Knowledge Base Category -

Medicare Educational Resources

Revised MLN Fact Sheet: Medicare Disproportionate Share Hospital

CMS issued a revised edition of the Medicare Disproportionate Share Hospital MLN Fact Sheet (link). Specifically, the Fact Sheet includes information about how CMS calculates uncompensated care payments for FY 2021 and FY 2022.

Revised MLN Fact Sheet: Medicare Billing for Cardiac Device Credits

This revised Fact Sheet (link) includes the following two changes highlighted in dark red font in the text:

• When a hospital gets a replaced device credit 50% or greater than the device’s cost, report the amount in the claim’s FD code value portion.
• Beginning in 2020, Medicare applies a device offset cap to the Ambulatory Payment Classification (APC) claims that require implantable devices and have significant device offset (greater than 30%) based on the FD value code’s listed credit amount.”

MLN Educational Tool: Medicare Preventive Services Revised

CMS updated this Education Tool (link) in May. Information available in this tool includes:

• Link to National Coverage Determination (NCD) services webpage when applicable to a service,
• HCPCS and CPT codes,
• Prolonger Prevention Services information,
• ICD-10-CM diagnosis codes,
• Billing for telehealth during COVID-19,
• Coverage Requirement,
• Frequency Requirements,
• Patient liability, and
• Telehealth eligibility.

COVID-19 Updates

June 3, 2021: Myths and Facts about COVID-19 Vaccines

The CDC developed this webpage (link) to help stop common myths and rumors such as:

• The COVID-19 vaccine can make you be magnetic,
• The COVID-19 vaccine will alter my DNA, or
• The COVID-19 vaccine will make me sick with COVID-19.

June 9, 2021: Medicare to Increase Payment for Medicare Vaccination Administration in the Home

In a Special Edition MLN Connects, CMS announced additional payment for administering in-home COVID-19 vaccinations to Medicare beneficiaries (link). A related infographic (link) was also updated to include this information.

June 17, 2021: CMS MLN Connects – Emergency Use Authorization (EUA) for Monoclonal Antibody Updates

CMS noted that on May 26, 2021, the FDA released an EUA for the COVID-19 monoclonal antibody product sotrovimab. Coinciding with the FDA release, CMS created new HCPCS codes also effective May 26th for sotrovimab. This drug can be administered in health care setting and the home. The following is an excerpt from the MLN Connects newsletter:

Q0247

• Long descriptor: Injection, sotrovimab, 500 mg
• Short descriptor: Sotrovimab
• Price: The government won’t provide this drug for free; visit the COVID-19 Vaccines and Monoclonal Antibodies webpage for pricing information (available soon)

M0247

• Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
• Short Descriptor: Sotrovimab infusion
• Price: $450.00 per infusion

M0248

• Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
• Short Descriptor: Sotrovimab inf, home admin
• Price: $750.00 per infusion

On June 3rd, the FDA released a revised EUA for Regnereon’s COVID-19 monoclonal antibody combination product casirivimab and imdevimab. Updates includes new dosing regimen and allows a new route of administration. “In response to this change, CMS created a new HCPCS code, effective June 3, and updated the short and long code descriptors. This information is detailed in the MLN Connects newsletter (link).

Other Medicare Updates

July 1, 2021: Interim Final Rule Banning Surprise Billing and Certain Out-of-Network Charges

HHS issued the interim final rule, “Requirements Related to Surprise Billing: Part 1,” that will restrict surprise billing for insured patients that receive emergency care, non-emergency care from out-of-network providers at their in-network facility, and air ambulance services from out-of-network providers. One way this helps patient, as noted in a Related CMS Fact Sheet (link), is that “if your health plan provides or covers any benefits for emergency services, this rule requires emergency services to be covered:

• Without any prior authorization (meaning you no not need to get approval beforehand).
• Regardless of whether a provider or facility is in-network.”

This rule will take effect on January 1, 2022. CMS is excepting written comments through 5 p.m. 60 days after the rule is displayed in the Federal Register. At the time of this article, the interim final rule had not been published in the Federal Register. You can learn more about the interim rule requirements in another CMS Fact Sheet (link).

Medicare MLN Articles & Transmittals – Recurring Updates

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 0240U, 0231U and 87637

• Article Release Date: June 11, 2021
• What You Need to Know: The FDA has issued Emergency Use Authorizations (EUAs) for the COVID-19 tests represented by these three HCPCS codes. “For Medicare to recognize these tests performed under a CLIA certificate of waiver or a CLIA certificate for provider-performed microscopy procedures, you must add the modifier QW.”
• MLN MM12318: (link)

July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: June 14, 2021
• What You Need to Know: This article provides a summary of changes to and billing instructions for payment policies to be implemented by CMS on July 1, 2021.
• MLN MM12316: (link)

July 2021 Update of the Ambulatory Surgical Center [ASC] Payment System

• Article Release Date: June 25, 2021
• What You Need to Know: For the July 2021 Update there are 8 new CPT Category III codes, a new device pass through code, new HCPCS codes for drugs and biologicals, a change to a skin substitute HCPCS code from the low to the high-cost skin substitute group and a new technology HCPCS code as been established to describe the technology associated with vaginal colpopexy by sacrospinous ligation fixation.
• MLN MM12341: (link)

Revised Medicare MLN Articles & Transmittals

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update

• Article Release Date: February 23, 2021 – Most recent revision June 3, 2021
• What You Need to Know: In the third iteration of this MLN article, important information about the use of the QW modifier was added in red print on page 10 of this document.
• MLN MM12131: (link)

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

• Article Release Date: May 18, 2021 – Revised June 3, 2021
• What You Need to Know: This article was revised to reflect NCD specific changes made in a revised Change Request (CR) 12124.
• MLN MM12124: (link)

July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: April 27, 2021 – Revised June 8, 2021
• What You Need to Know: This article was revised to reflect a revised CR 12244 which added language about Section 405 of the Consolidated Appropriates Act, 2021.
• MLN MM12244: (link)

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

• Article Release Date: May 24, 2021 – Revised June 15, 2021
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12885 which included the addition of new codes to the national HCPCS file.
• MLN MM12285: (link)

Medicare Coverage Updates

June 10, 2021: NGS Reminder Regarding General Anesthesia, Conscious Sedation and Facet Joint Interventions

NGS posted a reminder regarding the recent revision to Local Coverage Determination (LCD) (L35936) “Facet Joint Interventions for Pain Management” and Local Coverage Article (LCA) (A57826) “Billing and Coding: Facet Joint Interventions for Pain Management.” As of April 25, 2021, one Limitation of LCD L359356 (link) indicates that “general anesthesia is considered not reasonable and necessary for facet joint interventions.” Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.”

National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs)

• Article Release Date: June 11, 2021
• What You Need to Know: Effective December 1, 2020, CMS covers VADs under certain criteria. Change Request (CR) 12290 revises NCD 20.9 in the Medicare NCD Manual and Chapter 32, Section 320 of the Medicare Claims Processing Manual.
• MLN MM12290: (link)

July 2, 2021: Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches

CMS issued Proposed Decision Memo CAG-00296R2 (link). Two changes being proposed includes:

• Remove NCD 240.2.2 of the Medicare NCD Manual, ending coverage with evidence development, and allow the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for cluster headaches (CH), and
• Modify NCD 240.2 Home Use of Oxygen to expand patient access to oxygen and oxygen equipment in the home, and to permit MACs to cover the use of home oxygen and equipment in order to treat CH and other acute conditions.

You can submit comments through August 1, 2021. The related National Coverage Analysis (NCA) Tracking Sheet for this Decision Memo CAG-00296R2 (link) will enable you to follow the progress of this proposal.

In late June, the FY 2022 ICD-10-CM diagnosis code updates were posted to the CMS website (link) and the CDC website (link). Since then, the CDC updated their announcement on July 2, 2021. Specifically, they advise, if you downloaded the following two documents prior to June 30, 2021, you would need to download them again:

• A new version of the ICD-CM-tabular addenda for FY 2022 has been added to correct the missing I5A, Non-ischemic myocardial injury (non-traumatic) code for the addenda, and
• A new version of the FY 2022 Conversion table has been added.

Social Determinants of Health (SDOH)

Of the 159 new codes for FY 2022, I want to focus on the code additions to code categories Z55-Z65. These codes identify persons with potential health hazards related to socioeconomic and psychosocial circumstances.

Social Determinants of Health Defined

The World Health Organization defined SDOHs as being “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”

New and Revised SDOH Z Codes for FY 2022:

• Z55.5 Less than a high school diploma
• Z58 Problems related to physical environment
• Z58.6 Inadequate drinking-water supply
• Z59.00 Homelessness unspecified
• Z59.01 Sheltered homelessness
• Z59.02 Unsheltered homelessness
• Z59.4 was revised from “Lack of adequate food and safe drinking water” to
• Z559.4 “Lack of adequate food”
• Z59.41 Food insecurity
• Z59.48 Other specific lack of adequate food
• Z59.81 Housing instability, housed
• Z59.811 Housing instability, housed with risk of homelessness
• Z59.812 Housing instability, housed, homelessness in past 12 months
• X59.819 Housing instability, housed unspecified
• Z59.89 Other problems related to housing and economic circumstances

Coding Clinic Guidance

A question was asked, in Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, to verify whether these Z codes could be assigned based on non-physician documentation. Advice provided indicated that these codes represent social information, and it would be acceptable to report them based on documentation from other clinicians following the patient.

ICD-10-CM Official Guidelines for Coding and Reporting

Guidance related to coding SDOH category Z codes first appeared in the FY 2019 ICD-10-CM Official Coding Guidelines in Section B.14: Documentation by Clinicians Other than the Patient’s Provider:

“For social determinants of health, such as information found in categories Z55- Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.”

In FY 2021, the following additional statements was added to the guidelines:

“Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

CMS Acknowledges Impact of SDOH on Health

In January of this year, CMS issued guidance to state health officials to drive the adoption of strategies addressing SDOH in Medicaid and the Children’s Health Insurance Program (CHIP) to help improve beneficiary outcomes. CMS ends a related Press Release (link) by indicating that they have “placed an emphasis on addressing SDOH across all of its programs in its continued efforts to move toward a value-based model of care delivery.”

With the addition of new ICD-10-CM codes specific to SDOH, hospitals could assist in identifying “at risk” patient. Hospital coding professionals should be aware of these codes and look to documentation by a Social Worker, Case Manager, or the admitting nurse as socioeconomic issues can be identified as part of the admission history and discharge planning process.

If you are interested in learning more about SDOH, visit the CDC’s SDOH website (link) that will connect you to CDC resources for SDOH data, research, tools for action, programs and policy.

MMP and RealTime Medicare Data (RTMD) have collaborated to highlight Health Awareness Month topics throughout the year with an infographic spotlight on Medicare Fee-for-Service (FFS) paid claims data comparatives and a related article. June is Cataract Awareness Month. The American Academy of Ophthalmology notes that “cataract is one of blindness in the United States. If not treated, cataracts can lead to blindness. In addition, the longer cataracts are left untreated, the more difficult it can be to successfully remove the cataract and restore vision. During Cataract Awareness Month in June, the American Academy of Ophthalmology reminds the public that early detection and treatment of cataracts is critical to preserving sight.”

Did You Know?

According to Medicare.gov (link) the average amount that a patient pays for extracapsular lens removal with insertion of intraocular lens prosthesis (CPT 66984) is $316 in the Ambulatory Surgery Center (ASC) setting and $524 in a Hospital Outpatient Department.

Several Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) related to cataract removal.

Why Does this Matter?

The CERT, Recovery Auditors and a two of the MACs are reviewing cataract procedure records. Reviews include the ASC and Hospital Outpatient Department Settings.

Comprehensive Error Rate Testing (CERT)

In the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data (link), the CERT review contractor indicates they reviewed 209 Part B claims and identified a 6% improper payment rate that equates to a projected improper payment amount of $111,696,441.

Recovery Auditors

There are currently three approved RAC issues related to cataracts:

• Issue 0002: Cataract Removal: Medical Necessity & Documentation Requirements,
• Issue 0083: Cataract Removal: Excessive Units (partial), and
• Issue 0084: Cataract Removal: Partial Payment.

Provider Types they have been approved to review includes ASC, Outpatient Hospitals and specific to Issue 0083 and 0084 Professional Services.

CGS MAC for Jurisdiction 15 (J15)

Prior to CMS temporarily pausing the Targeted Probe and Educate (TPE) Program, reviewing Medicare Part A claims for cataract removal was part of CGS’, the MAC for Kentucky and Ohio, list of review topics. A Cataract Extraction with IOL ADR Checklist (link) is available on the CGS website.

Palmetto GBA JJ and JM

Palmetto GBA, the MAC for Jurisdictions J (Alabama, Georgia, and Tennessee) and M (North and South Carolina, Virginia and West Virginia) recently published service-specific post payment probe review results of CPT 66984, Extracapsular Cataract Removal with insertion for both Jurisdictions. Both articles include state specific findings, reasons for claims denials and recommendations to prevent future denials.

• April 14, 2021, Palmetto GBA JJ Part B results (link): 680 claims were reviewed, with 110 (16.17%) claims being completely or partially denied. The charge denial rate of 15.65% equated to $59,466.77 in denials.
• May 11, 2021, Palmetto GBA, JM Part B results (link): 2,508 claims were reviewed, with 128 (5.1%) claims being completely or partially denied. The charge denial rate of 5.13% equated to $76,598.10 in denials.

Based on their findings, Palmetto plans to continue post-payment reviews of CPT 66984 in both Jurisdictions.

What You Can Do About It?

• Identify whether there is an applicable LCD and LCA for your MAC jurisdiction.
• Read Palmetto GBA’s Cataract Removal article (link) which provides conditions or circumstances when lens extraction is considered medically necessary and therefore covered by Medicare.
• Share this information with Providers performing these procedures at your facility.
• Review a sample of your cataract claims for documentation supporting the medical necessity of the service.

Resource

• CMS MLN Matters SE1319: Cataract Removal, Part B: (link)

Did you know?

Did you know that coding advice regarding Diabetes and Cataracts has changed?

Why it matters.

You may not be capturing the most accurate severity of illness of the patient.

What can I do?

Read the following Coding Clinics: September-October 1985, page 11 and 4th Quarter 2016, page 142.

Advice from 1985 stated that Diabetic Cataracts are rare, but may appear in Type 1 Diabetics. Simply put, we were advised that most cataracts occurring in a diabetic patient were not coded as a diabetic complication.

Advice from 2016 now states that diabetes and cataracts should be coded as related conditions as they are not rare and are a major cause of eye sight issues in diabetics. The Coding Clinic advice from 1985 was revised because more is known about cataracts and that the occurrence in diabetic patients was found to be higher and occurring at younger ages than nondiabetics.

Medicare Coverage Updates

May 18, 2021: CMS Initiates National Coverage Analysis for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

• Coverage Analysis Issue: The United States Preventive Services Task Force (USPSTF) recently published an updated recommendation for certain persons at high risk for lung cancer based on age and smoking history for screening for lung cancer with LDCT.
• CMS Actions: CMS received a complete, formal request to reconsider the National Coverage Determination 210.14 and are soliciting public comment. The public comment period ends on June 17, 2021.
• Resources
• March 9, 2021 USPSTF Lung Cancer Screening Recommendation Statement: (link)
• Coverage Analysis (CAG-00439R): (link)
• NCD 210.14: (link)

National Coverage Determination (NCD) Removal

• Article Release Date: May 24, 2021
• What You Need to Know: 6 NCDs are being removed from the NCD Manual based on rulemaking in the Calendar Year 2021 Medicare Physician Fee Schedule.
• NCD 20.5 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
• NCD 20.5 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
• NCD 100.9 Implantation of Gastrointestinal Reflux Devices,
• NCD 110.19 Abarelix for the Treatment of Prostate Cancer,
• NCD 220.2.1 Magnetic Resonance Spectroscopy, and
• NCD 220.6.16 FDG PET for Inflammation and Infection.
• MLN MM12254: (link)

National Coverage Determination (NCD 110.24) Chimeric Antigen Receptor (CAR) T-cell Therapy

• Article Release Date: May 24, 2021
• What You Need to Know: Effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cells expressing at least 1 CAR when administered at healthcare facilities:
• MLN MM12177: (link)

National Coverage Determination (NCD) 210.3 – Screening for Colorectal Cancer (CRC) – Blood-Based Biomarker Tests

• Article Release Date: May 26, 2021
• What You Need to Know: Effective January 19, 2021, CMS determined that the blood-based biomarker test is an appropriate CRC screening test once every three years for Medicare patients when performed in a CLIA certified lab, ordered by a treating physician, and the patient is:
• Aged 50-85 years, and
• Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test); and, • At average risk of developing CRC (no personal history of adenomatous polyps, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of CRCs or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis CRC).
• MLN MM12280: (link)

Medicare Educational Resources

Revised MLN Booklet: Behavioral Health Integration Services

CMS issued a revised version of this MLN Booklet (link) to add CY 2021 MPFS Final Rule CMS-1734-F Updates and add new HCPCS code G2214 (Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional).

Revised MLN Booklet: Medicare Mental Health

CMS issued a revised version of this MLN Booklet (link) to include a new outpatient psychiatric services medical records checklist, an acute care hospital section, and CPT codes updates and additions.

Revised MLN Fact Sheet: Complying with Medicare Signature Requirements

CMS issued a revised version of this MLN Fact Sheet (link) to include information about signing documentation written by a medical student.

Revised MLN Booklet: Medicare Diabetes Prevention & Diabetes Self-Management Training

CMS issued a revised version of this MLN Booklet (link) to add information about flexibilities extended in the March 1, 2020, COVID-19 Interim Final Rule and the CY 2021 Physician Fee Schedule Final Rule to all patients receiving services as of March 31, 2020. They also spotlight that in January 2020, the American Association of Diabetes Educator (AADE) changed their name to the Association of Diabetes Care & Education Specialists (ADCES).

National Osteoporosis Month

National Osteoporosis Month falls in May each year. Following is information CMS provided in their Thursday May 6th edition of MLN Connects:

“Medicare covers bone mass measurements, and your patients pay nothing if you accept assignment. During National Osteoporosis Month, talk to your Medicare patients about their risk factors and bone health.

More Information:

• Medicare Preventive Services educational tool (link)
• Preventive Services webpage (link)
• CDC Osteoporosis webpage (link)
• National Osteoporosis Foundation website (link)
• Information for your patients on bone mass measurements” (link)

MLN Booklet: Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

The Thursday May 13, 2021 edition of the CMS e-newsletter, MLN Connects (link), included the following information related to complying with Medicare billing requirements for outpatient rehabilitation therapy services:

“An Office of Inspector General report (link) found that payments for physical therapy services didn’t comply with Medicare billing requirements. Review the Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements (PDF) (link) booklet to help you bill correctly, reduce common errors, and avoid overpayments. CMS listed additional resources in the newsletter.

April 2021 MLN Fact Sheet: Medical Record Maintenance & Access Requirements

This MLN Fact Sheet (link) provides information on updated documentation maintenance and access requirements for billing services to Medicare patients. It also includes how long providers are to keep the documentation and who is responsible for providing access.

Medicare MLN Articles & Transmittals – Recurring Updates

July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: April 27, 2021
• What You Need to Know: This article includes quarterly updates effective July 1, 2021 for ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
• MLN MM12244: (link)

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

• Article Release Date: May 18, 2021
• What You Need to Know: You will find information about updated ICD-10 conversions and coding updates specific to NCDs as a result of newly available code, coding revisions to NCDs released separately and coding feedback received.
• MLN MM12124: (link)

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update

• Article Release Date: May 21, 2021
• What You Need to Know: July 2021 updates to the 2021 MPFS are detailed in this MLN article.
• MLN MM12289: (link)

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

• Article Release Date: May 21, 2021
• What You Need to Know: MACs perform updates to the RARC and CARC based on the code update schedule and occur around March 1, July 1, and November 1.
• MLN MM12220: (link)

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

• Change Request Release Date: May 21, 2021
• What You Need to Know: This recurring transmittal is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. Two NCDs specific to this update are NCD 30.3.3 Acupuncture for Chronic Low-Back Pain (cLBP), and NCD 20.33 Transcatheter Mitral Valve Repair/Transcatheter Edge-to-Edge Repair (TMVR/TEER).
• Change Request (CR) 12279: (link)

Other Medicare MLN Articles & Transmittals

New Waived Tests

• Article Release Date: April 27, 2021
• What You Need to Know: This article highlights newly FDA approved Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests.
• MLN MM12204: (link)

Waiver of Coinsurance and Deductible for Hepatitis B Preventive Service Vaccine Code, Section 4104 of the Patient Protection and Affordable Health Care Act (the Affordable Care Act), Removal of Barriers to Preventive Services in Medicare

• Article Release Date: May 11, 2021
• What You Need to Know: The Hepatitis B vaccine (HCPCS 90739) has been added to the preventive services recommended by the U.S. Preventive Services Task Force. Consequently, coinsurance and deductibles won’t apply for this code. Medicare will make a reasonable cost reimbursement for Types of Bill (TOB) 012X, 013X, 022X, and 034X.
• MLN MM12230: (link)

Addition of the Shared System CWF to the Business Requirements for the Healthcare Common Procedure Coding System (HCPCS) Codes U0002QW and 87635QW Mentioned in Change Request 11765

• Article Release Date: May 20, 2021
• What You Need to Know: For labs billing MACs for COVID-19 testing services, this article informs you about a revision to CR 11765 that requires changes to Medicare Common Working File (CWF) for:
• o HCPCS U0002QW [2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC], and
• o 87635 [Infectious agent detection by nucleic acid (DNC or RNA0; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique].
• MLN MM12294: (link)

Other Medicare Updates

New CMS Hospital Star Ratings

On April 28th, CMS updated the Hospital Compare Overall Hospital Quality Ratings (link). Hospital specific scores are based on performance for 5 measure groups (Mortality, Safety of Care, Readmission, Patient Experience and Timely & Effective Care). April 2021 results:

• 455 hospitals received the highest rating of 5 stars,
• 1,018 hospitals received 3 stars, and
• 204 hospitals received a 1 star rating.

Clinical Diagnostic Laboratory Resources about the Private Payor Rate-Based CLFS

CMS posted the following information in the Thursday April 29, 2021 edition of MLN Connects (link): “If you’re a laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS), you must report information, including laboratory test HCPCS codes, associated private payor rates, and volume data.” You can find links to updated resources and the data collection and reporting timeline in the MLN Connects post.

April 29, 2021: CJR Three-Year Extension Final Rule

CMS released the Comprehensive Care for Joint Replacement Model Final Rule which extends the model through December 31, 2021 by adding an additional 3 performance years (PYs). This final rule also revises the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements and the appeals process. The episode of care definition was revised to include outpatient Total Knee and Total Hip Arthroplasty (TKA/THA) procedures. You can read more about this Model on the CJR CMS webpage (link).

May 7, 2021: Advance Copy of Hospital Interpretive Guidelines for Admission, Discharge and Transfer Notification Requirements

CMS issued a memorandum (link) to State Survey Agency Directors providing an advance copy of the hospital interpretive guidelines for the admission, discharge, and transfer notification requirements outlined in the Interoperability and Patient Access final rule. This guidance is for Hospitals, Psychiatric Hospitals and Critical Access Hospitals and it will also be published in an updated Appendix A of the State Operations Manual.

May 2021: United Healthcare Sepsis Claims Review Change Effective July 1, 2021

While this article focuses on Medicare updates, I believe it is important for Clinical Documentation Integrity Specialists and Utilization Review staff to be aware of this notice. United Healthcare (UHC) has announced (link) that “effective July 1, 2021, Medicare Advantage and commercial claims for sepsis-related treatment may be reviewed on a pre-payment or post payment basis.” UHC will use their Sepsis Clinical Guidelines which includes using Sepsis-3.

May 10, 2021: University of Miami to Pay $22 Million to Settle Claims Involving Medically Unnecessary Laboratory Tests and Fraudulent Billing Practices

This Department of Justice release (link) indicates that the University of Miami (UM):

• Knowingly engaged in improper billing relating to its Hospital Facilities,
• Billed federal health care programs for medically unnecessary laboratory tests for patients who received kidney transplants at the Miami Transplant Institute (MTI) – a transplant program operate by UM and Jackson Memorial Hospital (JMH) and
• Caused JMH to submit inflated claims for reimbursement for pre-transplant laboratory testing conducted at the MTI.

This settlement resolves allegations made in three lawsuits filed under the qui tam (whistleblower) provisions of the False Claims Act.

May 18, 2021: CMS Delays Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule

MMP first wrote about this Proposed Rule in October 2020 (link). CMS published a notice further delaying this final rule until December 15, 2021 (link). They note this additional time provides “an opportunity to address all of the issues raised by stakeholders, especially Medicare patient protections, evidence criteria and lack of coordination between coverage, coding and payment.”

This week, as we highlight key updates spanning from May 18h through May 24th, 2021, will be our last weekly COVID-19 update. While COVID-19 remains a serious issue, the availability of COVID-19 vaccinations and the significant decrease in new cases being reported are positive reasons to end this weekly addition to our newsletter. MMP is thankful to all front line workers who have worked tirelessly and continue to care for patient’s diagnosed with COVID-19.

Resource Spotlight: CDC Clinical Outreach Call – Underlying Medical Conditions and Severe COVID-19: Evidence-based Information for Healthcare Providers

The CDC is offering this call on Thursday May 27, 2021 from 2:00 PM – 3:00 PM ET. They note that clinicians will be updated “on the underlying medical conditions associated with severe COVID-19, describe methods used to rate the evidence linking conditions to severe COVID-19, review the evidence on risk for conditions included, and provide resources for healthcare providers caring for patients with underlying medical conditions.” If you are interested in this information but unable to attend, call materials will be posted on this CDC webpage after the call. (link)

May 17, 2021: U.S. Attorney’s Office and OIG Advise Providers Not to Charge Individuals Seeking COVID-19 Vaccines

The U.S. Department of Justice issued a notice for immediate release (link) advising the public that they should not be asked to pay to receive the COVID-19 vaccine and warned COVID-19 vaccination providers to not seek payments from people who received a vaccine.

May 19, 2021: HHS Issues Request for Information (RFI) regarding the Medical Reserve Corps (MRC) Program

The American Rescue Plan provides $100 million to the MRC Program. HHS issued an RFI (link) to “solicit specific input regarding current strengths and needs of MRC units and stakeholders, resource gaps highlighted during the COVID-19 response and recommendations for short- and long-term priorities for the MRC.

May 19, 2021: FDA Reminder – Antibody Testing Not for Assessing Immunity after COVID-19 Vaccination

The FDA issued a reminder (link) to the public and health care providers that the currently authorized antibody test should not be used to assess “immunity or protection from COVID-19 at any time, and especially after the person received a COVID-19 vaccination.”

May 20, 2021: Medicare COVID-19 Data Snapshot Updated

This most recent release of Preliminary COVID-19 Data (link) includes Medicare claims and encounter data from January 1, 2020 to March 20, 2021 and were received by April 16, 2021. As of April 16, 2021 there have been 691,077 Medicare Fee-for-Service COVID-19 hospitalizations with a total Medicare payment for these hospitalizations of $16.6 billion and the average payment for a beneficiary hospitalized with COVID-19 being $24,033.

MMP and RealTime Medicare Data (RTMD) have collaborated to highlight Health Awareness Month topics throughout the year with an infographic spotlight on Medicare Fee-for-Service (FFS) paid claims data comparatives and a related article. May is Stroke Awareness Month. The American Heart Association notes this month was created to promote public awareness and reduce the incidence of stroke in the United States. This article focuses on the National Institutes of Health Stroke Scale (NIHSS).

Did You Know?

Originally, the National Institutes of Health Stroke Scale (NIHHS) was developed to measure baseline data for patients involved in acute stroke clinical trials. In 1995, after the publication of the Trial, the NIHSS became the de facto standard for rating clinical deficits in stroke trials.*

Prior to the implementation of ICD-10-CM, there was no way for Coding Professionals to capture the NIHSS. In fact, it wasn’t until FY 2017 that coding guidance was added to the ICD-10-CM Official Guidelines for Coding and Reporting related to coding NIHSS codes (link).

Why Does this Matter?

In the FY 2018 IPPS Final Rule, CMS finalized a refinement to the Stroke 30-Day Mortality Measure (MORT-30-STK) for the FY 2023 payment determination by including the NIHSS. CMS noted in Final Rule that they had “received comments that the more rigorous risk adjustment facilitated by the NIH Stroke Scale would help ensure the measure accurately risk adjusts for different hospital populations without unfairly penalizing high-performance providers, and the NIH Stroke Scale is well validated, highly reliable, widely used by providers caring for stroke patients, and a strong predictor of mortality and short- and long-term functional outcomes. However, we were not able to test the ICD-10 CM codes for NIH Stroke Scale score in claims during measure development because those codes were not available for hospitals to use in their claims until October 2016. Therefore, we proposed this measure now to inform hospitals they should begin to include the NIH stroke severity scale codes in the claims they submit for patients with a discharge diagnosis of ischemic stroke.”

This month’s related RTMD infographic spotlights how often one of the NIHSS codes was included on Ischemic Stroke MS-DRGs 061, 062, and 063 Medicare FFS paid claims in FY 2019. Across RTMD’s Footprint, 40.1% of the claims included an NIHSS. Drilling down to the state compare, you will find a wide variance in how often the NIHSS codes are being captured.

The February 1, 2021 Update to the MORT-30-STK Measure notes that “the major revision is to include the NIH Stroke Scale as a measure of stroke severity in the risk-adjustment.”

What You Can Do About It?

Be aware that the absence of an NIHSS on your acute stroke claims can negatively impact the risk adjustment for your Hospital 30-Day Mortality Following Acute Ischemic Stroke Hospitalization Measure.

Then moving forward:

• Make sure this information is consistently being documented in your medical records, and
• Educate your Coding staff about the NIHSS and the need to ensure it is coded on all of your acute stroke cases.

Education Resource

The National Institutes of Health (NIHs) website Know Stroke (link) includes health professional specific resources related to NIHSS.

*”Using the National Institutes of Health Stroke Scale A Cautionary Tale.” Lyden, Patrick. AHA Stroke Journal, 11 Jan 2017, https://www.ahajournals.org/doi/10.1161/strokeaha.116.015434

This week we highlight key updates spanning from May 11h through May 17th, 2021.

Resource Spotlight: Happy Belated National Women’s Health Week

National Women’s Health Week was last week (May 9th – 15th). This effort is led by the U.S. Department of Health and Human Services’ Office on Women’s Health (OWH). According to a related Fact Sheet (link), this year’s week served “as a reminder for women and girls, especially during the outbreak of COVID-19, to make their health a priority and take care of themselves. It is extremely important for all women and girls, especially those with underlying health conditions, such as hypertension, diabetes, obesity, cardiovascular and respiratory conditions and older adults, to take care of your health now.” You can read more about this event on the OWH website by clicking here.

Palmetto Statement in daily newsletter:

“CMS would like to make you aware that the federally supported website (link) that makes it easier for individuals to access COVID-19 vaccines is now live. Vaccines.gov (link) — powered by the trusted VaccineFinder brand — is available in English and Spanish, with high accessibility standard, and will help connect Americans with locations offering vaccines near them. In addition to the website, people in the U.S. are also now able to utilize a text message service, available in both English and Spanish. People can text their ZIP Code to 438829 (GETVAX) and 822862 (VACUNA) to find three locations nearby that have vaccines available.

Vaccines.gov is meant to complement the number of state and pharmacy websites that have been successfully connecting many Americans with vaccinations, by providing a unified federal resource for Americans to use no matter where they are.

In addition to the website and text messaging service, the National COVID-19 Vaccination Assistance Hotline is now available to help those who prefer to get information by phone on where to get a vaccine. Call 1-800-232-0233 to find a location near you.”
Link to announcement

May 11, 2021: CMS Issues Interim Final Rule for Long Term Care Facilities

CMS announced in a Special Edition MLN Connects (link) that they have released an interim final rule “that will ensure long-term care facilities , and residential facilities serving clients with intellectual disabilities, educate and offer the COVID-19 vaccine to residents, clients, and staff.” While the requirements of this rule is for Long-Term Care (LTC) facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID), CMS ends this announcement by indicating they are “seeking comment on opportunities to expand these policies to help encourage vaccine uptake and access in other congregate care settings.”

At the onset of the pandemic, FDA inspections began to be reserved for what they describe as “mission-critical issues” based on the following four factors:

May 13, 2021: CDC Updates Guidance for Fully Vaccinated People

The CDC provided the following two updates on their Guidance for Fully Vaccinated People webpage (link):

• You no longer need to wear a mask or physically distance in any setting, except where required by federal , state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance, and
• You can refrain from testing following a known exposure unless they are residents or employees of a correctional or detention facility or a homeless shelter.

I encourage you to visit this webpage for additional recommendations for indoor and outdoor settings and travel (Domestic and International).

May 14, 2021: CDC Morbidity and Mortality Weekly Report: COVID-19 Vaccine Effectiveness

The CDC posted a report (link) regarding vaccine effectiveness of Pfizer-BioNTech and Moderna COVID-19 vaccines among health care personnel (HCP) at 33 U.S. sites from January to March 2021. In the report summary they indicate what is added by this report is information about COVID-19 effectiveness:

• A single dose of Pfizer-BioNTech or Moderna COVID-19 vaccines is 82% effective against symptomatic COVID-19, and
• Two doses is 94% effective.

May 14, 2021: CDC Call – "What Clinicians Need to Know about Pfizer-BioNTech COVID-19 Vaccination of Adolescents" – In case you missed it, the CDC held a Clinician Outreach and Communication Activity (COCA) call this past Friday, May 14th. This call:

• Provided clinicians with an overview of the Pfizer-BioNTech COVID-19 Vaccination in adolescents who are 12-to-15 years old, and
• Provided information about safety and efficacy of the vaccine, vaccine recommendations, and clinical guidance.

You can access the call materials including slides on this CDC webpage (link).