Knowledge Base Category -

Monthly, MMP provides a summary of Medicare Transmittals, related MLN Articles, Coverage Updates, CMS education resources and any other Medicare updates we believe to be pertinent to our readers. With the holiday season, December’s updates were released in last week’s Wednesday@One article. Since then, CMS has released additional MLN articles with updates effective early in January. For this reason, following is a list of pertinent updates that providers need to know before the end of January when our usual monthly article is published.

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

• Article Release Date: January 5, 2021
• What You Need to Know: The following major changes made in Change Request (CR) 12120 are highlighted in this MLN article:
• COVID-19 Laboratory Tests and Services Coding Update,
• CPT Proprietary Laboratory Analyses (PLA) coding changes effective October 6, 2020,
• Monoclonal antibody therapy product and administration codes for drugs granted emergency use authorizations (EUAs) to treat mild to moderate cases of COVID-19,
• New COVID-19 CPT vaccines and administration codes,
• New device pass-through categories, device offset from payment, transitional pass-through payments for designated devices, and alternative pathway for devices that have a Food and Drug Administration (FDA) Breakthrough Device designation,
• New HCPCS code describing the administration of subretinal therapies requiring vitrectomy,
• New HCPCS code describing nasal endoscopy with cryoablation of nasal tissue(s) and/or nerve(s),
• New HCPCS code describing peripheral intravascular lithotripsy (IVL) procedures,
• Comprehensive APCs (C-APCs) updates,
• Changes to the Inpatient-Only List (IPO) for CY 2021,
• Removals of selected National Coverage Determinations (NCDs) Effective January 1, 2021,
• Changes to some Opioid Treatment Program (OTP) – related codes,
• Change to the Status Indicator for HCPCS code P9099 (blood component or product not otherwise classified) from SI “ER” to SI “R,”
• Drugs, Biologicals, and Radiopharmaceuticals updates,
• Skin Substitutes,
• Reporting for certain Outpatient Department services (that are similar to Therapy Services)(“Non-therapy outpatient department services”) and are Adjunctive to Comprehensive APC Procedures,
• Payment Adjustment for Certain Cancer Hospitals Beginning CY 2021,
• Method to control for unnecessary increased in utilization of outpatient services /G0463 with Modifier PO,
• Changes to OPPS Pricer Logic,
• Updates to the Outpatient Provider Specific File (OPSF),
• Wage Index Policies in the CY 2021 OPPS,
• Coverage Determinations reminder, and
• General Supervision of Outpatient Hospital Therapeutic Services currently assigned to the Non-Surgical Extended Duration Therapy Services (NSEDTS) level of supervision.
• MLN Article MM12120: https://www.cms.gov/files/document/mm12120.pdf

January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: January 5, 2021
• What You Need to Know: This article details changes and billing instructions for policies implemented in the January 2021 Ambulatory Surgical Center (ASC) update. Following are key points from the related Change Request (CR) 12129 included in this MLN article are:
• Three new device pass through categories,
• Device offset from Payment,
• Device Pass-Through Payments,
• New HCPCS code describing the administration of subretinal therapies requiring vitrectomy,
• New HCPCS code describing nasal endoscopy with cryoablation of nasal tissue(s) and/or nerve(s),
• Four new HCPCS code describing peripheral intravascular lithotripsy (IVL) procedures,
• Removal of five National Coverage Determinations (NCDs) effective January 1, 2021 as stated in the CY 2021 Physician Fee Schedule (PFS) final rule.
• The one existing and fifteen new HCPCS codes for certain drugs and biologicals in the ASC setting that will start to receive separate payment beginning January 1, 2021.
• Retroactive payment for HCPCS J1097 (Phenylep ketorolac opth soln), brand name Omidria. This code became separately payable October 1, 2020. However, there was no available payment rate for MACs. “Consequently, ASCs that may have submitted claims for this drug, may not have been paid correctly…suppliers who think they may have previously received an incorrect payment or incorrect disposition associated with this correction for J1097, for claims beginning October 1, 2020, may request their MAC adjust the previously processed claims.”
• Drugs and Biologicals with payments based on Average Sales Price (ASP),
• Drugs and Biologicals based on ASP methodology with restated payment rates, and
• Skin substitute procedure edits.

CMS ends this MLN article with the following statement about Coverage Determinations:

“Assignment of an HCPCS code and payment rate under the ASC payment system to a drug, device, procedure, or service doesn’t imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it’s excluded from payment.”

• MLN Article MM12129: https://www.cms.gov/files/document/mm12129.pdf

January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.0

• Article Release Date: January 5, 2021
• What You Need to Know: This article details changes to the January 2021 version of the Integrated Outpatient Code Editor (I/OCE) instructions and specifications for the Integrated OCE that Medicare uses:
• Under the OPPS and Non-OPPS for hospital outpatient departments, community mental health centers and all non-OPPS providers,
• For limited services when provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System, and
• For a hospice patient for the treatment of a non-terminal illness.
• MLN Article MM12114: https://www.cms.gov/files/document/mm12114.pdf

REVISED MEDICARE TRANSMITTALS

Billing for Home Infusion Therapy Services on or After January 1, 2021

• Article Release Date: August 7, 2020 – Revised December 31, 2020
• What You Need to Know: A revised Change Request (CR) 11880 was issued on December 31, 2020. This MLN Article was revised to reflect the CR where two codes (J1559 JB and J7799 JB) were added in Table 3.2 on page 7 of this article.
• MLN MM11880: https://www.cms.gov/files/document/MM11880.pdf

MEDICARE EDUCATIONAL RESOURCES

Hospital Price Transparency Webcast: Audio Recording & Transcript

CMS provided the following information in their Thursday, January 7, 2021 edition of MLN Connects: “An audit recording, transcript, and clarification are available for the December 8 Medicare Learning Network webcast on Hospital Price Transparency. Effective January 1, each hospital operating in the United States is required to provide clear, accessible pricing information online. Learn about resources to help you prepare for compliance.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2021 – Recurring File Update

• Article Release Date: December 4, 2020
• What You Need to Know: Since 2017 CMS has updated the FQHC PPS rate annually. Based on historical data through the second quarter of 2020, the FQHC market basket for CY 2021 is 1.7 percent increasing the FQHC PPS base payment of $173.50 in 2020 to $176.45 for 2021.
• MLN MM12046: https://www.cms.gov/files/document/mm12046.pdf

Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2021

• Article Release Date: December 4, 2020
• What You Need to Know: This article provides the CY 2021 payment limit for RHCs. The CY 2021 amount has increased from $86.31 in 2020 to $87.52 effective January 1, 2021. The related Change Request (CR) 12035 was released on October 29, 2020.
• MLN MM12035: https://www.cms.gov/files/document/mm12035.pdf

Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction list, and Preventive Services List

• Article Release Date: December 4, 2020
• What You Need to Know: CR 12071 provides a summary of policies in the CY 2021 MPFS Final Rule and makes other policy changes that apply to Medicare Part B. This MLN article is a supplement to the CR.
• MLN MM12071: https://www.cms.gov/files/document/mm12071.pdf

2021 Annual Update of Per-Beneficiary Threshold Amounts

• Article Release Date: December 7, 2020
• What You Need to Know: The related Change Request (CR) 12014 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2021.
• MLN MM12014: https://www.cms.gov/files/document/mm12014.pdf

CY 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: December 7, 2020
• What You Need to Know: Information on the data files, update factors, and other information related to the CY 2021 update to the fee schedule can be found in this article.
• MLN MM12063: https://www.cms.gov/files/document/mm12063.pdf

Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

• Article Release Date: December 18, 2020
• What You Need to Know: Information provided in this article is related to CR 12080 and intended for clinical diagnostic laboratories. CR 12080 provided instructions for CY 2021 CLFS, mapping for new codes for clinical laboratory tests, and an update for laboratory costs subject to reasonable charge payment.
• MLN MM12080: https://www.cms.gov/files/document/MM12080.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.1, Effective April 1, 2021

• Article Release Date: December 23, 2020
• What You Need to Know: This article provides a background on NCCI Edits and refers to CR 12110, which provides quarterly updates to the NCCI PTP edits.
• MLN MM12110: https://www.cms.gov/files/document/mm12110.pdf

Updating Calendar Year (CY) 2021 Medicare Diabetes Prevention Program (MDPP) Payment Rates

• Article Release Date: December 23, 2020
• What You Need to Know: For organizations enrolled as MDDP suppliers, this article includes a link to the accompanying CR 12030, which contained instructions for MACs and the Railroad Specialty MAC to update the MDPP Expanded Model payment rates for CY 2021.
• MLN MM12030: https://www.cms.gov/files/document/mm12030.pdf

Quarterly Update to Home Health (HH) Grouper

• Article Release Date: December 30, 2020
• What You Need to Know: This article provides information regarding the January 2021 update to the HH Grouper software to reflect new COVID-19-related diagnosis code changes.
• MLN MM12047: https://www.cms.gov/files/document/MM12047.pdf

2021 Annual Update to the Therapy Code List

• Article Release Date: December 31, 2020
• What You Need to Know: This article provides updates to the list of codes that sometimes or always describe therapy services.
• MLN MM12126: https://www.cms.gov/files/document/MM12126.pdf

OTHER MEDICARE TRANSMITTALS

Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes (A-04-18-04067)

• Article Release Date: December 1, 2020
• What You Need to Know: An OIG audit report released August 2020 (report No. A-04-18-04067) identified Medicare overpayments to hospitals that did not comply with Medicare’s post-acute-care transfer policy. This MLN Special Edition article was published to remind hospitals of proper coding of the patient discharge status code and the use of condition codes 42 and 43.
• MLN SE20025: https://www.cms.gov/files/document/SE20025.pdf

FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients

• Article Release Date: December 3, 2020
• What You Need to Know: This Special Edition MLN article is informational in nature. CMS notes that In May of this year, the OIG released the report, Medicare Made $11.7 Million in Overpayments for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient Stays. This article includes FAQs to help providers avoid incorrect billing for outpatient services within 3 days before date of admission and on the date of admission.
• MLN SE20024: https://www.cms.gov/files/document/SE20024.pdf

REVISED MEDICARE TRANSMITTALS

Changed to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020

• Article Release Date: July 31, 2020 – Revised November 30, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11889 issued on August 14th. CR 11889 was revised to update the codes for NCD 190.15.
• MLN MM11889: https://www.cms.gov/files/document/MM11889.pdf

Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised December 2, 2020
• What You Need to Know: This is the second time that CMS has updated this MLN article. The December 2nd revisions added information for reporting the use of cinacalcet by ESRD facilities. “Beginning January 1, 2021, cinacalcet is an oral drug eligible for consideration as an ESRD outlier service. ESRD facilities should report revenue code 250 with the drug’s NDC.
• MLN MM12011: https://www.cms.gov/files/document/mm12011.pdf

New & Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE

• Article Releases Date: April 17, 2020 – Revised December 3, 2020
• What You Need to Know: Revisions to this article includes additional guidance on telehealth services that have cost-sharing and cost-sharing waived and language changes for clarity that did not alter the substance of the article.
• MLN MMSE20016: https://www.cms.gov/files/document/se20016.pdf

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

• Article Release Date: November 4, 2020 – Revised December 10, 2020
• What You Need to Know: This article was revised due to a revised CR 12027. Revisions made did not impact the substance of this article.
• MLN MM12027: https://www.cms.gov/files/document/MM12027.pdf

Medicare Claims Processing Transmittal 10521: New Medicare Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs

• Transmittal 10266 Release Date: August 6, 2020
• Transmittal 10521 Release Date: December 16, 2020
• What You Need to Know: Transmittal 10266 was rescinded and replaced by Transmittal 10266 to add the Provider Type "34", note that CAH's are paid via the OTP fee schedule, and clarification on the 2020 OTP fee schedule file (attachment 1) versus the 2021 OTP fee schedule file (new attachment 3). This correction revises business requirement 1856-4.1 and only impacts publication 100-04. All other information remains the same.
• Transmittal 10521: https://www.cms.gov/files/document/r10521cp.pdf
• Effective Date: January 1, 2021 for claims received on or after 1/1/2021

Note, a related Medicare Financial Management Transmittal 10521 revises business requirement 1856-4.1 and only impacts publication 100-04. (https://www.cms.gov/files/document/r10521fm.pdf)

Transmittal 10525: Implementation of the New Ambulatory Surgical Center (ASC) Payment Indicator “K5”

• Transmittal 10245 Release Date: July 30, 2020
• Transmittal 10525 Release Date: December 17, 2020
• What You Need to Know: Transmittal 10245 was rescinded and replaced by Transmittal 10525 to remove the word “DRAFT” from Attachment A. CMS created “a new ASC payment indicator, specifically, “K5” to identify codes that describe items, procedures, and services for which pricing information and claims data are not available, and consequently, no ASC payment will be made. This new payment indicator, effective January 1, 2021, provides the assignment, definition, and detail needed for this subset of HCPCS codes.”
• Transmittal 10525: https://www.cms.gov/files/document/r10525otn.pdf

Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) – Implementation

• Article Release Date: August 10, 2020 – Revised December 22, 2020
• What You Need to Know: Revisions were made due to a revised CR 11870 with updates to some denial edits.
• MLN MM11870: https://www.cms.gov/files/document/MM11870.pdf

MEDICARE COVERAGE UPDATES

December 1, 2020: CMS Updates Coverage Policies for Artificial Hearts and Ventricular Access Devices (VADs)

CMS released Decision Memo CAG-00453N on December 1st updating coverage requirements for artificial hearts and VADs. Specifically,

• Artificial Hearts: “CMS is removing the NCD at § 20.9, ending coverage with evidence development for artificial hearts and permitting Medicare coverage determinations for artificial hearts to be made by the Medicare Administrative Contractors (MACs) under § 1862(a)(1)(A) of the Social Security Act.”
• VADs: CMS notes in a related Press Release that “The final national coverage determination, which is effective today, also provides updated coverage criteria for VADs that better aligns with current medical practice and that we believe will expand coverage to a greater number of candidates who are likely to benefit from this technology. Specifically, the updated patient criteria in the NCD aligns with the inclusion criteria derived from recent large randomized controlled trials, which demonstrated improved patient outcomes.”

December 21, 2020: Proposed Updates to Coverage Policy for Autologous Blood-Derived Products from Chronic Non-Healing Wounds

CMS proposed to “update coverage of Platelet Rich Plasma (PRP) for the treatment of chronic non-healing diabetic, venous, and pressure wounds. PRP is a blood-derived product prepared from the patient’s own blood to be used as a wound covering in the management of chronic wounds. PRP is currently covered under the Coverage with Evidence Development (CED) pathway for the treatment of chronic, non-healing diabetic, venous, and pressure wounds when beneficiaries are enrolled in a clinical study. This proposed National Coverage Determination would eliminate the CED requirement and nationally cover PRP for the treatment of chronic non-healing diabetic wounds. The proposal also would provide for coverage determinations for PRP for all other chronic non-healing wounds to be made by local Medicare Administrative Contractors.”

CMS is seeking comments on the proposed national coverage determination.

MEDICARE EDUCATIONAL RESOURCES

December 10, 2020: MLN Call – Physician Fee Schedule Final Rule: Understanding 4 Key Concepts

CMS hosted a Medicare Learning Event to provide information about the following four key concepts in the 2021 PFS Final Rule:

• Extending Telehealth & Licensing Flexibilities,
• Evaluation and Management (E/M) Visits and Analogous Services,
• Quality Payment Program Updates, and
• Opioid Use Disorder/Substance Use Disorder Provisions.

You can access the Presentation on the 2020-12-10 Physician Fee Schedule webpage. 

KEPRO Case Review Connections: Acute Care Edition Winter 2020

KEPRO has released their Winter 2020 Edition of their Case Review Connections e-newsletter for Acute Care. Examples of what’s in this newsletter are the Medical Director’s Corner, a notice about them now accepting Medical Records electronically and an immediate advocacy success story.

MLN Educational Tool Medicare Preventive Services Updated in December

CMS has revised this Medicare Learning Network educational too. The tool provides information about coding, coverage and the beneficiary’s copayment/coinsurance and deductible.

• ICN: MLN006559: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243319?DLPage=1&DLEntries=10&DLFilter=preventive%20ser&DLSort=0&DLSortDir=ascending

OTHER MEDICARE UPDATES

December 1, 2020: CMS Releases 2021 Medicare Physician Fee Schedule (PFS) Final Rule

The following list highlights several of the changes found in the PFS Final Rule for 2021:

• Within the Final Rule, CMS issued two interim final rules with comment period.
• The first interim final rule is “to establish coding and payment for virtual check-in services to support the continued need for coding and payment to reflect the provisions of lengthier audio-only services outside of the PHE for COVID,19, if not as substitutes for in-person services.”
• The second interim final rule is “to establish coding and payments for PPE as a bundled service and certain supply pricing increases in recognition of the increased market-based costs for certain types of PPE.”
• Payments have been Increased to physicians and other practitioners for additional time spent with patients providing chronic disease management,
• Sixty additional services have been added to the telehealth list that will continue to be covered beyond the COVID-19 public health emergency (PHE),
• CMS established on an interim final basis a new HCPCS G-code describing 11-20 minutes of medical discussion to determine the necessity of an inpatient visit.”
• CMS commissioned a study of its telehealth flexibilities during the COVID-19 PHE,
• The increase in payment rates for office/outpatient face-to-face evaluation and management (E/M) visits finalized in 2020 goes into effect in 2021. According to a related CMS Press Release, the payment increases “support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home,”
• Simplified coding and documentation changes for Medicare billing for E/M office visits goes into effect January 1, 2021 modernizing guidelines developed in the 1990’s,
• CMS Finalized the following workforce flexibilities that have been provided during the COVID-19 PHE:

• “Certain non-physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
• Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
• Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.”

• CMS notes in a related Fact Sheet that “direct supervision may be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the PHE ends or December 31, 2021.”
• CMS finalized the elimination of six older National Coverage Determinations (NCDs) and noted in the final rule “that if the previous NCD barred coverage for an item or service under title XVIII (that is, national noncoverage NCD), a MAC would now be able to cover the item or service if the MAC determined that such action was appropriate under the statue…proactively removing obsolete broad non-coverage NCDs removes barriers to innovation and reduces burden for stakeholders and CMS.” The effective date for removal of the following six NCDs is on the date of the final rule:
• NCD 20.5 – Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
• NCD 30.4 – Electrosleep Therapy,
• NCD 100.9 – Implantation of Gastrointestinal Devices,
• NCD 110.19 – Abarelix for the Treatment of Prostate Cancer
• NCD 220.2.1 – Magnetic Resonance Spectroscopy, and
• NCD 220.6.16 - FDG PET for Inflammation and Infection.

December 2, 2020: OIG Fall 2020 Semiannual Report to Congress

The OIG Semiannual Report reflects work performed from April 1, 2020 through September 30, 2020. Following are some of the high-level findings from the report by the numbers:

• 97 – the number of audit reports completed
• 27 – the number of evaluation reports completed
• $337 million – the amount identified in expected recoveries,
• $446 million – costs questions by the OIG because of an alleged violations, costs not supported by adequate documentation, or the expenditure of funds where the intended purpose is unnecessary or unreasonable,
• $2 billion – potential savings identified for HHS; and
• 416 – The number of new audit and evaluation recommendations made by the OIG.

December 7, 2020: 2021 IPPS Final Rule Correction Notice Published in Federal Register

This document corrects technical and typographical errors in the September 18, 2020 issue of the FY 2021 IPPS Final Rule.

December 10, 2020: CMS Proposed Modifications to the HIPAA Privacy Rule

HHS notes in their announcement the proposed changes will “support individuals’ engagement in their care, remove barriers to coordinated care, and reduce regulatory burdens on the health care industry.” The Summary statement in the Proposed Rule indicates that “these modifications address standards that may impede the transition to value-based health care by limiting or discouraging care coordination and case management communications among individuals and covered entities (including hospitals, physicians, and other health care providers, payors, and insurers) or posing other unnecessary burdens. The proposals in this NPRM address these burdens while continuing to protect the privacy and security of individuals’ protected health information.”

December 10, 2020: CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers

CMS released the following information in a December 12, 2020 Special Edition of MLNConnects:

On December 10, under President Trump’s leadership, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care. For More Information:

• Proposed Rule (PDF): Comment period closes January 4
• Full press release
• Fact sheet
• Blog
• CMS Interoperability and Patient Access Final Rule”

December 16, 2020: CMS Report – National Healthcare Spending in 2019

“The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. The data are presented by type of service, sources of funding, and type of sponsor.

U.S. health care spending grew 4.6 percent in 2019, reaching $3.8 trillion or $11,582 per person.  As a share of the nation's Gross Domestic Product, health spending accounted for 17.7 percent.”

You can download the entire report on the CMS National Health Expenditure Data Historical webpage.

December 18, 2020: Special Edition MLNConnects: Monitoring for Hospital Price Transparency

CMS indicated in this Special Edition MLNConnects that they plan “to audit a sample of hospitals for compliance starting in January, in addition to investigating complaints that are submitted to CMS and reviewing analyses of non-compliance, and hospitals may face civil monetary penalties for noncompliance.” CMS also reminds providers of their Hospital Price Transparency website where they have provided several resources for hospitals as they work towards compliance with Hospital Price Transparency. 

December 31, 2020: Palmetto GBA offers Introduction to 2021 E&M Changes

Palmetto GBA included the following information in their December 31st Daily Newsletter:

“Effective January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented a new coding, prefatory language, and interpretive guidance framework that the American Medical Association Current Procedural Terminology Editorial Panel issued for office and outpatient E/M visits. Please review the information in this job aid and share it with your staff.” You can access this introduction education material at: https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20B~BWSU772836?opendocument.

January 1, 2021: CMS Releases MLN Guide Titled Evaluation and Management (E/M) Services

CMS has released publication ICN: 006764 that serves as a guide to learning the principles of documentation, common sets of codes used to bill for services, and other considerations.

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update - Revised

• Article Release Date: August 7, 2020 – revised October 27, 2020
• What You Need to Know: Revisions reflect changes made to CR11939 where CMS added information about codes 3170F, 0599T, A4226, and the new codes 86408, 86409, 86413, and 99072.
• MLN MM11939: https://www.cms.gov/files/document/MM11939.pdf

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

• Article Release Date: November 4, 2020
• What You Need to Know: This article provides information found in the October 30, 2020 Change Request (CR) 12027 about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs).
• MLN MM12027: https://www.cms.gov/files/document/mm12027.pdf

Changes to the End Stage Renal Disease (ESRD) PRICER to Accept the New Outpatient Provider Specific File Supplemental Wage Index Fields, the Network Reduction Calculation and New Value Code for Time on Machine

• Article Release Date: November 12, 2020
• What You Need to Know: This article provides information about changes to the ESRD PRICER software, the new value code required for reporting minutes of dialysis provided during the billing period and explains the ESRD Network Reduction calculations from the FIAA into the PRICER.
• MLN MM11871: https://www.cms.gov/files/document/mm11871.pdf

OTHER MEDICARE TRANSMITTALS

Special Provisions for Radiology Additional Documentation Requests

• Article Release Date: October 30, 2020
• What You Need to Know: This article discusses a pilot process enabling MACs to request pertinent documentation from treating/ordering provider during medical review, in an effort to support the necessity and payment for radiology service(s)/items(s) (billed to Medicare.”
• MLN MM11659: https://www.cms.gov/files/document/mm11659.pdf

Update to Chapter 10 of Publication (Pub.) 100-08- Enrollment Policies for Home Infusion Therapy (HIT) Suppliers

• Article Release Date: October 30, 2020
• What You Need to Know: Change Request (CR) 11954 informs MACs of the policies and procedures for enrolling HIT suppliers in Medicare. MACs will accept enrollment applications beginning on or after November 1, 2020.
• MLN MM11954: https://www.cms.gov/files/document/mm11954.pdf

Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum

• Article Release Date: November 6, 2020
• What You Need to Know: CMS is modifying the Medicare Benefit Policy Manual to include modifications to the election statement and the requirements for the hospice election statement addendum that became effective for hospice elections beginning on or after October 1, 2020.
• MLN MM12015: https://www.cms.gov/files/document/mm12015.pdf

Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims

• Article Release Date: November 9, 2020
• What You Need to Know: This article provides updated information about claims processing instructions to adhere to current Medicare policy.
• MLN MM11992: https://www.cms.gov/files/document/mm11992.pdf

Updates to Vaccine Services Editing

• Article Release Date: November 13, 2020
• What You Need to Know: This article is for those that provide vaccines to Medicare beneficiaries and bill Medicare Administrative Contractors (MACs) for those services. Specific for hospitals related CR 11975 “modifies current editing to allow vaccines and their administration when they are the only services on a 12x claim where the service date is equal to the discharge date of an inpatient claim for the same provider and the service date is equal to the "From" date of another inpatient claim with condition code B4 for the same provider.”
• MLN MM11975: https://www.cms.gov/files/document/mm11975.pdf

Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2021

• Article Release Date: November 20, 2020
• What You Need to Know: Among other rates, Medicare beneficiaries without a secondary insurance will have a $1,484.00 Part A Deductible to pay if admitted as an inpatient beginning January 1, 2021.
• MLN Matters: MM12024: https://www.cms.gov/files/document/mm12024.pdf

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: November 20, 2020
• What You Need to Know: This article provides Medicare system updates based on the CORE Code Combination List to be published on or about February 1, 2021.
• MLN MM11988: https://www.cms.gov/files/document/mm11988.pdf

Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service Provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)”

• Article Release Date: November 20, 2020
• What You Need to Know: The following two new NUBC codes will be effective for claims received on or after February 1, 2021
• “90” – To allow providers to report when the service is provided as part of an Expanded Access approval, and
• “91” – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA).
• MLN MM12049: https://www.cms.gov/files/document/mm12049.pdf

Claim Status Category and Claim Status Codes Update

• Article Release Date: November 20, 2020
• What You Need to Know: This article informs you that all code changes approved during the January/February 2021 committee meeting shall be posted on or about March 1, 2021 with an effective date of April 1, 2021 and Implementation Date of April 5, 2021.
• MLN MM11957: https://www.cms.gov/files/document/mm11957.pdf

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

• Article Release Date: November 20, 2020
• What You Need to Know: This article updates the RARC and CARC lists and instructs the Medicare’s system maintainers to update MREP and PC Print. Note, the code update schedule is published three times a year with the next implementation date being April 5, 2021.
• MLN MM11943: https://www.cms.gov/files/document/mm11943.pdf

REVISED MEDICARE TRANSMITTALS

Penalty for Delayed Request for Anticipated Payment (RAP) Submission -- Implementation

• Article Release Date: July 31, 2020 – Revised October 27, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11855 including adding remittance advice message information.
• MLN MM11855: https://www.cms.gov/files/document/mm11855.pdf

October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: August 28, 2020 – Revised October 28, 2020
• What You Need to Know: This article was revised to reflect a revised CR11956 clarifying the claims processing jurisdiction for code K1109.
• MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf

Billing for Home Infusion Therapy Services on or After January 1, 2021

• Article Release Date: August 7, 2020 – Revised November 13, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11880. Additions to the article include statements related to the status indicator for the G codes on the Physician Fee Schedule and noting that MACs will post HIT fees on their websites as soon as possible.
• MLN MM11880: https://www.cms.gov/files/document/mm11880.pdf

Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised November 20, 2020
• What You Need to Know: This article provides several payment updates related to the HH PPS. Note, this article was revised to reflect an updated CR 12017 that revised the Policy section and updated the Payment Rate Tables.
• MLN MM12017: https://www.cms.gov/files/document/mm12017.pdf

Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model

• Article Release Date: May 4, 2015 – Revised November 20, 2020
• What You Need to Know: This article was revised to show the model will not end December 1, 2020. “The model no longer has an end date and will remain in effect for the nine model states.”
• MLN SE1514: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1514.pdf

Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021

• Article Release Date: November 9, 2020 – Revised November 23, 2020
• What You Need to Know: This article provides information about payment rate updates and policies for CY 2021. Note, this article was revised to reflect a revised CR 12011.
• MLN MM12011: https://www.cms.gov/files/document/mm12011.pdf

MEDICARE COVERAGE UPDATES

November 13, 2020: National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy

• Article Release Date: November 17, 2020
• What You Need to Know: Effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS) and meets specified FDA conditions. Note, this article includes billing requirements guidance.
• MLN Matters MM11783: https://www.cms.gov/files/document/mm11783.pdf

OTHER MEDICARE UPDATES

October 27, 2020: New CMS Proposals Streamline Medicare Coverage, Payment, and Coding for Innovative New Technologies and Provide Beneficiaries with Diabetes Access to More Therapy Choices

CMS published a Special Edition MLNConnects announcing a Durable Medical Equipment (DME) proposed rule aimed at reducing administrative burden for new innovative technologies.

November 2, 2020: Long-Term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet

CMS announced the release of a Long-Term Services and Supports (LTSS) Rebalancing Toolkit “to support states in their efforts to expand and enhance home and community-based services (HCBS) and to rebalance, or recalibrate, LTSS from institutional to community-based systems. You can read more about this in the CMS Press Release and related Fact Sheet.

November 2, 2020: CMS issues End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule

This final rule updates payment policies and rates under the ESRD PPS for renal dialysis services furnished to beneficiaries enrolled in Original Medicare on or after January 1, 2021. It also updates the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and finalized changes to the ESRD Quality Incentive Program. “Medicare expects to pay $10.3 billion to approximately 7,400 ESRD facilities for the costs associated with furnishing renal dialysis services.”

For More Information:

• Final rule

• Press release
• Full text of fact sheet

November 4, 2020: HHS Proposes Unprecedented Regulatory Reform through Retrospective Review

HHS announced a notice of proposed rulemaking that would require “the Department to assess its regulations every ten years to determine whether they are subject to review under the Regulatory Flexibility Act (RFA), which requires regular review of certain significant regulations. If a given regulation is subject to the RFA, the Department must review the regulation every ten years to determine whether the regulation is still needed and whether it is having appropriate impacts. Regulations will expire if the Department does not assess and (if required) review them in a timely manner.”

November 6, 2020: OIG Report – $35 Million in Overpayments for Medical Devices

Hospitals seem to continue to struggle with the Federal regulations for medical device credits as evidenced by the $35 million in overpayments reported by the OIG in this November 6, 2020 report.  

November 6, 2020: 2021 Medicare Parts A & B Premiums and Deductibles

The 2021 Monthly Medicare Parts A and B premiums, deductibles and coinsurance were announced in a CMS Press Release. Following are the changes from 2020 to 2021:

Medicare Part A Inpatient Deductible

• 2020 - $1,408
• 2021 - $1,484

Medicare Part B Enrollees Standard Monthly Premium

• 2020 - $144.60
• 2021 - $148.50

Medicare Part B Enrollees Annual Deductible

• 2020 - $198
• 2021 - $203

For a fact sheet on the 2021 Medicare Parts A & B premiums and deductibles, please visit: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-parts-b-premiums-and-deductibles

November 9, 2020: Medicaid and CHIP Managed Care Final Rule Released

CMS announced the release of this final rule noting that “the purpose of the rule is to ensure state Medicaid and CHIP agencies are able to work effectively to develop and implement managed care programs that better serve each state’s growing number of Medicaid and CHIP beneficiaries.”

November 16, 2020: OIG Report – Hospitals Did Not Comply with Medicare Requirements for Reporting Cardiac Device Credits

The OIG found that hospitals did not always comply with Medicare requirements associated with reporting manufacturer credits for recalled or prematurely failed cardiac medical devices. Specifically, “911 hospitals received payments of $76 million rather than the $43 million they should have received, resulting in $33 million in potential overpayments. Medicare contractors made these overpayments because they do not have a postpayment review process that would ensure that hospitals reported manufacturer credits for cardiac medical devices.” The first of seven recommendations made by the OIG is that MAC’s should recover the portion of the $33 million overpayment that are within the reopening period.

November 17, 2020: CMS to Retire Original Compare Tools December 1st

CMS will retire the Original Compare Tools as they have been replaced with Care Compare on Medicare.gov. This new site streamlines the eight original health care compare tools. CMS notes that “Care Compare offers a new design that makes it easier to find the same information that’s on the original compare tools. It gives you, patients, and caregivers one user-friendly place to find cost, quality of care, service volume, and other CMS quality data to help make informed health care decisions.”

To learn more about the history of and what information is available go to CMS’ Hospital Compare webpage.

November 17, 2020: Medicare FFS Estimated Improper Payments Decline by $15 Billion Since 2016

In the Thursday November 19th edition of the MLNConnects Newsletter, CMS touts a “continued reduction marks fourth year Medicare FFS improper payment rate has been below 10%.” A related November 16th CMS Fact Sheet indicates that the Medicare FFS improper payment rate decreased from 7.25% in 2019 to an estimated 6.27% for 2020.

• CMS Press Release: Trump Administration Announced Medicare Fee-for-Service Estimated Improper Payments Decline by $15 Billion Since 2016
• CMS Fact Sheet: 2020 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs

November 20, 2020: Two New HHS Final Rules Advancing Value-Based Care

HHS announced the release of an OIG and CMS Final Rule, both aimed “to reduce regulatory barriers to care coordination and accelerate the transformation of the healthcare system into one that pays for value and promotes the delivery of coordinated care.”

• OIG Final Rule: “Revisions to the Safe Harbors Under the Anti-Kickback Statue and Civil Monetary Penalty Rules Regarding Beneficiary Inducements” - “OIG’s new safe harbor regulations are designed to facilitate better coordinated care for patients, value-based care, and improved cybersecurity, while also protecting against fraudulent or abusive conduct,” said Christi A. Grimm, Principal Deputy Inspector General.”

• CMS Final Rule: “Modernizing and Clarifying the Physician Self-Referral Regulations” - “The CMS final rule clarifies and modifies existing policies to ease unnecessary regulatory burden on physicians and other healthcare providers while reinforcing the physician self-referral law’s (often called the “Stark Law”) goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

• Article Release Date: October 9, 2020
• What You Need to Know: This article informs providers about updates to the Quarterly ASP Medicare Part B Pricing Files and informs you of revisions, if needed to prior quarterly pricing files.
• MLN MM12020: https://www.cms.gov/files/document/MM12020.pdf

OTHER MEDICARE TRANSMITTALS

 New Waived Tests

• Article Release Date: October 5, 2020 – Revised October 15, 2020
• What You Need to Know: This article tells you of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the FDA. CMS notes that “MACs will not search their files to either retract payment or retroactively pay claims, however, MACs should adjust claims if you bring those claims to their attention.”
• Note, this article was revised to correct a date for one of the codes for 87804QW.
• MLN Matters MM11982: https://www.cms.gov/files/document/mm11982.pdf

Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 and Productivity Adjustment

• Article Release Date: October 16, 2020
• What You Need to Know: This article provides the CY 2021 AIF for determining the payment limit for ambulance services.
• MLN MM12031: https://www.cms.gov/files/document/mm12031.pdf

REVISED MEDICARE TRANSMITTALS

October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3

• Article Release Date: August 28, 2020 – Revised October 5, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11944 including adding several items to the Summary of Quarterly Release Modifications table.
• MLN Matters MM11944: https://www.cms.gov/files/document/mm11944.pdf

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020

• Article Release Date: August 31, 2020 – Revised September 24, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11876 which changed the hourly Continuous Home Care rates in the hospice tables.
• MLN Matters MM11876: https://www.cms.gov/files/document/mm11876.pdf

Change to the Payment of Allogeneic Stem Cell Acquisition Services

• Article Release Date: July 13, 2020 – Revised October 21, 2020
• What You Need to Know: This article was revised to reflect the revised CR 11729 issued on October 20, 2020. This revision did not impact the substance of the article.
• MLN Matters: MM11729: https://www.cms.gov/files/document/mm11729.pdf

MEDICARE COVERAGE UPDATES

October 22, 2020: MCD Overview Page and Advanced Search Function Going Away

CMS has posted the following alert on the Medicare Coverage Database (MCD) Notice Board:

“On December 11, 2020, the Overview page of the Medicare Coverage Database (MCD) application will be removed in an effort to streamline the site. The website address will remain cms.gov/medicare-coverage-database but users will be directed to the Search page by default, instead of the Overview page.

On April 30, 2021, the Advanced Search function of the MCD application will be removed. All features related to the Advanced Search were incorporated into the new Search function, which was released on September 3, 2020. The new Search function is both faster and easier to use than the Advanced Search, so please switch to the new Search if you haven't already. Bookmarks to advanced-search.aspx and search-results.aspx will no longer work after April 30, 2021.”

MEDICARE EDUCATIONAL RESOURCES

September 28, 2020: MLN Fact Sheet: ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets

• What You Need to Know: CMS released this educational tool to give “health care providers, suppliers, medical coders, billing and claims staff an easy reference to information on the code sets used to bill Medicare claims.” CMS advises using this tool when submitting inpatient and outpatient diagnoses, procedures, and supplies on Medicare claims.
• ICN MLN900943 September 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

October 2020: Medicare Quarterly Provider Compliance Newsletter

This CMS quarterly newsletter provides information on how to avoid common billing errors and includes top issues of a particular quarter. The October 2020 edition of the newsletter highlights Recovery Auditor Findings related to the following two issues:

Issue #0070: Critical Care Billed on the Same Day as Emergency Room Services: Unbundling

• Provider Types Affected: Physicians and Non-Physician Practitioners (NPPs)
• Problem: “Hospital emergency department services are not payable for the same calendar date as critical care services when billed for the same beneficiary, on the same date of service and by the same service provider (based on Tax ID and Provider Specialty Code).
• Affected Codes: 99281, 99282, 99283, 99284, 99285
• Type of Review: Automated Review

Issue #0131: Pneumatic Compression Device (PCD): Medical Necessity and Documentation Requirements.

• Provider Types Affected: Durable Medical Equipment (DME) Suppliers, including physicians who supply DME
• Problem: When providing PCDs to patients, be sure the patient meets all Medicare coverage criteria.
• Affected codes: E0650, E0651, E0652, E0656, E0657, E0667, E0668, E0669 and E0670.
• Type of review: Complex Review

Link to newsletter: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/mln5230120

OTHER MEDICARE UPDATES

September 28, 2020: CMS Guidance Related to the Emergency Preparedness Testing Exercise Requirements – COVID-19

CMS posted a Memo to State Surveyors on their website which included the following summary statements and a link to the memorandum:

“CMS regulations for Emergency Preparedness require specific testing exercises be conducted to validate the facility’s emergency program. During or after an actual emergency, the regulations allow for an exemption to the testing requirements based on real world actions taken by providers and suppliers.

This worksheet presents guidance for surveyors, as well as providers and suppliers, with relevant scenarios on meeting the testing requirements in light of many of the response activities associated with the COVID-19 Public Health Emergency (PHE).”

September 28, 2020: CY 2021 Annual Amount In Controversy (AIC) Adjustments

CMS published the AIC Adjustments for CY 2021 in the Federal Register:

• Administrative Law Judge (ALJ) hearings AIC threshold: $180, and
• Judicial Review AIC threshold: $1,760.

October 5, 2020: Compliance with Residents’ Rights Requirement related to Nursing Home Residents’ Right to Vote

CMS sent this Memorandum to State Survey Agency Directors on October 5, 2020. Following are the three Memorandum Summary bullets:

• The Centers for Medicare & Medicaid Services (CMS) is affirming the continued right of nursing home residents to exercise their right to vote.
• While the COVID-19 Public Health Emergency has resulted in limitations for visitors to enter the facility to assist residents, nursing homes must still ensure residents are able to exercise their Constitutional right to vote.
• States, localities, and nursing home owners and administrators are encouraged to collaborate to ensure a resident’s right to vote is not impeded.

Additionally, CMS has published a letter to be sent to nursing home residents or family members.

October 8, 2020: CMS Press Release: Medicare Advantage and Medicare Part D Quality Ratings

CMS indicates in this Press Release that “according to the latest data, quality ratings of Medicare Advantage and Medicare Part D drug plans remain strong. Most Medicare beneficiaries – about 77 percent – who enroll in Medicare Advantage plans with drug coverage will be in plans with four or more stars in 2021.”

October 9, 2020: New National Action Plan for Combating Antibiotic-Resistant Bacteria

The CDC announced the release of the next National Action Plan for Combating Antibiotic-Resistant Bacteria for 2020-2025. They note in the announcement that antibiotic-resistant infections kill more than 35,000 people in the United States each year.

October 19, 2020: Palmetto GBA Outpatient Department (OPD) Prior Authorization (PA) Alert!

Palmetto GBA included in the following Alert in their October 21, 2020 Daily eNewlsetter:

“As of October 9, 2020, if you are a physician/NPP (Part B provider), you are required to provide two (2) fax numbers to receive your Outpatient Department (OPD) Prior Authorization (PA) decision. If a second fax number is not provided, your OPD PA will be rejected. 

If the requestor is a representative of the Hospital Outpatient Facility, only one (1) fax number is required.

Did you know?
...that the when requesting an OPD PA you must include both the hospital and the requestor’s fax number if the requestor is the physician/NPP (Part B provider)? If not, your PA will be rejected.

Did you know?
...that if the requestor is a representative of the Hospital Outpatient Facility, only one fax number is required.”

October 21, 2020: CMS Announcement, Radiation Oncology Model Delayed

CMS posted the following update to the CMS Radiation Oncology Model webpage:

“UPDATE: (10/21/2020) - CMS has received feedback from a number of stakeholders about the challenges of preparing to implement the RO Model by January 1, 2021. Based on this feedback, CMS intends to delay the RO Model start date to July 1, 2021. We are pursuing rulemaking to make this change.” Note, slides for two recent events related to this model as well as an FAQ document are also available on the Radiation Oncology Model webpage.

October 2020 C2C Innovative Solutions, Inc. Quarterly Newsletter Released

C2C Innovative Solutions Inc. (C2C), the Qualified Independent Contractor (QIC) for Medicare Part A for 26 eastern states, Washington D.C. and two U.S. territories, has released its quarterly newsletter.

October 21, 2020: Alabama Medicaid Alert: National Changes for Office Visit Procedure Codes

The Alabama Medicaid Agency issued an Alert reminding providers about the upcoming changes for Evaluation and Management (E&M) Procedure Codes effective January 1, 2021. This Alert includes links to National Information and Additional Resources about the changes.

MEDICARE TRANSMITTALS – RECURRING UPDATES

October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: August 31, 2020
• What You Need to Know: This article informs providers about changes to and billing instructions for various payment policies implemented in the October 2020 OPPS update.
• MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf

October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3

• Article Release Date: August 28, 2020
• What You Need to Know: This article provides information about the October 2020 version of the I/OCE instructions and specifications that Medicare uses.
• MLN MM11944: https://www.cms.gov/files/document/mm11944.pdf

Annual Clotting Factor Furnishing fee Update 2021

• Article Release Date: August 28, 2020
• What You Need to Know: The annual clotting factor furnishing fee for 2021 is $0.238 per unit.
• MLN MM11932: https://www.cms.gov/files/document/mm11932.pdf

2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

• Article Release Date: August 28, 2020
• What You Need to Know: Section 413(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment file. This article lets providers know that CMS will provide MACs with files for the automated payments of HPSA bonuses for dates of service January 1, 2021 through December 31, 2021.
• MLN MM11852: https://www.cms.gov/files/document/mm11852.pdf

October Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

• Article Release Date: August 28, 2020
• What You Need to Know: This article provides details about the changes to the DMEPOS fee schedules that Medicare updates quarterly, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Specific to the ongoing Public Health Emergency (PHE) due to the COVID-19 pandemic, “the October 2020 DMEPOS and PEN fee files continue to include the non-rural contiguous non-CBA 75/25 blended fees required by Section 3712(b) of the CARES Act signed into law on March 27, 2020.
• MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: August 28, 2020
• What You Need to Know: This article informs providers that Medicare will update its claims processing systems based on the Committee on Operating Rules for Information Exchange (CORE), Code Combination List, which will be published on or about October 1, 2020.
• MLN Matters MM11881: https://www.cms.gov/files/document/mm11881.pdf

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice PRICER for FY 2021

• Article Release Date: August 31, 2020 – Revised September 10, 2020
• What You Need to Know: This article provides updates in Change Request (CR) 11876 to hospice payment rates, wage index, PRICER, and aggregate cap amounts for Fiscal Year (FY) 2021. Note, this article was revised on September 10th to correct two typos. All other information remained the same.
• MLN Matters MM11876: https://www.cms.gov/files/document/mm11876.pdf

Claim Status Category and Claim Status Codes Updates

• Article Release Date: August 28, 2020
• What You Need to Know: This article informs providers of updates to the Claim Status and Claims Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Code changes during the September/October 2020 National Code Maintenance Committee (NCMC) meeting will be posted on or about November 1, 2020.
• MLN Matters MM11796: https://www.cms.gov/files/document/mm11796.pdf

2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing facility (SNF) Consolidated Billing (CB) Update

• Article Release Date: September 16, 2020
• What You Need to Know: This articles provides information regarding changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that Medicare uses to revise Common Working File (CWF) edits to allow MACs to make appropriate payments.
• MLN Matters MM11968: https://www.cms.gov/files/document/mm11968.pdf

Fiscal Year (FY) Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes

• Article Release Date: September 22, 2020
• What You Need to Know: This article provides FY 2021 update to the IPPS and LTCH PPS.
• MLN MM11879: https://www.cms.gov/files/document/mm11879.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021

• Article Release Date: September 25, 2020
• What You Need to Know: CR 11984 provides quarterly updates to the NCCI PTP edits. A test file will be available around November 2, 2020 with a final file available on or about November 17, 2020.
• MLN MM11984: https://www.cms.gov/files/document/mm11984.pdf

OTHER MEDICARE TRANSMITTALS

Updates to Chapter 23 – Fee Schedule Administration and Coding Requirements

• Change Request Release Date: August 28, 2020
• What You Need to Know:
• CR 11941 (Transmittal 10320): https://www.cms.gov/files/document/r10320cp.pdf
• Effective Date: December 1, 2020
• Implementation Date: December 1, 2020

Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19

• Article Release Date: September 4, 2020
• What You Need to Know: CMS has removed the reference to Electrocardiogram (EKG) services in the Medicare Claims Processing Manual, Chapter 16, Section 60.1.2 and Chapter 26, Section 10.4, Item 19. This change only clarifies existing content.
• MLN Matters MM11935: https://www.cms.gov/files/document/mm11935.pdf

Update to the Medicare Claims Processing Manual

• Article Release Date: September 18, 2020
• What You Need to Know: This article provides information regarding updated to the Medicare Claims Processing Manual, Chapters 12 and 23.
• MLN Matters MM111958: https://www.cms.gov/files/document/mm11958.pdf

REVISED MEDICARE TRANSMITTALS

National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low back Pain (cLPB)

• Article Release Date: May 13, 2020 – Revised September 1, 2020
• What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11755 that provides revised messaging (page 3 in the article). It also revised the Claims Processing Manual at Section 410.4.
• MLN Matters MM11755: https://www.cms.gov/files/document/MM11755.pdf

Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries

• Article Release Date: September 4, 2020 – Revised September 15, 2020
• What You Need to Know: This article provides information about CMS modifying and streamlining the model admission questions for providers to ask Medicare beneficiaries or authorized representatives upon admission or start of care.
• Note, this article was revised on September 15th to reflect the CR revision adding part of sentence that had been left out of manual Section 20.2.2 of the Medicare Secondary Payer Manual.
• MLN Matters MM11945: https://www.cms.gov/files/document/mm11945.pdf

October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: September 11, 2020 – Revised September 24, 2020
• What You Need to Know: This article is based on Change Request (CR) 11963 which provides information about changes to and billing instructions for various payment policies implemented in the October 2020 ASC payment system update.
• Note, this article was revised to reflect the updated CR revision to HCPCS code C9066 in Table 2 in the CR.
• MLN MM11963: https://www.cms.gov/files/document/mm11963.pdf

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

• Article Release Date: August 7, 2020 – Latest Revision September 24, 2020
• What You Need to Know: This article informs laboratories of changes from the quarterly update to the clinical laboratory fee schedule. Now in its third iteration, this article was most recently updated to add new COVID-19 code (86413) and ADLT code (0090U).
• MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf

Change to the Payment of Allogeneic Stem Cell Acquisition Services

• Article Release Date: July 13, 2020 – Revised September 24, 2020
• What You Need to Know: This article was revised to reflect a revised CR issued on September 24, 2020. All other information remains the same.
• MLN MM11729: https://www.cms.gov/files/document/mm11729.pdf

October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: August 31, 2020 – Revised September 25, 2020
• What You Need to Know: This article has been revised to reflect an updated CR 11960 that made several changes including adding a new COVID-19 CPT code, 86413, to Table 1.
• MLN MM11960: https://www.cms.gov/files/document/mm11960.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer

• Article Release Date: September 15, 2020
• What You Need to Know: CMS “has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician, and when specific requirements are met.
• NCD Implementation Date: November 13, 2020
• NCD Effective Date: January 27, 2020
• MLN MM11837: https://www.cms.gov/files/document/mm11837.pdf

OTHER MEDICARE UPDATES

August 27, 2020: OIG Report – Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments in the Provider Appeals Process

• Link to Report: https://oig.hhs.gov/oas/reports/region5/51800024.pdf

Proposed Rule: Medicare Program; Modernizing and Clarifying the Physician Self-Referral Regulations Extension of Timeline for Publication of Final Rule

Link to notice in Federal Register: https://www.govinfo.gov/content/pkg/FR-2020-08-27/pdf/2020-18867.pdf

September 2, 2020: FY 2021 IPPS Final Rule released.

September 3, 2020: Medicare Preventive Services Tool and Poster Revised

CMS noted in their September 3rd edition of MLNConnects that the Medicare Preventive Services Medicare Learning Network Educational Tool and Poster have been revised. The tool is extremely useful to understand Coding, Coverage, and Copayment/coinsurance and deductible requirements for Preventative Services covered by Medicare.

• Link to Revised Tool: Medicare Preventive Services
• Link to Revised Poster: Medicare Preventive Services Poster

September 10, 2020: OIG Report: Billions in Estimated Medicare Advantage Payments from Diagnoses Reported Only on Health Risk Assessments Raise Concerns

The OIG performed this review due to concerns that Medicare Advantage Organizations may use Health Risk Assessments (HRAs) to inappropriately increase risk adjusted payments. The key takeaway highlighted in the Report Brief is that “billions in estimated risk-adjusted payments supported solely through HRAs raise concerns about the completeness of payment data, validity of diagnoses on HRAs, and quality of care coordination for beneficiaries.”

September 11, 2020: Community Health Access and Rural Transformation (CHART) Model CMS Fact Sheet

CMS announced the CHART Model in a Fact Sheet, indicating that “the approximately 57 million Americans living in rural communities, including millions of Medicare and Medicaid beneficiaries, face unique challenges when seeking health care services, such as limited transportation options, shortages of health care services, and an inability to fully benefit from technological and care-delivery innovations.” CMS goes on to highlight the following three items to be accomplished through this model:

• “Increase financial stability for rural health care providers through multiple new funding approaches, including the use of up-front investments and predictable, capitated payments that pay for quality and patient outcomes over volume;

• Provide the necessary operational and regulatory flexibilities to allow health care providers and CMS to test the Model in their local communities and successfully transform themselves; and
• Support local rural communities’ transformation efforts by being directly engaged at CMS, offering real-time technical expertise and other learning when needed to foster success.”

New Understanding Your Remittance Advice Reports MLN Booklet (MLN8788099)

CMS has published a new MLN Booklet providing information to:

• Help you learn which types of Remittance Advice (RA) are available,
• What information is included in an RA,
• How to view an RA, and
• Frequently Asked Questions.

Checking Medicare Eligibility MLN Booklet (MLN8816413 September 2020)

CMS advises providers, in this MLN Booklet, “to ensure you are billing appropriately for Medicare-covered supplies and services, check for eligibility. Regularly review your patients’ eligibility information.” This booklet provides guidance on who may be eligible for Medicare and how to check for eligibility.

September 15, 2020: New Roadmap for States to Accelerate Adoption of Value-Based Care (VBC) through Medicaid

CMS sent a letter to State Medicaid Directors on September 15, 2020 “to provide information on how states can advance value-based care (VBC) across the healthcare systems, with a particular emphasis on Medicaid populations, and to share pathways for adoption of such approaches with interested states.

CMS noted in a related Fact Sheet, that just as they have made a “strong commitment to advancing VBC in Medicare for its 61.7 million enrollees” guidance released on September 15, 2020 “is designed to ensure that this same commitment can be made at the state level through Medicaid with its nearly 74 million beneficiaries.”

September 18, 2020: CMS Announces New Model of Care for Medicare Beneficiaries with Chronic Kidney Disease

CMS has finalized the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, “to improve or maintain the quality of care and reduce Medicare expenditures for patients with chronic kidney disease” (CKD). CMS notes in a Press Release that the model is set to be implemented January 1, 2021, will impact approximately 30 percent of kidney care providers, and the estimated savings from the model is $23 million over five and half years.

September 18, 2020: CMS Announced Radiation Oncology Model

CMS has finalized the Radiation Oncology (RO) Model which is “expected to improve the quality of care for cancer patients receiving radiotherapy and reduce Medicare expenditures through bundled payments that allow providers to focus on delivering high-quality treatments.” CMS notes in a Press Release that the RO Model is set to begin January 1, 2021 and the estimated savings is $230 million over five years.

September 21, 2020: OIG Report (A-07-17-01176) Incorrect Acute Stroke Diagnosis Codes Increased Payments to Medicare Advantage Organizations

In this audit, the OIG focused on Medicare eligible patients who were covered under traditional Medicare one year and the following year chose a Medicare Advantage Plan. Data mining enabled them to identify several diagnosis codes at high risk of being miscoded. Specifically for this audit, the OIG focused on the acute stroke diagnosis codes reported on one physician’s claim without being reported on the corresponding inpatient claim. The objective being to determine if selected acute stroke codes submitted by physicians under traditional Medicare were later used by CMS to make payments to MA organizations complied with Federal Requirements. The OIG found that in 580 of 582 claims, the record did not support the acute stroke diagnosis codes. In turn, this meant the ischemic stroke codes used as HCC’s were not valid. CMS estimated just over $14.4 million inaccurate payments were made to MA Plans.

September 22, 2020: CMS Expands Ambulance Program Integrity Model Nationwide

CMS announced the expansion of the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. CMS notes in the Press Release that the model has saved Medicare $650 million over four years.

The initial model began for transports on or after December 15, 2014 and is scheduled to end in all model states on December 1, 2020, based on date of service. You can read more about this model in Special Edition MLN article SE1514. Information is also available on the Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport CMS webpage.

September 24, 2020: Importation of Prescription Drugs FDA Final Rule

This Final Rule was issued “to implement a provision of the Federal Food, Drug, and Cosmetic Act (FD&C Act) to allow importation of certain prescription drugs from Canada. Under this final rule, States and Indian Tribes, and in certain future circumstances pharmacists and wholesalers, may submit importation program proposals to the Food and Drug Administration (FDA, the Agency, or we) for review and authorization…The purpose of the final rule is to achieve a significant reduction in the cost of covered products to the American consumer while posing no additional risk to the public’s health and safety.”

• Final Rule 4164.01-P: https://www.hhs.gov/sites/default/files/importation-final-rule.pdf
• FDA News Release: https://www.fda.gov/news-events/press-announcements/fda-takes-actions-help-lower-us-prescription-drug-prices?utm_medium=email&utm_source=govdelivery

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

• Article Release Date: August 4, 2020
• What You Need to Know: This article informs providers about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs). Change Request 11905 includes coding changes for the following NCDs:
• NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
• NCD 50.3 Cochlear Implants
• NCD 90.2 Next Generation Sequencing (NGS)
• NCD 220.6.17 Positron Emission Tomography (FDG) for Oncologic Conditions
• MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update

• Article Release Date: August 7, 2020
• What You Need to Know: This article provides information about the issuance of updated payment files in October of the 2020 MPFS.
• MLN MM11939: https://www.cms.gov/files/document/mm11939.pdf

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

• Article Release Date: August 7, 2020
• What You Need to Know: This article informs laboratories of changes resulting from the quarterly update to the clinical laboratory fee schedule. With the ongoing Public Health Emergency (PHE) this quarterly update includes changes made due to the COVID-19 pandemic.
• MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2021

• Article Release Date: August 21, 2020
• What You Need to Know: This article identifies changes required as part of the annual IPF PPS update. Changes are applicable to discharges occurring from October 1, 2020, through September 30, 2021 (FY 2021). The related Change Request (CR) applies to the Medicare Claims Processing Manual (CLM), Chapter 3, Section 190.4.3.
• MLN 11949: https://www.cms.gov/files/document/mm11949.pdf

OTHER MEDICARE TRANSMITTALS

New Waived Tests

• Article Release Date: July 28, 2020
• What You Need to Know: This article provides information about five new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests that have been approved by the FDA. These tests are marketed immediately after approval so CMS must notify the MACs of the new tests for accurate claims processing. “Note: MACs will not search their files to either retract payment or retroactively pay claims. However, MACs should adjust claims if you bring those claims to their attention.
• MLN Matters MM11916: https://www.cms.gov/files/document/mm11916.pdf

Update to Osteoporosis Drug Codes Billable on Home Health Claims

• Article Release Date: August 7, 2020
• What You Need to Know: Change Request (CR) adds instructions for billing and payment of additional codes for osteoporosis drugs under the home health benefit.
• MLN MM11846: https://www.cms.gov/files/document/mm11846.pdf

Correction to Editing Update for Vaccine Services

• Article Release Date: August 7, 2020
• What You Need to Know: This article informs you that Medicare is changing the Common Working File (CWF) to bypass line-item dates of service for vaccines reported on inpatient Part B claims with Type of Bill (TOB) 12X and 22X when the dates of service (DOS) equal a posted outpatient TOB 73X or 77X service dates, or if present, occurrence span code visit date, regardless of the date of service.
• MLN MM11867: https://www.cms.gov/files/document/mm11867.pdf

Billing for Home Infusion Therapy Services on or After January 1, 2021

• Article Release Date: August 7, 2020
• What You Need to Know: This article provides guidance, for qualified Home Infusion Therapy (HIT) suppliers who bill Medicare Part B MACs, about claims processing systems changes necessary to implement Section 5012(d) of the 21st Century Cures Act. Changes will be effective on or after January 1, 2021.
• MLN Article: MM11880: https://www.cms.gov/files/document/mm11880.pdf

Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) – Implementation

• Article Release Date: August 10, 2020
• What You Need to Know: This article provides information about the PARHM and the “Transformation Plans” for participating hospitals. CR 11870 expands the allowable telehealth services for Model-participant hospitals. Without this CR, some hospitals may fail to meet healthcare transformation goals set by the Model. Make sure your billing staffs are aware of these changes.
• MLN Article MM11870: https://www.cms.gov/files/document/mm11870.pdf

The Intravenous Immune Globulin (IVIG) Demonstration: Demonstration is ending on December 31, 2020

• Article Release Date: August 21, 2020
• What You Need to Know: This article is notification of the IVIG Demonstration ending December 31, 2020.
• MLN MM11877: https://www.cms.gov/files/document/mm11877.pdf

REVISED MEDICARE TRANSMITTALS

Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season

• Article Release Date: July 10, 2020 – Revised July 31, 2020
• What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11882 that extended the implementation date to no later than October 1, 2020 and for mass adjustments no later than November 1, 2020.
• MLN MM11882: https://www.cms.gov/files/document/mm11882.pdf

October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files – REVISED

• Article Release Date: July 2, 2020 – Revised August 14, 2020
• What You Need to Know: Changes made on August 14th were a revised Change Request (CR) release date, transmittal number and web address. All other information remained the same.
• MLN MM11854: undefined

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021

• Article Release Date: July 2, 2020 – Revised August 19, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11859 which “shows that effective for Fiscal Year (FY) 2021, a 5 percent cap will be adopted and applied to all Skilled Nursing Facility providers on any decrease to a provider’s FY 2021 final wage index from that provider’s final wage index of the prior fiscal year (FY 2020).”
• MLN MM11859: https://www.cms.gov/files/document/MM11859.pdf

MEDICARE COVERAGE UPDATES

CMS Transmittal 10228 (Change Request 11884): Updates to Chapters 1-8, 10, and 11 to Publication 100-08 (Medicare Program Integrity Manual)

• Transmittal Release Date: July 27, 2020
• What You Need to Know: The purpose of Change Request (CR) 11884 is to update all references of Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) to Unified Program Integrity Contractor (UPIC) within Chapters 1-8, 10, 11, and Exhibits in the Medicare Program Integrity Manual (Publication 100-08).
• CR11884: https://www.cms.gov/files/document/r10228pi.pdf

CMS Proposes Updates to Coverage Policy for Artificial Hearts and Ventricular Assist Devices (VADs)

CMS announced in an August 12, 2020 Press Release their proposed updates to coverage policies for artificial hearts and VADs, “both of which are used to treat patients with life-threatening advanced heart failure.” The proposed decision memorandum would:

• Eliminate the coverage with evidence development (CED) requirement for artificial hearts,
• MACs would become responsible for providing coverage determinations for artificial hearts, and
• Providers updated coverage criteria for VADs “that better aligns with current medical practice and provides additional flexibility for patients and providers to choose the most appropriate treatments.”

CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-artificial-hearts-and-ventricular-assist-devices-vads

OTHER MEDICARE UPDATES

July 31, 2020: CMS Releases Inpatient Psychiatric Facility (IPF), Skilled Nursing Facilities (SNF), and Hospices FY 2021 Final Rules

CMS announced in a News Alert that they are “finalizing three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF) and hospices.”   For fact sheets on each final rule, visit:

• IPF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-final-medicare-payment-and-policy-changes-inpatient-psychiatric-facilities-cms-1731
• SNF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1737-f
• Hospices PPS -- https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-hospice-payment-rate-update-final-rule-cms-1733-f

CY 2021 Physician Fee Schedule (PFS) Proposed Rule with Comment Period

CMS announced the release of this proposed rule in an August 3, 2020 CMS Fact Sheet. A few of the proposals highlighted in the Fact Sheet includes:

• A proposed CY 2021 PFS conversion factor of $32.26 which is down $3.83 from the CY 2020 PFS conversion factor of $36.09,
• Proposal to add several services to the Medicare telehealth list on a Category 1 basis,
• Proposal to create a third temporary category of criteria for adding services to the Medicare telehealth services list. Category 3 describes services added during the PHE for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends. The PHE determination as a result of COVID-19 was most recently renewed on July 23, 2020,
• Proposal to make permanent following the COVID-19 PHE, the same policy that was finalized under the May 1st COVID-19 IFC, for the duration of the COVID-19 PHE. This proposal would allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians, and
• Proposal to make permanent our Part B policy for maintenance therapy services that we adopted on an interim basis for the PHE in the May 1st COVID-19 IFC that grants a physical therapist (PT) and occupational therapist (OT) the discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant – a physical therapist assistant (PTA) or an occupational therapy assistant (OTA). 

August 2020 OIG Report: Inadequate Edits and Oversight Caused Medicare to Overpay More Than $267 Million for Hospital Inpatient Claims with Post-Acute-Care Transfers to Home Health Services

The OIG’s objective in performing this audit was to determine whether Medicare properly paid acute-care hospital inpatient claims subject to the transfer policy when hospitals:

• Did not code the claims as a discharge to home with home health services when the beneficiary resumed home health services within 3 days of discharge,
• Applied condition code 43 indicating that the home health services were not provided within 3 days of discharge, or
• Applied condition code 42 indicating that the home health services were not related to the inpatient hospital services.

The OIG audit 150 inpatient claims with dates of service in fiscal years 2016 and 2017 and found that 147 claims were improperly paid with $722,288 in overpayments. Based on the sample the OIG estimated that Medicare improperly paid $267 million during the 2-year period when services should have been paid at a graduated per diem rate.

• OIG Report Number A-04-18-04067: https://oig.hhs.gov/oas/reports/region4/41804067.pdf

CMS Announces Initiative to Transform Rural Health

CMS announced new funding opportunities to increase access and improve quality. The Community Health Access and Rural Transformation (CHART) Model “also ties payment to value, increase choice and lowers cost to patients.

Link to August 11, 2020 Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health

Link to CHART Model webpage: https://innovation.cms.gov/innovation-models/chart-model

OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in the HHS Program

The OIG released their annual publication of this report on August 11th. The top 25 recommendations made are based on audits and evaluations issued through December 31, 2019. Seven of the top twenty-five recommendations are related to Medicare Parts A and B. One of the seven recommendations is that CMS re-evaluate the Inpatient Rehabilitation Facility (IRF) payment system.

The U.S. government’s PaymentAccuracy website “is dedicated to ensuring the American people that its government is addressing…and taking concrete steps on prevention and recovery of improper payments.” According to the Department of Health and Human Services Q4 2019 Payment Scorecard, IRF medical necessity errors resulted in overpayments of $6,740M. Program goals include continuing to educate IRF providers through the Targeted Probe and Educate (TPE) program and approve IRF issues for Recovery Audit Contractor (RAC) review, as appropriate.

Link to PaymentAccuracy website: https://www.paymentaccuracy.gov/about-payment-accuracy/

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.3, Effective October 1, 2020

• Article Release Date: June 23, 2020
• What You Need to Know: Change Request (CR) 11840 providers the quarterly updates to the NCCI PTP edits.
• MLN MM11840: https://www.cms.gov/files/document/mm11840.pdf

Quarterly Update to the End Stage Renal Disease Prospective Payment System (ERSD PPS)

• Article Release Date: June 29, 2020
• What You Need to Know: CR 11835 informs providers about the twenty new diagnosis codes eligible for the ESRD PPS comorbidity payment adjustment effective October 1, 2020.
• MLN MM11835: https://www.cms.gov/files/document/mm11835.pdf

October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: July 2, 2020
• What You Need to Know: This article updates the Quarterly ASP Medicare Part B Files and informs providers of revisions to prior quarterly filing prices.
• MLN MM11854: https://www.cms.gov/files/document/mm11854.pdf

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021

• Article Release Date: July 2, 2020
• What You Need to Know: This article provides FY 2020 Updates to the SNF PPS payment rates, as required by statue.
• MLN MM11859: https://www.cms.gov/files/document/mm11859.pdf

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2020 Update

• Article Release Date: July 6, 2020
• What You Need to Know: Change Request (CR) 11769 released on June 23, 2020 updates the HCPCS code set for codes related to drugs and biologicals effective July 1, 2020. The related MLN article MM11769 provides links to the updated quarterly HCPCS complete code set.
• MLN MM11769: https://www.cms.gov/files/document/mm11769.pdf

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020

• Article Release Date: July 10, 2020
• What You Need to Know: This article announced changes included in the October 2020 quarterly release of the edit module for clinical diagnostic laboratory services.
• MLN MM11889: https://www.cms.gov/files/document/MM11889.pdf

Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season

• Article Release Date: July 10, 2020
• What You Need to Know: This article informs you of the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 each year.
• MLN MM11882: https://www.cms.gov/files/document/mm11882.pdf

Other Medicare Transmittals

Revising Chapters 3 and 5 of Publication (Pub.) 100-08, to Reflect the Recent Final Rule CMS-1713-F

• Article Release Date: July 1, 2020
• What You Need to Know: CR 11599, released June 19, 2020, revises the Medicare Program Integrity Manual, Chapters 3 (Verifying Potential Errors and Taking Corrective Actions) and 5 (Items and Services Having Special DMEPOS Review Considerations) to include finalized regulatory updates, including those related to face-to-face encounter and written order requirements.
• MLN Matters MM11599: https://www.cms.gov/files/document/mm11599.pdf

Change to the Payment of Allogeneic Stem Cell Acquisition Services

• Article Release Date: July 13, 2020
• What You Need to Know: Currently payment for this service is included in the MS-DRG payment for allogeneic hematopoietic stem cell transplants when transplants occurred in the inpatient setting. Change Request (CR) Transmittal R10218CP provides instructions to pay inpatient hospital Allogeneic Stem Cell Acquisition services on a reasonable cost basis.
• MLN Matters MM11729: https://www.cms.gov/files/document/mm11729.pdf

Revised Medicare Transmittals

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2020 Update

• Article Release Date: February 25, 2020 – Revised June 22, 2020
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11655 in which CMS removed the CPT code 0048U from the business requirement for NCD 90.2 Next Generation Sequencing (NGS) and corresponding removals of CPT 0048U and its associated diagnosis codes from the NCD 90.2 NGS spreadsheet. Changes were made due to the CPT code not meeting the policy criteria in NCD 90.2 for NGS.
• MLN MM11655: https://www.cms.gov/files/document/mm11655.pdf

July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) Revised

• Article Release Date: June 8, 2020 – Revised July 2, 2020
• What You Need to Know: This article was revised to reflect updates in the related CR R10207CP. Updates include the following:
• Added CPT code 99458 with status indicator "B".
• "New Separately Payable Procedure Codes – Surgical Procedures" has been updated with corrected APC assignment for HCPCS code C9760.
• "OPPS PRICER Logic and Data Changes for the July 2020 Update" has been removed. There is also a new, "Inadvertent Deletion of CPT code 0126T" added.
• Therefore, the existing section 16 "Changes to the Wage Index" has become section 15. Table 1 has been updated by adding a new PLA COVID-19 code, 0202U.
• Table 2 has been updated by adding CPT code 99458 with status indicator "B".
• Table 21 has been updated by changing APC number for HCPCS code C9760 from APC 1591 to APC 1589. We also changed the CR release date, transmittal number and link to the transmittal. All other information is unchanged.
• MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf

July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System

• Article Release Date: June 24, 2020 – Revised July 2, 2020
• What You Need to Know: This article describes changes to and billing instructions for various payment policies implemented in the July 2020 ASC payment system update. This notification also includes HCPCS updates. The July 2nd revision was made to correct the last section in Section 6.e, on page 10. CMS notes it should have stated, “C9058 is replaced by Q5120 effective July 1, 2020.”
• MLN MM11842: https://www.cms.gov/files/document/mm11842.pdf

Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model

• Article Release Date: May 4, 2015 – Revised July 24, 2020
• What You Need to Know: This article was revised to provide information on transportation information for beneficiaries in the Additional Information section of this article.
• MLN SE1514: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1514.pdf

Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

• Article Release Date: May 1, 2020 – Revised July 21, 2020
• What You Need to Know: This article was revised to reflect revisions in Change Request (CR) 11850 also issued on July 21, 2020. This CR reflects additional sections to the Medicare Claims Procession Manual – Chapter 32 – Billing Requirements for Special Services. Section 66.2 of the chapter identifies CAR-T as having significant costs for Medicare Advantage. Due to the significant cost Providers may bill the A/B MAC for this NCD service provided to a MA beneficiary.
• MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf

Medicare Coverage Updates

MLN Booklet: How to Use the Medicare Coverage Database (MCD)

• Booklet Release Date: June 2020
• What You Need to Know: This MLN education booklet provides information on what the MCD is, why you would use it, a background about Medicare coverage and coverage determinations, how up-to-date is the MCD and how to search the MCD.
• ICN MLN901347 June 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareCvrgeDatabase_ICN901346.pdf

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS) MLN Article Revised

• MLN Article Revised: June 23, 2020
• What You Need to Know: This article was revised to reflect the revised CR11461 issued on June 23, 2020. The revised CR clarifies instructions for the MACs and changed the implementation date to July 22, 2020.
• MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf

Medicare Compliance Tips

MLN Booklet: How to Use the Medicare National Correct Coding Initiative (NCCI) Tools

• Booklet Release Date: June 2020
• What You Need to Know: This MLN education booklet provides information on what is the Medicare NCCI, why would you use it, how up to date are the NCCI tables and manual, how to locate the NCCI tables and manual and using the NCCI tools.
• ICN 901346 June 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

Medicare Quarterly Provider Compliance Newsletter

• Newsletter Release Date: July 2020
• What You Need to Know: This newsletter is released on a quarterly basis to share Medicare Contractor Audit Findings and provide information on how to address and avoid top issues in a particular quarter. The July 2020 edition includes information from the following three RAC Auditor Reviews:
• New Issue #0099 – Skilled Nursing Facility Consolidated Billing: Outpatient Facility – Not Separately Payable Services: Unbundling,
• New Issue #0129 – Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements, and
• New Issue #0103 – Urological Supplies: Medical Necessity and Documentation Requirements.
• ICN MLN5829840 July 2020: https://www.cms.gov/files/document/medicare-quarterly-provider-compliance-newsletter-volume-10-issue-4.pdf

Other Medicare Updates

CMS Announces the Creation of the Office of Burden Reduction and Health Informatics

In a June 23rd Press Release, CMS announced a new Office of Burden Reduction and Health Information meant “to unify the agency’s efforts to reduce regulatory and administrative burden and to further the goal of putting patients first.” CMS Administrator Seema Verma said in the announcement that “The Office of Burden Reduction and Health Informatics will ensure the agency’s commitment to reduce administrative costs and enact meaningful and lasting change in our nation’s health care system…Specifically, the work of this new office will be targeted to help reduce unnecessary burden, increase efficiencies, continue administrative simplification, increase the use of health informatics, and improve the beneficiary experience.”

June 25, 2020: CMS Issues Home Health PPS Proposed Rule [CMS-1730-P] CY 2021

In addition to updating payment rates and wage index for calendar year 2021, “this proposed rule proposes to permanently finalize the changes to §409.43(a) as finalized in the first COVID-19 PHE IFC (85 FR 19230), to state that the plan of care must include any provision of remote patient monitoring and other services furnished via a telecommunications system and describe how the use of such technology is tied to the patient-specific needs as identified in the comprehensive assessment and will help to achieve the goals outlined on the plan of care.”

• Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-proposes-calendar-year-2021-payment-and-policy-changes-home-health-agencies-and-calendar-year

June 26, 2020: HHS Submits Status Report on Medicare Appeals Backlog at the ALJ Level

In this June 26th report, HHS indicated that they have reduced that “By the end of the second quarter of 2020, a total of 242,995 appeals remain pending at OMHA, which is a 43% reduction from the starting number of appeals identified in the Court’s order (426,594 appeals).”

https://www.aha.org/system/files/media/file/2020/06/alj-delay-status-report-6-26-2020.pdf

AHA Announcement: https://www.aha.org/news/headline/2020-06-26-result-aha-lawsuit-hhs-continues-reduce-appeals-backlog

July 6, 2020: CMS Issues End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Calendar Year (CY) 2021 Proposed Rule (CMS-1732-P)

In addition to proposed updates to payment policies and rates, this rule is also proposing updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and proposes changes to the ESRD Quality Incentive Program (QIP).

• CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-payment-changes-support-innovation-and-increased-access-dialysis-home-setting
• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/end-stage-renal-disease-esrd-prospective-payment-system-pps-calendar-year-cy-2021-proposed-rule-cms

July 15, 2020: OIG Report: Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims

This is not the first time the OIG has focused on malnutrition diagnosis codes and based on their findings I do not anticipate this will be the last time. The parameters of the OIG audit included:

• Focusing on Diagnosis Codes E41 (Nutritional marasmus) and E43 (Unspecified severe protein calorie malnutrition), and
• Auditing a random sample of 200 claims with a discharge date in Fiscal Year 2016 or 2017.

OIG Findings:

• 173 of the 200 records reviewed were not correctly billed by the hospitals
• 9 of the 173 incorrectly coded claims the removal of the malnutrition code did not impact DRG assignment or payment.
• The 164 claims that were incorrectly coded results in net overpayments of $914, 128
• The OIG extrapolated their sample and estimated that hospitals received overpayments of$1 billion for FYs 2016 and 2017.

Based on OIG recommendations, “CMS stated that it will instruct its contractors to review a sample of claims in the sampling frame to determine whether they were billed correctly. Based on the findings of the sample review, CMS will determine the appropriate course of action. CMS will recover, as appropriate, any identified overpayments associated with the reviews consistent with agency policy and procedures.” You can read the entire report at https://www.oig.hhs.gov/oas/reports/region3/31700010.pdf.

July 15, 2020: Contract Award for A/B MAC Jurisdiction 6

CMS posted the following information on the CMS MAC What’s New webpage:

“On July 15, 2020, the Centers for Medicare & Medicaid Services (CMS) awarded National Government Services, Inc. (NGS) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims for Illinois, Minnesota, and Wisconsin (Jurisdiction 6). This contract will also administer Medicare Home Health and Hospice (HH+H) FFS claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington. As NGS is the incumbent contractor for this A/B MAC jurisdiction, CMS anticipates that implementation of the new contract will go smoothly, with few, if any, service issues for Medicare beneficiaries and providers. Learn more about this at A/B MAC Jurisdiction 6 Award Fact Sheet (PDF).”

July 17, 2020: The Joint Commission’s (TJC’s) Continued Approval of its Hospital Accreditation Program Limited to 2 Years

CMS published their decision to approve TJC for continued recognition as a national accrediting organization for hospitals participating in the Medicare and Medicaid Programs in the Federal Register on July 17, 2020. CMS can approve an accrediting agency for up to 6 years. However, the Final Notice indicated the TJCs continued approval is effective for only two years from July 15, 2020 through July 15, 2022. The following excerpt from the Federal Register outlines CMS reasons for this shorter term of approval:

“This shorter term of approval is based on our concerns related to the comparability of TJC’s survey processes to those of CMS, as well as what CMS has observed of TJC’s performance on the survey observation. Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC’s processes surrounding its staff interview practices. Additionally, we are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment condition of participation. Based on these observations and review of TJC’s processes as discussed at section V.A. (Differences Between TJC’s Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements), we remain concerned about the thoroughness of review conducted within the facilities. While TJC has taken action based on the findings annotated in section V.A., as authorized under §488.8, we will continue ongoing review of TJC’s survey processes across all their approved accrediting programs to ensure that all our recommended changes have been implemented. In keeping with CMS’s initiative to increase AO oversight, and ensure that our requested revisions by TJC are complied with, CMS expects more frequent review of TJC’s activities to avoid any continued inconsistencies.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Influenza Virus Vaccine Code Update – July 2020

• Article Release Date: January 31, 2020
• What You Need to Know: The influenza virus vaccine code set is updated on a quarterly basis. Reminder, effective for claims processed with dated of service on or after July 1, 2020, influenza virus vaccine code 90694 (influenza virus vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use) is payable by Medicare.
• MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf

July 2020 Integrated Outpatient Code Editor (I/OCE) Specification Version 21.2

• Article Release Date: June 5, 2020
• What You Need to Know: This article provides the I/OCE instructions and specifications for the I/OCE employed under the Outpatient Prospective Payment System (OPPS) and non-OPPS. The specifications are for:
• Hospital outpatient departments
• Community mental health centers
• All non-OPPS hospital providers
• For limited services when provided in a Home Health Agency (HHA) not under the HH Prospective Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/.
• MLN Matters MM11792: https://www.cms.gov/files/document/mm11792.pdf

July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: June 5, 2020
• What You Need to Know: The following list highlights the main topics included in this document:
• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update,
• Status Indicator Changes for Certain Virtual Services,
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinical (RHC) or Federally Qualified Health Center (FQHC) Only,
• New CPT Category III Codes Effective July 1, 2020,
• CPT Proprietary Laboratory Analysis (PLA) Coding Changes Effective July 1, 2020,
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755,
• Device Pass-Through Updates,
• Changes to Certain Device Offsets for 2020,
• Drugs, Biologicals, and Radiopharmaceuticals,
• Skin Substitutes – New Products,
• New Separately Payable Procedure Codes – Surgical Procedures,
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI),
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy,
• Supervision of Outpatient Therapeutic Services,
• MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf

July Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

• Article Release Date: June 5, 2020
• What You Need to Know: This article informs DME MACs about changes to the DMEPOS fee schedules that are updated quarterly, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies.

Note, this update includes guidance from the interim final rule with comment period (CMS-5531-IFC) entitled “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” published in the Federal Register May 8, 2020. This final rule implements a section of the Coronavirus Aid, Relief, and Economic Security (CARES) Act regarding fee schedule adjustments.

• MLN MM11810: https://www.cms.gov/files/document/mm11810.pdf
  

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2020

• Article Release Date: June 5, 2020
• What You Need to Know: Medicare Updates the DMEPOS CBP files on a quarterly basis to implement necessary changes to HCPCS, ZIP code, and supplier files. Related Change Request CR 11819 provides specific instruction for implementing the DMEPOS CBP files.
• MLN MM11819: https://www.cms.gov/files/document/mm11819.pdf

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

• Article Release Date: June 12, 2020
• What You Need to Know: This article informs labs about changes in the quarterly update. Several of the updates are specific to guidance regarding lab testing related to COVID-19.
• MLN MM11815: https://www.cms.gov/files/document/mm11815.pdf

OTHER MEDICARE TRANSMITTALS

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advise Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: May 22, 2020
• What You Need to Know: Informs you of updates the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, CAGC rule publications. Updates are based on the CORE Combination Codes List to be published on or about June 1, 2020.
• MLN Matters MM11709: https://www.cms.gov/files/document/mm11709.pdf

New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

• Article Release Date: June 12, 2020
• What You Need to Know: Code “G” is a new Point of Origin (PoO) code to indicate a “transfer from a Designated Disaster Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency (PHE).
• MLN MM11836: https://www.cms.gov/files/document/mm11836.pdf

REVISED MEDICARE TRANSMITTALS

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update

• Article Release Date: May 1, 2020 – Rescinded May 26, 2020
• What You Need to Know: This article was rescinded on May 26, 2020, as the related Change Request (CR) 11749, Transmittal 10092, dated May 1, 2020, was rescinded in its entirety. Therefore, any coding changes to NCD 90.2, Next Generation Sequencing are null and void.
• MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf

Supplier Education on Use of Upgrades for Multi-Function Ventilators

• Article Release Date: May 29, 2020
• What You Need to Know: This article was revised to show that the policy on use of multi-function ventilators, as discussed in the “What You Need to Know” section, is a permanent change.
• MLN SE20012: https://www.cms.gov/files/document/se20012.pdf

Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component

• Article Release Date: May 29, 2020 – Revised June 9, 2020
• What You Need to Know: This article provides information about the hospice benefit component associated with the VBID Model being tested by the CMS Innovation Center and starting in Calendar Year (CY) 2021. CMS highlights that “providers MUST still submit claims for these services to Medicare.” CMS revised this MLN article on June 9th to reflect a revised CR 11754 issued on June 9th.
• MLN Matters MM11754: https://www.cms.gov/files/document/mm11754.pdf

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Article Release Date: March 24, 2020 – Revised June 10, 2020
• What You Need to Know: This article was revised to reflect formatting revisions in Change Request 11660. The substance of the article was not altered.
• MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)

• Article Release Date: June 1, 2020
• What You Need to Know: Change Request (CR) 11461 was published on May 22, 2020 highlighting that new to NCD 160.16, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met. The accompanying MLN article was released on June 1, 2020.
• MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf

Other Medicare Updates

Prior Authorization (PA) Program for Certain Hospital Outpatient Department (ODP) Services CMS Operational Guide and FAQs

In last May CMS released an Operational Guide and FAQs related to this Program set to begin July 1, 2020.

• Operation Guide: https://www.cms.gov/files/document/opd-operational-guide.pdf
• Frequently Asked Questions: https://www.cms.gov/files/document/opd-frequently-asked-questions.pdf

2021 ICD-10-PCS Codes for Discharges Occurring from October 1, 2020 through September 30, 2021

On May 28, 2020, CMS posted the 2021 Official ICD-10-PCS Coding Guidelines, Code Tables, and Addendum on the 2021 ICD-10-PCD CMS webpage.

• Link to CMS webpage: https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs

KEPRO Case Review Connections: Acute Care Edition: Summer 2020

KEPRO published their Summer 2020 Case Review Connections e-newsletter. Topics included in this newsletter includes:

• Medical Director’s Corner,
• A Reminder About Appeals Cases,
• Updates from CMS Related to COVID-19,
• An Immediate Advocacy Success Story,
• Frequently Asked Questions, and
• Staff Education about BFCC-QIO Services.

June 17, 2020 CMS Proposed Rule: Establishing Minimum Standards in Medicaid State Drug Utilization (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS 2482-P)

CMS Administrator Seema Verma noted in a Press Release that “CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models…by modernizing our rules, we are creating opportunities for drug manufacturers to have skin in the game through payment arrangement that challenge them to put their money where their mouth is.”

The Press Release includes links to a related Fact Sheet and the Proposed Rule. CMS is accepting comments no later than 5 p.m. on July 20, 2020. 

MEDICARE TRANSMITTALS – RECURRING UPDATES

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update

• Article Release Date: May 1, 2020
• What You Need to Know: Change Request (CR) 11749 provides information about updated ICD-10 conversions as well as coding updates specific to NCDs. In this update new ICD-10-CM codes have been added to NCD 90.2 Next Generation Sequencing.
• MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2020 Update

• Article Release Date: May 12, 2020
• What You Need to Know: CMS has issued payment files to the MACs based on the 2020 MPFS Final Rule.
• MLN MM11788: https://www.cms.gov/files/document/mm11788.pdf

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

• Article Release Date: May 22, 2020
• What You Need to Know: CR 11708 is a code update notification indicating when updates to the CARC and RARC lists are made available at the official Accredited Standards Committee (ASC) X12 website.
• MLN MM11708: https://www.cms.gov/files/document/mm11708.pdf

October 2020 Healthcare Common Procedure Coding System (HCPCS) Quarterly Update Reminder

• Transmittal Release Date: May 22, 2020
• What You Need to Know: The complete HCPCS file is updated and released quarterly to the Medicare contractors. The file contains existing, new, revised and discontinued HCPCS codes for the October 2020 quarter. Contractors must download the file via the CMS mainframe in September 2020. The recurring update notification applies to chapter 23, section 20 of the Medicare Claims Processing Manual.
• Transmittal 10153: https://www.cms.gov/files/document/r10153cp.pdf

OTHER MEDICARE TRANSMITTALS

 Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

• Article Release Date: May 1, 2020
• What You Need to Know:
• Change Request (CR) 11580 modifies Medicare system edits on inpatient claims when a beneficiary’s MA plan becomes effective during the inpatient admission.
• The CMS is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered significant cost. FFS Medicare will pay for services obtained by beneficiaries enrolled in MA plans in this circumstance.
• MACs will allow Condition Code (CC) 78 on inpatient and outpatient claims for MA beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost. An update will occur to any current editing that does not allow this scenario.
• Condition Code 78 = newly covered Medicare service for which a HMO does not pay.
• MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf

New Codes for Therapist Assistants Providing Maintenance Programs in the Home Health Setting

• Article Release Date: May 1, 2020
• What You Need to Know: CR 11721 details changes to Home Health (HH) billing and processing instructions, including new G-codes describing therapy assistant services. Also included is a correction to the processing of HH claims that receive episode sequence edits.
• MLN MM11721: https://www.cms.gov/files/document/mm11721.pdf

Medicare Clarifies Recognition of Interstate License Compacts

• Special Edition Article Release Date: May 5, 2020
• What You Need to Know: This article clarifies the CMS recognition of interstate license compacts. CMS acknowledges that more compacts may be underway as new legislation is passed but at this time they have determined that interstate license compact for the following provider types will be treated as valid and full licenses for purposes of meeting federal license requirements:
• Physicians,
• Physical and Occupational Therapists,
• Speech Language Therapists,
• Nurse Practitioners, and
• MLN Article SE20008: https://www.cms.gov/files/document/SE20008.pdf

Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process

• Article Release Date: May 8, 2020
• What You Need to Know: Change Request 11727 contains updates to Medicare’s claims processing systems to make corrections to processing of adjustments and other billing issues for SNF Patient Driven Payment Model (PDPM) claims. CMS advises you to make sure your billing staffs are aware of these updates.
• MLN Article MM11727: https://www.cms.gov/2020-mln-matters-articles-0

New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services

• Article Release Date: May 11, 2020
• What You Need to Know: This article highlights new physician specialty codes for MDS (D7) and ACHD (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6).
• MLN MM11750: https://www.cms.gov/files/document/MM11750.pdf

Therapy Codes Update

• Article Release Date: May 15, 2020
• What You Need to Know: This article includes updates to the list of codes that sometimes or always describe therapy services. Additions to the list reflect changes made in Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE).
• MLN MM11791: https://www.cms.gov/files/document/MM11791.pdf

Manual Update Pub. 100.-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section

• Article Release Date: May 15, 2020
• What You Need to Know: Medicare is removing section 20 (and all of its subsections) of chapter 38 of the Medicare Claims Processing Manual (Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico). The key impact of this notification is that modifier CS will no longer be used to denote services related to the 2010 oil spill. The effective and implementation date for this change is June 16, 2020.
• MLN Matters MM11778: https://www.cms.gov/files/document/MM11778.pdf

REVISED MEDICARE TRANSMITTALS

Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy

• Date Article Revised: April 30, 2020
• What You Need to Know: This article was revised to reflect revised Change Request 11559. The CR informs MACs about changes to Medicare Common Working File (CWF) edits to ensure the original 1-Day and 3-Day Payment Window edits’ set and bypass conditions are consistent with current policy. There are no policy changes. Current policy is in the Medicare Claims Processing Manual, Chapter 4, Section 10.12 and Section 40.3.
• MLN Article MM1159: https://www.cms.gov/files/document/mm11559.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update

• Date Article Revised: May 4, 2020
• What You Need to Know: This article was revised to reflect revisions in CR 11661 issued on May 1, 2020. The following changes were made:
• The relative value units for codes 99441-99442, and 99443 were revised,
• Information for codes G2025 and G0071 was added, and
• The statement at the end of page was updated.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Medicare Continues to Modernize Payment Software

• Article Release Date: May 19, 2020
• What You Need to Know: This articles provides information about the CMS efforts to modernize payment grouping and code edit software. Specifically, this article is meant to inform providers that in October 2020, CMS will expand this effort to include the following additional software products:
• The IRF Case-Mix Group (CMG) Grouper, and
• The IRF Pricer and PC Pricer.
• MLN SE20019: https://www.cms.gov/files/document/SE20019.pdf

Claim Status Category Codes and Claim Status Codes Updates

• Article Release Date: May 22, 2020
• What You Need to Know: CR 11699 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.
• MLN MM11699: https://www.cms.gov/files/document/mm11699.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)

• Article Release Date: May 13, 2020
• What Your Need to Know: This article informs you that CMS will cover acupuncture for cLBP effective for claims with dates of service on or after January 21, 2020. The article reminds you that acupuncture for fibromyalgia or osteoarthritis is still non-covered by Medicare.
• MLN MM11755: https://www.cms.gov/files/document/MM11755.pdf
  

National Coverage Determinations (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)

• Date Article Released: May 12, 2020
• What You Need to Know: For dates of service on and after July 2, 2019, the CMS will cover ABPM for the diagnosis of hypertension in Medicare under updated criteria detailed in this article. The Effective Date was July 2, 2019. The Implementation Date for Local MAC edits is June 16, 2020.
• MLN MM11650: https://www.cms.gov/files/document/MM11650.pdf

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)

• Date Transmittal Released: May 22, 2020
• What You Need to Know: NCD 160.18, Vagus Nerve Stimulation was initially issued in 1999 to provide coverage for VNS for patients with medically refractory partial onset seizures, for whom surgery is not recommended or for whom surgery had failed. New to this NCD, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met.
• Transmittal 10145: https://www.cms.gov/files/document/r10145ncd.pdf

OTHER MEDICARE UPDATES

MLN Booklet (ICN MLN901623) April 2020: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants

This MLN Booklet outlines the required healthcare practitioner qualifications and coverage, billing, and payment criteria for Medicare services furnished by:

• Advanced Practice Registered Nurses (APRNs), including:
• Certified Registered Nurse Anesthetists (CRNAs)
• Nurse Practitioners (NPs)
• Certified Nurse-Midwives (CNMs)
• Clinical Nurse Specialists (CNSs)
• Anesthesiology Assistants (AAs), and
• Physician Assistants (PAs)

Fiscal Year 2021 IPPS and LTCH PPS Proposed Rule

CMS released the FY 2021 IPPS and LTCH PPR Proposed Rule. In a related Fact Sheet CMS indicates the agency’s singular objective is “transforming the healthcare delivery system through competition and innovation to provide patients with better value and results.” CMS is accepting comments on the Proposed Rule through 5 pm EDT on July 10, 2020.

May 7, 2020: Original Medicare (Fee-for-Service) Appeals: Enhanced Opportunity for Submission of 2nd Level of Appeals, Reconsiderations

CMS posted the following announcement on their Original Medicare (Fee-for-Service) Appeals webpage on May 7th: Qualified Independent Contractors (QICs) that process 2nd level Medicare Fee-For-Service (FFS) claim appeals, reconsiderations, on behalf of the Centers for Medicare & Medicaid Services (CMS) have established alternative communication mediums for CMS stakeholders to submit reconsideration requests and related documentation to the QIC. The websites for the respective QIC jurisdictions contain instructions to stakeholders for electronic (e.g., fax or portal) submission of reconsideration requests or documentation.” A table on this page provides guidance regarding the options for submitting reconsiderations and related documentation by QIC jurisdiction.

May 8, 2020: Hospital Outpatient Therapeutic Services That Have Been Evaluated for a Change in Supervision Level

On May 8th, CMS added this document to the available downloads on the CMS Hospital Outpatient PPS 

Webpage. Included in the download is a table providing the level of supervision required for hospital outpatient therapeutic services. Information prior to the table highlights changes made in an interim final rule addressing supervision requirements for non-surgical extended duration services (NSEDTS) and pulmonary rehabilitation services, cardiac rehabilitation services, and intensive cardiac rehabilitation services during the COVID-19 Public Health Emergency (PHE).

MEDICARE TRANSMITTALS – RECURRING UPDATES

April 2020 Average Sales Price (AS) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: March 20, 2020
• What You Need to Know: Article informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
• MLN MM11701: https://www.cms.gov/files/document/mm11701.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020

• Article Release Date: March 27, 2020
• What You Need to Know: This MLN article is a companion article to Change Request 11734 which providers the quarterly updated to the NCCI PTP edits. CMS advises making sure your billing staffs know the updates.
• MLN MM11734: https://edit.cms.gov/files/document/mm11734.pdf

July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: March 27, 2020
• What You Need to Know: Related Change Request (CR) 11745 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.
• MLN MM11745: https://www.cms.gov/files/document/mm11745.pdf

April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: April 7, 2020
• What You Need to Know: Change Request 11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 OPPS update.
• MLN MM11691: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/r4544cp

Quarterly Update to the Fiscal Year 2020 Inpatient Psychiatric Facilities Pricer

• Article Release Date: April 10, 2020
• What You Need to Know: CR 11759 updates the Inpatient Psychiatric Facilities (IPF) Pricer software used in Medicare claims procession. This update includes updates to the comorbidity tables to include the new ICD-10 diagnosis code for COVID-19 (U01.7) effective for claims with discharges on or after April 1, 2020.
• MLN MM11758: https://www.cms.gov/files/document/mm11759.pdf

Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer

• Article Release Date: April 24, 2020
• What You Need to Know: CT 11742 updates the LTCH Pricer software. The new version include the payment policy for an LTCH that is subject to the Discharge Payment Percentage (DPP) payment adjustment described in CR 11616. CR 11742 also included new payment policy for COVID-19.
• MLN MM11742: https://www.cms.gov/files/document/MM11742.pdf

July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer

• Article Release Date: April 24, 2020
• What You Need to Know: CR 11764 updates the FY 2020 IPPS Pricer software. This new version includes new payment policy for individuals diagnosed with COVID-19.
• MLN MM11764: https://www.cms.gov/files/document/MM11764.pdf

OTHER MEDICARE TRANSMITTALS

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Article Release Date: March 13, 2020
• What You Need to Know: Effective June 21, 2019, CMS will continued coverage of TAVR under Covered with Evidence Development (CED) when the procedure is provided for the treatment of symptomatic aortic valve stenosis and according to a FDA-approved indication for use with an approved device.
• MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitations Facilities (IRFs), and Long Term Care Hospitals (LTCHs)

• Article Release Date: 3/13/2020
• What You Need to Know: This MLN article includes links to hospital specific data for determining adjustments to be made for caring for low-income patients (LIP).
• MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf

Supplier Education on Use of Upgrades for Multi-Function Ventilators

• Article Release Date: April 3, 2020
• What You Need to Know: This article informs DME suppliers that effective immediately, you may provide and bill for multi-function ventilators described by code E0467 as an upgrade in situations where beneficiaries only meet the coverage criteria for a ventilator.
• MLN SE20012: https://www.cms.gov/files/document/se20012.pdf

New Waived Tests

• Article Release Date: April 17, 2020
• What You Need to Know: Change Request 11747 informs MACs of new Clinical Laboratory Amendments of 1988 (CLIA) waived tests by the FDA. These tests are marketed immediately after approval and as such, the CMS must notify MACs of the new tests for accurate claims processing. The following statement is included in the article: “Note: MACs will not search their files to either retract payment or retroactively pay claims; however, MACs should adjust claims if you bring those claims to their attention.”
• MLN MM11747: https://www.cms.gov/files/document/mm11747.pdf

REVISED MEDICARE TRANSMITTALS

New Medicare Beneficiary Identifier (MBI) Get It, Use It – Revised

• Article Release Date: March 19, 2020
• What You Need to Know: This article was revised to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool. All other information remains the same.
• MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

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

• Article Revised: March 24, 2020
• What You Need to Know: This article was revised to reflect an update CR 11604. CR 11640 informs the MACs about new HCPCS codes for 2020 that are subject to and excluded from CLIA Edits.
• MLN MM11640: https://www.cms.gov/files/document/mm11640.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020

• Article Revised: March 25, 2020
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 11628. This revision had no impact on the substance of the article.
• MLN MM11628: https://www.cms.gov/files/document/mm11628.pdf

Implementation of Additional Requirements to add HCPC and CPT as Paired Items of Service for Prior Authorization and Medicare Claims Processing for Part A, Part B, DME, and Home Health and Hospice

• Change Request revised date: March 27, 2020
• What You Need to Know: Transmittal 2438, dated February 21, 2020 was rescinded and replaced with Transmittal 10021, dated March 27, 2020 to remove business requirement 11516.7 and to change the PA Program Indicator in the attachment Criteria Template. All other information remains the same.
• Transmittal 10021: https://www.cms.gov/files/document/r10021otn.pdf

April 1, 2020: Update to ICD-10-CM for Vaping Related Disorder and 2019 Novel Coronavirus (COVID-19)

• Article Revised: April 1, 2020
• What You Need to Know: This article was revised to reflect the update to Change Request (CR) 11623 where the new ICD-10-CM code for the 2019 Novel Coronavirus (COVDI-19) was added.
• MLN MM11623: https://www.cms.gov/files/document/MM11623.pdf

April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1

• Article Revised: April 1, 2020
• What You Need to Know: CR 11680 provides the I/OCE instruction and specifications for the April 1, 2020 updates. This article was revised to reflect the CR revisions adding information to Table 1, including COVID-19 changes.
• MLN MM11680: https://www.cms.gov/files/document/MM11680.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Pay

• Article Revised: April 6, 2020
• What You Need to Know: This article was revised to reflect revisions to Change Request 1168 where the section on the delay of the CLFS reporting period was removed and the following codes were added:
• 87635: added to HCPCS file, effective March 13, 2020
• Two new COVID-19 test codes (G2023 and G2024), effective March 1, 2020
• MLN MM11681: https://www.cms.gov/files/document/mm11681.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update – Revised

• Article Revised: April 6, 2020
• What You Need to Know: The revision was made to reflect the revised CR 11661 to make MPFSDB file revisions for COVID-19.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Claim Status Category and Claim Status Codes Update

• Article Revised: April 10, 2020
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11467. Specifically the Uniform Resource Locators (URLs) references (page 2 in this article) in Background Section in the CR was revised.
• MLN MM11467: https://www.cms.gov/files/document/mm11467.pdf

April 2020 Updated of the Ambulatory Surgical Center (ASC) Payment System - Revised

• Article Revised: April 14, 2020
• What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implemented in the April 2020 ASC payment system update. MLN 11694 was revised on April 14th due the revised CR that added information on Q4206 to the policy section of the CR (page 6 in the MLN article).
• MLN MM11694: https://www.cms.gov/files/document/mm11694.pdf

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

• Article Revised: April 16, 2020
• What You Need to Know: This article was updated to reflect a revised WPC website address in the background section of Change Request 11638 on page 2 of the article. All other information remained the same.
• MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf

Implement Operating Rules – Phase III Electronic Remittance Advice (ERAA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) – Update from Council for Affordability Quality Healthcare (CAQH) CORE

• MLN Article Revised: April 23, 2020
• What You Need to Know: This article was revised to reflect the revised Change Request (CR) 11490. Specifically, the CR updated the WPC website address. This change was made in this Article as well as changing the CR Release Date to April 23, 2020.

MEDICARE COMPLIANCE TIPS

Medicare Advance Written Notices of Non-Coverage MLN Booklet Revised

CMS noted in the April 9, 2020 MLNConnects eNewsletter that a revised Medicare Advance Written Notices of Noncoverage Medicare Learning Network Booklet is now available. This booklet provides guidance on how to complete the form and collect payment.

OTHER MEDICARE UPDATES

Fiscal Year (FY) 2021 Proposed Rules Released April 10, 2020: Skilled Nursing Facilities, Inpatient Psychiatric Facilities, and Hospice

On April 10th CMS released Fact Sheets announcing the FY 2021 Proposed Rules for Skilled Nursing Facilities, Inpatient Psychiatric Facilities and Hospice have been put on display in the Federal Register. In each of the Fact Sheets, CMS notes the proposed rules are being published consistent with legal requirements to update Medicare payment policies. CMS acknowledges that the entire healthcare system is focused on responding to the COVID-19 public health emergency. 

• FY 2021 Proposed Medicare Payment and Policy Changes for Skilled Nursing Facilities (CMS-1737-P) CMS Fact Sheet
• FY 2021 Proposed Medicare Payment and Policy Changes for Inpatient Psychiatric Facilities (CMS-1731-P) CMS Fact Sheet
• FY 2021 Hospice Payment Rate Update Proposed Rule (CMS-1733-P) CMS Fact Sheet

CMS is accepting comments on all three proposed rules through June 9, 2020.

March 18, 2020: Advanced Beneficiary Notice Form Update

CMS put the following announcement on the CMS Fee-for-Service ABN webpage:

“The ABN, Form CMS-R-131, is currently awaiting OMB approval for renewal. CMS will provide instructions when it does get approved.  In the meantime, continue to use the current form until further instruction is provided.”

March 27, 2020: KEPRO Releases Spring 2020, Special COVID-19 Edition Newsletter

The following topics are included in the Spring 2020 edition of KEPRO’s Case Review Connections newsletter:

• COVID-19 Guidance for Providers,
• Beneficiary Notice Delivery Guidance in Light of COVID-19,
• Frequently Asked Questions,
• An Immediate Advocacy Success Story; and
• Staff Education about BFCC-QIO Services.

April 16, 2020: CMS Fact Sheet: Fiscal Year (FY) 2021 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) Proposed Rule (CMS-1729-P)

Similar to the proposed rules released on April 10th, CMS indicates this proposed rule is being published consistent with legal requirements. They go on to indicate that “In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual IRF rulemaking required by statute to essential policies including Medicare payment to IRFs, as well as proposals that reduce provider burden and may help providers in the COVID-19 response.” CMS is accepting comments on this proposed rule until June 15, 2020.

• FY 2021 IRF PPS Proposed Rule (CMS-1729-P) CMS Fact Sheet

April 21, 2020: CMS Interoperability and Patient Access Final Rule

This Final Rule was initially released on March 9th, 2020. However, it took until April 21st for the

unpublished version to be filed in the Federal Register. The Final Rule is scheduled to be published in the Federal Register on May 1, 2020. Following is an excerpt from a related CMS Press Release detailing how this Rule will impact hospitals:

“To further advance the mission of fostering innovation, the CMS final rule establishes a new Condition of Participation (CoP) for all Medicare and Medicaid participating hospitals, requiring them to send electronic notifications to another healthcare facility or community provider or practitioner when a patient is admitted, discharged, or transferred. These notifications can facilitate better care coordination and improve patient outcomes by allowing a receiving provider, facility, or practitioner to reach out to the patient and deliver appropriate follow-up care in a timely manner.”

Effective Date for New CoP

In the March 9th release of the Final Rule CMS stated the CoPs would be effective 6 months after the Rule was published in the Federal Register. However, the Final Rule currently on display indicates this date has been changed to indicate the new CoPs at 42 CFR Parts 482 and 485 will now be effective 12 months after the Final Rule is published in the Federal Register. This delay is due to CMS recognizing that hospitals, including psychiatric hospitals, and critical access hospitals, are on the front line of the COVID-19 public health emergency. You can learn more about this Final Rule on the CMS Interoperability and Patient Access final rule webpage.

April 24, 2020: 340B Hospital Survey

The 340B hospital survey is now available for hospitals paid under the OPPS, that were enrolled in the 340B program during calendar year Q4 2018 and/or Q1 2019. Both a detailed and "Quick Survey" method are available to submit 340B-acquired drug acquisition cost information to the Centers for Medicare & Medicaid Services through https://www.340bsurvey.com/survey. The survey closes on May 15, 2020.