Knowledge Base Category -

“The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”

• Source: Appendix A: Economic Analysis of FY 2025 IPPS Proposed Rule

New Technologies Eligible for Add-On Payment (NTAPs) Background

Effective for discharges beginning on or after October 1, 2002, Section 1886(d)(5)(K)(i) of the Act requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies under the payment system under the subsection which establishes the system for paying for the operating costs of inpatient hospital services.

The system of payment for capital costs is established in section 1886(g) of the Act. For this reason, capital costs are not included in the add-on payments for a new medical service or technology.

NTAPs are not budget neutral and the “newness” for payment is limited to the 2-to-3-year period after the point at which data begin to become available reflecting the inpatient hospital code assigned to the new service or technology.

There are three pathways for a new service or technology to be approved for the add-on payment (Traditional pathway, Certain Antimicrobial Products Alternative Pathway, and Certain Transformative New Devices Alternative Pathway).

For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS reviews the application based on the information provided by the applicant only under the alternative pathway specified by the applicant at the time of new technology add-on payment application submission. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable FDA designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”

Coding NTAPs

Section X New Technology was added to ICD-10-PCS effective October 1, 2015. CMS has indicated (https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Section-X-New-Technology-.pdf) that “Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures.”  To receive payment for an eligible NTAP, the applicable section X New Technology ICD-10-PCS code must be on the claim submitted for adjudication.

NTAPs by the Numbers

For FY 2025, CMS has proposed to:

• Discontinue 7 technologies no longer considered to be “new,”
• Continue coverage for 24 technologies they consider to still be “new,” and
• Have assessed 26 applications.

For the 24 technologies that CMS considers to still be “new,” CMS estimates that collectively there will be 50,910 cases with an estimated total financial impact of just over $416 million.

Based on preliminary information from the FY 2025 applicants for new technology approval, CMS estimates the collective impact to be $345.3 million.

FY 2025 NTAP Program Proposals

Consistent with CMS’ Sickle Cell Disease Action Plan, CMS is proposing to increase the NTAP percentage from 65% to 75% for a gene therapy that is indicated specifically for the treatment of sickle cell disease (SCD) (subject to CMS’ determination in the FY 2025 IPPS final rule that any applicable gene therapy(ies) indicated and used specifically for treatment of SCD meets the criteria for approval for NTAP).

CMS has also proposed to use the October 1^st start of a new fiscal year, instead of April 1^st, to determine whether a technology is within its 2- to 3- year newness period. This change would be effective in FY 2026 for new applicants and extending the NTP an additional year for technologies initially approved in FY 2025.

CMS is accepting comments on the proposed rule through June 10, 2024.

Resource

FY 2025 IPPS Proposed Rule CMS webpage:

https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2025-ipps-proposed-rule-home-page

As part of the Annual Proposed and Final Rule process, CMS evaluates diagnosis codes and their impact on hospital resource utilization. The following timeline of events highlights CMS efforts from FY 2008 to what is being proposed in the FY 2025 IPPS Proposed Rule.

FY 2008 IPPS Final Rule

CMS described their process for establishing three different levels of CC severity into which diagnosis codes would be subdivided. The categorization of diagnoses as a MCC, a CC, or a NonCC was accomplished by evaluating each diagnosis code to determine the extent to which its presence as a secondary diagnosis would result in increased hospital resource use.

FY 2020 IPPS Proposed Rule

CMS noted with the transition to ICD-10-CM and the significant changes to diagnosis codes since FY 2008, a new comprehensive analysis was warranted. At that time, CMS proposed changes to the severity level designation for 1,492 ICD-10-CM diagnosis codes. After consideration of comments received, the proposal was not finalized.

October 8, 2019

CMS held a listening session that included a review of the methodology CMS utilized to mathematically measure the impact on resource use.

FY 2021 IPPS Final Rule

CMS discussed their plan to continue a comprehensive CC/MCC analysis, using a combination of mathematical analysis of claims data and the application of the following nine guiding principles:

1. Represents end of life/near death or has reached an advanced stage associated with systemic physiologic decompensation and disability,
2. Denotes organ system instability or failure.
3. Involves a chronic illness with susceptibility to exacerbations or abrupt decline.
4. Serves as a marker for advanced disease states across multiple different comorbid conditions.
5. Reflects systemic impact.
6. Post-operative/post-procedure condition/complication impacting recovery.
7. Typically requires higher level of care (that is, intensive monitoring, greater number of caregivers, additional testing, intensive care unit care, extended length of stay).
8. Impedes patient cooperation or management of care or both.
9. Recent (in the last 10 years) changes in best practice, or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use.

FY 2025 IPPS Proposed Rule: CMS indicates they have continued to solicit feedback since the nine guiding principles were first introduced in the FY 2021 IPPS Final Rule but have received no additional feedback or comments since then. They are now proposing to finalize the nine guiding principles to be used in combination with mathematical analysis of claims to determine the extent to which the presence of a diagnosis code as a secondary diagnosis resulting in increased hospital resource use.

FY 2025 Proposed ICD-10-CM Diagnosis Severity Changes

For FY 2025, CMS is proposing the addition of four ICD-10-CM codes to the MCC list, the addition of twenty-nine ICD-10-CM codes to the CC list, and eighteen ICD-10-CM codes be deleted from the CC list.

Question:

A few of our providers document that conditions are hospital-acquired while others document healthcare-acquired.  Are these two terms synonymous?  Are they both assigned as nosocomial?

Answer: Yes.  Per Coding Clinic, Fourth Quarter 2013:  Page 118,

The term hospital-acquired indicates that a patient has contracted a condition from being in the hospital setting, e.g., inpatient, outpatient, emergency department, etc.

The term healthcare-acquired indicates that a patient has contracted a condition from being in another type of healthcare facility, besides a hospital, e.g., nursing home, rehab, etc.

A documented acquired condition may include pneumonia, sepsis, influenza, etc.

Both documented hospital-acquired conditions and healthcare-acquired conditions can be assigned as a nosocomial condition (Y95), which is found in the External Cause of Morbidity section of the ICD-10-CM Alphabetic Index, under Nosocomial.

Reference

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2013:  Page 118

Compliance Education Updates

March 2024: MLN8659122: MLN Fact Sheet Original Medicare vs. Medicare Advantage Updated

CMS updated the payment rules for patients enrolled in Medicare Advantage Organizations. https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf

April 2024: MLN Educational Tool Medicare Preventive Services Revised

CMS has revised this tool to clarify social determinants of health information, add a link to the most current and comprehensive list of ICD-10 codes for bone mass measurement and colorectal cancer screening, add coding, coverage, and payment information for COVID-19 vaccine and administration, and replace Hepatis B information with a link to the Hepatitis B screening service. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Other Updates

March 26, 2024: GAO Improper Payments: Information on Agencies’ Fiscal Year 2023 Estimates

In this report the Government Accountability Office (GAO) indicates the importance of this information due to the fact that “improper payments – those that should not have been made or were made in the incorrect amount – have consistently been a government-wide issue. Since fiscal year 2003, cumulative improper payment estimated by executive branch agencies have totaled about $2.7 trillion. Reducing improper payments is critical to safeguarding federal funds.” With an estimated $51 billion in estimated improper payments HHC’s Medicare (Medicare Fee-for-Service (Parts A and B), Medicare Advantage (Part C), and Medicare Prescription Drug (Part D)) had the highest estimated improper payments across 14 government agencies.

https://www.gao.gov/assets/d24106927.pdf?emci=4185bdfa-36ed-ee11-aaf0-002248223794&emdi=645794fb-40ed-ee11-aaf0-002248223794&ceid=7931774

March 27, 2024: CMS Releases FY 2025 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1804-P)

CMS is proposing to update payment rates by 2.8 percent. This proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, associated impact analysis, and IRF Quality Reporting Program (QRP). Also included are two requests for information (RFIs) (1) Future Measure Concepts for the IRF QRP, and (2) Creating and IRF QRP Star Rating System.

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1804

CMS Proposed Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/rules-related-files/cms-1804-p

IRF QRP webpage: https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility

March 28, 2024: CMS Issues 3 FY 2025 Proposed Rules: SNF, Inpatient Psych and Hospice

FY 2025 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1802-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-25-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1802-p

FY 2025 Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Quality Reporting (IPFQR) Updates Proposed Rule (CMS-1806-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-medicare-inpatient-psychiatric-facilities-prospective-payment-system-ipf-pps-and

• Of note, CMS has proposed to increase the per treatment amount for electroconvulsive therapy (ECT) from the current FY 2024 payment per treatment of $385.58 to $660.30. CMS believes this increase would help ensure that patients who need ECT are more able to access it. (ECT CPT 90870)

Medicare MLN Articles

March 20, 2024: MLN MM11003: Electronic Medical Documentation Requests via the Electronic Submission of Medical Documentation System – Revised

This MLN was first released February 1, 2019. In the March 20, 2024 revision to this article, CMS has added information about the implementation of a new feature to accept review outcome letters during October 2023 release. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf

April 4, 2024: MLN MM13577: Ambulatory Surgical Center Payment Update – April 2024

Make sure your billing staff knows about new CPT and HCPCS codes, Device code changes, iDose TR (travoprost intracameral implant) for the treatment of glaucoma, Drug and biological code changes, and Skin code updates. https://www.cms.gov/files/document/mm13577-ambulatory-surgical-center-payment-update-april-2024.pdf

April 15, 2024: MLN MM13574: DMEPOS Fee Schedule: April 2024 Quarterly Update – Revised

This MLN article was revised on April 15^th to show the addition of 4 HCPCS Level II codes to Common Working File category 58. CMS also revised the effective date and the web address of Change Request (CR) 13574). https://www.cms.gov/files/document/mm13574-dmepos-fee-schedule-april-2024-quarterly-update.pdf

April 15, 2024: MLN MM13587: Medicare Claims Processing Manual Update: Inpatient Rehabilitation Facility

CMS advised that you make sure your billing staff know that hospitals may open a new IRF unit at any time during the cost reporting year, and any IRF unit excluded during a cost reporting Year will stay excluded for the rest of the cost reporting year. https://www.cms.gov/files/document/mm13587-medicare-claims-processing-manual-update-inpatient-rehabilitation-facility.pdf

Coverage Updates

April 15, 2024: CMS Releases Fact Sheet for Potential NCD for Preexposure Prophylaxis (PrER) Using Antiretroviral Drugs to Prevent HIV

CMS is sharing this information to encourage pharmacies and other interested parties to prepare for a potential National Coverage Determination (NCD) for PrEP Using Antiretroviral Drugs to Prevent HIV.

• National Coverage Analysis (NCA) Tracking Sheet: https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?NCAId=310
• CMS Fact Sheet: https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf

April 16, 2024: MLN MM13512: National Coverage Determination 20.7: Percutaneous Transluminal Angioplasty

This article provides education about the changes in coverage for PTA of the carotid artery concurrent with stenting effective October 11, 2023:

• Patients don’t have to enroll in a clinical trial.
• Facilities don’t need CMS approval to perform this service.
• You must engage in a formal shared decision-making (SDM) process with the patient. This must include documentation of four key elements outlined in this MLN article.
• MACs can decide if this service is covered if it’s not addressed in this NCD.

Note, your MAC will adjust claims processed in error that you bring to their attention. https://www.cms.gov/files/document/mm13215-national-coverage-determination-207-percutaneous-transluminal-angioplasty.pdf

Did You Know?

In mid-February CMS announced a new Prior Authorization Demonstration for certain Ambulatory Surgical Center (ASC) Services.

Why It Matters?

In their announcement, CMS references the nationwide prior authorization process for certain hospital outpatient department (OPD) services that was finalized in the Calendar Year 2020 OPPS Final Rule and implemented on July 1, 2020. The initial services subject to prior authorization in 2020 were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.

This 5-year demonstration project design will include ASC providers that:

• Submit claims with place of service 24 (Ambulatory Surgical Center) for one of the five previously mentioned services,
• Are in one of the ten demonstration states (California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York), and
• Submit claims to Medicare fee-for-service.

CMS plans to implement this demonstration for all ten states in one phase and they do not anticipate beginning the demonstration earlier than the fall of 2024.

Why now? CMS indicates that data from 2019 to 2021 shows there has been a significant increase in utilization in the ASC for the above five services and they were selected “for inclusion in this demonstration, based upon problematic events, data, trends, and potential billing behavior impacts of the OPD Prior Authorization Program which requires prior authorization as a condition of payment for these services.”

What Can You Do?

Take the time to read CMS Form CMS-10884 to learn about details of the demonstration design and justification for the need for this demonstration.

Since “the documentation requirements that MACs already have for the services in the OPD program, including local coverage determinations (LCDs), are applicable to these ASC services as well” visit your MACs website to find related resources. For example, Palmetto GBA Jurisdiction J (JJ), the MAC for Tennessee and Georgia has several resources available on their Medical Review / Outpatient Prior Department Prior Authorization (PA) webpage (i.e., Blepharoplasty and Medical Necessity Module).

Finally, if you are in one of the demonstration states, share this information with key stakeholders at your facility.

Question:

We have a patient record where documentation stated the patient had two large blisters on her RLE that received wound care. The patient had a history of PVD and had the left great toe amputated during a prior hospitalization. In the encoder, Blister is assigned to S80.821A, Blister (nonthermal), Right Lower Leg. However, in this case there was no documentation of trauma occurring in this patient, so I don’t think that code is appropriate. What code should be assigned for blisters of the RLE?

Answer:

You are correct about not assigning the trauma code as there was no documentation of trauma causing the blisters. There was documentation in the record of more than one blister, so under Blister in the encoder, there is an option of coding this to, “multiple, skin, nontraumatic”. The correct code in this case for blisters of the RLE is, Other Skin Changes (R23.8).

Resource:

TruCode Encoder

Coverage Updates

February 29, 2024: Solid Organ Transplant Rejection Billing & Coding Articles Updated

CMS published an announcement indicating that the MACs have provided updated Solid Organ Transplant Rejection billing and coding articles. CMS notes “these updates restore the table of solid organ allograft rejection tests, as requested by interested parties, and removes the explanatory language that may have confused physicians and patients. The March 2023 articles have been removed and the new articles can be found on the Medicare Coverage Database

Full CMS statement: https://www.cms.gov/newsroom/press-releases/cms-statement-current-status-blood-tests-organ-transplant-rejection-0

March 6, 2024: CMS National Coverage Determination (NCD) Dashboard

CMS updated this document on February 15, 2024 and notes that they prioritize “NCD requests based on the magnitude of the potential impact on Medicare program and beneficiaries. As of February 15^th, there are seven topics on the NCD Wait List, two Open NCDs, and 3 NCDs have been finalized in the past 12 months. Links to all NCDs are included in this document. https://www.cms.gov/files/document/ncd-dashboard.pdf

March 6, 2024: Allogeneic Hematopoietic Stem cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) Final Decision Memo

CMS has published a final decision memo and has finalized the proposed HSCT for MDS using bone marrow or peripheral blood stem cell products and is adding coverage to the final NCD to include the use of umbilical cord blood stem cell products. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=312

Compliance Education Updates

March 7, 2024: Provider Compliance Fast Facts: Comprehensive Outpatient Rehabilitation Facility (CORF) Services: Prevent Claim Denials

CMS notes that the CORF Services improper payment rate in 2022 was 89.7% and advises you to review the CORF services provider compliance tip for information on requirements for claim payment, documentation requirements and example of improper payment, and links to additional resources. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/fast-facts/comprehensive-outpatient-rehabilitation-facility-services-prevent-claim-denials

March 11, 2024: Updated CERT A/B MAC Outreach & Education Task Force PowerPoint

The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force PowerPoint presentation was updated on March 11^th.  In this six-slide presentation, the Task Force includes links to their most popular educational products and answers three questions:

• How are we reducing improper Medicare payments?
• How are the MACs and the CERT contractor different?
• What’s my MAC’s role in a CERT review?

CMS Resource: Understanding Medicare Advantage Plans

March 4, 2024: MLN MM13449: Stay of Enrollment

Make sure your staff knows about a new provider enrollment status called a stay of enrollment and updates to the Medicare Program Integrity Manual, Chapter 10. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

March 7, 2024: MLN MM13546: New Waived Tests

Make sure your billing staff is aware of the Clinical Laboratory Improvement Amendment (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13546-new-waived-tests.pdf

March 14, 2024: MLN MM13548: Medicare Claims Processing Manual Updates – HCPCS Billing Codes & Advance Beneficiary Notice of Non-coverage Requirements

Make sure your staff knows the HCPCS codes to bill and what CPT codes to not bill for an initial preventive physical exam (IPPE) and annual wellness visit (AWV) services. CMS also includes information about providing a patient an Advanced Beneficiary Notice of Non-coverage (ABN) in this article. https://www.cms.gov/files/document/medicare-claims-processing-manual-updates-hcpcs-billing-codes-advance-beneficiary-notice-non.pdf

March 18, 2024: MLN MM13554: Changes to the Laboratory National Coverage Determination Edit Software: July 2024 Update

Make sure your billing staff knows about newly available codes, recent coding changes, and how to find NCD coding information. Relevant laboratory NCD coding with changes July 2024 includes NCD 190.18 (Serum Iron Studies), 190.21B (Glycated Hemoglobin/Glycated Protein), and 190.31 (Prostate Specific Antigen). https://www.cms.gov/files/document/mm13554-changes-laboratory-national-coverage-determination-edit-software-july-2024-update.pdf

March 21, 2024: Transmittal R12552CP: April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)

This Recurring Update Notification (RUN) provides instructions on coding changes and policy updates that are effective April 1, 2024, for the Hospital OPPS. Updates include coding and policy changes for new services, pass-through drug, and devices, eleven new Proprietary Lab Analysis (PLA) codes and other items and services, for example payment for intensive cardiac rehabilitation services (ICR) provided by an off-campus, non-excepted provider-based department (PBD) of a hospital.

In the CY 2024 OPPS/ASC final rule, CMS excluded ICR from the 40 percent Physician Fee Schedule Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (ICR; with or without continuous ECG monitoring with exercise, per session) and G0423 (ICR; with or without continuous ECG monitoring without exercise, per session). “Under this change 100 percent of the OPPS rate for ICR is paid irrespective of the presence of the PN modifier on the claim…please not that claims for HCPCS A0422 and G0433 submitted with the PN modifier from January to April 2024 were paid at the 40 percent rate. However, upon the April IOCE release, an additional amount will be retroactively applied to these past claims so that they are paid at 100 percent of the OPPS rate.” https://www.cms.gov/files/document/r12552cp.pdf

MMP’s Medicare Compliance Assessment Tool (MedCAT) combines current Medicare Fee-for-Service (FFS) review targets (i.e., MAC, RAC, SMRC) with hospital specific Medicare FFS paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD).

In general, MedCAT Minute articles spotlight current contractor review activities. The focus of this article is RAC Issue 0210: Hypoglossal Nerve Stimulation (HNS) for Obstructive Sleep Apnea (OSA).

Background

For patients with OSA who are unable to tolerate CPAP, HNS is one available alternative treatment strategy. The American Academy of Otolaryngology (AAO) (2016) position statement indicates that “The AAO considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.” ¹

Medicare Coverage Guidance

In 2020, each Medicare Administrative Contractor (MAC) published a Local Coverage Determination (LCD) and related Billing and Coding Article (LCA) for HNS. In general, coverage guidance in each of the LCD’s includes the following statements:

“Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.”

In several of the MAC’s Response to Comments Articles, commenters requested that CPAP refusal or non-acceptance should be included with CPAP failure or intolerance as criteria. The refusal/non-acceptance should be clearly documented along with conversations of the benefits of CPAP and the limitations of HNS.

In each instance, the MAC responded to this request by noting that failure of conservative therapy should be tried and failed and or not tolerated prior to a surgical approach and no change was made to the LCD.

RAC Issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

RAC Issue 0210 was approved for review by CMS on June 7, 2022.

• Review Type: Complex
• Provider Type: Outpatient Hospital, Ambulatory Surgical Center, and Professional Services
• Issue Description: Hypoglossal Nerve Stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe OSA when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.
• Affected Code: CPT 64582
  • Note: This CPT code was effective on January 1, 2022.
• Applicable Policy References: The related National Coverage Determination (NCD) 2401.4.1 Sleep Testing for OSA and each of the MACs LCD and related Billing and Coding Articles are included in this section of the RAC Issue.

By July 1, 2022, all RACs had added this issue to their list of issues that they would review for all three listed provider types.

Meeting Medical Necessity and Documentation Gaps

Palmetto GBA, the Jurisdiction J MAC, has published an article highlighting requirements to meet criteria for HNS and indications when HNS would not be reasonable and necessary.