Knowledge Base - Full Library

COVID-19 Updates

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency on October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. The sixty days prior to January 11, 2023 came and went without notice from the Secretary so it appears the COVID-19 PHE will last at least to April 2023.

HHS Releases Long COVID Report

In a November 21, 2022 press release (link), the U.S. Department of Health and Human Services (HHS) announced the release of a new report highlighting patients’ experience of Long COVID. “Long COVID is a set of conditions. Researchers have cataloged more than 50 conditions linked to Long COVID that impact nearly every organ system. Estimates vary, but research suggests that between 5 percent and 30 percent of those who had COVID-19 may have Long COVID symptoms, and roughly one million people are out of the workforce at any given time due to Long COVID. This figure equates to approximately $50 billion annually in lost salaries.”

Other Updates

October 27, 2022: OIG Report – CMS Can Use OIG Audit Reports to Improve Its Oversight of Hospital Compliance

In this Report (link), the OIG notes that they performed this audit to determine CMS’s actions taken regarding 12 Hospital Compliance Audits during calendar years (CYs) 2016 through 2018. Collectively, the OIG reviewed 1,290 claims from the 12 hospitals. The most common error types identified by the OIG were incorrectly billed Inpatient Rehabilitation Facility (IRF) services and incorrectly billed HCPCS codes.

The OIG determined that, after considering results of first and second level appeals, the 12 hospitals received overpayments totaling $82 million. While the OIG found that CMS had taken some recommended actions based on these audits, they noted that CMS provided insufficient information to be able to identify if actions had been taken to ensure the hospitals had repaid funds or followed the 60-day rule.

The categories of claims at high risk for noncompliance with Medicare requirements, for this report, included the following “risk areas” that were the focus of the 12 hospital compliance audits:

• Inpatient rehabilitation facility claims,
• Inpatient claims billed with high CERT DRG codes,
• Inpatient claims billed with high-severity level DRG codes,
• Inpatient claims paid in excess of billed charges,
• Inpatient claims billed with adverse events, inpatient claims billed with elective procedures,
• Inpatient claims billed with mechanical ventilation,
• Inpatient claims covering same day discharge and readmission,
• Inpatient psychiatric facility claims,
• Inpatient claims paid in excess of $150,000,
• Inpatient claims paid in excess of $25,000,
• Outpatient claims paid in excess of charges,
• Outpatient claims billed with right heart catheterizations HCPCS codes,
• Outpatient surgery claims billed with units greater than one,
• Outpatient claims billed with bypass modifiers,
• Outpatient skilled nursing facility (SNF) consolidated billing claims, and
• Outpatient claims paid in excess of $25,000.

The OIG notes that “if CMS used our provider-specific audit reports, it could improve Medicare program oversight by focusing on services at high risk for improper payment. In addition, CMS’s actions could lead to improvements in hospital specific internal controls.”

October 28, 2022: Implementing Certain Provisions of the Consolidated Appropriations Act (CAA), 2021 and other Revisions to Medicare Enrollment and Eligibility Rules (CMS-4199-F)

Currently, for those approaching sixty-five, the date when your coverage becomes effective depends on when you enroll. As noted in a CMS Fact Sheet related to this final rule (link):

• “If an individual enrolls during any of the first three months of their Initial Enrollment Period (IEP), their coverage will start the first month of eligibility (e.g., age 65).
• If an individual enrolls during their IEP in the month they become eligible, their coverage will start the month after they enroll.
• If an individual enrolls during any of the last three months of their IEP, their coverage will start 2-3 months after they enroll.
• If an individual enrolls during the General Enrollment Period (GEP), which runs from January 1st through March 31st every year, their coverage will start

As mandated in the CAA and finalized in this rule, beginning January 1, 2023, Medicare coverage will become effective the month after enrollment for individuals enrolling in the last three months of their IEP or in the GEP, reducing any potential gaps in coverage.

October 31, 2022: CY 2023 Home Health Prospective Payment System rate Update and Home Infusion Therapy Services Requirements – Final Rule (CMS-1766-F)

In a Fact Sheet (link), CMS estimates that Medicare payments to Home Health Agencies (HHAs) in CY 2023 will increase $125 million compared to CY 2022.

October 31, 2022: CY 2023 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule (CMS-1768-F)

CMS projects that payment updates for CY 2023 will increase the total payments to all ESRD facilities by 3.1% compared to CY 2022. You can read about this Final Rule in the CMS Fact Sheet announcing the release of the final rule (link).

Medicare Transmittals & MLN Articles

Telehealth Home Health Services: New G-Codes

• MLN Release Date: November 2, 2022
• What You Need to Know: Starting on or after January 1, 2023, Home Health (HH) providers may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. Starting July 1, 2023, providers will be required to report this information. This MLN article details the three G-codes that will need to be used when submitting the use of telecommunication technology on the HH claim.
• MLN MM12805: link)

Billing for Hospital Part B Inpatient Services

• Transmittal Issue Date: November 9, 2022.
• What You Need to Know: The purpose of this Change Request (CR) 12965 is to provide billing instructions for hospital Part B inpatient services. For example, effective 7/1/2022 three new “Not Allowed Revenue Codes” were added to the list of codes a Medicare Administrative Contractor will set a revenue code edit to prevent payment on Type of Bill 012X. The implementation date for the updates is December 12, 2022.
• CR 12965: link)

ESRD & Acute Kidney Injury Dialysis: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article details information about rates and policies for the ESRD Prospective Payment System and payment for renal dialysis services provided to patients with acute kidney injury in ESRD facilities.
• MLN MM12978: link)

Home Health Prospective Payment System: CY 2023 Updates

• MLN Release Date: November 10, 2022
• What You Need to Know: This article highlights changes related to 30-day period payment rates, national per-visit amounts, and cost-per-unit payment amounts used for calculating outlier payments under the Home Health Prospective Payment System. These changes will be effective January 1, 2023.
• MLN MM12957: link)

Medicare Physician Fee Schedule Final Rule Summary: CY 2023

• MLN Release Date: November 17, 2022
• What You Need to Know: This article details updates effective January 1, 2023 to the telehealth originating site facility fee payment amount, expansion of coverage for colorectal cancer screening, coverage of audiology services, and other covered services.
• MLN MM12982: link)

New Waived Tests

• MLN Release Date: November 23, 2022
• What You Need to Know: This article highlights seven newly added waived complexity tests that must have the modifier QW to be recognized as a waived test.
• MLN MM12996: link)

Revised Medicare MLN Articles & Transmittals

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

• MLN Release Date: September 6, 2022 – Revised November 10, 2022
• What You Need to Know: This article was revised due to a revised Change Request (CR) 12888. No substantive changes were made to the article.
• MLN MM12888: link)

Coverage Updates

ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2023 Update

• MLN Release Date: November 9, 2022
• What You Need to Know: This MLN is related to CR 12960 which is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. Relevant NCD coding changes in CR 12960 include:
• NCD 20.4 (Implantable Automatic Defibrillators ICDs): ICD-10 diagnosis code I47.2 end effective date was September 30, 2022. New codes effective on or after October 1, 2022 includes I47.20, I47.21, and I47.29.
• NCD 210.10 (Screening for STIs): CPT 0353U is a new code for this NCD with an effective date October 1, 2022.

CMS notes that MACs will adjust any claims processed in error associated with CR 12960 that you bring to their attention.

• MLN MM12960: link)

Compliance Education Updates

Medicare Provider Compliance Tips – Revised

CMS noted in the Thursday, November 3, 2022 edition of MLN Connects (link) that the educational tool Medicare Provider Compliance Tips has been updated with the latest improper payment rates, denial reasons, and codes. Additional information and new tips have been added to several of the topics included in this tool (i.e., new tips for cataract removal, lipid panels and psychiatry).

Federally Qualified Health Center — Revised
Excerpt from 11/23 MLN Matters newsletter:

This MLN booklet (link)">link) was reviewed in October 2022 and includes the following changes:

• Payment for hospice attending physician services by specific providers
• Mental health services using telecommunications
• Concurrent billing for chronic care management and transitional care management services
• Changes to care management services codes
• CMS also added information on COVID-19 shot and monoclonal antibody therapy administration.

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on the new service to be added to the Prior Authorization for Certain Hospital Outpatient (OPD) Services effective July 1, 2023.

Did You Know?

CMS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services through the Calendar Year (CY) 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC).

Initially, effective July 1, 2020 blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation required a prior authorization when performed in the hospital OPD. For claims on or after July 1, 2021, implanted spinal neurostimulators and cervical fusion with disc removal were added to the list.

New for 2023, CMS finalized the addition of facet joint interventions requiring prior authorization for claims on or after July 1, 2023. This service category includes facet joint injections, medial branch blocks, and facet joint nerve destruction. A list of the specific CPT codes that will require prior authorization are listed in Table 103 of the CY 2023 OPPS/ASC Final Rule (CMS-1772-FC).

Why it Matters?

Reviewing facet joint records has been a target by several different entities.

Medicare Administrative Contractors

Noridian Jurisdiction E (JE) Part B MAC has conducted a Targeted and Probe and Educate (TPE) review of CPT 64635 (Destruction by Neurolytic Agent, Paravertebral Facet Joint Nerve). Dates of service reviewed were January 2020 through March 2020. The claims error rate was 75% with the top denial reasons being:

• Failure to return records,
• Documentation does not support the medical necessity as listed in the Coverage Requirement, and
• Duplicate billing.

Noridian indicated in their review results that “Local Coverage Determination L34993 provides an overview of the coverage requirements for these services. Documentation must support the history of pain which has not been responsive to conservative measures. Documentation must also support the conservative measures that have been tried and failed. The LCD also further clarifies that documentation must support a clinical assessment which supports that the pain is a result of the facet joint and that there is no other pathology that may be causing the pain.

Documentation must reflect the patient pre and post procedure pain rating, procedure report, and the injectate used is within the LCD requirements.”

Other Part B MACs that have reviewed or are currently reviewing facet joint injections include Novitas JH and JL and WPS J8.

Office of Inspector General (OIG)

CMS notes in the OPPS/ASC final rule that the OIG has published multiple reports indicating questionable billing practices, improper Medicare payments, and questionable utilization of facet joint interventions. Based on their findings, the OIG recommended that CMS and its contractors provide additional oversight on claims for facet joint injections to prevent additional improper payments.

Supplemental Medical Review Contractor

Just last month on October 10th, the Supplemental Medical Review Contractor (SMRC) posted their review findings of Project 01-304: facet joint injections. The October 2020 OIG report was referenced in the review results. Claims reviewed included hospital outpatient and critical access hospitals with dates of service in CY 2019. The claims error rate was 92% and common denial reasons included:

• Documentation submitted was insufficient or incomplete,
• Documentation submitted did not support medical necessity as listed in National and Local Coverage Determinations, and
• No response to the documentation request by the provider.

What Can I Do?

You can begin to prepare for the July 1, 2023 addition of Facet joint procedures to the Prior Authorization for Certain Hospital OPD Services now by:

• Identifying applicable Medicare Coverage Documents (Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs)), and
• Ensuring key stakeholders are aware of the need for prior authorization effective July 1, 2023 (i.e., Outpatient Department Nurse Manager, Scheduling, Physicians performing these procedures) and educate them on applicable documentation requirements found in the LCDs and LCAs.

The CMS released the Calendar Year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule on November 1, 2022. Following are highlights from the final rule:

CY 2023 OPPS and ASC Payment Rates

CMS is updating the CY 2023 OPPS and ASC payment rate by 3.8%.

• The estimated total payments to OPPS providers in CY 2023 would be approximately $86.5 billion, an increase of approximately $6.5 billion compared to CY 2022 OPPS payments.
• The estimated total payments to ASCs for CY 2023 will be approximately $5.3 billion, an increase of approximately $230 million compared to CY 2022 ASC payments.

Comprehensive Ambulatory Payment Categories (C-APCs) for CY 2023

C-APCs were first implemented on January 1, 2015. A C-APC is defined as “a classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service.”

CMS expanded the C-APC methodology in 2016 to include a “Comprehensive Observation Services” C-APC (C-APC 8011). The payment rate for C-APC 8011 in CY 2023 is $2,439.02.

For CY 2023, CMS finalized one new C-APC, C-APC 5372 (Level 2 Urology and Related Services).

For the duration of the COVID-19 PHE, any new FDA approved drug or biological approved for emergency use authorization (EUA) to treat COVID-19 that is authorized for use in the outpatient setting, or not limited to use in the inpatient setting, will be separately paid and will not package into the C-APC when provided on the same claim as the primary C-APC service.

Rural Emergency Hospital (REH)

REH is a new Medicare Provider type that includes facilities who elect to convert either from a critical access hospital (CAH) or a rural hospital with less than fifty beds to an REH. Policies for this new provider type will take effect January 1, 2023.

By statute REH services include emergency department services and observation care. Specific to observation care, CMS notes “there may be instanced in which REH patients receive observation services at an REH for a period exceeding 24 hours, but REHs are not required to provide required notification under the NOTICE Act, known as the Medicare Outpatient Observation Notice (MOON), because REHs are excluded from the definition of “hospital.”

An REH can also elect to provide other outpatient medical and health services furnished on an outpatient basis. CMS finalized the proposal that REHs may provide outpatient services not otherwise paid under the OPPS (i.e., services paid under the Clinical Lab Fee Schedule, post-hospital extended care services in a distinct part unit licensed as a skilled nursing facility).

REHs will receive a monthly facility payment of $272,866. This payment will increase in subsequent years by the hospital market basket percentage increase.

340B-Acquired Drugs

“CMS notes in the final rule that “for CY 2023, in light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), we are applying the default rate, generally average sales price (ASP) plus 6 percent, to 340B acquired drugs and biologicals in this final rule with comment period for CY 2023 and removing the increase to the conversion factor that was made in CY 2018 to implement the 340B policy in a budget neutral manner.

We are still evaluating how to apply the Supreme Court’s decision to prior calendar years. In the CY 2023 OPPS/ASC proposed rule, we solicited public comments on the best way to craft any potential remedies affecting cost years 2018-2022, and we will take these comments into consideration for separate rulemaking that will be published in advance of the CY 2024 OPPS/ASC proposed rule.”

Reminder, for 2022 claims prior to September 28th, providers will need to submit adjustment claims to recalculate their payments (link).

Medicare Inpatient Only (IPO) List

For CY 2023, CMS is removing 11 services and adding 8 newly created CPT codes to the IPO List. Table 65 of the final rule includes all services to be removed or added to the IPO list.

ASC Covered Procedure Lists

Procedures on the ASC Covered Procedure List (CPL) are surgical procedures that are appropriately performed on an inpatient basis in a hospital but that can also be safely performed in an ASC, a CAH, or an HOPD. Four procedures are being added to this list and can be found in table 80 of the final rule.

Hospital Outpatient Department Prior Authorization Process: New Service Category

Effective for dates of service on or after July 1, 2023, Facet joint interventions will be added to the list of service categories that hospital outpatient departments will be required to get prior authorization to receive payment. Specific Facet Joint CPT codes that will require prior authorization are listed in Table 103 of the final rule.

Outpatient Non-PHP Mental Health Services Furnished Remotely by Hospital Staff to Beneficiaries in Their Homes

CMS finalized its proposal to consider mental health services furnished remotely by hospital staff using communication technology to a beneficiary in his or her home a covered outpatient department service.

An in-person service will be required within 6 months prior to the initiation of remote service and then every 12 months thereafter, exceptions may be made to this requirement based on a beneficiary’s clinical needs and the reason being documented in the medical record. The in-person requirement will not apply to beneficiaries who began receiving mental health telehealth services during the PHE or during the 151-day period after the end of the PHE.

Audio-only interactive telecommunications systems may be used when a beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.

Resources

CY 2023 OPPS Final Rule CMS Press Release: https://www.cms.gov/newsroom/press-releases/hhs-continues-biden-harris-administration-progress-promoting-health-equity-rural-care-access-through

CY 2023 OPPS Final Rule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-2

Did You Know?

On September 28, 2022, the United States District Court for the District of Columbia vacated (link) the previously applied differential payment rates for 340B-acquired drugs in the Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS) final rule.

Why it Matters?

As a result of this of this ruling, CMS will revert to paying the default rate (generally ASP plus 6%) under the Medicare status for 340B-acquired drugs.

CMS noted in the Thursday, October 13, 2022 edition of MLN Connects (link) that “CMS is uploading revised OPP drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. CMS also will reprocess claims our contractors paid on or after September 28, 2022, using the default rate.”

What Can You Do?

To receive payments for claims prior to September 28, 2022, providers will need to submit adjustment claims to recalculate their payments. Medicare Administrative Contractors (MACs) nationwide have posted information about this issue on their websites. For example, Noridian JF, the MAC for Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming has posted the following information in their October 27, 2022 daily email (link):

Provider/Supplier Action Required:

“Although MACs shall not reprocess 2022 date of service claims prior to 09/28/22 as contractor-initiated adjustments, MACs shall process provider-submitted adjustments to 2022 date of service claims that were paid prior to September 28, 2022. The adjustments can be submitted using type of bill (TOB) XX7 with condition code D9 and remarks indicating “340B adjustment”.

Question

What is the code assignment for a patient with Type 2 DM with Nephropathy and CKD?

Answer

Assign only one code, Type 2 DM with CKD (E11.22) because CKD is more specific than nephropathy per advice found in Coding Clinic, 3rd Quarter 2019, page 3.

References

Coding Clinic, 3rd Quarter 2019, page 3

CMS recently published the following information about expanding the use of (bivalent) COVID-19 vaccines and new bivalent vaccine CPT codes in the Thursday, October 27, 2022 edition of MLN Connects (link).

The CDC recently expanded the use of updated (bivalent) COVID-19 vaccines to children ages 5 through 11 years. This followed the FDA’s authorization of updated COVID-19 vaccines from Pfizer-BioNTech for children ages 5 through 11 years and from Moderna for children and adolescents ages 6 through 17 years. People with Medicare, Medicaid, Children’s Health Insurance Program coverage, private insurance coverage, or no health coverage can get COVID-19 vaccines, including the updated Moderna and Pfizer-BioNTech COVID-19 vaccines, at no cost, for as long as the federal government continues purchasing and distributing these COVID-19 vaccines.

CMS issued 4 new CPT codes effective October 12, 2022:

Code 91314 for Moderna COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 25MCG/.25ML

Code 91315 for Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 10MCG/0.2ML

Code 0144A for Moderna COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose
• Short descriptor: ADM SRSCV2 BVL 25MCG/.25ML B

Code 0154A for Pfizer-BioNTech COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose
• Short descriptor: ADM SARSCV2 BVL 10MCG/.2ML B

Visit the COVID-19 Vaccine Provider Toolkit (link) for more information, and get the most current list of billing codes, payment allowances, and effective dates (link).

See the full news alert (link)

Source: Thursday October 27, 2022 MLN Connects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-10-27-mlnc

Did you Know?

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout®.

Why it Matters?

The American Cancer Society indicates that this event is important because “about 34 million American adults still smoke cigarettes, and smoking remains the single largest preventable cause of death and illness in the world. Smoking causes an estimated 480,000 deaths every year, or about 1 in 5 deaths.”

What Can You do About It?

For health care providers, know what resources are available for your patients.

Counseling to Prevent Tobacco Use

This service falls in the benefit category of additional preventive services and National Coverage Determination (NCD 210.4.1) Counseling to Prevent Tobacco Abuse details the covered indications for this service. Specifically, CMS covers this service for outpatient and hospitalized patients with Medicare Part B who meet the following criteria:

• The patient uses tobacco, regardless of whether they exhibit signs and symptoms of tobacco-related disease,
• The patient is competent and alert when counseling is delivered, and
• The counseling is provided by a qualified physician or other Medicare-recognized practitioner.

Counseling Frequency

Medicare covers two cessation attempts per year and each attempt may include a maximum of four intermediate or intensive sessions, with the patient getting up to eight sessions per year. There is no copayment, coinsurance, or deductible for the patient.

Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (NCD 210.14)

Lung Cancer Screening also falls in the benefit category of additional preventive services. Screening is covered for patients with Medicare Part B who meet all the following categories:

• The patient is 50 – 77 years of age,
• The patient is asymptomatic,
• The patient has a smoking history of at least 20 pack-years (1 pack-year = smoking 1 pack per day for 1 year, 1 pack + 20 cigarettes),
• Is a current smoker or quit smoking within the last fifteen years, and
• The physician orders the lung cancer screening with LDCT.

Screening Frequency

Medicare will cover this service annually. Of note, before the first lung cancer LDCT screening, the physician must counsel the patient as a shared decision-making visit. Like counseling to prevent tobacco use, the patient has no copayment, coinsurance, or deductible.

Resource:

CMS MLN Educational Tool Medicare Preventive Services (link)

Did You Know?

Division D, Sections 101 and 102 of the Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023 has extended the temporary low-volume hospital payment adjustment and Medicare Dependent Hospital (MDH) Program that were set to end October 1, 2022.

Why it Matters?

CMS released MLN Matters Article MM12970 (link) on October 21, 2022. This article details information about the above-mentioned Act that extends the temporary changes through December 16, 2022.

What Can You Do?

Per CMS, provider actions needed includes:

• Sending a written request to your MAC by November 16 to get the applicable low-volume hospital payment adjustment, and
• Read this MLN article and related transmittal to determine if you are eligible for continued MDH status.

Medicare MLN Articles & Transmittals

Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data

• MLN Release Date: September 29, 2022
• What You Need to Know: Data for the Ninth Circuit’s jurisdiction has been updated based on Supreme Court decision in Azar v. Empire Health Foundation. This includes hospitals in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington. Data for all other hospitals is unchanged.
• MLN MM12906: (link)

New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

• MLN Release Date: October 6, 2022
• What You Need to Know: Make sure your billing staff knows about a new consistency edit that validates the attending provider NPI and that organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met.
• MLN MM12889: (link)

Medicare Deductible, Coinsurance & Premium Rates: Calendar Year 2023 Update

• MLN Release Date: October 13, 2022
• What You Need to Know: CMS advises to make sure your billing staff know about the calendar year 2023 rate changes. I would also encourage you to make sure your case management and social services staff are aware of this information too.
• MLN MM12903: (link)

Revised Medicare MLN Articles & Transmittals

Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests

• MLN Release Date: April 29, 2022 – Revised September 29, 2022
• What You Need to Know: The article was revised to add the Other Amount Indicator “B2” for co-insurance reduction amount to the claim, modify edits that affects the co-insurance reduction amount, and report the applied coinsurance amounts in the c-insurance field.
• MLN MM12656: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)-January 2023 Update – 2 of 2

• MLN Release Date: August 12, 2022 – Revised October 5, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 12842. The update for NCD 150.3 (Bone Mineral Density Studies) was removed due to ICD-10 diagnosis codes that were added in error and restore ICD-10 diagnosis C91.92 that was removed in error to NCD 110.23 (Stem Cell Transplantation).
• MLN MM12842: (link)

October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal Release Date: Transmittal 11610 released September 23, 2022 is being rescinded and replaced by Transmittal 11661 dated October 23, 2022
• What You Need to Know: This transmittal has been updated to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11.
• Transmittal 11661: (link)

Coverage Updates

Cochlear Implantation Final Decision Memo (CAG-00107R)

On September 26, 2022, CMS published a final decision memo (link) for NCD 50.3 Cochlear Implantation. CMS has concluded there is sufficient evidence for cochlear implantation be “be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.” Patient’s must also meet specific criteria detailed in the Decision Memo.