Knowledge Base Category -

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.

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

• Article Release Date: February 21, 2020
• What You Need to Know: CR11655 informs providers about ICD-10 updates to specific NCDs. “Note: Coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria. Revisions to codes within an NCD are carefully and thoroughly reviewed and vetted by CMS and are not intended to change the original intent of the NCD. The exception to this is when coding revisions are released as official implementation of new or reconsidered NCD policy following a formal national coverage analysis…MACs will adjust any claims processed in error associated with CR 11491 that you bring to their attention.”
• MLN MM11655: https://www.cms.gov/files/document/mm11655.pdf

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

• Change Request Release Date: March 3, 2020
• What You Need to Know: CR 11691 is a recurring update notification describing changes to and billion instructions for various payment policies implemented in the April 2020 OPPS update.
• CR 11691: https://www.cms.gov/files/document/r4544cp.pdf

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

• Article Release Date: March 6, 2020
• What You Need to Know: CR 11680 providers the I/OCE instructions and specifications for the I/OCE that is being updated April 1, 2020. The two new codes for COVID lab tests (U0001 and U0002) are included in this update.
• MLN MM11680: https://www.cms.gov/files/document/mm11680.pdf

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

• Change Request (CR) Release Date: March 6, 2020
• What You Need to Know: CR 11681 is a Recurring Update Notice (RUN) providing instructions for the quarterly update the clinical laboratory fee schedule with an effective date of April 1, 2020.
• CR 11681: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/document/r4541cp.pdf

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

• Article Release Date: March 13, 2020
• What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implements in the April 2020 ASC payment system update.
• MLN MM11694: https://www.cms.gov/files/document/MM11694.pdf

OTHER MEDICARE TRANSMITTALS

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

• Provider Types Affected: Physicians, Providers and Suppliers
• Change Request (CR) Release Date: February 21, 2020
• What You Need to Know: CR 11638 updates RARC and CARC lists and instructs ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print Software.
• MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf

NCD 20.4 Implantable Cardiac Defibrillators (ICDs)

• Article Release Date: March 3, 2020
• Provider Types Affected: Physicians, Providers, and Suppliers
• What You Need to Know: This special edition article updated providers on Medicare coverage rules and policies for NCD20.4 and outlines the coding requirements (including heart failure codes) are not more restrictive than the NCD.
• MLN SE20006: https://www.cms.gov/files/document/se20006.pdf

Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare

• Article Release Date: March 3, 2020
• What You Need to Know: This special edition article reinforces existing Medicare policy allowing non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.
• MLN SE20009: https://www.cms.gov/files/document/se20009.pdf

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

• Article release date: March 9, 2020
• What You Need to Know: CR11640 informs 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

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

• Article Release Date: March 13, 2020
• What You Need to Know: Specific to hospitals, CR 11679 provides updates for determining Disproportionate Share (DSH) adjustment.
• MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf

REVISED MEDICARE TRANSMITTALS

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

• Article Revised: February 27, 2020
• Change Request Revised: new Transmittal number R4540CP
• What You Need to Know: The MLN article was revised to reflect the revised change request date and change an MP RVU code in Table 2.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Proper Use of Modifier 59

• Special Edition MLN Article Revised March 2, 2020
• What You need to Know: This article was revised to include modifiers –X{EPSU}. All other information is unchanged.
• MLN SE1418: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf

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

• Special Edition MLN Article Revised 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.
• MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

MEDICARE COVERAGE UPDATES

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Change Request: 11660
• What You Need to Know: The purpose of this Change Request (CR) is to inform MACs that effective June 21, 2029, CMS will continue to cover TAVR under Coverage with Evidence Devlopment (CED) when the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA approved indication for use with an approved device, in addition to the coverage criteria outlined in the NCD manual.
• CR 11660: https://www.cms.gov/files/document/r217ncd.pdf

MEDICARE PRESS RELEASES AND FACT SHEETS

February 20, 2020: Comprehensive Care for Joint Replacement Model Three Year Extension and Changed to Episode Definition and Pricing (CMS 5529 P)

CMS issued a proposed rule in the Federal Register proposing a three year extension, changes to the  definition of an episode, and changes in pricing in the Comprehensive Care for Joint Replacement (CJR) Model. This model began April 1, 2016 and has a current end date of December 31, 2020. Since this model began total hip and total knee procedures have been removed from the Medicare Inpatient Only Procedure List. Consequently, one proposal being made is to incorporate outpatient hip and knee replacements in the episode of care definition. Comments on the proposed rule must be received no later than 5 p.m. EST on April 24, 2020.

• CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/comprehensive-care-joint-replacement-model-three-year-extension-and-changes-episode-definition-and
• Proposed Rule: https://www.federalregister.gov/documents/2020/02/24/2020-03434/medicare-program-comprehensive-care-for-joint-replacement-model-three-year-extension-and-changes-to
• CJR Model webpage on CMS Innovation Center: https://innovation.cms.gov/initiatives/CJR

CMS Press Release: CMS Administrator Seema Verma at the 2020 CMS Quality Conference

https://www.cms.gov/newsroom/press-releases/speech-remarks-cms-administrator-seema-verma-2020-cms-quality-conference

https://www.beckershospitalreview.com/patient-safety-outcomes/cms-revamps-quality-strategy-5-things-to-know.html?origin=QualityE&utm_source=QualityE&utm_medium=email&oly_enc_id=1461H5080234E6F

MEDICARE EDUCATIONAL RESOURCES

MLNconnects March 19, 2020 Newsletter: Provider Minute Video: The Importance of Proper Documentation

CMS has med this Provider Minute video available discussing how proper documentation affects items/services, claim payment and medical review by discussing the following:

• Top five documentation errors,
• How to submit documentation for a Comprehensive Error Rate Testing (CERT) review, and
• How your Medicare Administrative Contractor (MAC) can help.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-19-mlnc#_Toc35426083

OTHER MEDICARE UPDATES

February 19, 2020: Medicare Advantage Denial Notice

CMS has posted the following information to the CMS MA Denial Notices webpage:

“The Office of Management and Budget (OMB) has approved revisions to the Notice of Denial of Medical Coverage (or Payment), also known as the Integrated Denial Notice (IDN). The expiration date is different on this renewed notice. Plans should begin using the revised IDN as soon as possible, but no later than April 1, 2020. Both the previous and new versions of the notice are acceptable for use through March 31, 2020. Significant revisions made to the notice and instructions include:

• Addition of adjudication timeframes for Part B drugs.
• Removal of language regarding State Fair Hearing as first level of appeal.
• Removal of option to add state specific Medicaid appeal filing timeframe.
• New determination option if an item, service, Part B drug, or payment is partially approved.
• New language notifying enrollees they cannot request an expedited appeal for a request for payment.
• New language informing enrollees they may ask for a good cause extension and should include their reason for being late.
• Option to add information for submitting appeal via plan website.”

March 9, 2020: HHS Finalized Two Transformative Rules Giving Patients Unprecedented, Safe, Secure Access to Their Health Data

Two rules issued by the HHS Office of the National Coordinator for Health information Technology (ONC) and CMS implement interoperability and patient access provisions of the bipartisan 21st century Cures Act (Cures Act) and support the MyHealthEData initiative. 

“The CMS final rule established a new Condition of Participation (CoP) for all Medicare and Medicaid participating hospitals, requiring them to send electronic notifications to another health care facility or community provider or practitioner when a patient is admitted, discharge, or transferred.”  For More Information:

• ONC Cures Act Final Rule website: View the rule,
• CMS Interoperability and Patient Access Final Rule webpage: View the rule,
• CMS Interoperability and Patient Access Fact Sheet,
• Register for Medicare Learning Network call on April 7,
• See the full text of this excerpted CMS Press Release (issued March 9).

March 2020: New OIG Work Plan Item: Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-care Transfer Policies

The OIG indicated they will review Medicare hospital discharges that were paid a full DRG payment when the patient was transferred to a facility covered by the acute and post-acute transfer policies where Medicaid paid for the service. Under the acute- and post-acute transfer policies, these hospital inpatient stays should have been paid a reduced amount. Additionally, we will assess the transfer policies to determine if they are adequately preventing cost shifting across healthcare settings.

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000445.asp

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Influenza Virus Vaccine Code Update – July 2020

Provider Types Affected: Physicians, providers and suppliers billing MACs for influenza vaccine services.

This update includes one new influenza virus code: 90694.  

MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf

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

Article Release Date: February 14, 2020

What You Need to Know: Change Request 11661 amends payment files based upon the 2020 MPFS Final Rule. Make sure billing staff is aware of these changes.

MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

OTHER MEDICARE TRANSMITTALS

Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging

Change Request (CR) Release Date: January 31, 2020

CR 11571: https://www.cms.gov/files/document/r2425otn.pdf

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

Provider Type Affected: Physicians, Hospitals, other Providers, and Suppliers

What You Need to Know: CR11559 informs MACs about changes to CWF edits to ensure the original 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: “Payment Window for Outpatient Services Treated as Inpatient Services,” and
• Chapter 3, Section 40.3: “Outpatient Services Treated as Inpatient Services

MLN Article MM11559: https://www.cms.gov/files/document/mm11559.pdf

Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment

Article Release Date: February 14, 2020

What You Need to Know: This article is for hospitals who submit claims for inpatient services provided to Medicare beneficiaries by LTHCs.

MLN MM11616: https://www.cms.gov/files/document/mm11616.pdf

REVISED MEDICARE TRANSMITTALS

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

MLN 11605 was revised on February 4, 2020 to add a section for radiopharmaceuticals with pass-through status and for Extravascular Implantable Cardioverter Defibrillator (EV ICD).

MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf

January 2020 Annual Update to the Therapy Code List

Provider Type Affected: Physicians, providers and suppliers billing Medicare for therapy services

Transmittal Change: Two new biofeedback codes will be paid under the Medicare Physician Fee Schedule.

MLN Article: MM11501:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf

Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

Article Release Date: January 31, 2020

What You Need to Know: This article was revised to reflect an updated Change Request (CR), transmittal number and link to transmittal.

MLN Article MM11623: https://www.cms.gov/files/document/mm11623.pdf

International Classification of Disease, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2020 Update

Article Release Date: February 4, 2020

What You Need to Know: This article was revised on February 10, 2020 to reflect a revised CR 11491. This CR was revised to amend the spreadsheet for NCD 110.4. All other information remains the same.

MLN MM11491: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf

New Medicare Beneficiary Identifier (MBI) Get It Use It

Article Release Date: February 12, 2020

What You Need to Know: Article was revised to add a sentence to the MBI look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death.

MLN SE18006 Revised: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0

Article Release Date: February 13, 2020

What You Need to Know: This article was revised due to a Change Request that added two new attachments due to legislation.

MLN Article: MM11564: https://www.cms.gov/files/document/mm11564.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging-Approval of Using the K3 Segment for Institutional Claims

Article Release Date: February 20, 2020

What You Need to Know: This article was revised to include the listing of Clinical Decision Support Mechanisms (CDSMs) and to update the paper billing instruction.

MLN Article SE20002: https://www.cms.gov/files/document/se20002.pdf

Accepting Payment from Patients with a Medicare Set-Aside Arrangement

Article Release Date: February 19, 2020

What You Need to Know: This article was revised to add information about submitting electronic attestations via the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).

MLN Article: SE17019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17019.pdf

MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES

Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator, Pulse Generator, Any Type

Article Release Date: January 29, 2020

Issue: CMS has identified that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Please make sure you billing staff are aware of the correct policy.

MLN SE20001: https://www.cms.gov/files/document/se20001.pdf

MEDICARE COVERAGE UPDATES

January 27, 2020: Final Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R)

Policy covers FDA approved or cleared laboratory diagnostic tests using Next Generation Sequencing (NGS) for patients with germline (inherited) ovarian or breast cancer.

Decision Memo: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=296

Related CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-expands-coverage-next-generation-sequencing-diagnostic-tool-patients-breast-and-ovarian-cancer

February 3, 2020: National Coverage Analysis (NCD) Tracking Sheet for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy

Issue: Currently, Medicare covers artificial hearts under coverage with evidence development (CED) when a beneficiary is enrolled in a clinical study that meets all the criteria in NCD 20.9. CMS has received two formal requests:

• Request that CMS reconsider CED for artificial hearts based on evidence since the NCD was last updated in 2008.
• A second request asked CMS reconsider Ventricular Assist Devices (VADs) specifically for coverage indications for bridge-to-transplant and destination therapy based on scientific evidence available since the NCD was last reconsidered in 2013.

CMS is soliciting public comment. The initial 30-day public comment period is from 2/3/2020 – 3/4/2020.

CAG-00453N: https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=298&TimeFrame=7&DocType=All&bc=AgAAUAAAIAAA& 

February 5, 2020: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)

Issue: Approved Study Posted

On February 15, 2019, CMS issued NCD covering FDA approved VNS devices for TRD through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial. On February 5, 2020, CMS posted a new approved Clinical Study. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS

MEDICARE EDUCATIONAL RESOURCES

CMS 2020 Medicare Costs Information Product

CMS has published a 2020 Medicare Costs document which includes Beneficiary costs for Medicare Part A and Part B, Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) Premiums

https://www.medicare.gov/Pubs/pdf/11579-Medicare-Costs.pdf

CMS 2020 Your Medicare Benefits Product

This booklet contains important information about the items and services covered by Original Fee-for-Service Medicare.

https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf#

MLN Booklet: Medicare Mental Health

This booklet was released in January and provides information about Medicare mental health services (i.e. Covered and non-covered mental health services, outpatient psychiatric hospital services, and medical record requirements).

ICN MLN1986542 January 2020: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/2020-01-3

MLN Booklet: Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B

ICN MLN006799 January 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr-immun-billTextOnly.pdf

MEDICARE COMPLIANCE TIPS

Specimen Validity Testing Billing in Combination with Urine Drug Testing

CMS provided Compliance information in the February 13, 2020 MLNConnects e-newsletter regarding proper coding for specimen validity testing billed in combination with urine drug testing. They reminded providers that “current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient and referenced MLN Matters Special Edition Article SE18001 for descriptors for presumptive and definitive drug testing codes.

OTHER MEDICARE UPDATES

February 6, 2020 Memorandum to State Survey Agency Directors.

Subject: Information Regarding Patients with Possible Coronavirus Illness (2091-nCoV)

Memorandum Summary: Links to information documents issued by the CDC on the respiratory illness cause by the 2019 Novel Coronavirus (2019-nCoV) are included in the memorandum. “CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.”

Memorandum Ref: QSO 20-09-ALL: https://www.cms.gov/files/document/qso-20-09-all.pdf

February 6, 2020 Memorandum to State Survey Agency Directors

Subject: Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for use in CDC Qualified Laboratories.

Memorandum Summary: Guidance is being provided to surveyors regarding Authorization for Emergency Use (AEU) for the Diagnostic Panel. These assays remain subject to CLIA regulations. The Panel assay and corresponding protocols have been developed by the CDC for use by CDC qualified labs.

Memorandum Ref: QSO 20-10-CLIA: https://www.cms.gov/files/document/qso-20-10-clia.pdf

MEDICARE TRANSMITTALS – RECURRING UPDATES

Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Provider Type Affected: Clinical Diagnostic Labs

Provider Action Needed: Change Request (CR) 11598 provides instructions for CY 2020, mapping for new codes, and updates for lab costs subject to reasonable charge payment.

MLN Article MM11598: https://www.cms.gov/files/document/mm11598.pdf

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

Provider Type Affected: ASCs billing Medicare Administrative Contractors

Provider Action Needed: CR 11607 informs MACs about updates to the ASC payment system for Calendar Year (CY) 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the HCPCS. Be sure your billing staffs are aware of these changes.

MLN Article MM11607: https://www.cms.gov/files/document/MM11607.pdf

January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0

Provider Type(s) Affected: Hospitals, Other Providers and Suppliers Billing MACs

What You Need to Know: This article is based on CR 11564, informs MACs, including Home Health MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2010.

MLN Article MM11564: https://www.cms.gov/files/document/mm11564.pdf

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

What You Need to Know: This Change Request (CR) revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for calendar year 2020.

MLN Article MM11641: https://www.cms.gov/files/document/mm11641.pdf

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

MLN Article MM11628: https://www.cms.gov/files/document/mm11628.pdf

OTHER MEDICARE TRANSMITTALS

Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory date of Service Policy

Provider Type Affected: Laboratories & other providers

What You Need to Know: In response to comments, CMS finalized excluding blood banks or centers from the laboratory DOS exception at 42 CFR 414.510(b)(5) in the CY 2020 OPPS/ASC final rule published on November 12, 2019. CMS also adopted a definition of “blood bank or center” and clarified that this policy change categorically excludes molecular pathology testing performed by laboratories that are blood banks or blood centers from the laboratory DOS exception at 42 CFR 414.510(b)(5).

MLN Article MM11574: https://www.cms.gov/files/document/mm11574.pdf

Revised Medicare Transmittals

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

Transmittal 266 replaces transmittal 264 released on December 20, 2019. Corrections made include:

• Section 5: change “removing 12 procedures from IPO list” to “removing 11 procedures from IPO list”
• Add a new section, number 18, “Correction of deductible and Coinsurance for HCPCS code, G0404,” and
• Change section 18 “Coverage Determinations” to section 19.

MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf

MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES

SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It

On January 2, 2020 to update language reflected the use of the MBI number is fully implemented. 

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System

Article Release Date: January 8, 2020

The Data Reporting Period has been delayed one year and as such all references to the 2020 data reporting period have been changed to 2021.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19006.pdf

SE20002: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims

Article Release Date: January 10, 2020

Provider Action Needed: This article provides guidance for processing claims for certain institutional claims that are subject to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. The CMS will begin to accept claims with this information as of January 1, 2020. This SE article contains an attached advanced diagnostic imaging UB-04 claim examples to help better understand the claims-based reporting concept of the AUC program.

https://www.cms.gov/files/document/se20002.pdf

MEDICARE EDUCATIONAL RESOURCES

January 2020 MLN Catalog

2020 marks the Medicare Learning Network’s® (MLN’s) 20th anniversary and the January 2020 Edition of the MLN Catalog is now available. Resources you will find in the catalog:

• MLN Matters® Articles
• Publications and Educational Tools
• MLN Connects® Newsletter
• Web-based Training Courses, and
• Provider Association Partnerships.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf

Billing Correctly for Polysomnography

The January 16, 2020 edition of MLN Connects provided Polysomnography Compliance Information, noting in a recent report, the Office of Inspector General (OIG) determined that CMS improperly paid practitioners for some claims associated with polysomnography services that did not meet Medicare requirements. We revised the Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF) Fact Sheet to help you bill correctly. Additional resources:

• Medicare Claims Processing Manual, Chapter 15 (PDF) , Section 70
• Questionable Billing for Polysomnography Services OIG Report
• Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report

OTHER MEDICARE UPDATES

2020 OPPS Correction Notice

On January 3, 2020, CMS published a correction notice in the Federal Register. This document corrects technical errors that appeared in the final rule that appeared in the November 12, 2019 issue of the Federal Register. Included in the notice is the inadvertent omission of two additional botulinum toxin injection codes J0586 and J0588 that have now been added to the codes in Table 65 – Final List of Outpatient Services That Require Prior Authorization.

You can read more about the new Prior Authorization requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations.

Palmetto GBA Jurisdiction J Medicare Advantage (MA) Plan Overpayments Update

On January 3, 2020, Phase III Settlement Offer Letters were mailed to affected providers. The settlement offer is intended to address all remaining unresolved “MA overpayment” claims.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"AZ9J8M2780?opendocument

New Important Message from Medicare (IM) and Detailed Notice of Discharge

The Office of Management and Budget (OMB) has renewed the IM (CMS-10065) and DND (CMS-10066). The revised IM has a new CMS Form number (CMS-10065). It was formerly CMS-R-193. Hospitals are required to use the new forms as of April 1, 2020. Until then the previous and new versions are acceptable for use.  You can access the forms at the following links:

• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Important-Message-English-and-Spanish.zip
• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Detailed-Notice-English-and-Spanish.zip

New Medicare Outpatient Observation Notice (MOON)

The OMB has renewed the MOON (CMS-10611). The only change made was the expiration date is now 12/31/2022. Similar to the IM and DND, hospitals are required to use the new MOON beginning April 1, 2020. Both previous and new versions are acceptable for use through March 31, 2020. You can access the MOON at the following link:

• https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON

January 13, 2020 Memorandum: Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes

Aims of Memorandum:

• To improve the identification of quality issues, the CMS is in the process of integrating the psychiatric hospital program survey into the hospital program survey,
• Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals, and
• Develop training to provide the necessary competencies for all State Survey Agency surveyors to evaluate compliance with the psychiatric hospital CoPs.

Link to Memorandum: https://www.cms.gov/files/document/admin-info-20-05-hospitalpsych.pdf

Link to Related CMS Newsroom Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-reduces-psychiatric-hospital-burden-new-survey-process

2020 Updates to OIG Work Plan

OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Beginning in January 2020, completed Work Plan items will remain in the active Work Plan for one month, after which they will be moved into the Archive. Recently completed reports can be found on OIG's What's New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.

January 2020 Medicare Quarterly Provider Compliance Newsletter

The January 2020 edition of this newsletter includes CERT review findings specific to the provision of Lumbar Sacral Orthosis (LSO) and Recovery Auditor findings from a review of Trastuzumab (Herceptin), J9355.

https://www.cms.gov/files/document/medicare-quarterly-provider-compliance-newsletter-volume-10-issue-2.pdf

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11523.pdf

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

A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf

2020 Annual Update to the Therapy Code List

Updates the list of codes that sometimes or always describe therapy services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf

2020 Annual Update of Per-Beneficiary Threshold Amounts

Updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11532.pdf

Claim Status Category and Claim Status Codes Update

https://www.cms.gov/files/document/mm11467

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

https://www.cms.gov/files/document/mm11489

Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020

https://www.cms.gov/files/document/MM11542

OTHER MEDICARE TRANSMITTALS

Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy

Medicare Severity Diagnosis-Related Groups (MS-DRGs) 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without major complications and comorbidities (MCC), respectively) added to the list of MS-DRGs subject to the policy for replaced devices offered without cost or with a credit.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11508.pdf

Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators

Status Indicator Q (therapy functional information code) is no longer effective with the 2020 MPFSDB beginning January 1, 2020. Medicare no longer requires functional therapy reporting.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11453.pdf

Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the Fiscal Intermediary Shared System (FISS)

Currently, the system does not recognize HCPCS Q9982 and Q9983 as valid radiopharmaceutical tracer codes and claims are incorrectly returned to the provider as unprocessed or rejected.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11537.pdf

Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home

Implements the newly approved National Uniform Billing Committee (NUBC) Condition Code “A7” and improved edit criteria in Medicare systems to bypass edits that match service facility location on certain hospital claims.

https://www.cms.gov/files/document/mm11470

Summary of Policies in the Calendar Year (CY) 2020 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

A summary of the policies in the CY 2020 MPFS Final Rule, announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.

https://www.cms.gov/files/document/mm11560

Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements

Updates language pertaining to the National Correct Coding Initiative (NCCI).

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4465CP.pdf

Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35

New Global Billing and Separate TC/PC billing instructions. For both paper and electronic claims, when a global diagnostic service code is billed (for example, no modifier TC and no modifier -26), the address where the TC was performed must be reported on the claim.

https://www.cms.gov/files/document/mm10882

REVISED MEDICARE TRANSMITTALS

April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Revision - Reference added to a related article SE19009 which replaces Section 6 - Chimeric Antigen Receptor (CAR) T- Cell Therapy - instructions on pages 5-7 of this article.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11216.pdf

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

Revision - Updates and clarifies information regarding the eMDR registration/enrollment to indicate the provider and the HIH roles with more detail.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11003.pdf

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements

Revision - Removes codes that are not available for 2020.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf

MEDICARE COVERAGE UPDATES

Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer

Expands coverage of  Next Generation Sequencing (NGS) as a diagnostic laboratory test when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specified requirements are met.

https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=296&TimeFrame=7&DocType=All&bc=AgAAYAAAQAAA&

MEDICARE PRESS RELEASES AND FACT SHEETS

CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2020

The Hospital VBP Program works by adjusting what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality and cost of inpatient care the hospitals provide to patients.

https://www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2020

MEDICARE EDUCATIONAL RESOURCES

Palmetto GBA 2020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule

Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2020.

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Bill Correctly for Medicare Telehealth Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

Extension of Detailed Notice of Discharge Beyond Expiration Date

The currently available Detailed Notice of Discharge (hospital notice) has an expiration date of October 31, 2019. The current notice is covered under an extension and hospitals should continue using it until CMS publishes the updated notice.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices

2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year 2020.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24138.pdf

2020 Medicare Physician Fee Schedule Final Rule

This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; and other topics.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf

Patients over Paperwork Newsletter November 2019

Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. 

https://www.cms.gov/files/document/november-2019-patients-over-paperwork-newsletter

KEPRO Case Review Connections Winter 2020 – Acute Care Edition

KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for 29 states. Case Review Connections is a quarterly newsletter that provides a glimpse into KEPRO and the services provided, along with success stories and updates from the Centers for Medicare & Medicaid Services (CMS).

https://keproqio.com/bene/newsletter/2020winteracute/

Hospital Price Transparency Requirements Final Rule

Establishes requirements for hospitals operating in the United States to establish, update, and make public a list of their standard charges for the items and services that they provide.

https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf

Transparency in Coverage Proposed Rule

Sets forth proposed requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of such individual’s cost-sharing liability for covered items or services furnished by a particular provider.

https://www.hhs.gov/sites/default/files/cms-9915-p.pdf

CY 2020 - Clinical Laboratory Fee Schedule Test Codes Final Determinations

In November of each year, CMS finalizes the basis of payment for new and substantially revised test codes and the amount of payment through the annual CMS instruction implementing the updated CLFS for the next CY.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

Revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines for clinic visit services at excepted off-campus PBDs for 2019.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2012-12-12-enews#_Toc26953011

Extension of the MOON Beyond Expiration Date

The currently available Medicare Outpatient Observation Notice (MOON) has an expiration date of December 31, 2019. The currently available MOON is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON

MEDICARE TRANSMITTALS – RECURRING UPDATES

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

Announces changes to be included in the January 2020 quarterly release of the edit module for clinical diagnostic laboratory services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11485.pdf

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

Informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11495.pdf

Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates

CMS intends to calculate the payment rates for each calendar year, based on the Consumer Price Index for All Urban Consumers (CPI-U); and instruct the MACs and the Railroad Specialty MAC to update the MDPP payment rates each year.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11455.pdf

Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2020

The interest rate for the first quarter of FY 2020 is 10.125%. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R327FM.pdf

OTHER MEDICARE TRANSMITTALS

Provider Enrollment Rebuttal Process

Puts into operation the provision which permits providers/suppliers whose Medicare billing privileges are deactivated to file a rebuttal.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10978.pdf

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020

Identifies changes as part of the annual IPF PPS update established in the IPF PPS FY 2020 Final Rule. These changes are applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11420.pdf

Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

The Fiscal Year (FY) 2020 update to the Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11361.pdf

Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS

Instructs Medicare's Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD).This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11335.pdf

REVISED MEDICARE TRANSMITTALS

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update – REVISED

Revised on October 1, 2019, to clarify that the effective date is January 1, 2020, unless noted otherwise.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11392.pdf

October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) – REVISED

Revised to correct Table 7 to reinstate C9043 rather than delete it effective October 1, 2019. Also adds a new HCPCS code J0642, which is effective October 1, 2019, and revises the descriptor for J0641.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11451.pdf

MEDICARE SPECIAL EDITION ARTICLES

Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N

CMS is providing this information for hospitals providing CAR T-cell therapy to beneficiaries enrolled in Medicare Advantage (MA) plans.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19024.pdf

MEDICARE EDUCATIONAL RESOURCES

Medicare Fast Facts

Medicare Fast Facts resources this month include:

• Cardiac Device Credits: Medicare Billing
• Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
• Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts.html?DLSort=1&DLEntries=10&DLPage=1&DLSortDir=descending

OTHER MEDICARE UPDATES

Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAH), and Home Health Agencies (HHA), and Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care

The rule finalizes requirements for hospitals, CAHs, and HHAs to implement discharge planning processes that will provide more information (such as a PAC provider or supplier’s performance in quality measures and resource measures) to patients and their families to help them make more informed decisions about PACs in order to better address their goals for care and treatment preferences.

https://www.cms.gov/newsroom/fact-sheets/cms-discharge-planning-rule-supports-interoperability-and-patient-preferences

Final Rule: Omnibus Burden Reduction (Conditions of Participation) 

Finalizes provisions of three separate proposed rules: the Omnibus Burden Reduction proposed rule (dated September 20, 2018); Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care proposed rule (dated June 6, 2016); and the Fire Safety Requirements for Certain Dialysis Facilities proposed rule (dated November 4, 2016).

https://www.cms.gov/newsroom/fact-sheets/omnibus-burden-reduction-conditions-participation-final-rule-cms-3346-f

Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule

A proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989.

https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule

Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2020

The annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review. The 2020 AIC threshold is $170 for ALJ hearings and $1,670 for judicial review. 

https://www.govinfo.gov/content/pkg/FR-2019-10-07/pdf/2019-21751.pdf

Medicare Quarterly Provider Compliance Newsletter October 2019

This quarter’s newsletter addresses Ambulance Services Subject to SNF Consolidated Billing Requirements and Outpatient Physical Therapy Services.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN7346924.pdf

MAC UPDATES

Palmetto GBA 2020 Medical Review TPE Teleconference Schedule

https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument

I am so excited about this, that I have to mention it. Cooler weather has finally made its way to the deep South. Now granted, at the time of the writing of this article, this means mid-80’s, but anything beats the sweltering heat of the last few weeks with record-setting temperatures in September and October. In fact, September was the hottest September ever. As the weather cools, so does the temperature of lakes, rivers, the ocean in coastal regions, and even backyard pools. If you plan to go for a swim at this time of year, it is a good idea to test the waters first so you will be prepared for that chilly plunge. Evidently, some Medicare Administrative Contractors (MACs) are “testing the waters” before announcing their Targeted Probe and Educate (TPE) issues. For example, Palmetto GBA, the MAC for Jurisdictions J and M, finally added the topic of DRG 460, Spinal Fusion, to their list of TPE Active Medical Reviews in September although providers in these jurisdictions have been receiving letters for months with the following wording:

“Your organization was selected for review based on Internal Data Analytics. A prepayment review has been initiated to probe a sample of your claims billed with the following DRG 460 code(s): DRG 460 – Spinal Fusion except Cervical without MCC”

One of the major concerns with spinal fusion surgery is that it is not always effective. From the Mayo Clinic website, “Spinal fusion is typically an effective treatment for fractures, deformities or instability in the spine. But study results are more mixed when the cause of the back or neck pain is unclear. In many cases, spinal fusion is no more effective than nonsurgical treatments for nonspecific back pain.” This puts a greater burden on providers in selection of this treatment option and the documentation requirements from Medicare to support this service. The Palmetto Spinal Fusion LCD includes a requirement for, where possible, a documented shared decision making with the patient or patient rep “with the appropriate discussion of anticipated risks and benefits of the procedure.”

The questionable efficacy of spinal fusion over nonsurgical treatments for certain indications also causes Medicare to require conservative treatments be tried and failed or contraindicated before moving on to surgery. Again, from the Palmetto LCD – “The medical record must clearly reflect which conservative treatments the patient has tried or is not a candidate for and why, including medical therapies, physical and exercise therapies and injections.” The problem here for hospital providers is that this information is generally located in the physician’s office record and not always addressed in detail in the hospital H&P. Palmetto also released an article earlier this year that discussed claim denial reasons – “By far the most common reason for denial has been a lack of specific information about conservative care before the surgical intervention. Statements such as: ‘Failed outpatient therapy, admit for spinal fusion’ are simply not sufficient evidence of medical necessity for the admission or the surgery.” The Palmetto article includes suggestions for hospitals and physicians to ensure documentation is complete.

• Hospitals may want to proactively obtain the necessary documentation from the physician office record, radiologic results, therapy treatment notes, therapeutic procedures and other documentation supporting the medical necessity of the surgery. If this documentation is not made part of the hospital record at the time of admission, be sure to have processes in place to gather this information before responding to a data request for records from a Medicare contractor.
• “Practitioners should either create clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records.”

Pulling from the Palmetto article and the LCD referenced above, here is a list of the elements that should be included in your documentation.

• History of illness from onset to decision for surgery
• Such as H&P from physician’s office notes, progress notes, documentation of progression of condition
• Prior courses of treatment and results
• Such as previous non-surgical treatment, including, but not limited to physical and/or occupational therapy, joint injections, analgesics, and assistive devices
• Current symptoms and functional limitations
• Such as neurological deficits, upper or lower extremity strength, activity limitations and modification, and pain levels
• Physical exam detailing objective findings supporting history of illness
• Such as patient history and physical exam
• Results of special tests
• Such as diagnostic test results and interpretations, such as MRI

• Shared decision-making
• Such as a physician office note detailing the physician’s discussion with the patient about the risks and benefits of the surgery and documenting the patient’s decision to proceed

MMP reached out to Palmetto to see if there were any additional requirements for the shared decision-making. Palmetto responded that, “It is generally accepted in medicine that patients should be educated about any procedure they are undergoing, and that the patients should provide informed consent for the procedure. Our expectation would be that this general requirement be met for lumbar spinal fusion as it would be met for other invasive procedures.”

Hospital providers may want to “test the waters” themselves by proactively reviewing their own records to see if the documentation is sufficient to support the medical necessity and other requirements of an admission for spinal fusion surgery. First, educate yourself on the requirements by reviewing your MAC’s LCD and coverage articles and any other education resources from your MAC for documentation tips and suggestions. If you need more information, check out the websites of other MACs and look for articles on-line – just be careful that your sources are credible. Secondly, perform some reviews of records to determine if all the necessary documentation is present. These reviews can be done by internal staff (maybe Compliance) or by a trusted external consultant. Finally, if shortcomings are identified in the reviews, institute processes and procedures and educate those involved on what is needed for complete and compliant documentation.

For this newsletter, I often write articles about other articles. I expect the quality and worth of the articles I write are judged by our readers, and likewise, I have an opinion on the worth of the articles I reference. Therefore, I have to applaud Palmetto GBA on their article on Therapeutic Exercise. This is one of the most comprehensive yet concise explanations of the requirements for therapy services I have seen. I will note some of the major points in my discussion below, but I encourage anyone who has a vested interest in this topic to read Palmetto’s article. In fact, I recommend you print and/or save it electronically for future reference. I know I will.

One of the main reasons for Medicare denials of therapy services is the lack of medical necessity. The Palmetto article breaks this down to 4 points and then discusses each of the requirements in more detail. 

“Medical necessity — four main requirements

• Presence of a disabling condition
• Individualized treatment
• Expectation that the beneficiary will benefit from therapy
• Requires skilled care”

Presence of a disabling condition

It seems obvious that the patient must have an injury, post-surgical limitations, or a medical condition that requires therapy. The issue is that there must be documentation beyond simply stating the medical problem. Documenting the patient has a sprained ankle, is post-surgical from a rotator cuff repair, or had a stroke is not enough. The therapist performing the evaluation needs to include the functional deficits the patient has and how these affect the patient’s ability to perform activities of daily living (ADLs). For example, following a shoulder injury or surgery, the patient could have pain, swelling, weakness, and limited range of motion that results in an inability to perform dressing and self-care independently. I like to think of documenting times 3 –

1. the medical condition, such as post-surgical repair of torn rotator cuff,
2. the symptoms and deficits, such as pain, swelling, weakness, and limited range of motion (be sure to include objective measures), and
3. the activity limitations and participation restrictions in the patient’s daily life, such as patient is unable to reach up to wash hair, dress independently and perform house-keeping chores.

The Palmetto articles states, “Per the LCD, include one of the following: weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance (pain is not listed, but it is acceptable as pain typically can cause several of the above conditions).”

Individualized treatment

This is the Plan of Care (POC) where the therapist selects the types of exercises, amount, frequency, and duration of treatment tailored to the specific patient’s needs and abilities. In listing the goals, the therapist can tie the types of exercises chosen to the patient’s activity limitations or participation restrictions identified. For example, therapeutic exercises may be performed to increase strength and improve range of motion to allow the patient to be able to perform self-care activities independently.

Again, from the Palmetto article – “Per the LCDs, goals should address the following: patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation.”

Expectation that the beneficiary will benefit from therapy

If you do not think it would benefit the patient, you should not be doing it. The goals included in the POC should address your expectations of the benefits the patient will have from the therapy. The progress reports as the patient participates in therapy will hopefully reflect the benefits the therapist expected from the therapy treatment. These should include objective measures, such as measures of the patient’s range of motion or strength, and subjective observations and patient reports of improvements in their abilities to perform ADLs. Not all patients respond as expected – if a patient is not benefiting from therapy, the therapist may modify the plan or discontinue therapy.

Notice that this says the beneficiary should “benefit” from therapy, not “improve” from therapy. That is an important distinction since all patients may not be able to improve, but therapy is needed to prevent or slow further decline in functional status. This is acceptable for Medicare coverage, but the expectation and outcomes should be clearly documented.

Requires skilled care

The treatments provided to the patient must require the skills of a therapist or therapy assistant under the direction of a therapist. If the services could be provided by someone without the skills of a therapist, then the services do not meet Medicare’s requirements for skilled care. Skills may include providing instructions on proper exercise form, direction to the patient during exercises, providing assistance, ensuring the safety of the patient during the performance of treatment, and/or monitoring the patient medically. The requirement for skilled care is addressed in the evaluation, plan of care, and in the daily treatment notes, where the therapist might document cueing the patient, instruction in proper form, or stand-by assist for patient safety, for example. The Palmetto article points out “Keywords in documentation to support use of skilled care (are) educate, education, corrected, instruct, instruction, trained, directed, reassessed, medical monitoring.”

As long as patients are benefiting from therapy and continue to require skilled care, documentation in the record must indicate the patient’s progression and the continuing need for the skills of the therapist. Once a patient is able to perform exercises independently or with non-skilled assistance, therapy services are no longer covered by Medicare. Patients may continue with a home or gym exercise program on their own.

The Palmetto article goes on to discuss all the different types of required therapy documents and what needs to be included in each – evaluation, plan of care, certification/recertification, progress reports, and treatment notes. Medical necessity is whether the patient needs therapy, but therapy documentation provides the support for that medical necessity in addition to supporting the services provided. That is a big job for words on a page. And Medicare will be judging the quality and worth of that writing.