Knowledge Base Category -

MMP has been sending out the Wednesday@One since 2012. Over the past decade, I have often shared with our readers my love of fall. Fall means the return of college football, front yards filled with inflatable pumpkins and ghosts, and this year I am seeing the addition of exceptionally large decorative black spiders crawling up the outside walls of homes and strings of glowing witch hats lighting front porches.

Even with pots of chili still to be cooked and caramel apples still to be consumed, it is never too early to prepare for the New Year. Along with the October 1st start of the CMS 2023 Inpatient Prospective Payment System (IPPS) Fiscal Year, this article highlights recent news to help you prepare for the coming year.

2023 Dollar Amount in Controversy Required for Administrative Law Judge (ALJ) Hearing or Federal District Court Review

The fifth level of appeal for Medicare Fee-for-Service appeals is an ALJ hearing or Federal District Court review. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires an annual reevaluation of the dollar amount in controversy (AIC) required to advance to this level of appeal.

On September 30, 2022, the annual adjustment that will be effective on January 1, 2023 was published in the Federal Register (link). The calendar year (CY) 2023 AIC threshold amounts are:

• ALJ hearing requests filed on or after January 1, 2023 remains the same as CY 2022 at $180.
• Federal District Court requests filed on or after January 1, 2023 will increase from the CY 2022 amount of $1,760 to $1,850.

You can learn more about the appeal process in the CMS MLN Booklet Medicare Parts A & B Appeals Process (link).

Inflation Reduction Act

President Biden signed the Inflation Reduction Act (IRA) into law on August 16, 2022. On October 5th, CMS released a Fact Sheet (link) where CMS notes that “this law means millions of Americans across all 50 states, the United States territories, and the District of Columbia will save money from meaningful benefits.” Insulin cost sharing is one of the benefits that will start in 2023 and includes:

• Starting January 1, 2023, people enrolled in a Medicare prescription drug plan will not pay more than $35 for a month’s supply of each insulin that they take and is covered by their Medicare prescription drug plan and dispensed at a pharmacy or through a mail-order pharmacy. Also, Part D deductibles will not apply to the covered insulin product.
• Starting July 1, 2023, people with traditional Medicare who take insulin through a traditional pump will not pay more than $35 for a month’s supply of insulin, and the deductible will not apply to the insulin. This will apply to people using pumps covered through the durable medical equipment benefit under Part B.

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency this past Thursday, 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. Sixty days prior to January 11, 2023 is Saturday, November 12th, 2022.

Social Security Benefits in 2023

In an October 13th Press Release (link), the Social Security Administration announced that “approximately 70 million Americans will see a 8.7% increase in their Social Security benefits and Supplemental Security Income (SSI) payments in 2023. On average, Social Security benefits will increase by more than $140 per month starting in January.”

Calendar Year 2023 Medicare Deductible, Coinsurance & Payment Rates

Since writing about the updated Medicare deductible, coinsurance and payment rates in last week’s newsletter (link), CMS has published MLN Matters article MM12903 (link) which includes background information regarding a Medicare beneficiary’s “spell of illness” and Medicare coverage in a skilled nursing facility (SNF) as well as the 2023 payment rate changes.

As we wait for the release of the CY 2023 Outpatient Prospective Payment System (OPPS) Final Rule, the 2022 CERT Report, and the possible notification of the end of the COVID-19 PHE, I wish all our readers a happy fall y’all.

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on seven of the recent review results posted by the Supplemental Medicare Review Contractor (SMRC).

Project 01-034 Transforaminal Epidural Injections

Background: 2018 CERT Improper Payment Report noted a 29.1% error rate for this service. Also, a previous SMRC contractor found a claim error rate of 40% with 30% of the claims error being due to no response to documentation request.

• Dates of Service (DOS) Reviewed: July 1, 2018 - June 30, 2019.
• Claims Error Rate: 65%

Common Denial Reasons: Incomplete/insufficient documentation, no response to documentation request, and documentation submitted did not support identification and administration of medication and or dosage limitations.

Project 01-058: Traditional Telehealth

Background: Under COVID-19 waivers and flexibilities, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including the patient’s place of residence starting March 6, 2020.

• DOS Reviewed: March 6, 2020 - May 13, 2021
• Claims Error Rate: 88%

Common Denial Reasons: documentation did not support the use of appropriate real-time telecommunication technology and documentation did not support the signs and symptoms to warrant billing an E&M visit.

Project 01-302 Cataract Surgery

Background: This surgery had been a topic of the OIG for many years. They have reviewed surgery in both the outpatient facility and ambulatory surgery center setting. CMS data reflects a potential vulnerability.

• DOS Reviewed: CY 2019
• Claims Error Rate: 51%

Common Denial Reasons: No response to the documentation request, documentation submitted did not support the required documentation needed for cataract surgery, and the documentation did not include a signed physician order or documentation to support intent to order.

Project 01-304 Facet Joint Injections

Background: The OIG has found significant billing errors in this area in the past and an October 2020 OIG report found that due to coverage limitations Medicare improperly paid out $748,555.

• DOS Reviewed: CY 2019
• Claim Error Rate: 92%

Common Denial Reasons: Documentation submitted was insufficient or incomplete. Documentation submitted did not support medical necessity as listed in National and Local Coverage determinations. No response to the documentation request.

Project 01-305 Inpatient Psychiatric Facility

Background: The OIG found on 87% error rate on claims reviewed dated fiscal years 2014 – 2015. A CERT report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service with the highest improper payment rate.

• DOS Reviewed: January 16, 2019 through December 31, 2019
• Claim Error Rate: 26%

Common Denial Reasons: documentation submitted lacked evidence that category requirements were met. No response to the documentation request. Documentation submitted did not include the required certifications or recertifications for the inpatient psychiatric stay.

Project 01-308 Outpatient Therapy

Background: The Bipartisan Budget Act (BBA) of 2018 created a medical review (MR) expense threshold of $3,000 or physical therapy (PT) and speech-language pathology (SLP) combined and $3,000 for occupational therapy (OT). The SMRC was directed to perform data analysis on outpatient therapy claims below the 2019 therapy threshold and recommend codes to be selected for review, recommend a sampling strategy, and identify MR strategy for the project.

• DOS Reviewed: CY 2019
• Claim Error Rate: 39%

Common Denial Reasons: No response to the documentation request. Certifications for the Plan of Care (POC) not present. Documentation did not support the initial POC was certified by the physician / NPP. Lack of evidence of delayed certification attempts to obtain the certification. Documentation did not support the units billed.

Project 01-310 Endomyocardial Biopsy with Right Heart Catheterization

Background: Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure. Potential misuse of this modifier represents a potential vulnerability and has been featured in work done by the OIG.

• Dates of Service Reviewed: CY 2019
• Claim Error Rate: 60%

Common Denial Reasons: No response to the documentation request. Documentation was not sufficient to support the medical necessity of the procedure performed. Documentation did not support that the procedure was performed.

Moving Forward What Can You Do?

• First, make sure your hospital has a process in place to respond to documentation request from the SMRC,
• Read the entire review results that can be found on the SMRC website (link), and
• Identify services that have a related National or Local Coverage Determination (NCD/LCD) that you are providing at your hospital and share this information with key stakeholders.

Did You Know?

Chances are you; a family member, close friend or acquaintance has been impacted by breast cancer. October is Breast Cancer Awareness Month. According to a CDC (link), each year:

• About 264,000 women in the United States get breast cancer and 42,000 women die from the disease,
• Men can also get breast cancer, but it is not common. About one out of every one hundred breast cancers diagnoses in the United States is found in a man, and
• While most breast cancers are found in women who are 50 years old or older, breast cancer also affects younger women.

Why Should You Care?

Even though family history increases the risk of breast cancer, most women diagnosed with breast cancer have no known family history of the disease. Early detection allows for a higher chance of cure. Mammography is used to detect breast cancer and is one of many Preventative Services covered by Medicare.

A related RealTime Medicare (RTMD) infographic, in this week’s newsletter, highlights the impact of the COVID-19 pandemic on the volume of Medicare Fee-for-Service beneficiaries undergoing screening mammography in RTMD’s footprint.

NCD 220.4 Mammograms

The CMS National Coverage Determination (NCD) 220.4 Mammograms (link) distinguishes the difference between diagnostic and screening mammography.

Diagnostic Mammography

A radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure. CMS covers this service if ordered by a Doctor of Medicine or Osteopathy in addition to the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated,
• A patient has a history of breast cancer, or
• A patient is asymptomatic but, based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Screening Mammography

A radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Routine screening includes:

• Asymptomatic women 50 years and older, and
• Asymptomatic women 40 years and older whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

Guidance for coding and billing for screening mammography is available in the MLN Educational Tool: Medicare Preventive Services (link).

What Can I Do?

Know Ways to Lower Your Risk for Breast Cancer

The CDC details thing you can do to help lower your risk of breast cancer including:

• Keep a health weight and exercise regularly,
• Choose not to drink alcohol, or dink alcohol in moderation,
• If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks, and
• Breastfeed your children, if possible.

Know the Warning Signs of Breast Cancer

While there are different symptoms of breast cancer, and some people have no symptoms at all, symptoms can include:

• Any change in the size or shape of the breast,
• Pain in any area of the breast,
• Nipple discharge other than breast milk (including blood),
• A new lump in the breast or underarm, thickening or swelling or part of the breast,
• Irritation or dimpling of the breast,
• Redness or flaky skin in the nipple area of the breast.

Be Your Own Patient Advocate

If you have any signs or symptoms that worry you, follow-up with a health care provider as soon as possible.

Talk to your health care provider about when and how often to get a screening mammogram. If you are worried about the cost, the CDC’s National Breast Cancer Early Detection Program (NBCCEDP) (link) provides breast and cervical cancer screenings and diagnostic services to women who have low incomes and are uninsured or underinsured.

Compliance Updates

MLN Booklet: Chronic Care Management (CCM) Services

This MLN booklet (link) was updated this month. Changes made to this booklet are highlighted in dark red font and include:

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

COVID-19 Updates

September 12, 2022: COVID-19 Vaccines Providing Protection from Omicron Variant Available at No Cost

CMS published a special edition MLN Connects (link) announcing that “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.”

You will also find information in the newsletter about the four new CPT codes effective August 31, 2022, that CMS has issued for the Pfizer-BioNTech and Moderna Bivalent vaccines.

September 13, 2022: CDC Clinical Outreach and Communication Activity (COCA) Call: Recommendations for Bivalent COVID-19 Booster

The CDC held a COCA call (link) to discuss their new guidance on bivalent COVID-19 booster doses for people ages 12 years and older, included those who are moderately or severely immunocompromised. In the overview of the call the CDC noted that “Updated COVID-19 vaccines add an Omicron BA.4/5 spike protein component to the previous monovalent composition. These bivalent booster doses help restore protection that has waned since previous vaccination by targeting more transmissible and immune-evading variants. These boosters also broaden the spectrum of variants that the immune system is ready to respond to.” A recording of the call, slides and transcript are now available on this CDC webpage.

September 20, 2022: CDC COCA Call: Evaluating and Supporting Patients Presenting with Cardiovascular Symptoms Following COVID

In the “Overview” section on the CDC webpage (link), the CDC notes that of all of the post-COVID conditions (PCC) that people experience “cardiovascular symptoms and complications are among the most common and debilitating.” Presenters during this call outlined “the recommended clinical approach to identifying and managing cardiovascular complications in these patients.” A recording of the call and slides are now available.

Other Updates

National Correct Coding Initiative: October Quarterly Update

In the Thursday, September 15, 2022 edition of MLN Connects (link), CMS encourages you to get the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective October 1, 2022 and provides links to the Procedure-to-Procedure Edits, Medically Unlikely Edits, and Add-on Code Edits webpages.

CMS Resources by Language

Did you know that there is a collection of CMS resources categorized by language? This CMS webpage (link) was last modified on September 13th and includes resources in 18 languages “to help people make informed healthcare decisions and be active partners in their healthcare and the healthcare of their families.” These resources can be downloaded or ordered at no cost. A link to additional Medicare resources in 23 languages can also be found on this webpage. .

Medicare MLN Articles & Transmittals

Exceptions to Average Sales Price (ASP) Payment Methodology – Claims Processing Manual Changes

• MLN Release Date: August 30, 2022
• What You Need to Know: Your billing staff need to be made aware of updates to Chapter 17 Section 20.1.3 (Exceptions to Average Sales Price (ASP) Payment Methodology) and Section 20.3 (Calculation of the Payment Allowance Limit for DME MAC Drugs) of the Medicare Claims Processing Manual
• MLN MM12854: link)

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

• MLN Release Date: September 6, 2022
• What You Need to Know: This article lists the lab specific NCDs with coding updates effective January 1, 2023.
• MLN MM12888: link)

Billing for Hospital Part B Inpatient Services

• Change Request (CR) 12816 Release Date: September 8, 2022
• What You Need to Know: The purpose of this CR is to provide billing instructions for hospital Part B inpatient services. Specifically, there are additions to the “Not Allowed Revenue Codes.” No policy change is being made in this CR. You can find more information in the following CMS manuals:
• Section 10 Medicare Benefit Policy Manual, Chapter 6 (link): when to bill Part B for inpatient services
• Section 70 Medicare Claims Processing Manual, Chapter 1 (link): time limitations for filing Part B claims
• Section 240 Medical Claims Processing Manual, Chapter 4 (link): services allowed on inpatient Part B claims
• CR 12816: link)

October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• MLN Release Date: September 13, 2022
• What You Need to Know: CMS advises that your billing staff should know about the new COVID-19 CPT vaccine and administration codes, redosing update for EVUSHELD™, and a new procedure to assess coronary disease severity using computed tomography angiography that is detailed in this article.
• MLN MM12885: link)

Ambulatory Surgical Center Payment System: October 2022 Update

• MLN Release Date: September 26, 2022
• What You Need to Know: Your billing staff needs to know about updates to the ASC payment system, a new OPPS device pass-through code, new HCPCS codes for drugs and biologicals, and new skin substitute products low-cost or high-cost group assignment.
• MLN MM12915: link)

Revised Transmittals & MLN Articles

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

• MLN Release Date: August 15, 2022 – Revised September 8, 2022 – Revised September 19, 2022
• What You Need to Know: The article was revised on September 8th to reflect the change in CR 12870. Specifically, a note was added about code 0340U in dark red font on page 3 of the article. It was once again revised on September 19th to correct an acronym on page three.
• MLN MM12870: link)

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide medical review updates and educate resources from the Medicare Administrative Contractors (MACs)

CGS Administrators, LLC J15 MAC

Review of Implantable Automatic Defibrillator CERT Errors Education Session

CGS is offering this education session on Monday September 26, 2022, from 10:00 AM – 11:00 AM CDT (link). During this session they will discuss an increase in CERT errors related to the “formal shared decision-making encounter using an evidence-based decision tool prior to implantation” as outlined in National Coverage Determination (NCD) 20.4.

First Coast Service Options, Inc. JN MAC

TPE Rehabilitation Services (Outpatient) Review Results

First Coast recently published review results for outpatient rehabilitation services (CPT® 97110, 97112 and 97140) (link). In addition to CPT specific review results, First Coast provides a link to a documentation checklist to help providers when responding to medical documentation requests for therapy and rehabilitation services.

National Government Services (NGS), Inc. J6/JK MAC

Prior Authorization Exemption Status Inquiry Tool Alert

This month NGS announced (link) that they have developed this tool as a way to unnecessary prior authorization requests by exempt providers.

Noridian Healthcare Solutions, LLC JE/JF MAC

Noridian JE Medical Record Review Results

On August 31st, TPE medical record review results were posted on the Noridian JE (link) and Noridian JF (link) websites.

Noridian JE Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 48.78%,
• Lumbar Epidural Injection (CPT® 64483): Error rate 34.43%, and
• Dual-energy X-ray absorptiometry (DXA) (CPT®77080): Error rate 26.43%.

Noridian JF Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 55.64%, and
• Total Knee Arthroplasty (CPT® 27447): Error rate 44.83%.

Review Results for both jurisdictions were for dates of service April 1, 2022, through June 30, 2022. Articles for review topics includes top denial reasons, links to educational resources, and education specific to documentation requirements and medical necessity.

Novitas Solutions, Inc. JH/JL MAC

Forms Catalog for Medicare Part A

Novitas Solutions has recently modified their Forms Catalog for Medicare Part A webpage (link). Examples of forms you will find on this webpage includes:

• Link to the Advanced Beneficiary Notice (ABN) Form (CMS-R-131),
• Hospital-Issued Notices of Noncoverage (HINNs), and
• Prior authorization request for certain hospital outpatient department services.

Palmetto GBA JJ/JM MAC

MACtoberfest®

Annually, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, hosts their provider education event MACtoberfest. This virtual three-day conference includes a Medicare Part A and Part B track. Registration is now open and you can learn more about this event on their website (link).

New Local Coverage Determination (LCD)

Palmetto published LCD L39270 Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin’s and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (link). This policy is effective for services performed on or after September 4, 2022. There is a National Coverage Determination (NCD) 110.23 Stem Cell Transplantation. Palmetto notes in their LCD, “This policy describes additional locally covered indications for allo-HSCT for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin that are medically necessary in patients for whom there are no other curative intent options.”

WPS J5/J8 MAC

WPS recently published Quarter 2 Targeted Probe and Educate (TPE) review results for WPS J5 (link) and WPS J8 (link).

WPS J5 TPE Review Results

• Infusion Services (CPT® 96413 or 96415): Trending error rate 99%. The top reason for denial cited by WPS was the documentation did not support frequent monitoring.
• Routine Foot Care: Trending error rate 24%. The top reason for denial being documentation did not support the presence of severe systemic conditions.
• Outpatient Therapy (CPT® 97110): Trending error rate 52%. The top denial reason was documentation did not support the skills of a licensed professional therapist.
• Group Psychotherapy (CPT® 90853): Trending error rate 49%. The top denial reason was claim billing did not meet the National Correct Coding Initiative (NCCI) guidelines.

WPS J8 TPE Review Results

• Wound Care (CPT® 11042): Trending error rate 43%. The top denial reason was that documentation did not contain initial wound measurements.
• Infusion Services (CPT® 96361): Trending error rate 53%. Denials occurred due to documentation supporting intravenous fluids for the purpose of keeping a vein open. “According to CPT coding guidelines providers should not bill codes 96360 and 96361, when the purpose of the fluids is to keep open a vein.”
• Basic Life Support (BLS) Ambulance transports (HCPCS A0429): Trending error rate 29%. Denials occurred cue to the Assignment of Benefits (AOB) being incomplete or missing.

Did You Know?

CAR T-cell Therapy entails the use of CAR T-cells that have been genetically altered to improve the ability of the T-cells to fight cancer. The genetic modification creating a CAR can enhance the ability of the T-cell to recognize and attach to a specific protein, called an antigen, on the surface of a cancer cell.

In 2017, the FDA gave approval to two CAR T-cell therapies (Kymriah® and Yescarta®). Effective October 1, 2018, both therapies were approved for new-technology add-on payments with a maximum add-on payment of $186,500.

Effective for claims with dates of service on or after August 7, 2019, Medicare began covering autologous treatment for cancer with T-cells expressing at least 1 Chimeric Antigen Receptor (CAR) when the treatment is:

• Administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS), and
• Is used for a medically accepted indication as defined at section 1861(t)(2)-i.e., or
• Is used for either an FDA-approved indication (according to the FDA-approved label for that product, or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

Not surprisingly, CAR T-cell therapy is expensive. So much so that CMS clinical advisors noted in the Fiscal Year (FY) 2021 IPPS proposed rule that they had found a vast discrepancy in resource consumption and clinical differences warranting the creation of new MS-DRG. Effective October 1, 2020, CAR T-cell therapy had its own MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell immunotherapy).

In the current CMS FY 2022, MS-DRG 018 has a relative weight of 37.4501. On the October 1, 2022, start date of the CMS 2023 FY, MS-DRG 018 will once again have the highest relative weight at 36.1452.

Since 2017, the FDA has approved additional CAR T-cell therapies. Three of these are eligible for a New Technology Add-On Payment (NTAP) in Fiscal Year 2023:

• ABECMA® and CARVYKTI ™ to treat patients with relapsed or refractory multiple myeloma with a maximum add-on payment of $289,532.75, and
• TECARTUS® to treat relapsed or refractory mantle cell lymphoma with a maximum add-on payment of $259,350.00.

Why it Matters?

In addition to CMS guidance, several of the Medicare Administrative Contractors (MACs) have published guidance regarding CAR T-cell therapy. If your hospital provides this service, I encourage you to become familiar with both CMS and the MACs guidance.

CMS Guidance

• National Coverage Determination Chimeric Antigen Receptor (CAR) T-cell Therapy (NCD 110.24): (link)
• MLN Matters Article National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell therapy – This CR Rescinds and Fully Replaces CR 11783 (MM12177): (link)
• MLN Matters Article Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions (SE19009): (link)
• MLN Matters Article International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – January 2023 Update: link)
• Note: Revisions to NCD 110.24 include updated codes and coding guidance for all currently available CAR T-cell therapies.

MAC Specific Guidance

• CGS J15 (KY and OH) Article (link)
• NGS JK (CT, NY, ME, MA, NH, RI, VT) FAQs (link)
• Novitas JH (AR, CO, LA, MS, MN, OK, TX) Article (link)

Did You Know?

Even if it was true that fifty is the new forty, for men, fifty is fifty when it comes to thinking about when to begin prostate cancer screening.

Why it Matters?

While all men are at risk for prostate cancer, according to the CDC, age is the most common risk factor. For men aged 50 and older with Medicare Part B, coverage of prostate cancer screening by Medicare begins the day after your 50th birthday (link).

What Should I Do?

The U.S. Preventive Services Task Force recommendation is that men aged 55 to 69 years should participate in a shared decision-making process with their physician by discussing the potential benefits and harms of screening with a PSA test and incorporating their values and preferences in the decision (link).

This recommendation applies to men who:

• Are at average risk for prostate cancer,
• Are at increased risk for prostate cancer,
• Do not have symptoms of prostate cancer, and
• Have never been diagnosed with prostate cancer.

According to the CDC (link), men can have varying symptoms or no symptoms at all for prostate cancer. If you are experiencing any of the following symptoms, first keep in mind the symptoms can be caused by other conditions, but err on the side of caution and see your doctor sooner rather than later:

• Difficulty starting urination.
• Weak or interrupted flow or urine.
• Urinating often, especially at night.
• Trouble emptying the bladder completely.
• Pain or burning during urinations.
• Blood in urine or semen.
• Pain in the back, hips, or pelvis that does not go away.
• Painful ejaculation.

COVID-19 Updates

August 18, 2022: Roadmap for the End of the COVID-19 Public Health Emergency

CMS published a blog (link), announcing their efforts to create a roadmap for the end of the COVID-19 PHE. CMS reminds you that “HHS Secretary Becerra has committed to giving states and the health care community writ large 60 days’ notice before ending the PHE. In the meantime, CMS encourages health care providers to prepare for the end of these flexibilities as soon as possible and to begin moving forward to reestablishing previous health and safety standards and billing practices.”

Included in this CMS Blog is a list of fact sheets summarizing the status of Medicare Blanket waivers and flexibilities by provider type. The fact sheets include information about waivers and flexibilities that:

• Have already been terminated,
• Will be made permanent, or
• Will end at the end of the PHE.

CMS expects “that the health care system can begin taking prudent action to prepare to return to normal operations and to wind down those flexibilities that are no longer critical in nature.”

The COVID-19 PHE declaration was last extended on July 15, 2022 (link). PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary meaning the current COVID-19 PHE declaration will last until October 13, 2022.

With the CMS release of a Road Map to wind down the COVID-19 PHE, it seems hospitals are being put on notice that the end of the PHE is near.

Other Updates

Friday, July 27, 2022: CMS Releases Three FY 2023 Final Rules

In late July, CMS published Fiscal Year (FY) 2023 Final Rules. You can read about each of the Final Rules in related CMS Fact Sheets.

• FY 2023 Inpatient Rehabilitation Facility (IRF) Prospective Payment System Final Rule (CMS-1767-F) CMS Fact Sheet: link
• FY 2023 Medicare Inpatient Psychiatric Facility Prospective Payment System Final Rule (CMS-1769-F) CMS Fact Sheet: link
• FY 2023 Hospice Payment Rate Update Final Rule (CMS-1773-F) CMS Fact Sheet: link

Monkeypox & Smallpox Vaccines: New Product Codes

CMS included the following guidance related to monkeypox and smallpox vaccines in the August 11, 2022 edition of MLN Connects (link).

On July 23, the World Health Organization declared monkeypox a public health emergency, and HHS issued a statement regarding the Biden-Harris Administration’s actions to make vaccines, testing, and treatments available. CMS issued two new CPT codes effective July 26, 2022:

Code 90611 for smallpox and monkeypox vaccine product:

• Long descriptor: Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use
• Short descriptor: SMALLPOX&MONKEYPOX VAC 0.5ML

Code 90622 for vaccinia (smallpox) virus vaccine product:

• Long descriptor: Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use
• Short descriptor: VACCINIA VRS VAC 0.3 ML PERQ

CORRECTION: Monkeypox & Smallpox Vaccines: Include Product Code on Claims

Initially, Medicare instructed to only bill for vaccine administration when you got the vaccine at no cost from the government. In the September 1, 2022 MLN Connects newsletter, these instructions were changed. These new instructions are to include these 3 elements on your claim, even if you get the vaccine from the government for free:

1. product code (90611 or 90622)
2. applicable ICD-10-CM diagnosis code
3. administration code

We’ll address the no cost government vaccine product payment adjustments during claims processing. You’ll see it on your remittance advice.

Code 90611 for smallpox and monkeypox vaccine product:

• Long descriptor: Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use
• Short descriptor: SMALLPOX&MONKEYPOX VAC 0.5ML

Code 90622 for vaccinia (smallpox) virus vaccine product:

• Long descriptor: Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use
• Short descriptor: VACCINIA VRS VAC 0.3 ML PERQ

Patient cost sharing applies. Your Medicare Administrative Contractor will give you more information soon about coverage and billing.

Medicare MLN Articles & Transmittals

Inpatient Psychiatric facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2023

• MLN Release Date: August 4, 2022
• What You Need to Know: This MLN article provides Key Changes for FY 2023 related to market basket update, wage index update, IPF quality reporting programs, PRICER updates, provider specific file update, ICD-10-CM/PCS updates, COLA adjustment, and rural adjustment.
• MLN MM12859: link)

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2022 Update

• Transmittal 11544 Release Date: August 4, 2022
• What You Need to Know: This Change Request (CR) was issued to amend the 2022 MPFS Final Rule payment files. Changes includes new HCPCS and CPT codes, codes that are no longer valid and changes to a short descriptor.
• Transmittal 11544/Change Request 12869: link)

New Waived Tests

• MLN Release Date: August 4, 2022
• What You Need to Know: information about CLIA requirements, new CLIA waived tests approved by the FDA and the use of modifier QW for CLIA-waived tests can be found in this MLN article.
• MLN MM12841: link)

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes FY 2023

• MLN Release Date: August 5, 2022
• What You Need to Know: CMS advises you to make sure your billing staff knows about changes to the Fiscal Year (FY) 2023 payment rates and wage index cap.
• MLN MM12807: link)

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

• MLN Release Date: August 15, 2022
• What You Need to Know: Your staff needs to be aware of newly available codes added to NCDs, separate NCD coding revisions and coding feedback.
• MLN MM12822: 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 15, 2022
• What You Need to Know: This is the second of two MLN matters articles detailing January 2023 updates to NCDs.
• MLN MM12842: link)

Significant Updates to Internet Only Manual (IOM) Publication (Pub.) 100-05 Medicare Secondary Payer (MSP) Manual, Chapter 5

• MLN Release Date: August 15, 2022
• What You Need to Know: This article highlights key updates of importance for providers, for example, “Medicare is the secondary payer throughout the entire 30-month ESRD coordination period when a patient is eligible for, or entitled to, Medicare on the basis of ESRD. (See section 30.3.1.).”
• MLN MM12765: link)

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

• MLN Release Date: August 15, 2022
• What You Need to Know: You will find information about updated to Advanced Diagnostic Laboratory Tests (ADLTs), the next CLFS data reporting period, and new codes added to the National HCPCS file in this MLN article.
• MLN MM12870: link)