Knowledge Base Category -

On November 22nd, CMS published the following announcement regarding new ICD-10 diagnosis and procedure codes that will become effective April 1, 2023:

In an effort to better enable the collection of health-related social needs (HRSNs), defined as individual-level, adverse social conditions that negatively impact a person’s health or healthcare, are significant risk factors associated with worse health outcomes as well as increased healthcare utilization, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing 42 new diagnosis codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting effective April 1, 2023.

Fourteen of the new diagnosis codes are identified as external cause of injury codes and as such there is no assigned severity level, MDC, or MS-DRG.

In addition, the Centers for Medicare & Medicaid Services (CMS) is implementing 34 new procedure codes into the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), effective April 1, 2023.

The ICD-10 MS-DRG V40.1 Grouper Software, Definitions Manual Table of Contents, and the Definitions of Medicare Code Edits V40.1 manual to accommodate these new diagnosis and procedure codes, effective for discharges on or after effective April 1, 2023 will be available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html.

The Code Tables, Index and related Addenda files for the 34 new procedure codes will be available at: https://www.cms.gov/medicare/icd-10/2023-icd-10-pcs.

The Index and Tabular Addenda for the new diagnosis codes will be made available via the CDC website at: https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm.

Did You Know?

December 5th – 9th, 2022 is National Influenza Vaccination Week (NIVW). This annual observance is a time to remind everyone that for individuals 6 months and older there is still time to get vaccinated against the flu. This is especially important for individuals at higher risk (i.e., people 65 years and older, diabetics, people with heart disease, and young children) for developing serious complications from the flu.

Why It Matters?

The CDC estimated, that during the 2021 – 2022 influenza season (link), influenza was associated with:

• 9 million illnesses,
• 4 million medical visits,
• 10,000 hospitalizations, and
• 5,000 deaths.

The CDC estimates that, from October 1, 2022 through November 26, 2022, there have been:

• 8.7 – 19 million flu illnesses,
• 4.2 – 9.5 million flu medical visits,
• 78,000 – 170,000 flu hospitalizations, and
• 4,500 – 13,000 flu deaths.

Note, the above 2022 estimates were last reviewed December 2, 2022, are preliminary and change week-by-week as new hospitalizations are reported to the CDC.

What Can I Do?

If you are a healthcare provider, CMS has updated their Flu Shot Toolkit (link) with information about payment for the 2022-2023 flu season, frequency and coverage, billing, coding, and additional resources.

Receiving an annual flu vaccine reduces your risk of flu. Seasonal influenza viruses are detected year-round, however most flu activity peaks between December and February. As a healthcare consumer, if you have not already received your flu shot, it is not too late to get one.

Medicare Transmittals & MLN Articles

Telehealth Home Health Services: New G-Codes

• MLN Release Date: November 2, 2022
• What You Need to Know: Starting on or after January 1, 2023, Home Health (HH) providers may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. Starting July 1, 2023, providers will be required to report this information. This MLN article details the three G-codes that will need to be used when submitting the use of telecommunication technology on the HH claim.
• MLN MM12805: link)

Billing for Hospital Part B Inpatient Services

• Transmittal Issue Date: November 9, 2022.
• What You Need to Know: The purpose of this Change Request (CR) 12965 is to provide billing instructions for hospital Part B inpatient services. For example, effective 7/1/2022 three new “Not Allowed Revenue Codes” were added to the list of codes a Medicare Administrative Contractor will set a revenue code edit to prevent payment on Type of Bill 012X. The implementation date for the updates is December 12, 2022.
• CR 12965: link)

ESRD & Acute Kidney Injury Dialysis: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article details information about rates and policies for the ESRD Prospective Payment System and payment for renal dialysis services provided to patients with acute kidney injury in ESRD facilities.
• MLN MM12978: link)

Home Health Prospective Payment System: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article highlights changes related to 30-day period payment rates, national per-visit amounts, and cost-per-unit payment amounts used for calculating outlier payments under the Home Health Prospective Payment System. These changes will be effective January 1, 2023.
• MLN MM12957: link)

Medicare Physician Fee Schedule Final Rule Summary: CY 2023

• MLN Release Date: November 17, 2022
• What You Need to Know: This article details updates effective January 1, 2023 to the telehealth originating site facility fee payment amount, expansion of coverage for colorectal cancer screening, coverage of audiology services, and other covered services.
• MLN MM12982: link)

New Waived Tests

• MLN Release Date: November 23, 2022
• What You Need to Know: This article highlights seven newly added waived complexity tests that must have the modifier QW to be recognized as a waived test.
• MLN MM12996: link)

Revised Medicare MLN Articles & Transmittals

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023

• MLN Release Date: September 6, 2022 – Revised November 10, 2022
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12888. No substantive changes were made to the article.
• MLN MM12888: link)

Coverage Updates

ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2023 Update

• MLN Release Date: November 9, 2022
• What You Need to Know: This MLN is related to CR 12960 which is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. Relevant NCD coding changes in CR 12960 include:
• NCD 20.4 (Implantable Automatic Defibrillators ICDs): ICD-10 diagnosis code I47.2 end effective date was September 30, 2022. New codes effective on or after October 1, 2022 includes I47.20, I47.21, and I47.29.
• NCD 210.10 (Screening for STIs): CPT 0353U is a new code for this NCD with an effective date October 1, 2022.

CMS notes that MACs will adjust any claims processed in error associated with CR 12960 that you bring to their attention.

• MLN MM12960: link)

Compliance Education Updates

Medicare Provider Compliance Tips – Revised

CMS noted in the Thursday, November 3, 2022 edition of MLN Connects (link) that the educational tool Medicare Provider Compliance Tips has been updated with the latest improper payment rates, denial reasons, and codes. Additional information and new tips have been added to several of the topics included in this tool (i.e., new tips for cataract removal, lipid panels and psychiatry).

Federally Qualified Health Center — Revised
Excerpt from 11/23 MLN Matters newsletter:

This MLN booklet (link)">link) was reviewed in October 2022 and includes the following changes:

• Payment for hospice attending physician services by specific providers
• Mental health services using telecommunications
• Concurrent billing for chronic care management and transitional care management services
• Changes to care management services codes
• CMS also added information on COVID-19 shot and monoclonal antibody therapy administration.

COVID-19 Updates

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency on October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. The sixty days prior to January 11, 2023 came and went without notice from the Secretary so it appears the COVID-19 PHE will last at least to April 2023.

HHS Releases Long COVID Report

In a November 21, 2022 press release (link), the U.S. Department of Health and Human Services (HHS) announced the release of a new report highlighting patients’ experience of Long COVID. “Long COVID is a set of conditions. Researchers have cataloged more than 50 conditions linked to Long COVID that impact nearly every organ system. Estimates vary, but research suggests that between 5 percent and 30 percent of those who had COVID-19 may have Long COVID symptoms, and roughly one million people are out of the workforce at any given time due to Long COVID. This figure equates to approximately $50 billion annually in lost salaries.”

Other Updates

October 27, 2022: OIG Report – CMS Can Use OIG Audit Reports to Improve Its Oversight of Hospital Compliance

In this Report (link), the OIG notes that they performed this audit to determine CMS’s actions taken regarding 12 Hospital Compliance Audits during calendar years (CYs) 2016 through 2018. Collectively, the OIG reviewed 1,290 claims from the 12 hospitals. The most common error types identified by the OIG were incorrectly billed Inpatient Rehabilitation Facility (IRF) services and incorrectly billed HCPCS codes.

The OIG determined that, after considering results of first and second level appeals, the 12 hospitals received overpayments totaling $82 million. While the OIG found that CMS had taken some recommended actions based on these audits, they noted that CMS provided insufficient information to be able to identify if actions had been taken to ensure the hospitals had repaid funds or followed the 60-day rule.

The categories of claims at high risk for noncompliance with Medicare requirements, for this report, included the following “risk areas” that were the focus of the 12 hospital compliance audits:

• Inpatient rehabilitation facility claims,
• Inpatient claims billed with high CERT DRG codes,
• Inpatient claims billed with high-severity level DRG codes,
• Inpatient claims paid in excess of billed charges,
• Inpatient claims billed with adverse events, inpatient claims billed with elective procedures,
• Inpatient claims billed with mechanical ventilation,
• Inpatient claims covering same day discharge and readmission,
• Inpatient psychiatric facility claims,
• Inpatient claims paid in excess of $150,000,
• Inpatient claims paid in excess of $25,000,
• Outpatient claims paid in excess of charges,
• Outpatient claims billed with right heart catheterizations HCPCS codes,
• Outpatient surgery claims billed with units greater than one,
• Outpatient claims billed with bypass modifiers,
• Outpatient skilled nursing facility (SNF) consolidated billing claims, and
• Outpatient claims paid in excess of $25,000.

The OIG notes that “if CMS used our provider-specific audit reports, it could improve Medicare program oversight by focusing on services at high risk for improper payment. In addition, CMS’s actions could lead to improvements in hospital specific internal controls.”

October 28, 2022: Implementing Certain Provisions of the Consolidated Appropriations Act (CAA), 2021 and other Revisions to Medicare Enrollment and Eligibility Rules (CMS-4199-F)

Currently, for those approaching sixty-five, the date when your coverage becomes effective depends on when you enroll. As noted in a CMS Fact Sheet related to this final rule (link):

• “If an individual enrolls during any of the first three months of their Initial Enrollment Period (IEP), their coverage will start the first month of eligibility (e.g., age 65).
• If an individual enrolls during their IEP in the month they become eligible, their coverage will start the month after they enroll.
• If an individual enrolls during any of the last three months of their IEP, their coverage will start 2-3 months after they enroll.
• If an individual enrolls during the General Enrollment Period (GEP), which runs from January 1st through March 31st every year, their coverage will start

As mandated in the CAA and finalized in this rule, beginning January 1, 2023, Medicare coverage will become effective the month after enrollment for individuals enrolling in the last three months of their IEP or in the GEP, reducing any potential gaps in coverage.

October 31, 2022: CY 2023 Home Health Prospective Payment System rate Update and Home Infusion Therapy Services Requirements – Final Rule (CMS-1766-F)

In a Fact Sheet (link), CMS estimates that Medicare payments to Home Health Agencies (HHAs) in CY 2023 will increase $125 million compared to CY 2022.

October 31, 2022: CY 2023 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1768-F)

CMS projects that payment updates for CY 2023 will increase the total payments to all ESRD facilities by 3.1% compared to CY 2022. You can read about this Final Rule in the CMS Fact Sheet announcing the release of the final rule (link).

The CMS released the Calendar Year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule on November 1, 2022. Following are highlights from the final rule:

CY 2023 OPPS and ASC Payment Rates

CMS is updating the CY 2023 OPPS and ASC payment rate by 3.8%.

• The estimated total payments to OPPS providers in CY 2023 would be approximately $86.5 billion, an increase of approximately $6.5 billion compared to CY 2022 OPPS payments.
• The estimated total payments to ASCs for CY 2023 will be approximately $5.3 billion, an increase of approximately $230 million compared to CY 2022 ASC payments.

Comprehensive Ambulatory Payment Categories (C-APCs) for CY 2023

C-APCs were first implemented on January 1, 2015. A C-APC is defined as “a classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service.”

CMS expanded the C-APC methodology in 2016 to include a “Comprehensive Observation Services” C-APC (C-APC 8011). The payment rate for C-APC 8011 in CY 2023 is $2,439.02.

For CY 2023, CMS finalized one new C-APC, C-APC 5372 (Level 2 Urology and Related Services).

For the duration of the COVID-19 PHE, any new FDA approved drug or biological approved for emergency use authorization (EUA) to treat COVID-19 that is authorized for use in the outpatient setting, or not limited to use in the inpatient setting, will be separately paid and will not package into the C-APC when provided on the same claim as the primary C-APC service.

Rural Emergency Hospital (REH)

REH is a new Medicare Provider type that includes facilities who elect to convert either from a critical access hospital (CAH) or a rural hospital with less than fifty beds to an REH. Policies for this new provider type will take effect January 1, 2023.

By statute REH services include emergency department services and observation care. Specific to observation care, CMS notes “there may be instanced in which REH patients receive observation services at an REH for a period exceeding 24 hours, but REHs are not required to provide required notification under the NOTICE Act, known as the Medicare Outpatient Observation Notice (MOON), because REHs are excluded from the definition of “hospital.”

An REH can also elect to provide other outpatient medical and health services furnished on an outpatient basis. CMS finalized the proposal that REHs may provide outpatient services not otherwise paid under the OPPS (i.e., services paid under the Clinical Lab Fee Schedule, post-hospital extended care services in a distinct part unit licensed as a skilled nursing facility).

REHs will receive a monthly facility payment of $272,866. This payment will increase in subsequent years by the hospital market basket percentage increase.

340B-Acquired Drugs

“CMS notes in the final rule that “for CY 2023, in light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), we are applying the default rate, generally average sales price (ASP) plus 6 percent, to 340B acquired drugs and biologicals in this final rule with comment period for CY 2023 and removing the increase to the conversion factor that was made in CY 2018 to implement the 340B policy in a budget neutral manner.

We are still evaluating how to apply the Supreme Court’s decision to prior calendar years. In the CY 2023 OPPS/ASC proposed rule, we solicited public comments on the best way to craft any potential remedies affecting cost years 2018-2022, and we will take these comments into consideration for separate rulemaking that will be published in advance of the CY 2024 OPPS/ASC proposed rule.”

Reminder, for 2022 claims prior to September 28th, providers will need to submit adjustment claims to recalculate their payments (link).

Medicare Inpatient Only (IPO) List

For CY 2023, CMS is removing 11 services and adding 8 newly created CPT codes to the IPO List. Table 65 of the final rule includes all services to be removed or added to the IPO list.

ASC Covered Procedure Lists

Procedures on the ASC Covered Procedure List (CPL) are surgical procedures that are appropriately performed on an inpatient basis in a hospital but that can also be safely performed in an ASC, a CAH, or an HOPD. Four procedures are being added to this list and can be found in table 80 of the final rule.

Hospital Outpatient Department Prior Authorization Process: New Service Category

Effective for dates of service on or after July 1, 2023, Facet joint interventions will be added to the list of service categories that hospital outpatient departments will be required to get prior authorization to receive payment. Specific Facet Joint CPT codes that will require prior authorization are listed in Table 103 of the final rule.

Outpatient Non-PHP Mental Health Services Furnished Remotely by Hospital Staff to Beneficiaries in Their Homes

CMS finalized its proposal to consider mental health services furnished remotely by hospital staff using communication technology to a beneficiary in his or her home a covered outpatient department service.

An in-person service will be required within 6 months prior to the initiation of remote service and then every 12 months thereafter, exceptions may be made to this requirement based on a beneficiary’s clinical needs and the reason being documented in the medical record. The in-person requirement will not apply to beneficiaries who began receiving mental health telehealth services during the PHE or during the 151-day period after the end of the PHE.

Audio-only interactive telecommunications systems may be used when a beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.

Resources

CY 2023 OPPS Final Rule CMS Press Release: https://www.cms.gov/newsroom/press-releases/hhs-continues-biden-harris-administration-progress-promoting-health-equity-rural-care-access-through

CY 2023 OPPS Final Rule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-2

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on the new service to be added to the Prior Authorization for Certain Hospital Outpatient (OPD) Services effective July 1, 2023.

Did You Know?

CMS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services through the Calendar Year (CY) 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC).

Initially, effective July 1, 2020 blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation required a prior authorization when performed in the hospital OPD. For claims on or after July 1, 2021, implanted spinal neurostimulators and cervical fusion with disc removal were added to the list.

New for 2023, CMS finalized the addition of facet joint interventions requiring prior authorization for claims on or after July 1, 2023. This service category includes facet joint injections, medial branch blocks, and facet joint nerve destruction. A list of the specific CPT codes that will require prior authorization are listed in Table 103 of the CY 2023 OPPS/ASC Final Rule (CMS-1772-FC).

Why it Matters?

Reviewing facet joint records has been a target by several different entities.

Medicare Administrative Contractors

Noridian Jurisdiction E (JE) Part B MAC has conducted a Targeted and Probe and Educate (TPE) review of CPT 64635 (Destruction by Neurolytic Agent, Paravertebral Facet Joint Nerve). Dates of service reviewed were January 2020 through March 2020. The claims error rate was 75% with the top denial reasons being:

• Failure to return records,
• Documentation does not support the medical necessity as listed in the Coverage Requirement, and
• Duplicate billing.

Noridian indicated in their review results that “Local Coverage Determination L34993 provides an overview of the coverage requirements for these services. Documentation must support the history of pain which has not been responsive to conservative measures. Documentation must also support the conservative measures that have been tried and failed. The LCD also further clarifies that documentation must support a clinical assessment which supports that the pain is a result of the facet joint and that there is no other pathology that may be causing the pain.

Documentation must reflect the patient pre and post procedure pain rating, procedure report, and the injectate used is within the LCD requirements.”

Other Part B MACs that have reviewed or are currently reviewing facet joint injections include Novitas JH and JL and WPS J8.

Office of Inspector General (OIG)

CMS notes in the OPPS/ASC final rule that the OIG has published multiple reports indicating questionable billing practices, improper Medicare payments, and questionable utilization of facet joint interventions. Based on their findings, the OIG recommended that CMS and its contractors provide additional oversight on claims for facet joint injections to prevent additional improper payments.

Supplemental Medical Review Contractor

Just last month on October 10th, the Supplemental Medical Review Contractor (SMRC) posted their review findings of Project 01-304: facet joint injections. The October 2020 OIG report was referenced in the review results. Claims reviewed included hospital outpatient and critical access hospitals with dates of service in CY 2019. The claims error rate was 92% and common denial reasons included:

• Documentation submitted was insufficient or incomplete,
• Documentation submitted did not support medical necessity as listed in National and Local Coverage Determinations, and
• No response to the documentation request by the provider.

What Can I Do?

You can begin to prepare for the July 1, 2023 addition of Facet joint procedures to the Prior Authorization for Certain Hospital OPD Services now by:

• Identifying applicable Medicare Coverage Documents (Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs)), and
• Ensuring key stakeholders are aware of the need for prior authorization effective July 1, 2023 (i.e., Outpatient Department Nurse Manager, Scheduling, Physicians performing these procedures) and educate them on applicable documentation requirements found in the LCDs and LCAs.

Compliance Education Updates

MLN Educational Tool: Medicare Preventive Services

This MLN tool (link) was updated in September. Updates include pneumococcal shot resources, thirteen new bone mass measurement codes and three new hepatitis B screening codes.

MLN Educational Tool: Medicare Payment Systems

This MLN tool (link) was also updated in September to include updates for FY 2023 for:

• The Acute Care Hospital Inpatient Prospective Payment System (IPPS),
• The Hospice Payment System,
• The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS),
• The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS),
• The Long-Term Care Hospital Prospective Payment System (LTCH PPS), and
• The Skilled Nursing Facility Prospective Payment System (SNF PPS).

MLN Booklet: Chronic Care Management Services

This Booklet (link) has been updated. Substantive content changes are in dark red font and includes:

• Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same period,
• In 2021 CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
• Beginning 2022 CMS replaced G2058 with 99439.

COVID-19 Updates

October 13, 2022: Update to COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

This CMS document (link) was updated on October 13th. The waiver related to the Director of Food and Nutrition Services was terminated on 10/1/2022 per the FY 2023 SNF Prospective Payment System Final Rule (1765-F).

Other Updates

September 23, 2022 Award of Medicare Administrative Contractor (MAC) Contract for Jurisdiction M

On September 23rd, Palmetto GBA, the incumbent MAC for Jurisdiction M (JM) was again awarded the contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the states of North and South Carolina, Virginia, and West Virginia. The claims volume in JM equates to more than $26.4 billion in Medicare benefit payments annually. Palmetto GBA will provide Medicare services to more than three hundred hospitals, approximately 75,000 physicians, and 3.2 million beneficiaries.

CMS Implements Temporary Increase in Payment under Medicare for Qualifying Biosimilars

Section 11403 of the Inflation Reduction Act provides for a temporary increase in the add-on payment for qualifying biosimilars from the current ASP plus an add-on of 6% of the reference biological product’s ASP to ASP plus 8% for a 5-year period. CMS noted in the Thursday, October 6th edition of MLN Matters (link) that “the goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.”

If you are interested in learning more about biosimilars, there are two FDA resources:

• FDA Biological Product Definition Fact Sheet (link), and
• A Curriculum Materials for Health Care Degree Programs / Biosimilars (link). The “FDA’s curriculum materials are intended to help educate students in health care professional degree programs, for medicine, nursing, physician assistants, and pharmacy, as well as practicing professionals, to improve understanding of biosimilar and interchangeable biosimilar products and the regulatory approval pathway in the United States.”

CMS Request for Information (RFI): Developing a National Directory of Health Care Providers and Services

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

• Helping patients locate providers that meet their individual needs and preferences, and
• A modern NDH “should enable healthcare providers, payers, and others involved in patient care to identify one another’s digital contact information also referred to as digital endpoints, for interoperable electronic data exchange.”

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

Medicare MLN Articles & Transmittals

Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data

• MLN Release Date: September 29, 2022
• What You Need to Know: Data for the Ninth Circuit’s jurisdiction has been updated based on Supreme Court decision in Azar v. Empire Health Foundation. This includes hospitals in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington. Data for all other hospitals is unchanged.
• MLN MM12906: (link)

New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

• MLN Release Date: October 6, 2022
• What You Need to Know: Make sure your billing staff knows about a new consistency edit that validates the attending provider NPI and that organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met.
• MLN MM12889: (link)

Medicare Deductible, Coinsurance & Premium Rates: Calendar Year 2023 Update

• MLN Release Date: October 13, 2022
• What You Need to Know: CMS advises to make sure your billing staff know about the calendar year 2023 rate changes. I would also encourage you to make sure your case management and social services staff are aware of this information too.
• MLN MM12903: (link)

Revised Medicare MLN Articles & Transmittals

Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests

• MLN Release Date: April 29, 2022 – Revised September 29, 2022
• What You Need to Know: The article was revised to add the Other Amount Indicator “B2” for co-insurance reduction amount to the claim, modify edits that affects the co-insurance reduction amount, and report the applied coinsurance amounts in the c-insurance field.
• MLN MM12656: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)-January 2023 Update – 2 of 2

• MLN Release Date: August 12, 2022 – Revised October 5, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 12842. The update for NCD 150.3 (Bone Mineral Density Studies) was removed due to ICD-10 diagnosis codes that were added in error and restore ICD-10 diagnosis C91.92 that was removed in error to NCD 110.23 (Stem Cell Transplantation).
• MLN MM12842: (link)

October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal Release Date: Transmittal 11610 released September 23, 2022 is being rescinded and replaced by Transmittal 11661 dated October 23, 2022
• What You Need to Know: This transmittal has been updated to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11.
• Transmittal 11661: (link)

Coverage Updates

Cochlear Implantation Final Decision Memo (CAG-00107R)

On September 26, 2022, CMS published a final decision memo (link) for NCD 50.3 Cochlear Implantation. CMS has concluded there is sufficient evidence for cochlear implantation be “be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.” Patient’s must also meet specific criteria detailed in the Decision Memo.

Did You Know?

A new code has been created to identify a non-ischemic myocardial injury (non-traumatic).

Why Should I Care?

Myocardial injury, in the absence of ischemia, is categorized as acute or chronic nonischemic myocardial injury. Previously, non-ischemic, non-traumatic, myocardial injury was assigned to code (I51.89) (Other ill-defined heart diseases). Effective October 1, 2021, non-ischemic, non-traumatic, myocardial injury is assigned to code I5A (CC).

Non-ischemic myocardial injury (non-traumatic) code (I5A) includes:

• Acute myocardial injury (non-ischemic)
• Chronic myocardial injury (non-ischemic)
• Unspecified myocardial injury (non-ischemic)

Instructions under I5A:

• Code first the underlying causes, if known and applicable, such as: acute kidney failure, acute myocarditis, cardiomyopathy, chronic kidney disease, etc.
• Excludes1: acute myocardial infarction and injury of heart
• Excludes2: other acute ischemic heart diseases

Clinicians can now determine whether patients have suffered a non-ischemic myocardial injury or one of the other myocardial injuries: Type 1 MI (myocardial ischemic injury) or Type 2 MI (supply/demand without acute atherothrombosis).

The new code will allow for the appropriate classification of these patients. Accurate coding of myocardial injury will allow for appropriate reimbursement and support resource costs as well.

What Should I Do?

If you see documentation of myocardial injury, remember that this condition is codable, even if the patient doesn’t have a myocardial infarction (ischemic).

References:

ICD-10-CM Official Coding Book

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2021: Page 14

Coding Clinic for ICD-10-CM/PCS, Second Quarter, 2019: Page 5

Did You Know?

Chances are you; a family member, close friend or acquaintance has been impacted by breast cancer. October is Breast Cancer Awareness Month. According to a CDC (link), each year:

• About 264,000 women in the United States get breast cancer and 42,000 women die from the disease,
• Men can also get breast cancer, but it is not common. About one out of every one hundred breast cancers diagnoses in the United States is found in a man, and
• While most breast cancers are found in women who are 50 years old or older, breast cancer also affects younger women.

Why Should You Care?

Even though family history increases the risk of breast cancer, most women diagnosed with breast cancer have no known family history of the disease. Early detection allows for a higher chance of cure. Mammography is used to detect breast cancer and is one of many Preventative Services covered by Medicare.

A related RealTime Medicare (RTMD) infographic, in this week’s newsletter, highlights the impact of the COVID-19 pandemic on the volume of Medicare Fee-for-Service beneficiaries undergoing screening mammography in RTMD’s footprint.

NCD 220.4 Mammograms

The CMS National Coverage Determination (NCD) 220.4 Mammograms (link) distinguishes the difference between diagnostic and screening mammography.

Diagnostic Mammography

A radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure. CMS covers this service if ordered by a Doctor of Medicine or Osteopathy in addition to the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated,
• A patient has a history of breast cancer, or
• A patient is asymptomatic but, based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Screening Mammography

A radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Routine screening includes:

• Asymptomatic women 50 years and older, and
• Asymptomatic women 40 years and older whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

Guidance for coding and billing for screening mammography is available in the MLN Educational Tool: Medicare Preventive Services (link).

What Can I Do?

Know Ways to Lower Your Risk for Breast Cancer

The CDC details thing you can do to help lower your risk of breast cancer including:

• Keep a health weight and exercise regularly,
• Choose not to drink alcohol, or dink alcohol in moderation,
• If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks, and
• Breastfeed your children, if possible.

Know the Warning Signs of Breast Cancer

While there are different symptoms of breast cancer, and some people have no symptoms at all, symptoms can include:

• Any change in the size or shape of the breast,
• Pain in any area of the breast,
• Nipple discharge other than breast milk (including blood),
• A new lump in the breast or underarm, thickening or swelling or part of the breast,
• Irritation or dimpling of the breast,
• Redness or flaky skin in the nipple area of the breast.

Be Your Own Patient Advocate

If you have any signs or symptoms that worry you, follow-up with a health care provider as soon as possible.

Talk to your health care provider about when and how often to get a screening mammogram. If you are worried about the cost, the CDC’s National Breast Cancer Early Detection Program (NBCCEDP) (link) provides breast and cervical cancer screenings and diagnostic services to women who have low incomes and are uninsured or underinsured.