Knowledge Base - Full Library

Medicare Transmittals & MLN Articles

June 1, 2023: MLN MM13055: Audiologists May Provide Certain Diagnostic Tests Without a Physician Order

Effective July 1, 2023, one visit to an audiologist without a physician or NPP order is permitted, per patient, once every 12 months. This change was finalized in the CY 2023 Physician Fee Schedule (PFS) rulemaking. https://www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf

June 2, 2023: MLN MM13056: New JZ Claims Modifier for Certain Medicare Part B Drugs

CMS advises that your billing staff know about using JW modifier data to show discarded amounts of drugs in a single-dose container or single-use package and reporting requirements for the new JZ modifier starting July 1, 2023. https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b-drugs.pdf

June 5, 2023: MLN MM13235: DMEPOS Fee Schedule: July 2023 Quarterly Update

Make sure your billing staff knows about the fee schedule adjustment relief for rural and non-contiguous areas and supplier education on power wheelchair repair. https://www.cms.gov/files/document/mm13235-dmepos-fee-schedule-july-2023-quarterly-update.pdf

June 7, 2023: MLN MM13164: Skilled Nursing Facility Probe and Educate Review

Medicare Administrative Contractors (MACs) will be reviewing a small sample of five SNF claims for each SNF in their jurisdiction. This strategy is in response to the CERT identifying SNF services as a top driver of the overall Medicare Fee-for-Service improper payment rate. CMS notes a contributing factor may be the change from the Resource Utilization Group (RUG) IV to the Patient Driven Payment Model (PDPM) for claims with dates of service on or after October 1, 2019.  https://www.cms.gov/files/document/mm13164-skilled-nursing-facility-probe-and-educate-review.pdf

June 13, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

CMS advised providers to make sure billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

June 15, 2023: MLN MM13235: New Waived Tests

This MLN highlights new waived tests effective October 1, 2023.  https://www.cms.gov/files/document/mm13253-new-waived-tests.pdf

June 22, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: July 2023 Update – Revised

Coverage Updates

June 7, 2023: Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)

The CMS issued a National Coverage Analysis (NCA) Tracking Sheet. CMS has received a complete, formal request to reconsider NCD 110.23, they requested full coverage of allogeneic HSCT for individuals with MDS and the removal of the Coverage with Evidence Development (CED requirement currently tied to coverage for HSCT for Medicare beneficiaries with MDS. CMS is soliciting public comments relevant to the request and is accepting comments from 6/7/2023 – 7/7/2023. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=312

June 22, 2023: CMS Fact Sheet: Details of Plan to Cover New Alzheimer's Drugs

CMS notes that if the FDA grants traditional approval, then Medicare will cover the drug in appropriate settings that also support the collection of real-world information to study the usefulness of these drugs. This fact sheet gives more details on how a registry will work to make sure coverage will be available for any Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease that received FDA traditional approval. https://www.cms.gov/files/document/fact-sheet-june-2023.pdf

June 22, 2023: CMS Proposed Transitional Coverage for Emerging Technologies (TCET) Pathway

On June 22, 2023 CMS announced a proposed Transitional Coverage for Emerging Technologies (TCET) pathway as part of its commitment to fostering innovation while ensuring faster and more consistent access to emerging technologies. In addition, CMS released three proposed guidance documents: 1) Coverage with Evidence Development; 2) Evidence Review and 3) Clinical Endpoints Guidance for Knee Osteoarthritis. Additional information on today’s releases can be found here: https://www.cms.gov/blog/transforming-medicare-coverage-new-medicare-coverage-pathway-emerging-technologies-and-revamped and https://www.cms.gov/newsroom/fact-sheets/notice-comment-transitional-coverage-emerging-technologies-cms-3421-nc

Education Updates

MLN Fact Sheet: Medicare Part D Vaccines

This MLN Fact Sheet was updated this month to clarify that Medicare Part B covers vaccines and vaccine administration and Part D patient cost-sharing may include a vaccine administration fee. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/vaccines-part-d-factsheet-icn908764.pdf

Other Updates

June 5, 2023: OIG Publishes Spring 2023 Semiannual Report to Congress

The OIG notes that this semiannual report is intended to keep the HHS Secretary and Congress fully and currently informed of OIG’s crucial findings and recommendations during the reporting period October 1, 2022 through March 31, 2023. https://oig.hhs.gov/reports-and-publications/archives/semiannual/2023/spring-sar-2023.pdf

Did You Know?

CMS recently published ICD-10-PCS and ICD-10-CM files for Fiscal Year 2024. Changes to the codes will be in effect for discharges occurring from October 1, 2023, through September 30, 2024.

ICD-10-PCS Files

The 2024 ICD-10-PCS files (https://www.cms.gov/medicare/icd-10/2024-icd-10-pcs) and FY 2024 ICD-10-PCS Guidelines for Coding and Reporting were published as of June 6, 2023.  

For FY 2024, there are 78 new codes and 5 deleted codes bringing the total number of ICD-10-PCS codes to 78,603. Note, with an increase of 40 codes for FY 2024, New Technology codes make up more than 50% of the new codes.

One change noted when compared to the FY 2023 PCS guidelines is in the Device General Guidelines section B6.1a. This section provides guidance that “if a device that is intended to remain after the procedure is completed requires removal before the end of the operative episode in which it was inserted, both the insertion and removal of the device should be coded.”

The FY 2023 guidelines included an example of when you would code both the insertion and the removal “(for example, the device size is inadequate or an event documented as a complication occurs).” The example has been removed from the FY 2024 guidelines.  

ICD-10-CM Files

The ICD-10-CM files (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm) became available on June 16, 2023. For FY 2024, there are 395 new codes and 25 deleted codes bringing the number of ICD-10-CM codes to 74,044.

CMS noted in their announcement that the FY 2024 ICD-10-CM Coding Guidelines, FY 2024 Conversion Table and FY 2024 Present on Admission (POA) Exempt Code List will be posted when available.

Why it matters?

CMS notes, on the opening page of the 2024 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

What can I do?

Share this information with coding and clinical documentation professions at your facility as you begin to prepare for the October 1, 2023, start of the CMS FY 2024.

It has been almost four years since the September 30, 2019 publication of the Discharge Planning Conditions of Participation (CoP) Final Rule in the Federal Register. At that time, CMS indicated that they would provide sub-regulatory interpretive guidance after the publication of the final rule, which will provide further clarification for implementing the final discharge planning requirements. You can read more about this final rule in a related MMP article.

In 2020, COVID-19 was declared a Public Health Emergency (PHE), and CMS used emergency waiver authorities so providers could rapidly respond to people impacted by COVID-19. Specific to the Discharge Planning CoPs, CMS waived the following requirements:

§482.43(A)(8) Quality and Resource Use Measures

“The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.”

§482.43 (C)(1) Patient Choice Lists

“The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.”

§482.61(e): Discharge Planning and Discharge Summary

“The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient’s condition on discharge.”

The discharge planning waivers expired on May 11, 2023 at the end of the COVID-19 PHE.

On June 6, 2023, CMS issued a Memorandum (QSO-23-16-Hospitals) to State Survey Agency Directors and noted in the Memorandum Summary that:

“CMS is committed to ensuring that the health and safety of patients are protected when discharges from hospitals and transfers to post-acute care providers occur. Therefore, we are providing the following information:

• Reminding state agencies (SAs), accrediting organizations (AOs), and hospitals of the regulatory requirements for discharges and transfers to post-acute care providers.
• Highlighting the risks to patients’ health and safety that can occur due to an unsafe discharge.
• Recommendations that hospitals can leverage to improve their discharge policies and procedures to improve and protect patients’ health and safety.”

   

  Areas of Concern

  Examples from the list of concerns identified by CMS related to missing or inaccurate patient information includes:

• Incomplete comprehensive list of all medications that have been prescribed to a patient during, and prior to, the hospitalization,
• Skin tears, pressure ulcers, bruising, or lacerations, including orders or instructions for cultures, treatments, or dressings, and
• A patient’s preferences and goals for care, such as their choices for treatment or their advance directives for end-of-life care.

After noting how missing and inaccurate patient information can have a negative impact for the patient, caregiver, and PAC providers, CMS reminds SAs and AOs about the discharge planning CoPs and advises that “when conducting surveys, SAs and AOs should be alert to the common issues identified above and ensure these discharges are occurring in a compliant and safe manner.”

Moving Forward

As of June 20, 2023, interpretive guidance for the Discharge Planning CoPs is still “pending and will be updated in future release” of the State Operations Manual – Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for hospitals. In the meantime, I encourage you to share this memorandum with your Discharge Planning staff so they can use the full list of areas of concern to make sure your medical record does not have missing or inaccurate patient information.

Resources

September 30, 2019 Discharge Planning CoP Final Rule: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf

Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHs: CMS Flexibilities to Fight COVID-19: https://www.cms.gov/files/document/hospitals-and-cahs-ascs-and-cmhcs-cms-flexibilities-fight-covid-19.pdf

June 6, 2023 CMS Memorandum (QSO-23-16-Hospitals): https://www.cms.gov/files/document/qso-23-16-hospitals.pdf

CMS State Operations Manual – Appendix A: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

Recovery Audit Contractors

RAC Issue 0002 cataract removal (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0002-Cataract-Removal-Medical-Necessity-and-Documentation-Requirements) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included on this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2021 and 2022 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

2021 CERT Report

The improper payment rate for this surgery was 12.7%. The CERT cited two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically,

the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

2022 CERT Report

The improper payment rate for this surgery was 8.3%. Unlike 2021, 100% of the errors were due to insufficient documentation. The project improper payment rate was $146,067,233.

Medicare Administrative Contractors (MACs)

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were for claims with dates of service from January 1, 2023 through March 31, 2023.

Review results for jurisdictions were published April 12, 2023:

• Noridian JE error rate of 48.67%. https://med.noridianmedicare.com/web/jea/cert-review/mr/review-results
• Noridian JF error rate 45.88%. https://med.noridianmedicare.com/web/jfa/cert-review/mr/review-results

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals. In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.”

The SMRC published review results on September 27, 2022 (https://noridiansmrc.com/completed-projects/01-302/). The error rate was 51%.

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

• Respond to ADRs in a timely manner,
• Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
• Be aware of who is performing cataract surgery reviews,
• Read published review results to understand reasons for denials and ways to prevent future denials, and
• Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Did You Know?
According to the American Lung, about 10 to 30% of adults in the U.S. may have sleep apnea and your risk increases with age and weight. One relatively new treatment for this condition is Hypoglossal Nerve Stimulation (HNS).

Effective January 1, 2022, there were three new CPT codes related to implantation, revision, or removal of the HNS system. A few months later, on June 7, 2022, the first RAC approved issue in 2022 was RAC Issue 0201 (Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements). You can read more about this in a related MMP article.

The affected CPT code for RAC Issue 0201 is 64582 (open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array). The following table highlights the place of service, volume and claims paid in CY 2022 for this CPT code.  

Why It Matters?

Medicare Administrative Contractors (MACs) have published Local Coverage Determinations (LCDs) and related coding and billing articles for this procedure. Currently, two of the indications are a body mass index (BMI) less than 35 kg/m2, and a polysomnography (PSG) demonstrating an apnea-hypopnea index (AHI) of 15 to 65 events per hour within 24 months of initial consultation for HNS implant.

In the U.S. Food & Drug Administration’s June 9, 2023 FDA Roundup, they announced they have approved an expanded indication for the Inspire Medical Systems’ Inspire Upper Airway Stimulation (UAS) System to include an updated AHI and BMI threshold.

“The safety and effectiveness data available now increased the AHI baseline to 100 and a BMI level of 40 for adults with moderate to severe Obstructive Sleep Apnea (OSA).”

What Can I Do?

With this device being on the RAC approved issue list you should:

• Be mindful of the timing of the FDA’s expanded indications in the event you receive a request for records for dates of service on or after June 9, 2023.
• Watch for updated indication information in your MACs related LCD.
• Share this information with key stakeholders.

Resources

American Lung Association article Learn About Sleep Apnea at https://www.lung.org/lung-health-diseases/lung-disease-lookup/sleep-apnea/learn-about-sleep-apnea

FDA Roundup: June 9, 2023: https://www.fda.gov/news-events/press-announcements/fda-roundup-june-9-2023

Did You Know?

In the OIG’s 2022 Top Unimplemented Recommendations report, they focus on the top 25 unimplemented recommendations that in their view would most positively affect HHS programs in terms of cost savings, public health and safety, and program effectiveness and efficiency, if implemented. One of the three Medicare Parts A and B unimplemented recommendations in this report is related to coding malnutrition. Specifically, the OIG has recommended that “CMS should recover overpayments of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims, ensure that hospitals bill appropriately moving forward, and conduct targeted reviews of claims at the highest severity level that are vulnerable to upcoding.” (OIG Report A-03-17-00010 dated July 2020)

Why It Matters?

The OIG reports that CMS has taken the following three initial steps to implement recommendations related to severe malnutrition.

Step One: CMS Tasked the Supplemental Medical Review Contractor (SMRC) with research and analysis to develop a medical review strategy for Malnutrition claims. The SMRC determined providers’ use of the severe malnutrition diagnosis code (E41 and E43) continued to trend upward and made several recommendations to CMS, including development and creation of policy regarding malnutrition diagnostic criteria in the form of local coverage determinations (LCDs) to provided consistent guidance from the Medicare Administrative Contractors (MACs).

While I have not read about the development of an LCD, I have recently noticed that several of the MACs have published guidance for providers related to malnutrition:

Novitas JL

May 16, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00277111)

Fist Coast JN

May 17, 2023 Article: Coding Guidelines: Part A Inpatient Billing for Malnutrition Diagnosis Codes (https://medicare.fcso.com/Claim_submission_guidelines/0503220.asp)

Palmetto GBA JJ

On May 18, 2023, Palmetto GBA JJ: Severe Malnutrition Diagnosis Codes Checklist (https://www.palmettogba.com/palmetto/jja.nsf/DID/KFD3OSLEO9#ls)

Palmetto GBA JJ

May 23, 2023 Article: DRG 640 Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC, 641 without MCC (https://www.palmettogba.com/palmetto/jja.nsf/DID/C5NQ03L60L#ls)

National Government Services (NGS) J6

May 31, 2023 Article: Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims (https://www.ngsmedicare.com/web/ngs/billing?selectedArticleId=9201872&lob=93617&state=97257&rgion=93624)

Step Two: With respect to net overpayments, CMS has so far recovered $400,208 of the $505,400 that was within the 4-year reopening period.

Step Three: CMS also tasked the SMRC with post-payment review of claims with E41 and E43 from calendar year (CY) 2019. The SMRC posted notification of this medical review (Project 01-045) on January 10, 2022 and published their review findings on December 13, 2022. They reported a 53% error rate for claims reviewed. Most concerning to me is that the number one reason cited by the SMRC for denials was no response to the documentation request. You can read the entire medical review findings at https://noridiansmrc.com/completed-projects/01-045/.

OIG Active Work Plan Item

In addition to malnutrition being included in the OIG’s top unimplemented recommendations for 2022, it is also an active Work Plan item focused on Medicaid inpatient hospital claims with severe malnutrition. The OIG notes they will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims. The expected issue date of a report with their review findings is in FY 2023.

In addition to being an active Work Plan item, if you search the word malnutrition on the OIG website, you will find links to reports and work plans as far back as 2021.

What Can You Do?

Hospitals should never have a claim denied due to lack of response to a request for records. Be sure your hospital has a process in place to respond to additional documentation requests (ADRs) in a timely manner.

Specific to severe malnutrition, take the time to read the review results and articles mentioned above as they contain links to additional resources (i.e., ASPEN guidelines, ACDIS Q&A Documentation and ICD-10-CM coding for severe malnutrition by ACDIS) and share this information with Clinical Documentation Integrity (CDI) specialists and coding professionals at your facility.

Severe malnutrition is also a current target area on the Short-Term Acute Care Program for Evaluating Payments Patterns Electronic Report (PEPPER). Yesterday, June 6, 2023, the PEPPER team announced the release of the Q1 FY 2023 PEPPER. Review this report and if you are a high or low outlier, the User’s Guide provides suggested interventions for sampling your medical records.

Resources

2022 OIG’s Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2022.pdf

PEPPER User’s Guide Thirty-Sixth Edition for Short-Term Acute Care Hospitals available on PEPPER Resources website at https://pepper.cbrpepper.org/

Question:

How do you code provider documentation of CKD G4A3?  Is this the same as stage 4 chronic kidney disease?  The provider also noted an estimated glomerular filtration rate of 25 (eGRF25).

Answer:

Yes.  According to Coding Clinic, provider documentation of CKD G4A3 is the same as stage 4 chronic kidney disease.  This is a new categorization of CKD referred to as CGA staging, and is based on the cause (C), glomerular filtration rate (G) and albuminuria (A).  CGA provides a more detailed description of the patient’s CKD.  The number following (G) describes the stage of the CKD. 

The effective date for this guidance begins with April 1, 2023 discharges.

Refer to the following link for more information regarding the CGA classification:  http://ckdpathway.ca/Content/pdfs/Classification_of_CKD.pdf 

References:

Coding Clinic for ICD-10-CM/PCS, First Quarter 2023, Page 17

Coverage Updates

May 9, 2023: U.S. Preventive Services Task Forces (USPSTF) Posts Draft Recommendation Statement for Screening Breast Cancer

The USPSTF issued a draft recommendation indicating that science now shows all women should get screened for breast cancer every other year starting at age 40. This recommendation applies to women at average risk of breast cancer and includes people with a family history of breast cancer, and people who have other risk factors, such as dense breasts. https://uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/breast-cancer-screening-draft-rec-bulletin.pdf

Compliance Education Updates

MLN Fact Sheet: Clinical Laboratory Fee Schedule

This fact sheet has been updated to include the CY 2023 specimen collection amounts and flat-rate travel allowance. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/clinical-laboratory-fee-schedule-fact-sheet-icn006818.pdf

MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing

The end of the COVID-19 PHE brought an end to the 3-day prior hospitalization waiver. CMS has updated this MLN Fact Sheet to remove language related to this waiver. For Case Managers hired during the pandemic, this is a must read to help understand what is required for your Medicare Fee-for-Service beneficiary to qualify for admission to a Skilled Nursing Facility. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

COVID-19 Updates

May 19, 2023: End of COVID-19 PHE FAQs Updates

Learn about updates to the Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency (questions 21-23 on page 9). For example, CMS answers the question, can hospitals bill for outpatient physical therapy (PT), occupational therapy (OT), speech language therapy (SLF) services, Diabetes Self-Management Training (DSMT), or Medical Nutrition Therapy (MNT) provided to beneficiaries in their homes through telecommunication technology by hospital-employed staff?

May 25, 2023: FDA Approved Oral Antiviral Paxlovid for Treatment of Mild to Moderate COVID-19

This drug is for use in adults at high risk for progression to severe CODI-19, including hospitalization and death. Approved during the COVID-19 PHE, Patrizia Cavazzoni, M.D., director for the FDA’s Center for Drug Evaluation and Research notes that “Today’s approval demonstrates that Paxlovid has met the agency’s rigorous standards for safety and effectiveness, and that it remains an important treatment option for people at high risk for progression to severe COVID-19.” https://content.govdelivery.com/accounts/USFDA/bulletins/35c86d9

Other Updates

Comprehensive Error Rate Testing (CERT) Review Contractor: Same Company, New Name

The CERT review contractor, formerly known as NCI Information Systems, Inc. has changed their company name to Empower AI, Inc. Their email domain is @empower.ai.

You can learn more about changes to the CERT Contractors (Review Contractor and Statistical Contractor) in a related Palmetto GBA article at https://www.palmettogba.com/palmetto/jja.nsf/DID/M5PPHI24YK#ls

May 4, 2023 MLN Connects: May is National Mental Health Month

CMS notes in the May 4^th edition of MLN connects that 20% of Americans experience mental illness each year and disproportionately affects racial and ethnic minority groups. I encourage you to read this edition of MLN Connects to learn about appropriate preventive services covered by Medicare (i.e., Depression Screening) and additional mental health resources made available by CMS. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-05-04#_Toc134022248

May 24, 2023: Inpatient Rehabilitation Review Choice Demonstration and Targeted Probe and Educate

Medicare Transmittals & MLN Articles

April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf

May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process

Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf

May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates

Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf

May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules

Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf

May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule

The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf

May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update

Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf

May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update

This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf

May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers

First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf

May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update