comments through April 16, 2021. In addition to operational practicalities cited by CMS as making them incapable of implementing the MCIT program on March 15, 2021, CMS notes the following additional reasons:

  • “The higher than anticipated volume of devices receiving FDA breakthrough device designation exponentially complicates the operational concerns that we have identified. Further, public comments highlighted the importance of the agency having the ability to not only cover an FDA-designated breakthrough device expeditiously, but also to be able to have coding and payment levels established at the same time.”
Article Author: Beth Cobb, RN, BSN, ACM, CCDS
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 Protection Assessment Tool.

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.