Knowledge Base Category -

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 15th – 22nd.

Resource Spotlight This Week:

This week’s COVID-19 resource spotlight is on the HHS Coronavirus (COVID-19) Home webpage. The HHS indicates that they and their federal partners “are working together with state, local, tribal and territorial governments, public health officials, health care providers, researchers, private sector organizations and the public to execute a whole-of-America response to the COVID-19 pandemic to protect the health and safety of the American people.” Following is a list of a few of the topics related to COVID-19 available on this webpage:

• CARES Act Provider Relief Fund,
• Testing,
• Telehealth, and
• Mental Health and Coping.

June 15, 2020: FDA Revokes Emergency Use Authorization for Chloroquine and Hydroxychloroquine

The FDA has revoked the Emergency Use Authorization (EUA) for the use of these two drugs in treating COVID-19. They indicated in a News Release that “Based on its ongoing analysis of the EUA and emerging scientific data, the FDA determined that chloroquine and hydroxychloroquine are unlikely to be effective in treating COVID-19 for the authorized uses in the EUA. Additionally, in light of ongoing serious cardiac adverse events and other potential serious side effects, the known and potential benefits of chloroquine and hydroxychloroquine no longer outweigh the known and potential risks for the authorized use.” At the same time of the News Release, the FDA posted a related FAQ Document.

June 15, 2020: FDA Warns of Newly Discovered Potential Drug Interaction Related to Remdesiver

On June 15th, in addition to revoking the EUA for Chloroquine and Hydroxychloroquine, the FDA posted another News Release warning health care providers that “Based on a recently completed non-clinical laboratory study, the FDA is revising the fact sheet for health care providers that accompanies the drug to state that co-administration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not recommended as it may result in reduced antiviral activity of remdesivir. The agency is not aware of instances of this reduced activity occurring in the clinical setting but is continuing to evaluate all data related to remdesivir.”

June 16, 2020: Applying COVID-19 Infection Prevention and Control Strategies in Nursing Homes

On Tuesday June 16th, the CDC hosted a webinar where presenters used case-based scenarios to discuss how to apply infection prevention and control guidance for nursing home and other long-term care facilities. A recording of the call and slide deck are available on the CDC Clinical Outreach and Communications (COCA) Calls/Webinars webpage.

June 17, 2020: Senate Health Committee Chair: Make the Two Most Important COVID-19 Telehealth Policy Changes Permanent

A June 17, 2020 Press Release provides remarks made by Senate health committee Chairman Lamar Alexander (R-TN) during the “Telehealth: Lessons from the COVID-19 Pandemic” committee hearing.

Senator Alexander noted that “As dark as this pandemic event has been, it creates an opportunity to learn from and act upon these three months of intensive telehealth experiences, specifically what permanent changes need to be made in federal and state policies.” Specifically, Alexander said the following two changes should be permanent:

• Permanently extend policy changes allowing physicians to be reimbursed for telehealth appointment wherever the patient is located, including the patient’s home, and
• Permanently extent the policy change that nearly doubled the number of telehealth services that could be reimbursed by Medicare.

He also indicated that there are 29 other temporary federal policy changes that could also be considered for being made permanent. You can view the entire Press Release at https://www.help.senate.gov/chair/newsroom/press/alexander-make-the-two-most-important-covid-19-telehealth-policy-changes-permanent.

Link to White Paper: Preparing for the Next Pandemic by Senator Lamar Alexander: https://www.alexander.senate.gov/public/_cache/files/0b0ca611-05c0-4555-97a1-5dfd3fa2efa4/preparing-for-the-next-pandemic.pdf

June 18, 2020: COVID-19 Diagnostic Laboratory Tests: Billing for Clinician Services

CMS provided the following reminders in the June 18, 2020 edition of their weekly MLNConnects eNewsletter:

“Physicians and Non-Physician Practitioners (NPPs): Here are several reminders related to billing for COVID-19 symptom and exposure assessment and specimen collection performed on and after March 1, 2020:

• Use CPT Code 99211 to bill for assessment and collection provided by clinical staff (such as pharmacists) incident to your services, unless you are reporting another Evaluation and Management (E/M) code for concurrent services. This applies to all patients, not just established patients.
• Submit the CS modifier with 99211 (or other E/M code for assessment and collection) to waive cost sharing.
• Contact your Medicare Administrative Contractor if you did not include the CS modifier when you submitted 99211 so they can reopen and reprocess the claim.
• We will automatically reprocess claims billed for 99211 that we denied due to place of service editing.”

June 19, 2020: Weekly Update of Nursing Home COVID-19 Data as of June 7, 2020

CMS has posted the second set of COVID-19 Nursing Home Data as of June 7th and is available at https://data.cms.gov/stories/s/bkwz-xpvg.

Residents Cases and Deaths as of June 7, 2020:

• 107,389 total confirmed cases of COVID-19,
• 71,278 total suspected cases of COVID-19, and
• 29,497 total deaths attributed to COVID-19.

Moving forward this data will be updated weekly. In addition to the data release, CMS has released additional FAQs on Nursing Home COVID-19 data at  https://data.cms.gov/api/views/b62a-ieuz/files/e883f38f-77da-4f58-975f-390b858ccf9f?filename=NH%20COVID-19%20data%20FAQ%206-18-2020.pdf.

June 19, 2020: Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

CMS announced in a June 19th, 2020 Special Edition MLNConnects that they have instructed Medicare Administrative Contractors and notified Medicare Advantage plans that they “must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.”

June 19, 2020: FDA Letter: Stop Using COVID-19 Antibody Tests on the FDA’s “Removed” Test List

On June 19th, the FDA issued a Letter to Clinical Laboratory Staff and Health Care Providers with the recommendation to stop using COVID-19 antibody tests listed on their “removed” test list.” “The “removed” test list includes tests in which significant clinical performance problems were identified that cannot be or have not been addressed by the commercial manufacturer in a timely manner, tests for which an Emergency Use Authorization request has not been submitted by a commercial manufacturer of a serology test within a reasonable period of time as outlined in the FDA’s guidance, and tests voluntarily withdrawn by the respective commercial manufacturers.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 8th – June 15th

Weekly COVID-19 Resource Spotlight: CDC Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations

According to the CDC, the Toolkit Communication Toolkit was created to help public health professionals, health departments, community organizations, and healthcare systems and providers reach populations who may need COVID-19 prevention messaging in their native languages. Currently there are materials available in 28 languages ranging from Amharic to Vietnamese. The toolkit provides:

• Current messaging from a trusted source.
• Information in plain language available for downloading and sharing.
• Translated materials to help communities disseminate messages to a wider audience.

June 8, 2020: Addressing the Disparate Impact of COVID-19 on African Americans and Other Racial and Ethnic Minorities.

This HHS Office of Civil Rights Fact Sheet details initiatives underway to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities. A link to this document as well as other COVID-19 Announcements can be found on the HHS Civil Rights and COVID-19 webpage.

June 8, 2020: New FDA Webpages: Innovation to Respond to COVID-19 and Education Resources

In their June 8th COVID-19 Update: Daily Roundup, the FDA announced that they had published two new web pages to help the public access information:

• Innovation to Respond to COVID-19 provides an overview of FDA’s innovative approaches to respond to COVID-19 as quickly and safely as possible, and
• Educational Resources provides links to FDA-produced COVID-19-related resources that help explain FDA’s work.

June 9, 2020: CMS Recommendations for Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare and a Guide for Patients as they consider In-Person Care Options

As the country moves towards “re-opening our towns” CMS has provided two documents for consideration during this transition. First is a guide for patients and beneficiaries as they consider “in-person” care options. Recommendations for the following topics can be found in this guide:

• Do Not Postpone Necessary Care.
• Is It Safe to Go to your Doctor or Hospital?
• Consider Telehealth or Virtual Visits.
• What to Expect when you Seek Healthcare.
• Should I get tested for COVID-19 before seeking healthcare?
• Vulnerable Populations: When Possible, Stay Home.

This new guide is available in English and Spanish.

Second, is CMS’ document providing recommendations for re-opening facilities to provide non-emergent, Non-COVID-19 healthcare. The recommendations are intended for states or regions who have determined with their public health officials that they have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, proceeded to Phase I, and are now ready for Phase II of re-opening. In this document, CMS recommends:

• Optimization of telehealth services, when available and appropriate, to minimize the need for in-person services.
• All individuals at higher risk for severe COVID-19 illness should continue to shelter in place unless an in-person healthcare visit is warranted.
• The phased recommendations in this document “may guide healthcare systems, providers, and facilities as they consider delivering in-person care to non-COVID-19 patients in regions with lower or declining-without-rebound, levels of COVID-19.”

You can read more in a June 9th Press Release that includes links to both of these documents.

June 10, 2020: COVID-19 FAQs for Non Long-Term Care Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IIDs)

CMS released this FAQ Document on June 10th and indicates that “The purpose of this FAQs document is to clarify existing guidance and flexibilities and provide stakeholders with additional information based on questions received regarding the following entities:

• Ambulatory Surgical Centers (ASCs)
• Hospitals & Critical Access Hospitals (CAHs)
• Hospice
• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)
• Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs).”

June 10, 2020: Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic

The CDC has created a webpage dedicated to the use of telehealth. Their purpose in providing this guidance is “to describe the landscape of telehealth services and provide considerations for healthcare systems, practices, and providers using telehealth services to provide virtual care during and beyond the COVID-19 pandemic. As of June 10th, you will find the following on this webpage:

• Telehealth background,
• Telehealth modalities,
• Benefits and Potential Uses for Telehealth,
• Strategies to Increase Telehealth Update,
• Telehealth Reimbursement,
• Safeguards for Telehealth Services,
• Potential Limitations of Telehealth, and

June 12, 2020: CMS One-Time Notification: New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

This Change Request (CR) 11836 implements a new Point of Origin (PoO) Code “G” to indicate a “Transfer from a Designated Disease Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency.

“Background: The National Uniform Billing Committee (NUBC) practice is to align Discharge Status Codes and Point of Origin (PoO) Codes whenever possible. It came to the Committee's attention that there is a Discharge Status Code for Alternate Care Sites (ACS) but no specific matching PoO Code. Relative to the COVID-19 Public Health Emergency, NUBC created a new Point of Origin (PoO) Code "G" to be effective 07/01/2020, and defined as "Transfer From a Designated Disaster Alternate Care Site."

June 12, 2020: OCR Issues Guidance on HIPAA and Contacting Former COVID-19 Patients about Blood and Plasma Donation

The OCR has released a document answering the question of whether or not covered healthcare providers are permitted to use protected health information (PHI) to identify and contact patients who have recovered from COVID-19 to provide them with information about donating blood and plasma that could help other COVID-19 patients. The short answer is yes. As the late Andy Rooney would say, you can find the entire two page document for “the rest of the story” on the HHS.gov HIPAA and COVID-19 webpage.

June 13, 2020: HHS Awards $15 Million to Support Telehealth Providers During the COVID-19 Pandemic

The Department of Health and Human Services (HHS) announced that they have awarded $15 million to 159 organizations across five health workforce programs to increase telehealth capabilities in response to the COVID-19 pandemic. These awards are funded through the Coronavirus Aid, Relief and Economic Security (CARES) Act.

HHS indicated in the announcement that “these investments will train students, physicians, nurses, physician assistants, allied health and other high-demand professionals in telehealth. This will enable these professionals to maximize telehealth for COVID-19 referrals for screening and testing, case management, outpatient care, and other essential care during the crisis.”

This announcement provides a link to the complete list of award recipients.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 1st through June 8th.

Resource Spotlight This Week:

As our nation works to “re-open” and move forward towards a “new normal,” it is important to understand Policy Actions in your state and states you may be traveling to. This week’s spotlight resource can help provide that information. On June 3rd the Kaiser Family Foundation (KFF) published the State Data and Policy Actions to Address Coronavirus. Following is a list of key information that is available on this webpage:

• COVID-19: Confirmed cases & Deaths by State,
• State Social Distancing Actions,
• State COVID-19 Health Policy Actions,
• State Actions on Telehealth,
• State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (as of May 28, 2020),
• Guidance for Long-Term Care Facilities Related to COVID-19 (as of May 7, 2020),
• Adults at Higher Risk of Serious Illness if Infected with Coronavirus,
• Medicaid Expansion Status and Health Insurance Coverage,
• Private Insurance Deductibles and Self-Insured Plans,
• Health Care Provider Capacity, and
• Influenza and Pneumonia Deaths and Vaccinations

This publication was authored by Jennifer Tolbert, Cornelia Hall, Kendral Orgera, Natalie Singer, Salem Mengisut, and Marina Tian.

June 1, 2020: Nursing Home COVID-19 Data and Inspection Results leads to Enhanced Enforcement Actions

In a June 1st Press Release, the CMS announced enhanced enforcement directed towards nursing homes with violations of longstanding infection control practices.

A couple of key points in a related State Survey Memo summary are as follows:

• “Following the March 6, 2020 survey prioritization, CMS has relied on State Survey Agencies to perform Focused Infection Control surveys of nursing homes across the country. We are now initiating a performance-based funding requirement tied to the Coronavirus Aid, Relief and Economic Security (CARES) Act supplemental grants for State Survey Agencies. Further, we are providing guidance for the limited resumption of routine survey activities.
• CMS is also enhancing the penalties for noncompliance with infection control to provide greater accountability and consequence for failures to meet these basic requirements... The enhanced enforcement actions are more significant for nursing homes with a history of past infection control deficiencies, or that cause actual harm to residents or Immediate Jeopardy.”

CMS also provided link to the following information in the Press Release:

• Letter to the Governors (PDF)
• State breakdown of the Nursing Home COVID-19 data (PDF).

June 3, 2020: CMS Innovation Center Models COVID-19 Related Flexibilities

CMS posted an announcement on the CMS Innovation Center COVID-19 Flexibilities webpage regarding flexibilities being made to several CMS Innovation Center Value-Based Payment Models in response to COVID-19. For example, the Comprehensive Care for Joint Replacement (CJR) Model performance year 5 has been extended through March 2021.

In a news blog CMS indicated the Innovation Center will work “directly with model participants on the specific model changes and the processes for implanting them. CMS will also continue to review the data from our models during this COVID-19 pandemic, to identify short-term and long-term lessons learned.”

June 4, 2020: PEPPER Q1 FY 2020 Release Delayed

The PEPPER Team sent out a notice alerting providers that in keeping with the CMS effort to take measures to free up the attention of providers during the COVID-19 pandemic, the release of the Q1FY20 PEPPER for short-term (ST) acute care hospitals has been delayed. When information becomes available, the PEPPER Team will notify providers about the rescheduled release date.

June 4, 2020: FDA Video – Explaining Different Categories of Tests in Fight against COVID-19

The FDA has released a new video to provide information about the diagnostic tests and antibody tests used in the fight against COVID-19.

June 4, 2020: OCR Alert: HHS Awards More than a Half Billion Dollars to Help Vulnerable and Underserved Communities Gain Access to COVID-19 Testing

The OCR indicates in this alert that they are “sharing this update to promote awareness about COVID-19 testing and testing-related availability to people who are geographically isolated, economically disadvantaged, or medically vulnerable, including people with HIV, pregnant women, people experiencing homelessness, agricultural workers, residents of public housing, older persons and our nation’s veterans.

‎In case you missed it: On ‎May ‎7, ‎2020, the U.S. Department of Health and Human Services, through the Health Resources and Services Administration (HRSA), awarded nearly $583 million to 1,385 HRSA-funded health centers in all 50 states, the District of Columbia, and eight U.S. territories to expand COVID-19 testing. Nearly 88 percent of HRSA-funded health centers report testing patients, with more than 65 percent offering walk-up or drive-up testing. Health centers are currently providing more than 100,000 weekly COVID-19 tests in their local communities.

This Alert provided the following links:

• The Full Press Release may be found on HHS’s website here.
• For a list of award recipients, visit https://bphc.hrsa.gov/emergency-response/expanding-capacity-coronavirus-testing-FY2020-awards. 
• To learn more about health center capacity and the impact of COVID-19 on health center operations, patients and staff, visit https://bphc.hrsa.gov/emergency-response/coronavirus-health-center-data.
• For more information about COVID-19, visit http://coronavirus.gov
• For more information about COVID-19 and civil rights, visit https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/index.html

June 4, 2020: CMS News Alert – Nursing Home COVID-19 Data and Inspection Results Available on Nursing Home Compare

CMS announced in a June 4, 2020 Press Release that they are posting the first set of underlying COVID-19 nursing home data as well as posting results from targeted inspections announced on March 4, 2020 that allowed inspectors to focus on the most serious health and safety threats like infectious disease and abuse during the pandemic.

COVID-19 Nursing Home Data

As of May 31, 2020

• About 13,600 (approximately 88%) of Medicare and Medicaid Nursing Homes had reported the required data to the CDC.
• These facilities reported 95,000 confirmed COVID-19 cases and almost 32,000 deaths.

The CMS announced the next set of data will be released in two weeks and then plans to update the data weekly.

June 4, 2020: New Laboratory Data Reporting Guidance for COVID-19 Testing

The U.S. Department of Health and Human Services (HHS) announced new guidance specifying what additional data must be reported to HHS by laboratories along with COVID-19 test results. “The requirement to include demographic data like race, ethnicity, age, and sex will enable us to ensure that all groups have equitable access to testing, and allow us to accurately determine the burden of infection on vulnerable groups,” said ADM Brett P. Giroir, MD, Assistant Secretary for Health. “With these data we will be able to improve decision-making and better prevent or mitigate further illnesses among Americans.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from May 26th – June 1st 2020.   

Resource Spotlight This Week:

This week’s spotlight is the CDC’s CDC COVID Data Tracker. The Data Tracker includes maps, charts, and data on the following:

• S. Cases of COVID-19,
• S. COVID Testing,
• S. Forecasting,
• S. Trends,
• S. Cases and Deaths by County,
• Social Impact,
• School Closures, Mobility, and
• A “Learn More” tab covering topics ranging from COVID-19 FAQs and hospitalization rates to information on the use of cloth face coverings to daily life and coping.

May 26, 2020: Fact Sheet for State and Local Governments – CMS Programs & Payment for Care in Hospital Alternate Care Sites (ACS)

In order to expand capacity to care for patients during the COVID-19 Public Health Emergency (PHE) alternate care sites are being developed. CMS indicates that the purpose of this Fact Sheet is to provide “state and local governments developing alternate care sites with information on how to seek payments through CMS programs – Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) – for acute inpatient and outpatient care furnished at the site.”

May 27, 2020: The Joint Commission to Resume some Survey and Review Activities in June

The Joint Commission announced in their Wednesday May 27 Edition of Joint Commission Online that they are “committed to working closely with organizations, with safety being the first and foremost priority. As we start to resume some of these survey and review activities, account executives will begin to contact organizations due for a survey to assess the impact that the coronavirus pandemic had on their operations and their current state.”

They go on to note “our survey will focus on a thorough assessment but will not retroactively review compliance…rather, we will work to understand how you have adapted to the pandemic and review your current practices to assure you are providing safe care and working in a safe environment.”

May 27, 2020: COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

CMS has once again updated this now seventy-one page FAQ document. In addition to now containing a table of contents, new FAQS have been posted for the following topics:

• Hospital IPPS Payments under the CARES Act,
• Expansion of Virtual Communication Services for FQHCs/RHCs,
• Medicare telehealth,
• General Billing Requirements, specifically related to COVID-19 testing administered prior to and in association with a procedure.

Also, the following three new sections have been added to this document:

• Diagnosis Coding under ICD-10-CM,
• Chronic Care Management Services, and
• Outpatient Therapy Services

May 29, 2020: Alabama Medicaid Alert: Additional Laboratory Testing for COVID-19

Alabama Medicaid announced in a May 29th Alert that Providers may begin submitting claims on June 1, 2020, for dates of service on or after April 1, 2020 for the following testing procedure codes:

• 86328 Immunoassay for infectious agent antibody (ies), qualitative or semi quantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).

June 1, 2020: CDC Updates COVID-19 Transmission Webpage to Clarify Information about Types of Spread

The CDC announced in an email update that “after media reports appeared that suggested a change in CDC’s view on transmissibility, it became clear that these edits were confusion. Therefore, CDC has once again edited the page to provide clarity. 

The primary and most important mode of transmission for COVID-19 is through close contact from person-to-person. Based on data from lab studies on COVID-19 and what we know about similar respiratory diseases, it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this isn’t thought to be the main way the virus spreads.” This page also includes a link to a video titled “How does COVID-19 Spread?”

June 1, 2020: Medicare Fee-for-Service Response to the Public Emergency on COVID-19 MLN Article Revised

CMS revised MLN SE20011 on June 1st to add a section on Clarifications for using the “CR” Modifier and “DR” Condition Code. All other information remained the same.

• MLN SE20011: https://www.cms.gov/files/document/se20011.pdf

At least annually, MS-DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the first article in a series of article about the 2021 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications.

Pre-MDC: Bone Marrow Transplants

Surgical vs. Medical MS-DRGs

Currently, the Bone Marrow Transplant (BMT) MS-DRGs (MS-DRG 014 (Allogeneic Bone Marrow Transplant), MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell Immunotherapy), and MS-DRG 017 (Autologous Bone Marrow Transplant without CC/MCC) are designated as surgical MS-DRGs.

A request was made to re-designate these three MS-DRGs as medical MS-DRGs as a Bone Marrow Transplant does not involve a surgical procedure or require the use of an O.R. The requestor noted that this change “would clinically align with the resources utilized in the performance of these procedures.

CMS clinical advisors agreed and the proposal has been made to re-designate MS-DRGs 014, 016, and 017 as medical MS-DRGs effective October 1, 2020.

BMT Procedures Designation O.R. vs. Non-O.R.

The requestor also noted that MS-DRGs 016 and 017 includes ICD-10-PCS procedures codes designated as Non-O.R. while the following eight procedures are designated as O.R. Procedures:

• 30230AZ: Transfusion of embryonic stem cells into peripheral vein, open approach
• 30230G0: Transfusion of autologous bone marrow into peripheral vein, open approach
• 30230X0: Transfusion of autologous cord blood stem cells into peripheral vein, open approach
• 30230Y0: Transfusion of autologous hematopoietic stem cells into peripheral vein, open approach
• 30240AZ: Transfusion of embryonic stem cells into central vein, open approach
• 30240G0: Transfusion of autologous bone marrow into central vein, open approach
• 30240X0: Transfusion of autologous cord blood stem cells into central vein, open approach
• 30240Y0: Transfusion of autologous hematopoietic stem cells into central vein, open approach.

CMS is proposing to re-designate these codes from O.R. to Non-O.R. procedures effective October 1, 2020.

Chimeric Antigen Receptor (CAR) T-Cell Therapies: New MS-DRG

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. The requestor noted this would improve payment in the inpatient setting. CMS did not believe enough data was available to make a change at that time. However, CMS did seek comments on payment alternatives for CAR-T cell therapies.

In the FY 2020 Final Rule CMS finalized the continuation of the new technology status and add-on payments for FY 2020 for this therapy.

There were several requests made, in the FY 2021 proposed rule, to create a new MS-DRG as this therapy will no longer be eligible for the new technology add-on payment (NTAP) for FY 2021. CMS has responded by noting they now have enough data to consider the development of a new MS-DRG. Further, CMS clinical advisors found a vast discrepancy in resource consumption and clinical differences warranting the creation of new MS-DRG.

CMS is proposing to do the following:

• Create new MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell immunotherapy, and
• Revise the MS-DRG 016 title to “Autologous Bone Marrow Transplant with CC/MCC.”

The following table highlights the proposed MS-DRG relative weight (RW) and geometric mean length of stay (GMLOS) for the BMT MS-DRGs and the proposed new CAR T-Cell MS-DRG:

‍MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures: Background

In FY 2020 CMS finalized their proposal to reassign 96 ICD-10-PCS procedures describing dilation of carotid artery with an intraluminal device(s):

• From MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC respectively)
• To MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively)

Carotid Artery Stent Procedures: FY 2021 Proposals

In response to a request, CMS is proposing to reassign the following six ICD-10-PCS codes describing dilation of carotid artery with drug eluting intraluminal device(s) using an open approach from MS-DRGs 037, 038, and 039 to MS-DRGs 034, 035, and 036:

• 037H04Z: Dilation of right common carotid artery with drug-eluting intraluminal device, open approach
• 037J04Z: Dilation of left common carotid artery with drug-eluting intraluminal device, open approach
• 037K04Z: Dilation of right internal carotid artery with drug-eluting intraluminal device, open approach
• 037L04Z: Dilation of left internal carotid artery with drug-eluting intraluminal device, open approach
• 037M04Z: Dilation of right external carotid artery with drug-eluting intraluminal device, open approach
• 037N04Z: Dilation of left external carotid artery with drug-eluting intraluminal device, open approach

CMS further reviewed to see if any of the six codes were included in MS-DRGs outside of MDC 1. They found a total of 36 ICD-10 PCS codes for procedures describing dilation of the carotid artery with an intraluminal device with an open approach that are currently assigned to MS-DRG 252 (Other Vascular Procedures with MCC) in MDC 5 (Diseases and Disorders of the Circulatory System). Interestingly, they found 8 claims with one of these 36 ICD-10-PCS codes and a Principal Diagnosis in MDC 1 causing the claims to group to the Extensive O.R. Procedure Unrelated to Principal Diagnosis MS-DRG Group (981, 982, and 983).

CMS is proposing to add the 36 ICD-10-PCS codes currently in MDC 5 to the GROUPER logic for MS-DRGs 034, 035, 036 in MDC 1. As my instructor told me when first learning about the MS-DRG system, this change will permit cases with a Principal Diagnosis in MDC 1 to “remain in the family.”

MDC 3: Diseases and Disorders of Ear, Nose, and Throat

Temporomandibular Joint Replacements

A request was made to reassign ICD-10-PCS procedures 0RRC0JZ (Replacement of right temporomandibular joint with synthetic substitute, open approach), and 0RRD0JZ (Replacement of left temporomandibular joint with synthetic substitute, open approach):

• From MS-DRGs 133 and 134 (Other Ear, Nose, Mouth and Throat O.R. Procedures with and without CC/MCC, respectively)
• To MS-DRGs 131 and 132 (Cranial and Facial Procedures with and without CC/MCC, respectively) in MDC 03.

The requestor stated that it is inaccurate for these two codes that involve the excision of the TMJ and replacement with a prosthesis to Group to MS-DRGs 133 and 134 when the codes for the TMJ excision alone (0RBC0ZZ (Excision of right temporomandibular joint, open approach) and 0RBD0ZZ (Excision of left temporomandibular joint, open approach) group to the higher weighted MS-DRGs 131 and 132.

The requestor also recommended analysis of all procedures involving the mandible and maxilla and consider reassignment of these procedures codes describing procedure performed on facial and cranial structure:

• From MS-DRGs 129 (Major Head and Neck Procedures with CC/MCC or Major Device) and 130 (Major Head and Neck Procedures without CC/MCC)
• To MS-DRGs 131 and 132.

CMS undertook a comprehensive review of all procedures currently assigned to MS-DRGs 129, 130, 131, 132, 133, and 134. Based on data analysis and this comprehensive review, the Clinical Advisors support restructuring of these MS-DRGs by assigning procedures currently assigned to these MS-DRGs based on clinical intensity, complexity of service and resource utilization.

Additional Findings as a result of this comprehensive review included:

• CMS noting the current special logic defined as “Major Device Implant” for MS-DRG 129 that identified procedures describing the insertion of a cochlear implant or other hearing device. “Clinical advisors supported the removal of this special logic from the definition for assignment to any proposed modifications to the MSDRGs, noting the costs of the device have stabilized over time and the procedures can be appropriately grouped along with other procedures involving devices in any restructured proposed MS-DRGs.”
• CMS identified 338 procedure codes that were inadvertently assigned to MS-DRGs 133 and 134 as a result of replication during the transition from ICD-9 to ICD-10 based MS-DRGs. This list of codes is available in Table 6P.2c.

As a result of their review, CMS has proposed the following:

• Delete the three MS-DRGs groups with a two-way severity level subgroup (129 & 130, 131 & 132, and 133 & 134)
• Create two new base MS-DRGs with a three-way severity level split:
• MS-DRGs 140, 141, and 142 (Major head and Neck Procedures with MCC, with CC, without CC/MCC respectively), and
• MS-DRGs 143, 144, and 145 (Other Ear, Nose, Mouth, and Throat O.R. Procedures with MCC, with CC, without CC/MCC respectively).

MDC 5: Diseases and Disorders of the Circulatory System

Left Atrial Appendage Closure (LAAC)

Requests were made to create a new MS-DRG for the LAAC procedure or to map all LAAC procedures to a different MS-DRG with payment rates aligned with procedural costs.  The following table shows the current corresponding MS-DRGs for the 9 ICD-10-PCS codes describing LAAC Procedures

As detailed in the table, ICD-10-PCS procedures currently map to an MS-DRG based on the approach. CMS has proposed to reassign the ICD-10-PCS procedure codes for an open approach to MS-DRGs 273 and 274. “Clinical advisors stated this reassignment would allow all LAAC procedures to be grouped to the same MS-DRGs and improve clinical coherence. The following table highlights the difference in R.W., GMLOS and national average payment in FY 2020:

‍Potential Impact by the Numbers

With the national payment rate for MS-DRGs 273 and 274 being significantly higher than MS-DRG 250 and 251, I wanted to see what the potential volume of claims and payment impact this change might have. To answer these questions I pulled Medicare fee-for-service paid claims data from RealTime Medicare Data (RTMD). Specifically, all claims with one of the 9 ICD-10-PCS procedure codes for LAAC for Alabama, Georgia and Tennessee in Calendar Year (CY) 2019. Following is what I found “by the numbers:”

• 314: The number of LAAC procedures performed in CY 2019.
• 1: The volume of claims grouping to MS-DRG 250.
• 8: The volume of claims grouping to MS-DRG 251.
• $74,166.95: The increase in payment for this group of 9 MS-DRGs based on FY 2020 national average payment.

Insertion of Cardiac Contractility Modulation Device

A request was made to review the MS-DRG assignment for cases identifying patients receiving a cardiac contractility modulation (CCM) device system for CHF. “CCM is indicated for patients with moderate to severe heart failure resulting from either ischemic or non-ischemic cardiomyopathy. CCM utilizes electrical signals which are intended to enhance the strength of the heart and overall cardiac performance. CCM delivery device systems consist of a programmable implantable pulse generator (IPG) and three leads which are implanted in the heart. One lead is implanted into the right atrium and the other two leads are inserted into the right ventricle.”

Reasons for this request:

• MS-DRGs 222, 223, 224, 225, 226, and 227 (Cardiac Defibrillator Implant with and without Cardiac Catheterization with and without AMI/HF/Shock with and without MCC, respectively include “code pairs” describing the insertion of contractility modulation devices.
• Currently, GROUPER logic requires the combination of the CCM device codes and a left ventricular lead to map to this group of MS-DRGs.
• Per the requestor, a CCM device is contraindicated in patients with a left ventricular lead. Consequently, no case involving insertion of the CCM system can be appropriately mapped to this group of MS-DRGs.
• Currently, CCM system insertion maps to MS-DRG 245 (AICD Generator Procedures).
• Requester noted to date this procedure has been performed on an outpatient bases but expects that some Medicare patients will receive CCM devices as an inpatient.

CMS analysis found that the ICD-10-PCS procedure code combinations for right ventricular and/or right atrial lead insertion with insertion of CCM devices were inadvertently excludes from this group of MS-DRGs as a result of replicating the ICD-9 based MS-DRGs. Based on their analysis, CMS is making the following two proposals:

• Add 24 ICD-10-PCS code combinations for CCM devices to this group of MS-DRGs, and
• Delete the 12 clinically invalid code combinations from the GROUPER logic of this MS-DRG group describing the insertion of CCM device and the insertion of a cardiac lead into the left ventricle.

MDC 6: Diseases and Disorders of the Digestive System

Acute Appendicitis

A request was made to add K35.20 (Acute appendicitis with generalized peritonitis, without abscess) to the list of complicated Principal Diagnoses grouping to MS-DRGs 338, 339, and 340 (Appendectomy with Complicated Principal Diagnosis with MCC, with CC, without CC/MCC, respectively) so that all ruptured/perforated appendicitis codes in MDC 6 would groups to these MS-DRGs.

Clinical Advisors agreed that the “presence of an abscess would clinically determine whether a diagnosis of acute appendicitis would be considered a complicated principal diagnosis.” However, since K35.20 is “without an abscess,” CMS did not make a proposal to add K35.20 to this MS-DRG group.

The requestor had also noted that K35.32 (Acute appendicitis with perforation and localized peritonitis, without abscess) currently groups to MS-DRGs 338, 339, and 340. Subsequently, CMS identified all diagnosis codes describing acute appendicitis under subcategory K35.2 and K35.3 to review MS-DRG assignments for clinical coherence. As a result of this review, CMS is making the following proposals specific to diagnosis code K35.32:

• Reassign diagnosis code from MS-DRGs 338, 339 and 340 to MS-DRGs 341, 342, and 343; and
• Remove diagnosis code from the complicated principal diagnosis list in MS-DRGs 338, 339, and 340.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Hip and Knee Joint Replacements

A requestor recommended restructuring MS-DRGs for total joint arthroplasty that utilize oxidized zirconium bearing surface implants in total hip and total knee replacements. They went on to offer three options for restructuring the MS-DRGs. Based this request and lengthy data analysis by CMS, CMS is proposing to create two new MS-DRGs for FY 2021:

• MS-DRG 521: Hip Replacement with Principal Diagnosis of Hip Fracture with MCC, and
• MS-DRG 522: Hip Replacement with Principal Diagnosis of Hip Fracture without MCC.

Request for Comment

CMS noted that the Comprehensive Care for Joint Replacement (CJR) model includes episodes triggered by MS-DRG 469 with hip fracture and MS-DRG 470 with hip fracture. Given the proposal for new MS-DRGs for hip fracture, CMS is seeking comments on the effect this proposal would have on the CJR model and whether to incorporate the new MS-DRGs into the model if finalized.

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Kidney Transplants

Currently, Kidney Transplants group to MS-DRG 652 (Kidney Transplant) in MDC 11. There was a request to designate kidney transplants as Pre-MDC MS-DRGs similar to other organ transplants. CMS analysis found that all kidney transplants in MS-DRGs 981 and 982 reported a principal diagnosis in MDC 5 (Diseases and Disorders of the Circulatory System). CMS is proposing an alternate option “to modify the GROUPER logic for MS-DRG 652 by allowing the presence of a procedure code describing transplantation of the kidney to determine the MS-DRG assignment independent of the MDC of the principal diagnosis in most instances.”

CMS goes on to discuss how the Pre-MDCs came into existence and that the proposal for kidney transplant represent a “first step in investigating” how they may consider shifting transplants out of Pre-MDCs as their clinical advisors have noted that while once considered as being very resource intensive, “treatment practices have shifted since the inception of Pre-MDCs.”

Kidney Transplants and Dialysis during an Inpatient Stay

An additional request was made to create a new MS-DRG for kidney transplant cases where a patient receives dialysis during the inpatient stay and after the date of the transplant. The following three ICD-10-PCS procedure codes identify the performance of hemodialysis:

• 5A1D70Z: Performance of urinary filtration, intermittent, less than 6 hours per day
• 5A1D80Z: Performance of urinary filtration, prolonged intermittent, 6-18 hours per day
• 5A1D90Z: Performance of urinary filtration, continuous, greater than 18 hours per day

CMS believes that creating separate MS-DRGs when hemodialysis is performed either before or after a kidney transplant or simultaneous pancreas/kidney transplant “would appropriately address the differential in resource consumption consistent with the President’s Executive Order on Advancing American Kidney Health (see https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/). CMS is proposing the following three new MS-DRGs:

• Proposed new Pre-MDC MS-DRG 019 (Simultaneous Pancreas/Kidney Transplant with Hemodialysis),
• CMS is proposing to add the procedure codes from current Pre-MDC MS-DRG 008 to the proposed new Pre-MDC MS-DRG 019 with the procedure codes describing a hemodialysis procedure.
• Proposed new MS-DRG 650 (Kidney Transplant with Hemodialysis with MCC) and
• Proposed new MS-DRG 651 (Kidney Transplant with Hemodialysis without MCC).
• Similarly, CMS is also proposing to add the procedure codes from current MS-DRG 652 to the proposed new MS-DRGs 650 and 651 with the procedure codes describing a hemodialysis procedure.

Hemodialysis procedure codes are currently “designated as Non-O.R. procedure, therefore, as part of the logic for these proposed new MS-DRGs, we are also proposing to designate these codes as non-O.R. procedures affecting the MS-DRG.”

Proposed Addition of Diagnoses to MS-DRGs 673, 674, and 675 (Other Kidney and Urinary Tract Procedure Logic

In response to a request, CMS reviewed the GROUPER logic for this MS-DRG group including the special logic for certain MDC 11 diagnoses reported with procedures codes for the insertion of tunneled or totally implantable vascular access devices. Based on their review, CMS is making several proposals for code reassignment to this MS-DRG group.

MDC 17: Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasms

Inferior Vena Cava Filters

A requestor noted that currently when the procedure code describing the placement of an inferior vena cava (IVC) filter (06H03DZ – Insertion of intraluminal device into inferior vena cava, percutaneous approach) is also reported with the codes describing the introduction of a high dose chemotherapy agent or report a chemotherapy principal diagnosis with a secondary diagnosis describing acute leukemia, the cases are assigned to a lower weighted MS-DRG group than when the IVC filter code is not on the claim.

CMS notes in the proposed rule that “our clinical advisors believe that, given the similarity in factors such as complexity, resource utilization, and lack of a requirement for anesthesia administration between all procedures describing insertion of a device into the inferior vena cava, it would be more appropriate to designate these three ICD-10-PCS codes describing the insertion of an intraluminal device into the inferior vena cava as Non-O.R. procedures. Therefore, we are proposing to remove ICD-10-PCS procedure codes 06H00DZ, 06H03DZ, and 06H04DZ from the FY 2021 ICD-10 MS-DRG Version 38 Definitions Manual in Appendix E--Operating Room Procedures and Procedure Code/MS-DRG Index as O.R. procedures. Under this proposal, these procedures would no longer impact MS-DRG assignment.”

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

There are several proposals being made to move diagnosis and procedures codes back into a specific MDC for FY 2021. For those interested, you can find these proposals on pages 32526 – 32542 of the Proposed Rule.

MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on July 10, 2020.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from May 12th through May 15th.  

Resource Spotlight This Week:

This week’s spotlight is on a May 4th pdf document titled COVID-19 Regulations & Waivers to Enable Health System Expansion highlighting how CMS has enabled significant health system flexibility during the COVID-19 Public Health Emergency (PHE) through Medicare 1135 blanket waivers and the passage of two interim final rules. You can also find this presentation on the CMS Coronavirus Waivers and Flexibilities webpage. 

May 12, 2020: Price Transparency Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing

In a May 12 Special Edition MLNConnects newsletter, CMS noted the following regarding Price Transparency Requirements:

“The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes a number of provisions to provide relief to the public from issues caused by the pandemic, including price transparency for COVID -19 testing. Section 3202(b) of the CARES Act requires providers of diagnostic tests for COVID-19 to post the cash price for a COVID-19 diagnostic test on their website from March 27 through the end of the public health emergency. For more information, see the FAQs. (PDF).”

CMS has also posted a Q&A Document specific to the Price Transparency Requirement.

May 13, 2020: CMS Issues Nursing Homes Best Practices Toolkit to Combat COVID-19

This Toolkit includes recommendations and best practices from front line health care providers, governors’ COVID-19 task forces, associations, organizations and experts. It is intended to provide a catalogue of resources dedicated to address challenges facing nursing homes in the fight against COVID-19. You can read more in a related CMS Press Release.

May 14, 2020: FDA Informs Public about Possible Accuracy Concerns with Abbott ID NOW Point-of-Care Test for COVID-19

The FDA Alert indicates that early data suggests potential inaccurate results from using this point-of-care to diagnose COVID-19. Specifically, the test may return false negative results. They will continue to work with Abbott and communicate any updates publicly.

May 14, 2020: FDA Health Advisory Issued: Multisystem Inflammatory Syndrome in Children (MIS-C) Association with COVID-19

The CDC issued an official Health Advisory alert providing background information on several cases of a recently reported MIS-C associated with COVID-19 and a case definition of the syndrome. “CDC recommends healthcare providers report any patient who meets the case definition to local, state, and territorial health departments to enhance knowledge of risk factors, pathogenesis, clinical course, and treatment of this syndrome.”

The Case Definition for MIS-C includes the following:

• An individual aged <21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
• No alternative plausible diagnoses; AND
• Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

May 14, 2020: Health Affairs Research Article: Strong Social Distancing Measures in the United States Reduced the COVID-19 Growth Rate

Economists at the University of Kentucky evaluated the impact of imposed social distancing measures on growth rate of confirmed COVID-19 cases across US counties in March and April of 2020. The end date of this study was April 27 as this date coincided with the re-opening of restaurants and other entertainment facilities in Georgia. Results of this study imply there would have been more than 35 times greater spread of the disease without any of the social distancing measures having been put into place.

May 15, 2020: American College of Surgeons (ACS) Post-COVID-19 Readiness Checklist for Resuming Surgery

The ACS developed this checklist “to help surgeons ultimately communicate to their patients the important items they want to know. You can read the full announcement and download a print-friendly version of the checklist on the ACS website at https://www.facs.org/covid-19/checklist.

May 15, 2020: OCR Bulletin: Ensuring the Rights of Persons with Limited English Proficiency (LEP) in Health Care During COVID-19

This OCR Bulletin reminds health care providers that they “must take reasonable steps to provide meaningful access to individuals with LEP eligible to be served or likely to be encountered in their health programs and activities. This longstanding obligation is not waived during a National Emergency.” You will find suggestions for providing meaningful access for persons with LEP and links to several available resources.

May 15, 2020: Special Edition MLNConnects: Deadline Approaching for Nursing Homes to Report Confirmed and Suspected COVID-19 Cases

The April 30th Interim Final Rule with Comment Period requires nursing homes to begin reporting data to the CDC no later than Sunday May 17th. Facilities have to enroll in the CDC’s National Healthcare Safety Network (NHSN) to report data. “As nursing homes report this data to the CDC, CMS will be taking swift action and publicly posting this information so all Americans have access to accurate and timely information on COVID-19 in nursing homes. More information on the CDC’s NHSN COVID-19 module can be found here.”

May 15, 2020: Special Edition MLNConnects: Telephone Evaluation and Management Visits

“The March 30 Interim Final Rule with Comment Period added coverage during the Public Health Emergency for audio-only telephone evaluation and management visits (CPT codes 99441, 99442, and 99443) retroactive to March 1. On April 30, a new Physician Fee Schedule was implemented increasing the payment rate for these codes. Medicare Administrative Contractors (MACs) will reprocess claims for those services that they previously denied and/or paid at the lower rate.

There are also a number of add on services (CPT codes 90785, 90833, 90836, 90838, 96160, 96161, 99354, 99355, and G0506) which Medicare may have denied during this Public Health Emergency. MACs will reprocess those claims for dates of service on or after March 1.

You do not need to do anything.”

May 17, 2020: New CDC Activities and Initiatives Supporting the COVID-19 Response and the President’s Plan for Opening America Up Again – May 2020

This CDC Document was posted to the CDC website on May 17th. In addition to highlighting CDC activities and initiatives, this document includes the following appendices:

• Appendix A: Surveillance for COVID-19,
• Appendix B:Healthcare System Surveillance,
• Appendix C: Guidance on Infection Control and Contact Tracing,
• Appendix D: Guidance on Test Usage (Asymptomatic Populations and Serology),
• Appendix E: Assessing Surveillance and Hospital Gating Indicators, and
• Appendix F: Setting Specific Guidance.

Appendix F offers interim guidance for child care programs, interim guidance for schools and day camps, interim guidance for employers with workers at high risk, interim guidance for restaurants and bars, and interim guidance for mass transit administrators. The CDC notes the guidance in Appendix F is meant to assist establishments as they open. Further, they will update guidance as more is learned about COVID-19 and best practices to prevent its spread.

Last week’s Wednesday@One included an article providing details about the CMS Prior Authorization Program for certain hospital outpatient department (ODP) services. As a reminder this program will begin for services provided on or after July 1, 2020. We have continued to follow Medicare Administrative Contractor (MAC) websites for news about the program. This article provides details about which MACs have scheduled provider education. Also included in this article, are tables posted on two different MACs websites that provide links to applicable Local Coverage Determinations (LCDs) and Articles.

J15 MAC: CGS Administrators, LLC (CGS)
Jurisdiction Area: Kentucky, Ohio

CGS is providing a webinar to introduce the new prior authorization program for certain hospital outpatient services on Thursday May 21, 2020 at 11:00 a.m. Eastern Time. You can go to the CGS Part A Calendar of Events to register for this webinar.

CGS has also created an OPD Prior Authorization webpage in the Medical Review section of their website. Currently you will find a list of applicable HCPCS codes. Also, Process and Results are “coming soon!” to this webpage.

JN MAC: First Coast Service Options, Inc.
Jurisdiction Area: Florida, Puerto Rico, U.S. Virgin Islands

On May 4th First Coast reminded providers that the CMS is implementing a prior authorization program for the following hospital outpatient department services for dates of service on or after July 1, 2020:

• Blepharoplasty, eyelid surgery, brow lift, and related services,
• Botulinum toxin injections,
• Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services,
• Rhinoplasty and related services, and
• Vein ablation and related services.

First Coast will be hosting two webcasts in which they will review the guidelines for submitting a Prior Authorization Request (PAR) and the potential results and options available. Specialists will be present to answer questions relating to the process. The dates for the webcasts are Thursday, May 28th and Thursday, June 11th. To register for a webcast you can go to the First Coast events calendar under their Education Section of their website (https://medicare.fcso.com/index.asp). To learn more the Prior Authorization Program you can look under the Medical Review section of the website.

First Coast JN: Documentation Guidance

First Coast has posted the following table on their website to provide more information on coverage and documentation requirements.

‍JK and J6 MAC: National Government Services, Inc. (NGS)
JK Jurisdiction Area: Connecticut, New York, Main, Massachusetts, New Hampshire, Rhode Island, Vermont
J6 Jurisdiction Area: Illinois, Minnesota, Wisconsin

As of Monday May 18th, MMP was unable to find any information about this program or planned provider education on the NGS website.

JE and JF MAC: Noridian Healthcare Solutions, LLC (Noridian)
JE Jurisdiction Area: California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands
JF Jurisdiction Area: Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming

Noridian will be hosting webinars on the following dates:

• May 28, 2020,
• June 4, 2020,
• June 10, 2020,
• June 18, 2020, and
• June 24, 2020.

This Provider Outreach and Education (POE) webinar will include the following:

• Overview,
• Authorization Process,
• Submitting Prior Authorization Request,
• Services Requiring Prior Authorization,
• Advanced Beneficiary Notice of Noncoverage (ABN)
• Cosmetics, and
• Resources

Link to Webinar Announcement on JE website: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/prior-authorization-for-certain-hospital-outpatient-department-opd-services-webinars

Link to Webinar Announcement on JF website: https://med.noridianmedicare.com/web/jfa/article-detail/-/view/10529/prior-authorization-for-certain-hospital-outpatient-department-opd-services-webinars

JH and JL MACs: Novitas Solutions, Inc. (Novitas)
JH Jurisdiction Area: Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana, Mississippi 
JL Jurisdiction Area: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania

Novitas will be hosting a webinar on Thursday May 28, 2020. This webinar will review the details and submission guidelines for the Prior Authorization (PA) program for certain hospital outpatient department (OPD) services being implemented by the Centers for Medicare & Medicaid Services (CMS) effective June 17, 2020, for dates of service on or after July 1, 2020, nationwide. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare trust fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers. You can register for this webinar on the Novitas Medicare Part A Educational Event Calendar webpage at: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008010

Novitas JH and JL: Documentation Guidance:

Similar to First Coast, Novitas has posted the following table on their website providing more information on coverage and documentation requirements.

‍JJ and JM MAC: Palmetto GBA, LLC (Palmetto)
JJ Jurisdiction Area: Alabama, Georgia, And Tennessee
JM Jurisdiction Area: North Carolina, South Carolina, Virginia, West Virginia

On May 13th Palmetto release an article letting providers know they will be providing a two-part webcast on May 26, 2020 regarding the Outpatient Department (OPD) Prior Authorization (PA) program. The first session will be an overview of the program and begins at 10 a.m. ET. The second session will begin at 1 p.m. ET and will discuss “Medical Necessity.” These webcasts are available for Medicare Part A and Part B providers. Links to register for both sessions are included in the Article.  

The next day on May 14th, Palmetto included in their Daily Newsletter the following article specific to the procedures in this program:

• Blepharoplasty and Blepharoptosis Repair
• Panniculectomy
• Rhinoplasty
• Vein Ablation and Related Services 

All of the articles include details about documentation requirements and a procedure specific Documentation Checklist.

J5 and J8 MAC: Wisconsin Physician Service Government Health Administrators (WPS)
J5 Jurisdiction Area: Iowa, Kansas, Missouri, Nebraska
J8 Jurisdiction Area: Indiana, Michigan

WPS has scheduled a teleconference that will cover the new prior authorization process, the services specific to this process, and the responsibilities of both the physician and the facility. This training is intended for J5 and J8 Part A/B providers billing on a UB-04/CMS-1500 or electronic equivalent. There will be two different sessions both held on June 10, 2020. The first teleconference will be from 10:00 AM – 11:30 AM CT and the second session will be from 1:00 PM – 2:30 PM CT. You can sign up for these sessions on the WPS Learning Center at: http://wpsghalearningcenter.com/login.

Welcome to the fifth edition of our monthly MAC Talk article. This month before diving into updates from the MACs there are a couple of updates that have come about due to the current COVID-19 Public Health Emergency (PHE) that I wanted to share. Specifically, an NGS update about telehealth and an MLN Connects announcement regarding who can certify a home health plan of care.

Medicare Telehealth versus Telemedicine

On April 22, 2020 NGS included the following post in their Latest COVID-19 News:

“We have received many questions that have indicated confusion between telehealth and telemedicine, and which rules apply to which services within these two benefit categories. While there is a perceived relation between these types of services they are distinctly different.

Telemedicine refers to a group of services that may be provided to a patient without any physical patient contact. Services may be provided via a telephone (audio) connection, or via some type of online communication such as a patient/provider portal or via email interactions between the patient and practitioner. Typically, most telemedicine services are non-covered by Medicare. However, CMS has opened some of the codes for coverage during the COVID-19 public health emergency (PHE).

Telehealth refers to a distinct level of established services that have traditionally been performed via a face-to-face interaction between the patient and practitioner. This group of services has been grouped together in a distinct policy that allows this limited amount of traditional face-to-face services to be performed via an audio and video connection as a replacement to the in person, face-to-face interaction. Telehealth allows the interaction to still occur face-to-face; however, it can be achieved via the audio and video connection.

This benefit was set apart as a specific addition to Medicare policy in SSA 1834(m). The criteria requires real time communication between the patient and practitioner (audio and video), the patient geographic location is in a rural or non-metropolitan statistical area (based on ZIP Code eligibility), and patient consent is required. 

The site where the patient is located is considered the originating site and may bill Q3014 to cover the cost of a professional to set up the audio and video communication system and assist with the service provided, if required. The site where the practitioner is rendering the telehealth service is known as the distant site. The practitioner will bill for the service s/he provides based on the list of approved telehealth services. All telehealth services in the benefit are professional services.

CMS issued the MLN Telehealth Booklet which explains the coverage criteria, provides a listing of eligible originating sites, and eligible distant site practitioners that may perform services via telehealth. The booklet also contains a listing of applicable procedure codes that are allowed to be performed via telehealth and information on the appropriate geographic location of the patient that is allowed for telehealth services. During the PHE, the list of services allowed to be performed via telehealth have been temporarily expanded. The MLN Telehealth Booklet includes the complete list of codes, with those that are temporarily identified as such.”

May 7, 2020: MLNConnects Home Health Plans of Care: NPs, CNSs and PAs Allowed to Certify

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act to allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This is a permanent change that will continue after the Public Health Emergency.

Effective for claims with dates of service on or after March 1, 2020, these non-physician practitioners may bill the following codes:

• G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care
• G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care
• G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans

The descriptors of the three codes will be revised at a later date to include the non-physician practitioner specialties.

May MAC Talk: The Local Scene

April 22, 2020: Palmetto GBA JJ Posts TPE Progress Updates

In last month’s MAC Talk article, we included TPE Progress Updates that had been posted by Palmetto GBA for Jurisdiction M and J. Since then Palmetto GBA has posted additional articles. Following is a list of specific TPE articles released to date by Palmetto GBA JJ:

• March 25, 2020: HBO Therapy G0277,
• March 25, 2020: JJ Part A Skilled Nursing Facility (SNF),
• March 25, 2020: Therapeutic Exercise 97110,
• April 3, 2020: DRG 885 Psychoses; and
• April 3, 2020: DRG 470 Major Joint Replacement,
• April 10, 2020: Manual Therapy 97140,
• April 10, 2020: Inpatient Rehabilitation Facility (IRF) Ao604-D0604
• April 10, 2020: Pegfilgrastim J205,
• April 10, 2020: DRGs 291 and 292: Heart Failure and Shock with MCC and with CC,
• April 11, 202: Rituximab J9310,
• April 11, 2020: Infliximab J1745,
• April 11, 2020: Denosumab J0897,
• April 11, 2020: Bevacizumab J9035, and
• April 20, 2020: DRGs 682/683 – Renal Failure.

Links to all of the articles can be found on Palmetto GBA’s JJ Target Probe and Educate webpage.

April 24, 2020: Palmetto GBA Daily Newsletter: Provider Contact Center FAQs and Reminder of Suspended Sequestration

• Palmetto GBA is publishing the following Frequently Asked Questions (FAQ) based upon data analytics identifying topics generating a high volume of telephone inquiries from January 1, 2020, through March 31, 2020. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC). https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BNYKJU2621?opendocument
• Providers are reminded that Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.  https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/BNYMSN1444?opendocument

April 23, 2020: Palmetto GBA Daily Newsletter: Clarification of Negative Reimbursement

Palmetto GBA’s April 23rd Daily Newsletter included an article about negative reimbursement. The article opens with the following: “Negative reimbursement happens when the beneficiary cost sharing, such as coinsurance and/or deductible, exceeds the reimbursement due to the provider. Medicare Administrative Contractors (MACs) are instructed to withhold payments if the Medicare deductible/coinsurance is more than the reimbursement rate. For example, if the set deductible for an inpatient stay is $100 and the reimbursement for the stay is $95, Medicare will show a negative $5 for the reimbursement amount. Further examples are provided in this article.”

April 28, 2020: Noridian Announcement: Outpatient Therapy A/B Physical, Occupational, and Speech Language Pathology Webinar – May 28, 2020

The Noridian Provider Outreach and Education (POE) staff announced they are hosting this webinar on May 28, 2020. This webinar includes:

• Certification and Re-certification,
• Coding and Billing,
• Maintenance Services,
• CMS and Noridian Resources.

They advise providers that you can sign up for this webinar and other events of interest by visiting the Noridian Schedule of Events.

April 29, 2020: WPS GHA Medicare eNews: June 9, 2020 Hospital Notices of Non-Coverage Webinar

WPS announced they will be hosting this webinar that will cover the different notices of non-coverage issued by hospitals and clarifies when to issue each. The following notices will be covered during this presentation:

• Hospital-Issued Notices of Noncoverage (HINNs) 1, 10, 11, and 12
• Important Message from Medicare (IM) and the Detailed Notice of Discharge (DND) (CMS-R-193 and CMS-10066)
• Medicare Outpatient Observation Notice (MOON) (CMS-10611)
• Advance Beneficiary Notice of Noncoverage (ABN) (CMS-R-131)

You can sign up for this course through the WPS Learning Center.

May 4, 2020: WPS GHA eNews: Procedure Code 94762 – Are You Billing Correctly?

In their May 4th eNews, WPS noted that procedure code 94762 represents a continuous overnight pulse oximetry service. Further, they have recently evaluated claim data for this service. The analysis compared Jurisdiction 5 (J5) and Jurisdiction 8 (J8) claim submission rates to national data. The data showed J5 providers billing Type of Bill 12X submitted this code twice as often providers in the rest of the country. WPS encourages all providers to review their records to ensure they are billing the procedure correctly. You can find information in our resource Continuous Overnight Pulse Oximetry (CPT 94762) - Evaluate Use.

May 4, 2020: Palmetto GBA Daily eNewsletter: CERT Task Force Education Material

Palmetto GBA reminds provider that the Medicare A/B Contractor CERT Task Force is a joint effort of the Part A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. They also encourage providers to review the CERT Task Force Educational Material available on their website and share with your staff.

May 5, 2020: Palmetto GBA Daily eNewsletter: Spring Virtual Tour

Palmetto GBA announced they will be presenting their first ever Medicare Part A Spring Virtual Tour for Jurisdictions J and M. There will be two days of sessions with presenters from the following:

• The Provider Outreach and Education (POE) Team,
• The Appeals Department,
• Medical Review, Audit and Reimbursement,
• MCG Health, and
• C2C Solutions.

You can read more about this event and select sessions you would like to register for on the JJ/JM Part A Springing into Summer Virtual Tour 2020: June 8-9, 2020 webpage.

May 8, 2020: Noridian JF: Sleep Lab Credentialing: Polysomnography and Other Sleep Studies Retirement – Effective May 14, 2020

Noridian provided the following Notice in their daily eNewsletter. Even though they are retiring this article (A57698), Noridian cautions against a change in your current practice.

This coverage article has been retired under contractor numbers: 02101 (AK), 02201 (ID), 02301 (OR), 02401 (WA), 03101 (AZ), 03201 (MT), 03301 (ND), 03401 (SD), 03501 (UT), and 03601 (WY).

Effective Date: May 14, 2020
Summary: Coverage articles may be retired due to lack of evidence of current problems or CMS may have issued guidance regarding national coverage. The Noridian guidance in the retired article may still be helpful in assessing medical necessity. Where providers have adjusted their billing and coding practices to correspond to the guidance in a coverage article, they will want to be very careful in departing from these practices just because the article is retired. Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is a coverage article in place.

Note: Noridian JE also announced the retirement of their Polysomnography and Other Sleep Studies Article (A57697) effective May 14, 2020.

May 15, 2020: Palmetto GBA Daily Newsletter: Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Webcast

Palmetto will be hosting this webcast on June 1, 2020. Their Medical Review subject matter experts will be available to discuss and answer questions about the current TPE model. This announcement includes a link for you to register for this event.

May 15, 2020: Palmetto GBA Daily Newsletter: Appeals and Clerical Error Reopenings Module 

Palmetto notes this “updated module provides education on correcting incomplete and/or invalid submissions, correcting claims with medically denied lines, clerical error reopening, and redetermination requests. There is also a further explanation on the submission of documentation for a clerical error reopening (bilateral procedure) and on adding late charges during the appeal process. A new section, Correcting Inpatient Discharge Status, was added to the module. Please review the updated module and share it with your staff.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates that span from May 5th through May 11th.

May 5, 2020: Advanced Persistent Threat (APT) Groups are Exploiting the COVID-19 Pandemic

The United States Department of Homeland Security (DHS) Cybersecurity and Infrastructure Security Agency (CISA) and the United Kingdom’s National Cyber Security Centre (NCSC) released a Joint Alert highlighting ongoing activity by APT groups against organizations involved in national and international COVID-19 responses. In addition to this alert including a link to a graphical summary of joint alerts, the May 5th alert also includes information about the following:

• COVID-19 Related Targeting,
• Targeting of pharmaceutical and research organizations, and
• COVID-19 Related Password Spraying Activity.

May 5, 2020: FDA Continues to Update FAQs on Testing for SARS-CoV-2

The FDA has recently added several FAQs to their growing list of questions related to Testing for SARS-CoV-2. As of May 5th, FAQs Topics available on this webpage include the following:

• What Laboratories and Manufacturers are Offering Tests for COVID-19?
• General FAQs
• What If I Do Not Have...?
• Clinical Laboratory Diagnostic Test FAQs
• Test Kit Manufacturer Diagnostic Test FAQs
• Serology/Antibody Test FAQs

The FDA plans to update this page regularly and provides the opportunity for you to sign up for email alerts.

May 5, 2020: OCR Issues Guidance on Covered Health Care Providers and Restrictions on Media Access to Protected Health Information (PHI) about Individuals in Their Families

This Guidance was issued to remind covered health care providers that the HIPAA Privacy Rule does not permit giving media and film crews access to facilities where patients’ PHI will be accessible without the patients’ prior authorization. Per the OCR Director Roger Severino, “The last thing hospital patient’s need to worry about during the COVID-19 crisis is a film crew walking around their bed shooting ‘B-roll…Hospitals and health care providers must get authorization from patients before giving the media access to their medical information, obscuring faces after the fact just doesn’t cut it.”

May 6, 2020: Memorandum (QSO-20-29-NH): Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes

In addition to CMS indicating an interim Final Rule is to be published May 8, 2020, the Memorandum Summary also included the following:

• COVID-19 Reporting Requirements: CMS is requiring NHs to report COVID-19 facility data to the CDC and to residents, their representatives, and families of residents in facilities.
• Enforcement: failure to report in accordance with 42 CFR 483.80(g) can result in an enforcement action.
• Updated Survey Tools: CMS has updated survey for Nursing Homes to reflect COVID-19 reporting requirements.
• COVID-19 Tags:
• F884: COVID-19 Report to CDC
• F885: COVID-19 Reporting to Residents, their Representatives, and Families
• Transparency: CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholder, or the general public. The COVID-19 public use fill will be available on https://data.cms.gov/.

Enforcement Actions specific to COVID-19 Tag F885: If it is determined that facility failed to comply with the requirement to report COVID-19 related information to the CDC, this will result in an enforcement action. Regulations require a minimum of weekly reporting, and noncompliance with this requirement will receive a deficiency citation and results in a civil monetary penalty (CMP) imposition.

• Facilities will have an initial two-week grace period to begin reporting cases in the NSHN system (period ends 11:59 p.m. on May 24, 2020).
• Facilities that fail to being reporting after the third week (by 11:59 p.m. on May 31st) will receive a warning letter reminding them to begin reporting required information to the CDC.
• Facilities that have not started reporting in the NSHN system by 11:59 p.m. on June 7th, CMS will impose a per day (PD) CMP of $1,000 for one day for failure to report that week.
• For each subsequent week that a facility fails to submit the required report, the noncompliance will results in an additional one-day PD CMP imposed at an amount increased by $500.

May 7, 2020: New YouTube Video with Guidance for Certifying Deaths Due to COVID-19

The National Centers for Health Statistics (NCHS) is responding to COVID-19 with new resources to monitor and report deaths. On April 2nd the document Guidance for Certifying Deaths Due to Coronavirus Disease 2019 (COVID-19) was posted on the CDC’s National Vital Statistics System (NVSS) Coronavirus Disease (COVID-19) Death Data and Reporting Guidance webpage. This document provides guidance to death certifiers on proper cause-of-death certification for cases where confirmed or suspected COVID-19 infection resulted in death. You can also find provisional death counts for COVID-19 (updated daily Monday through Friday) and NVSS COVID-19 Alerts on this webpage.

On May 8th the CDC announced that to supplement the previous published guidance, the CDC and NCHS has released a short video via the NCHS YouTube channel. The video runs about three minutes and can be accessed here. 

May 7, 2020: MLNConnects: COVID-19 Modified Ordering Requirements for Laboratory Billing

During the COVID-19 Public Health Emergency, CMS is relaxing billing requirements for laboratory tests (PDF) required for a COVID-19 diagnosis. Any health care professional authorized under state law may order tests. Medicare will pay for tests without a written order from the treating physician or other practitioner:

• If an order is not written, an ordering or referring National Provider Identifier (NPI) is not required on the claim
• If an order is written, include the NPI of the ordering or referring professional, consistent with current billing guidelines

For More Information:

• Laboratory Tests (PDF) with modified requirements
• Interim Final Rule

May 7, 2020: MLNConnects: New Coronavirus Specimen Collection Code

To identify and pay for specimen collection for COVID-19 testing, CMS established a new Level II HCPCS code for billing Medicare under the Outpatient Prospective Payment System (OPPS).

The new code, C9803, Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source, is effective for services provided on or after March 1, 2020. 

OPPS claims received on or after May 1, 2020, with Coronavirus Specimen Collection HCPCS Codes G2023 and G2024 will be returned to you with edit W7062. Resubmit returned claims as a packaged service to include Code C9803, when appropriate.

May 8, 2020: OIG Updates FAQs – Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the COVID-19 Public Health Emergency

On May 8th the following question was answered on the OIG’s COVID-19 FAQs webpage:

• During the time period subject to the COVID-19 Declaration, can a clinical laboratory that bills Federal health care programs for laboratory tests to diagnose COVID-19 pay a retail pharmacy a fee for certain costs that the retail pharmacy incurs related to testing collection sites?

The OIG is accepting inquiries from the health care community regarding the application of OIG's administrative enforcement authorities, including the Federal anti-kickback statute and civil monetary penalty (CMP) provision prohibiting inducements to beneficiaries (Beneficiary Inducements CMP).2 If you have a question regarding how OIG would view an arrangement that is directly connected to the public health emergency and implicates these authorities, please submit your question to OIGComplianceSuggestions@oig.hhs.gov.

May 8, 2020: Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing

Special Edition MLN Matters article SE20017 provides information for Pharmacies and other suppliers on how to enroll temporarily as an independent clinical diagnostic laboratory during the COVID-19 Public Health Emergency (PHE). This opportunity is open to Pharmacies and other suppliers currently enrolled in Medicare and those who are not currently enrolled in Medicare.

May 8, 2020: Telehealth Video: Medicare Coverage and Payment of Virtual Services

CMS has posted an updated video providing answers to common questions about the expanded Medicare telehealth services benefit under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

May 8, 2020: MLN Matters MM11784: Extension of Payment for Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)

Information in MM11784 affects supplies billing MACs for DMEPOS items and services provided to Medicare beneficiaries. Specifically, this article provides information about the implementation of the new April 2020 DMEPOS fee schedule amounts based on changes mandated by Section 372 (b) of the CARES Act.

May 11, 2020: Expanded Ability for Hospitals to Offer Long-term Care Services (“Swing Beds”)

On May 11th, CMS added additional blanket waivers to their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. CMS has indicated which blanket waivers are new since the 4/30 release of this document. Following is the details enabling hospitals to provide “swing bed” services:

Expanded Ability for Hospitals to Offer Long-term Care Services (“Swing-Beds”) for Patients Who do not Require Acute Care but do Meet the Skilled Nursing Facility (SNF) Level of Care Criteria as Set Forth at 42 CFR 409.31. (New since 4/30 Release)

Under section 1135(b)(1) of the Act, CMS is waiving the requirements at 42 CFR 482.58, “Special Requirements for hospital providers of long-term care services (“swing-beds”)” subsections (a)(1)-(4) “Eligibility”, to allow hospitals to establish SNF swing beds payable under the SNF prospective payment system (PPS) to provide additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF.

In order to qualify for this waiver, hospitals must:

• Not use SNF swing beds for acute level care.
• Comply with all other hospital conditions of participation and those SNF provisions set out at 42 CFR 482.58(b) to the extent not waived.
• Be consistent with the state’s emergency preparedness or pandemic plan.

Hospitals must call the CMS Medicare Administrative Contractor (MAC) enrollment hotline to add swing bed services. The hospital must attest to CMS that:

• They have made a good faith effort to exhaust all other options
• There are no skilled nursing facilities within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 public health emergency (PHE);
• The hospital meets all waiver eligibility requirements; and
• They have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.

This waiver applies to all Medicare enrolled hospitals, except psychiatric and long term care hospitals that need to provide post-hospital SNF level swing-bed services for non-acute care patients in hospitals, so long as the waiver is not inconsistent with the state’s emergency preparedness or pandemic plan. The hospital shall not bill for SNF PPS payment using swing beds when patients require acute level care or continued acute care at any time while this waiver is in effect. This waiver is permissible for swing bed admissions during the COVID-19 PHE with an understanding that the hospital must have a plan to discharge swing bed patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.”

Following is a list of the additional new blanket waivers since the 4/30 release of this CMS document:

• Hospitals Classified as Sole Community Hospitals (SCHs): CMS is waving distance requirements, “market share” and bed requirements for the duration of the Public Health Emergency.
• Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDHs): CMS is waiving the eligibility requirement that the hospital has 100 or fewer beds during the cost reporting period and the requirement that at least 60 percent of the hospital’s inpatient days or discharges were attributable to individuals entitled to Medicare Part A benefits during the specified hospital cost reporting period.
• Paid Feeding Assistance: CMS is modifying the minimum training timeframe requirements from 8 hours to 1 hour in length.
• Occupational Therapists (OTs), Physical Therapists (PTs) and Speech Language Pathologists (SLPs) to Perform Initial and Comprehensive Assessment for all Patients
• Furnishing Dialysis Services on the Main Premises: CMS is waiving the requirement that dialysis facilities provide services directly on its main premises or on other premises that are contiguous with the main premises.
• Specific Life Safety Code (LSC) for Multiple Providers: CMS is waiving and modifying requirements related to Alcohol-based Hand-Rub (ABHR) Dispensers, Fire Drills, and Temporary Construction.

MMP encourages you to read about all of the new blanket waivers.

Jig-Saw Puzzles: Gathering all of the Pieces

Depending on the size of a jig-saw puzzle, putting it together successfully can be a very simple or daunting task. Keys to success include having a clear picture of what the puzzle is supposed to look like and not being left with missing pieces.

CMS finalized a Prior Authorization Program for certain hospital procedures in the Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) CY 2020 Final Rule. Since then I have been waiting for sub-regulatory guidance to provide additional “puzzle pieces” needed for Provider success with this Program.

CMS released the first puzzle piece on April 24, 2020 in the form of a One-Time Notification (Transmittal 10061/Change Request (CR) 11671) titled Provider Education for Required Prior Authorization (PA) of Hospital Outpatient Department (OPD) Services. This CR provides Medicare Administrative Contractors (MACs) with instructions for provider education regarding this Program. The CR also includes a template letter to be sent to Providers, a template letter to be sent to Practitioners, and a table of the HCPCS procedure codes included in this Program. The effective and implementation date of this CR is May 26, 2020.

So now we wait for additional puzzle pieces from the MACs. While we wait, this article is meant to equip you with additional puzzle pieces from the Final Rule, data analysis for Alabama, Georgia and Tennessee utilizing RealTime Medicare Data (RTMD) Medicare Fee-for-Service paid claims data and leave you with potential next steps for implementing a process at your hospital.

Puzzle Piece: CMS Data Analysis

A significant “piece” of CMS’ responsibility to protect the Medicare Trust Funds is data analysis. Specific to the Prior Authorization Program, CMS noted in the Final Rule that they had conducted a compare of “the total number of Medicare beneficiaries served by providers to help ensure the continued appropriateness of payment for services furnished in the hospital outpatient department (OPD).” Following are highlights from CMS’ data analysis in the CY 2020 OPPS/ASC Final Rule:

• CMS “targeted services that represent procedures that are likely to be cosmetic surgical procedures and/or are directly related to cosmetic surgical procedures that are not covered by Medicare, but may be combined with or masquerading as therapeutic services.”
• Over 1.1 billion OPD claims were reviewed during the 11-year period from 2007 through 2017.
• On average, the overall rate of OPD claims submitted for payment increased annually by an average rate of 3.2 percent.
• The 3.2 percent increase equated to an increase in claims submitted for payment from approximately 90 million in 2007 to approximately 118 million in 2017.
• On average, the annual rate-of-increase in the Medicare allowed amount (“the amount that Medicare would pay for services regardless of external variables, such as beneficiary plan differences, deductibles, and appeals”) was 8.2 percent.
• The 8.2 percent equated to an increase in the total Medicare allowed for OPD services claims from $31 billion in 2007 to $65 billion in 2017.
• The 8.2 percent increase exceeded the average per year overall health care spending increase of 5.8 percent during 2007 through 2017.
• During this same time, the average annual increase in the number of Medicare beneficiaries per year was only 1.1 percent.
• Higher than expected volumes were found in five general categories of services (blepharoplasty, Botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation).

CMS believes “the increases in volume associated with certain covered OPD services described…are unnecessary because the data show that the volume of utilization of these services far exceeds what would be expected in light of the average rate-of-increase in the number of Medicare beneficiaries.”

Puzzle Piece: Program Definitions

• Prior Authorization Request (PAR): a process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the service is provided to the beneficiary and before the claim is submitted.
• Provisional Affirmation: A preliminary finding that a future claim for the service will meet Medicare’s coverage, coding, and payment rules.
• List of Services: The list of hospital outpatient department services requiring prior authorization. This list includes blepharoplasty, Botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

Puzzle Piece: About the Program

• The implementation date for this program is July 1, 2020.
• Prior authorization for the five categories of services listed above will be a condition of Medicare payment.
• A PAR will need to include all documentation necessary to show the service meets applicable Medicare coverage, coding and payment rules.
• Claims submitted that require prior authorization that have not received a provisional affirmation of coverage will be denied.
• A provisional affirmation does not preclude a claim being denied due to a technical requirement that could only be evaluated after the claim has been submitted for formal processing or information not available at the time of the prior authorization request is received.
• MACs will be the Contractor reviewing PARs for compliance with applicable Medicare coverage, coding, and payment rules.
• An issuance of Affirmation or Non-Affirmation is to be issued by the MAC within 10 business days of a request.
• The Program will allow a PAR for an “expedited review when a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.” Documentation to support this must be submitted with the request.
• Expedited reviews are to be completed by the MAC within 2 business days.
• If a provider receives a Non-Affirmation they are allowed to resubmit a request with additional relevant documentation.
• Non-affirmations are not appealable, but the provider will receive a detailed explanation as to why the request was non-affirmed can resubmit an unlimited number of requests.
• When a claim is submitted without provisional affirmation, it will be denied. The denial is considered an initial determination and the provider may submit a redetermination request.
• Claims associated with or related to a service for which a claim denial is issued will also be denied. These associated services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. The associated claims would be denied whether a non-affirmation was received or the provider did not request a prior authorization request.

Puzzle Piece: Potential Provider Exemption

• CMS may elect to exempt a provider from the PA process if a provider demonstrates compliance with Medicare coverage, coding, and payment rules.
• Providers achieving a prior authorization provisional affirmation threshold of at least 90 percent during a semiannual assessment would be exempted.
• An exemption would remain in effect until CMS elects to withdraw the exemption.
• CMS anticipates that exemptions will take approximately 60 calendar days to effectuate.
• If evidence becomes available based on claims reviews that a provider has begun to submit claims not payable based on Medicare’s coverage, coding and payment rules then CMS might withdraw an exemption.
• If the rate of non-payable claims submitted becomes higher than 10 percent during a semiannual assessment, CMS will consider withdrawing an exemption.

Puzzle Piece: CMS Response to Comments

• Why the Prior Authorization Program is limited to Hospital ODPs: At this time, this process is limited to hospital OPDs as the program is being adopted as part of the OPPS Final Rule. CMS will monitor data and consider additional program integrity oversight if shifts to other settings for these procedures occur (i.e., Ambulatory Surgery Centers).
• Why Choose the Prior Authorization Process? CMS believes “that the use of prior authorization in the OPD context will be an effective tool in controlling unnecessary increases in the volume of covered OPD services by ensuring that the correct payments are made for medically necessary OPD services.”
• Who is Responsible for Obtaining Prior Authorization? CMS indicated that “in light of the different arrangement that could exist I different hospitals, we determined that enabling either the physician or the hospital to submit the prior authorization request on behalf of the hospital outpatient department was the best approach, though the hospital ultimately remains responsible for ensuring this condition of payment is met.”
• Communicating Prior Authorization Decisions as Unique Tracking Number (UTN): All PARs submitted will be assigned a UTN. The UTN must be included on any claim submitted for the services listed. The UTN will be used to verify compliance with the prior authorization process.
• Claim Denials to Include Associated Claims: “Any claims associated with or related to a service that requires prior authorization for which a claim denial is issued would also be denied. These associated services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services.”
• Claims could still be reviewed by CERT and OIG: It is possible for a claim subject to prior authorization to fall within a CERT sample. In this situation, the claim would not be protected from the CERT audit. In addition, the Office of Inspector General’s (OIG) authority to audit claims is not impacted by the protection from future audits provided by the provisional affirmation prior authorization decision.
• Non-Affirmations: Impact on Care for the Beneficiary: With regard to the impact on care for those beneficiaries for which hospitals receive non-affirmations, CMS specifically chose services that are often cosmetic and believes that it is appropriate to deny such services in the case of a non-affirmation, because a non-affirmation would indicate that Medicare’s coverage, coding, and/or payment rules for the service are not being met.
• How often are Prior Authorization Requests Affirmed? Our experience in our other prior authorization and pre-claim review processes has been that approximately 95 percent of submissions are affirmed within two requests, and that the impact of non-affirmation decisions has been minimal for necessary, covered services.
• Prior Authorization for a Specific Course of Treatment: CMS acknowledged that there are circumstances when a prior authorization could apply for a specific course of treatment such a botulinum toxin injections and will allow for prior authorization requests for a number of treatments over a specific period of time.

Puzzle Piece: RealTime Medicare Data (RTMD) Claims Analysis

As I so often do, I turned to our sister company RTMD to have an understanding of the actual volume of claims that will be impacted by this Program. Specifically, I reviewed all paid claims for the applicable HCPSC codes for calendar year 2019 for the Jurisdiction J MAC (Alabama, Georgia, and Tennessee).

Puzzle Piece: CMS March 2020 MLN Booklet – Hospital Outpatient Prospective Payment System (ICN MLN006820)

This MLN Booklet was updated in March of this year. In the Innovation section of the booklet, CMS informs the reader that beginning July 1, 2020, you must request prior authorization for the outpatient department services in the Program and that medical necessity documentation requirements remain the same. So, unless something unforeseen happens between now and July 1, it appears the Prior Authorization requirement is a go.

Missing Puzzle Piece: CMS Additional Resources

CMS informs Providers and Physicians in the template letters to be sent by the MACs that “To facilitate open and ongoing dialogue with both patients and physician/practitioners, and to support program transparency, CMS has established a dedicated website for prior authorization program for Certain Hospital Outpatient Department (OPD) Services with comprehensive information for patients, suppliers, and physician/practitioners at: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services.”

CMS has indicated that they will post additional information about this program on this website. However, at the time this article was written, the last time this webpage was modified was January 17, 2020. I encourage you to check this webpage often for any additional information.

Missing Puzzle Piece: MAC Provider and Physician Education

Also, at the time this article was written, First Coast Services the JN MAC for Florida was the only MAC to have posted information about this program on their website.

The first “piece” of information was a May 1st article under the Part A Medical Review section of their website that includes a background and general information about the program and a table of applicable Local Coverage Determinations and Local Articles for the procedures included in this program.

The second “piece” of information was an announcement to participate in one of two webcasts to learn about the prior authorization program. (Thursday, May 28 or Thursday, June 11). Providers can access information about this event under the Education section of their website.

Putting the Puzzle Pieces Together

Now that you are equipped with many of the “pieces” for success and July 1st is less than two months away following are things to consider as you put your processes in place:

• Decide who the key stakeholders are that need to be involved in this process? (i.e., Outpatient Department Nurse Manager, Scheduling, Physicians performing these procedures, Physician Advisor, etc.)
• Work with your IT Department to understand the anticipated volume at your hospital and identify which Physicians are performing these procedures.
• Several other insurance plans already requires prior authorization for these procedures. With that in mind, determine who is currently completing this process at your hospital. Is it feasible for them to incorporate prior authorization for Medicare claims in their process?
• Who needs to receive education about this program (i.e. Physicians performing the procedures, Outpatient Department Staff, Chief Medical Officer, and Physician Advisors)?
• How will the Prior Authorization UTN be communicated to the Physician Office and Hospital Billing Department?
• Identify applicable Medicare Coverage Determinations (NCDs, LCDs, and Articles) specific for the procedures included in this program?
• Who will be responsible for the Appeals Process if a claim is denied?

MMP has sent a question to Palmetto GBA the JJ and JM MAC to find out what their plan is for education. In the meantime we will continue to monitor the CMS and MAC websites and provide you with any additional “puzzle pieces” in future Wednesday@One newsletters.