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Medicare Transmittals Effective October 2020

Published on 

Wednesday, September 9, 2020

 | AL Medicaid 
 | Billing 
 | Coding 
 | Miscellaneous 
 | Outpatient Services 

To paraphrase a Barbara Mandrell song, I was a pumpkin spice latte fan before pumpkin spice was cool. In fact, two weeks ago I drank my first pumpkin spice latte for 2020. Did you know that one grande pumpkin spice latte from Starbucks has about 150mg of caffeine? That is enough caffeine to be equivalent to about two shots of expresso. To keep with musical references, Amy Grant once referred to expresso as being a “nap in a can” on one of her live albums. 

So why the focus on caffeine? The October 1st start date of the 2021 CMS Fiscal Year is just 22 days from today and CMS has been publishing updates effective October 1st at a pace worthy of a shot or two of expresso to keep you energized as you prepare for these changes. This article highlights recently released MLN articles providing guidance on updates effective October 1st.

Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

  • Article Release Date: July 21, 2020 – Revised July 21, 2020
  • What You Need to Know: This article is “for providers, especially hospitals, submitting claims to Medicare Administrative Contractors (MACs) for Part A services provided to Medicare beneficiaries when a beneficiary’s Medicare Advantage (MA) plan becomes effective during the inpatient admission.”
  • MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf
  • Change Request 11580: https://www.cms.gov/files/document/r10229CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87426

New Waived Tests

  • Article Release Date: July 28, 2020
  • What You Need to Know: This article provides information about five new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests that have been approved by the FDA. These tests are marketed immediately after approval so CMS must notify the MACs of the new tests for accurate claims processing. “Note: MACs will not search their files to either retract payment or retroactively pay claims. However, MACs should adjust claims if you bring those claims to their attention.
  • MLN Matters MM11916: https://www.cms.gov/files/document/mm11916.pdf
  • Change Request 11916: https://www.cms.gov/files/document/r10230CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

July 31, 2020: CMS Releases Inpatient Psychiatric Facility (IPF), Skilled Nursing Facilities (SNF), and Hospices FY 2021 Final Rules

CMS announced in a News Alert that they are “finalizing three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF) and hospices.”   For fact sheets on each final rule, visit:

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year 2021

  • Article Release Date: August 21, 2020
  • What You Need to Know: This article provides updates related to the IPF PPS FY 2021 Final Rule including information about:
  • Market Basket Update,
  • FY 2021 Wage Index Update,
  • IPF Quality Reporting Program,
  • PRICER Updates,
  • ICD-10 CM/PCS Updates,
  • Cost of Living Adjustment (COLA) Adjustment, and
  • Rural Adjustment.
  • MLN MM11949: https://www.cms.gov/files/document/mm11949.pdf
  • Change Request 11949: https://www.cms.gov/files/document/r10312CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

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

  • Article Release Date: August 7, 2020 – Revised August 24, 2020
  • What You Need to Know: This article provides information about the quarterly update to the clinical laboratory fee schedule. On August 24th it was updated to reflect changes to Change Request (CR) 11937 that includes additional COVID-19 codes 86408, 86409, 0225U, 0226U, effective August 10, 2020. This CR also added codes 0015M and 0016M, effective October 1, 2020.
  • MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf
  • Change Request 11937: https://www.cms.gov/files/document/r10318CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update

October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files – REVISED

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021

  • Article Release Date: July 2, 2020 – Revised August 19, 2020
  • What You Need to Know: This article was revised to reflect a revised CR 11859 which “shows that effective for Fiscal Year (FY) 2021, a 5 percent cap will be adopted and applied to all Skilled Nursing Facility providers on any decrease to a provider’s FY 2021 final wage index from that provider’s final wage index of the prior fiscal year (FY 2020).”
  • MLN MM11859: https://www.cms.gov/files/document/MM11859.pdf
  • Change Request 11859: https://www.cms.gov/files/document/r10314CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3

October Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

  • Article Release Date: August 28, 2020
  • What You Need to Know: This article provides details about the changes to the DMEPOS fee schedules that Medicare updates quarterly, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Specific to the ongoing Public Health Emergency (PHE) due to the COVID-19 pandemic, “the October 2020 DMEPOS and PEN fee files continue to include the non-rural contiguous non-CBA 75/25 blended fees required by Section 3712(b) of the CARES Act signed into law on March 27, 2020.
  • MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf
  • Change Request 11956: https://www.cms.gov/files/document/r10334CP.pdf
  • Effective Date: October 1, 2020
  • Implementation Date: October 5, 2020

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice PRICER for FY 2021

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) PRICER Changes for FY 2020

As if all of this isn’t expresso worthy, the FY 2021 Inpatient Prospective Payment System Final Rule was released last Wednesday September 2nd. So grab yourself a pumpkin spice latte and enjoy while reading about MS-DRGs changes in the IPPS Final Rule discussed in a related article in this week’s edition of Wednesday@One.

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.