Knowledge Base Category -
It has been thirteen years since CMS published the first Medicare Quarterly Compliance Newsletter in 2010. At that time, this Medicare Learning Network® (MLN) educational product was meant “to help providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations such as the Office of Inspector General.”
In the second edition of this newsletter CMS indicated that it was “designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities, such as failure to submit timely medical record documentation, when dealing with the Medicare FFS program.”
Thirteen years later, the newsletter is published twice a year instead of quarterly, and there have been additions to who is reviewing records (i.e., Noridian as the current Supplemental Medical Review Contractor (SMRC) and Livanta as the National Medicare Claim Review Contractor for short stay reviews (SSRs) and higher-weighted DRG (HWDRG) reviews nationally).
CMS announced the release of the September 2023 newsletter in the October 5, 2023 edition of MLN Connects. This edition of the newsletter includes guidance from the Comprehensive Error Rate Testing (CERT) and the Recovery Auditor program.
CERT: Hospital Outpatient Services
The CERT guidance affects physicians, non-physician practitioners (NPPs), and providers who bill 12x-19x. For 2022, the CERT reported an improper payment rate of 5.4% for hospital outpatient services. While the error rate is relatively low, it equates to a projected improper payment of $4.4 billion.
Ninety-one percent of the improper payments were attributed to insufficient documentation. CMS notes that “hospital outpatient claims with insufficient documentation errors most commonly were due to a missing order, missing provider’s intent to order, or inadequacies (that is, required elements are missing) with an order.” An example of a missing order or provider’s intent to order is in the newsletter as well as links to resources to help avoid errors when billing hospital outpatient services.
Recovery Auditor Review 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements
The Recovery Auditor guidance affects outpatient hospitals, ambulatory surgical centers (ASCs), and professional services. The problem cited related to this RAC topic is that providers should know the documentation and medical necessity requirements when billing for this service.
The CPT code for this procedure 64582 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array) became effective January 1, 2022 and CMS approved this RAC topic for review on June 7, 2022.
There are very specific indications that must be met for this procedure to be covered (i.e., beneficiary must be 22 years of age or older with a body mass index less than 35, and Shared Decision-Making (SDM) must occur between the beneficiary, sleep physician, and qualified otolaryngologist (if they are not the same).
CMS recommends that providers review coverage indications, limitations, and medical necessity requirements in Local Coverage Determinations (LCDs) and related Local Coverage Articles (LCAs) for billing and coding guidance.
The September Medicare Provider Compliance Newsletter includes links to a National Government Services, Inc. (NGS) LCA and a Palmetto GBA LCD. If neither one of these Medicare Administrative Contractors (MACs) is your MAC, you can find a listing of all MACs that have published an LCD and related LCA on the RAC approved topic description for recovery auditor review 0210 on the CMS webpage.
CPT Code 64582 by the Numbers
With this being a relatively new CPT code and RAC approved topic, I turned to our sister company, RealTime Medicare Data (RTMD), to quantify actual claims volume and payment for this service. The following data represents Medicare Fee-for-Service paid claims data available in RTMD’s database for all U.S. States and D.C. for calendar year 2022.
Hospital Outpatient Setting
- Claims volume: 5,632
- Sum of CPT Paid: $113,462,444.15
- Average Payment: $20,146.03
- Top five states performing this procedure in the hospital outpatient setting: Florida, Texas, Arizona, South Carolina, and Indiana
ASC Setting
- Claims Volume: 1,052
- Sum of CPT Paid: $5,207,088.00
- Average Payment: $4,949.70
- Top five states performing this procedure in an ASC: Texas, Illinois, New Jersey, New Mexico, and Washington
In addition to ensuring that documentation in the medical record supports indications, documentation requirements, and coding and billing guidance, CMS recommends that you respond to RAC review requests promptly and completely. While this seems obvious, no/insufficient documentation continues to be cited as a cause for claim denials. For this reason, make sure you have processes in place to ensure record requests from contractors make it to the right person and/or department in your hospital, you send all documentation needed to support the service provided, and the review contractor receives the record in a timely manner.
Beth Cobb
Medicare Transmittals & MLN Articles
August 28, 2023: MLN MM13350: Changes to the Laboratory National Coverage Determination Edit Software: January 2024 Update
Billing staff need to know about newly available codes, recent coding changes, and how to find NCD coding information. CMS noted that there are no policy changes in this ICD-10 quarterly update. Instead, they follow the current, longstanding NCD process to implement policy changes. https://www.cms.gov/files/document/mm13350-changes-laboratory-national-coverage-determination-edit-software-january-2024-update.pdf
August 28, 2023: MLN MM13335: Inpatient Psychiatric Facilities Prospective Payment System: FY 2025 Updates
This article discusses changes for FY 2024 that are effective October 1, 2023. Make sure your billing staff knows about FY 2024 market basket update, wage index update, and changes to the Inpatient Psychiatric Facility (IPF) Quality Reporting Program (IPFQRP). https://www.cms.gov/files/document/mm13335-inpatient-psychiatric-facilities-prospective-payment-system-fy-2024-updates.pdf
August 31, 2023: MLN MM13353: Ambulatory Surgical Payment System: October 2023 Update
CMS advises in this MLN article that you make sure your billing staff knows about the new HCPCS code for renal/kidney histotripsy, the new drugs and biological codes, and the new skin substitute HCPCS codes. https://www.cms.gov/files/document/mm13353-ambulatory-surgical-center-payment-system-october-2023-update.pdf
September 6, 2023: MLN MM13340: Hospital Outpatient Prospective Payment System: October 2023 Update
This article highlights new COVID-19 CPT vaccines and administration codes, proprietary laboratory analyses (PLA) coding changes, multianalyte assays with algorithmic analyses (MAAA) CPT coding change, advanced diagnostics tests (ADLTs) under the clinical lab fee schedule (CLFS) and HCPCS code changes. https://www.cms.gov/files/document/mm13340-hospital-outpatient-prospective-payment-system-october-2023-update.pdf
September 6, 2023: MLN MM13343: DMEPOS Fee Schedule: October 2023 Quarterly Update
Make sure your billing staff knows about fee schedule adjustment relief for rural and non-contiguous areas, new HCPCS codes added, and new fee schedule amounts. https://www.cms.gov/files/document/mm13343-dmepos-fee-schedule-october-2023-quarterly-update.pdf
September 12, 2023: MLN MM11262: Limitation on Recoupment of Overpayments
This article reviews how Medicare recoups overpayments and how appeals and reconsiderations affect the recoupment process. https://www.cms.gov/files/document/mm11262-limitation-recoupment-overpayments.pdf
September 14, 2023: MLN MM13306: Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2024 Changes
Highlights of policy changes for FY 2024 are included in this MLN article. Of note, CMS indicates that for FY 2024, hospitals have until late-September to notify them of any errors in the calculation of their Total Hospital Acquired Conditions (HAC) Reduction Program score. For this reason, the list of hospitals subject to the HAC Reduction Program will not be available by October 1, 2023. They note that “until we issue a final list of hospitals that are subject to the HAC Reduction Program for FY 2024, MACs will hold hospital claims. We anticipate issuing the list on or about October 3, 2023.” https://www.cms.gov/files/document/mm13306-inpatient-long-term-care-hospital-prospective-payment-system-fy-2024-changes.pdf
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.
Beth Cobb
Did You Know?
Noridian Healthcare Solutions, LLC (Noridian) is the current Supplemental Medical Review Contractor (SMRC). “With CMS directed topic selections and timeframes, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices.”
Reviews are assigned to the SMRC based on analysis of national claims data issues identified by other Federal agencies (i.e., OIG, Government Accountability Office (GAO), the Comprehensive Error Rate Testing Program (CERT), and Program for Evaluating Payment Patterns Electronic Report (PEPPER)).
Why It Matters?
As of August 15, 2023, the SMRC has thirteen current projects. Examples of current projects includes hyperbaric oxygen of lower extremities diabetic wounds, hospice general inpatient (GIP) level of care, cryosurgery of the prostate, and Mohs surgery.
Also, as of August 15, 2023, Noridian has completed sixty projects since being awarded the $227 million SMRC contract by CMS in 2018. Error rates for their completed projects range from 1% to 98%.
The 1% error rate was for a sample of claims reviewed related to the 20% add-on payment for COVID-19 that was in place during the COVID-19 Public Health Emergency. The 98% error rate was for a review of claims for Medicare Part B emergency ambulance services.
In July of this year, in addition to reporting an error rate for the reviewed claims, Noridian began reporting an error rate for the number of claims denied due to no response to an Additional Documentation Request (ADR). To date, SMRC medical review findings that include the no response error rate, includes:
Project 01-080: Vitamin B12 with Modifier 25 Findings of Medical Review
Error Rate for Reviewed Claims: 43%
No Response to ADR Denials: 39%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-080/
Project 01-081: Outpatient Dental Services CPT 41899 Findings of Medical Review
Error Rate for Reviewed Claims: 95%
No Response to ADR: 20%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-081/
Project 01-093: Overlapping Claims – Hospital Transfers During the PHE Findings of Medical Review
Error Rate for Reviewed Claims: 12%
No Response to ADR: 8%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-093/
Project 01-050: Podiatry Findings of Medical Review
Error Rate for Reviewed Claims: 45%
No Response to ADR Denials: 29%
Published August 8, 2023
https://noridiansmrc.com/completed-projects/01-050/
Project 01-072: Neurostimulator Implantation Findings of Medical Review
Error Rate for Reviewed Claims: 39%
No Response to ADR Denials: 23%
Results Published August 15, 2023
https://noridiansmrc.com/completed-projects/01-072/
Noridian notes they must notify CMS of identified improper payments and noncompliance with documentation requests. They will initiate claims adjustments and/or overpayment recoupment by the standard overpayment recovery process.
What Can I Do?
First and foremost, make sure you have a process to receive and respond to ADR requests from the SMRC and other review contractors (i.e., CERT).
If a claim is denied for no receipt of documentation, you can complete the following steps posted to the Noridian Jurisdiction E (JE) MAC website:
SMRC Reviews Denied for No Documentation
“When a claim is denied for no receipt of documentation requested by the SMRC, the next step is to submit the documentation to the MAC that issued the demand letter for the overpayment. This must occur within 120 calendar days of the demand letter.
This situation is considered a reopening and the MAC will send the submitted documentation to the SMRC for a re-review decision. The SMRC has up to 60 calendar days to make this decision. The SMRC will then mail a letter to the supplier with their findings, either to pay the claim or they will outline the reasons for denial.
The SMRC will next notify the MAC of the payment or denial decision. The MAC will adjust the claim and a remittance advice with the adjustment results will be generated. The provider has the right to appeal the SMRC decision, if the claim remains denied.
Based on the timeframes and steps listed above, please call the MAC about the status of the SMRC re-review only after at least 140 days have passed from when documentation was sent.”
Last, become familiar with information available on the SMRC website (https://noridiansmrc.com/).
Beth Cobb
August 10, 2023: New Place of Service Code 27 – Outreach Site/Street
CMS published Change Request (CR) 13314 to inform providers about the new Place of Service (POS) code 27 for “Outreach Site/Street” – a non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals. This code becomes effective on October 1, 2023.
In the August 25th MLN connects e-newsletter, CMS noted “at this time, Medicare won’t use this code in claims processing. If you submit a claim with this code, we’ll return it to you.”
August 10, 2023: Review Choice Demonstration for Inpatient Rehabilitation Facility Services FAQs
On May 15, 2023, CMS announced the new initiative, The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services. This demonstration started in Alabama with the first cycle of review dates being August 21, 2023 through February 29, 2024.
Palmetto GBA Jurisdiction J is the Medicare Administrative Contractor for Alabama, and they have a dedicated webpage specific to this demonstration (https://palmettogba.com/palmetto/jja.nsf/DID/FHT2JV6UCF). On August 28th, they posted a link to FAQs. Topics covered in this document include general questions, choice selection questions, submission questions, pre-claim review (PCR) questions, and medical necessity questions.
For IRF Providers outside of Alabama, I encourage you to pay close attention to the general question 4 asking what states does this demonstration impact.
CMS notes the demonstration initially for providers physically located in the state of Alabama and bill to MAC Jurisdiction J. The demonstration will then expand to Pennsylvania, Texas, and California, “as well as any state that bill to the MAC jurisdictions JJ, JL, JH, and JE, regardless of where they are physically located.”
Here is one example included in the answer to question 4:
I am an IRF located in a demonstration state but bill to a different MAC than the one for that state.
“You are included in the demonstration if the MAC that you bill to is JJ, JE, JL, or JH. If you bill to another MAC, then you are not included in the demonstration.”
You can find additional information about this demonstration on the CMS website at https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/review-choice-demonstration-inpatient-rehabilitation-facility-services#timeline.
August 21, 2023: CMS Issues Draft Guidance on New Program to Allow People with Traditional Medicare Fee-for-Service to Pay Out-of-Pocket Prescription Drug Costs in Monthly Payments
The Inflation Reduction Act of 2022 was signed into law on August 16, 2022. This law caps annual out-of-pocket prescription drug costs at $2,000 for 2025.
In addition to capping the out-of-pocket amount, the law gives people with Medicare prescription drug coverage (Medicare Part D) the option to make monthly payments spread over the year, also starting in 2025. On August 21st, CMS published draft guidance for comment outlining the requirements and procedures for spreading out the cost sharing over the year.
Due to the size of the new program, CMS indicated they would release the guidance in two parts. Part one was released August 21st and focuses on “helping Medicare Part D plan sponsors and pharmacies prepare for the new programs and build necessary infrastructure for successful implementation.” CMS is soliciting comments on topics and strategies included in the guidance to ensure eligible Part D enrollees benefit from the programs.
You can submit comments to CMS on the first draft guidance through September 30, 2023.
The planned release date for part two of the guidance will be in early 2024. This second release will focus on Medicare Part D enrollee outreach and education, Medicare Part D plan bid information, monitoring and compliance. “CMS also intends to develop tools, such as calculators, to help people with Medicare Part D and their caregivers learn what monthly payments may look like under the new program.”
Links to a Fact Sheet about the Medicare Prescription Payment Plan, an implementation timeline, and the August 21st draft guidance are included in an August 21st CMS Press Release. https://www.cms.gov/newsroom/press-releases/cms-issues-draft-guidance-new-program-allow-people-medicare-pay-out-pocket-prescription-drug-costs
Beth Cobb
Coverage Updates
August 9, 2023: MLN MM13278: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2024 Update
Relevant National Coverage Determinations (NCDs) include NCD 50.3 (Cochlear Implants), NCD 90.2. (Next Generation Sequencing (NGS), and NCD 210.1 (Prostate Screening Tests). Make sure your billing staff are aware of newly available codes, recent coding changes, and how to find NCD coding information. https://www.cms.gov/files/document/mm13278-icd-10-other-coding-revisions-national-coverage-determinations-january-2024-update.pdf
August 9, 2023: MLN MM13288: National Coverage Determination 30.3.3 – Acupuncture for Chronic Low Back Pain
Make sure your billing staff knows about updated frequency edits for acupuncture for chronic low back pain (cLBP) and relevant codes for acupuncture and dry needling services starting January 1, 2024. Reminder, CMS won’t cover more than 20 acupuncture treatments annually. https://www.cms.gov/files/document/mm13288-national-coverage-determination-3033-acupuncture-chronic-low-back-pain.pdf
Compliance Education Updates
August 2023: MLN Booklet Federally Qualified Health Center Revised
There have been several updates made to this MLN booklet. For example, CMS clarified the definition of telehealth and added consent for information for care management and virtual communications services. https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf
Other Updates
July 27, 2023: MLN Connects Notification: CMS Updated the Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy FAQs
In the July 27, 2023 edition of MLN Connects, CMS notes that they have updated the Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy FAQs to clarify the applicability of the reporting requirements to various outpatient settings and certain not otherwise classified billing codes. They also clarify how to use the JW and JZ modifiers when you prepare the dose with more than 1 single-dose container.
Finally, they remind providers that they use the JW and JZ Modifiers to collect information on discarded drug amounts from drugs that are packaged in single-dose containers that are separately payable under Part B.
Starting July 1, 2023, report the JZ modifier when there are no discarded amounts and report the JQ modifier when there are discarded amounts. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/1368246344/2023-07-27-mlnc
August 16, 2023: CMS Fact Sheet: Anniversary of the Inflation Reduction Act: Update on CMS Implementation
In this Fact Sheet, CMS details Milestones that they have met for implementing the provisions in this Act. You will also find links to public education resources that CMS has produced to help people with Medicare and those who assist them understand the changes under the new drug law (i.e., Frequently Asked Questions: Medicare Part B & D Insulin Benefit). https://www.cms.gov/newsroom/fact-sheets/anniversary-inflation-reduction-act-update-cms-implementationBeth Cobb
July 21, 2023: MLN MM13240: Patient Driven Payment Model Claim Edits
CMS advises that Skilled Nursing Facilities (SNFs) and Hospitals need to make sure your billing staff knows about edits for SNFs billing on Type of Bill (TOB) 21X and Swing Bed TOB 18X, and hospitals billing during an interrupted stay. https://www.cms.gov/files/document/mm13240-patient-driven-payment-model-claim-edits.pdf
July 21, 2023: MLN MM13248: Processing Services During Disenrollment from the Program of All-Inclusive Care for the Elderly (PACE)
Hospitals, SNFs and other providers billing Medicare Administrative Contractors (MACs) for inpatient services they provide to PACE-eligible Medicare patients need to make sure your billing staff knows how CMS handles payment for Medicare patients disenrolling from PACE and condition codes and value code (VC) CMS requires to prevent claims denials. https://www.cms.gov/files/document/mm13248-processing-services-during-disenrollment-program-all-inclusive-care-elderly.pdf
July 27, 2023: MLN MM13275: ESRD Prospective Payment System: October 2023 Update
Make sure your billing staff knows about billing J0889 for daprodustat and new ICD-10-CM codes for comorbidity payment adjustment and acute kidney injury. https://www.cms.gov/files/document/mm13275-esrd-prospective-payment-system-october-2023-update.pdf
Augst 3, 2032: MLN MM13299: HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement: October 2023 Update
Make sure billing staff knows about updates to the lists of HCPCS codes that are subject to the CB provision of the SNF prospective payment system (PPS), and additions and deletions of certain chemotherapy, blood clotting factors, and therapies inclusion codes from the Medicare Part A SNF files. https://www.cms.gov/files/document/mm13299-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-october-2023.pdf
August 10, 2023: MLN MM13289: Hospice Payments: FY 2024 Update
This article provides information about payment rates, inpatient and aggregate caps and wage index update effective October 1, 2023 for hospices and providers billing for hospice services. https://www.cms.gov/files/document/mm13289-hospice-payments-fy-2024-update.pdf
August 16, 2023: SE19007 Revised: Activation of Validation Edits for Providers with Multiple Service Locations
This special edition MLN article was originally published on March 26, 2019 and recently updated for the fifth time on August 16th. CMS has added information about the practice location address screen for round 3 testing Substantive changes are in dark red on pages 3 and 4.
Effective August 1, 2023, CMS started deploying the systematic validation edits requirements in Section 170 of the Medicare Claims Processing Manual, Chapter 1. MACs have been told to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t exactly match.
CMS notes in the MLN article that they “expect that the almost 7-year time frame that the edits haven’t been active gave you ample time to validate your claims submission system and the PECOS information for your off-campus provider departments are exact matches.” https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
August 17, 2023: MLN MM13321: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Make sure your billing staff know about private payor data reporting (you must report data between January – March 2024), general specimen collection fee increase, and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13321-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
August 24, 2023: Transmittal 12222: Inpatient Psychiatric Facilities Prospective Payment System Updates for Fiscal Year 2024
This Change Request (CR) 13335 identifies changes that are required as part of the annual IPF PPS update and applicable to discharges occurring from October 1, 2023 through September 30, 2024. https://www.cms.gov/files/document/r12222cp.pdf
Beth Cobb
Did You Know?
It has been almost two years since the October 2021 release of the CMS Change Request (CR) 12471 (https://www.cms.gov/files/document/R11059CP.pdf). There were two stated purposes for this CR noted in the Summary of Changes:
- Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
- Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason why laterality could not be determined.
Why this Matters?
In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”
Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.
You will find the initial complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page).
This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”
Mechanism to Bypass new MCE Edit 20-
The provider may enter a remark:
- Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
- “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality.
Entering this language will enable your MAC to systematically bypass the edit and process your claim.
However, “if there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”
New Unspecified Codes Subject to MCE Edit 20-
In the FY 2024 IPPS Final Rule, CMS finalized the addition of six new diagnosis codes that are designated as a CC to the Unspecified code edit code list and four diagnosis codes that were inadvertently omitted from the Unspecified code edit list effective with discharges on or after April 1, 2022.
New FY 2024 Unspecified ICD-10-CM Diagnosis Codes
- M80.0B9A: Age-related osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
- M80.0B9K: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
- M80.0B9P: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
- M80.8B9A: Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
- M80.8B9K: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
- M80.8B9P: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
- L89.103: Pressure ulcer of unspecified part of back, stage 3
- L89.104: Pressure ulcer of unspecified part of back, stage 4
- L89.93: Pressure ulcer of unspecified site, stage 3
- L89.94: Pressure ulcer of unspecified site, stage 4
What Can You Do?
Share this information with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists) including background information found in CR 12471 and related MLN Matters article MM12471 (https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf).Beth Cobb
Medicare Transmittals & MLN Articles
June 30, 2023: MLN MM13269: ICD-10 & Other Revisions to Laboratory National Coverage Determinations: October 2023 Update
CMS advises that you make sure your billing staff is aware of newly available codes, recent coding changes, and how to find NCD coding information. https://www.cms.gov/files/document/mm13269-icd-10-other-coding-revisions-laboratory-ncds-october-2023-update.pdf
July 5, 2023: MLN Matters MM13216: Ambulatory Surgical Center Payment System: July 2023 Update - Revised
Now in it’s fourth iteration, CMS has revised this MLN article to change the number of separately payable drugs in Section 5.a to 18 to agree with the change for HCPCS J9322 in Table 3 of Change Request (CR) 13216. Substantive changes are in dark red on page 3. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf
July 11, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised
Now in its fifth iteration, CMS has revised this special edition MLN article to add information on Round 5 testing and national implementation of edits. Substantive changes are in dark red on pages 1 and 4. Note that these are not new requirements, but CMS did announce a delay of activation of these edits on March 24, 2022 until further notice. On August 1, 2023, CMS will start deploying editing into full procedure and have told the MACs to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t match exactly. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
Coverage Updates
July 17, 2023: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease Proposed Decision Memo
CMS is proposing to remove National Coverage Determination (NCD) 220.6.20, ending coverage with evidence development (CED) from positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging be made by the Medicare Administrative Contractors (MACs). https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=308
July 20, 2023: HCPCS Modifier JZ Reminder
Palmetto GBA JJ Part B published a reminder that “the JZ HCPCS modifier is reports on a claim to attest that no amount of drug was discarded and eligible for payment. The modifier should only be used for claims that bill for single-dose container drugs. Effective July 1, 2023 providers are required to use the JZ modifier on applicable claims. https://www.palmettogba.com/palmetto/jjb.nsf/DID/1HF9LYKONE#ls
Compliance Education Updates
June 2023: Medicare’s Home Health Benefit Brochure Revised
CMS has revised their Medicare home health brochure. This brochure includes information about a beneficiary knowing their rights, where to get more information, what is covered, who can get covered home health care, what to pay, and how to protect yourself and Medicare from fraud. https://tinyurl.com/yc2ej3sv
June 2023: MLN Fact Sheet Telehealth Services Revised
CMS has recently updated this Fact Sheet and notes that they have made significant updates to explain recent policy changes. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf
Beth Cobb
Medicare Transmittals & MLN Articles
April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI
This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf
May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process
Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf
May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates
Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf
May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules
Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf
May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule
The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf
May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update
Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf
May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update
This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf
May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf
May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update
CMS advises that providers make sure your billing staff know about payment system updates, including new drug biological and procedure codes, an ASC Payment Indicator (PI) correction for CPT code 0698T, and additional skin substitute products. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdfBeth Cobb
Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.
Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.
My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.
While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.
In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.
The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.
My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.
I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.
With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at
https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.
As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:
- Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
- Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.
- Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
- Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.
Resources
National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/
NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf
National Institute on Aging: https://www.nia.nih.gov/health/osteoporosisBeth Cobb
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