Knowledge Base Category -

Question

Our gastroenterologists rarely state if a patient’s personal history of colon polyps is adenomatous in nature or hyperplastic, or both. Typically, the documentation only reflects that the patient has a “history of colon polyps”. If the physician specifies the patient’s previous colon polyps as being hyperplastic, what ICD-10-CM diagnosis code should be assigned?

Answer

For a personal history of hyperplastic colon polyps, assign ICD-10-CM diagnosis code Z87.19 (personal history of other diseases of the digestive system).

Medicare MLN Articles & Transmittals – Recurring Updates

Expedited Review Process for Hospital Inpatients in Original Medicare

• Article Release Date: January 21, 2022
• What You Need to Know: CMS has reformatted the current instructions for delivery of the Important Message from Medicare (IMM) and the beneficiary’s rights to an expedited review. While this MLN article notes in bold to “make sure your staff knows this is a reformatting of the current instructions and there are no policy or instructional changes,” following are three noteworthy clarifications:
• The effective date for the related Change Request is April 21, 2022.
• A new exception of who you would not provide an IMM to is the beneficiary that ends care on their own initiative by electing the hospice benefit.
• A new note indicates “the IM should only be given when an inpatient admission is pending or has occurred. It should not be given ‘just in case,’ such as a hospital delivering to all Medicare patients being treated in a hospital emergency room.”
• CMS has included a statement that “an IM must be delivered even if the beneficiary agrees with the discharge.”
• MLN MM12546: (link)

Internet-Only Manual Updates for Critical Care Evaluation and Management Services

• Article Release Date: January 22, 2022
• What You Need to Know: You will learn about critical care updates for a patient in a global surgical period and the use of modifier FT.
• MLN MM12550: (link)

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

• Article Release Date: January 27, 2022
• What You Need to Know: This article provides instructions for the April 2022 update to the CLFS and new codes effective April 1, 2022.
• MLN MM12612: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022

• Article Release Date: February 10, 2022
• What You Need to Know: This article provides information about newly available codes, separate NCD coding revisions, and coding feedback.
• MLN MM12606: (link)

Gap Billing Between Hospice Transfers

• Article Release Date: February 10, 2022
• What You Need to Know: A new CWF edit will no longer allow gaps of care to occur during a transfer.
• MLN 12619: (link)

Omnibus Change Request to Remove Two NCDs, Updates Medical Nutritional Therapy Policy and Updates to Pulmonary Rehabilitation, (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage

• Change Request 12613/Transmittal 11272 Release Date: February 18, 2022
• What You Need to Know: Updates became effective January 1, 2022, by statute with an implementation date of July 5, 2022. Specific to PR, the CY 2022 MPFS final rule removed the requirements for direct physician-patient contact and expanded coverage of PR for beneficiaries with confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least 4 weeks. The two NCDs being removed are:
• NCD 180.2 Enteral/Parenteral Nutritional Therapy, and
• NCD 220.6 Positron Emission Tomography (PET) Scans.
• Transmittal 11272: (link)

Revised Medicare MLN Articles & Transmittals

April 2022 Update to the MS-DRG Group and Medicare Code Editor Version 39.1 for ICD-10 Diagnosis Codes for 2019 COVID-19 Vaccination Status and ICD-10-PCS codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment

• Article Release Date: Initial article January 19, 2022 – Revised February 8, 2022
• What You Need to Know: This article was revised to add two new procedure codes describing the introduction or infusion of therapeutics including vaccines for COVID-19 treatment, effective April 1, 2022.
• MLN MM12578: (link)

Coverage Updates

National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: September 15, 2021 – Latest Revision January 24, 2022
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
• MLN MM12403: (link)

CWF Editing – NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds

• Article Release Date: February 16, 2022
• What You Need to Know: This article provides information about new edits for autologous Platelet-Rich Plasma (PRP) claims for diabetes and chronic ulcers.
• MLN MM12611: (link)

Final Decision Memo: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

CMS posted a Final Decision Memo ((link) for Lung Cancer Screening with LDCT on February 10, 2022. The eligibility age for screening has decreased from 55 years to 50 years. The tobacco smoking history has decreased from thirty packs per year to at least twenty packs per year. Counseling and shared decision-making are required prior to a beneficiary’s first screening test. Shared Decision Making (SDM) shall “include the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

COVID-19 Updates

January 31, 2022: FDA Approves Second COVID-19 Vaccine

The FDA announced the approval of a second COVID-19 vaccine ((link). The vaccine under emergency use authorization has been known as the Moderna COVID-19 vaccine. The approved vaccine will be marketed as Spikevax. Spikevax has the same formulation as the EUA Moderna COVID-19 Vaccine and is administered as a primary series of two doses, one month apart.

February 18, 2022: FDA Authorized Monoclonal Antibody Bebtelovimab

CMS announced in a special edition of MLN Connects ((link) that the FDA has approved the monoclonal antibody Bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when specific criteria apply. CMS has created three new codes for administering this drug. You can find information about this and other monoclonal antibody drugs on the CMS COVID-19 Monoclonal Antibodies webpage (link).

Other Updates

February 1, 2022: DOJ News: False Claims Act Settlements and Judgements Exceed $5.6 Billion in Fiscal Year 2021

In this DOJ announcement ((link) the DOJ reports that over $5 billion of the more than $5.6 billion in settlements in the past fiscal year related to matters involving the health care industry, “including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians.”

Did You Know?

February is American Heart Month. Per NCD 210.11 (link), cardiovascular disease (CVD):

• Is the leading cause of mortality in the United States,
• Is comprised of hypertension, coronary artery disease (i.e., myocardial infarction and angina pectoris), heart failure and stroke, and
• Is the leading cause of hospitalizations.

Risk Factors for CVD includes:

• Being overweight,
• Obesity,
• Physical inactivity,
• Diabetes,
• Cigarette smoking,
• High Blood Pressure (HTN),
• High blood cholesterol,
• Family history of myocardial infarction, and
• Older age

Why this Matters?

Annually, the CERT publishes a supplemental improper payment data report. Table D4, in the supplemental report (link), highlights the top 20 service types with the highest improper payments for Part A IPPS Hospitals. This table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical necessity.
• Incorrect coding, and
• Other.

In the 2021 supplemental data, nine of the top twenty service types with highest improper payments were DRGs in the major diagnostic category (MDC) 5 Diseases and Disorders of the Circulatory System. Insufficient documentation and medical necessity were the two most common type of errors cited for this group of service types.

The projected improper payment for the circulatory system service types is $714,632,739 representing 36% of the total projected improper payments for the top twenty service types.

What Can You Do?

Be proactive for your patients by becoming familiar with the cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease covered by Medicare and additional resources published in the February 10, 2022 edition of MLN Connects (link):

• Preventive Services webpage (link)
• Achieving Health Equity web-based training (link)
• CMS Office of Minority Health, Health Observances webpage (link)
• Million Hearts® (link): HHS initiative to prevent a million heart attacks and strokes
• Cardiovascular disease screenings coverage (link) & behavioral therapy (link): information for your patients

Become familiar with coverage determinations related to the top services. For example:

• For DRGs 226 and 227 (Cardiac Defibrillator Implant without cardiac catheterization with MCC and without MCC respectively), there is a National Coverage Determination (NCD 20.4) and Medicare Administrative Contractor (MAC) specific Local Coding and Billing Articles.
• Transcatheter Aortic Valve Replacement (TAVR) and TEER (Transcatheter Edge-to-Edge Repair) procedures fall within DRGs 266 and 267. Both procedures have a related NCD (TAVR NCD 20.32 and TEER NCD 20.33).
• Percutaneous Left Atrial Appendage Closure (LAAC) procedures fall within DRGs 273 and 274 and has a related NCD (20.34).
• For DRG 313 (Chest Pain), Palmetto GBA the Jurisdiction J and M MAC, has a Local Coverage Determination (LCD L34551) titled, One Day Stays for Chest Pain.

Finally, respond to requests for documentation in a timely manner, sending adequate documentation to support the medical necessity of the services provided.

Did You Know?

In October 2021, CMS published Change Request (CR) 12471 (link). 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

The effective date for this CR is April 1, 2022.

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 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 (link).

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the providers responsibility to determine if documentation in the medical record support’s 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

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.”

“0 or 1 day” Length of Stay Claims

After reading this CR, my first thought was, how often are one of these codes being included on a claim. To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Following are the numbers for Medicare Fee-for-Service paid claims data with dates of service from October 1, 2020, through August 31, 2021, available in RTMD’s footprint:

• • 57,951 claims included one of the unspecified codes in Table 6P.3a of the FY 2022 IPPS/LTCH Final Rule,
• • The paid claims total for this set of claims was $1,010,178,584.54, and
• • The top five states by claims volume included:
• o California: 5,926 claims - $135,738,052.81
• o Texas: 5,872 claims - $104,453,156.02
• o New York: 3,290 claims - $70,001,125.23
• o Pennsylvania: 3,192 claims - $48,281,839.67
• o Illinois: 2,750 claims - $41,821,442.35

What Can You Do?

This is not a large volume of claims in the world of Medicare Fee-for-Service Inpatient paid claims. However, just over $1 billion in paid claims is a significant amount of money. With a little over a month to prepare, you should make sure that CR 12471 and related MLN Matters article MM12471(link) are shared with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists). You should also work with your IT department to anticipate the potential volume of claims that will be impacted by the new Code Edit 20-.

Question

We have a patient that was admitted through the ED with significant shortness of breath and acute respiratory distress, with the CT scan of the lungs showing bilateral infiltrates. The patient tested negative for COVID-19 on admission. The patient was treated for pneumonia and acute hypoxic respiratory failure. However, four days into the stay, a second COVID-19 test was performed and the results were positive. What POA do we assign in this case?

Answer

Due to the many nuances, complexities, and incubation period of COVID-19, we cannot assume that the infection was POA or occurred after admission, based on the date of the test. Any issues relating signs and symptoms, the timing of test results, or findings, should be referred to the provider for the most appropriate assignment of the POA.

References:

• ICD-10 Official Guidelines
• AHA Coding Handbook
• cdc.gov
• Revenue Cycle Advisor / March 27, 2021

Fiscal Year 2021 Estimated Improper Payment Rates

In mid-November 2021, the Comprehensive Error Rate Testing (CERT) program published the Fiscal Year (FY) 2021 Annual CERT Report. A related Press Release, (link) noted that “CMS’ aggressive corrective actions led to an estimated $20.72 billion in reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.”

While CMS cites an impressive reduction in improper payments over seven years, there was only a slight change from 2020 to 2021.

• Improper Payment Rate
• o FY 2020: 6.27%
• o FY 2021: 6.26%
• Improper Payment Amount
• o FY 2020: $25.74 billion
• o FY 2021: $25.03 billion

As I have noted in past articles, CMS noted in the Press Release that “while fraud and abuse may lead to improper payments, it is important to note that the vast majority of improper payments do not constitute fraud, and improper payment estimates are not fraud rate estimates.”

Fiscal Year 2021 Supplemental Improper Payment Data

The 2021 Supplemental Improper Payment Data Report (link) was published on December 12, 2021. This report highlights common causes of improper payments and includes tables allowing you to drill down into the review findings.

COVID-19 Impact

• From March 27, 2020, until August 10, 2020, CERT program activities were suspended,
• CMS reduced the claim sample size for FY 2021 (claims submitted July 1, 2019, through June 30, 2020), and
• Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities.

“0 or 1 day” Length of Stay Claims

Since implementation of the Two-Midnight Rule, the supplemental data report has included a table comparing improper payments rates for Part A hospital claims by length of stay (LOS). The improper payment rate for “0 or 1 Day” stay claims was highest in 2014 at 37.18% and in 2021 hit an all-time low of 16.8%. However, with the project improper payment rate being $1.5 billion, it is not surprising that Two-Midnight Stays are currently on the OIG Work Plan (link) and Livanta as the National Medicare Claim Review Contractor (link), is focusing their review efforts solely on Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews.

Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories:

• No documentation,
• Insufficient documentation,
• Medical Necessity,
• Incorrect Coding, and
• Other.

Overall, 58.9% of the errors in this table were due to the error category medical necessity. The CERT places a claim into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. One hundred percent of the errors for the following four DRG Types was attributed to medical necessity:

• DRG 069: Transient Ischemia,
• DRGs 308, 309, 310: Cardiac Arrhythmia & Conduction Disorders,
• DRG 312: Syncope, and
• DRG 313: Chest Pain.

Moving Forward

For the Septicemia DRGs 871 and 872, 37.2% of the errors was attributed to “no documentation.” Unfortunately, denied claims due to no documentation is also a frequent issue reported by the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor (SMRC).

Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:

• Visit the CERT Provider Website (link) to find information about the CERT, how to submit records, sample request letters and much more.
• Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of specific services. For example, DRGs 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity) had the highest projected improper payment in Table D4 at $724,055,597. The CERT attributed 19.5% of the error to insufficient documentation and 80.3% to medical necessity. CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (link) that provides guidance on what to document to avoid denied claims.
• Become familiar with and utilize your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER).
• And finally, take the time to review the CERT’s Supplemental Improper Payment Data report annually.

A related article in this week’s newsletter (link), provides detail from the 2021 Comprehensive Error Rate Testing (CERT) program annual report and annual supplement data to the report. This article provides key facts about the CERT.

About the CERT

• The objective of the CERT program is to monitor and report the accuracy of claims payment in the Medicare Fee-for-Service program.
• CMS uses the CERT error rate to evaluate the performance of the Medicare Administrative Contractors (MACs).
• There are two CERT contractors:
• The CERT Review Contractor (CERT RC), and
• CERT Statistical Contractor (CERT SC).
• The CERT claim selection includes a stratified random sample of approximately 50,000 claims that are chosen by claim type (Part A, Part B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and includes paid and denied claims by the MAC.
• The CERT process is a federally mandated program and not responding to documentation requests will result in a denial of all services billed on the claim.
• CERT request letters are mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS).
• You can submit requested documentation to the CERT via postal mail, fax, Electronic Submissions of Medical Documentation (esMD), via CD or via email attachment(s).
• For short (less than 24 – 48 hours stay) inpatient hospital stay, a discharge summary is not required when a beneficiary is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
• The billing provider is responsible for obtaining medical records from the third-party to substantiate the claim that was billed.
• The CERT makes every effort to obtain the request documentation. Providers have 45 days to respond to the first letter requesting documentation. When the CERT does not receive the requested documentation by the 75th day, a claim is counted as a non-response error and is subject to overpayment recovery by the MAC.
• Claims reviews by the CERT includes program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and provision in the CMS instructional manuals.
• Denied claims as well as overpayments and underpayments are all considered to be an improper payment by the CERT program.
• Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
• The improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements.
• Providers that wish to appeal a CERT contractor’s determination can follow the normal redetermination process to appeal all CERT denials.
• The CERT A/B MAC Outreach & Education Task Force has a goal to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force webpage (link) includes education resources for providers.

Resources:

CERT C3Hub: https://c3hub.certrc.cms.gov/

CMS.gov CERT webpage: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Improper-Payment-Measurement-Programs/CERT

Medicare MLN Articles & Transmittals – Recurring Updates

Clinical Laboratory Fee Schedule – Medicare Travel Allowance for Collection of Specimens

• • Article Release Date: January 18, 2022
• • What You Need to Know: This article provides information about CY 2022 changes to travel allowances when you bill on a per mileage basis and on a flat rate basis.
• • MLN MM12593: https://www.cms.gov/files/document/mm12593-clinical-laboratory-fee-schedule-medicare-travel-allowance-fees-collection-specimens.pdf

Internet-Only Manual Updates (IOM) for Critical Care, Split/Shared Evaluation and Management Visits, Teaching Physicians, and Physician Assistants

• • Article Release Date: January 18, 2022
• • What You Need to Know: You will learn about Medicare manual revisions for critical care services, split/shared E&M visits, teaching physician services and physician assistant billing and payment.
• • MLN MM12543: https://www.cms.gov/files/document/mm12543-internet-only-manual-updates-iom-critical-care-split-shared-evaluation-and-management-visits.pdf

New Waived Tests

• • Article Release Date: January 18, 20221
• • What You Need to Know: You will learn about the latest tests approved by the FDA as waived tests under CLIA, laboratory claim edits, and facility certification requirements.
• • MLN MM12581: https://www.cms.gov/files/document/mm12581-new-waived-tests.pdf

CY 2022 Telehealth Update Medicare Physician Fee Schedule

• • Article Release Date: January 19, 2022
• • What You Need to Know: There are two additional modifiers for CY 2022 for telehealth services and this article includes a link to the updated telehealth services list.
• • MLN MM12549: https://www.cms.gov/files/document/mm12549-cy2022-telehealth-update-medicare-physician-fee-schedule.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement (CLIA) Edits

• • Article Release Date: January 20, 2022
• • What You Need to Know: You will learn about discontinued and new HCPCS codes and which codes are subject to and excluded from CLIA edits.
• • MLN MM12573: https://www.cms.gov/files/document/mm12573-healthcare-common-procedure-coding-system-hcpcs-codes-subject-and-excluded-clinical.pdf

Expedited Review Process for Hospital Inpatients in Original Medicare

• • Article Release Date: January 21, 2022
• • What You Need to Know: CMS has reformatted the manual section of chapter 30 of the Medicare Claims Processing Manual to improve “readability and understanding.” CMS makes a point to note in bold font that no policy or instructional changes have been made.
• • MLN MM12546: https://www.cms.gov/files/document/mm12546-expedited-review-process-hospital-inpatients-original-medicare.pdf

Revised Medicare MLN Articles & Transmittals

International Classification of Diseases, 10th revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2022 (CR 1 of 2)

• • Article Release Date: Initial article November 1, 2021 – Revised January 13, 2022
• • What You Need to Know: The CR release date, transmittal number, and the web address of the CR has been updated. The revisions did not affect the substance of the article.
• • MLN MM12480: https://www.cms.gov/files/document/mm12480-international-classification-diseases-10th-revision-icd-10-and-other-coding-revisions.pdf

Calendar year (CY) 2022 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

• • Article Release Date: Initial article December 13, 2021 – Revised January 13, 2022
• • What You Need to Know: This article was revised to show the delay in the CLFS data reporting period for clinical diagnostic lab tests and note the delay in the application of the 15% phase-in reduction.
• • MLN MM12558: https://www.cms.gov/files/document/mm12558-calendar-year-cy-2022-annual-update-clinical-laboratory-fee-schedule-and-laboratory-services.pdf

Medicare Coverage Updates

January 11, 2022: Proposed Decision Memo for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

CMS published a Proposed Decision Memorandum (https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=305&fromTracking=Y&)88 in which they are proposing to cover FDA approved monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease through Coverage with Evidence Development (CED). The public comment period is from January 11, 2022 through February 20, 2022. You can read more about this proposed policy in a related CMS Press Release (https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-coverage-policy-monoclonal-antibodies-directed-against-amyloid-treatment)88.

Medicare Educational Updates

CMS MLN Fact Sheet: Original Medicare vs. Medicare Advantage

This MLN Fact Sheet (https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf)88 describes what providers need to know about how different coverage affects seeing patients, processing claims and filing appeals.

January 5, 2022: CDC Expands Booster Shot Eligibility for 12-17 Year Old’s

The CDC announced in a newsroom release (link), they are endorsing the Advisory Committee on Immunization Practices’ (ACIP) recommendation to expand eligibility of booster doses to those 12 to 15 years old. They are also recommending that those 12 to 17 years old should receive a booster shot 5 months after their initial Pfizer-BioNTech vaccination series.

January 7, 2022: New HCPCS Code for Remdesivir Antiviral Medication

CMS issued a Special Edition MLN Connects (link) to let providers know they had created a HCPCS code J0248 for VEKLURY™ (remdesivir) antiviral medication when administered in the outpatient setting. This code is available for use by all payers and is effective for dates of service on or after December 23, 2021. They note that the MACs will determine Medicare coverage for HCPCS code J0248 administered in the outpatient setting and the MACs will be sharing coverage and claims processing information for this code.

December 31, 2021: CDC Health Advisory – Using Therapeutics to Prevent and Treat COVID-19

• Article Release Date: April 17, 2020 – most recent revision: January 13, 2022
• What You Need to Know: This article was revised to add 2022 payment rate information for distant site telehealth services and information on RHC payment limits.
• MLN SE20016: https://www.cms.gov/files/document/se20016-new-expanded-flexibilities-rhcs-fqhcs-during-covid-19-phe.pdf

January 12, 2022: 2 New Procedure Codes Effective April 1, 2022

CMS published an ERRATA (link) to the ICD-10 MS-DRGs Version 39.1 effective April 1, 2022 to inform providers of “2 new procedure codes, in addition to the 7 new procedure codes previously announced, bringing the total to 9 new procedure codes, to describe the introduction of infusion or therapeutics, including vaccines for COVOID-19 treatment, into the” ICD-10-PCS. The 2 new codes are:

• XW023X7: Introduction of tixagevimab and cilgavimab monoclonal antibody into muscle, percutaneous approach, new technology group 7, and
• XW023Y7: Introduction of other new technology monoclonal antibody into muscle, percutaneous approach, new technology group 7.

January 13, 2022: COVID-19 Updates in CMS MLN Connects

The Thursday January 13th edition of MLN Connects (link) included information and resources about the following topics:

• Updated Materials for Visiting Nursing Homes During Omicron Surge,
• Vaccine Access in Long-Term Care Settings,
• New HCPCS Code for Remdesivir Antiviral Medication – Updated NIH Treatment Guidelines Panel Link, and
• Pfizer Booster Doses for Ages 12+ & Immunocompromised Ages 5-11.

January 14, 2022: Public Health Emergency Declaration due to COVID-19 Renewed

As expected, the COVID-19 Public Health Emergency was extended again on Friday, January 14th (link). This means waivers will remain in effect for 90 days (April 14, 2022).

April 2022 Update to the Medicare Severity-Diagnosis Related Group (MS-DRG) Grouper and Medicare Code Editor (MCE) Version 39.1 for ICD-10 Diagnosis Codes for 2019 COVID-19 Vaccination Status and ICD-10-PCS Codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment

• Article Release Date: January 19, 2022
• What You Need to Know: You will learn about new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status, seven new ICD-10-PCS codes describing the introduction of infusion of therapeutics, including vaccines for COVID-19 treatments, and update for a new MCE list.
• MLN MM12578: https://www.cms.gov/files/document/mm12578-april-2022-update-medicare-severity-diagnosis-related-group-ms-drg-grouper-and-medicare-code.pdf

January 24, 2022: Free At-Home COVID-19 Tests

The CDC’s January 24th COVID-19 updates included a notice (link) that “every home in the United States is eligible to order 4 free at-home COVID-19 rapid antigen tests. Orders will usually ship in 7-12 days. These tests give results within 30 minutes (no lab drop-off required).” You can also go to https://www.covidtests.gov/ to order your tests.