Knowledge Base Category -
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Influenza Virus Vaccine Code Update – July 2020
Provider Types Affected: Physicians, providers and suppliers billing MACs for influenza vaccine services.
This update includes one new influenza virus code: 90694.
MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update
Article Release Date: February 14, 2020
What You Need to Know: Change Request 11661 amends payment files based upon the 2020 MPFS Final Rule. Make sure billing staff is aware of these changes.
MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging
Change Request (CR) Release Date: January 31, 2020
CR 11571: https://www.cms.gov/files/document/r2425otn.pdf
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy
Provider Type Affected: Physicians, Hospitals, other Providers, and Suppliers
What You Need to Know: CR11559 informs MACs about changes to CWF edits to ensure the original edits set and bypass conditions are consistent with current policy. There are no policy changes. Current policy is in the Medicare Claims Processing Manual:
- Chapter 4, Section 10.12: “Payment Window for Outpatient Services Treated as Inpatient Services,” and
- Chapter 3, Section 40.3: “Outpatient Services Treated as Inpatient Services
MLN Article MM11559: https://www.cms.gov/files/document/mm11559.pdf
Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment
Article Release Date: February 14, 2020
What You Need to Know: This article is for hospitals who submit claims for inpatient services provided to Medicare beneficiaries by LTHCs.
MLN MM11616: https://www.cms.gov/files/document/mm11616.pdf
REVISED MEDICARE TRANSMITTALS
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
MLN 11605 was revised on February 4, 2020 to add a section for radiopharmaceuticals with pass-through status and for Extravascular Implantable Cardioverter Defibrillator (EV ICD).
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
January 2020 Annual Update to the Therapy Code List
Provider Type Affected: Physicians, providers and suppliers billing Medicare for therapy services
Transmittal Change: Two new biofeedback codes will be paid under the Medicare Physician Fee Schedule.
MLN Article: MM11501: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf
Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder
Article Release Date: January 31, 2020
What You Need to Know: This article was revised to reflect an updated Change Request (CR), transmittal number and link to transmittal.
MLN Article MM11623: https://www.cms.gov/files/document/mm11623.pdf
International Classification of Disease, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2020 Update
Article Release Date: February 4, 2020
What You Need to Know: This article was revised on February 10, 2020 to reflect a revised CR 11491. This CR was revised to amend the spreadsheet for NCD 110.4. All other information remains the same.
MLN MM11491: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf
New Medicare Beneficiary Identifier (MBI) Get It Use It
Article Release Date: February 12, 2020
What You Need to Know: Article was revised to add a sentence to the MBI look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death.
MLN SE18006 Revised: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Article Release Date: February 13, 2020
What You Need to Know: This article was revised due to a Change Request that added two new attachments due to legislation.
MLN Article: MM11564: https://www.cms.gov/files/document/mm11564.pdf
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging-Approval of Using the K3 Segment for Institutional Claims
Article Release Date: February 20, 2020
What You Need to Know: This article was revised to include the listing of Clinical Decision Support Mechanisms (CDSMs) and to update the paper billing instruction.
MLN Article SE20002: https://www.cms.gov/files/document/se20002.pdf
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Article Release Date: February 19, 2020
What You Need to Know: This article was revised to add information about submitting electronic attestations via the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).
MLN Article: SE17019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17019.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator, Pulse Generator, Any Type
Article Release Date: January 29, 2020
Issue: CMS has identified that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Please make sure you billing staff are aware of the correct policy.
MLN SE20001: https://www.cms.gov/files/document/se20001.pdf
MEDICARE COVERAGE UPDATES
January 27, 2020: Final Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R)
Policy covers FDA approved or cleared laboratory diagnostic tests using Next Generation Sequencing (NGS) for patients with germline (inherited) ovarian or breast cancer.
Decision Memo: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=296
Related CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-expands-coverage-next-generation-sequencing-diagnostic-tool-patients-breast-and-ovarian-cancer
February 3, 2020: National Coverage Analysis (NCD) Tracking Sheet for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy
Issue: Currently, Medicare covers artificial hearts under coverage with evidence development (CED) when a beneficiary is enrolled in a clinical study that meets all the criteria in NCD 20.9. CMS has received two formal requests:
- Request that CMS reconsider CED for artificial hearts based on evidence since the NCD was last updated in 2008.
- A second request asked CMS reconsider Ventricular Assist Devices (VADs) specifically for coverage indications for bridge-to-transplant and destination therapy based on scientific evidence available since the NCD was last reconsidered in 2013.
CMS is soliciting public comment. The initial 30-day public comment period is from 2/3/2020 – 3/4/2020.
February 5, 2020: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)
Issue: Approved Study Posted
On February 15, 2019, CMS issued NCD covering FDA approved VNS devices for TRD through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial. On February 5, 2020, CMS posted a new approved Clinical Study. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS
MEDICARE EDUCATIONAL RESOURCES
CMS 2020 Medicare Costs Information Product
CMS has published a 2020 Medicare Costs document which includes Beneficiary costs for Medicare Part A and Part B, Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) Premiums
https://www.medicare.gov/Pubs/pdf/11579-Medicare-Costs.pdf
CMS 2020 Your Medicare Benefits Product
This booklet contains important information about the items and services covered by Original Fee-for-Service Medicare.
https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf#
MLN Booklet: Medicare Mental Health
This booklet was released in January and provides information about Medicare mental health services (i.e. Covered and non-covered mental health services, outpatient psychiatric hospital services, and medical record requirements).
ICN MLN1986542 January 2020: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/2020-01-3
MLN Booklet: Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B
ICN MLN006799 January 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr-immun-billTextOnly.pdf
MEDICARE COMPLIANCE TIPS
Specimen Validity Testing Billing in Combination with Urine Drug Testing
CMS provided Compliance information in the February 13, 2020 MLNConnects e-newsletter regarding proper coding for specimen validity testing billed in combination with urine drug testing. They reminded providers that “current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient and referenced MLN Matters Special Edition Article SE18001 for descriptors for presumptive and definitive drug testing codes.
OTHER MEDICARE UPDATES
February 6, 2020 Memorandum to State Survey Agency Directors.
Subject: Information Regarding Patients with Possible Coronavirus Illness (2091-nCoV)
Memorandum Summary: Links to information documents issued by the CDC on the respiratory illness cause by the 2019 Novel Coronavirus (2019-nCoV) are included in the memorandum. “CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.”
Memorandum Ref: QSO 20-09-ALL: https://www.cms.gov/files/document/qso-20-09-all.pdf
February 6, 2020 Memorandum to State Survey Agency Directors
Subject: Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for use in CDC Qualified Laboratories.
Memorandum Summary: Guidance is being provided to surveyors regarding Authorization for Emergency Use (AEU) for the Diagnostic Panel. These assays remain subject to CLIA regulations. The Panel assay and corresponding protocols have been developed by the CDC for use by CDC qualified labs.
Memorandum Ref: QSO 20-10-CLIA: https://www.cms.gov/files/document/qso-20-10-clia.pdf
Beth Cobb
MEDICARE TRANSMITTALS – RECURRING UPDATES
Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Provider Type Affected: Clinical Diagnostic Labs
Provider Action Needed: Change Request (CR) 11598 provides instructions for CY 2020, mapping for new codes, and updates for lab costs subject to reasonable charge payment.
MLN Article MM11598: https://www.cms.gov/files/document/mm11598.pdf
January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Provider Type Affected: ASCs billing Medicare Administrative Contractors
Provider Action Needed: CR 11607 informs MACs about updates to the ASC payment system for Calendar Year (CY) 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the HCPCS. Be sure your billing staffs are aware of these changes.
MLN Article MM11607: https://www.cms.gov/files/document/MM11607.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Provider Type(s) Affected: Hospitals, Other Providers and Suppliers Billing MACs
What You Need to Know: This article is based on CR 11564, informs MACs, including Home Health MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2010.
MLN Article MM11564: https://www.cms.gov/files/document/mm11564.pdf
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
What You Need to Know: This Change Request (CR) revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for calendar year 2020.
MLN Article MM11641: https://www.cms.gov/files/document/mm11641.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective Date: April 1, 2020
MLN Article MM11628: https://www.cms.gov/files/document/mm11628.pdf
OTHER MEDICARE TRANSMITTALS
Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory date of Service Policy
Provider Type Affected: Laboratories & other providers
What You Need to Know: In response to comments, CMS finalized excluding blood banks or centers from the laboratory DOS exception at 42 CFR 414.510(b)(5) in the CY 2020 OPPS/ASC final rule published on November 12, 2019. CMS also adopted a definition of “blood bank or center” and clarified that this policy change categorically excludes molecular pathology testing performed by laboratories that are blood banks or blood centers from the laboratory DOS exception at 42 CFR 414.510(b)(5).
MLN Article MM11574: https://www.cms.gov/files/document/mm11574.pdf
Revised Medicare Transmittals
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Transmittal 266 replaces transmittal 264 released on December 20, 2019. Corrections made include:
- Section 5: change “removing 12 procedures from IPO list” to “removing 11 procedures from IPO list”
- Add a new section, number 18, “Correction of deductible and Coinsurance for HCPCS code, G0404,” and
- Change section 18 “Coverage Determinations” to section 19.
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It
On January 2, 2020 to update language reflected the use of the MBI number is fully implemented.
SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
Article Release Date: January 8, 2020
The Data Reporting Period has been delayed one year and as such all references to the 2020 data reporting period have been changed to 2021.
SE20002: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims
Article Release Date: January 10, 2020
Provider Action Needed: This article provides guidance for processing claims for certain institutional claims that are subject to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. The CMS will begin to accept claims with this information as of January 1, 2020. This SE article contains an attached advanced diagnostic imaging UB-04 claim examples to help better understand the claims-based reporting concept of the AUC program.
https://www.cms.gov/files/document/se20002.pdf
MEDICARE EDUCATIONAL RESOURCES
January 2020 MLN Catalog
2020 marks the Medicare Learning Network’s® (MLN’s) 20th anniversary and the January 2020 Edition of the MLN Catalog is now available. Resources you will find in the catalog:
- MLN Matters® Articles
- Publications and Educational Tools
- MLN Connects® Newsletter
- Web-based Training Courses, and
- Provider Association Partnerships.
Billing Correctly for Polysomnography
The January 16, 2020 edition of MLN Connects provided Polysomnography Compliance Information, noting in a recent report, the Office of Inspector General (OIG) determined that CMS improperly paid practitioners for some claims associated with polysomnography services that did not meet Medicare requirements. We revised the Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF) Fact Sheet to help you bill correctly. Additional resources:
- Medicare Claims Processing Manual, Chapter 15 (PDF) , Section 70
- Questionable Billing for Polysomnography Services OIG Report
- Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report
OTHER MEDICARE UPDATES
2020 OPPS Correction Notice
On January 3, 2020, CMS published a correction notice in the Federal Register. This document corrects technical errors that appeared in the final rule that appeared in the November 12, 2019 issue of the Federal Register. Included in the notice is the inadvertent omission of two additional botulinum toxin injection codes J0586 and J0588 that have now been added to the codes in Table 65 – Final List of Outpatient Services That Require Prior Authorization.
You can read more about the new Prior Authorization requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations.
Palmetto GBA Jurisdiction J Medicare Advantage (MA) Plan Overpayments Update
On January 3, 2020, Phase III Settlement Offer Letters were mailed to affected providers. The settlement offer is intended to address all remaining unresolved “MA overpayment” claims.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"AZ9J8M2780?opendocument
New Important Message from Medicare (IM) and Detailed Notice of Discharge
The Office of Management and Budget (OMB) has renewed the IM (CMS-10065) and DND (CMS-10066). The revised IM has a new CMS Form number (CMS-10065). It was formerly CMS-R-193. Hospitals are required to use the new forms as of April 1, 2020. Until then the previous and new versions are acceptable for use. You can access the forms at the following links:
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Important-Message-English-and-Spanish.zip
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Detailed-Notice-English-and-Spanish.zip
New Medicare Outpatient Observation Notice (MOON)
The OMB has renewed the MOON (CMS-10611). The only change made was the expiration date is now 12/31/2022. Similar to the IM and DND, hospitals are required to use the new MOON beginning April 1, 2020. Both previous and new versions are acceptable for use through March 31, 2020. You can access the MOON at the following link:
January 13, 2020 Memorandum: Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes
Aims of Memorandum:
- To improve the identification of quality issues, the CMS is in the process of integrating the psychiatric hospital program survey into the hospital program survey,
- Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals, and
- Develop training to provide the necessary competencies for all State Survey Agency surveyors to evaluate compliance with the psychiatric hospital CoPs.
Link to Memorandum: https://www.cms.gov/files/document/admin-info-20-05-hospitalpsych.pdf
Link to Related CMS Newsroom Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-reduces-psychiatric-hospital-burden-new-survey-process
2020 Updates to OIG Work Plan
OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Beginning in January 2020, completed Work Plan items will remain in the active Work Plan for one month, after which they will be moved into the Archive. Recently completed reports can be found on OIG's What's New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.
January 2020 Medicare Quarterly Provider Compliance Newsletter
The January 2020 edition of this newsletter includes CERT review findings specific to the provision of Lumbar Sacral Orthosis (LSO) and Recovery Auditor findings from a review of Trastuzumab (Herceptin), J9355.
Does it seem that people are less willing to make concessions these days than in the past? I am not sure if this is generally true, but if you look at our governments, it certainly seems so. In Britain, the government cannot agree or compromise to accomplish Brexit, and in our own country, the political parties cannot seem to agree on anything. They also seem completely unwilling to compromise or offer any concessions to the opposing viewpoint. Due to my cynicism from such an environment, I was a bit surprised to read in the 2020 Physician Fee Schedule (PFS) Final Rule that CMS made 3 significant concessions concerning the requirements for the new modifiers for therapy services provided in whole or in part by a therapy assistant.
These new modifiers are mandated by the Balanced Budget Act (BBA) of 2018 which required that these modifiers:
- Be established by January 1, 2019;
- Be applied to claims lines for outpatient therapy services being furnished in whole or in part by a therapy assistant for dates of services beginning on January 1, 2020; and
- Effectuate a payment reduction for services furnished on and after January 1, 2022.
This is all in keeping with the major intent of the BBA provision that “for services furnished on or after January 1, 2022, payment for outpatient physical and occupational therapy services for which payment is made under sections 1848 or 1834(k) of the Act which are furnished in whole or in part by a therapy assistant must be paid at 85 percent of the amount that is otherwise applicable.”
This means beginning in 2022, therapy services furnished by physical or occupational therapy assistants will be paid less than services provided by therapists – 15% less to be specific. These services will be paid 85% of the usual applicable payment rate. For example, if a unit of therapeutic exercise (CPT 97110) is normally paid $35, when billed with one of the assistant modifiers, the payment would be $29.75. Remember the PFS therapy rates are dependent on your carrier jurisdiction and the multiple procedure payment reductions (MPPR) continue to apply also.
The modifiers that are required to be reported on therapy line items when the services are furnished in whole or in part by a therapy assistant beginning in 2020 are:
- CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
- CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.
These new modifiers will be reported alongside the GP and GO modifiers used to identify services furnished under a PT or OT plan of care, respectively. Other modifiers used for therapy services, such as the KX and 59 modifiers, should also continue to be reported. Thank goodness the functional limitation reporting modifiers are no longer required.
In the 2019 PFS Final Rule, CMS finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA. For example, for therapy services of 60 minutes, 10% would be 6 minutes and for the assistant to furnish more than 10% would be 7 minutes or more. This means once the PTA/OTA furnishes at least 7 minutes of the service, the CQ/CO modifier would be required to be added to the claim for that service. Untimed codes include services such as evaluative services, group therapy, and supervised modalities. Although assistants cannot perform an evaluation or re-evaluation, they can assist the therapists by performing clinical labor tasks such as obtaining vital signs, providing self-assessment tools to the patient and verifying their completion.
So, what are the concessions CMS made concerning the new therapy modifiers?
- CMS agreed with commenters that the time when a therapist and a therapist assistant furnish services to the same patient at the same time should not be counted as part of the assistant time. This means the time spent by a PTA/OTA furnishing a therapeutic service “concurrently,” or at the same time, with the therapist will not count for purposes of assessing whether the 10 percent standard has been met. The final policy is that only the minutes that the PTA/OTA spends independent of the therapist will count towards the 10 percent de minimis standard.
- CMS proposed, for billing purposes, that each outpatient therapy service that is subject to the 10 percent de minimis standard would be identified on the claim by a single procedure code, for both untimed codes and codes described in 15-minute-unit increments. Commenters pointed out the 15-minute code issue, so CMS finalized a revised definition of a service to which the de minimis standard is applied to include untimed codes and each 15-minute unit of codes described in 15-minute increments as a service. This revised definition will allow the separate reporting, on two different claim lines, of the number of 15-minute units of a code to which the therapy assistant modifiers do not apply, and the number of 15-minute units of a code to which the therapy assistant modifiers do apply.
For a 15-minute increment that equals 1 unit of a timed code, the assistant would have to furnish 3 or more minutes of the treatment to meet the 10% de minimis standard. If a PTA independently furnishes 8 consecutive minutes of therapeutic exercises to a patient who receives a total of 45 minutes of ther ex (therapist provides the other 37 minutes of ther ex), then the hospital would bill 2 units of CPT 97110 without the CQ modifier and 1 unit of CPT 97110 with the CQ modifier.
- CMS proposed to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day. CMS agreed that the addition of narrative phrases for each service could be duplicative of existing documentation requirements so they did not finalize this requirement. Neither does the documentation have to specify therapist and therapy assistant minutes.
However, CMS does expect the documentation in the medical record to be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished “in part” by a therapist assistant, in sufficient detail to permit the determination of whether the 10% standard was exceeded.
Particularly related to number 1 and 2 above, CMS intends to provide further detail regarding examples of clinical scenarios to illustrate their final policies regarding the applicability of the therapy assistant modifiers through information that will be posted on the cms.gov website. Check the CMS therapy website at https://www.cms.gov/Medicare/billing/therapyServices/index for updates.
The modifier reporting and future payment reductions do not apply to critical access hospitals (CAHs) or to other providers that are not paid based on PFS rates. It also does not apply to outpatient therapy services that are furnished by, or incident to the services of, physicians or nonphysician practitioners (NPPs). This is because only therapists and not therapy assistants can furnish outpatient therapy services incident to the services of a physician or NPP.
Bottom line for hospitals – be sure to have the new therapy assistant modifiers set up and processes in place to get them appended to line item therapy services. Apply the modifiers:
- To all therapy services’ billing codes that are furnished in whole by therapy assistants,
- To untimed therapy services’ billing codes when an assistant independently furnishes more than 10% of the service (time of service divided by 10, rounded to the nearest whole integer, plus one minute)
- To timed 15-minute increments of a timed-code service when the assistant independently furnishes 3 minutes or more of a 15-minute service (for services > 8 minutes, but < 23, determine 10% as described above for untimed codes, i.e. 8-14 minutes – 2 minutes Assistant time; 15-23 minutes – 3 minutes Assistant time).
This last explanation of assistant time for timed codes is my understanding from the discussion in the final rule. I will be looking for more examples from CMS as promised to verify my understanding is correct. I definitely concede that Medicare rules can be difficult to understand and follow.
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2020 Update
A maintenance update of ICD-10 conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
2020 Annual Update to the Therapy Code List
Updates the list of codes that sometimes or always describe therapy services.
2020 Annual Update of Per-Beneficiary Threshold Amounts
Updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020.
Claim Status Category and Claim Status Codes Update
https://www.cms.gov/files/document/mm11467
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
https://www.cms.gov/files/document/mm11489
Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020
https://www.cms.gov/files/document/MM11542
OTHER MEDICARE TRANSMITTALS
Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy
Medicare Severity Diagnosis-Related Groups (MS-DRGs) 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without major complications and comorbidities (MCC), respectively) added to the list of MS-DRGs subject to the policy for replaced devices offered without cost or with a credit.
Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators
Status Indicator Q (therapy functional information code) is no longer effective with the 2020 MPFSDB beginning January 1, 2020. Medicare no longer requires functional therapy reporting.
Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the Fiscal Intermediary Shared System (FISS)
Currently, the system does not recognize HCPCS Q9982 and Q9983 as valid radiopharmaceutical tracer codes and claims are incorrectly returned to the provider as unprocessed or rejected.
Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home
Implements the newly approved National Uniform Billing Committee (NUBC) Condition Code “A7” and improved edit criteria in Medicare systems to bypass edits that match service facility location on certain hospital claims.
https://www.cms.gov/files/document/mm11470
Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
A summary of the policies in the CY 2020 MPFS Final Rule, announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment.
https://www.cms.gov/files/document/mm11560
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements
Updates language pertaining to the National Correct Coding Initiative (NCCI).
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4465CP.pdf
Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35
New Global Billing and Separate TC/PC billing instructions. For both paper and electronic claims, when a global diagnostic service code is billed (for example, no modifier TC and no modifier -26), the address where the TC was performed must be reported on the claim.
https://www.cms.gov/files/document/mm10882
REVISED MEDICARE TRANSMITTALS
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Revision - Reference added to a related article SE19009 which replaces Section 6 - Chimeric Antigen Receptor (CAR) T- Cell Therapy - instructions on pages 5-7 of this article.
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
Revision - Updates and clarifies information regarding the eMDR registration/enrollment to indicate the provider and the HIH roles with more detail.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Revision - Removes codes that are not available for 2020.
MEDICARE COVERAGE UPDATES
Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer
Expands coverage of Next Generation Sequencing (NGS) as a diagnostic laboratory test when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specified requirements are met.
MEDICARE PRESS RELEASES AND FACT SHEETS
CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2020
The Hospital VBP Program works by adjusting what Medicare pays hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality and cost of inpatient care the hospitals provide to patients.
MEDICARE EDUCATIONAL RESOURCES
Palmetto GBA 2020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule
Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2020.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Bill Correctly for Medicare Telehealth Services
OTHER MEDICARE UPDATES
Extension of Detailed Notice of Discharge Beyond Expiration Date
The currently available Detailed Notice of Discharge (hospital notice) has an expiration date of October 31, 2019. The current notice is covered under an extension and hospitals should continue using it until CMS publishes the updated notice.
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices
2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year 2020.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24138.pdf
2020 Medicare Physician Fee Schedule Final Rule
This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute; and other topics.
https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf
Patients over Paperwork Newsletter November 2019
Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.
https://www.cms.gov/files/document/november-2019-patients-over-paperwork-newsletter
KEPRO Case Review Connections Winter 2020 – Acute Care Edition
KEPRO is the Beneficiary and Family Centered Care QIO (BFCC-QIO) for 29 states. Case Review Connections is a quarterly newsletter that provides a glimpse into KEPRO and the services provided, along with success stories and updates from the Centers for Medicare & Medicaid Services (CMS).
https://keproqio.com/bene/newsletter/2020winteracute/
Hospital Price Transparency Requirements Final Rule
Establishes requirements for hospitals operating in the United States to establish, update, and make public a list of their standard charges for the items and services that they provide.
https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf
Transparency in Coverage Proposed Rule
Sets forth proposed requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative), including an estimate of such individual’s cost-sharing liability for covered items or services furnished by a particular provider.
https://www.hhs.gov/sites/default/files/cms-9915-p.pdf
CY 2020 - Clinical Laboratory Fee Schedule Test Codes Final Determinations
In November of each year, CMS finalizes the basis of payment for new and substantially revised test codes and the amount of payment through the annual CMS instruction implementing the updated CLFS for the next CY.
Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments
Revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines for clinic visit services at excepted off-campus PBDs for 2019.
Extension of the MOON Beyond Expiration Date
The currently available Medicare Outpatient Observation Notice (MOON) has an expiration date of December 31, 2019. The currently available MOON is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice.
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/MOON
My youngest son got married earlier this month, and I have already conveyed to him and his bride my desire for more grandchildren. Grandkids are such fun because you can love on them and spoil them, then turn them back over to their parents for the serious stuff. A friend of mine has a one-year old granddaughter and I love to spend time with her. She is currently learning the word “no,” and I get to sit back and smile as it is obvious that she knows what it means but pretends she doesn’t. That slight hesitation and determined expression are “cute” from my perspective, but frustrating for her parents as she proceeds with her actions, undeterred by their instruction of “No!”
Do you think the judicial system and affected parties are frustrated by CMS’s decisions to go forward with certain actions when the judicial system has given the instruction of “no?” Maybe CMS is more like teenagers than babies, because they are old enough to argue, and are putting forth appeals, the potential to appeal, and alternative options as they proceed with their original actions. The 2020 Outpatient Prospective Payment System (OPPS) Final Rule was released Friday, November 1, 2019 and CMS is continuing for 2020 a couple of policies the courts have already found to be inappropriate.
First is the reduction in payment for clinic visits performed in excepted off-campus provider-based departments (PBDs). A little history here – in November 2015, Congress passed a law to pay “new” off-campus hospital provider-based departments that began furnishing and billing for services on or after November 2, 2015 at a different, lower payment rate than that of OPPS. This was done to address concerns about higher payments for services provided in hospital outpatient departments than the lower payments for the same services provided in a physician office setting. Hospitals were instructed to report the services in these non-excepted off-campus PBDs with a PN modifier and CMS determined to pay these under the physician fee schedule at 40% of the OPPS rate (a payment reduction of 60%). Services provided in excepted off-campus PBDs and reported with the PO modifier continued to be paid at OPPS rates at that time. That is until 2019, when CMS decided to expand site-neutrality payments further to include clinic visits (HCPCS code G0463) provided in excepted off-campus PBDs. They phased in the 60% payment reduction over two years, with a 30% reduction for 2019 and the full 60% reduction in 2020 – this makes the payment for clinic visits at all off-campus PBDs the same as the physician fee schedule payment for non-excepted PBD services of 40% of OPPS payment rates.
CMS claims they are “removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.” They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power “to adopt a method to control unnecessary increases in the volume of covered outpatient department services.” They are also implementing this payment reduction in a “non-budget neutral manner” which means the costs savings to the Medicare program will not be redistributed back to hospitals. So far, the courts have not agreed with CMS on their authority to implement this payment reduction policy.
On September 17, 2019, the United States District Court for the District of Columbia entered an order vacating the portion of the CY 2019 OPPS/ASC final rule that adopted the payment reduction for clinic visit services furnished by excepted off-campus PBDs. In October, the district court denied CMS’s request for stay and entered final judgment. CMS acknowledges the court’s decision and states they are “working to ensure affected 2019 claims for clinic visits are paid consistent with the court’s order.” Despite these statements, CMS chose to proceed with the second year of the two-year phase-in of the clinic visit policy for 2020. This means for CY 2020, clinic visits (G0463) provided in excepted off-campus PBDs and billed with the PO modifier will be paid at 40% of the OPPS payment rate. CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.
The second policy for which the courts have issued a negative opinion is the payment of drugs purchased through the 340B program at Average Sales Price (ASP) minus 22.5%. The district courts have found that for both the 2018 and 2019 payment reductions, CMS exceeded their statutory authority by making such a large adjustment in payment rate. The case is currently under appeal from CMS and although they are requesting comments on options to remedy the underpayments of those years, they are also proceeding for 2020 with the same reduced payment amount of ASP-22.5% for drugs purchased through the 340B program including such drugs in a non-excepted off-campus PBD.
Since this policy was implemented in a budget-neutral manner (money saved was redistributed to all OPPS hospitals) and a remedy is “no easy task, given Medicare’s complexity,” the courts have remanded the issue to HHS to devise an appropriate remedy while also retaining jurisdiction. There is abundant discussion, comments and responses in the Final Rule about possible options to address the underpayments. As part of one such remedy, CMS is conducting a 340B hospital survey to collect drug acquisition cost data for CY 2018 and 2019. Since the district court has acknowledged that CMS may base the Medicare payment amount on average acquisition cost when survey data are available, it is obvious in the FR that CMS expects the survey data to show that ASP minus 22.5% was a conservative adjustment that overcompensates hospitals. If so, this remedy would get CMS out of their bind and possibly allow the current reduced payment rate to stand. The Final Rule does offer other options for consideration.
For other drugs and biologicals, CMS finalized the following policies:
- A packaging threshold of $130 – this means Medicare will package items with a per day cost less than or equal to $130, and identify items with a per day cost greater than $130 as separately payable unless they are policy-packaged (such as anesthesia, intraoperative items, and drugs that function as supplies, etc.)
- A payment rate of ASP plus 6% for pass-through and separately payable non-pass-through drugs other than those purchased through the 340B program
- Payment rate of Wholesale Acquisition Costs (WAC) plus 3% for drugs paid under WAC (such as when ASP data is not available)
Like stubborn children, the policies of the OPPS Final Rule show that just because CMS has been told “no” does not mean they plan to change their ways. We will be addressing other policies and decisions from the OPPS Final Rule in future articles in this newsletter.
Debbie Rubio
Over the past few weeks, articles in our Wednesday@One newsletter have addressed some of the new and revised policies from the 2020 Medicare Outpatient Prospective Payment System (OPPS) Final Rule. One such article last week discussed the continuation of two policies that the courts have already found to be outside of CMS’s authority – 1) the second year and further decrease in payment rates for outpatient clinic visits in excepted off-campus provider-based departments to the same rate (40% of OPPS rates) as paid for services in nonexcepted off-campus PBDs and 2) payment of separately payable drugs purchased through the 340B program at average sales price (ASP) minus 22.5%. This article will examine the changes in the level of supervision required for hospital outpatient therapeutic services and the new requirement for prior authorization for select cosmetic procedures. The change in supervision requirements is a relief for hospitals, especially critical access and small rural hospitals. Unfortunately, the prior authorizations are an added burden on hospitals, regardless of how CMS tries to couch it.
Level of Supervision of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals (CAHs)
Around 2010 and in subsequent years, CMS “clarified” in the OPPS final rules, that they expected direct supervision of therapeutic services in a hospital outpatient setting. Direct supervision in a hospital was defined to mean that a physician was immediately available to direct or take over performance of the procedure. Due to the difficulties in meeting this requirement, CMS or Congress have continually had a nonenforcement rule for CAHs and small rural hospitals for this policy, the latest of which is expiring December 31, 2019. You can read more about the direct supervision requirements and where we currently stand in a prior Wednesday@One article.
In the 2020 OPPS Final Rule, CMS finalized their proposed policy to change the “generally applicable minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs.” General supervision means that the procedure is furnished under the physician’s overall direction and control, but that the physician’s presence is not required during the performance of the procedure. CMS took this action to reduce the burden for outpatient hospital providers, to allow more flexibility to provide medical care, and to eliminate what has in effect been a two-tiered system of supervision levels between CAHs/small rural hospitals and all other hospitals. CMS feels comfortable changing the required level of supervision for hospital outpatient therapeutic services because:
- CMS is not aware of any supervision-related complaints from patients or of any data or information from providers indicating the quality of care for services furnished under general supervision was affected,
- There are Medicare Conditions of Participation (CoPs) and State and federal laws that require physician direction and supervision of hospital services to ensure the safety, health, and quality standards of outpatient therapeutic services,
- Hospitals and physicians can decide to furnish direct supervision for services when they believe a higher level of supervision is necessary to ensure the quality and safety of the procedure and to protect the patient from complications that might occur,
- CMS retains the ability to change the supervision level of an individual hospital outpatient therapeutic service or the default minimum level to a more intensive level of supervision, and
- CMS plans to monitor care furnished to Medicare beneficiaries to determine if there is any decline in the quality of therapeutic outpatient services provided as a result of this policy.
This policy becomes effective January 1, 2020 and will remain in place for future years unless modified by later notice and comment rulemaking.
Prior Authorization for Select Hospital Outpatient Services
As part of their responsibility to protect the Medicare Trust Funds, CMS routinely monitors the utilization of services. They have identified several surgical procedures with higher than expected volume increases that could be potentially noncovered by Medicare due to their cosmetic nature. In order to manage the growth of Medicare spending and control unnecessary increases in the volume of hospital outpatient department (OPD) services, CMS is implementing a policy for the prior authorization of certain procedures to “reduce the instances in which Medicare pays for these services when they are merely cosmetic and not medically necessary.”
- The affected procedures are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. A listing of the affected CPT codes can be found in the final rule. (See page 316 of the 2020 OPPS Final Rule pdf.)
- The requirement would begin for dates of service on or after July 1, 2020.
- Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to Medicare or its contractors for review before the service is provided to the patient and before the claim is submitted.
- The PA request should include all documentation necessary to show that the service meets applicable Medicare coverage, coding and payment rules.
- Claims submitted for services that require a PA that have not received a provisional affirmation of coverage from Medicare would be denied unless the provider is exempt.
- Claims associated with the denied service, such as anesthesiology services, physician services, and/or facility services will also be denied.
- Upon submission of a PA request, CMS or its contractors would issue a decision (affirmative or non-affirmative) within 10 business days.
- Providers can request an expedited review if a delay could seriously jeopardize the patient’s life, health or ability to regain maximum function and a decision will be rendered within 2 business days. Documentation supporting the risk of serious jeopardy must be submitted with the request for an expedited PA.
- Exemption Process - CMS may elect to exempt providers from the PA process who achieve a PA affirmation threshold of at least 90% during a semiannual assessment. This exemption could be removed if the provider subsequently has a rate of non-payable claims greater than 10%.
- A non-affirmation PA decision is not appealable, but the provider will receive a detailed explanation as to why the request was non-affirmed and can resubmit an unlimited number of requests. Appeal rights exist once a claim is denied.
- There will be more sub-regulatory guidance before the requirement becomes effective, but the final rule indicates either the hospital or the physician may submit the PA request, though the hospital is ultimately responsible for ensuring this condition of payment is met.
- A unique tracking number (UTN) corresponding to the PA decision must be included on the OPD claim.
CMS argues this is not an additional burden on hospitals since no new documentation is required beyond what should already be present in the record and the hospital is just having to submit the records before the procedure instead of afterwards as they would have to do in the case of a Medicare medical review. Everyone knows it will be an additional burden, but the good news is that hospitals are used to PA requirements from most other payers, it causes the hospital to get the required documentation together before providing the service, and it likely will prevent some inappropriate payments for cosmetic procedures that do not meet Medicare’s medical necessity requirements.
So, a little relief for some, a little burden for others – is that a wash?
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
Announces changes to be included in the January 2020 quarterly release of the edit module for clinical diagnostic laboratory services.
January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates
CMS intends to calculate the payment rates for each calendar year, based on the Consumer Price Index for All Urban Consumers (CPI-U); and instruct the MACs and the Railroad Specialty MAC to update the MDPP payment rates each year.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 1st Qtr Notification for FY 2020
The interest rate for the first quarter of FY 2020 is 10.125%.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R327FM.pdf
OTHER MEDICARE TRANSMITTALS
Provider Enrollment Rebuttal Process
Puts into operation the provision which permits providers/suppliers whose Medicare billing privileges are deactivated to file a rebuttal.
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
Identifies changes as part of the annual IPF PPS update established in the IPF PPS FY 2020 Final Rule. These changes are applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).
Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
The Fiscal Year (FY) 2020 update to the Inpatient Prospective Payment System (IPPS) and LTCH Prospective Payment System (PPS).
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
Instructs Medicare's Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD).This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.
REVISED MEDICARE TRANSMITTALS
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update – REVISED
Revised on October 1, 2019, to clarify that the effective date is January 1, 2020, unless noted otherwise.
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) – REVISED
Revised to correct Table 7 to reinstate C9043 rather than delete it effective October 1, 2019. Also adds a new HCPCS code J0642, which is effective October 1, 2019, and revises the descriptor for J0641.
MEDICARE SPECIAL EDITION ARTICLES
Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N
CMS is providing this information for hospitals providing CAR T-cell therapy to beneficiaries enrolled in Medicare Advantage (MA) plans.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Cardiac Device Credits: Medicare Billing
- Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
- Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
OTHER MEDICARE UPDATES
Final Rule: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAH), and Home Health Agencies (HHA), and Hospital and CAH Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
The rule finalizes requirements for hospitals, CAHs, and HHAs to implement discharge planning processes that will provide more information (such as a PAC provider or supplier’s performance in quality measures and resource measures) to patients and their families to help them make more informed decisions about PACs in order to better address their goals for care and treatment preferences.
Final Rule: Omnibus Burden Reduction (Conditions of Participation)
Finalizes provisions of three separate proposed rules: the Omnibus Burden Reduction proposed rule (dated September 20, 2018); Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care proposed rule (dated June 6, 2016); and the Fire Safety Requirements for Certain Dialysis Facilities proposed rule (dated November 4, 2016).
Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule
A proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989.
Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2020
The annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review. The 2020 AIC threshold is $170 for ALJ hearings and $1,670 for judicial review.
https://www.govinfo.gov/content/pkg/FR-2019-10-07/pdf/2019-21751.pdf
Medicare Quarterly Provider Compliance Newsletter October 2019
This quarter’s newsletter addresses Ambulance Services Subject to SNF Consolidated Billing Requirements and Outpatient Physical Therapy Services.
MAC UPDATES
Palmetto GBA 2020 Medical Review TPE Teleconference Schedule
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"BGQT2X1030?opendocument
MEDICARE TRANSMITTALS – RECURRING UPDATES
2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Annual Clotting Factor Furnishing Fee Update 2020
The clotting factor furnishing fee for 2020 is $0.226 per unit.
Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Includes numerous new and revised codes.
October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
OTHER MEDICARE TRANSMITTALS
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System – REVISED
Article revised on August 26, 2019, to reflect changes made to the eMDR registration screens within NPPES. The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs.
Implementation of the Award for the Jurisdiction H Part A and Part B Medicare Administrative Contractor (JH A/B MAC)
Announces the Jurisdiction JH A/B MAC re-competition procurement that was recently awarded to Novitas Solutions, Inc., the incumbent contractor for this workload.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2358OTN.pdf
Billing for Hospital Part B Inpatient Services
Reminder of the policy regarding billing instructions for hospital Part B inpatient service claims, including the allowance of Revenue Code 0240 on 012x Type of Bills (TOB).
MEDICARE SPECIAL EDITION ARTICLES
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System – REVISED
Revised on September 5, 2019, to delete incorrect information in the section titled Only Applicable Information Attributed to non-Hospital Patients is Reported.
Activation of Systematic Validation Edits for OPPSProviders with Multiple Service Locations – Update – REVISED
Revised on September 5, 2019, to announce a delay of full implementation until April 2020.
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
OTHER MEDICARE UPDATES
Case Review Connections, Fall 2019
KEPRO Quarterly Acute Care Newsletter
Back in 2017, I wrote the section below about changes to the laboratory date-of-service policy changes from the 2018 OPPS Final Rule. The importance of laboratory date of service (DOS) requirements is that they are used to determine whether a hospital bills Medicare directly for a clinical diagnostic laboratory test (CDLT) or whether the laboratory performing the test bills Medicare. Remember, most CDLTs are conditionally packaged under OPPS, and are only paid separately to the hospital when they are: (1) the only service provided to a beneficiary on a claim; (2) considered a preventive service; (3) a molecular pathology test; or (4) an advanced diagnostic laboratory test (ADLT) that meets certain criteria. Preventive services, molecular pathology tests, and ADLTs are assigned an OPPS status indicator (SI) of “A” and paid under the Clinical Lab Fee Schedule (CLFS). CDLTs with an SI of “Q4” are paid separately under the CLFS when they are the only types of services on the claim, but payment is bundled when they appear with other outpatient services.
Excerpt from Prior Wednesday@One Article on Laboratory Date of Service Rule
“Laboratory date of service (DOS) rules start simple:
- The DOS for clinical diagnostic laboratory services generally is the date the specimen is collected.
- For archived lab specimens that are stored for more than 30 days before testing, the DOS is the date the specimen was obtained from storage.
Now this is where it starts getting complicated with what is known as the 14-day rule.
- The DOS is the date the test was performed (instead of the date of collection) if the following conditions are met:
- The test is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
- The specimen was collected while the patient was undergoing a hospital surgical procedure;
- It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
- The results of the test do not guide treatment provided during the hospital stay; and
- The test was reasonable and medically necessary for the treatment of an illness.
- Another 14-day rule applies to chemotherapy sensitive tests performed on live tissue under the same conditions as described above with only slight variation to the first condition:
- The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge;
Both of these 14-day rules apply to hospital inpatients and outpatients and the key point is that the test is ordered at least 14 days after discharge. These DOS requirements determine whether the hospital bills Medicare for a clinical diagnostic laboratory test (CDLT) or whether the laboratory performing the test bills Medicare directly. When the 14-day rule applies, laboratory tests are not bundled into the hospital stay, but are instead paid separately under Medicare Part B to the testing laboratory.
Stakeholders expressed concerns about the current (2017) DOS policy because it requires hospitals to bill for tests they did not perform and that may have no relationship to or bearing on treatment received by the patient while in the hospital and it creates billing difficulties for the hospital. CMS agreed with these concerns and modified the date of service rule for hospital outpatients for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs) that are not packaged under OPPS. These types of lab test have a Status Indicator of “A” on Addendum B.
The new rule (from the 2018 OPPS Final Rule) states that in the case of a molecular pathology test or an ADLT, the DOS of the test must be the date the test was performed only if—
- The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
- The specimen was collected from a hospital outpatient during an encounter (as both are defined in 42 CFR 410.2);
- It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;
- The results of the test do not guide treatment provided during the hospital outpatient encounter; and
- The test was reasonable and medically necessary for the treatment of an illness.
This new exception to the laboratory DOS policy does not apply to ADLT or molecular pathology tests when performed on a specimen collected from a hospital inpatient.
This new laboratory DOS policy will enable laboratories performing ADLTs and molecular pathology tests excluded from the OPPS packaging policy to bill Medicare directly for those tests, instead of requiring them to seek payment from the hospital outpatient department. In fact, for molecular pathology tests and ADLTs meeting the above requirements, the DOS must be the date the test was performed and the test must be billed by the performing laboratory. Hospital laboratories cannot bill for these tests unless they perform them.”
Although the “new” lab DOS rule from the 2018 OPPS Final Rule described above was originally set to be implemented July 2, 2018, many hospitals and laboratories reported to CMS they were having administrative difficulties implementing the DOS exception. For that reason, CMS has repeatedly exercised enforcement discretion regarding the new rule, with the latest enforcement discretion in effect until January 2, 2020.
Because of continued concerns about the readiness of labs and hospitals to implement the new rule and additional concerns that some entities performing molecular pathology testing subject to the laboratory DOS exception, such as blood banks and blood centers, may not be enrolled in the Medicare program and may not have established a mechanism to bill Medicare directly, CMS is rethinking this DOS rule. In the 2020 OPPS Proposed Rule, they are seeking comments on three options for potential changes to the laboratory DOS exception.
- Changing the Test Results Requirements – Under this option, the test would be considered a hospital service unless the ordering physician determines that the test does not guide treatment during a hospital outpatient encounter.
- Limiting the Laboratory DOS Exception to ADLTs
- Excluding Blood Banks and Blood Centers from the Laboratory DOS Exception
These options would only affect the new lab DOS exception put forth in the 2018 OPPS Final Rule that applies to molecular pathology tests and ADLTs. The basic lab DOS rules and the 14-day rule DOS exception and the chemotherapy sensitivity test DOS exception would not be affected.
I encourage hospitals and laboratories affected by these date of service rules to read the discussion in the Proposed Rule and to submit comments to CMS. (Lab DOS Policy section begins on page 201 of 247 pages of the pdf printed version.)
Debbie Rubio
MEDICARE TRANSMITTALS – RECURRING UPDATES
Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly update.
October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Updates the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
Changes from IPF Final Rule applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020).
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update
Relevant NCD coding changes for:
- NCD20.7 Percutaneous Transluminal Angioplasty
- NCD110.18 Aprepitant
- NCD110.23 Stem Cell Transplantation
- NCD150.3 Bone Mineral Density Studies
- NCD220.4 Mammography
- NCD220.13 Percutaneous Image-Guided Breast Biopsy
- NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
Claim Status Category and Claim Status Codes Update
Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update
OTHER MEDICARE TRANSMITTALS
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment - REVISED
Removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit and allows billing E/M codes (99211, 99212, and 99213) for levels I through III with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.
Oxygen Policy Update
Implements a new policy and coding for oxygen content.
Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
To assist in reminding laboratories of their reporting obligations, the following new alert RARC code will appear on remittances:
- N817: ALERT-Applicable laboratories are required to collect and report private payor data and report that data to CMS between January 1, 2020 - March 31, 2020
Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual
Adds a link to the current influenza codes and payment rates.
MEDICARE SPECIAL EDITION ARTICLES
Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management
Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain.
New Medicare Beneficiary Identifier (MBI) Get It, Use It – REISSUED
Use MBIs now for all Medicare transactions.
New Documentation Requirements for Filing Medicare Cost Reports
The FY 2019 Medicare IPPS final rule changed the required supporting documentation that providers must submit with the Medicare cost report.
MEDICARE COVERAGE UPDATES
Decision Memo for Chimeric Antigen Receptor (CAR) T-cell Therapy for Cancers (CAG-00451N)
Posted final decision memo.
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291
Medicare Press Releases
MEDICARE EDUCATIONAL RESOURCES
Medicare Fast Facts
Medicare Fast Facts resources this month include:
- Ambulance Fee Schedule and Medicare Transports
- Skilled Nursing Facility 3-Day Rule Billing
Skilled Nursing Facility 3-Day Rule Billing
MLN Fact Sheet
Ambulance Fee Schedule and Medicare Transports Booklet
MLN Booklet
OTHER MEDICARE UPDATES
FY 2020 Coding Updates
ICD-10-CM Coding Guidelines - https://www.cdc.gov/nchs/icd/icd10cm.htm
ICD-10-CM (Diagnosis Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html
ICD-10-PCS (Procedure Codes) - https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS.html
2020 Advance Beneficiary Notice (ABN) Forms
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
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