Knowledge Base Category -

Medicare Transmittals & MLN Articles

Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2023 Changes

• MLN Release Date: December 1, 2022
• What You Need to Know: This article highlights FY 2023 updates. For example, providers are reminded that CMS is not adjusting payments for any hospital in the Hospital Value Based Purchasing program or the Hospital Acquired Condition Reduction Program for FY 2023.
• MLN MM12814: (link)

DMEPOS Fee Schedule: CY 2023 Update

• MLN Release Date: December 2, 2022
• What You Need to Know: This article provides information for your billing staff about the annual update to fee schedule amounts for new and existing codes and payment policy changes.
• MLN MM13006: (link)

Clinical Laboratory Fee Schedule: CY 2023 Annual Update

• MLN Release Date: December 9, 2022
• What You Need to Know: This article provides information for your billing staff about instructions for the CY 2023 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes, and updates for laboratory costs subject to the reasonable charge payment.
• MLN MM13023: (link)

HCPCS Codes & Clinical Laboratory Improvement Amendments (CLIA) Edits: April 2023

• MLN Release Date: December 9, 2022
• What You Need to Know: This article provides information for your billing staff about new HCPCS and discontinued HCPCS codes and required CLIA certificates.
• MLN MM13024: (link)

Laboratory Edit Software Changes: April 2023

• MLN Release Date: December 12, 2022
• What You Need to Know: NCDs with April 2023 updates includes 190.18 – Serum Iron Studies, 190.22 – Thyroid Testing, 190.23A – Lipids Testing, and 190.23B – Lipids Testing.
• MLN MM13026: (link)

Hospital Outpatient Prospective Payment System: January 2023 Update

• MLN Release Date: December 14, 2022
• What You Need to Know: CMS advises providers to make sure their billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices and other items and services.
• MLN MM13031: (link)

New Medicare Part B Immunosuppressant Drug Benefit

• MLN Release Date: December 16, 2022
• What You Need to Know: Your billing staff needs to know about the extension of Medicare coverage for immunosuppressant drugs beyond 36 months for certain patients with kidney transplants and coverage of premiums and cost sharing for these patients. This is a new benefit that was included in the Consolidated Appropriations Act (CAA) and is effective January 1, 2023.
• MLN MM12804: (link)

Ambulatory Surgical Center Payment System: January 2023 Update

• MLN Release Date: December 22, 2022
• What You Need to Know: CMS advises providers to make sure your billing staff knows about new HCPCS C-codes on the ASC Covered Procedure List (CPL), new HCPCS codes for drugs and biologics, and the skin substitute product assignments to high and low-cost groups.
• MLN MM13041: (link)

Revised Transmittals & MLN Articles

Extension of Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital Program

• MLN Release Date: October 21, 2022 – Revised December 9, 2022
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12970. CMS will give your MAC 60 days to reprocess claims affected by the CR.
• MLN MM12970: (link)

Coverage Updates

National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy

• MLN Release Date: December 1, 2022
• What You Need to Know: CMS advises providers to make sure your billing staff know about the following changes to CAR-T billing:
• Include additional place of services (POS) codes for office and independent clinics,
• Bill in 0.1-unit fractions, and
• Use 3 modifiers, including the new modifier -LU.
• MLN MM12928: (link)

National Coverage Determination 200.3: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

• MLN Release Date: December 8, 2022
• What You Need to Know: This article provides information about FDA-approved monoclonal antibodies and CMS-approved studies that your billing staff needs to know.
• MLN MM12950: (link)

Compliance Education Updates

Biosimilars & Interchangeable Products: Free Continuing Education Courses from FDA

CMS reminded providers in the December 8, 2022 edition of MLN Connects (link) that the FDA has free accredited continuing education courses for health care providers on biosimilars and interchangeable products.

Other Updates

December 2, 2022: Letter to U.S. Governors from HHS Secretary Xavier Becerra on COVID-19, Flu, and RSV Resources

HHS Secretary Xavier Becerra noted in a letter to U.S. Governors (link) that “I write today to reinforce that the Biden-Harris Administration stands ready to continue assisting you with resources, supplies, and personnel, as it has throughout our fight against COVID-19.”

December 6, 2022: CMS Proposed Rule to Expand Access to Health Information and Improve the Prior Authorization Process

CMS provided the following information in the December 8, 2022 MLN Connects Newsletter (link):

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and investing in interoperability, CMS issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

Medicare National Correct Coding Initiative: Annual Policy Manual Update for 2023

On December 1st, CMS posted the updated Medicare National Correct Coding Initiative Policy Manual effective January 1, 2023. Additions and revisions to the manual are noted in red font.

National Correct Coding Initiative: January Update

You can find the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective January 1, 2023, on these Medicare NCCI webpages:

• Procedure-to-Procedure Edits
• Medically Unlikely Edits
• Add-on Code Edits

December 14, 2022: Guidelines for Achieving a Compliant Query Practice (2022 Update)

In December, the final version of the 2022 update to the Guidelines for Achieving a Compliant Query Practice was released. This document is a joint effort of the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American Health Information Management Association (AHIMA). This document supersedes all previous versions of this document. As noted in this practice brief, it “should be used to guide organizational policy and process development for a compliant query practice.” You can read more about this document in a related AHIMA press release (link).

December 15, 2022: OIG’s Top Unimplemented Recommendations 2022 Report

The OIG announced the publication of their 2022 Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in the HHS Programs report (link). Specific to Medicare Parts A and B and in keeping with the 2020 and 2021 reports, unimplemented recommendation for inpatient rehabilitation facilities (IRFs) and a call for CMS to seek legislative authority to comprehensively reform the hospital wage index system remains on the list. The third unimplemented recommendation was also in the 2021 report and calls for CMS to recover overpayment of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims.

December 21, 2022 Joint Commission Announces Major Standard Reductions and Freezes Hospital Accreditation Fees

On Wednesday, December 21st, the Joint Commission announced (link) the elimination of 168 standards (14%), the revision of 14 other standards and that they would not be “raising its accreditation fees for domestic hospitals in 2023 in recognition of the many financially challenges hospitals and health systems continue to face.”

December 23, 2022: First Generic Drug Approvals

The FDA has published a list of First-Time Generic Drug Approvals in 2022 (link). They note that first generics “are just what they sound like – the first approval by FDA which permits a manufacturer to market a generic drug product in the United States.”

PAMA Regulations Update

On December 30, 2022, CMS updated their PAMA (Protecting Access to Medicare Act of 2014) CMS webpage (link) with the following information:

DELAY!!! IMPORTANT UPDATE: The next data reporting period is January 1, 2024 through March 31, 2024, will be based on the original data collection period of January 1, 2019 through June 30, 2019.

On December 29, 2022, Section 4114 of Consolidated Appropriations Act, 2023 revised the next data reporting period for CDLTs that are not ADLTs and the phase-in of payment reductions under the Medicare private payor rate-based CLFS. The next data reporting period of January 1, 2024 through March 31, 2024 will be based on the original data collection period of January 1, 2019 through June 30, 2019. After the next data reporting period, there is a three-year data reporting cycle for CDLTs that are not ADLTs (that is 2027, 2030, etc.).

Medicare Transmittals & MLN Articles

Telehealth Home Health Services: New G-Codes

• MLN Release Date: November 2, 2022
• What You Need to Know: Starting on or after January 1, 2023, Home Health (HH) providers may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. Starting July 1, 2023, providers will be required to report this information. This MLN article details the three G-codes that will need to be used when submitting the use of telecommunication technology on the HH claim.
• MLN MM12805: link)

Billing for Hospital Part B Inpatient Services

• Transmittal Issue Date: November 9, 2022.
• What You Need to Know: The purpose of this Change Request (CR) 12965 is to provide billing instructions for hospital Part B inpatient services. For example, effective 7/1/2022 three new “Not Allowed Revenue Codes” were added to the list of codes a Medicare Administrative Contractor will set a revenue code edit to prevent payment on Type of Bill 012X. The implementation date for the updates is December 12, 2022.
• CR 12965: link)

ESRD & Acute Kidney Injury Dialysis: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article details information about rates and policies for the ESRD Prospective Payment System and payment for renal dialysis services provided to patients with acute kidney injury in ESRD facilities.
• MLN MM12978: link)

Home Health Prospective Payment System: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article highlights changes related to 30-day period payment rates, national per-visit amounts, and cost-per-unit payment amounts used for calculating outlier payments under the Home Health Prospective Payment System. These changes will be effective January 1, 2023.
• MLN MM12957: link)

Medicare Physician Fee Schedule Final Rule Summary: CY 2023

• MLN Release Date: November 17, 2022
• What You Need to Know: This article details updates effective January 1, 2023 to the telehealth originating site facility fee payment amount, expansion of coverage for colorectal cancer screening, coverage of audiology services, and other covered services.
• MLN MM12982: link)

New Waived Tests

• MLN Release Date: November 23, 2022
• What You Need to Know: This article highlights seven newly added waived complexity tests that must have the modifier QW to be recognized as a waived test.
• MLN MM12996: link)

Revised Medicare MLN Articles & Transmittals

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023

• MLN Release Date: September 6, 2022 – Revised November 10, 2022
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12888. No substantive changes were made to the article.
• MLN MM12888: link)

Coverage Updates

ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2023 Update

• MLN Release Date: November 9, 2022
• What You Need to Know: This MLN is related to CR 12960 which is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. Relevant NCD coding changes in CR 12960 include:
• NCD 20.4 (Implantable Automatic Defibrillators ICDs): ICD-10 diagnosis code I47.2 end effective date was September 30, 2022. New codes effective on or after October 1, 2022 includes I47.20, I47.21, and I47.29.
• NCD 210.10 (Screening for STIs): CPT 0353U is a new code for this NCD with an effective date October 1, 2022.

CMS notes that MACs will adjust any claims processed in error associated with CR 12960 that you bring to their attention.

• MLN MM12960: link)

Compliance Education Updates

Medicare Provider Compliance Tips – Revised

CMS noted in the Thursday, November 3, 2022 edition of MLN Connects (link) that the educational tool Medicare Provider Compliance Tips has been updated with the latest improper payment rates, denial reasons, and codes. Additional information and new tips have been added to several of the topics included in this tool (i.e., new tips for cataract removal, lipid panels and psychiatry).

Federally Qualified Health Center — Revised
Excerpt from 11/23 MLN Matters newsletter:

This MLN booklet (link)">link) was reviewed in October 2022 and includes the following changes:

• Payment for hospice attending physician services by specific providers
• Mental health services using telecommunications
• Concurrent billing for chronic care management and transitional care management services
• Changes to care management services codes
• CMS also added information on COVID-19 shot and monoclonal antibody therapy administration.

COVID-19 Updates

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency on October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. The sixty days prior to January 11, 2023 came and went without notice from the Secretary so it appears the COVID-19 PHE will last at least to April 2023.

HHS Releases Long COVID Report

In a November 21, 2022 press release (link), the U.S. Department of Health and Human Services (HHS) announced the release of a new report highlighting patients’ experience of Long COVID. “Long COVID is a set of conditions. Researchers have cataloged more than 50 conditions linked to Long COVID that impact nearly every organ system. Estimates vary, but research suggests that between 5 percent and 30 percent of those who had COVID-19 may have Long COVID symptoms, and roughly one million people are out of the workforce at any given time due to Long COVID. This figure equates to approximately $50 billion annually in lost salaries.”

Other Updates

October 27, 2022: OIG Report – CMS Can Use OIG Audit Reports to Improve Its Oversight of Hospital Compliance

In this Report (link), the OIG notes that they performed this audit to determine CMS’s actions taken regarding 12 Hospital Compliance Audits during calendar years (CYs) 2016 through 2018. Collectively, the OIG reviewed 1,290 claims from the 12 hospitals. The most common error types identified by the OIG were incorrectly billed Inpatient Rehabilitation Facility (IRF) services and incorrectly billed HCPCS codes.

The OIG determined that, after considering results of first and second level appeals, the 12 hospitals received overpayments totaling $82 million. While the OIG found that CMS had taken some recommended actions based on these audits, they noted that CMS provided insufficient information to be able to identify if actions had been taken to ensure the hospitals had repaid funds or followed the 60-day rule.

The categories of claims at high risk for noncompliance with Medicare requirements, for this report, included the following “risk areas” that were the focus of the 12 hospital compliance audits:

• Inpatient rehabilitation facility claims,
• Inpatient claims billed with high CERT DRG codes,
• Inpatient claims billed with high-severity level DRG codes,
• Inpatient claims paid in excess of billed charges,
• Inpatient claims billed with adverse events, inpatient claims billed with elective procedures,
• Inpatient claims billed with mechanical ventilation,
• Inpatient claims covering same day discharge and readmission,
• Inpatient psychiatric facility claims,
• Inpatient claims paid in excess of $150,000,
• Inpatient claims paid in excess of $25,000,
• Outpatient claims paid in excess of charges,
• Outpatient claims billed with right heart catheterizations HCPCS codes,
• Outpatient surgery claims billed with units greater than one,
• Outpatient claims billed with bypass modifiers,
• Outpatient skilled nursing facility (SNF) consolidated billing claims, and
• Outpatient claims paid in excess of $25,000.

The OIG notes that “if CMS used our provider-specific audit reports, it could improve Medicare program oversight by focusing on services at high risk for improper payment. In addition, CMS’s actions could lead to improvements in hospital specific internal controls.”

October 28, 2022: Implementing Certain Provisions of the Consolidated Appropriations Act (CAA), 2021 and other Revisions to Medicare Enrollment and Eligibility Rules (CMS-4199-F)

Currently, for those approaching sixty-five, the date when your coverage becomes effective depends on when you enroll. As noted in a CMS Fact Sheet related to this final rule (link):

• “If an individual enrolls during any of the first three months of their Initial Enrollment Period (IEP), their coverage will start the first month of eligibility (e.g., age 65).
• If an individual enrolls during their IEP in the month they become eligible, their coverage will start the month after they enroll.
• If an individual enrolls during any of the last three months of their IEP, their coverage will start 2-3 months after they enroll.
• If an individual enrolls during the General Enrollment Period (GEP), which runs from January 1st through March 31st every year, their coverage will start

As mandated in the CAA and finalized in this rule, beginning January 1, 2023, Medicare coverage will become effective the month after enrollment for individuals enrolling in the last three months of their IEP or in the GEP, reducing any potential gaps in coverage.

October 31, 2022: CY 2023 Home Health Prospective Payment System rate Update and Home Infusion Therapy Services Requirements – Final Rule (CMS-1766-F)

In a Fact Sheet (link), CMS estimates that Medicare payments to Home Health Agencies (HHAs) in CY 2023 will increase $125 million compared to CY 2022.

October 31, 2022: CY 2023 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1768-F)

CMS projects that payment updates for CY 2023 will increase the total payments to all ESRD facilities by 3.1% compared to CY 2022. You can read about this Final Rule in the CMS Fact Sheet announcing the release of the final rule (link).

CMS recently published the following information about expanding the use of (bivalent) COVID-19 vaccines and new bivalent vaccine CPT codes in the Thursday, October 27, 2022 edition of MLN Connects (link).

The CDC recently expanded the use of updated (bivalent) COVID-19 vaccines to children ages 5 through 11 years. This followed the FDA’s authorization of updated COVID-19 vaccines from Pfizer-BioNTech for children ages 5 through 11 years and from Moderna for children and adolescents ages 6 through 17 years. People with Medicare, Medicaid, Children’s Health Insurance Program coverage, private insurance coverage, or no health coverage can get COVID-19 vaccines, including the updated Moderna and Pfizer-BioNTech COVID-19 vaccines, at no cost, for as long as the federal government continues purchasing and distributing these COVID-19 vaccines.

CMS issued 4 new CPT codes effective October 12, 2022:

Code 91314 for Moderna COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 25MCG/.25ML

Code 91315 for Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 10MCG/0.2ML

Code 0144A for Moderna COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose
• Short descriptor: ADM SRSCV2 BVL 25MCG/.25ML B

Code 0154A for Pfizer-BioNTech COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose
• Short descriptor: ADM SARSCV2 BVL 10MCG/.2ML B

Visit the COVID-19 Vaccine Provider Toolkit (link) for more information, and get the most current list of billing codes, payment allowances, and effective dates (link).

See the full news alert (link)

Source: Thursday October 27, 2022 MLN Connects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-10-27-mlnc

Did You Know?

On September 28, 2022, the United States District Court for the District of Columbia vacated (link) the previously applied differential payment rates for 340B-acquired drugs in the Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS) final rule.

Why it Matters?

As a result of this of this ruling, CMS will revert to paying the default rate (generally ASP plus 6%) under the Medicare status for 340B-acquired drugs.

CMS noted in the Thursday, October 13, 2022 edition of MLN Connects (link) that “CMS is uploading revised OPP drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. CMS also will reprocess claims our contractors paid on or after September 28, 2022, using the default rate.”

What Can You Do?

To receive payments for claims prior to September 28, 2022, providers will need to submit adjustment claims to recalculate their payments. Medicare Administrative Contractors (MACs) nationwide have posted information about this issue on their websites. For example, Noridian JF, the MAC for Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming has posted the following information in their October 27, 2022 daily email (link):

Provider/Supplier Action Required:

“Although MACs shall not reprocess 2022 date of service claims prior to 09/28/22 as contractor-initiated adjustments, MACs shall process provider-submitted adjustments to 2022 date of service claims that were paid prior to September 28, 2022. The adjustments can be submitted using type of bill (TOB) XX7 with condition code D9 and remarks indicating “340B adjustment”.

Did You Know?

Division D, Sections 101 and 102 of the Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023 has extended the temporary low-volume hospital payment adjustment and Medicare Dependent Hospital (MDH) Program that were set to end October 1, 2022.

Why it Matters?

CMS released MLN Matters Article MM12970 (link) on October 21, 2022. This article details information about the above-mentioned Act that extends the temporary changes through December 16, 2022.

What Can You Do?

Per CMS, provider actions needed includes:

• Sending a written request to your MAC by November 16 to get the applicable low-volume hospital payment adjustment, and
• Read this MLN article and related transmittal to determine if you are eligible for continued MDH status.

Did you Know?

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout®.

Why it Matters?

The American Cancer Society indicates that this event is important because “about 34 million American adults still smoke cigarettes, and smoking remains the single largest preventable cause of death and illness in the world. Smoking causes an estimated 480,000 deaths every year, or about 1 in 5 deaths.”

What Can You do About It?

For health care providers, know what resources are available for your patients.

Counseling to Prevent Tobacco Use

This service falls in the benefit category of additional preventive services and National Coverage Determination (NCD 210.4.1) Counseling to Prevent Tobacco Abuse details the covered indications for this service. Specifically, CMS covers this service for outpatient and hospitalized patients with Medicare Part B who meet the following criteria:

• The patient uses tobacco, regardless of whether they exhibit signs and symptoms of tobacco-related disease,
• The patient is competent and alert when counseling is delivered, and
• The counseling is provided by a qualified physician or other Medicare-recognized practitioner.

Counseling Frequency

Medicare covers two cessation attempts per year and each attempt may include a maximum of four intermediate or intensive sessions, with the patient getting up to eight sessions per year. There is no copayment, coinsurance, or deductible for the patient.

Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (NCD 210.14)

Lung Cancer Screening also falls in the benefit category of additional preventive services. Screening is covered for patients with Medicare Part B who meet all the following categories:

• The patient is 50 – 77 years of age,
• The patient is asymptomatic,
• The patient has a smoking history of at least 20 pack-years (1 pack-year = smoking 1 pack per day for 1 year, 1 pack + 20 cigarettes),
• Is a current smoker or quit smoking within the last fifteen years, and
• The physician orders the lung cancer screening with LDCT.

Screening Frequency

Medicare will cover this service annually. Of note, before the first lung cancer LDCT screening, the physician must counsel the patient as a shared decision-making visit. Like counseling to prevent tobacco use, the patient has no copayment, coinsurance, or deductible.

Resource:

CMS MLN Educational Tool Medicare Preventive Services (link)

Compliance Education Updates

MLN Educational Tool: Medicare Preventive Services

This MLN tool (link) was updated in September. Updates include pneumococcal shot resources, thirteen new bone mass measurement codes and three new hepatitis B screening codes.

MLN Educational Tool: Medicare Payment Systems

This MLN tool (link) was also updated in September to include updates for FY 2023 for:

• The Acute Care Hospital Inpatient Prospective Payment System (IPPS),
• The Hospice Payment System,
• The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS),
• The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS),
• The Long-Term Care Hospital Prospective Payment System (LTCH PPS), and
• The Skilled Nursing Facility Prospective Payment System (SNF PPS).

MLN Booklet: Chronic Care Management Services

This Booklet (link) has been updated. Substantive content changes are in dark red font and includes:

• Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same period,
• In 2021 CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
• Beginning 2022 CMS replaced G2058 with 99439.

COVID-19 Updates

October 13, 2022: Update to COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

This CMS document (link) was updated on October 13th. The waiver related to the Director of Food and Nutrition Services was terminated on 10/1/2022 per the FY 2023 SNF Prospective Payment System Final Rule (1765-F).

Other Updates

September 23, 2022 Award of Medicare Administrative Contractor (MAC) Contract for Jurisdiction M

On September 23rd, Palmetto GBA, the incumbent MAC for Jurisdiction M (JM) was again awarded the contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the states of North and South Carolina, Virginia, and West Virginia. The claims volume in JM equates to more than $26.4 billion in Medicare benefit payments annually. Palmetto GBA will provide Medicare services to more than three hundred hospitals, approximately 75,000 physicians, and 3.2 million beneficiaries.

CMS Implements Temporary Increase in Payment under Medicare for Qualifying Biosimilars

Section 11403 of the Inflation Reduction Act provides for a temporary increase in the add-on payment for qualifying biosimilars from the current ASP plus an add-on of 6% of the reference biological product’s ASP to ASP plus 8% for a 5-year period. CMS noted in the Thursday, October 6th edition of MLN Matters (link) that “the goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.”

If you are interested in learning more about biosimilars, there are two FDA resources:

• FDA Biological Product Definition Fact Sheet (link), and
• A Curriculum Materials for Health Care Degree Programs / Biosimilars (link). The “FDA’s curriculum materials are intended to help educate students in health care professional degree programs, for medicine, nursing, physician assistants, and pharmacy, as well as practicing professionals, to improve understanding of biosimilar and interchangeable biosimilar products and the regulatory approval pathway in the United States.”

CMS Request for Information (RFI): Developing a National Directory of Health Care Providers and Services

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

• Helping patients locate providers that meet their individual needs and preferences, and
• A modern NDH “should enable healthcare providers, payers, and others involved in patient care to identify one another’s digital contact information also referred to as digital endpoints, for interoperable electronic data exchange.”

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

Medicare MLN Articles & Transmittals

Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data

• MLN Release Date: September 29, 2022
• What You Need to Know: Data for the Ninth Circuit’s jurisdiction has been updated based on Supreme Court decision in Azar v. Empire Health Foundation. This includes hospitals in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington. Data for all other hospitals is unchanged.
• MLN MM12906: (link)

New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

• MLN Release Date: October 6, 2022
• What You Need to Know: Make sure your billing staff knows about a new consistency edit that validates the attending provider NPI and that organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met.
• MLN MM12889: (link)

Medicare Deductible, Coinsurance & Premium Rates: Calendar Year 2023 Update

• MLN Release Date: October 13, 2022
• What You Need to Know: CMS advises to make sure your billing staff know about the calendar year 2023 rate changes. I would also encourage you to make sure your case management and social services staff are aware of this information too.
• MLN MM12903: (link)

Revised Medicare MLN Articles & Transmittals

Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests

• MLN Release Date: April 29, 2022 – Revised September 29, 2022
• What You Need to Know: The article was revised to add the Other Amount Indicator “B2” for co-insurance reduction amount to the claim, modify edits that affects the co-insurance reduction amount, and report the applied coinsurance amounts in the c-insurance field.
• MLN MM12656: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)-January 2023 Update – 2 of 2

• MLN Release Date: August 12, 2022 – Revised October 5, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 12842. The update for NCD 150.3 (Bone Mineral Density Studies) was removed due to ICD-10 diagnosis codes that were added in error and restore ICD-10 diagnosis C91.92 that was removed in error to NCD 110.23 (Stem Cell Transplantation).
• MLN MM12842: (link)

October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal Release Date: Transmittal 11610 released September 23, 2022 is being rescinded and replaced by Transmittal 11661 dated October 23, 2022
• What You Need to Know: This transmittal has been updated to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11.
• Transmittal 11661: (link)

Coverage Updates

Cochlear Implantation Final Decision Memo (CAG-00107R)

On September 26, 2022, CMS published a final decision memo (link) for NCD 50.3 Cochlear Implantation. CMS has concluded there is sufficient evidence for cochlear implantation be “be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.” Patient’s must also meet specific criteria detailed in the Decision Memo.