Knowledge Base Article

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

• Article Release Date: August 7, 2020 – revised October 27, 2020
• What You Need to Know: Revisions reflect changes made to CR11939 where CMS added information about codes 3170F, 0599T, A4226, and the new codes 86408, 86409, 86413, and 99072.
• MLN MM11939: https://www.cms.gov/files/document/MM11939.pdf

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

• Article Release Date: November 4, 2020
• What You Need to Know: This article provides information found in the October 30, 2020 Change Request (CR) 12027 about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs).
• MLN MM12027: https://www.cms.gov/files/document/mm12027.pdf

Changes to the End Stage Renal Disease (ESRD) PRICER to Accept the New Outpatient Provider Specific File Supplemental Wage Index Fields, the Network Reduction Calculation and New Value Code for Time on Machine

• Article Release Date: November 12, 2020
• What You Need to Know: This article provides information about changes to the ESRD PRICER software, the new value code required for reporting minutes of dialysis provided during the billing period and explains the ESRD Network Reduction calculations from the FIAA into the PRICER.
• MLN MM11871: https://www.cms.gov/files/document/mm11871.pdf

OTHER MEDICARE TRANSMITTALS

Special Provisions for Radiology Additional Documentation Requests

• Article Release Date: October 30, 2020
• What You Need to Know: This article discusses a pilot process enabling MACs to request pertinent documentation from treating/ordering provider during medical review, in an effort to support the necessity and payment for radiology service(s)/items(s) (billed to Medicare.”
• MLN MM11659: https://www.cms.gov/files/document/mm11659.pdf

Update to Chapter 10 of Publication (Pub.) 100-08- Enrollment Policies for Home Infusion Therapy (HIT) Suppliers

• Article Release Date: October 30, 2020
• What You Need to Know: Change Request (CR) 11954 informs MACs of the policies and procedures for enrolling HIT suppliers in Medicare. MACs will accept enrollment applications beginning on or after November 1, 2020.
• MLN MM11954: https://www.cms.gov/files/document/mm11954.pdf

Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum

• Article Release Date: November 6, 2020
• What You Need to Know: CMS is modifying the Medicare Benefit Policy Manual to include modifications to the election statement and the requirements for the hospice election statement addendum that became effective for hospice elections beginning on or after October 1, 2020.
• MLN MM12015: https://www.cms.gov/files/document/mm12015.pdf

Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims

• Article Release Date: November 9, 2020
• What You Need to Know: This article provides updated information about claims processing instructions to adhere to current Medicare policy.
• MLN MM11992: https://www.cms.gov/files/document/mm11992.pdf

Updates to Vaccine Services Editing

• Article Release Date: November 13, 2020
• What You Need to Know: This article is for those that provide vaccines to Medicare beneficiaries and bill Medicare Administrative Contractors (MACs) for those services. Specific for hospitals related CR 11975 “modifies current editing to allow vaccines and their administration when they are the only services on a 12x claim where the service date is equal to the discharge date of an inpatient claim for the same provider and the service date is equal to the "From" date of another inpatient claim with condition code B4 for the same provider.”
• MLN MM11975: https://www.cms.gov/files/document/mm11975.pdf

Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2021

• Article Release Date: November 20, 2020
• What You Need to Know: Among other rates, Medicare beneficiaries without a secondary insurance will have a $1,484.00 Part A Deductible to pay if admitted as an inpatient beginning January 1, 2021.
• MLN Matters: MM12024: https://www.cms.gov/files/document/mm12024.pdf

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: November 20, 2020
• What You Need to Know: This article provides Medicare system updates based on the CORE Code Combination List to be published on or about February 1, 2021.
• MLN MM11988: https://www.cms.gov/files/document/mm11988.pdf

Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service Provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)”

• Article Release Date: November 20, 2020
• What You Need to Know: The following two new NUBC codes will be effective for claims received on or after February 1, 2021
• “90” – To allow providers to report when the service is provided as part of an Expanded Access approval, and
• “91” – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA).
• MLN MM12049: https://www.cms.gov/files/document/mm12049.pdf

Claim Status Category and Claim Status Codes Update

• Article Release Date: November 20, 2020
• What You Need to Know: This article informs you that all code changes approved during the January/February 2021 committee meeting shall be posted on or about March 1, 2021 with an effective date of April 1, 2021 and Implementation Date of April 5, 2021.
• MLN MM11957: https://www.cms.gov/files/document/mm11957.pdf

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

• Article Release Date: November 20, 2020
• What You Need to Know: This article updates the RARC and CARC lists and instructs the Medicare’s system maintainers to update MREP and PC Print. Note, the code update schedule is published three times a year with the next implementation date being April 5, 2021.
• MLN MM11943: https://www.cms.gov/files/document/mm11943.pdf

REVISED MEDICARE TRANSMITTALS

Penalty for Delayed Request for Anticipated Payment (RAP) Submission -- Implementation

• Article Release Date: July 31, 2020 – Revised October 27, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11855 including adding remittance advice message information.
• MLN MM11855: https://www.cms.gov/files/document/mm11855.pdf

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

• Article Release Date: August 28, 2020 – Revised October 28, 2020
• What You Need to Know: This article was revised to reflect a revised CR11956 clarifying the claims processing jurisdiction for code K1109.
• MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf

Billing for Home Infusion Therapy Services on or After January 1, 2021

• Article Release Date: August 7, 2020 – Revised November 13, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11880. Additions to the article include statements related to the status indicator for the G codes on the Physician Fee Schedule and noting that MACs will post HIT fees on their websites as soon as possible.
• MLN MM11880: https://www.cms.gov/files/document/mm11880.pdf

Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised November 20, 2020
• What You Need to Know: This article provides several payment updates related to the HH PPS. Note, this article was revised to reflect an updated CR 12017 that revised the Policy section and updated the Payment Rate Tables.
• MLN MM12017: https://www.cms.gov/files/document/mm12017.pdf

Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model

• Article Release Date: May 4, 2015 – Revised November 20, 2020
• What You Need to Know: This article was revised to show the model will not end December 1, 2020. “The model no longer has an end date and will remain in effect for the nine model states.”
• MLN SE1514: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1514.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: November 9, 2020 – Revised November 23, 2020
• What You Need to Know: This article provides information about payment rate updates and policies for CY 2021. Note, this article was revised to reflect a revised CR 12011.
• MLN MM12011: https://www.cms.gov/files/document/mm12011.pdf

MEDICARE COVERAGE UPDATES

November 13, 2020: National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy

• Article Release Date: November 17, 2020
• What You Need to Know: Effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) and meets specified FDA conditions. Note, this article includes billing requirements guidance.
• MLN Matters MM11783: https://www.cms.gov/files/document/mm11783.pdf

OTHER MEDICARE UPDATES

October 27, 2020: New CMS Proposals Streamline Medicare Coverage, Payment, and Coding for Innovative New Technologies and Provide Beneficiaries with Diabetes Access to More Therapy Choices

CMS published a Special Edition MLNConnects announcing a Durable Medical Equipment (DME) proposed rule aimed at reducing administrative burden for new innovative technologies.

November 2, 2020: Long-Term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet

CMS announced the release of a Long-Term Services and Supports (LTSS) Rebalancing Toolkit “to support states in their efforts to expand and enhance home and community-based services (HCBS) and to rebalance, or recalibrate, LTSS from institutional to community-based systems. You can read more about this in the CMS Press Release and related Fact Sheet.

November 2, 2020: CMS issues End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule

This final rule updates payment policies and rates under the ESRD PPS for renal dialysis services furnished to beneficiaries enrolled in Original Medicare on or after January 1, 2021. It also updates the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and finalized changes to the ESRD Quality Incentive Program. “Medicare expects to pay $10.3 billion to approximately 7,400 ESRD facilities for the costs associated with furnishing renal dialysis services.”

For More Information:

• Final rule

• Press release
• Full text of fact sheet

November 4, 2020: HHS Proposes Unprecedented Regulatory Reform through Retrospective Review

HHS announced a notice of proposed rulemaking that would require “the Department to assess its regulations every ten years to determine whether they are subject to review under the Regulatory Flexibility Act (RFA), which requires regular review of certain significant regulations. If a given regulation is subject to the RFA, the Department must review the regulation every ten years to determine whether the regulation is still needed and whether it is having appropriate impacts. Regulations will expire if the Department does not assess and (if required) review them in a timely manner.”

November 6, 2020: OIG Report – $35 Million in Overpayments for Medical Devices

Hospitals seem to continue to struggle with the Federal regulations for medical device credits as evidenced by the $35 million in overpayments reported by the OIG in this November 6, 2020 report.  

November 6, 2020: 2021 Medicare Parts A & B Premiums and Deductibles

The 2021 Monthly Medicare Parts A and B premiums, deductibles and coinsurance were announced in a CMS Press Release. Following are the changes from 2020 to 2021:

Medicare Part A Inpatient Deductible

• 2020 - $1,408
• 2021 - $1,484

Medicare Part B Enrollees Standard Monthly Premium

• 2020 - $144.60
• 2021 - $148.50

Medicare Part B Enrollees Annual Deductible

• 2020 - $198
• 2021 - $203

For a fact sheet on the 2021 Medicare Parts A & B premiums and deductibles, please visit: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-b-premiums-and-deductibles

November 9, 2020: Medicaid and CHIP Managed Care Final Rule Released

CMS announced the release of this final rule noting that “the purpose of the rule is to ensure state Medicaid and CHIP agencies are able to work effectively to develop and implement managed care programs that better serve each state’s growing number of Medicaid and CHIP beneficiaries.”

November 16, 2020: OIG Report – Hospitals Did Not Comply with Medicare Requirements for Reporting Cardiac Device Credits

The OIG found that hospitals did not always comply with Medicare requirements associated with reporting manufacturer credits for recalled or prematurely failed cardiac medical devices. Specifically, “911 hospitals received payments of $76 million rather than the $43 million they should have received, resulting in $33 million in potential overpayments. Medicare contractors made these overpayments because they do not have a postpayment review process that would ensure that hospitals reported manufacturer credits for cardiac medical devices.” The first of seven recommendations made by the OIG is that MAC’s should recover the portion of the $33 million overpayment that are within the reopening period.

November 17, 2020: CMS to Retire Original Compare Tools December 1st

CMS will retire the Original Compare Tools as they have been replaced with Care Compare on Medicare.gov. This new site streamlines the eight original health care compare tools. CMS notes that “Care Compare offers a new design that makes it easier to find the same information that’s on the original compare tools. It gives you, patients, and caregivers one user-friendly place to find cost, quality of care, service volume, and other CMS quality data to help make informed health care decisions.”

To learn more about the history of and what information is available go to CMS’ Hospital Compare webpage.

November 17, 2020: Medicare FFS Estimated Improper Payments Decline by $15 Billion Since 2016

In the Thursday November 19th edition of the MLNConnects Newsletter, CMS touts a “continued reduction marks fourth year Medicare FFS improper payment rate has been below 10%.” A related November 16th CMS Fact Sheet indicates that the Medicare FFS improper payment rate decreased from 7.25% in 2019 to an estimated 6.27% for 2020.

• CMS Press Release: Trump Administration Announced Medicare Fee-for-Service Estimated Improper Payments Decline by $15 Billion Since 2016
• CMS Fact Sheet: 2020 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs

November 20, 2020: Two New HHS Final Rules Advancing Value-Based Care

HHS announced the release of an OIG and CMS Final Rule, both aimed “to reduce regulatory barriers to care coordination and accelerate the transformation of the healthcare system into one that pays for value and promotes the delivery of coordinated care.”

• OIG Final Rule: “Revisions to the Safe Harbors Under the Anti-Kickback Statue and Civil Monetary Penalty Rules Regarding Beneficiary Inducements” - “OIG’s new safe harbor regulations are designed to facilitate better coordinated care for patients, value-based care, and improved cybersecurity, while also protecting against fraudulent or abusive conduct,” said Christi A. Grimm, Principal Deputy Inspector General.”

• CMS Final Rule: “Modernizing and Clarifying the Physician Self-Referral Regulations” - “The CMS final rule clarifies and modifies existing policies to ease unnecessary regulatory burden on physicians and other healthcare providers while reinforcing the physician self-referral law’s (often called the “Stark Law”) goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest.”