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Medicare Transmittals & MLN Articles

June 30, 2023: MLN MM13269: ICD-10 & Other Revisions to Laboratory National Coverage Determinations: October 2023 Update

CMS advises that you make sure your billing staff is aware of newly available codes, recent coding changes, and how to find NCD coding information.  https://www.cms.gov/files/document/mm13269-icd-10-other-coding-revisions-laboratory-ncds-october-2023-update.pdf

July 5, 2023: MLN Matters MM13216: Ambulatory Surgical Center Payment System: July 2023 Update - Revised

Now in it’s fourth iteration, CMS has revised this MLN article to change the number of separately payable drugs in Section 5.a to 18 to agree with the change for HCPCS J9322 in Table 3 of Change Request (CR) 13216. Substantive changes are in dark red on page 3. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf

July 11, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

Now in its fifth iteration, CMS has revised this special edition MLN article to add information on Round 5 testing and national implementation of edits. Substantive changes are in dark red on pages 1 and 4. Note that these are not new requirements, but CMS did announce a delay of activation of these edits on March 24, 2022 until further notice. On August 1, 2023, CMS will start deploying editing into full procedure and have told the MACs to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t match exactly. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

Coverage Updates

July 17, 2023: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease Proposed Decision Memo

CMS is proposing to remove National Coverage Determination (NCD) 220.6.20, ending coverage with evidence development (CED) from positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging be made by the Medicare Administrative Contractors (MACs). https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=308

July 20, 2023: HCPCS Modifier JZ Reminder

Palmetto GBA JJ Part B published a reminder that “the JZ HCPCS modifier is reports on a claim to attest that no amount of drug was discarded and eligible for payment. The modifier should only be used for claims that bill for single-dose container drugs. Effective July 1, 2023 providers are required to use the JZ modifier on applicable claims. https://www.palmettogba.com/palmetto/jjb.nsf/DID/1HF9LYKONE#ls

Compliance Education Updates

June 2023: Medicare’s Home Health Benefit Brochure Revised

CMS has revised their Medicare home health brochure. This brochure includes information about a beneficiary knowing their rights, where to get more information, what is covered, who can get covered home health care, what to pay, and how to protect yourself and Medicare from fraud. https://tinyurl.com/yc2ej3sv

June 2023: MLN Fact Sheet Telehealth Services Revised

CMS has recently updated this Fact Sheet and notes that they have made significant updates to explain recent policy changes. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf

Question:

There is confusion about coding an elevated troponin level. Should we use R77.8 per codebook or R79.89 per advice from Coding Clinic, Second Quarter 2019, pg. 6?

Answer:

The correct code assignment for an elevated troponin level is R77.8, Other Specified Abnormalities of Plasma Proteins. Coding Clinic, Second Quarter 2019, page 6 was superseded by the changes to the index that were effective with the discharges October 1, 2020. The ICD-10-CM Conventions and Coding Guidelines take precedence over Coding Clinic advice. 

References:

Coding Clinic Correspondence dated June 9, 2023

Coding Clinic, Second Quarter 2019, page 6

Coding Clinic, Fourth Quarter 2018, page 90

Did You Know?

The 2024 ICD-10-CM Official Guidelines for Coding and Reporting were posted to the CMS website on July 6, 2023 (https://www.cms.gov/medicare/icd-10/2024-icd-10-cm). You can also find the guidelines on the CDC ICD-10-CM webpage (https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm).

Why It Matters?

“These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses 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. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.” As of July 19^th, there are only 73 days to become familiar with the October 1, 2023, changes.

Narrative guideline changes appear in bold text in this document.

What Can You Do?

For Coding and Clinical Documentation Integrity professionals, reading the new guidelines should be a requirement on your summer reading list. In addition to identifying the bolded text, pay attention to each time the guidelines tell you to query the provider if documentation is unclear.

For example, Section 1.A.19: Code Assignment and Clinical Criteria

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”

Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1^st start of the 2024 CMS Fiscal Year.

There are five covered indications in section B of National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA) for when PTA is covered.  

In June 2022, the Multispecialty Carotid Alliance (MSCA) submitted a letter to CMS for reconsideration of covered indication B4 (concurrent with carotid stent placement in patients at high risk for carotid endarterectomy (CEA).

Last week, on July 11, 2023, CMS published Proposed Decision Memo CAG-00085R8: Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting. CMS notes, the scope of this reconsideration is limited to PTA concurrent with CAS including transcarotid artery revascularization (TCAR) procedures.

CMS summarizes that their proposals, which affect NCD 20.7 sections B4 and D, will revise Medicare coverage for PTA of the carotid arteries concurrent with stenting by:

1. Expanding coverage to individuals previously only eligible for coverage in clinical trials.
2. Expanding coverage to standard surgical risk individuals by removing the limitation of coverage to only high surgical risk individuals.
3. Removing facility standards and approval requirements.
4. Adding formal shared decision-making with the individual prior to furnishing CAS; and
5. Allowing MAC discretion for all other coverage of PTA of the carotid artery concurrent with stenting not otherwise addressed in NCD 20.7.

CAS By the Numbers

Moving Forward

CMS is seeking comments on whether the shared decision-making interaction should require the use of a validated shared decision-making tool and/or if there are other options to achieve the goal of truly informed decision-making. The comment period is from July 11, 2023 through August 10, 2023.  

Resources

NCD 20.7: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=201

Proposed Decision Memo CAG-0085R8: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&ncaid=311&fromTracking=Y&

July is UV Safety Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to the treatment costs of Melanoma.

Did You Know?

Anyone can get skin cancer, but people with certain characteristics are at greater risk—

A lighter natural skin color.

• Skin that burns, freckles, reddens easily, or becomes painful in the sun.
• Blue or green eyes.
• Blond or red hair.
• Certain types and many moles.
• A family history of skin cancer.
• A personal history of skin cancer.
• Older age.

Why It Matters?

Basal and Squamous Cell Carcinomas

According to the CDC (https://www.cdc.gov/cancer/skin/statistics/index.htm), skin cancer is the most common form of cancer in the United States. “An examination of Medical Expenditure Panel Survey data suggests that each year, about 6. 1 million adults are treated for basal cell and squamous cell carcinomas at a cost of about $8.9 billion.”

These numbers have increased exponentially from 2022 when the panel survey data suggested that each year about 4.3 million adults are treated for basal and squamous cell carcinomas at a cost of about $4.8 billion.

Melanoma

Following are recent National Cancer Institute cancer facts about melanoma:

• In 2020, there were an estimated 1,413,976 people living with melanoma of the skin in the U.S.
• Represents 5% of all new cancers in the U.S.
• Is more common in men than women.
• Is most frequently diagnosed among people ages 65-74 with a median age at diagnosis of 66.
• In 2023, it is estimated that there will be 97,610 new cases of melanoma of the skin and an estimated 7,990 people will die of this disease.

https://seer.cancer.gov/statfacts/html/melan.html

What Can I Do?

Be proactive in lowering your risk for melanoma and other skin cancers by following key sun safety tips from the FDA ( https://www.fda.gov/drugs/understanding-over-counter-medicines/sunscreen-how-help-protect-your-skin-sun):

• Limit time in the sun, especially between the hours of 10 a.m. and 4 p.m., when the sun’s rays are most intense,
• Wear clothing to cover skin exposed to the sun, such as long-sleeved shirts, pants, sunglasses, and broad-brimmed hats.
• Use broad spectrum sunscreens with SPF values of 15 or higher regularly and as directed.
• Reapply sunscreen at least every two hours, and more often if you are sweating or jumping in and out of the water.

Also, be mindful that certain medications can cause sensitivity to the sun, for example:

• Antibiotics (ciprofloxacin, doxycycline, levofloxacin, ofloxacin, tetracycline, trimethoprim),
• Antihistamines including Diphenhydramine (common brands include Benadryl and Nytol),
• Oral contraceptives and estrogens, and
• Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen).

You can read more about this on the FDA website (https://www.fda.gov/drugs/special-features/sun-and-your-medicine).

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

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

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?

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.

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