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September Medicare Transmittals and Other Updates

Published on 

Tuesday, September 29, 2020

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

MEDICARE TRANSMITTALS – RECURRING UPDATES

 

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

  • Article Release Date: August 31, 2020
  • What You Need to Know: This article informs providers about changes to and billing instructions for various payment policies implemented in the October 2020 OPPS update.
  • MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf

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

  • Article Release Date: August 28, 2020
  • What You Need to Know: This article provides information about the October 2020 version of the I/OCE instructions and specifications that Medicare uses.
  • MLN MM11944: https://www.cms.gov/files/document/mm11944.pdf

Annual Clotting Factor Furnishing fee Update 2021

2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

  • Article Release Date: August 28, 2020
  • What You Need to Know: Section 413(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment file. This article lets providers know that CMS will provide MACs with files for the automated payments of HPSA bonuses for dates of service January 1, 2021 through December 31, 2021.
  • MLN MM11852: https://www.cms.gov/files/document/mm11852.pdf

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

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: August 28, 2020
  • What You Need to Know: This article informs providers that Medicare will update its claims processing systems based on the Committee on Operating Rules for Information Exchange (CORE), Code Combination List, which will be published on or about October 1, 2020.
  • MLN Matters MM11881: https://www.cms.gov/files/document/mm11881.pdf

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

  • Article Release Date: August 31, 2020 – Revised September 10, 2020
  • What You Need to Know: This article provides updates in Change Request (CR) 11876 to hospice payment rates, wage index, PRICER, and aggregate cap amounts for Fiscal Year (FY) 2021. Note, this article was revised on September 10th to correct two typos. All other information remained the same.
  • MLN Matters MM11876: https://www.cms.gov/files/document/mm11876.pdf

Claim Status Category and Claim Status Codes Updates

  • Article Release Date: August 28, 2020
  • What You Need to Know: This article informs providers of updates to the Claim Status and Claims Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Code changes during the September/October 2020 National Code Maintenance Committee (NCMC) meeting will be posted on or about November 1, 2020.
  • MLN Matters MM11796: https://www.cms.gov/files/document/mm11796.pdf

2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing facility (SNF) Consolidated Billing (CB) Update

  • Article Release Date: September 16, 2020
  • What You Need to Know: This articles provides information regarding changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that Medicare uses to revise Common Working File (CWF) edits to allow MACs to make appropriate payments.
  • MLN Matters MM11968: https://www.cms.gov/files/document/mm11968.pdf

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

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021

  • Article Release Date: September 25, 2020
  • What You Need to Know: CR 11984 provides quarterly updates to the NCCI PTP edits. A test file will be available around November 2, 2020 with a final file available on or about November 17, 2020.
  • MLN MM11984: https://www.cms.gov/files/document/mm11984.pdf

 

OTHER MEDICARE TRANSMITTALS

 

Updates to Chapter 23 – Fee Schedule Administration and Coding Requirements

Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19

  • Article Release Date: September 4, 2020
  • What You Need to Know: CMS has removed the reference to Electrocardiogram (EKG) services in the Medicare Claims Processing Manual, Chapter 16, Section 60.1.2 and Chapter 26, Section 10.4, Item 19. This change only clarifies existing content.
  • MLN Matters MM11935: https://www.cms.gov/files/document/mm11935.pdf

Update to the Medicare Claims Processing Manual

  • Article Release Date: September 18, 2020
  • What You Need to Know: This article provides information regarding updated to the Medicare Claims Processing Manual, Chapters 12 and 23.
  • MLN Matters MM111958: https://www.cms.gov/files/document/mm11958.pdf

 

REVISED MEDICARE TRANSMITTALS

 

National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low back Pain (cLPB)

  • Article Release Date: May 13, 2020 – Revised September 1, 2020
  • What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11755 that provides revised messaging (page 3 in the article). It also revised the Claims Processing Manual at Section 410.4.
  • MLN Matters MM11755: https://www.cms.gov/files/document/MM11755.pdf

Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries

  • Article Release Date: September 4, 2020 – Revised September 15, 2020
  • What You Need to Know: This article provides information about CMS modifying and streamlining the model admission questions for providers to ask Medicare beneficiaries or authorized representatives upon admission or start of care.
  • Note, this article was revised on September 15th to reflect the CR revision adding part of sentence that had been left out of manual Section 20.2.2 of the Medicare Secondary Payer Manual.
  • MLN Matters MM11945: https://www.cms.gov/files/document/mm11945.pdf

October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

  • Article Release Date: September 11, 2020 – Revised September 24, 2020
  • What You Need to Know: This article is based on Change Request (CR) 11963 which provides information about changes to and billing instructions for various payment policies implemented in the October 2020 ASC payment system update.
  • Note, this article was revised to reflect the updated CR revision to HCPCS code C9066 in Table 2 in the CR.
  • MLN MM11963: https://www.cms.gov/files/document/mm11963.pdf

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

  • Article Release Date: August 7, 2020 – Latest Revision September 24, 2020
  • What You Need to Know: This article informs laboratories of changes from the quarterly update to the clinical laboratory fee schedule. Now in its third iteration, this article was most recently updated to add new COVID-19 code (86413) and ADLT code (0090U).
  • MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf

Change to the Payment of Allogeneic Stem Cell Acquisition Services

  • Article Release Date: July 13, 2020 – Revised September 24, 2020
  • What You Need to Know: This article was revised to reflect a revised CR issued on September 24, 2020. All other information remains the same.
  • MLN MM11729: https://www.cms.gov/files/document/mm11729.pdf

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

  • Article Release Date: August 31, 2020 – Revised September 25, 2020
  • What You Need to Know: This article has been revised to reflect an updated CR 11960 that made several changes including adding a new COVID-19 CPT code, 86413, to Table 1.
  • MLN MM11960: https://www.cms.gov/files/document/mm11960.pdf

 

MEDICARE COVERAGE UPDATES

 

National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer

  • Article Release Date: September 15, 2020
  • What You Need to Know: CMS “has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician, and when specific requirements are met.
  • NCD Implementation Date: November 13, 2020
  • NCD Effective Date: January 27, 2020
  • MLN MM11837: https://www.cms.gov/files/document/mm11837.pdf

 

OTHER MEDICARE UPDATES

 

August 27, 2020: OIG Report – Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments in the Provider Appeals Process

Proposed Rule: Medicare Program; Modernizing and Clarifying the Physician Self-Referral Regulations Extension of Timeline for Publication of Final Rule

Link to notice in Federal Register: https://www.govinfo.gov/content/pkg/FR-2020-08-27/pdf/2020-18867.pdf

September 2, 2020: FY 2021 IPPS Final Rule released.

September 3, 2020: Medicare Preventive Services Tool and Poster Revised

CMS noted in their September 3rd edition of MLNConnects that the Medicare Preventive Services Medicare Learning Network Educational Tool and Poster have been revised. The tool is extremely useful to understand Coding, Coverage, and Copayment/coinsurance and deductible requirements for Preventative Services covered by Medicare.

September 10, 2020: OIG Report: Billions in Estimated Medicare Advantage Payments from Diagnoses Reported Only on Health Risk Assessments Raise Concerns

The OIG performed this review due to concerns that Medicare Advantage Organizations may use Health Risk Assessments (HRAs) to inappropriately increase risk adjusted payments. The key takeaway highlighted in the Report Brief is that “billions in estimated risk-adjusted payments supported solely through HRAs raise concerns about the completeness of payment data, validity of diagnoses on HRAs, and quality of care coordination for beneficiaries.”

September 11, 2020: Community Health Access and Rural Transformation (CHART) Model CMS Fact Sheet

CMS announced the CHART Model in a Fact Sheet, indicating that “the approximately 57 million Americans living in rural communities, including millions of Medicare and Medicaid beneficiaries, face unique challenges when seeking health care services, such as limited transportation options, shortages of health care services, and an inability to fully benefit from technological and care-delivery innovations.” CMS goes on to highlight the following three items to be accomplished through this model:

  • “Increase financial stability for rural health care providers through multiple new funding approaches, including the use of up-front investments and predictable, capitated payments that pay for quality and patient outcomes over volume;
  • Provide the necessary operational and regulatory flexibilities to allow health care providers and CMS to test the Model in their local communities and successfully transform themselves; and
  • Support local rural communities’ transformation efforts by being directly engaged at CMS, offering real-time technical expertise and other learning when needed to foster success.”

New Understanding Your Remittance Advice Reports MLN Booklet (MLN8788099)

CMS has published a new MLN Booklet providing information to:

  • Help you learn which types of Remittance Advice (RA) are available,
  • What information is included in an RA,
  • How to view an RA, and
  • Frequently Asked Questions.

Checking Medicare Eligibility MLN Booklet (MLN8816413 September 2020)

CMS advises providers, in this MLN Booklet, “to ensure you are billing appropriately for Medicare-covered supplies and services, check for eligibility. Regularly review your patients’ eligibility information.” This booklet provides guidance on who may be eligible for Medicare and how to check for eligibility.

September 15, 2020: New Roadmap for States to Accelerate Adoption of Value-Based Care (VBC) through Medicaid

CMS sent a letter to State Medicaid Directors on September 15, 2020 “to provide information on how states can advance value-based care (VBC) across the healthcare systems, with a particular emphasis on Medicaid populations, and to share pathways for adoption of such approaches with interested states.

CMS noted in a related Fact Sheet, that just as they have made a “strong commitment to advancing VBC in Medicare for its 61.7 million enrollees” guidance released on September 15, 2020 “is designed to ensure that this same commitment can be made at the state level through Medicaid with its nearly 74 million beneficiaries.”

September 18, 2020: CMS Announces New Model of Care for Medicare Beneficiaries with Chronic Kidney Disease

CMS has finalized the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, “to improve or maintain the quality of care and reduce Medicare expenditures for patients with chronic kidney disease” (CKD). CMS notes in a Press Release that the model is set to be implemented January 1, 2021, will impact approximately 30 percent of kidney care providers, and the estimated savings from the model is $23 million over five and half years.

September 18, 2020: CMS Announced Radiation Oncology Model

CMS has finalized the Radiation Oncology (RO) Model which is “expected to improve the quality of care for cancer patients receiving radiotherapy and reduce Medicare expenditures through bundled payments that allow providers to focus on delivering high-quality treatments.” CMS notes in a Press Release that the RO Model is set to begin January 1, 2021 and the estimated savings is $230 million over five years.

September 21, 2020: OIG Report (A-07-17-01176) Incorrect Acute Stroke Diagnosis Codes Increased Payments to Medicare Advantage Organizations

In this audit, the OIG focused on Medicare eligible patients who were covered under traditional Medicare one year and the following year chose a Medicare Advantage Plan. Data mining enabled them to identify several diagnosis codes at high risk of being miscoded. Specifically for this audit, the OIG focused on the acute stroke diagnosis codes reported on one physician’s claim without being reported on the corresponding inpatient claim. The objective being to determine if selected acute stroke codes submitted by physicians under traditional Medicare were later used by CMS to make payments to MA organizations complied with Federal Requirements. The OIG found that in 580 of 582 claims, the record did not support the acute stroke diagnosis codes. In turn, this meant the ischemic stroke codes used as HCC’s were not valid. CMS estimated just over $14.4 million inaccurate payments were made to MA Plans.

September 22, 2020: CMS Expands Ambulance Program Integrity Model Nationwide

CMS announced the expansion of the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. CMS notes in the Press Release that the model has saved Medicare $650 million over four years.

The initial model began for transports on or after December 15, 2014 and is scheduled to end in all model states on December 1, 2020, based on date of service. You can read more about this model in Special Edition MLN article SE1514. Information is also available on the Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport CMS webpage.

September 24, 2020: Importation of Prescription Drugs FDA Final Rule

This Final Rule was issued “to implement a provision of the Federal Food, Drug, and Cosmetic Act (FD&C Act) to allow importation of certain prescription drugs from Canada. Under this final rule, States and Indian Tribes, and in certain future circumstances pharmacists and wholesalers, may submit importation program proposals to the Food and Drug Administration (FDA, the Agency, or we) for review and authorization…The purpose of the final rule is to achieve a significant reduction in the cost of covered products to the American consumer while posing no additional risk to the public’s health and safety.”

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.