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MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from November 9th through the 12th.

Resource Spotlight: Celebrating Thanksgiving

As we quickly close in on Thanksgiving Day, the CDC has posted a webpage filled with information on how to safely celebrate Thanksgiving. This page opens with the statement that “traditional Thanksgiving gatherings with family and friends are fun but can increase the chances of getting or spreading COVID-19 or the flu…The safest way to celebrate Thanksgiving this year is to celebrate with people in your household. If you do plan to spend Thanksgiving with people outside your household, take steps to make your celebration safer.”

November 9, 2020: ORCHID Trial Debunks Effectiveness of Hydroxychloroquine in Adults Hospitalized with COVID-19

In a November 9, 2020 Press Release, the National Institutes of Health (NIH) announced findings from the trial called Outcomes Related to COVID-19 treated with Hydroxychloroquine among Inpatients with Symptomatic Disease (ORCHID). The ORCHID Trial enrolled participants between April 2 and June 19, 2020 who were a median age of 57. “At day 14, those who received hydroxychloroquine and those who received a placebo had a similar health status, with most participants in both groups discharged from the hospital and able to perform a range of activities.”

Per Wesley Self, M.D., M.P.H., emergency medicine physician at Vanderbilt University, “The finding that hydroxychloroquine is not effective for the treatment of COVID-19 was consistent across patient subgroups and for all evaluated outcomes, including clinical status, mortality, organ failures, duration of oxygen use, and hospital length of stay,”

November 10, 2020: OIG Posts Information about Operation CARE

The OIG has posted details about Operate CARE (Caring, Awareness, & Resources for Elders). With a long history of protecting the health and well-being of HHS beneficiaries they note that “Unfortunately, during the COVID-19 pandemic, we have seen a spike in the number of reports of elder harm and neglect.”

The OIG Operation CARE webpage includes resources (i.e., awareness posters) available to the public to also advocate for this population by reporting patient safety and fraud concerns.

November 12, 2020: COVID-19 Non-Physician Practitioner Billing for CPT Codes 98966-98968

In the Thursday November 12th edition of MLNConnects, CMS reminders non-physician practitioners that “During the COVID-19 Public Health Emergency (PHE), non-physician practitioners who are eligible to bill Medicare directly, including registered dietitians and nutrition professionals, may bill for audio-only telephone assessment and management services:

• CPT codes 98966-98968

• Dates of service on or after March 1 until the end of the PHE”

November 12, 2020: CMS Guidance - COVID-19 Vaccine Shots

CMS added the following new webpages to CMS.gov website regarding COVID-19 Vaccine Shots:

• Enrollment for Administering COVID-19 Vaccine Shots,
• Coding for COVID-19 Vaccine Shots,
• Medicare COVID-19 Vaccine Shot Payment,
• Medicare Billing for COVID-19 Vaccine Shot Administration,
• Beneficiary Incentives for COVID-19 Vaccine Shots, and
• CMS Quality Reporting for COVID-19 Vaccine Shots

November 12, 2020: CMS Monoclonal Antibody COVID-19 Infusion

In addition to information about COVID-19 Vaccine Shots, CMS has added a Monoclonal Antibody COVID-19 Infusion webpage which includes information on the following topics:

• Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction,
• Coding for Monoclonal Antibody COVID-19 Infusion,
• Medicare Payment for Monoclonal Antibody COVID-19 Infusion, and
• Billing for Monoclonal Antibody COVID-19 Infusion Administration.

You can read more about the first Monoclonal Antibody drug to received Emergency Use Authorization for treating COVID-19 in a related FAQ in this week’s newsletter. 

November 12, 2020: Special Edition MLN Connects – COVID-19 Vaccine Codes and PC-ACE Software Update

CMS noted the following in this Special Edition of MLN Connects:

“In anticipation of the availability of a vaccine(s), for the novel coronavirus (SARS-CoV-2) in response to the coronavirus disease 2019 (COVID-19), the American Medical Association (AMA), working with the Centers for Medicare & Medicaid Services (CMS), created new codes for the vaccine and the administration of the vaccine.  To prepare for the vaccine administration claims, the PC-ACE software is also updated and ready for providers to download.

If you intend to administer the COVID-19 vaccines when they become available, or the new monoclonal antibody bamlanivimab, especially if you intend to roster bill these codes, please download and install the new release of PC-ACE. This release includes the coding structure, currently comprised of both a HCPCS Level I CPT code structure issued by the American Medical Association (AMA) and a HCPCS Level II code structure issued by CMS. Together, these codes support the administration of the COVID-19 vaccines and the monoclonal antibody infusions, as they become available; this structure includes the codes for bamlanivimab. This code structure was developed to facilitate efficient claims processing for any COVID-19 vaccines and monoclonal antibody infusions that receive FDA EUA or approval. CMS and the AMA are working collaboratively regarding which codes to submit for COVID-19 vaccines and administration.  Most of these codes are not currently effective and not all codes will be used.  We will issue specific code descriptors in the future.  Effective dates for the codes for Medicare purposes will coincide with the date of the FDA EUA or approval.”

CDC COVID Data Tracker – United States COVID-19 Cases

October 26, 2020: Novitas Article – Billing Outpatient Observation Services

Novitas Solutions posted the article Billing Outpatient Observation Services which defines outpatient observation, clarifies that observation is a service not a status, discusses the physician order for observation, reminds providers about delivery of the Medicare Outpatient Observation Notice (MOON), covers observation hours and billing requirements, and general reminders about observation.

October 29, 2020: CGS Article – Use of Human Amniotic Based Products

CGS posted the following information about the use of human amniotic based products:

“CGS has seen multiple claims where cellular and/or tissue-based products (CTPs), specially micronized or particulated human amniotic membrane and/or placental tissue matrix, are being injected into joints and tissues for osteoarthritis, plantar fasciitis, and other complaints. The labeled indications for these products are to treat non-healing wounds and burn injuries and are intended for external application to the wound. CGS covers the application of CTPs for ulcers or wounds as outlined in the LCD L36690 Wound Application of Cellular and/or Tissue-Based Products, Lower extremities. Use of these products topically or as an injection outside of the labeled use and as defined in L36690 is considered off-labeled and may not be a covered service.

Off label usage may be reviewed pre-pay or on appeal. The appeal request should include medical record documentation supporting the unique usage and include full-text copies of evidence-based, peer-reviewed articles from core medical journals supporting such use. Such articles should include the results of robust CMS and/or FDA approved clinical trials and/or meta-analysis that support any additional indications.”

November 2, 2020: First Coast Service Options Prior Authorization Program Q&As Modified

First Coast most recently modified their list of Q&A's related to the CMS Prior Authorization (PA) program for certain hospital outpatient department (OPD) services that went into effect in July. They note the document consists of questions and answers posed during their educational webinars.

November 3, 2020: Noridian JE and JF Local Coverage Determination (LCD) for Treatment of Osteoporotic Vertebral Compression Fracture Finalized

Noridian announced that their LCD and Local Coverage Article (LCA) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) has completed the Open Public Meeting and Contractor Advisory Committee (CAC) comment period and is now final.

• Noridian JE
• LCD L34228 / Article A56572
• Effective Date: January 10, 2021
• Noridian JF
• LCD L34160 / Article A56573
• Effective Date: January 10, 2021

November 5, 2020: Noridian JF Article: Hospital Discharge Status Assistance

Nordian JF reminds providers in this article that “overpayment or underpayment of Medicare claims may result when facilities incorrectly bill a discharge status code.” Included in this article are tips to getting the discharge status correct and links to a quick reference guide of patient status codes and MLN Article SE1411 – Clarification of Patient Discharge Status Codes and Hospital Transfer Policies.

November 6, 2020: Noridian Article: Computed Tomography Cerebral Perfusion Analysis (CTP) Final LCD and Billing and Coding Article

Effective December 13, 2020, Noridian’s LCD and related Coverage Article will be effective meaning that CTP will be considered medically reasonable and necessary in patients with small acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers.

• Noridian JE
• LCD L38709 / Article A58223
• Effective Date: December 13, 2020
• Noridian JF
• LCD L38700 / Article A58225
• Effective Date: December 13, 2020

November 6, 2020: The SMRC Goes Green

Noridian announced that the Supplemental Medical Review Contractor (SMRC) has started mailing additional documentation requests in green envelopes to assist with proper notification review. Noridian advises providers to let you mail department know of this change to allow requests be received by the appropriate departments and handled timely. Palmetto GBA also included a similar announcement in their November 10th Daily Newsletter.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from November 3rd through November 9th.

Resource Spotlight: Telehealth Information for Providers and Patients

Telehealth.HHS.GOV offers resources for Providers and Patients.

Telehealth Resources for Providers: Content available on the Telehealth for Providers webpage includes:

• Getting Started,
• Planning your telehealth workflow,
• Preparing patients for telehealth,
• Policy changes during the COVID-19 Public Health Emergency,
• Billing and Reimbursement during the COVID-19 Public Health Emergency, and
• Legal Considerations

Telehealth Resources for Patients: Content available on the Telehealth for Patients webpage includes:

• Understanding telehealth,
• Telehealth during the COVID-19 emergency,
• Finding telehealth options, and
• Preparing for a video visit.

November 4, 2020: Provider-Specific Fact Sheets on New Waivers and Flexibilities Updated

CMS updated almost all of the Provider-Specific Fact Sheets on News Waivers and Flexibilities to include information from the October 28, 2020 Interim Final Rule (IFC) to ensure all Americans have access to a COVID-19 vaccine when one becomes available. Of note, “for calendar years 2020 and 2021, Medicare will pay directly for the COVID-19 vaccine and its administration for beneficiaries enrolled in Medicare Advantage (MA) plans. Providers should submit COVID-19 claims to Original Medicare for all patients enrolled in MA in 2020 and 2021. MA plans will not be responsible for reimbursing providers to administer the vaccine during this time. MA beneficiaries also pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.” All of the Face Sheets can be accessed on the CMS Coronavirus waivers and flexibilities webpage. Note, the Toolkit for States to Mitigate COVID-19 in Nursing Homes found on the COVID-19 Current Emergencies webpage was also updated on November 4th to include the vaccine information.

November 5, 2020: Governor Ivey Extends Safer at Home order until December for the State of Alabama

The Safer at Home order has been extended until December 11, 2020 and include the mask ordinance requiring masks be worn in schools and in public when interacting within 6 feet of someone from another household. Following are two new amendments to the order:

• Occupancy Rates: Emergency occupancy rates will be removed from retailers, gyms and fitness centers, and entertainment venues.
• Use of Partitions: An exception to social-distancing rules will be allowed for many businesses – including barber shops, hair salons, gyms, and restaurants – if people are wearing masks and separated by an “impermeable” barrier.

You can read the Press Release and access Safer at Home Information Sheets on the Alabama Governor’s Newsroom webpage.

November 5, 2020: Preparing to Administer COVID-19 Vaccine when it’s Available

CMS included the following information in their Thursday November 5th edition of MLNConnects:

“Get ready to administer the COVID-19 vaccine when it’s available. Read the enrollment section of our COVID-19 provider toolkit to see if you need to take action now:

• Many Medicare-enrolled providers don’t have to take any action until a vaccine is available – make sure your provider-type enrollment is all set
• Some Medicare-enrolled providers must also separately enroll as a mass immunizer to administer and bill for COVID-19 vaccines when they’re available – find out if you must also enroll as a mass immunizer
• If you’re not a Medicare-enrolled provider, you must enroll as a mass immunizer or other Medicare provider type that can bill for administering vaccines

Enrolling over the phone a mass immunizer is easy and quick — call your MAC-specific enrollment hotline (PDF) and give your valid legal business name, national provider identifier, tax identification number, practice location, and state license, if applicable.”

November 6, 2020: CDC Report: Telework before Illness Onset of COVID-19

The CDC’s Morbidity and Mortality Weekly Report (MMWR) for November 6th focused on employees working in the office versus telework and positive COVID-19 test. Following are answers to questions in the summary section of this report.

“What is added by this report? Adults who received positive test results for SARS-CoV-2 infection were more likely to report exclusively going to an office or school setting in the 2 weeks before illness onset, compared with those who tested negative, even among those working in a profession outside of the critical infrastructure.

What are the implications for public health practice? Businesses and employers should promote alternative work site options, such as teleworking, where possible, to reduce exposures to SARS-CoV-2. Where telework options are not feasible, worker safety measures should continue to be scaled up to reduce possible worksite exposures.”

November 6, 2020: OIG Audit – Office of Refugee Resettlement (ORR) Preparedness to Respond to COVID-19 Pandemic

The OIG released their report where they conducted a communicable disease preparedness audit of 11 selected facilities from March through June 2020 during the COVID-19 pandemic in the United States. They found that the facilities selected for review followed preparation requirements and were prepared to respond to the pandemic. The OIG report contains no recommendations.

“ORR officials stated that, since 2006, ORR has had a policy in place that required its facilities to prepare for and respond to a communicable disease outbreak; therefore, the facilities were generally able to quickly pivot to respond to the COVID-19 pandemic.”

November 6, 2020: FDA Authorizes First Test to Detect Neutralizing Antibodies from Recent or Prior SARS-CoV-2 Infection

Previously issued Emergency Authorization Use (EUAs) for antibody (serology) tests only detect the presence of binding antibodies. The EUA issued to GenScript USA Inc. for its cPass SARS-CoV-2 Neutralization Antibody Detection Kit is “the first serology test that detects neutralizing antibodies from recent or prior SARS-CoV-2 infection, which are antibodies that bind to a specific part of a pathogen and have been observed in a laboratory setting to decrease SARS-CoV-2 viral infection of cells.”

In the FDA’s press announcement they caution “against using the results from this test, or any serology test, as an indication that they can stop taking steps to protect themselves and others, such as stopping social distancing, discontinuing wearing masks or returning to work. The FDA also wants to remind patients that serology tests should not be used to diagnose an active infection, as they only detect antibodies that the immune system develops in response to the virus, not the virus itself.”

November 9, 2020: FDA Authorizes Monoclonal Antibody Treatment

The FDA announced the issuance of an emergency use authorization (EUA) for Bamlanivimab which is an investigational monoclonal antibody therapy. This drug is not authorized for patients already hospitalized due to COVID-19. Instead, it is to be given in an outpatient setting and  “is authorized for patients with positive results of direct SARS-CoV-2 viral testing who are 12 years of age and older weighing at least 40 kilograms (about 88 pounds), and who are at high risk for progressing to severe COVID-19 and/or hospitalization. This includes those who are 65 years of age or older, or who have certain chronic medical conditions.”

According to the Scope of Authorization in the emergency use authorization (EUA):

• Distribution of the authorized drug will be controlled by the U.S. Government,
• Again, it is authorized for use only by healthcare providers in an outpatient setting,
• The drug may only be administered in a setting where health care providers have immediate access to medications to treat a severe infusion reaction, and
• Use of the drug covered by the authorization must be in accordance with the dosing regiments in the authorized Fact Sheets.

You can also read more about the EUA in a related Lilly Investors announcement.

November 9, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) MLN Matters Article Revised

MLN Matters Article SE20011  was originally released March 16, 2020. The most recent iteration of this article includes revisions to clarify the billing instructions in the Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information section.

November 9, 2020: Pfizer Announces Vaccine Against COVID-19

In an early Monday morning Press Release, Pfizer announced the success of a joint effort with BioNTech in the development of a vaccine. Specifically, Pfizer indicated that the “vaccine candidate was found to be more than 90% effective in preventing COVID-19 in participants without evidence of prior SARS-CoV-2 infection in the first interim efficacy analysis.” Once the required safety milestone has been achieved Pfizer is planning to submit for Emergency Use Authorization (EUA) to the FDA. At the time of the Press Release the expectation for reaching that milestone was this week.

CDC COVID Data Tracker – United States COVID-19 Cases

Reprinted from Kaiser Health News (CC BY-NC-ND 4.0)

Jordan Rau, Kaiser Health News  November 2, 2020

Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.

The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.

The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.

For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.

Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.

The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.

“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”

The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.

A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.

Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.

“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”

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2020 has been a very long and challenging year. In addition to caring for the influx of COVID-19 patients, hospitals have been bombarded with information on how to code and bill for COVID-19. Included in last week’s newsletter was an FAQ detailing the requirement that documentation of a positive COVID-19 test be in the medical record for hospitals to receive the additional 20% payment for the duration of the COVID-19 public health emergency (PHE).

In March, CMS suspended most Medicare Fee-for-Service (FFS) medical reviews because of the COVID-19 pandemic. However, to add to the challenge for hospitals, medical reviews resumed in August. This article focuses on COVID-19 related reviews being conducted by the Office of Inspector General (OIG) and the Supplemental Medical Review Contractor (SMRC).  

Completed OIG Work Plan Reviews Related to COVID-19

As of November 6, 2020, the OIG’s Office of Evaluation and Inspections has issued reports for two Work Plan items related to the COVID-19 PHE.  

COVID-19 Hospital Response Report (OEI-06-20-00300)

In this report, the OIG notes that feedback from hospitals reflects “perspectives at a point in time-March 23-27, 2020.” At that time, the most significant challenges reported by hospitals was related to testing and caring for patients with COVID-19 and keeping staff safe. From anecdotal conversations with our clients, these challenges remain eight months later.

Highlights of OIG’s Emergency Preparedness Work: Insights for COVID-19 Response Reports

Prior to the COVID-19 PHE, the OIG had published several reports about community and health care facility emergency preparedness and response. The OIG developed the following two toolkits “to assist communities in responding to the current pandemic and to other emergencies as they arise.”

• Toolkit: Insights for Communities From OIG’s Historical Work on Emergency Response (OEI-09-20-00440), and
• Toolkit: Insights for Health Care Facilities from OIG’s Historical Work on Emergency Response (OIE-06-20-00470) OEI-06-20-00470

Active OIG Work Plan Reviews Related to COVID-19

Currently, thirteen of thirty Active Work Plan Items that are related to COVID-19 fall under the Centers for Medicare and Medicaid Services. The following table lists when each of these thirteen items were added to the Work Plan and the Titles of the Item.

I want to call your attention to the August 2020 Item: Audit of Medicare Payments for Inpatient Discharges Billed by Hospitals for Beneficiaries Diagnosed with COVID-19. Specifically, the following summary description for this Work Plan Item:

“Section 3710 of the Coronavirus Aid, Relief, and Economic Security Act directs the Secretary to increase the weighting factor that would otherwise apply to the assigned diagnosis-related group by 20 percent for an individual who is diagnosed with COVID-19 and discharged during the COVID-19 public health emergency period.”  We will audit whether payments made by Medicare for COVID-19 inpatient discharges billed by hospitals complied with Federal requirements.”

It is not clear the claims dates of service that the OIG will request. For claims requested with a date of service on or after September 1, 2020 keep in mind that CMS mandated that a positive COVID-19 test within 14 days of admission must be documented in the record to receive the 20% additional payment. If you receive a notice for records from the OIG and the dates of service are on or after September 1 you should verify whether or not a note for “No Pos Test” was submitted to your MAC. If not, be sure to submit the COVID-19 test results when submitting the record to the OIG. 

Supplemental Medical Review Contractor (SMRC)

Noridian Health Solutions, LLCL (Noridian) is the current SMRC. At the direction of CMS, Noridian conducts nationwide medical reviews for Medicare FFS Part A, Part B and Durable Medical Equipment (DME). On October 15, 2020, Noridian posted a Notification of Medical Review titled DRG COVID 20% Add On Payment.

This project will consist of post-payment reviews of Medicare Part A acute care inpatient hospital claims billed on dates of service from April 1, 2020 through August 30, 2020. Documentation requirements to be included in each Additional Documentation Request (ADR) are listed in Noridian’s notification. Included in this list is “Lab/Diagnostic reports, if applicable, including any that support the COVID-19 diagnosis.” Note, the claims being reviewed are prior to the CMS requirement of a positive COVID-19 test result be in the record to receive the 20% additional payment. This will be important to keep in mind in case you receive a denial based solely on the lack of this documentation being in the record.

CMS announced the release of the Transparency in Coverage Final Rule [CMS-9915-F] on October 28, 2020. According to a related CMS Fact Sheet, “This final rule is a historic step toward putting health care price information in the hands of consumers and other stakeholders, advancing the Administration’s goal to ensure consumers are empowered with the critical information they need to make informed health care decisions.”

Figuring out the plot to a mystery novel involves asking questions and looking for answers to basic questions asked when gathering information (who, what, when, where, and why). CMS Final Rules can at first glance seem like a mystery and require the same process of asking and answering these questions. This article asks key questions and provides you with answers to help you figure out what is included in the Transparency in Coverage Final Rule.

Who is required to Disclose Cost-Sharing Information? 

Group Health Plans and Health Insurance issuers in the Individual and Group Markets.

• Note, the term group health plan includes both insured and self-insured group health plans.

What Type of Cost-Sharing Information is required to be disclosed?

• An estimate of the individual’s cost-sharing liability for covered items or services furnished by a particular provider.
• In-network provider negotiated rates,
• Historical out-of-network allowed amounts, and
• Drug pricing information

What is the required format for Disclosure of Cost-Sharing Information?

• This information must be available on an internet website in machine-readable files, and
• If requested, in paper form.

How many and what type of machine-readable files are required?

Plans and issuers must disclose pricing information in three machine-readable files

• One file will disclosure of payment rates negotiated between plans or issuers and providers for all covered items and services,
• A second file will disclose unique amounts a plan or issuer allowed, as well as associated billed charges, for covered items or services furnished by out-of-network providers during a specific time period.
• A third file will include pricing information for prescription drugs.

How often will issuers be required to update the machine-readable files?

“The final rules adopt, as proposed, the requirement for a plan or issuer to update the information required to be included in each machine-readable file monthly. The final rules clarify that this requirement to update the machine-readable files monthly applies to all three machine-readable files being finalized through the final rules: the In-network Rate File, the Allowed Amount File, and the Prescription Drug File”

What are the benefits of Disclosing Cost-Sharing Information?

CMS indicates in the Final Rule that “by requiring the dissemination of price and benefit information directly to consumers and to the public, the transparency in coverage requirements will provide the following consumer benefits:

• enables consumers to evaluate health care options and to make cost-conscious decisions;
• strengthens the support consumers receive from stakeholders that help protect and engage consumers;
• reduces potential surprises in relation to individual consumers’ out-of-pocket costs for health care services;
• creates a competitive dynamic that may narrow price dispersion for the same items and services in the same health care markets; and
• Puts downward pressure on prices which, in turn, potentially lowers overall health care costs.”

Where can you find a list of the 500 Items and Services Identified by the Departments?

This information is included in the Final Rule in Table 1: 500 Items and Services List. The table includes the applicable HCPCS/CPT code with the code description and a plain language description. For example, the first item in the list is J0702: BETAMETHASONE ACET&SOD PHOS with the plain language description being “Injection to treat reaction to a drug.”

Where can you find definitions of key terms in the Final Rule?

There is a Transparency in coverage – Definitions section towards the end of the final rule. Here you will find definitions for the following key terms:

• Accumulated amounts,
• Beneficiary,
• Billed charge,
• Billing code,
• Bundled payment arrangement,
• Copayment assistance,
• Cost-sharing liability,
• Cost-sharing information,
• Covered items and services,
• Derived amount,
• Historical net price,
• In-network provider,
• Items or services,
• Machine-readable file,
• National Drug Code,
• Negotiated rate,
• Out-of-network allowed amount,
• Out-of-network provider,
• Out-of-pocket limit,
• Plain language,
• Prerequisite, and
• Underlying fee schedule rate.

What are the CMS Intended Outcomes from implementation of this Final Rule?

• Informed Consumers,
• Consumers may become more cost conscious,
• Timely payment of medical bills, and
• Increase competition among Providers

When will the regulations in this Final Rule go into effect?

“The final rules adopt a three-year, phased-in approach with respect to the scope of the requirement to disclose cost-sharing information. Plans and issuers must make cost-sharing information available for 500 items and services identified by the Departments for plan years (in the individual market, for policy years) beginning on or after January 1, 2023, and must make cost-sharing information available for all items and services for plan years (in the individual market, for policy years) beginning on or after January 1, 2024.”

How will Requirements in the Final Rule be enforced?

“States will generally be the primary enforcers of the requirements imposed upon health insurance issuers by the final rules. 233 The Departments expect to work closely with state regulators to design effective processes and partnerships for enforcing the final rules.”

Of note, this final rule also includes amendments to the Department of Health and Human Services (HHS) medical loss ratio (MLR) program “to allow issuers offering group or individual health insurance coverage to receive credit in their MLR calculations for savings they share with enrollees that result from the enrollees shopping for, and receiving care from, lower-cost, higher-value providers.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from October 27th – November 2nd.

Resource Spotlight: November 2, 2020 - CDC Adds to List of Medical Conditions Putting Patients at Risk for Severe Illness due to COVID-19

The CDC webpage People with Certain Medical Conditions has once again been updated to add sickle cell disease and chronic kidney disease to the conditions that might increase the risk of severe illness among children. As we approach the holiday season, this webpage also provides guidance regarding what to consider before being around people and things to consider to help make personal and social activities as safe as possible.

October 28, 2020: FDA Enforcement Policy for Non-Invasive Remote Monitoring Devices during COVID-19 PHE (Revised)

The FDA initially issued guidance in June 2020 “to provide a policy to help expand the availability and capability of non-invasive remote monitoring devices to facilitate patient monitoring while reducing patient and healthcare provider contact and exposure to COVID-19 for the duration of the COVID-19 public health emergency.” They note in this October 28, 2020 Announcement that the guidance has been updated and that it is intended to remain in effect only for the duration of the Public Health Emergency (PHE) related to COVID-19.

October 28, 2020: Fourth COVID-19 Interim Final Rule with Comment Period (IFC-4) – Eliminating Barriers, Flexibilities, Extension CJR Model,

CMS announced, in an October 28 Press Release, the release of a fourth COVID-19 Interim Final Rule. In a related Fact Sheet, CMS indicates that this final rule, “removes administrative barriers to eliminate potential delays to patient access to a lifesaving vaccine. In addition, the rule:

• Creates flexibilities for states maintaining Medicaid enrollment during the COVID 19 PHE;
• Establishes enhanced Medicare payments for new COVID-19 treatments;
• Takes steps to ensure price transparency for COVID-19 tests, and
• Provides an extension of Performance Year 5 for the Comprehensive Care for Joint Replacement (CJR) model; and
• Creates flexibilities in the public notice requirements and post-award public participation requirements for a State Innovation Waiver under Section 1332 of the Patient Protection and Affordable Care Act during the COVID-19 PHE.”

October 28, 2020: Fourth COVID-19 Interim Final Rule with Comment Period (ICF-4): New COVID-19 Treatments Add-On Payment (NCTAP)

As a segue to the new add-on payment, Section D. of ICF-4 reviews section 3710 of the CARES Act and the IPPS New Technology Add-On Payment process before transitioning to the FDA Coronavirus Treatment Acceleration Program created for possible coronavirus therapies. One aspect of this program is the issuance of Emergency Use Authorizations (EUAs) during the COVID-19 Public Health Emergency (PHE). “CMS has determined that it is appropriate for CMS to consider drug and biological products which are authorized for emergency use for COVID-19, with letters of authorization, and are used to treat COVID-19 disease, to fall within the drugs and biologicals” Medicare benefit category.

CMS believes that as “drugs or biological products become available and are authorized or approved by FDA for the treatment of COVID-19 in the inpatient setting, it would be appropriate to increase the current IPPS payment amounts to mitigate any potential financial disincentives for hospitals to provide these new treatments during the PHE.”

CMS indicates effective with the date of ICF-4 and until the end of the PHE, when a therapy meets specific criteria it will be eligible for NCTAP. They also note that currently there are only two drug and biological products that meet the criterion. The following table highlights the two products and the ICD-10-PCS codes assigned to the products.

“CMS is setting the NCTAP amount for a case that meets the NCTAP eligibility criteria equal to the lesser of: (1) 65 percent of the operating outlier threshold for the claim or (2) 65 percent of the amount by which the costs of the case exceed the standard DRG payment, including the adjustment to the relative weight under section 3710 of the CARES Act. As with the new technology add-on payment and outlier payments, the costs of the case are determined by multiplying the covered charges by the operating cost-to-charge ratio. In addition, the NCTAP will not be included as part of the calculation of the operating outlier payments.”

To date, no drug or biological product has a EUA for treatment of COVID-19 patients in the outpatient setting. However, this Interim Final Rule includes the criteria for separate payment for New COVID-19 Treatments in the Outpatient Setting for the remainder of the PHE if and when a product is granted EUA.

October 28, 2020: Incentive Payments to Nursing Home Curing COVID-19 Deaths and Infections

Over 10,000 nursing homes will be receiving money from the approximately $333 million in first round performance payments to be made by HHS through the Health Resources and Services Administration (HRSA). HHS Secretary Alex Azar indicated in an HHS Press Release that "These $333 million in performance payments are going to nursing homes that have maintained safer environments for residents between August and September. We've provided nursing homes with resources and training to improve infection control, and we're rapidly providing incentives to those facilities that are making progress in the fight against COVID-19."

October 30, 2020: CDC Morbidity & Mortality Report: COVID-19 Exposure and Infection Among Health Care Personnel

The CDC’s Morbidity and Mortality Weekly Report (MMWR) for October 30th focused on COVID-19 exposure and infection among health care professionals in Minnesota from March 6th through July 11, 2020. The report summary acknowledges that it is already known that health care personnel (HCP) are at increased risk for COVID-19 from workplace exposures. The authors of this report found that “HCP in congregate living and long-term care setting experience considerable risk and post a transmission risk to residents. Improved access to personal protective equipment, flexible medical leave and testing is needed.”

October 30, 2020: CMS Announces Launch of the Nursing Home Resource Center

CMS announced the launch of this new online platform which “consolidates all nursing home information, guidance and resources into a user-friendly, one-stop-shop that is easily navigable so providers and caregivers can spend less time searching for critical answers and more time caring for residents. Moreover, the new platform contains features specific to residents and their families, ensuring they have the information needed to make empowered decisions about their healthcare.”

The Resource Center includes information for Providers & CMS Partners and Patients & Caregivers. Resource Topics specific to Providers and CMS Partners includes the following:

• Regulations & Guidance,
• Training & Resources,
• Technical Information,
• COVID-19 Data & Updates, and
• Payment Policy Information.

October 30, 2020: Supply Kits to Safely Administer COVID-19 Vaccines to Americans

An HHS news release indicates that they have “recently contracted with McKesson Corporation to produce, store and distribute these vaccine ancillary supply kits on behalf of the Strategic National Stockpile. Each kit will contain enough supplies to administer up to 100 doses of vaccine and will include:

• Needles (various sizes for the population served by the ordering vaccination provider)
• Syringes
• Alcohol prep pads
• Surgical masks and face shields for vaccinators
• COVID-19 vaccination record cards for vaccine recipients
• Needle information card”

October 31, 2020: BinaxNOW COVID-19 Tests Distribution

HHS announced that in ongoing efforts to prevent COVID-19 outbreaks in high risk communities, 389,040 Abbott BinaxNOW COVID-19 rapid tests have been distributed at no cost to 83 Historically Black Colleges and Universities (HCBU’s) in 24 states. “The Abbott BinaxNOW test is the only rapid point of care test that does not require instrumentation – is easy to use, produces COVID-19 test results within fifteen minutes and costs just five dollars. In addition to responding quickly to flash outbreaks, these tests are ideally suited for the screening and ongoing surveillance of underserved demographic groups and in congregate settings such as group homes, nursing homes, K-12 schools and institutions of higher learning.”

CDC COVID Data Tracker – United States COVID-19 Cases

Q:

I have been told conflicting information about documenting a positive COVID-19 test. Is physician documentation that a patient has COVID-19 sufficient for the hospital to receive additional payment?

A:

The short answer is no. However, reminiscent of the late Paul Harvey, here is the rest of the story.

COVID-19: Timeline to a New Code

The CDC announced the release of a new code specifically for reporting COVID-19 during the March 18th ICD-10-CM Coordination and Maintenance Committee Meeting. This code became effective on April 1st, 2020. Following is a timeline of events prompting the speed with which this code was made available for use:

• January 31, 2020: An emergency meeting was convened by the World Health Organization (WHO) Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) and a new ICD-10 emergency code was established.
• U07.1, 2019-nCoV acute respiratory disease

• February 20, 2020: The CDC published supplemental guidance for coding encounters related to COVID-19. At that time hospitals were instructed to used ICD-10-CM code B97.29 (Other coronavirus as the cause of diseases classified elsewhere) when coding a confirmed COVID-19 infection. Note, ICD-10-CM code B97.29 was to be used by hospitals for discharges occurring on or after January 1, 2020, and on or before March 31, 2020.

• March 18, 2020: The Coordination and Maintenance Committee Meeting met virtually. It was announced that the COVID-19 code (U07.1) effective date was changed from October 1, 2020 to April 1, 2020 due to the national health emergency.

• March 31, 2020: The CDC released the document ICD-10-CM Official Coding and Reporting Guidelines for coding COVID-19 April 1, 2020 – September 30, 2020. The guidelines indicated that you are to “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.”

• April 1, 2020: The CDC published an ICD-10-CM Tabular Lists of Diseases and Injuries Addenda which established a new chapter (Chapter 22: Codes for special purposes [U00-U85https://www.cdc.gov/nchs/icd/icd10cm.htm">CDC ICD-10-CM webpage as well as the CMS ICD-10-CM webpage. The updated guidelines includes a new section in Chapter 1 (Certain Infectious and Parasitic Diseases) related to coding COVID-19.

Hospital Inpatient Setting: Timeline to Additional Payment for Treating COVID-19 Patients

• March 27, 2020: The Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. Within this law was the following guidance regarding additional payment for treatment of patients diagnosed with COVID-19:
• Sec. 3710 Medicare Hospital Inpatient Prospective Payment System Add-On Payment for COVID-19 Patients During Emergency Period: “For discharges occurring during the emergency period, in the case of a discharge of an individual diagnosed with COVID-19, the Secretary shall increase the weighting factor that would otherwise apply to the diagnosis-related group to which the discharge is assigned by 20 percent. The Secretary shall identify a discharge of such an individual through the use of diagnosis codes, condition codes, or other such means as may be necessary.”
  
  
• April 24, 2020: MLN Matters Article MM11764 details guidance in Change Request 11764 regarding coding COVID-19 and the implementation of the temporary payment adjustment as mandated by section 3710 of the CARES Act.

• August 14, 2020: Transmittal 10300 (Update to the Implementation of the Increased Payments for COVID-19 Discharges Under the Inpatient Prospective Payment System (IPPS) Under Section 3710 of the CARES Act) was released to prospectively update “the implementation of section 3710 of the CARES Act to require that a positive laboratory test be documented in the patient’s medical record for the increased payment for COVID-19 discharges under the Inpatient Prospective Payment System (IPPS).”
• Note, Transmittal 10300 has since been rescinded and replaced with Transmittal 10361 (Change Request 11925).

• August 17, 2020: MLN Matters Article SE20015 initially released on April 15, 2020 was revised on August 17, 2020 to add the following language:
• “To address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.

For this purpose, a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient’s medical record to satisfy this documentation requirement. For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government-run testing center can be added to the patient’s medical record. In the rare circumstance where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to that test result for purposes of this documentation requirement.”

Coding vs. Billing for COVID-19

As indicated earlier in this article, the ICD-10-CM guidelines indicate that you code only confirmed cases of COVID-19 as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result.

However, CR 11925, for admissions occurring on or after September 1, 2020 hospitals are “required to have a positive COVID-19 laboratory test documented in the patient’s medical record.  Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.”

What do you do when a physician documents that a patient has a confirmed case of COVID-19 but there is no positive test result in the record?

Both, CR 11925 and MLN Matters SE20015 provide the following guidance:

“A hospital that diagnoses a patient with COVID-19 consistent with the ICD-10-CM Official Coding and Reporting Guidelines but does not have evidence of a positive test result can decline, at the time of claim submission, the additional payment resulting from the application at the time of claim payment of the 20 percent increase in the MS-DRG relative weight to avoid the repayment. To do so, the hospital will inform its MAC and the MAC will notate the claim with MAC internal claim processing coding for processing. The Pricer software will not apply the 20 percent increase to the claim when that MAC internal claim processing coding is present on a claim with the ICD-10-CM diagnosis code U07.1 (COVID-19). The updated Pricer software package reflecting this change will be released in October 2020.

To notify your MAC when there is no evidence of a positive laboratory test documented in the patient’s medical record, enter a Billing Note NTE02 “No Pos Test” on the electronic claim 837I or a remark “No Pos Test” on a paper claim.”

Hospital IPPS Payments under Section 3710 the CARES Act

CMS has made available the document COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Section F of this document, titled Hospital IPPS Payments under the CARES Act, answers questions about section 3710 of the CARES Act and provides examples illustrating the increase in IPPS operating MS-DRG payments. Note, during the COVID-19 Public Health Emergency (PHE), this document has been updated on a fairly regular basis and as of the October 28, 2020, the update is 152 pages in length. I encourage you to check for updates on a regular basis.  

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from October 20th through October 26th.

Resource Spotlight: Tips for Voters

As we are just days away from the election, the CDC has created a Tips for Voters to Reduce Spread of COVID-19 webpage which includes 6 steps to follow before you vote and 6 steps to take the day you vote. For those of you who plan to vote in person, the CDC provides a checklist of recommended items to bring with you to your voting site, including:

• Necessary documentation such as your identification (check with your voting site),
• A mask,
• An extra mask,
• Tissues,
• Hand sanitizer with at least 60% alcohol,
• Water,
• Black ink pen, and
• Bring prepared items with you (e.g., registration forms, sample ballots)

October 20, 2020: New FAQs added to COVID-19 FAQs on Medicare Fee-for-Service (FFS) Billing

Three new FAQs were added to this now 150 page document on October 20, 2020. Two pertain to Medicare Telehealth (questions 46 and 47 in the Medicare Telehealth section of this document). The third FAQ is related to Medicare beneficiary SNF benefits as follows:

“Question: If a new benefit period was granted pursuant to the section 1812(f) waiver, and the PHE ends in the middle of that new benefit period, would the beneficiary be entitled to the full 100 days of renewed SNF benefits, or would that entitlement end on the day the PHE ends?

Answer: If a beneficiary has qualified for the special one-time renewal of SNF benefits under the benefit period aspect of the section 1812(f) waiver while the section 1812(f) waiver is in effect, that reserve of 100 additional SNF benefit days would remain available for the beneficiary to draw upon even after the waiver itself has expired.

New: 10/20/20”

As a reminder, Secretary Azar issued the most recent continuation of the Public Health Emergency (PHE) due to the COVID-19 pandemic on October 2, 2020 with an effective date of October 23, 2020.

October 21, 2020: CDC Guidance: Test for Current Infection Updated

The CDC webpage Test for Current Infection has been updated and lists the following considerations for who should get tested:

• People who have symptoms of COVID-19,
• People who had had close contact (within 6 feet of an infected person for a total of 15 minutes or more) with someone with confirmed COVID-19,
• People who have been asked or referred to get testing by their healthcare provider, local or state health department.

October 21, 2020: Expanding Access to COVID-19 Tests and Vaccines

HHS issued guidance under the Public Readiness and Emergency Preparedness Act (PREP Act) authorizing qualified pharmacy technicians and State-authorized pharmacy interns to administer, childhood vaccines, COVID-19 Vaccines when available, and COVID-19 tests. All those authorized to administer tests and vaccines are subject to several requirements. HHS provides a link to the guidance document in their Press Release.

October 22, 2020: Nursing Home COVID-19 Preparedness for Fall & Winter Web-Based Training

The Thursday October 22nd edition of the CMS MLNConnects newsletter informs providers about web-based training available to Nursing Homes to help them prepare for COVID-19, provide resident-centered care, and prevent and control infection. You can visit the Quality, Safety & Education Portal to access free scenario-based trainings for managers and frontline staff. See the flyer for more information.

October 22, 2020: FDA Approved First Treatment for COVID-19

The FDA announced their approval of the “antiviral drug Veklury (remdesivir) for use in adult and pediatric patients 12 years of age and older and weighing at least 40 kilograms (about 88 pounds) for the treatment of COVID-19 requiring hospitalization. Veklury should only be administered in a hospital or in a healthcare setting capable of providing acute care comparable to inpatient hospital care. Veklury is the first treatment for COVID-19 to receive FDA approval.” 

Reminder, effective August 1, 2020, CMS implemented 12 new ICD-10-PCS codes related to COVID-19 became effective, including the administration of Remdesivir.

October 22, 2020: Relief Fund Eligibility Expansion and Updated Reporting Requirements

Relief Fund Eligibility Expansion: HHS announced the expansion of Providers eligible to receive Phase 3 Provider Relief Funding. The announcement includes a list of eligible providers “regardless of whether they accept Medicaid or Medicare.” Note, applicants have until 11:59PM EST on November 6, 2020 to submit an application for payment consideration.

Reporting Requirement Update: An update to the reporting requirements was also included in the announcement. “In response to concerns raised, HHS is amending the reporting instructions to increase flexibility around how providers can apply PRF money toward lost revenues attributable to coronavirus. After reimbursing healthcare related expenses attributable to coronavirus that were unreimbursed by other sources, providers may use remaining PRF funds to cover any lost revenue, measured as a negative change in year-over-year actual revenue from patient care related sources.” Note, this announcement includes links to a policy memorandum and the amended reporting requirements.

CDC COVID Data Tracker – United States COVID-19 Cases

MEDICARE TRANSMITTALS – RECURRING UPDATES

January 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: October 9, 2020
• What You Need to Know: This article informs providers about updates to the Quarterly ASP Medicare Part B Pricing Files and informs you of revisions, if needed to prior quarterly pricing files.
• MLN MM12020: https://www.cms.gov/files/document/MM12020.pdf

OTHER MEDICARE TRANSMITTALS

 New Waived Tests

• Article Release Date: October 5, 2020 – Revised October 15, 2020
• What You Need to Know: This article tells you of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the FDA. CMS notes that “MACs will not search their files to either retract payment or retroactively pay claims, however, MACs should adjust claims if you bring those claims to their attention.”
• Note, this article was revised to correct a date for one of the codes for 87804QW.
• MLN Matters MM11982: https://www.cms.gov/files/document/mm11982.pdf

Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 and Productivity Adjustment

• Article Release Date: October 16, 2020
• What You Need to Know: This article provides the CY 2021 AIF for determining the payment limit for ambulance services.
• MLN MM12031: https://www.cms.gov/files/document/mm12031.pdf

REVISED MEDICARE TRANSMITTALS

October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3

• Article Release Date: August 28, 2020 – Revised October 5, 2020
• What You Need to Know: This article was revised to reflect changes made to CR 11944 including adding several items to the Summary of Quarterly Release Modifications table.
• MLN Matters MM11944: https://www.cms.gov/files/document/mm11944.pdf

Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020

• Article Release Date: August 31, 2020 – Revised September 24, 2020
• What You Need to Know: This article was revised to reflect a revised CR 11876 which changed the hourly Continuous Home Care rates in the hospice tables.
• MLN Matters MM11876: https://www.cms.gov/files/document/mm11876.pdf

Change to the Payment of Allogeneic Stem Cell Acquisition Services

• Article Release Date: July 13, 2020 – Revised October 21, 2020
• What You Need to Know: This article was revised to reflect the revised CR 11729 issued on October 20, 2020. This revision did not impact the substance of the article.
• MLN Matters: MM11729: https://www.cms.gov/files/document/mm11729.pdf

MEDICARE COVERAGE UPDATES

October 22, 2020: MCD Overview Page and Advanced Search Function Going Away

CMS has posted the following alert on the Medicare Coverage Database (MCD) Notice Board:

“On December 11, 2020, the Overview page of the Medicare Coverage Database (MCD) application will be removed in an effort to streamline the site. The website address will remain cms.gov/medicare-coverage-database but users will be directed to the Search page by default, instead of the Overview page.

On April 30, 2021, the Advanced Search function of the MCD application will be removed. All features related to the Advanced Search were incorporated into the new Search function, which was released on September 3, 2020. The new Search function is both faster and easier to use than the Advanced Search, so please switch to the new Search if you haven't already. Bookmarks to advanced-search.aspx and search-results.aspx will no longer work after April 30, 2021.”

MEDICARE EDUCATIONAL RESOURCES

September 28, 2020: MLN Fact Sheet: ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets

• What You Need to Know: CMS released this educational tool to give “health care providers, suppliers, medical coders, billing and claims staff an easy reference to information on the code sets used to bill Medicare claims.” CMS advises using this tool when submitting inpatient and outpatient diagnoses, procedures, and supplies on Medicare claims.
• ICN MLN900943 September 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICD9-10CM-ICD10PCS-CPT-HCPCS-Code-Sets-Educational-Tool-ICN900943.pdf

October 2020: Medicare Quarterly Provider Compliance Newsletter

This CMS quarterly newsletter provides information on how to avoid common billing errors and includes top issues of a particular quarter. The October 2020 edition of the newsletter highlights Recovery Auditor Findings related to the following two issues:

Issue #0070: Critical Care Billed on the Same Day as Emergency Room Services: Unbundling

• Provider Types Affected: Physicians and Non-Physician Practitioners (NPPs)
• Problem: “Hospital emergency department services are not payable for the same calendar date as critical care services when billed for the same beneficiary, on the same date of service and by the same service provider (based on Tax ID and Provider Specialty Code).
• Affected Codes: 99281, 99282, 99283, 99284, 99285
• Type of Review: Automated Review

Issue #0131: Pneumatic Compression Device (PCD): Medical Necessity and Documentation Requirements.

• Provider Types Affected: Durable Medical Equipment (DME) Suppliers, including physicians who supply DME
• Problem: When providing PCDs to patients, be sure the patient meets all Medicare coverage criteria.
• Affected codes: E0650, E0651, E0652, E0656, E0657, E0667, E0668, E0669 and E0670.
• Type of review: Complex Review

Link to newsletter: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/mln5230120

OTHER MEDICARE UPDATES

September 28, 2020: CMS Guidance Related to the Emergency Preparedness Testing Exercise Requirements – COVID-19

CMS posted a Memo to State Surveyors on their website which included the following summary statements and a link to the memorandum:

“CMS regulations for Emergency Preparedness require specific testing exercises be conducted to validate the facility’s emergency program. During or after an actual emergency, the regulations allow for an exemption to the testing requirements based on real world actions taken by providers and suppliers.

This worksheet presents guidance for surveyors, as well as providers and suppliers, with relevant scenarios on meeting the testing requirements in light of many of the response activities associated with the COVID-19 Public Health Emergency (PHE).”

September 28, 2020: CY 2021 Annual Amount In Controversy (AIC) Adjustments

CMS published the AIC Adjustments for CY 2021 in the Federal Register:

• Administrative Law Judge (ALJ) hearings AIC threshold: $180, and
• Judicial Review AIC threshold: $1,760.

October 5, 2020: Compliance with Residents’ Rights Requirement related to Nursing Home Residents’ Right to Vote

CMS sent this Memorandum to State Survey Agency Directors on October 5, 2020. Following are the three Memorandum Summary bullets:

• The Centers for Medicare & Medicaid Services (CMS) is affirming the continued right of nursing home residents to exercise their right to vote.
• While the COVID-19 Public Health Emergency has resulted in limitations for visitors to enter the facility to assist residents, nursing homes must still ensure residents are able to exercise their Constitutional right to vote.
• States, localities, and nursing home owners and administrators are encouraged to collaborate to ensure a resident’s right to vote is not impeded.

Additionally, CMS has published a letter to be sent to nursing home residents or family members.

October 8, 2020: CMS Press Release: Medicare Advantage and Medicare Part D Quality Ratings

CMS indicates in this Press Release that “according to the latest data, quality ratings of Medicare Advantage and Medicare Part D drug plans remain strong. Most Medicare beneficiaries – about 77 percent – who enroll in Medicare Advantage plans with drug coverage will be in plans with four or more stars in 2021.”

October 9, 2020: New National Action Plan for Combating Antibiotic-Resistant Bacteria

The CDC announced the release of the next National Action Plan for Combating Antibiotic-Resistant Bacteria for 2020-2025. They note in the announcement that antibiotic-resistant infections kill more than 35,000 people in the United States each year.

October 19, 2020: Palmetto GBA Outpatient Department (OPD) Prior Authorization (PA) Alert!

Palmetto GBA included in the following Alert in their October 21, 2020 Daily eNewlsetter:

“As of October 9, 2020, if you are a physician/NPP (Part B provider), you are required to provide two (2) fax numbers to receive your Outpatient Department (OPD) Prior Authorization (PA) decision. If a second fax number is not provided, your OPD PA will be rejected. 

If the requestor is a representative of the Hospital Outpatient Facility, only one (1) fax number is required.

Did you know?
...that the when requesting an OPD PA you must include both the hospital and the requestor’s fax number if the requestor is the physician/NPP (Part B provider)? If not, your PA will be rejected.

Did you know?
...that if the requestor is a representative of the Hospital Outpatient Facility, only one fax number is required.”

October 21, 2020: CMS Announcement, Radiation Oncology Model Delayed

CMS posted the following update to the CMS Radiation Oncology Model webpage:

“UPDATE: (10/21/2020) - CMS has received feedback from a number of stakeholders about the challenges of preparing to implement the RO Model by January 1, 2021. Based on this feedback, CMS intends to delay the RO Model start date to July 1, 2021. We are pursuing rulemaking to make this change.” Note, slides for two recent events related to this model as well as an FAQ document are also available on the Radiation Oncology Model webpage.

October 2020 C2C Innovative Solutions, Inc. Quarterly Newsletter Released

C2C Innovative Solutions Inc. (C2C), the Qualified Independent Contractor (QIC) for Medicare Part A for 26 eastern states, Washington D.C. and two U.S. territories, has released its quarterly newsletter.

October 21, 2020: Alabama Medicaid Alert: National Changes for Office Visit Procedure Codes

The Alabama Medicaid Agency issued an Alert reminding providers about the upcoming changes for Evaluation and Management (E&M) Procedure Codes effective January 1, 2021. This Alert includes links to National Information and Additional Resources about the changes.