Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: August 31, 2020
- What You Need to Know: This article informs providers about changes to and billing instructions for various payment policies implemented in the October 2020 OPPS update.
- MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf
October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3
- Article Release Date: August 28, 2020
- What You Need to Know: This article provides information about the October 2020 version of the I/OCE instructions and specifications that Medicare uses.
- MLN MM11944: https://www.cms.gov/files/document/mm11944.pdf
Annual Clotting Factor Furnishing fee Update 2021
- Article Release Date: August 28, 2020
- What You Need to Know: The annual clotting factor furnishing fee for 2021 is $0.238 per unit.
- MLN MM11932: https://www.cms.gov/files/document/mm11932.pdf
2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
- Article Release Date: August 28, 2020
- What You Need to Know: Section 413(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment file. This article lets providers know that CMS will provide MACs with files for the automated payments of HPSA bonuses for dates of service January 1, 2021 through December 31, 2021.
- MLN MM11852: https://www.cms.gov/files/document/mm11852.pdf
October Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Article Release Date: August 28, 2020
- What You Need to Know: This article provides details about the changes to the DMEPOS fee schedules that Medicare updates quarterly, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Specific to the ongoing Public Health Emergency (PHE) due to the COVID-19 pandemic, “the October 2020 DMEPOS and PEN fee files continue to include the non-rural contiguous non-CBA 75/25 blended fees required by Section 3712(b) of the CARES Act signed into law on March 27, 2020.
- MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE
- Article Release Date: August 28, 2020
- What You Need to Know: This article informs providers that Medicare will update its claims processing systems based on the Committee on Operating Rules for Information Exchange (CORE), Code Combination List, which will be published on or about October 1, 2020.
- MLN Matters MM11881: https://www.cms.gov/files/document/mm11881.pdf
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice PRICER for FY 2021
- Article Release Date: August 31, 2020 – Revised September 10, 2020
- What You Need to Know: This article provides updates in Change Request (CR) 11876 to hospice payment rates, wage index, PRICER, and aggregate cap amounts for Fiscal Year (FY) 2021. Note, this article was revised on September 10th to correct two typos. All other information remained the same.
- MLN Matters MM11876: https://www.cms.gov/files/document/mm11876.pdf
Claim Status Category and Claim Status Codes Updates
- Article Release Date: August 28, 2020
- What You Need to Know: This article informs providers of updates to the Claim Status and Claims Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Code changes during the September/October 2020 National Code Maintenance Committee (NCMC) meeting will be posted on or about November 1, 2020.
- MLN Matters MM11796: https://www.cms.gov/files/document/mm11796.pdf
2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing facility (SNF) Consolidated Billing (CB) Update
- Article Release Date: September 16, 2020
- What You Need to Know: This articles provides information regarding changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that Medicare uses to revise Common Working File (CWF) edits to allow MACs to make appropriate payments.
- MLN Matters MM11968: https://www.cms.gov/files/document/mm11968.pdf
Fiscal Year (FY) Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
- Article Release Date: September 22, 2020
- What You Need to Know: This article provides FY 2021 update to the IPPS and LTCH PPS.
- MLN MM11879: https://www.cms.gov/files/document/mm11879.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021
- Article Release Date: September 25, 2020
- What You Need to Know: CR 11984 provides quarterly updates to the NCCI PTP edits. A test file will be available around November 2, 2020 with a final file available on or about November 17, 2020.
- MLN MM11984: https://www.cms.gov/files/document/mm11984.pdf
OTHER MEDICARE TRANSMITTALS
Updates to Chapter 23 – Fee Schedule Administration and Coding Requirements
- Change Request Release Date: August 28, 2020
- What You Need to Know:
- CR 11941 (Transmittal 10320): https://www.cms.gov/files/document/r10320cp.pdf
- Effective Date: December 1, 2020
- Implementation Date: December 1, 2020
Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19
- Article Release Date: September 4, 2020
- What You Need to Know: CMS has removed the reference to Electrocardiogram (EKG) services in the Medicare Claims Processing Manual, Chapter 16, Section 60.1.2 and Chapter 26, Section 10.4, Item 19. This change only clarifies existing content.
- MLN Matters MM11935: https://www.cms.gov/files/document/mm11935.pdf
Update to the Medicare Claims Processing Manual
- Article Release Date: September 18, 2020
- What You Need to Know: This article provides information regarding updated to the Medicare Claims Processing Manual, Chapters 12 and 23.
- MLN Matters MM111958: https://www.cms.gov/files/document/mm11958.pdf
REVISED MEDICARE TRANSMITTALS
National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low back Pain (cLPB)
- Article Release Date: May 13, 2020 – Revised September 1, 2020
- What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11755 that provides revised messaging (page 3 in the article). It also revised the Claims Processing Manual at Section 410.4.
- MLN Matters MM11755: https://www.cms.gov/files/document/MM11755.pdf
Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries
- Article Release Date: September 4, 2020 – Revised September 15, 2020
- What You Need to Know: This article provides information about CMS modifying and streamlining the model admission questions for providers to ask Medicare beneficiaries or authorized representatives upon admission or start of care.
- Note, this article was revised on September 15th to reflect the CR revision adding part of sentence that had been left out of manual Section 20.2.2 of the Medicare Secondary Payer Manual.
- MLN Matters MM11945: https://www.cms.gov/files/document/mm11945.pdf
October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
- Article Release Date: September 11, 2020 – Revised September 24, 2020
- What You Need to Know: This article is based on Change Request (CR) 11963 which provides information about changes to and billing instructions for various payment policies implemented in the October 2020 ASC payment system update.
- Note, this article was revised to reflect the updated CR revision to HCPCS code C9066 in Table 2 in the CR.
- MLN MM11963: https://www.cms.gov/files/document/mm11963.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Article Release Date: August 7, 2020 – Latest Revision September 24, 2020
- What You Need to Know: This article informs laboratories of changes from the quarterly update to the clinical laboratory fee schedule. Now in its third iteration, this article was most recently updated to add new COVID-19 code (86413) and ADLT code (0090U).
- MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf
Change to the Payment of Allogeneic Stem Cell Acquisition Services
- Article Release Date: July 13, 2020 – Revised September 24, 2020
- What You Need to Know: This article was revised to reflect a revised CR issued on September 24, 2020. All other information remains the same.
- MLN MM11729: https://www.cms.gov/files/document/mm11729.pdf
October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: August 31, 2020 – Revised September 25, 2020
- What You Need to Know: This article has been revised to reflect an updated CR 11960 that made several changes including adding a new COVID-19 CPT code, 86413, to Table 1.
- MLN MM11960: https://www.cms.gov/files/document/mm11960.pdf
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer
- Article Release Date: September 15, 2020
- What You Need to Know: CMS “has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician, and when specific requirements are met.
- NCD Implementation Date: November 13, 2020
- NCD Effective Date: January 27, 2020
- MLN MM11837: https://www.cms.gov/files/document/mm11837.pdf
OTHER MEDICARE UPDATES
August 27, 2020: OIG Report – Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments in the Provider Appeals Process
- Link to Report: https://oig.hhs.gov/oas/reports/region5/51800024.pdf
Proposed Rule: Medicare Program; Modernizing and Clarifying the Physician Self-Referral Regulations Extension of Timeline for Publication of Final Rule
Link to notice in Federal Register: https://www.govinfo.gov/content/pkg/FR-2020-08-27/pdf/2020-18867.pdf
September 2, 2020: FY 2021 IPPS Final Rule released.
September 3, 2020: Medicare Preventive Services Tool and Poster Revised
CMS noted in their September 3rd edition of MLNConnects that the Medicare Preventive Services Medicare Learning Network Educational Tool and Poster have been revised. The tool is extremely useful to understand Coding, Coverage, and Copayment/coinsurance and deductible requirements for Preventative Services covered by Medicare.
- Link to Revised Tool: Medicare Preventive Services
- Link to Revised Poster: Medicare Preventive Services Poster
September 10, 2020: OIG Report: Billions in Estimated Medicare Advantage Payments from Diagnoses Reported Only on Health Risk Assessments Raise Concerns
The OIG performed this review due to concerns that Medicare Advantage Organizations may use Health Risk Assessments (HRAs) to inappropriately increase risk adjusted payments. The key takeaway highlighted in the Report Brief is that “billions in estimated risk-adjusted payments supported solely through HRAs raise concerns about the completeness of payment data, validity of diagnoses on HRAs, and quality of care coordination for beneficiaries.”
September 11, 2020: Community Health Access and Rural Transformation (CHART) Model CMS Fact Sheet
CMS announced the CHART Model in a Fact Sheet, indicating that “the approximately 57 million Americans living in rural communities, including millions of Medicare and Medicaid beneficiaries, face unique challenges when seeking health care services, such as limited transportation options, shortages of health care services, and an inability to fully benefit from technological and care-delivery innovations.” CMS goes on to highlight the following three items to be accomplished through this model:
- “Increase financial stability for rural health care providers through multiple new funding approaches, including the use of up-front investments and predictable, capitated payments that pay for quality and patient outcomes over volume;
- Provide the necessary operational and regulatory flexibilities to allow health care providers and CMS to test the Model in their local communities and successfully transform themselves; and
- Support local rural communities’ transformation efforts by being directly engaged at CMS, offering real-time technical expertise and other learning when needed to foster success.”
New Understanding Your Remittance Advice Reports MLN Booklet (MLN8788099)
CMS has published a new MLN Booklet providing information to:
- Help you learn which types of Remittance Advice (RA) are available,
- What information is included in an RA,
- How to view an RA, and
- Frequently Asked Questions.
Checking Medicare Eligibility MLN Booklet (MLN8816413 September 2020)
CMS advises providers, in this MLN Booklet, “to ensure you are billing appropriately for Medicare-covered supplies and services, check for eligibility. Regularly review your patients’ eligibility information.” This booklet provides guidance on who may be eligible for Medicare and how to check for eligibility.
September 15, 2020: New Roadmap for States to Accelerate Adoption of Value-Based Care (VBC) through Medicaid
CMS sent a letter to State Medicaid Directors on September 15, 2020 “to provide information on how states can advance value-based care (VBC) across the healthcare systems, with a particular emphasis on Medicaid populations, and to share pathways for adoption of such approaches with interested states.
CMS noted in a related Fact Sheet, that just as they have made a “strong commitment to advancing VBC in Medicare for its 61.7 million enrollees” guidance released on September 15, 2020 “is designed to ensure that this same commitment can be made at the state level through Medicaid with its nearly 74 million beneficiaries.”
September 18, 2020: CMS Announces New Model of Care for Medicare Beneficiaries with Chronic Kidney Disease
CMS has finalized the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, “to improve or maintain the quality of care and reduce Medicare expenditures for patients with chronic kidney disease” (CKD). CMS notes in a Press Release that the model is set to be implemented January 1, 2021, will impact approximately 30 percent of kidney care providers, and the estimated savings from the model is $23 million over five and half years.
September 18, 2020: CMS Announced Radiation Oncology Model
CMS has finalized the Radiation Oncology (RO) Model which is “expected to improve the quality of care for cancer patients receiving radiotherapy and reduce Medicare expenditures through bundled payments that allow providers to focus on delivering high-quality treatments.” CMS notes in a Press Release that the RO Model is set to begin January 1, 2021 and the estimated savings is $230 million over five years.
September 21, 2020: OIG Report (A-07-17-01176) Incorrect Acute Stroke Diagnosis Codes Increased Payments to Medicare Advantage Organizations
In this audit, the OIG focused on Medicare eligible patients who were covered under traditional Medicare one year and the following year chose a Medicare Advantage Plan. Data mining enabled them to identify several diagnosis codes at high risk of being miscoded. Specifically for this audit, the OIG focused on the acute stroke diagnosis codes reported on one physician’s claim without being reported on the corresponding inpatient claim. The objective being to determine if selected acute stroke codes submitted by physicians under traditional Medicare were later used by CMS to make payments to MA organizations complied with Federal Requirements. The OIG found that in 580 of 582 claims, the record did not support the acute stroke diagnosis codes. In turn, this meant the ischemic stroke codes used as HCC’s were not valid. CMS estimated just over $14.4 million inaccurate payments were made to MA Plans.
September 22, 2020: CMS Expands Ambulance Program Integrity Model Nationwide
CMS announced the expansion of the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. CMS notes in the Press Release that the model has saved Medicare $650 million over four years.
The initial model began for transports on or after December 15, 2014 and is scheduled to end in all model states on December 1, 2020, based on date of service. You can read more about this model in Special Edition MLN article SE1514. Information is also available on the Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport CMS webpage.
September 24, 2020: Importation of Prescription Drugs FDA Final Rule
This Final Rule was issued “to implement a provision of the Federal Food, Drug, and Cosmetic Act (FD&C Act) to allow importation of certain prescription drugs from Canada. Under this final rule, States and Indian Tribes, and in certain future circumstances pharmacists and wholesalers, may submit importation program proposals to the Food and Drug Administration (FDA, the Agency, or we) for review and authorization…The purpose of the final rule is to achieve a significant reduction in the cost of covered products to the American consumer while posing no additional risk to the public’s health and safety.”
Beth Cobb
To paraphrase a Barbara Mandrell song, I was a pumpkin spice latte fan before pumpkin spice was cool. In fact, two weeks ago I drank my first pumpkin spice latte for 2020. Did you know that one grande pumpkin spice latte from Starbucks has about 150mg of caffeine? That is enough caffeine to be equivalent to about two shots of expresso. To keep with musical references, Amy Grant once referred to expresso as being a “nap in a can” on one of her live albums.
So why the focus on caffeine? The October 1st start date of the 2021 CMS Fiscal Year is just 22 days from today and CMS has been publishing updates effective October 1st at a pace worthy of a shot or two of expresso to keep you energized as you prepare for these changes. This article highlights recently released MLN articles providing guidance on updates effective October 1st.
Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan
- Article Release Date: July 21, 2020 – Revised July 21, 2020
- What You Need to Know: This article is “for providers, especially hospitals, submitting claims to Medicare Administrative Contractors (MACs) for Part A services provided to Medicare beneficiaries when a beneficiary’s Medicare Advantage (MA) plan becomes effective during the inpatient admission.”
- MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf
- Change Request 11580: https://www.cms.gov/files/document/r10229CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87426
- Article Release Date: July 24, 2020
- What You Need to Know: This article provides information about the addition of the QW modifier to HCPCS code 87426 [(Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIAhttps://www.cms.gov/files/document/mm11927.pdf">https://www.cms.gov/files/document/mm11927.pdf
- Change Request 11927: https://www.cms.gov/files/document/r10231OTN.pdf
- Effective Date: June 25, 2020
- Implementation Date: October 5, 2020
New Waived Tests
- Article Release Date: July 28, 2020
- What You Need to Know: This article provides information about five new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests that have been approved by the FDA. These tests are marketed immediately after approval so CMS must notify the MACs of the new tests for accurate claims processing. “Note: MACs will not search their files to either retract payment or retroactively pay claims. However, MACs should adjust claims if you bring those claims to their attention.
- MLN Matters MM11916: https://www.cms.gov/files/document/mm11916.pdf
- Change Request 11916: https://www.cms.gov/files/document/r10230CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
July 31, 2020: CMS Releases Inpatient Psychiatric Facility (IPF), Skilled Nursing Facilities (SNF), and Hospices FY 2021 Final Rules
CMS announced in a News Alert that they are “finalizing three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF) and hospices.” For fact sheets on each final rule, visit:
- IPF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-final-medicare-payment-and-policy-changes-inpatient-psychiatric-facilities-cms-1731
- SNF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1737-f
- Hospices PPS -- https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-hospice-payment-rate-update-final-rule-cms-1733-f
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year 2021
- Article Release Date: August 21, 2020
- What You Need to Know: This article provides updates related to the IPF PPS FY 2021 Final Rule including information about:
- Market Basket Update,
- FY 2021 Wage Index Update,
- IPF Quality Reporting Program,
- PRICER Updates,
- ICD-10 CM/PCS Updates,
- Cost of Living Adjustment (COLA) Adjustment, and
- Rural Adjustment.
- MLN MM11949: https://www.cms.gov/files/document/mm11949.pdf
- Change Request 11949: https://www.cms.gov/files/document/r10312CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Article Release Date: August 7, 2020 – Revised August 24, 2020
- What You Need to Know: This article provides information about the quarterly update to the clinical laboratory fee schedule. On August 24th it was updated to reflect changes to Change Request (CR) 11937 that includes additional COVID-19 codes 86408, 86409, 0225U, 0226U, effective August 10, 2020. This CR also added codes 0015M and 0016M, effective October 1, 2020.
- MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf
- Change Request 11937: https://www.cms.gov/files/document/r10318CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update
- Article Release Date: August 7, 2020
- What You Need to Know: This article provides information about the issuance of updated payment files in October of the 2020 MPFS.
- MLN MM11939: https://www.cms.gov/files/document/mm11939.pdf
- Change Request 11939: https://www.cms.gov/files/document/r10288cp.pdf
- Effective Date: January 1, 2020
- Implementation Date: October 5, 2020
October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files – REVISED
- Article Release Date: July 2, 2020 – Revised August 14, 2020
- What You Need to Know: Changes made on August 14th were a revised Change Request (CR) release date, transmittal number and web address. All other information remained the same.
- MLN MM11854: https://www.cms.gov/files/document/MM11854.pdf
- Change Request 11854: https://www.cms.gov/files/document/r10306CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021
- Article Release Date: July 2, 2020 – Revised August 19, 2020
- What You Need to Know: This article was revised to reflect a revised CR 11859 which “shows that effective for Fiscal Year (FY) 2021, a 5 percent cap will be adopted and applied to all Skilled Nursing Facility providers on any decrease to a provider’s FY 2021 final wage index from that provider’s final wage index of the prior fiscal year (FY 2020).”
- MLN MM11859: https://www.cms.gov/files/document/MM11859.pdf
- Change Request 11859: https://www.cms.gov/files/document/r10314CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: August 28, 2020
- What You Need to Know:
- MLN MM11960: https://www.cms.gov/files/document/mm11960.pdf
- Change Request 11960: https://www.cms.gov/files/document/r10331CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3
- Article Release Date: August 28, 2020
- What You Need to Know: This article provides information about the October 2020 version of the I/OCE instructions and specifications that Medicare uses.
- MLN MM11944: https://www.cms.gov/files/document/mm11944.pdf
- Change Request 11944: https://www.cms.gov/files/document/r10332cp.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
October Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Article Release Date: August 28, 2020
- What You Need to Know: This article provides details about the changes to the DMEPOS fee schedules that Medicare updates quarterly, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Specific to the ongoing Public Health Emergency (PHE) due to the COVID-19 pandemic, “the October 2020 DMEPOS and PEN fee files continue to include the non-rural contiguous non-CBA 75/25 blended fees required by Section 3712(b) of the CARES Act signed into law on March 27, 2020.
- MLN MM11956: https://www.cms.gov/files/document/mm11956.pdf
- Change Request 11956: https://www.cms.gov/files/document/r10334CP.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice PRICER for FY 2021
- Article Release Date: August 31, 2020
- What You Need to Know: This article provides updates in Change Request (CR) 11876 to hospice payment rates, wage index, Pricer, and aggregate cap amounts for Fiscal Year (FY) 2021.
- MLN Matters 11876: https://www.cms.gov/files/document/mm11876.pdf
- Change Request 11876: https://www.cms.gov/files/document/r10338cp.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) PRICER Changes for FY 2020
- Article Release Date: September 3, 2020
- What You Need to Know: This article is meant to notify IRFs about a new IRF PRICER software package to be released prior to October 1, 2020.
- MLN Matters: 11858: https://www.cms.gov/files/document/mm11858.pdf
- Change Request 11858: https://www.cms.gov/files/document/r10321cp.pdf
- Effective Date: October 1, 2020
- Implementation Date: October 5, 2020
As if all of this isn’t expresso worthy, the FY 2021 Inpatient Prospective Payment System Final Rule was released last Wednesday September 2nd. So grab yourself a pumpkin spice latte and enjoy while reading about MS-DRGs changes in the IPPS Final Rule discussed in a related article in this week’s edition of Wednesday@One.
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2021 Update
- Article Release Date: August 4, 2020
- What You Need to Know: This article informs providers about updated ICD-10 conversions and coding updates specific to National Coverage Determinations (NCDs). Change Request 11905 includes coding changes for the following NCDs:
- NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
- NCD 50.3 Cochlear Implants
- NCD 90.2 Next Generation Sequencing (NGS)
- NCD 220.6.17 Positron Emission Tomography (FDG) for Oncologic Conditions
- MLN MM11905: https://www.cms.gov/files/document/mm11905.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update
- Article Release Date: August 7, 2020
- What You Need to Know: This article provides information about the issuance of updated payment files in October of the 2020 MPFS.
- MLN MM11939: https://www.cms.gov/files/document/mm11939.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Article Release Date: August 7, 2020
- What You Need to Know: This article informs laboratories of changes resulting from the quarterly update to the clinical laboratory fee schedule. With the ongoing Public Health Emergency (PHE) this quarterly update includes changes made due to the COVID-19 pandemic.
- MLN MM11937: https://www.cms.gov/files/document/mm11937.pdf
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2021
- Article Release Date: August 21, 2020
- What You Need to Know: This article identifies changes required as part of the annual IPF PPS update. Changes are applicable to discharges occurring from October 1, 2020, through September 30, 2021 (FY 2021). The related Change Request (CR) applies to the Medicare Claims Processing Manual (CLM), Chapter 3, Section 190.4.3.
- MLN 11949: https://www.cms.gov/files/document/mm11949.pdf
OTHER MEDICARE TRANSMITTALS
New Waived Tests
- Article Release Date: July 28, 2020
- What You Need to Know: This article provides information about five new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests that have been approved by the FDA. These tests are marketed immediately after approval so CMS must notify the MACs of the new tests for accurate claims processing. “Note: MACs will not search their files to either retract payment or retroactively pay claims. However, MACs should adjust claims if you bring those claims to their attention.
- MLN Matters MM11916: https://www.cms.gov/files/document/mm11916.pdf
Update to Osteoporosis Drug Codes Billable on Home Health Claims
- Article Release Date: August 7, 2020
- What You Need to Know: Change Request (CR) adds instructions for billing and payment of additional codes for osteoporosis drugs under the home health benefit.
- MLN MM11846: https://www.cms.gov/files/document/mm11846.pdf
Correction to Editing Update for Vaccine Services
- Article Release Date: August 7, 2020
- What You Need to Know: This article informs you that Medicare is changing the Common Working File (CWF) to bypass line-item dates of service for vaccines reported on inpatient Part B claims with Type of Bill (TOB) 12X and 22X when the dates of service (DOS) equal a posted outpatient TOB 73X or 77X service dates, or if present, occurrence span code visit date, regardless of the date of service.
- MLN MM11867: https://www.cms.gov/files/document/mm11867.pdf
Billing for Home Infusion Therapy Services on or After January 1, 2021
- Article Release Date: August 7, 2020
- What You Need to Know: This article provides guidance, for qualified Home Infusion Therapy (HIT) suppliers who bill Medicare Part B MACs, about claims processing systems changes necessary to implement Section 5012(d) of the 21st Century Cures Act. Changes will be effective on or after January 1, 2021.
- MLN Article: MM11880: https://www.cms.gov/files/document/mm11880.pdf
Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) – Implementation
- Article Release Date: August 10, 2020
- What You Need to Know: This article provides information about the PARHM and the “Transformation Plans” for participating hospitals. CR 11870 expands the allowable telehealth services for Model-participant hospitals. Without this CR, some hospitals may fail to meet healthcare transformation goals set by the Model. Make sure your billing staffs are aware of these changes.
- MLN Article MM11870: https://www.cms.gov/files/document/mm11870.pdf
The Intravenous Immune Globulin (IVIG) Demonstration: Demonstration is ending on December 31, 2020
- Article Release Date: August 21, 2020
- What You Need to Know: This article is notification of the IVIG Demonstration ending December 31, 2020.
- MLN MM11877: https://www.cms.gov/files/document/mm11877.pdf
REVISED MEDICARE TRANSMITTALS
Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season
- Article Release Date: July 10, 2020 – Revised July 31, 2020
- What You Need to Know: This MLN article was revised to reflect an updated Change Request (CR) 11882 that extended the implementation date to no later than October 1, 2020 and for mass adjustments no later than November 1, 2020.
- MLN MM11882: https://www.cms.gov/files/document/mm11882.pdf
October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files – REVISED
- Article Release Date: July 2, 2020 – Revised August 14, 2020
- What You Need to Know: Changes made on August 14th were a revised Change Request (CR) release date, transmittal number and web address. All other information remained the same.
- MLN MM11854: undefined
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021
- Article Release Date: July 2, 2020 – Revised August 19, 2020
- What You Need to Know: This article was revised to reflect a revised CR 11859 which “shows that effective for Fiscal Year (FY) 2021, a 5 percent cap will be adopted and applied to all Skilled Nursing Facility providers on any decrease to a provider’s FY 2021 final wage index from that provider’s final wage index of the prior fiscal year (FY 2020).”
- MLN MM11859: https://www.cms.gov/files/document/MM11859.pdf
MEDICARE COVERAGE UPDATES
CMS Transmittal 10228 (Change Request 11884): Updates to Chapters 1-8, 10, and 11 to Publication 100-08 (Medicare Program Integrity Manual)
- Transmittal Release Date: July 27, 2020
- What You Need to Know: The purpose of Change Request (CR) 11884 is to update all references of Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) to Unified Program Integrity Contractor (UPIC) within Chapters 1-8, 10, 11, and Exhibits in the Medicare Program Integrity Manual (Publication 100-08).
- CR11884: https://www.cms.gov/files/document/r10228pi.pdf
CMS Proposes Updates to Coverage Policy for Artificial Hearts and Ventricular Assist Devices (VADs)
CMS announced in an August 12, 2020 Press Release their proposed updates to coverage policies for artificial hearts and VADs, “both of which are used to treat patients with life-threatening advanced heart failure.” The proposed decision memorandum would:
- Eliminate the coverage with evidence development (CED) requirement for artificial hearts,
- MACs would become responsible for providing coverage determinations for artificial hearts, and
- Providers updated coverage criteria for VADs “that better aligns with current medical practice and provides additional flexibility for patients and providers to choose the most appropriate treatments.”
CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-updates-coverage-policy-artificial-hearts-and-ventricular-assist-devices-vads
OTHER MEDICARE UPDATES
July 31, 2020: CMS Releases Inpatient Psychiatric Facility (IPF), Skilled Nursing Facilities (SNF), and Hospices FY 2021 Final Rules
CMS announced in a News Alert that they are “finalizing three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for inpatient psychiatric facilities (IPF), skilled nursing facilities (SNF) and hospices.” For fact sheets on each final rule, visit:
- IPF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-final-medicare-payment-and-policy-changes-inpatient-psychiatric-facilities-cms-1731
- SNF PPS – https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1737-f
- Hospices PPS -- https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2021-hospice-payment-rate-update-final-rule-cms-1733-f
CY 2021 Physician Fee Schedule (PFS) Proposed Rule with Comment Period
CMS announced the release of this proposed rule in an August 3, 2020 CMS Fact Sheet. A few of the proposals highlighted in the Fact Sheet includes:
- A proposed CY 2021 PFS conversion factor of $32.26 which is down $3.83 from the CY 2020 PFS conversion factor of $36.09,
- Proposal to add several services to the Medicare telehealth list on a Category 1 basis,
- Proposal to create a third temporary category of criteria for adding services to the Medicare telehealth services list. Category 3 describes services added during the PHE for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends. The PHE determination as a result of COVID-19 was most recently renewed on July 23, 2020,
- Proposal to make permanent following the COVID-19 PHE, the same policy that was finalized under the May 1st COVID-19 IFC, for the duration of the COVID-19 PHE. This proposal would allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians, and
- Proposal to make permanent our Part B policy for maintenance therapy services that we adopted on an interim basis for the PHE in the May 1st COVID-19 IFC that grants a physical therapist (PT) and occupational therapist (OT) the discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant – a physical therapist assistant (PTA) or an occupational therapy assistant (OTA).
August 2020 OIG Report: Inadequate Edits and Oversight Caused Medicare to Overpay More Than $267 Million for Hospital Inpatient Claims with Post-Acute-Care Transfers to Home Health Services
The OIG’s objective in performing this audit was to determine whether Medicare properly paid acute-care hospital inpatient claims subject to the transfer policy when hospitals:
- Did not code the claims as a discharge to home with home health services when the beneficiary resumed home health services within 3 days of discharge,
- Applied condition code 43 indicating that the home health services were not provided within 3 days of discharge, or
- Applied condition code 42 indicating that the home health services were not related to the inpatient hospital services.
The OIG audit 150 inpatient claims with dates of service in fiscal years 2016 and 2017 and found that 147 claims were improperly paid with $722,288 in overpayments. Based on the sample the OIG estimated that Medicare improperly paid $267 million during the 2-year period when services should have been paid at a graduated per diem rate.
- OIG Report Number A-04-18-04067: https://oig.hhs.gov/oas/reports/region4/41804067.pdf
CMS Announces Initiative to Transform Rural Health
CMS announced new funding opportunities to increase access and improve quality. The Community Health Access and Rural Transformation (CHART) Model “also ties payment to value, increase choice and lowers cost to patients.
Link to August 11, 2020 Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-announces-initiative-transform-rural-health
Link to CHART Model webpage: https://innovation.cms.gov/innovation-models/chart-model
OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in the HHS Program
The OIG released their annual publication of this report on August 11th. The top 25 recommendations made are based on audits and evaluations issued through December 31, 2019. Seven of the top twenty-five recommendations are related to Medicare Parts A and B. One of the seven recommendations is that CMS re-evaluate the Inpatient Rehabilitation Facility (IRF) payment system.
The U.S. government’s PaymentAccuracy website “is dedicated to ensuring the American people that its government is addressing…and taking concrete steps on prevention and recovery of improper payments.” According to the Department of Health and Human Services Q4 2019 Payment Scorecard, IRF medical necessity errors resulted in overpayments of $6,740M. Program goals include continuing to educate IRF providers through the Targeted Probe and Educate (TPE) program and approve IRF issues for Recovery Audit Contractor (RAC) review, as appropriate.
Link to PaymentAccuracy website: https://www.paymentaccuracy.gov/about-payment-accuracy/
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.3, Effective October 1, 2020
- Article Release Date: June 23, 2020
- What You Need to Know: Change Request (CR) 11840 providers the quarterly updates to the NCCI PTP edits.
- MLN MM11840: https://www.cms.gov/files/document/mm11840.pdf
Quarterly Update to the End Stage Renal Disease Prospective Payment System (ERSD PPS)
- Article Release Date: June 29, 2020
- What You Need to Know: CR 11835 informs providers about the twenty new diagnosis codes eligible for the ESRD PPS comorbidity payment adjustment effective October 1, 2020.
- MLN MM11835: https://www.cms.gov/files/document/mm11835.pdf
October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- Article Release Date: July 2, 2020
- What You Need to Know: This article updates the Quarterly ASP Medicare Part B Files and informs providers of revisions to prior quarterly filing prices.
- MLN MM11854: https://www.cms.gov/files/document/mm11854.pdf
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021
- Article Release Date: July 2, 2020
- What You Need to Know: This article provides FY 2020 Updates to the SNF PPS payment rates, as required by statue.
- MLN MM11859: https://www.cms.gov/files/document/mm11859.pdf
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2020 Update
- Article Release Date: July 6, 2020
- What You Need to Know: Change Request (CR) 11769 released on June 23, 2020 updates the HCPCS code set for codes related to drugs and biologicals effective July 1, 2020. The related MLN article MM11769 provides links to the updated quarterly HCPCS complete code set.
- MLN MM11769: https://www.cms.gov/files/document/mm11769.pdf
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020
- Article Release Date: July 10, 2020
- What You Need to Know: This article announced changes included in the October 2020 quarterly release of the edit module for clinical diagnostic laboratory services.
- MLN MM11889: https://www.cms.gov/files/document/MM11889.pdf
Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season
- Article Release Date: July 10, 2020
- What You Need to Know: This article informs you of the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 each year.
- MLN MM11882: https://www.cms.gov/files/document/mm11882.pdf
Other Medicare Transmittals
Revising Chapters 3 and 5 of Publication (Pub.) 100-08, to Reflect the Recent Final Rule CMS-1713-F
- Article Release Date: July 1, 2020
- What You Need to Know: CR 11599, released June 19, 2020, revises the Medicare Program Integrity Manual, Chapters 3 (Verifying Potential Errors and Taking Corrective Actions) and 5 (Items and Services Having Special DMEPOS Review Considerations) to include finalized regulatory updates, including those related to face-to-face encounter and written order requirements.
- MLN Matters MM11599: https://www.cms.gov/files/document/mm11599.pdf
Change to the Payment of Allogeneic Stem Cell Acquisition Services
- Article Release Date: July 13, 2020
- What You Need to Know: Currently payment for this service is included in the MS-DRG payment for allogeneic hematopoietic stem cell transplants when transplants occurred in the inpatient setting. Change Request (CR) Transmittal R10218CP provides instructions to pay inpatient hospital Allogeneic Stem Cell Acquisition services on a reasonable cost basis.
- MLN Matters MM11729: https://www.cms.gov/files/document/mm11729.pdf
Revised Medicare Transmittals
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2020 Update
- Article Release Date: February 25, 2020 – Revised June 22, 2020
- What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11655 in which CMS removed the CPT code 0048U from the business requirement for NCD 90.2 Next Generation Sequencing (NGS) and corresponding removals of CPT 0048U and its associated diagnosis codes from the NCD 90.2 NGS spreadsheet. Changes were made due to the CPT code not meeting the policy criteria in NCD 90.2 for NGS.
- MLN MM11655: https://www.cms.gov/files/document/mm11655.pdf
July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) Revised
- Article Release Date: June 8, 2020 – Revised July 2, 2020
- What You Need to Know: This article was revised to reflect updates in the related CR R10207CP. Updates include the following:
- Added CPT code 99458 with status indicator "B".
- "New Separately Payable Procedure Codes – Surgical Procedures" has been updated with corrected APC assignment for HCPCS code C9760.
- "OPPS PRICER Logic and Data Changes for the July 2020 Update" has been removed. There is also a new, "Inadvertent Deletion of CPT code 0126T" added.
- Therefore, the existing section 16 "Changes to the Wage Index" has become section 15. Table 1 has been updated by adding a new PLA COVID-19 code, 0202U.
- Table 2 has been updated by adding CPT code 99458 with status indicator "B".
- Table 21 has been updated by changing APC number for HCPCS code C9760 from APC 1591 to APC 1589. We also changed the CR release date, transmittal number and link to the transmittal. All other information is unchanged.
- MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf
July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
- Article Release Date: June 24, 2020 – Revised July 2, 2020
- What You Need to Know: This article describes changes to and billing instructions for various payment policies implemented in the July 2020 ASC payment system update. This notification also includes HCPCS updates. The July 2nd revision was made to correct the last section in Section 6.e, on page 10. CMS notes it should have stated, “C9058 is replaced by Q5120 effective July 1, 2020.”
- MLN MM11842: https://www.cms.gov/files/document/mm11842.pdf
Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model
- Article Release Date: May 4, 2015 – Revised July 24, 2020
- What You Need to Know: This article was revised to provide information on transportation information for beneficiaries in the Additional Information section of this article.
- MLN SE1514: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1514.pdf
Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan
- Article Release Date: May 1, 2020 – Revised July 21, 2020
- What You Need to Know: This article was revised to reflect revisions in Change Request (CR) 11850 also issued on July 21, 2020. This CR reflects additional sections to the Medicare Claims Procession Manual – Chapter 32 – Billing Requirements for Special Services. Section 66.2 of the chapter identifies CAR-T as having significant costs for Medicare Advantage. Due to the significant cost Providers may bill the A/B MAC for this NCD service provided to a MA beneficiary.
- MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf
Medicare Coverage Updates
MLN Booklet: How to Use the Medicare Coverage Database (MCD)
- Booklet Release Date: June 2020
- What You Need to Know: This MLN education booklet provides information on what the MCD is, why you would use it, a background about Medicare coverage and coverage determinations, how up-to-date is the MCD and how to search the MCD.
- ICN MLN901347 June 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareCvrgeDatabase_ICN901346.pdf
National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS) MLN Article Revised
- MLN Article Revised: June 23, 2020
- What You Need to Know: This article was revised to reflect the revised CR11461 issued on June 23, 2020. The revised CR clarifies instructions for the MACs and changed the implementation date to July 22, 2020.
- MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf
Medicare Compliance Tips
MLN Booklet: How to Use the Medicare National Correct Coding Initiative (NCCI) Tools
- Booklet Release Date: June 2020
- What You Need to Know: This MLN education booklet provides information on what is the Medicare NCCI, why would you use it, how up to date are the NCCI tables and manual, how to locate the NCCI tables and manual and using the NCCI tools.
- ICN 901346 June 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf
Medicare Quarterly Provider Compliance Newsletter
- Newsletter Release Date: July 2020
- What You Need to Know: This newsletter is released on a quarterly basis to share Medicare Contractor Audit Findings and provide information on how to address and avoid top issues in a particular quarter. The July 2020 edition includes information from the following three RAC Auditor Reviews:
- New Issue #0099 – Skilled Nursing Facility Consolidated Billing: Outpatient Facility – Not Separately Payable Services: Unbundling,
- New Issue #0129 – Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements, and
- New Issue #0103 – Urological Supplies: Medical Necessity and Documentation Requirements.
- ICN MLN5829840 July 2020: https://www.cms.gov/files/document/medicare-quarterly-provider-compliance-newsletter-volume-10-issue-4.pdf
Other Medicare Updates
CMS Announces the Creation of the Office of Burden Reduction and Health Informatics
In a June 23rd Press Release, CMS announced a new Office of Burden Reduction and Health Information meant “to unify the agency’s efforts to reduce regulatory and administrative burden and to further the goal of putting patients first.” CMS Administrator Seema Verma said in the announcement that “The Office of Burden Reduction and Health Informatics will ensure the agency’s commitment to reduce administrative costs and enact meaningful and lasting change in our nation’s health care system…Specifically, the work of this new office will be targeted to help reduce unnecessary burden, increase efficiencies, continue administrative simplification, increase the use of health informatics, and improve the beneficiary experience.”
June 25, 2020: CMS Issues Home Health PPS Proposed Rule [CMS-1730-P] CY 2021
In addition to updating payment rates and wage index for calendar year 2021, “this proposed rule proposes to permanently finalize the changes to §409.43(a) as finalized in the first COVID-19 PHE IFC (85 FR 19230), to state that the plan of care must include any provision of remote patient monitoring and other services furnished via a telecommunications system and describe how the use of such technology is tied to the patient-specific needs as identified in the comprehensive assessment and will help to achieve the goals outlined on the plan of care.”
- Related CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-proposes-calendar-year-2021-payment-and-policy-changes-home-health-agencies-and-calendar-year
June 26, 2020: HHS Submits Status Report on Medicare Appeals Backlog at the ALJ Level
In this June 26th report, HHS indicated that they have reduced that “By the end of the second quarter of 2020, a total of 242,995 appeals remain pending at OMHA, which is a 43% reduction from the starting number of appeals identified in the Court’s order (426,594 appeals).”
https://www.aha.org/system/files/media/file/2020/06/alj-delay-status-report-6-26-2020.pdf
AHA Announcement: https://www.aha.org/news/headline/2020-06-26-result-aha-lawsuit-hhs-continues-reduce-appeals-backlog
July 6, 2020: CMS Issues End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Calendar Year (CY) 2021 Proposed Rule (CMS-1732-P)
In addition to proposed updates to payment policies and rates, this rule is also proposing updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and proposes changes to the ESRD Quality Incentive Program (QIP).
- CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-payment-changes-support-innovation-and-increased-access-dialysis-home-setting
- CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/end-stage-renal-disease-esrd-prospective-payment-system-pps-calendar-year-cy-2021-proposed-rule-cms
July 15, 2020: OIG Report: Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims
This is not the first time the OIG has focused on malnutrition diagnosis codes and based on their findings I do not anticipate this will be the last time. The parameters of the OIG audit included:
- Focusing on Diagnosis Codes E41 (Nutritional marasmus) and E43 (Unspecified severe protein calorie malnutrition), and
- Auditing a random sample of 200 claims with a discharge date in Fiscal Year 2016 or 2017.
OIG Findings:
- 173 of the 200 records reviewed were not correctly billed by the hospitals
- 9 of the 173 incorrectly coded claims the removal of the malnutrition code did not impact DRG assignment or payment.
- The 164 claims that were incorrectly coded results in net overpayments of $914, 128
- The OIG extrapolated their sample and estimated that hospitals received overpayments of$1 billion for FYs 2016 and 2017.
Based on OIG recommendations, “CMS stated that it will instruct its contractors to review a sample of claims in the sampling frame to determine whether they were billed correctly. Based on the findings of the sample review, CMS will determine the appropriate course of action. CMS will recover, as appropriate, any identified overpayments associated with the reviews consistent with agency policy and procedures.” You can read the entire report at https://www.oig.hhs.gov/oas/reports/region3/31700010.pdf.
July 15, 2020: Contract Award for A/B MAC Jurisdiction 6
CMS posted the following information on the CMS MAC What’s New webpage:
“On July 15, 2020, the Centers for Medicare & Medicaid Services (CMS) awarded National Government Services, Inc. (NGS) a new contract for the administration of Medicare Part A and Part B Fee-for-Service (FFS) claims for Illinois, Minnesota, and Wisconsin (Jurisdiction 6). This contract will also administer Medicare Home Health and Hospice (HH+H) FFS claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington. As NGS is the incumbent contractor for this A/B MAC jurisdiction, CMS anticipates that implementation of the new contract will go smoothly, with few, if any, service issues for Medicare beneficiaries and providers. Learn more about this at A/B MAC Jurisdiction 6 Award Fact Sheet (PDF).”
July 17, 2020: The Joint Commission’s (TJC’s) Continued Approval of its Hospital Accreditation Program Limited to 2 Years
CMS published their decision to approve TJC for continued recognition as a national accrediting organization for hospitals participating in the Medicare and Medicaid Programs in the Federal Register on July 17, 2020. CMS can approve an accrediting agency for up to 6 years. However, the Final Notice indicated the TJCs continued approval is effective for only two years from July 15, 2020 through July 15, 2022. The following excerpt from the Federal Register outlines CMS reasons for this shorter term of approval:
“This shorter term of approval is based on our concerns related to the comparability of TJC’s survey processes to those of CMS, as well as what CMS has observed of TJC’s performance on the survey observation. Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC’s processes surrounding its staff interview practices. Additionally, we are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment condition of participation. Based on these observations and review of TJC’s processes as discussed at section V.A. (Differences Between TJC’s Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements), we remain concerned about the thoroughness of review conducted within the facilities. While TJC has taken action based on the findings annotated in section V.A., as authorized under §488.8, we will continue ongoing review of TJC’s survey processes across all their approved accrediting programs to ensure that all our recommended changes have been implemented. In keeping with CMS’s initiative to increase AO oversight, and ensure that our requested revisions by TJC are complied with, CMS expects more frequent review of TJC’s activities to avoid any continued inconsistencies.”
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Influenza Virus Vaccine Code Update – July 2020
- Article Release Date: January 31, 2020
- What You Need to Know: The influenza virus vaccine code set is updated on a quarterly basis. Reminder, effective for claims processed with dated of service on or after July 1, 2020, influenza virus vaccine code 90694 (influenza virus vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use) is payable by Medicare.
- MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf
July 2020 Integrated Outpatient Code Editor (I/OCE) Specification Version 21.2
- Article Release Date: June 5, 2020
- What You Need to Know: This article provides the I/OCE instructions and specifications for the I/OCE employed under the Outpatient Prospective Payment System (OPPS) and non-OPPS. The specifications are for:
- Hospital outpatient departments
- Community mental health centers
- All non-OPPS hospital providers
- For limited services when provided in a Home Health Agency (HHA) not under the HH Prospective Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/.
- MLN Matters MM11792: https://www.cms.gov/files/document/mm11792.pdf
July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: June 5, 2020
- What You Need to Know: The following list highlights the main topics included in this document:
- COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update,
- Status Indicator Changes for Certain Virtual Services,
- New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinical (RHC) or Federally Qualified Health Center (FQHC) Only,
- New CPT Category III Codes Effective July 1, 2020,
- CPT Proprietary Laboratory Analysis (PLA) Coding Changes Effective July 1, 2020,
- Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755,
- Device Pass-Through Updates,
- Changes to Certain Device Offsets for 2020,
- Drugs, Biologicals, and Radiopharmaceuticals,
- Skin Substitutes – New Products,
- New Separately Payable Procedure Codes – Surgical Procedures,
- New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI),
- New HCPCS Codes Describing Peripheral Intravascular Lithotripsy,
- Supervision of Outpatient Therapeutic Services,
- MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf
July Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
- Article Release Date: June 5, 2020
- What You Need to Know: This article informs DME MACs about changes to the DMEPOS fee schedules that are updated quarterly, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies.
Note, this update includes guidance from the interim final rule with comment period (CMS-5531-IFC) entitled “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” published in the Federal Register May 8, 2020. This final rule implements a section of the Coronavirus Aid, Relief, and Economic Security (CARES) Act regarding fee schedule adjustments.
- MLN MM11810: https://www.cms.gov/files/document/mm11810.pdf
Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2020
- Article Release Date: June 5, 2020
- What You Need to Know: Medicare Updates the DMEPOS CBP files on a quarterly basis to implement necessary changes to HCPCS, ZIP code, and supplier files. Related Change Request CR 11819 provides specific instruction for implementing the DMEPOS CBP files.
- MLN MM11819: https://www.cms.gov/files/document/mm11819.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Article Release Date: June 12, 2020
- What You Need to Know: This article informs labs about changes in the quarterly update. Several of the updates are specific to guidance regarding lab testing related to COVID-19.
- MLN MM11815: https://www.cms.gov/files/document/mm11815.pdf
OTHER MEDICARE TRANSMITTALS
Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advise Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE
- Article Release Date: May 22, 2020
- What You Need to Know: Informs you of updates the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, CAGC rule publications. Updates are based on the CORE Combination Codes List to be published on or about June 1, 2020.
- MLN Matters MM11709: https://www.cms.gov/files/document/mm11709.pdf
New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site
- Article Release Date: June 12, 2020
- What You Need to Know: Code “G” is a new Point of Origin (PoO) code to indicate a “transfer from a Designated Disaster Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency (PHE).
- MLN MM11836: https://www.cms.gov/files/document/mm11836.pdf
REVISED MEDICARE TRANSMITTALS
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update
- Article Release Date: May 1, 2020 – Rescinded May 26, 2020
- What You Need to Know: This article was rescinded on May 26, 2020, as the related Change Request (CR) 11749, Transmittal 10092, dated May 1, 2020, was rescinded in its entirety. Therefore, any coding changes to NCD 90.2, Next Generation Sequencing are null and void.
- MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf
Supplier Education on Use of Upgrades for Multi-Function Ventilators
- Article Release Date: May 29, 2020
- What You Need to Know: This article was revised to show that the policy on use of multi-function ventilators, as discussed in the “What You Need to Know” section, is a permanent change.
- MLN SE20012: https://www.cms.gov/files/document/se20012.pdf
Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component
- Article Release Date: May 29, 2020 – Revised June 9, 2020
- What You Need to Know: This article provides information about the hospice benefit component associated with the VBID Model being tested by the CMS Innovation Center and starting in Calendar Year (CY) 2021. CMS highlights that “providers MUST still submit claims for these services to Medicare.” CMS revised this MLN article on June 9th to reflect a revised CR 11754 issued on June 9th.
- MLN Matters MM11754: https://www.cms.gov/files/document/mm11754.pdf
NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
- Article Release Date: March 24, 2020 – Revised June 10, 2020
- What You Need to Know: This article was revised to reflect formatting revisions in Change Request 11660. The substance of the article was not altered.
- MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)
- Article Release Date: June 1, 2020
- What You Need to Know: Change Request (CR) 11461 was published on May 22, 2020 highlighting that new to NCD 160.16, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met. The accompanying MLN article was released on June 1, 2020.
- MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf
Other Medicare Updates
Prior Authorization (PA) Program for Certain Hospital Outpatient Department (ODP) Services CMS Operational Guide and FAQs
In last May CMS released an Operational Guide and FAQs related to this Program set to begin July 1, 2020.
- Operation Guide: https://www.cms.gov/files/document/opd-operational-guide.pdf
- Frequently Asked Questions: https://www.cms.gov/files/document/opd-frequently-asked-questions.pdf
2021 ICD-10-PCS Codes for Discharges Occurring from October 1, 2020 through September 30, 2021
On May 28, 2020, CMS posted the 2021 Official ICD-10-PCS Coding Guidelines, Code Tables, and Addendum on the 2021 ICD-10-PCD CMS webpage.
- Link to CMS webpage: https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs
KEPRO Case Review Connections: Acute Care Edition: Summer 2020
KEPRO published their Summer 2020 Case Review Connections e-newsletter. Topics included in this newsletter includes:
- Medical Director’s Corner,
- A Reminder About Appeals Cases,
- Updates from CMS Related to COVID-19,
- An Immediate Advocacy Success Story,
- Frequently Asked Questions, and
- Staff Education about BFCC-QIO Services.
June 17, 2020 CMS Proposed Rule: Establishing Minimum Standards in Medicaid State Drug Utilization (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS 2482-P)
CMS Administrator Seema Verma noted in a Press Release that “CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models…by modernizing our rules, we are creating opportunities for drug manufacturers to have skin in the game through payment arrangement that challenge them to put their money where their mouth is.”
The Press Release includes links to a related Fact Sheet and the Proposed Rule. CMS is accepting comments no later than 5 p.m. on July 20, 2020.
MEDICARE TRANSMITTALS – RECURRING UPDATES
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update
- Article Release Date: May 1, 2020
- What You Need to Know: Change Request (CR) 11749 provides information about updated ICD-10 conversions as well as coding updates specific to NCDs. In this update new ICD-10-CM codes have been added to NCD 90.2 Next Generation Sequencing.
- MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2020 Update
- Article Release Date: May 12, 2020
- What You Need to Know: CMS has issued payment files to the MACs based on the 2020 MPFS Final Rule.
- MLN MM11788: https://www.cms.gov/files/document/mm11788.pdf
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
- Article Release Date: May 22, 2020
- What You Need to Know: CR 11708 is a code update notification indicating when updates to the CARC and RARC lists are made available at the official Accredited Standards Committee (ASC) X12 website.
- MLN MM11708: https://www.cms.gov/files/document/mm11708.pdf
October 2020 Healthcare Common Procedure Coding System (HCPCS) Quarterly Update Reminder
- Transmittal Release Date: May 22, 2020
- What You Need to Know: The complete HCPCS file is updated and released quarterly to the Medicare contractors. The file contains existing, new, revised and discontinued HCPCS codes for the October 2020 quarter. Contractors must download the file via the CMS mainframe in September 2020. The recurring update notification applies to chapter 23, section 20 of the Medicare Claims Processing Manual.
- Transmittal 10153: https://www.cms.gov/files/document/r10153cp.pdf
OTHER MEDICARE TRANSMITTALS
Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan
- Article Release Date: May 1, 2020
- What You Need to Know:
- Change Request (CR) 11580 modifies Medicare system edits on inpatient claims when a beneficiary’s MA plan becomes effective during the inpatient admission.
- The CMS is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered significant cost. FFS Medicare will pay for services obtained by beneficiaries enrolled in MA plans in this circumstance.
- MACs will allow Condition Code (CC) 78 on inpatient and outpatient claims for MA beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost. An update will occur to any current editing that does not allow this scenario.
- Condition Code 78 = newly covered Medicare service for which a HMO does not pay.
- MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf
New Codes for Therapist Assistants Providing Maintenance Programs in the Home Health Setting
- Article Release Date: May 1, 2020
- What You Need to Know: CR 11721 details changes to Home Health (HH) billing and processing instructions, including new G-codes describing therapy assistant services. Also included is a correction to the processing of HH claims that receive episode sequence edits.
- MLN MM11721: https://www.cms.gov/files/document/mm11721.pdf
Medicare Clarifies Recognition of Interstate License Compacts
- Special Edition Article Release Date: May 5, 2020
- What You Need to Know: This article clarifies the CMS recognition of interstate license compacts. CMS acknowledges that more compacts may be underway as new legislation is passed but at this time they have determined that interstate license compact for the following provider types will be treated as valid and full licenses for purposes of meeting federal license requirements:
- Physicians,
- Physical and Occupational Therapists,
- Speech Language Therapists,
- Nurse Practitioners, and
- MLN Article SE20008: https://www.cms.gov/files/document/SE20008.pdf
Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process
- Article Release Date: May 8, 2020
- What You Need to Know: Change Request 11727 contains updates to Medicare’s claims processing systems to make corrections to processing of adjustments and other billing issues for SNF Patient Driven Payment Model (PDPM) claims. CMS advises you to make sure your billing staffs are aware of these updates.
- MLN Article MM11727: https://www.cms.gov/2020-mln-matters-articles-0
New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services
- Article Release Date: May 11, 2020
- What You Need to Know: This article highlights new physician specialty codes for MDS (D7) and ACHD (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6).
- MLN MM11750: https://www.cms.gov/files/document/MM11750.pdf
Therapy Codes Update
- Article Release Date: May 15, 2020
- What You Need to Know: This article includes updates to the list of codes that sometimes or always describe therapy services. Additions to the list reflect changes made in Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE).
- MLN MM11791: https://www.cms.gov/files/document/MM11791.pdf
Manual Update Pub. 100.-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section
- Article Release Date: May 15, 2020
- What You Need to Know: Medicare is removing section 20 (and all of its subsections) of chapter 38 of the Medicare Claims Processing Manual (Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico). The key impact of this notification is that modifier CS will no longer be used to denote services related to the 2010 oil spill. The effective and implementation date for this change is June 16, 2020.
- MLN Matters MM11778: https://www.cms.gov/files/document/MM11778.pdf
REVISED MEDICARE TRANSMITTALS
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy
- Date Article Revised: April 30, 2020
- What You Need to Know: This article was revised to reflect revised Change Request 11559. The CR informs MACs about changes to Medicare Common Working File (CWF) edits to ensure the original 1-Day and 3-Day Payment Window edits’ set and bypass conditions are consistent with current policy. There are no policy changes. Current policy is in the Medicare Claims Processing Manual, Chapter 4, Section 10.12 and Section 40.3.
- MLN Article MM1159: https://www.cms.gov/files/document/mm11559.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update
- Date Article Revised: May 4, 2020
- What You Need to Know: This article was revised to reflect revisions in CR 11661 issued on May 1, 2020. The following changes were made:
- The relative value units for codes 99441-99442, and 99443 were revised,
- Information for codes G2025 and G0071 was added, and
- The statement at the end of page was updated.
- MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
Medicare Continues to Modernize Payment Software
- Article Release Date: May 19, 2020
- What You Need to Know: This articles provides information about the CMS efforts to modernize payment grouping and code edit software. Specifically, this article is meant to inform providers that in October 2020, CMS will expand this effort to include the following additional software products:
- The IRF Case-Mix Group (CMG) Grouper, and
- The IRF Pricer and PC Pricer.
- MLN SE20019: https://www.cms.gov/files/document/SE20019.pdf
Claim Status Category Codes and Claim Status Codes Updates
- Article Release Date: May 22, 2020
- What You Need to Know: CR 11699 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.
- MLN MM11699: https://www.cms.gov/files/document/mm11699.pdf
MEDICARE COVERAGE UPDATES
National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)
- Article Release Date: May 13, 2020
- What Your Need to Know: This article informs you that CMS will cover acupuncture for cLBP effective for claims with dates of service on or after January 21, 2020. The article reminds you that acupuncture for fibromyalgia or osteoarthritis is still non-covered by Medicare.
- MLN MM11755: https://www.cms.gov/files/document/MM11755.pdf
National Coverage Determinations (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)
- Date Article Released: May 12, 2020
- What You Need to Know: For dates of service on and after July 2, 2019, the CMS will cover ABPM for the diagnosis of hypertension in Medicare under updated criteria detailed in this article. The Effective Date was July 2, 2019. The Implementation Date for Local MAC edits is June 16, 2020.
- MLN MM11650: https://www.cms.gov/files/document/MM11650.pdf
National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)
- Date Transmittal Released: May 22, 2020
- What You Need to Know: NCD 160.18, Vagus Nerve Stimulation was initially issued in 1999 to provide coverage for VNS for patients with medically refractory partial onset seizures, for whom surgery is not recommended or for whom surgery had failed. New to this NCD, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met.
- Transmittal 10145: https://www.cms.gov/files/document/r10145ncd.pdf
OTHER MEDICARE UPDATES
MLN Booklet (ICN MLN901623) April 2020: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants
This MLN Booklet outlines the required healthcare practitioner qualifications and coverage, billing, and payment criteria for Medicare services furnished by:
- Advanced Practice Registered Nurses (APRNs), including:
- Certified Registered Nurse Anesthetists (CRNAs)
- Nurse Practitioners (NPs)
- Certified Nurse-Midwives (CNMs)
- Clinical Nurse Specialists (CNSs)
- Anesthesiology Assistants (AAs), and
- Physician Assistants (PAs)
Fiscal Year 2021 IPPS and LTCH PPS Proposed Rule
CMS released the FY 2021 IPPS and LTCH PPR Proposed Rule. In a related Fact Sheet CMS indicates the agency’s singular objective is “transforming the healthcare delivery system through competition and innovation to provide patients with better value and results.” CMS is accepting comments on the Proposed Rule through 5 pm EDT on July 10, 2020.
May 7, 2020: Original Medicare (Fee-for-Service) Appeals: Enhanced Opportunity for Submission of 2nd Level of Appeals, Reconsiderations
CMS posted the following announcement on their Original Medicare (Fee-for-Service) Appeals webpage on May 7th: Qualified Independent Contractors (QICs) that process 2nd level Medicare Fee-For-Service (FFS) claim appeals, reconsiderations, on behalf of the Centers for Medicare & Medicaid Services (CMS) have established alternative communication mediums for CMS stakeholders to submit reconsideration requests and related documentation to the QIC. The websites for the respective QIC jurisdictions contain instructions to stakeholders for electronic (e.g., fax or portal) submission of reconsideration requests or documentation.” A table on this page provides guidance regarding the options for submitting reconsiderations and related documentation by QIC jurisdiction.
May 8, 2020: Hospital Outpatient Therapeutic Services That Have Been Evaluated for a Change in Supervision Level
On May 8th, CMS added this document to the available downloads on the CMS Hospital Outpatient PPS
Webpage. Included in the download is a table providing the level of supervision required for hospital outpatient therapeutic services. Information prior to the table highlights changes made in an interim final rule addressing supervision requirements for non-surgical extended duration services (NSEDTS) and pulmonary rehabilitation services, cardiac rehabilitation services, and intensive cardiac rehabilitation services during the COVID-19 Public Health Emergency (PHE).
The SARS-CoV-2 "Coronavirus" outbreak has necessitated a response that has produced information at a prodigious rate. It is almost impossible for one person to be able to keep up with so many changes.
There is a wealth of information from many sources (i.e. the CMS, CDC and FDA) that has been released about COVID-19. This guidance has been updated and added to often. Finding the time to sort through what is available while carrying out your daily responsibilities can be a challenge. To that end, this Resource Guide is meant to provide you with key information and links to key resources where you can check for ongoing updates. Specifically, this guide primarily provides coding and billing guidance that has been implemented for COVID-19.
(Last updated: June 3, 2020)
CLICK HERE TO DOWNLOAD
MEDICARE TRANSMITTALS – RECURRING UPDATES
April 2020 Average Sales Price (AS) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- Article Release Date: March 20, 2020
- What You Need to Know: Article informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
- MLN MM11701: https://www.cms.gov/files/document/mm11701.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020
- Article Release Date: March 27, 2020
- What You Need to Know: This MLN article is a companion article to Change Request 11734 which providers the quarterly updated to the NCCI PTP edits. CMS advises making sure your billing staffs know the updates.
- MLN MM11734: https://edit.cms.gov/files/document/mm11734.pdf
July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- Article Release Date: March 27, 2020
- What You Need to Know: Related Change Request (CR) 11745 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.
- MLN MM11745: https://www.cms.gov/files/document/mm11745.pdf
April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Article Release Date: April 7, 2020
- What You Need to Know: Change Request 11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 OPPS update.
- MLN MM11691: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/r4544cp
Quarterly Update to the Fiscal Year 2020 Inpatient Psychiatric Facilities Pricer
- Article Release Date: April 10, 2020
- What You Need to Know: CR 11759 updates the Inpatient Psychiatric Facilities (IPF) Pricer software used in Medicare claims procession. This update includes updates to the comorbidity tables to include the new ICD-10 diagnosis code for COVID-19 (U01.7) effective for claims with discharges on or after April 1, 2020.
- MLN MM11758: https://www.cms.gov/files/document/mm11759.pdf
Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer
- Article Release Date: April 24, 2020
- What You Need to Know: CT 11742 updates the LTCH Pricer software. The new version include the payment policy for an LTCH that is subject to the Discharge Payment Percentage (DPP) payment adjustment described in CR 11616. CR 11742 also included new payment policy for COVID-19.
- MLN MM11742: https://www.cms.gov/files/document/MM11742.pdf
July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer
- Article Release Date: April 24, 2020
- What You Need to Know: CR 11764 updates the FY 2020 IPPS Pricer software. This new version includes new payment policy for individuals diagnosed with COVID-19.
- MLN MM11764: https://www.cms.gov/files/document/MM11764.pdf
OTHER MEDICARE TRANSMITTALS
NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
- Article Release Date: March 13, 2020
- What You Need to Know: Effective June 21, 2019, CMS will continued coverage of TAVR under Covered with Evidence Development (CED) when the procedure is provided for the treatment of symptomatic aortic valve stenosis and according to a FDA-approved indication for use with an approved device.
- MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitations Facilities (IRFs), and Long Term Care Hospitals (LTCHs)
- Article Release Date: 3/13/2020
- What You Need to Know: This MLN article includes links to hospital specific data for determining adjustments to be made for caring for low-income patients (LIP).
- MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf
Supplier Education on Use of Upgrades for Multi-Function Ventilators
- Article Release Date: April 3, 2020
- What You Need to Know: This article informs DME suppliers that effective immediately, you may provide and bill for multi-function ventilators described by code E0467 as an upgrade in situations where beneficiaries only meet the coverage criteria for a ventilator.
- MLN SE20012: https://www.cms.gov/files/document/se20012.pdf
New Waived Tests
- Article Release Date: April 17, 2020
- What You Need to Know: Change Request 11747 informs MACs of new Clinical Laboratory Amendments of 1988 (CLIA) waived tests by the FDA. These tests are marketed immediately after approval and as such, the CMS must notify MACs of the new tests for accurate claims processing. The following statement is included in the article: “Note: MACs will not search their files to either retract payment or retroactively pay claims; however, MACs should adjust claims if you bring those claims to their attention.”
- MLN MM11747: https://www.cms.gov/files/document/mm11747.pdf
REVISED MEDICARE TRANSMITTALS
New Medicare Beneficiary Identifier (MBI) Get It, Use It – Revised
- Article Release Date: March 19, 2020
- What You Need to Know: This article was revised to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool. All other information remains the same.
- MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits
- Article Revised: March 24, 2020
- What You Need to Know: This article was revised to reflect an update CR 11604. CR 11640 informs the MACs about new HCPCS codes for 2020 that are subject to and excluded from CLIA Edits.
- MLN MM11640: https://www.cms.gov/files/document/mm11640.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020
- Article Revised: March 25, 2020
- What You Need to Know: This article was revised to reflect a revised Change Request (CR) 11628. This revision had no impact on the substance of the article.
- MLN MM11628: https://www.cms.gov/files/document/mm11628.pdf
Implementation of Additional Requirements to add HCPC and CPT as Paired Items of Service for Prior Authorization and Medicare Claims Processing for Part A, Part B, DME, and Home Health and Hospice
- Change Request revised date: March 27, 2020
- What You Need to Know: Transmittal 2438, dated February 21, 2020 was rescinded and replaced with Transmittal 10021, dated March 27, 2020 to remove business requirement 11516.7 and to change the PA Program Indicator in the attachment Criteria Template. All other information remains the same.
- Transmittal 10021: https://www.cms.gov/files/document/r10021otn.pdf
April 1, 2020: Update to ICD-10-CM for Vaping Related Disorder and 2019 Novel Coronavirus (COVID-19)
- Article Revised: April 1, 2020
- What You Need to Know: This article was revised to reflect the update to Change Request (CR) 11623 where the new ICD-10-CM code for the 2019 Novel Coronavirus (COVDI-19) was added.
- MLN MM11623: https://www.cms.gov/files/document/MM11623.pdf
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1
- Article Revised: April 1, 2020
- What You Need to Know: CR 11680 provides the I/OCE instruction and specifications for the April 1, 2020 updates. This article was revised to reflect the CR revisions adding information to Table 1, including COVID-19 changes.
- MLN MM11680: https://www.cms.gov/files/document/MM11680.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Pay
- Article Revised: April 6, 2020
- What You Need to Know: This article was revised to reflect revisions to Change Request 1168 where the section on the delay of the CLFS reporting period was removed and the following codes were added:
- 87635: added to HCPCS file, effective March 13, 2020
- Two new COVID-19 test codes (G2023 and G2024), effective March 1, 2020
- MLN MM11681: https://www.cms.gov/files/document/mm11681.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update – Revised
- Article Revised: April 6, 2020
- What You Need to Know: The revision was made to reflect the revised CR 11661 to make MPFSDB file revisions for COVID-19.
- MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
Claim Status Category and Claim Status Codes Update
- Article Revised: April 10, 2020
- What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11467. Specifically the Uniform Resource Locators (URLs) references (page 2 in this article) in Background Section in the CR was revised.
- MLN MM11467: https://www.cms.gov/files/document/mm11467.pdf
April 2020 Updated of the Ambulatory Surgical Center (ASC) Payment System - Revised
- Article Revised: April 14, 2020
- What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implemented in the April 2020 ASC payment system update. MLN 11694 was revised on April 14th due the revised CR that added information on Q4206 to the policy section of the CR (page 6 in the MLN article).
- MLN MM11694: https://www.cms.gov/files/document/mm11694.pdf
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
- Article Revised: April 16, 2020
- What You Need to Know: This article was updated to reflect a revised WPC website address in the background section of Change Request 11638 on page 2 of the article. All other information remained the same.
- MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf
Implement Operating Rules – Phase III Electronic Remittance Advice (ERAA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) – Update from Council for Affordability Quality Healthcare (CAQH) CORE
- MLN Article Revised: April 23, 2020
- What You Need to Know: This article was revised to reflect the revised Change Request (CR) 11490. Specifically, the CR updated the WPC website address. This change was made in this Article as well as changing the CR Release Date to April 23, 2020.
MEDICARE COMPLIANCE TIPS
Medicare Advance Written Notices of Non-Coverage MLN Booklet Revised
CMS noted in the April 9, 2020 MLNConnects eNewsletter that a revised Medicare Advance Written Notices of Noncoverage Medicare Learning Network Booklet is now available. This booklet provides guidance on how to complete the form and collect payment.
OTHER MEDICARE UPDATES
Fiscal Year (FY) 2021 Proposed Rules Released April 10, 2020: Skilled Nursing Facilities, Inpatient Psychiatric Facilities, and Hospice
On April 10th CMS released Fact Sheets announcing the FY 2021 Proposed Rules for Skilled Nursing Facilities, Inpatient Psychiatric Facilities and Hospice have been put on display in the Federal Register. In each of the Fact Sheets, CMS notes the proposed rules are being published consistent with legal requirements to update Medicare payment policies. CMS acknowledges that the entire healthcare system is focused on responding to the COVID-19 public health emergency.
- FY 2021 Proposed Medicare Payment and Policy Changes for Skilled Nursing Facilities (CMS-1737-P) CMS Fact Sheet
- FY 2021 Proposed Medicare Payment and Policy Changes for Inpatient Psychiatric Facilities (CMS-1731-P) CMS Fact Sheet
- FY 2021 Hospice Payment Rate Update Proposed Rule (CMS-1733-P) CMS Fact Sheet
CMS is accepting comments on all three proposed rules through June 9, 2020.
March 18, 2020: Advanced Beneficiary Notice Form Update
CMS put the following announcement on the CMS Fee-for-Service ABN webpage:
“The ABN, Form CMS-R-131, is currently awaiting OMB approval for renewal. CMS will provide instructions when it does get approved. In the meantime, continue to use the current form until further instruction is provided.”
March 27, 2020: KEPRO Releases Spring 2020, Special COVID-19 Edition Newsletter
The following topics are included in the Spring 2020 edition of KEPRO’s Case Review Connections newsletter:
- COVID-19 Guidance for Providers,
- Beneficiary Notice Delivery Guidance in Light of COVID-19,
- Frequently Asked Questions,
- An Immediate Advocacy Success Story; and
- Staff Education about BFCC-QIO Services.
April 16, 2020: CMS Fact Sheet: Fiscal Year (FY) 2021 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) Proposed Rule (CMS-1729-P)
Similar to the proposed rules released on April 10th, CMS indicates this proposed rule is being published consistent with legal requirements. They go on to indicate that “In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual IRF rulemaking required by statute to essential policies including Medicare payment to IRFs, as well as proposals that reduce provider burden and may help providers in the COVID-19 response.” CMS is accepting comments on this proposed rule until June 15, 2020.
- FY 2021 IRF PPS Proposed Rule (CMS-1729-P) CMS Fact Sheet
April 21, 2020: CMS Interoperability and Patient Access Final Rule
This Final Rule was initially released on March 9th, 2020. However, it took until April 21st for the
unpublished version to be filed in the Federal Register. The Final Rule is scheduled to be published in the Federal Register on May 1, 2020. Following is an excerpt from a related CMS Press Release detailing how this Rule will impact hospitals:
“To further advance the mission of fostering innovation, the CMS final rule establishes a new Condition of Participation (CoP) for all Medicare and Medicaid participating hospitals, requiring them to send electronic notifications to another healthcare facility or community provider or practitioner when a patient is admitted, discharged, or transferred. These notifications can facilitate better care coordination and improve patient outcomes by allowing a receiving provider, facility, or practitioner to reach out to the patient and deliver appropriate follow-up care in a timely manner.”
Effective Date for New CoP
In the March 9th release of the Final Rule CMS stated the CoPs would be effective 6 months after the Rule was published in the Federal Register. However, the Final Rule currently on display indicates this date has been changed to indicate the new CoPs at 42 CFR Parts 482 and 485 will now be effective 12 months after the Final Rule is published in the Federal Register. This delay is due to CMS recognizing that hospitals, including psychiatric hospitals, and critical access hospitals, are on the front line of the COVID-19 public health emergency. You can learn more about this Final Rule on the CMS Interoperability and Patient Access final rule webpage.
April 24, 2020: 340B Hospital Survey
The 340B hospital survey is now available for hospitals paid under the OPPS, that were enrolled in the 340B program during calendar year Q4 2018 and/or Q1 2019. Both a detailed and "Quick Survey" method are available to submit 340B-acquired drug acquisition cost information to the Centers for Medicare & Medicaid Services through https://www.340bsurvey.com/survey. The survey closes on May 15, 2020.
MEDICARE TRANSMITTALS – RECURRING UPDATES
International Classification of Diseases 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2020 Update
- Article Release Date: February 21, 2020
- What You Need to Know: CR11655 informs providers about ICD-10 updates to specific NCDs. “Note: Coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria. Revisions to codes within an NCD are carefully and thoroughly reviewed and vetted by CMS and are not intended to change the original intent of the NCD. The exception to this is when coding revisions are released as official implementation of new or reconsidered NCD policy following a formal national coverage analysis…MACs will adjust any claims processed in error associated with CR 11491 that you bring to their attention.”
- MLN MM11655: https://www.cms.gov/files/document/mm11655.pdf
April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Change Request Release Date: March 3, 2020
- What You Need to Know: CR 11691 is a recurring update notification describing changes to and billion instructions for various payment policies implemented in the April 2020 OPPS update.
- CR 11691: https://www.cms.gov/files/document/r4544cp.pdf
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1
- Article Release Date: March 6, 2020
- What You Need to Know: CR 11680 providers the I/OCE instructions and specifications for the I/OCE that is being updated April 1, 2020. The two new codes for COVID lab tests (U0001 and U0002) are included in this update.
- MLN MM11680: https://www.cms.gov/files/document/mm11680.pdf
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- Change Request (CR) Release Date: March 6, 2020
- What You Need to Know: CR 11681 is a Recurring Update Notice (RUN) providing instructions for the quarterly update the clinical laboratory fee schedule with an effective date of April 1, 2020.
- CR 11681: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/document/r4541cp.pdf
April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
- Article Release Date: March 13, 2020
- What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implements in the April 2020 ASC payment system update.
- MLN MM11694: https://www.cms.gov/files/document/MM11694.pdf
OTHER MEDICARE TRANSMITTALS
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
- Provider Types Affected: Physicians, Providers and Suppliers
- Change Request (CR) Release Date: February 21, 2020
- What You Need to Know: CR 11638 updates RARC and CARC lists and instructs ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print Software.
- MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf
NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
- Article Release Date: March 3, 2020
- Provider Types Affected: Physicians, Providers, and Suppliers
- What You Need to Know: This special edition article updated providers on Medicare coverage rules and policies for NCD20.4 and outlines the coding requirements (including heart failure codes) are not more restrictive than the NCD.
- MLN SE20006: https://www.cms.gov/files/document/se20006.pdf
Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare
- Article Release Date: March 3, 2020
- What You Need to Know: This special edition article reinforces existing Medicare policy allowing non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.
- MLN SE20009: https://www.cms.gov/files/document/se20009.pdf
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits
- Article release date: March 9, 2020
- What You Need to Know: CR11640 informs MACs about new HCPCS codes for 2020 that are subject to and excluded from CLIA edits.
- MLN MM11640: https://www.cms.gov/files/document/mm11640.pdf
The Supplemental Security Income (SSI)/Medicare Beneficiary data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term care Hospitals (LTCHs)
- Article Release Date: March 13, 2020
- What You Need to Know: Specific to hospitals, CR 11679 provides updates for determining Disproportionate Share (DSH) adjustment.
- MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf
REVISED MEDICARE TRANSMITTALS
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update
- Article Revised: February 27, 2020
- Change Request Revised: new Transmittal number R4540CP
- What You Need to Know: The MLN article was revised to reflect the revised change request date and change an MP RVU code in Table 2.
- MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
Proper Use of Modifier 59
- Special Edition MLN Article Revised March 2, 2020
- What You need to Know: This article was revised to include modifiers –X{EPSU}. All other information is unchanged.
- MLN SE1418: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf
New Medicare Beneficiary Identifier (MBI) Get It, Use It
- Special Edition MLN Article Revised March 19, 2020
- What You Need to Know: This article was revised to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool.
- MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf
MEDICARE COVERAGE UPDATES
NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
- Change Request: 11660
- What You Need to Know: The purpose of this Change Request (CR) is to inform MACs that effective June 21, 2029, CMS will continue to cover TAVR under Coverage with Evidence Devlopment (CED) when the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA approved indication for use with an approved device, in addition to the coverage criteria outlined in the NCD manual.
- CR 11660: https://www.cms.gov/files/document/r217ncd.pdf
MEDICARE PRESS RELEASES AND FACT SHEETS
February 20, 2020: Comprehensive Care for Joint Replacement Model Three Year Extension and Changed to Episode Definition and Pricing (CMS 5529 P)
CMS issued a proposed rule in the Federal Register proposing a three year extension, changes to the definition of an episode, and changes in pricing in the Comprehensive Care for Joint Replacement (CJR) Model. This model began April 1, 2016 and has a current end date of December 31, 2020. Since this model began total hip and total knee procedures have been removed from the Medicare Inpatient Only Procedure List. Consequently, one proposal being made is to incorporate outpatient hip and knee replacements in the episode of care definition. Comments on the proposed rule must be received no later than 5 p.m. EST on April 24, 2020.
- CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/comprehensive-care-joint-replacement-model-three-year-extension-and-changes-episode-definition-and
- Proposed Rule: https://www.federalregister.gov/documents/2020/02/24/2020-03434/medicare-program-comprehensive-care-for-joint-replacement-model-three-year-extension-and-changes-to
- CJR Model webpage on CMS Innovation Center: https://innovation.cms.gov/initiatives/CJR
CMS Press Release: CMS Administrator Seema Verma at the 2020 CMS Quality Conference
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
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