Knowledge Base Category -
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
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.
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
Beth Cobb
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.
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
Beth Cobb
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.
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.
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.
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:
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.
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
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.
2020 Annual Update to the Therapy Code List
Updates the list of codes that sometimes or always describe therapy services.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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).
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).
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.
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.
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.
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.
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
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.
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).
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.
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.
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.
Debbie Rubio
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 –
- the medical condition, such as post-surgical repair of torn rotator cuff,
- the symptoms and deficits, such as pain, swelling, weakness, and limited range of motion (be sure to include objective measures), and
- 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.
Debbie Rubio
Medicare has National Coverage Determinations (NCDs) that describe the requirements that must be performed and documented for the cardiac services of Transcatheter Aortic Valve Replacement (TAVR), Left Atrial Appendage Closure (LAAC), and Transcatheter Mitral Valve Repair (TMVR). Be sure to read the other article in this week’s Wednesday@One that discusses these requirements. Hopefully your cardiology department is familiar with the NCDs and has implemented processes to ensure the documentation in your records supports Medicare’s requirements. But isn’t it frustrating if all the requirements are met and appropriately documented, to have your Medicare claim denied, rejected, or returned due to missing claim elements? And in addition to the frustration, your facility is delaying or missing out on your Medicare DRG payments.
Claims for these services obviously must include the appropriate procedure codes and diagnosis codes. In addition, since all of these cardiac services are covered under Coverage with Evidence Development (CED), the claims must include a secondary diagnosis code, condition code, and value code related to the clinical trial/registry. All three of these procedures are inpatient-only procedures and would be billed on an inpatient claim, type of bill, 11x and paid under a Medicare DRG payment.
Specifically, for each procedure the following is required on the institutional inpatient claim:
Left Atrial Appendage Closure (LAAC) (Watchman procedure):
- Procedure Code - 02L73DK (Occlusion of Left Atrial Appendage with Intraluminal Device, Percutaneous Approach)
- One of the following diagnosis codes –
- I48.0 - Paroxysmal Atrial Fibrillation
- I48.1 - Persistent Atrial Fibrillation
- I48.2 - Chronic Atrial Fibrillation
- I48.91 - Unspecified Atrial Fibrillation
- Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
- Condition Code 30 - Qualified Clinical Trial
- Value Code D4 and corresponding 8-digit clinical trial number (Clinical trail and/or registry numbers can be found on Medicare’s CED website.)
Transcatheter Aortic Valve Replacement (TAVR):
- Procedure Code – One of the following procedure codes –
- 02RF37Z (Replacement of Aortic Valve with Autologous Tissue Substitute, Percutaneous Approach),
- 02RF38Z (Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Approach),
- 02RF3JZ (Replacement of Aortic Valve with Synthetic Substitute, Percutaneous Approach),
- 02RF3KZ (Replacement of Aortic Valve with Nonautologous Tissue Substitute, Percutaneous Approach),
- 02RF37H (Replacement of Aortic Vavle with Autologous Tissue Substitute, Transapical, Percutaneous Approach),
- 02RF38H (Replacement of Aortic Valve with Zooplastic Tissue, Transapical, Percutaneous Approach),
- 02RF3JH (Replacement of Aortic Valve with Synthetic Substitute, Transapical, Percutaneous Approach), or
- 02RF3KH (Replacement of Aortic Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Approach)
- Procedure Code - X2A5312 (Cerebral Embolic Filtration, dual filter in innominate artery and left common carotid artery, percutaneous approach) when used
- One of the following diagnosis codes –
- I35.0 - Nonrheumatic aortic (valve) stenosis
- T82.222A - Displacement of biological heart valve graft, initial encounter (Code for when a previously placed valve was malpositioned or became displaced)
- T82.857A - Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter (Code for when the previously placed valve developed stenosis prematurely)
- T82.223A - Leakage of biological heart valve graft, initial encounter (Code for when the previously placed valve developed regurgitation prematurely)
- Z45.09 - Encounter for adjustment and management of other cardiac device (Code for when the previously placed valve developed stenosis or regurgitation as an expected occurrence as it degenerates towards end-of-life)
- Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
- Condition Code 30 - Qualified Clinical Trial
- Value Code D4 and corresponding 8-digit clinical trial number
Transcatheter Mitral Valve Repair (TMVR) (MitraClip procedure):
- One of the following Procedure Codes
- 02UG3JZ - Supplemental Mitral Valve with Synthetic Substitute, Percutaneous approach
- 02QG3ZE - Repair Mitral Valve created from Left Atrioventricular Valve, Percutaneous Approach
- 02QG4ZE - Repair Mitral Valve created from Left Atrioventricular Valve, Percutaneous Endoscopic Approach
- 02UG37E - Supplement Mitral Valve created from Left Atrioventricular Valve with Autologous Tissue Substitute, Percutaneous Approach
- 02UG38E - Supplement Mitral Valve created from Left Atrioventricular Valve with Zooplastic Tissue, Percutaneous Approach
- 02UG3JE - Supplement Mitral Valve created from Left Atrioventricular Valve with Synthetic Substitute, Percutaneous Approach
- 02UG3KE - Supplement Mitral Valve created from Left Atrioventricular Valve with Nonautologous Tissue Substitute, Percutaneous Approach
- 02UG3KZ - Supplement Mitral Valve with Nonautologous Tissue Substitute, Percutaneous Approach
- 02UG47E - Supplement Mitral Valve created from Left Atrioventricular Valve with Autologous Tissue Substitute, Percutaneous Endoscopic Approach
- 02UG48E - Supplement Mitral Valve created from Left Atrioventricular Valve with Zooplastic Tissue, Percutaneous Endoscopic Approach
- 02UG4JE - Supplement Mitral Valve created from Left Atrioventricular Valve with Synthetic Substitute, Percutaneous Endoscopic Approach
- 02UG4KE - Supplement Mitral Valve created from Left Atrioventricular Valve with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach
- 02WG37Z - Revision of Autologous Tissue Substitute in Mitral Valve, Percutaneous Approach
- 02WG38Z - Revision of Zooplastic Tissue in Mitral Valve, Percutaneous Approach
- 02WG3JZ - Revision of Synthetic Substitute in Mitral Valve, Percutaneous Approach
- 02WG3KZ - Revision of Nonautologous Tissue Substitute in Mitral Valve, Percutaneous Approach
- One of the following diagnosis codes –
- I34.0 - Nonrheumatic mitral (valve) insufficiency
- I34.1 - Nonrheumatic mitral valve prolapse
- Secondary diagnosis code – Z00.6 - Encounter for examination for normal comparison and control in clinical research program
- Condition Code 30 - Qualified Clinical Trial
- Value Code D4 and corresponding 8-digit clinical trial number
MACs will fully reject inpatient claims for these cardiac procedures when billed without the appropriate procedure, diagnosis, or clinical trial codes. Hospitals that perform these procedures need to put processes in place for communication between the clinical department, coding, and the billing office so that the appropriate claim elements are added. Internal claim processing edits to halt claims with one of the applicable procedure codes may be an option to verify appropriate diagnosis codes and allow the addition of the clinical trial codes.
Refer to the NCDs and corresponding claims processing instructions for complete Medicare requirements.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly update.
October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
Changes from IPF Final Rule applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update
Relevant NCD coding changes for:
- NCD20.7 Percutaneous Transluminal Angioplasty
- NCD110.18 Aprepitant
- NCD110.23 Stem Cell Transplantation
- NCD150.3 Bone Mineral Density Studies
- NCD220.4 Mammography
- NCD220.13 Percutaneous Image-Guided Breast Biopsy
- NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
Claim Status Category and Claim Status Codes Update
Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment - REVISED
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and allows billing E/M codes (99211, 99212, and 99213) for levels I through III with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.
Oxygen Policy Update
Implements a new policy and coding for oxygen content.
Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
To assist in reminding laboratories of their reporting obligations, the following new alert RARC code will appear on remittances:
- N817: ALERT-Applicable laboratories are required to collect and report private payor data and report that data to CMS between January 1, 2020 - March 31, 2020
Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual
Adds a link to the current influenza codes and payment rates.
MEDICARE SPECIAL EDITION ARTICLES
Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management
Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REISSUED
Use MBIs now for all Medicare transactions.
New Documentation Requirements for Filing Medicare Cost Reports
The FY 2019 Medicare IPPS final rule changed the required supporting documentation that providers must submit with the Medicare cost report.
MEDICARE COVERAGE UPDATES
Decision Memo for Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers (CAG-00451N)
Posted final decision memo.
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291
Medicare Press Releases
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Ambulance Fee Schedule and Medicare Transports
- Skilled Nursing Facility 3-Day Rule Billing
Skilled Nursing Facility 3-Day Rule Billing
MLN Fact Sheet
Ambulance Fee Schedule and Medicare Transports Booklet
MLN Booklet
OTHER MEDICARE UPDATES
FY 2020 Coding Updates
ICD-10-CM Coding Guidelines - https://www.cdc.gov/nchs/icd/icd10cm.htm
ICD-10-CM (Diagnosis Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html
ICD-10-PCS (Procedure Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS.html
2020 Advance Beneficiary Notice (ABN) Forms
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
Transcatheter Aortic Valve Replacement (TAVR) is for the treatment of symptomatic aortic valve stenosis where a biprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. In 2012, when CMS first published a National Coverage Determination (NCD) for TAVR, it was considered a new technology. Under that current NCD (NCD 20.32), TAVR is covered under Coverage with Evidence Development (CED) according to certain criteria detailed in the NCD. Coverage under CED means that the service is only covered in the context of a clinical trial (such as a national registry or a clinical study). This allows limited coverage for Medicare beneficiaries in a controlled environment while determining the efficacy, risks, and outcomes of the procedure. Once a new technology or procedure is proven to be safe and effective, CMS may remove the CED requirement and cover the procedure outright within set criteria.
TAVR is not there yet. In a recently released (June 21, 2019) new TAVR Coverage Decision Memo, the requirement for Coverage under Evidence Development remains.
- TAVR is covered according to CMS criteria when the procedure is furnished with a complete aortic valve and implantation system that has received FDA premarket approval (PMA) for that system's FDA approved indication and the heart team and hospital are participating in a prospective, national, audited registry.
- TAVR is covered for uses that are not expressly listed as an FDA-approved indication when performed within a clinical study that fulfills criteria set forth in the decision memo.
Other requirements that did not change from the current NCD to the new Decision Memo include:
- The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals;
- The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intra-operative technical aspects of TAVR; and
- TAVR must be furnished in a hospital with the appropriate infrastructure.
What did change with the Final Decision Memo and why? First the Why - TAVR now has 7 years of study since the original 2012 NCD and the incidence of and experience with performing the procedure has greatly increased. When the Proposed Decision Memo was released in March of this year, my fellow writer for this newsletter, Beth Cobb, included a table in her article about the memo that looked at the volumes of hospital services coding to MS-DRGs 266 and 267. These DRGs include TAVR and other valve replacements. From 2015 though 2018, the volumes of these DRGs increased around 160% in Alabama and approximately 80-85% in Tennessee and Georgia, respectively.
The major changes in the Final Decision Memo include a change in the pre-procedure patient evaluation requirements and changes in the volumes of services required for the hospital and the heart team to meet criteria for performing the TAVR procedure.
The current TAVR NCD required face-to-face evaluation of the patient’s suitability for TAVR surgery by two cardiac surgeons. The new Decision Memo changes the two cardiac surgeons to a cardiac surgeon and an interventional cardiologist. This makes more sense as these are the two physicians that jointly participate in the intra-operative technical aspects of TAVR. This requirement is addressed in the composition of the heart team as quoted here from the Final Decision Memo:
- “The heart team includes the following:
- Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have:
- independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
- documented and made available to the other heart team members the rationale for their clinical judgment.
- Providers from other physician groups as well as advanced patient practitioners, nurses, research personnel and administrators.”
Both the current NCD and the new Final Decision Memo require certain volumes of procedures for the hospital and the heart team based on whether they have previous TAVR experience or not. Here is a brief summary of the new and old requirements, but be sure to read the new Decision Memo for full details.
Hospitals – no previous TAVR experience
Current NCD (Old requirements)
- ≥ 50 total AVRs in the previous year prior to TAVR, including ≥ 10 high-risk patients, and;
- ≥ 2 physicians with cardiac surgery privileges, and;
- ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.
New Decision Memo (New Requirements)
- ≥ 50 open heart surgeries in the previous year prior to TAVR program initiation, and;
- ≥ 20 aortic valve related procedures in the 2 years prior to TAVR program initiation, and;
- ≥ 2 physicians with cardiac surgery privileges, and;
- ≥ 1 physician with interventional cardiology privileges, and;
- ≥ 300 percutaneous coronary interventions (PCIs) per year.
Heart Teams – no previous TAVR experience
Current NCD (Old requirements)
- Cardiovascular surgeon with:
- ≥ 100 career AVRs including 10 high-risk patients; or,
- ≥ 25 AVRs in one year; or,
- ≥ 50 AVRs in 2 years; and which include at least 20 AVRs in the last year prior to TAVR initiation; and,
- Interventional cardiologist with:
- Professional experience with 100 structural heart disease procedures lifetime; or,
- 30 left-sided structural procedures per year of which 60% should be balloon aortic valvuloplasty (BAV). Atrial septal defect and patent foramen ovale closure are not considered left-sided procedures; and,
- Additional members of the heart team such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social workers; and,
- Device-specific training as required by the manufacturer.
New Decision Memo (New Requirements)
- Cardiovascular surgeon with:
- ≥ 100 career open heart surgeries of which ≥ 25 are aortic valve related; and,
- Interventional cardiologist with:
- Professional experience of ≥ 100 career structural heart disease procedures; or, ≥ 30 left-sided structural procedures per year; and,
- Device-specific training as required by the manufacturer.
Hospital with previous TAVR experience
Current NCD (Old requirements)
- ≥ 20 AVRs per year or ≥ 40 AVRs every 2 years; and,
- ≥ 2 physicians with cardiac surgery privileges; and,
- ≥ 1000 catheterizations per year, including ≥ 400 percutaneous coronary interventions (PCIs) per year.
- Heart team - cardiovascular surgeon and an interventional cardiologist whose combined experience maintains the following:
- ≥ 20 TAVR procedures in the prior year, or,
- ≥ 40 TAVR procedures in the prior 2 years.
New Decision Memo (New Requirements)
- ≥ 50 AVRs (TAVR or SAVR) per year including ≥ 20 TAVR procedures in the prior year; or,
- ≥ 100 AVRs (TAVR or SAVR) every 2 years, including ≥ 40 TAVR procedures in the prior 2 years; and,
- ≥ 2 physicians with cardiac surgery privileges; and,
- ≥ 1 physician with interventional cardiology privileges, and
- ≥300 percutaneous coronary interventions (PCIs) per year.
What does all of this mean for hospitals? Here is a checklist for hospitals that perform the TAVR procedure:
- The patient must have symptomatic aortic valve stenosis;
- The patient is under the care of a heart team and the heart team's interventional cardiologist(s) and cardiac surgeon(s) jointly participate in the intra-operative technical aspects of TAVR;
- The hospital has the appropriate infrastructure for the procedure;
- Your medical record contains documentation of the face-to-face patient examinations by a cardiac surgeon and an interventional cardiologist (experienced in the care and treatment of aortic stenosis) evaluating the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy;
- Assess your hospital and heart team volumes to be sure you meet the requirements for performing the procedure under the new Decision Memo; and
- Read the new Decision Memo carefully and make sure you are following all of Medicare’s requirements.
As always with Decision Memos, the requirements are not yet effective until the NCD is updated and implemented. However, NCD revisions generally revert to the effective date of the Decision Memo, which is in this case June 21, 2019. This means hospitals need to know the new requirements now and be preparing now to meet those new requirements.
Debbie Rubio
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