Knowledge Base Article

Medicare Transmittals & MLN Articles

September 19, 2023: MLN MM13166: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update

Relevant NCD coding changes in related Change Request 13166 include:

• NCD 20.20: External Counterpulsation Therapy (ECP) for Severe Angina, effective August 7, 2023,
• NCD 90.2: Next Generation Sequencing (NGS), effective August 7, 2023, and
• NCD 210.1: Prostate Screening Tests, effective October 1, 2023.

https://www.cms.gov/files/document/mm13166-icd-10-other-coding-revisions-national-coverage-determinations-october-2023-update.pdf

October 11, 2023: MLN MM13381: Update for Blood Clotting Factor Add-on Payments

In this MLN article, CMS advises IPPS hospitals to make sure your billing staff knows about additional diagnosis codes eligible for blood clotting factors, and adjustment of certain claims with the added codes. https://www.cms.gov/files/document/mm13381-update-blood-clotting-factor-add-payments.pdf

October 12, 2023: Transmittal 12299: An Omnibus CR to Implement Policy Updates in the CY 2023 PFS Final Rule, Including (1) Removal of Selected NCDs (NCD 160.22 Ambulatory EEG Monitoring, and (2) Expanding Coverage of Colorectal Screening

Transmittal 11865 issued February 16, 2023 has been rescinded and replaced by Transmittal 12299 to provide clarification on CMS policy and related claims processing instructions for their approach to colonoscopies within the context of a complete colorectal cancer screening. Specifically, this CR is amended to remove the requirement that contractors shall return to provider / return as un-processable certain screening colonoscopy claims that do not include the KX modifier. https://www.cms.gov/files/document/r12299bp.pdf

October 19, 2023: MLN MM13365: Medicare Deductible, Coinsurance, & Premium Rates: CY 2024 Update

CMS advises providers to make sure your billing staff knows about the CY 2024 Medicare Part A and Medicare Part B deductible and coinsurance rates, and Part and Part B premium amounts. https://www.cms.gov/files/document/mm13365-cy-2024-update-medicare-deductible-coinsurance-premium-rates.pdf

Coverage Updates

October 13: NCD 220.6.20 Beta Amyloid PET in Dementia and Neurodegenerative Disease Final Decision Memo

CMS announced a final decision removing this NCD and now permitting Medicare coverage determinations to be made by the MACs. Removing the NCD also removes the current limitation of one PET beta-amyloid scan per lifetime from the coverage requirements.

Compliance Education Updates

October 12, 2023: Medicare Compliance Tips – Revised

In the October 12 edition of MLN Connects (https://www.cms.gov/training-education/medicare-learning-network/newsletter/2023-10-12-mlnc#_Toc147927962),

CMS noted they have added new topics and made updates to the Medicare Provider Compliance Tips MLN Product. I encourage you to take the time to read about the new topic of hip and knee replacements. CMS notes that according to the 2022 Medicare Fee-for-Service Supplemental Improper Payment Data by the CERT, major hip and knee replacements had the highest projected improper payments of all Part A services with a projected improper payment of $562.6 million. The primary reason for errors cited was that the inpatient admission wasn’t medically necessary when the invasive procedure should have been billed as an outpatient procedure.

MLN Booklet: Medicare Secondary Payer

CMS released an updated version of this MLN booklet in October. Seven changes have been made to this educational booklet, for example CMS has added clarification for situations where a Group Health Plan (GHP) is the primary payer but doesn’t pay in full for a service. All substantive changes in the booklet are in dark red. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/msp_fact_sheet.pdf

MLN Fact Sheet: Medicare Secondary Payer: Don’t Deny Services & Bill Correctly

CMS also released an updated version of this MLN Fact Sheet in which CMS has added Ongoing Responsibility for Medicals (ORM) indicator information and new billing in liability insurance situations. https://www.cms.gov/files/document/mln7748519-medicare-secondary-payer-dont-deny-services-bill-correctly.pdf

MLN Fact Sheet: Direct Data Entry: 10-Digit Screen Expansion

CMS published this Fact Sheet to let providers know that they have expanded the FISS monetary amount display screens to accept and process up to 10 digits ($99,999,999.99) to meet the procedures and treatments exceeding the $999,999.99 limitation. https://www.cms.gov/files/document/mln1701501-direct-data-entry-10-digit-screen-expansion.pdf

Other Updates

October 6, 2023: OIG Report: Medicare Could Save Millions if Implements an Expanded Hospital Payment Policy

The objective of the OIG’s audit was to determine how the hospital transfer policy for discharges to post acute care (PAC) would financially affect Medicare and hospitals if CMS expands the policy to include all MS-DRGs. The OIG estimated, based on claims sampled, that Medicare could have saved approximately $694 million, or an average of $6,407 per from 2017 through 2019 if the transfer policy had expanded to include all MS-DRGs.  They go on to note that “this policy change might negatively impact hospitals’ revenues, but the transfer payment would have exceeded hospital costs for an estimated 65 percent of all claims that hospitals submit to Medicare.”

The OIG recommended that CMS conduct an analysis of this payment policy and make revisions as necessary. CMS responded by noting that once sufficient data is available from after the end of the COVID-19 PHE, they will examine data to potentially identify additional MS-DRGs with disproportionate rates of post-acute care discharged. For FY 2024, 282 of 764 MS-DRGs are subject to the PAC transfer policy. https://oig.hhs.gov/oas/reports/region1/12100504.pdf

October 10, 2023: 2024 Dollar Amount in Controversy Required to Sustain ALJ and Federal District Court Review

Medicare Administrative Contractor (MAC) Palmetto GBA published an article providing the 2024-dollar amount in controversy required to sustain appeal rights for an Administrative Law Judge (ALJ) hearing or a Federal District Court review.

ALJ Hearing Requests: The amount that must remain in controversy for requests filed on or before December 31, 2023 is $180. This amount will remain the same for requests filed on or after January 1, 2024.