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CMS issued two Transmittals in June detailing updates being made in the Medicare Program Integrity Manual. This article highlights changes to Chapter 3 – Verifying Potential Error and Taking Corrective Actions. A related article in this week’s newsletter highlights changes to Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services.

Transmittal 10197 (Change Request (CR) 11730) was issued on June 26, 2020. The purpose of this CR is to clarify CMS’ authority to request and require documentation, upon request, to determine the appropriateness of claims for payment. Changes are being made in the following two sections of Chapter 3:

• Section 3.2.3.2: Time Frames for Submission, and
• Section 3.2.3.8: No Response or Insufficient Response to Additional Documentation Requests (ADRs).

Transmittal Background

Under the General Information section of this Transmittal CMS notes the following:

• There are times when Medicare Contractors (MACs, Comprehensive Error Rate Testing (CERT), Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractor (RACs), Unified Program Integrity Contractors (UPICs), and other contractors may not be able to make a pre- or post- payment determination based on information available on the claim, its attachments, or the billing history when applicable. When this happens a Contractor may require a provider or supplier to submit medical and related supporting documentation to determine payment amounts due. “CMS and its contractors require that sufficient documentation and information be furnished to support that selected claims meet applicable coverage, coding, and billing requirements for payment.”
• When a Medicare Contractor sends a provider an Additional Documentation Request (ADR), they request information be provided within specified time frames. “In cases where no supporting documentation is received to conduct a medical review, the claim shall be denied.”

Section 3.2.3.2: Time - Frames for Submission

Current Manual Guidance: This section applies to MACs, RACs, CERT, and ZPICs as indicated.

Effective July 27, 2020: This section will apply to MACs, RACs, CERT, SMRC, and UPICs, as indicated.

Current Manual Guidance: There is no additional information prior to subsection A.

Effective July 27, 2020: Contractors will be required, “when authoring correspondence related to ADRs, to cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation.

“Contractors are authorized to collect medical documentation by the Social Security Act (the Act).

Section 1815(a) of the Act states that "...no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period."

Section 1833(e) of the Act states that "[n]o payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period." In addition, Contractors are required to ensure that payment is limited to those items and services that are reasonable and necessary.

Section 1862(a)(1)(A) of the Act states that “[n]ot withstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services— which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Subsection 3.2.3.2.A: Prepayment Review Time Frames

Current Guidance: MACs and ZPICs

• Shall notify providers that documentation requested is to be submitted within 45 calendar days of the request,
• Should not grant an extension to providers who need more time to comply with the request, and
• Shall deny claims for which the requested documentation was not received by day 46.

Effective July 27, 2020: MACs and UPICs

• Shall notify providers “when they expect documentation to be received,”
• Should not grant extension to providers who need more time to comply with the request, and
• Shall deny claims “when” the requested documentation “to support payment is not received by the expected timeframe.”

Subsection 3.2.3.2.B: Post payment Review Time Frames

Current Guidance: MACs, CERT, and RACs, ZPICs

• MAC, CERT, and RACs shall notify providers that documentation requests is to be submitted within 45 calendar days of the request.
• ZPICs requesting documentation shall be within 30 calendar days of the request.
• Since there are no statutory requirements for when post payment reviews are to be completed, “MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.”

 Effective July 27, 2020: MACs, CERT, SMRC, UPICs and RACs

• “Shall notify providers when they expect documentation to be received.”
• “MACs, CERT, SMRC, UPICs and RACs have the discretion to gran extensions to providers who need more time to comply with the request. The MACs, CERT, SMRC, UPICs and RACs shall deny claims when the requested documentation to support payment is not received by the expected timeframe (including any applicable extensions).”

Subsection 3.2.3.8: No Response or Insufficient Response to Additional Documentation Requests

Current Guidance: This section applies to MACs, RACs, CERT, and ZPICs/UPICs, as indicated.

Effective July 27, 2020: This section will apply to MACs, RACs, CERT, SMRC, and UPICS, as indicated.

Subsection 3.2.3.8.A.: Additional Documentation Requests

Current Guidance: Information is to be provided with 45 calendar days for MACs and RACs or 30 calendar days for ZPICs/UPICs after the date of request (or within a reasonable time following an extension). If not received, the contractors “shall deny the claim, in full or in part, as not reasonable and necessary.”

Effective July 27, 2020:

The following sentence has been added to the beginning of this section:

• “The reviewer authority to request that documentation be submitted, to support claims payment, is outlined in Section 3.2.3.2 of this chapter.”

Also, specific calendar day timeframes have been replaced with the following:

• “If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following and extension), the MACs, RACs, SMRC, and UPICs shall deny the claim, in full or in part, as not reasonable and necessary.”

MACs will be the contractor responsible for counting denials as automated or non-medical record review.

Subsection 3.2.3.8.B: No Response

During Prepayment Review

Current Guidance: A claim shall be denied by MACs and ZPICs/UPICs if no response is received within 45 calendar days after the date of the ADR.

Effective July 27, 2020: Claims shall be denied by the MACs and UPICs if no response is received within “the expected timeframes.”

During Post-payment Review

Current Guidance:

• For MACs claims will be denied as not reasonable and necessary and count as non-medical record reviews if no response is received within 45 calendar days after the date or the ADR (or extension).
• ZPICs/UPICs shall deny the claim if not response is received within 30 calendar days.
• RACs shall count these as complex or non-complex reviews.

Effective July 27, 2020

• MACs, RACs, UPICs and SMRC shall deny claims as not reasonable and necessary if no response is received within the expected timeframes (or extension).
• “These contractors shall cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation, when denying claims for no response within the expected timeframes.”
• The MACs shall count these denials as non-medical record reviews.

Subsection 3.2.3.8.C.: Insufficient Response

The only change made to this section is that the SMRC has been added to the list of applicable contractors.

Moving forward, closely monitor ADR requests to ensure you provide documentation with “expected timeframes.”

In June, CMS issued Transmittal 10184 (Change Request (CR) 11812), providing information about updates being made to the Medicare Program Integrity Manual. Specifically, the Unified Program Integrity Contractors (UPICs) were inserted in several placed in this document. Transmittal specifics will be reviewed later in this article. However, as the UPICs are a recent addition to the acronym soup of Medicare Contractors (i.e., MAC, RAC, CERT, SMRC), I first want to provide you with background information about the UPIC Contractors.

What are the UPICs?

UPICs perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPIC’s perform integrity related activities associated with the following:

• Medicare Part A,
• Medicare Part B,
• Durable Medical Equipment (DME),
• Home Health and Hospice (HH+H), Medicaid, and
• The Medicare-Medicaid data match program (Medi-Medi).

The UPIC contracts operate in five (5) separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts.

Who Are The UPIC Contractors?

Western Jurisdiction
UPIC Contractor: Qlarant

• Western States: Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming
• Link to website: https://www.qlarant.com

Southwestern Jurisdiction
UPIC Contractor: Qlarant

• Southwestern States: Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, and Mississippi
• Link to website: https://www.qlarant.com

Mid-Western Jurisdiction
UPIC Contractor: CoventBridge Group

• Midwestern States: Iowa, Illinois, Indiana, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, Ohio and Wisconsin
• Link to website: https://coventbridge.com/midwest-upic/

Northeastern Jurisdiction
UPIC Contractor: SafeGuard Services LLC (SGS)

• Northeastern States: Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Your, Pennsylvania, New Jersey, Delaware, Maryland, and District of Columbia
• Link to website: http://www.safeguard-servicesllc.com

South-Eastern Jurisdiction
UPIC Contractor: SafeGuard Services LLC (SGS)

• South-Eastern States: West Virginia, Virginia, North Carolina, South Carolina, Tennessee, Alabama, Georgia, and Florida
• Link to website: http://www.safeguard-servicesllc.com

UPICs in Action

A June 25, 2019 CMS Blog titled Medicaid Program Integrity: A Shared and Urgent Responsibility highlighted the growth of the Medicaid program from $456 billion in 2013 to an estimated $576 billion in 2016 and with this “growth comes a commensurate and urgent responsibility by CMS on behalf of the American taxpayers to ensure sound stewardship and oversight of our program resources.”

The UPICs were cited in this blog for engaging in the following activity related to Education, Technical Assistance and Collaboration:

• CMS conducts State Program Integrity Reviews to assess the effectiveness of the state's program integrity efforts, including its compliance with federal statutory and regulatory requirements. The reviews also assist in identifying effective state program integrity activities and sharing best practices with other states. As a result of the opioid desk reviews, several states have acknowledged the need to increase their opioid-related audit activity and have engaged with the Unified Program Integrity Contractors (UPICs) to develop projects to address this weakness.

Another example of UPICs in Action is the CMS Victimized Provider Project. This program attempts to validate and remediate a provider’s claims as an identity theft victim. CMS advised providers to do the following if they think their identity has been stolen:

• Contact your UPIC who is the CMS fraud contractor that handles investigations on behalf of Medicare.
• Respond to any inquiry from your UPIC as part of a UPICs investigation is to interview the provider.
• Report any suspected ID theft to the police.

UPIC Actions Shared in the Unified Case Management System

CMS Transmittal 871 was released on March 29, 2019. The purpose of this Change Request (CR 11159) was to add Section 4.12 to Chapter 4 in the Medicare Program Integrity Manual. This new section provides instructions related to the UPIC workload entry and update requirements in the Unified Case Management System (UCM).

The purpose for me sharing this older transmittal with you is to make you aware of how many other Medicare Contractors can and probably are following the efforts of the UPICs. This is important because here at MMP we have found that review target efforts are often duplicated by more than one type of Medicare Contractor (i.e. MACs may select a review target based on SMRC findings).

Section 4.12 indicates that “the Unified Case Management (UCM) System is a national database that the UPICs use to enter and update Medicare and Medicaid fraud, waste, and abuse data analysis projects, leads, and investigations initiated by the UPIC. Additionally, the UCM allows the UPICs to enter and track various administrative actions (i.e., pre or post-payment reviews, payment suspensions, revocations, etc.), requests for assistance (RFAs), and requests for information (RFIs) that are fulfilled by UPICs at the request of law enforcement, CMS, or other stakeholders….The following agencies/organizations currently have access to the UCM:

• UPICs
• National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
• Railroad Retirement Board (RRB)
• CMS contractors (FPS, PIMAS, Acumen, IBM)
• MAC Medical Review Units associated with MPIP
• CMS
• FBI
• DOJ
• HHS/OIG
• Other federal and state partners seeking to address program integrity concerns in judicial or state health care programs

All workload received and/or initiated by the UPIC shall be saved in the UCM and shall contain identifying information on the potential subject(s) of a project, lead, investigation, etc., as well as general information on activities performed by the UPIC to substantiate the allegation of potential fraud, waste, or abuse. Investigative workload initiated by the UPIC shall contain a summary of the pertinent information related to any activities and/or resolution, and all fields in the UCM shall be updated with the applicable information as it is received by the UPIC.”

CMS Transmittal 10184: Medicare Program Integrity Manual (PIM) Chapter 6 Updates

Now, back to the CMS Transmittal 10184 issued on June 19, 2020. The purpose of this Change Request (CR 11812) is to update various sections within Chapter 4, 6, and 8 in the Medicare Program Integrity Manual. Today I want to call your attention to the updates in Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services.

Prior to this CR, the following sections in chapter 6:

• 2 - Medical Review of Home Health Services,
• 5.2 - Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions,
• 7 - Medical Review of Inpatient Rehabilitation Facility (IRF) Services, and
• 7.1 - Reviewing for Intensive Level of Rehabilitation Therapy Services Requirements)

Applied to the following CMS Contractors:

• Medicare Administrative Contractors (MACs),
• Supplemental Medical Review Contractor (SMRC),
• Recovery Audit Contractors (RACs), and the
• Comprehensive Error Rate Testing (CERT) Contractor.

Effective July 21, 2020, UPICs have been added to the applicable Contractors in each of these sections.

Additionally, the Zone Program Integrity Contractor (ZPIC) has been removed from sections 6.5.6 (Length of Stay Reviews), 6.5.9 (Circumvention of PPS), and 6.6 (Referrals to the Quality Improvement Organization (QIO)) and replaced by the UPIC as to the Contractor a referral would be made to.

UPICs and RACs

The following note can be found on the CMS Approved RAC Topics webpage:

“CMS often receives referrals of potential improper payments from the MACs, UPICs, and Federal investigative agencies (e.g., OIG, DOJ). At CMS discretion, CMS may require the RAC to review claims, based on these referrals. These CMS-Required RAC reviews are conducted outside of the established ADR limits.”

UPICs and the OIG

The OIG added the Item Results of UPICs’ Benefit Integrity Activities to their Work Plan in June 2020 indicating that “the Unified Program Integrity Contractors (UPICs) are the only benefit integrity contractors that safeguard both the Medicare and Medicaid programs from fraud, waste, and abuse. The Medicare and Medicaid programs provide health coverage to more than 100 million Americans. UPICs must effectively detect and deter fraud, waste, and abuse. This study will continue OIG's work examining the results from benefit integrity contractors' identification and investigation of fraud, waste, and abuse. It also will identify any barriers and challenges UPICs have experienced while conducting unified benefit integrity activities across Medicare and Medicaid.”

It remains to be seen how involved in medical review of inpatient hospital claims for Part A payment the UPICs may become. For now, it’s important to simply be aware of the UPICs in case they do send your hospital a medical record request.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 30th through July 6th.   

Resource Spotlight This Week: CMS Guidance Regarding Nursing Home and Hospital Visitation

CMS recently posted visitation guidance for hospitals and nursing homes on the CMS Current Emergencies webpage.

Nursing Home Visitation

First, on June 24th CMS posted the FAQ document discussing steps and recommendations for visitation in nursing homes. “Because nursing home residents are especially vulnerable, CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when:

• There have been no new, nursing home onset COVID-19 cases in the nursing home for 28 days (through phases one and two)
• The nursing home is not experiencing staff shortages
• The nursing home has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents
• The nursing home has adequate access to testing for COVID-19
• Referral hospital(s) have bed capacity on wards and intensive care units” 

Hospital Visitation

Two days later on June 26, 2020 CMS released a document regarding hospital visitation during Phase II. CMS notes in the opening paragraph that “Because hospital patients are vulnerable to potential COVID-19 infection, CMS does not recommend completely reopening facilities to visitors until Phase III. However, CMS also recognizes the significant toll of separation of patients from family and other loved ones.

In collaboration with State and local public health authorities, hospitals should develop plans for visitors that both consider patient and public health safety, as well as the emotional and care needs of patients and their families who are facing illness or life-events in separation. As facilities enter Phase II, facilities may consider additional flexibilities so that patients and their families can visit.”

The remainder of this document is in the form of questions and answers related to moving forward with hospital visitation prior to Phase III.

June 25, 2020: AMA Announced New CPT code for COVID-19 Antigen Tests

According to AMA President Susan R. Bailey, M.D. in this AMA announcement, “The new CPT code for antigen testing to detect the coronavirus is the latest in a series of CPT codes developed in rapid response to the pandemic...Moving quickly during this crisis to meet the medical coding needs of the health care industry has enhanced the reporting of innovative tools now available to advance medicine's overarching goals of reducing the COVID-19 disease burden, improving health outcomes and reducing long-term care costs.”

New Category I CPT code:

• 87426: Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])

You can read the entire Press Release on the AMA website.

June 30, 2020: CDC Updates Training for Healthcare Professionals Webpage

Examples of topics available to Healthcare Professionals on this CDC webpage related to COVID-19 includes:

• Clinical Outreach and Communication Activity (COCA) Calls where you can learn the latest clinical information and guidance about COVID-19. Recent calls address infection control in nursing homes and dental settings, multisystem inflammatory syndrome in children (MIS-C0), and clinical perspective from across the nation’s healthcare systems.
• COVID-19 Prevention in Long-term Care Facilities
• COVID-10 Prevention in Hemodialysis Facilities
• Donning and Doffing PPE
• Optimization Strategies for Healthcare PPE
• COVID-19 in Animals

July 1, 2020: MLN SE20011 Medicare Response to Public Health Emergency on the COVID-19 Revised Again!

MLN article SE2011 is now in its’ ninth iteration. In this latest revision CMS revised the billing instructions for SNF. Changes include instructions to readmit the beneficiary on day 101 to start the Skilled Nursing Facility (SNF) benefit period waiver. All other information remains the same, for now.

July 1, 2020: New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

MLN article MM11836 initially released on June 12, 2020 and was updated on July 1, 2020 to reflect an updated Change Request (CR) that changes the implementation date to August 3, 2020. The CR announced a new Point of Origin (PoO) Code “G” to indicate a “Transfer from a Designated Disaster Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency (PHE).

July 2, 2020: New OIG Work Plan Item – Use of Medicare Telehealth Services during COVID-19 Pandemic

Following is the detail regarding the new Use of Telehealth Services during COVID-19 Pandemic Work Plan Item:

• “In response to the coronavirus disease 2019 (COVID-19) pandemic, CMS made a number of changes that allowed Medicare beneficiaries to access a wider range of telehealth services without having to travel to a health care facility. Although these changes are currently temporary, CMS is exploring whether telehealth flexibilities should be extended. These two concurrent reviews will be based on Medicare Parts B and C data and will examine the use of telehealth services in Medicare during the COVID-19 pandemic. The first review will examine the extent to which telehealth services are being used by Medicare beneficiaries, how the use of these services compares to the use of the same services delivered face-to-face, and the different types of providers and beneficiaries using telehealth services. The second review will identify program integrity risks with Medicare telehealth services to ensure their appropriate use and reimbursement during the COVID-19 pandemic.”

There were also several Items related to COVID-19 added to the OIG Work Plan in June:

• A Review of Medicare Data to Understand Hospital Utilization During COVID-19,
• Trend Analysis of Medicare Laboratory Billing for Potential Fraud and Abuse with COVID-19 Add-on Testing,
• Medicaid Telehealth Expansion During COVID-19 Emergency,
• Audit of Foster Care Services During Coronavirus Disease 2019 (COVID-19),
• Meeting the Challenges Presented by COVID-19: Nursing Homes,
• Opioid Treatment Program Challenges During the COVID-19 Pandemic,
• Audit of Nursing Home’ Reporting of COVID-19 Information Under CMS’s New Requirements

July 2, 2020: FDA Warns Consumers about Dangerous Alcohol-Based Hand Sanitizers Containing Methanol

The FDA notes in this Press Announcement that they have seen an increase in hand sanitizer products labeled to contain ethanol (also known as ethyl alcohol) that have tested positive for methanol contamination. “State officials have also reported recent adverse events from adults and children ingesting hand sanitizer products contaminated with methanol, including blindness, hospitalizations and death. The agency continues to warn the public not to use specific products listed here and is communicating with manufacturers and distributors of these dangerous products about recalling them.”

July 5, 2020: CDC Health Advisory: Serious Adverse Health Events Associated with Methanol-based Hand Sanitizers

In the wake of the FDA’s warning to the public, the CDC posted an Official Health Advisory on Sunday July 5th highlighting the FDA’s June 19th warning to not use any hand sanitizer manufactured by “Eskbiochem SA de CV” in Mexico, due to the potential presence of methanol, a “toxic alcohol….which can cause blinding and/or death when absorbed through the skin or when swallowed.” This alert goes on to provide recommendations for Clinical and Public Health Officials as well as the general public.

July 6, 2020: Open Letter to the American Public Urging Simple Steps to Stop the Spread of COVID-19

The American Hospital Association (AHA), American Medical Association (AMA), and the American Nurses Association (ANA) posted an Open Letter to the American Public. This letter opens by noting that “Since the beginning of the COVID-19 pandemic, we have urged the American people to protect themselves, their neighbors and their loved ones amidst the worst global health crisis in generations.”

They drive home the fact that as the country has begun to “reopen” there has been “a dramatic uptick in COVID-19 cases” that is negating hard-won gains during the months of staying at home. According to the CDC as of July 6, 2020 the U.S. has had 2,886,267 total cases and 129,811 deaths. More significantly, from July 5th to July 6th there were 44,361 new cases and 235 deaths reported.

A key message in the letter is the urging for everyone to help stop the spread of the virus following three simple steps known to help:

• Wearing a face mask,
• Maintaining physical distancing, and
• Washing your hands.
  

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 18th – 29th.  

Resource Spotlight This Week: CDC Social Media Toolkit

The CDC Social Media Toolkit was created to help localize efforts in responding to the virus that causes COVID-19. The following messages and graphics are available to help in this effort:

• Ensure current, correct messaging from a trusted source,
• Create collateral materials, and
• Share resources.

“All graphics and suggested messages are available for use on social media profiles and web pages.

Within this guide you will find information and suggested messages from our COVID-19 response. For more images and CDC content you can visit our Communication Resources page. All social media content is public domain and free to use by anyone for any purpose without restriction under copyright law. Please remember to use the #COVID19 hashtag when tweeting out any COVID-19 related content.”

June 18, 2020: JAMA Network Article: Disparities in Coronavirus 2019 Reported Incidence, Knowledge, and Behavior Among US Adults

The authors of this JAMA Network article undertook this endeavor “to determine the association of sociodemographic characteristics with reported incidence, knowledge, and behavior regarding COVID-19 among US adults.”

US National Survey Parameters:

• Survey was conducted electronically from March 29 to April 13, 2020,
• Survey “oversampled COVID-19 hotspot areas,” and
• Participant criterion included age ≥ 18 years old and residence in the US.

Researchers found that African American participants, men, and people younger than 55 years showed less COVID-19-related knowledge than other groups. Survey results detailed in this article also provides insight into the probability of having COVID-19 or knowing someone who does, knowledge about the spread of and symptoms of COVID-19, and factors associated with hand washing and leaving the house.

June 19, 2020: MLN MM11742 Long Term Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer Revised

MLN article MM11742 was revised to reflect a revised Change Request (CR) 11742 also issued on June 19th. CMS made the following revisions to CR 11742:

• Revise the COVID-19 blanket waiver for the LTCH ALOS policy,
• To include revising the effective date and policy section, and
• Revise the CR release date, transmittal number, and web address of the CR.

June 19, 2020: American Hospital Association (AHA) urges HHS to extend Public Health Emergency (PHE)

In a letter to the Secretary of Health and Human Services (HHS), AHA President and Chief Executive Officer, Richard J. Pollack urged “to extend the public health emergency beyond its current July 25, 2020 expiration date so health care providers can continue to offer the most efficient and effective care possible during the continuing COVID-19 pandemic.” Mr. Pollack urged for the continuance of the PHE until four criteria outlined in the letter are met.

June 22, 2020: CMS Press Release: Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries

In a June 22nd Press Release, CMS is calling for a renewed commitment to value-based care based on Medicare claims data providing an early look at the impact of COVID-19 on the Medicare population. The initial data reflects claims with a COVID-19 diagnosis (B97.29 from 1/1/2020 – 3/31/2020) and U07.1 (starting 4/1/2020) billed in any of the 25 diagnosis code fields on the claim or encounter record with a date of service from January 1st through May 16, 2020. Data is broken down by Medicare beneficiaries’ state, race/ethnicity, age, gender, dual eligibility for Medicare and Medicaid, and urban/rural locations. Moving forward, CMS indicates that this data will be updated monthly.

“The data shows that older Americans and those with chronic health conditions are at the highest risk for COVID-19 and confirms long-understood disparities in health outcomes for racial and ethnic minority groups and among low-income populations.” This Press Release includes a link to more information on the Medicare COVID-19 data, an FAQ document related to the data release, and a blog by CMS Administrator Seema Verma.

June 25, 2020: Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star Quality Rating System Due to the COVID-19 PHE

CMS announced the following changes in a Memorandum Summary:

• “Staffing Measures and Ratings Domain: On July 29, 2020, Staffing measures and star ratings will be held constant, and based on data submitted for Calendar Quarter 4 2019.
• Also, CMS is ending the waiver of the requirement for nursing homes to submit staffing data through the Payroll-Based Journal System. Nursing homes must submit data for Calendar Quarter 2 by August 14, 2020.
• Quality Measures: On July 29, 2020, quality measures based on a data collection period ending December 31, 2019 will be held constant.”

June 25, 2020: CDC Revises Who is at Risk for Severe Illness from COVID-19

On June 25th, the CDC made revisions to the list of people at increased risk of severe illness from COVID-19. They noted that revisions were made to reflect data available as of May 29, 2020, and as new information becomes available, they will again update the information.

With this update comes several changes to the list of conditions. Prior to this update the CDC had indicated that “older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19:

• People aged 65 years and older,
• People living in a nursing home or long-term care facility,
• Other high-risk conditions include:
• People with chronic lung disease or moderate to severe asthma,
• People who have serious heart conditions,
• People who are immunocompromised including cancer treatment,
• People of any age with severe obesity (Body Mass Index [BMI] >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk,
• People who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk,
• Many conditions can cause a person to be immunocompromised, including cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDs, and prolonged use of corticosteroids and other immune weakening medications.

The June 25th revisions indicate that people of any age with the following conditions are at increased risk of severe illness from COVID-19:

• Chronic Kidney Disease,
• Chronic Obstructive Pulmonary Disease,
• Immunocompromised state (weakened immune system) from solid organ transplant,
• Obesity (body mass index {BMI} of 30 or higher),
• Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies,
• Sickle cell disease,
• Type 2 Diabetes, and
• Children who are medically complex, who have neurologic, genetic, metabolic conditions, or who have congenital heart disease are at higher risk for severe illness from COVID-19 than other children.

June 26, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on COVID-19 MLN Article Revised Again

MLN Article SE20011 initially released on March 16, 2020 has been updated twice in the past week and is now in its eight iteration. First, on June 19th, a revision added the section, “Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients.” Following is an excerpt from the information added to this MLN article:

“Starting on July 6, 2020, and for the duration of the public health emergency, consistent with sections listed below of CDC guidelines titled, “Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel,” Original Medicare and Medicare Advantage plans will cover diagnostic COVID-19 lab tests and non-cover tests not considered diagnostic.

• Viral Testing of Residents for SARS-CoV-2
• Initial Viral Testing in Response to an Outbreak
• Recommended testing to determine resolution of infection with SARS-CoV-2
• Public health surveillance for SARS-CoV-2

Tests that are considered non-diagnostic are not covered.”

This article was again updated on June 26th to add a section titled Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information and Billing Instruction. In this update CMS provides examples of when to document on the claims that a patient meets the requirement SNF requirement waiver.

June 28, 2020: CDC Updates Considerations for Wearing Cloth Face Coverings

On June 28th the CDC updated this webpage and is recommending people wear cloth face coverings in public settings and when around people outside of their household, especially when other social distancing measures are difficult to maintain. You will find information about the following on this webpage:

• Evidence for effectiveness of cloth face coverings,
• Who should wear a cloth face covering,
• Who should not wear a cloth face covering,
• Feasibility and Adaptations,
• Face shields,
• Surgical Masks, and
• Links to recent studies.

June 29, 2020: New Supplies of Remdesivir for the United States

The Department of Health and Human Services (HHS) announced an agreement to secure more than 500, 000 treatment courses of Remdesivir for the US from Gilead Sciences through September. Per the announcement “hospitals will receive the product shipped by AmerisourceBergen and will pay no more than Gilead’s Wholesale Acquisition Price (WAC), which amounts to approximately $3,200 per treatment course.”

Daniel O’Day, Chairman and CEO of Gilead Sciences indicated in a related Open Letter that normal pricing of a medicine is according to the value provided and cites an approximately $12,000 hospital savings per patient. He went on to indicate that “We have decided to price remdesivir well below this value. To ensure broad and equitable access at a time of urgent global need, we have set a price for governments of developed countries of $390 per vial. Based on current treatment patterns, the vast majority of patients are expected to receive a 5-day treatment course using 6 vials of remdesivir, which equates to $2,340 per patient.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

Quarterly Influenza Virus Vaccine Code Update – July 2020

• Article Release Date: January 31, 2020
• What You Need to Know: The influenza virus vaccine code set is updated on a quarterly basis. Reminder, effective for claims processed with dated of service on or after July 1, 2020, influenza virus vaccine code 90694 (influenza virus vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use) is payable by Medicare.
• MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf

July 2020 Integrated Outpatient Code Editor (I/OCE) Specification Version 21.2

• Article Release Date: June 5, 2020
• What You Need to Know: This article provides the I/OCE instructions and specifications for the I/OCE employed under the Outpatient Prospective Payment System (OPPS) and non-OPPS. The specifications are for:
• Hospital outpatient departments
• Community mental health centers
• All non-OPPS hospital providers
• For limited services when provided in a Home Health Agency (HHA) not under the HH Prospective Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/.
• MLN Matters MM11792: https://www.cms.gov/files/document/mm11792.pdf

July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: June 5, 2020
• What You Need to Know: The following list highlights the main topics included in this document:
• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update,
• Status Indicator Changes for Certain Virtual Services,
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinical (RHC) or Federally Qualified Health Center (FQHC) Only,
• New CPT Category III Codes Effective July 1, 2020,
• CPT Proprietary Laboratory Analysis (PLA) Coding Changes Effective July 1, 2020,
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755,
• Device Pass-Through Updates,
• Changes to Certain Device Offsets for 2020,
• Drugs, Biologicals, and Radiopharmaceuticals,
• Skin Substitutes – New Products,
• New Separately Payable Procedure Codes – Surgical Procedures,
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI),
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy,
• Supervision of Outpatient Therapeutic Services,
• MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf

July Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

• Article Release Date: June 5, 2020
• What You Need to Know: This article informs DME MACs about changes to the DMEPOS fee schedules that are updated quarterly, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies.

Note, this update includes guidance from the interim final rule with comment period (CMS-5531-IFC) entitled “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” published in the Federal Register May 8, 2020. This final rule implements a section of the Coronavirus Aid, Relief, and Economic Security (CARES) Act regarding fee schedule adjustments.

• MLN MM11810: https://www.cms.gov/files/document/mm11810.pdf
  

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2020

• Article Release Date: June 5, 2020
• What You Need to Know: Medicare Updates the DMEPOS CBP files on a quarterly basis to implement necessary changes to HCPCS, ZIP code, and supplier files. Related Change Request CR 11819 provides specific instruction for implementing the DMEPOS CBP files.
• MLN MM11819: https://www.cms.gov/files/document/mm11819.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

• Article Release Date: June 12, 2020
• What You Need to Know: This article informs labs about changes in the quarterly update. Several of the updates are specific to guidance regarding lab testing related to COVID-19.
• MLN MM11815: https://www.cms.gov/files/document/mm11815.pdf

OTHER MEDICARE TRANSMITTALS

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advise Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: May 22, 2020
• What You Need to Know: Informs you of updates the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, CAGC rule publications. Updates are based on the CORE Combination Codes List to be published on or about June 1, 2020.
• MLN Matters MM11709: https://www.cms.gov/files/document/mm11709.pdf

New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

• Article Release Date: June 12, 2020
• What You Need to Know: Code “G” is a new Point of Origin (PoO) code to indicate a “transfer from a Designated Disaster Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency (PHE).
• MLN MM11836: https://www.cms.gov/files/document/mm11836.pdf

REVISED MEDICARE TRANSMITTALS

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update

• Article Release Date: May 1, 2020 – Rescinded May 26, 2020
• What You Need to Know: This article was rescinded on May 26, 2020, as the related Change Request (CR) 11749, Transmittal 10092, dated May 1, 2020, was rescinded in its entirety. Therefore, any coding changes to NCD 90.2, Next Generation Sequencing are null and void.
• MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf

Supplier Education on Use of Upgrades for Multi-Function Ventilators

• Article Release Date: May 29, 2020
• What You Need to Know: This article was revised to show that the policy on use of multi-function ventilators, as discussed in the “What You Need to Know” section, is a permanent change.
• MLN SE20012: https://www.cms.gov/files/document/se20012.pdf

Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component

• Article Release Date: May 29, 2020 – Revised June 9, 2020
• What You Need to Know: This article provides information about the hospice benefit component associated with the VBID Model being tested by the CMS Innovation Center and starting in Calendar Year (CY) 2021. CMS highlights that “providers MUST still submit claims for these services to Medicare.” CMS revised this MLN article on June 9th to reflect a revised CR 11754 issued on June 9th.
• MLN Matters MM11754: https://www.cms.gov/files/document/mm11754.pdf

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Article Release Date: March 24, 2020 – Revised June 10, 2020
• What You Need to Know: This article was revised to reflect formatting revisions in Change Request 11660. The substance of the article was not altered.
• MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)

• Article Release Date: June 1, 2020
• What You Need to Know: Change Request (CR) 11461 was published on May 22, 2020 highlighting that new to NCD 160.16, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met. The accompanying MLN article was released on June 1, 2020.
• MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf

Other Medicare Updates

Prior Authorization (PA) Program for Certain Hospital Outpatient Department (ODP) Services CMS Operational Guide and FAQs

In last May CMS released an Operational Guide and FAQs related to this Program set to begin July 1, 2020.

• Operation Guide: https://www.cms.gov/files/document/opd-operational-guide.pdf
• Frequently Asked Questions: https://www.cms.gov/files/document/opd-frequently-asked-questions.pdf

2021 ICD-10-PCS Codes for Discharges Occurring from October 1, 2020 through September 30, 2021

On May 28, 2020, CMS posted the 2021 Official ICD-10-PCS Coding Guidelines, Code Tables, and Addendum on the 2021 ICD-10-PCD CMS webpage.

• Link to CMS webpage: https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs

KEPRO Case Review Connections: Acute Care Edition: Summer 2020

KEPRO published their Summer 2020 Case Review Connections e-newsletter. Topics included in this newsletter includes:

• Medical Director’s Corner,
• A Reminder About Appeals Cases,
• Updates from CMS Related to COVID-19,
• An Immediate Advocacy Success Story,
• Frequently Asked Questions, and
• Staff Education about BFCC-QIO Services.

June 17, 2020 CMS Proposed Rule: Establishing Minimum Standards in Medicaid State Drug Utilization (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS 2482-P)

CMS Administrator Seema Verma noted in a Press Release that “CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models…by modernizing our rules, we are creating opportunities for drug manufacturers to have skin in the game through payment arrangement that challenge them to put their money where their mouth is.”

The Press Release includes links to a related Fact Sheet and the Proposed Rule. CMS is accepting comments no later than 5 p.m. on July 20, 2020. 

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 15th – 22nd.

Resource Spotlight This Week:

This week’s COVID-19 resource spotlight is on the HHS Coronavirus (COVID-19) Home webpage. The HHS indicates that they and their federal partners “are working together with state, local, tribal and territorial governments, public health officials, health care providers, researchers, private sector organizations and the public to execute a whole-of-America response to the COVID-19 pandemic to protect the health and safety of the American people.” Following is a list of a few of the topics related to COVID-19 available on this webpage:

• CARES Act Provider Relief Fund,
• Testing,
• Telehealth, and
• Mental Health and Coping.

June 15, 2020: FDA Revokes Emergency Use Authorization for Chloroquine and Hydroxychloroquine

The FDA has revoked the Emergency Use Authorization (EUA) for the use of these two drugs in treating COVID-19. They indicated in a News Release that “Based on its ongoing analysis of the EUA and emerging scientific data, the FDA determined that chloroquine and hydroxychloroquine are unlikely to be effective in treating COVID-19 for the authorized uses in the EUA. Additionally, in light of ongoing serious cardiac adverse events and other potential serious side effects, the known and potential benefits of chloroquine and hydroxychloroquine no longer outweigh the known and potential risks for the authorized use.” At the same time of the News Release, the FDA posted a related FAQ Document.

June 15, 2020: FDA Warns of Newly Discovered Potential Drug Interaction Related to Remdesiver

On June 15th, in addition to revoking the EUA for Chloroquine and Hydroxychloroquine, the FDA posted another News Release warning health care providers that “Based on a recently completed non-clinical laboratory study, the FDA is revising the fact sheet for health care providers that accompanies the drug to state that co-administration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not recommended as it may result in reduced antiviral activity of remdesivir. The agency is not aware of instances of this reduced activity occurring in the clinical setting but is continuing to evaluate all data related to remdesivir.”

June 16, 2020: Applying COVID-19 Infection Prevention and Control Strategies in Nursing Homes

On Tuesday June 16th, the CDC hosted a webinar where presenters used case-based scenarios to discuss how to apply infection prevention and control guidance for nursing home and other long-term care facilities. A recording of the call and slide deck are available on the CDC Clinical Outreach and Communications (COCA) Calls/Webinars webpage.

June 17, 2020: Senate Health Committee Chair: Make the Two Most Important COVID-19 Telehealth Policy Changes Permanent

A June 17, 2020 Press Release provides remarks made by Senate health committee Chairman Lamar Alexander (R-TN) during the “Telehealth: Lessons from the COVID-19 Pandemic” committee hearing.

Senator Alexander noted that “As dark as this pandemic event has been, it creates an opportunity to learn from and act upon these three months of intensive telehealth experiences, specifically what permanent changes need to be made in federal and state policies.” Specifically, Alexander said the following two changes should be permanent:

• Permanently extend policy changes allowing physicians to be reimbursed for telehealth appointment wherever the patient is located, including the patient’s home, and
• Permanently extent the policy change that nearly doubled the number of telehealth services that could be reimbursed by Medicare.

He also indicated that there are 29 other temporary federal policy changes that could also be considered for being made permanent. You can view the entire Press Release at https://www.help.senate.gov/chair/newsroom/press/alexander-make-the-two-most-important-covid-19-telehealth-policy-changes-permanent.

Link to White Paper: Preparing for the Next Pandemic by Senator Lamar Alexander: https://www.alexander.senate.gov/public/_cache/files/0b0ca611-05c0-4555-97a1-5dfd3fa2efa4/preparing-for-the-next-pandemic.pdf

June 18, 2020: COVID-19 Diagnostic Laboratory Tests: Billing for Clinician Services

CMS provided the following reminders in the June 18, 2020 edition of their weekly MLNConnects eNewsletter:

“Physicians and Non-Physician Practitioners (NPPs): Here are several reminders related to billing for COVID-19 symptom and exposure assessment and specimen collection performed on and after March 1, 2020:

• Use CPT Code 99211 to bill for assessment and collection provided by clinical staff (such as pharmacists) incident to your services, unless you are reporting another Evaluation and Management (E/M) code for concurrent services. This applies to all patients, not just established patients.
• Submit the CS modifier with 99211 (or other E/M code for assessment and collection) to waive cost sharing.
• Contact your Medicare Administrative Contractor if you did not include the CS modifier when you submitted 99211 so they can reopen and reprocess the claim.
• We will automatically reprocess claims billed for 99211 that we denied due to place of service editing.”

June 19, 2020: Weekly Update of Nursing Home COVID-19 Data as of June 7, 2020

CMS has posted the second set of COVID-19 Nursing Home Data as of June 7th and is available at https://data.cms.gov/stories/s/bkwz-xpvg.

Residents Cases and Deaths as of June 7, 2020:

• 107,389 total confirmed cases of COVID-19,
• 71,278 total suspected cases of COVID-19, and
• 29,497 total deaths attributed to COVID-19.

Moving forward this data will be updated weekly. In addition to the data release, CMS has released additional FAQs on Nursing Home COVID-19 data at  https://data.cms.gov/api/views/b62a-ieuz/files/e883f38f-77da-4f58-975f-390b858ccf9f?filename=NH%20COVID-19%20data%20FAQ%206-18-2020.pdf.

June 19, 2020: Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

CMS announced in a June 19th, 2020 Special Edition MLNConnects that they have instructed Medicare Administrative Contractors and notified Medicare Advantage plans that they “must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.”

June 19, 2020: FDA Letter: Stop Using COVID-19 Antibody Tests on the FDA’s “Removed” Test List

On June 19th, the FDA issued a Letter to Clinical Laboratory Staff and Health Care Providers with the recommendation to stop using COVID-19 antibody tests listed on their “removed” test list.” “The “removed” test list includes tests in which significant clinical performance problems were identified that cannot be or have not been addressed by the commercial manufacturer in a timely manner, tests for which an Emergency Use Authorization request has not been submitted by a commercial manufacturer of a serology test within a reasonable period of time as outlined in the FDA’s guidance, and tests voluntarily withdrawn by the respective commercial manufacturers.”

Q:

What recourse do we have when a claim has been denied by the SMRC for no receipt of documentation requested?

A:

Noridian is the nationwide SMRC who conducts medical reviews as directed by CMS. If you have received a denial for no receipt of documentation requested you would need to do the following:

• Submit documentation to the Medicare Administrative Contractor (MAC), who issued the demand letter for overpayment within 120 calendar days of the demand letter.
• This situation is considered a reopening and the MAC will send the submitted information to the SMRC for a re-review decision.
• The SMRC has 60 days to make a decision and will mail a letter to the supplier with their findings to pay the claim or outline why the claim is being denied.
• The SMRC will also notify the MAC of the payment or denial decision.
• The MAC will then adjust the claim and a remittance advice with the adjustment results will be generated.
• If a claim remains denied, you have the right to appeal the SMRC decision.

The SMRC website can provide you with additional information about their medical review process and how to respond to an Additional Documentation Request (ADR).

Q:

Can you help me understand what a provisional affirmation prior authorization (PA) decision is as it pertains to the Outpatient Prior Authorization Program set to begin on July 1, 2020? 

A:

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M posted the following information about the Outpatient Department Prior Authorization in their June 22, 2020 Daily Newsletter:

“A provisional affirmation prior authorization (PA) decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. The provisional affirmation PA decision is valid for 120 days from the date decision was rendered.

Palmetto GBA's Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires. Just enter the date of the Prior Authorization Affirmation and click Calculate. The tool will tell you the last date your authorization will be valid.”

• Jurisdiction J Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction J Part B Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part B Outpatient Department Prior Authorization Calculator

Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, I wanted to alert readers about Change Request (CR) 11695. This CR was published on May 15, 2020 and provides details regarding revisions to the Targeted Probe and Educate (TPE) Program in the Medicare Program Integrity Manual (IOM 100-08), chapter 3, section 3.2.5.

Background

The TPE review strategy includes instruction to the MACs to refer providers/suppliers failing three rounds of TPE to the CMS for next steps. Prior to the release of CR 11695 there were no references available from CMS to the potential for more than three rounds of TPE review. As a result, CMS is revising the TPE language in section 3.2.5 in Chapter 3 of the Program Integrity Manual (Pub. 100-08) to include the possibility of additional rounds of TPE review.

The following language has been added to the guidance in section 3.2.5D. Post-Probe Activity – Final Results Letter:

“For providers/suppliers who will be released from review due to meeting the established error rate goal, results letters shall indicate that the provider is being released from review for one year, with the caveat that additional review may occur at any time should the MAC identified changes in billing pattern. For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the following language to remind providers of 42 CFR §424.535.

“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.””

May MAC Talk: The Local Scene

May 19, 2020: NGS Botulinum Toxin Injections for Chronic Headaches CERT Findings

This NGS article provides a list of the most common reasons the CERT determined there was insufficient documentation for the service provided.

• Missing evaluation to support patient is having 15 or more headaches a month for at least three months,
• Missing documentation to support a significant decrease in the number and frequency of headaches per month,
• Missing documentation to support the amount of waste for the botulinum toxin, and
• Missing electronic signature or legible signature.

You can learn more about NGS’ requirements for Botulinum Toxin Injections in their Local Coverage Determination (LCD): Botulinum Toxins (L33646) and related Coverage Article (A52848). As a reminder, Botulinum Toxin Injections is one of the procedures that will require a prior authorization beginning with dates of service on or after July 1, 2020. You can read more about the Prior Authorization Program for certain outpatient department procedures in a related MMP article.

May 20, 2020: First Coast Guidance for Submitting Prior Authorization for Certain Outpatient Department (OPD) Services

First Coast provided guidance in their May 20th eNews about the elements that must be submitted in a Prior Authorization Request (PAR) for services requiring one as part of the new Prior Authorization Program set to begin on July 1, 2020. First Coast is set to begin accepting PARs for these services as of today June 17, 2020, for services to be provided on or after July 1, 2020. You can read the full announcement under the Medical Review tab on the First Coast website.

May 27, 2020: Palmetto GBA Daily Newsletter: Medicare Secondary Payer (MSP) Basics Modules

Palmetto GBA posted information about an educational series available on their website on MSP guidelines. They note in the announcement that “this series provides guidance with condition payment provisions and common MSP billing questions.” They encourage you to review the modules with your staff.

May 28, 2020: CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Open Door Forum (ODF)

The CMS held a special ODF to go over the basics of this program. The presentation was followed by a very robust Q&A session. The slides from this session as well as an Operational Guide and FAQs document have been added to the downloads section of the CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webpage.

June 5, 2020: Noridian Article: SNF PDPM Assessment Diagnosis COVID-19 ICD-10 Code U07.1 and SNF Waiver to Extend Benefit Period

In this article, Noridian offers the following guidance for providers experience claims processing problems related to the April 1, 2020 effective date of applying the new U07.1 – 2019-nCoV acute respiratory disease ICD-10-CM code when the 5-day assessment window overlaps March into April dates of service:

“Based on the following guidance from the CMS PDPM FAQs Question 1.8 that states ‘Is it required that the principal diagnosis on the SNF claim match the primary diagnosis coded in item I0020B? While we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement'. Providers with a 5-Day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification. However, the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and is valid in the month of March.”

This article also provides details regarding the impact on typical billing and assessment processes when a beneficiary qualifies for renewed SNF benefits under the SNF waiver as a result of the COVID-19 pandemic.

June 8, 2020: WPS GBA Medicare eNews: Intravenous Immunoglobulin Therapy (IVIG)

WPS posted the following information regarding IVIG therapy in their June 8th eNews:

“Do you bill for IVIG? Before you bill for these services, read the Local Coverage Article: Billing and Coding: Immune Globulins (A57554). Why read the article? The Centers for Medicare & Medicaid Services (CMS) identified a potential vulnerability in the WPS GHA jurisdictions. Providers should follow the guidance in the local coverage article if they expect payment.”

June 12, 2020: Novitas eNews: Prior Authorization Hospital Outpatient Department Services (OPD) FAQs

Novitas posted this FAQ document in their June 12th eNews indicating the document had been developed to include questions and answers posed during their webinar about the PA program for certain hospital OPD services.

June 15, 2020: WPS GHA Medicare eNews: Appropriate Application of Modifier for Injections to Manage Age-Related Macular Degeneration (AMC)

WPS included the following information in their June 15th Medicare eNews:

“Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss that affects millions of Americans. Medicare Part B covers age-related macular degeneration (AMD) treatments, which include:

• Aflibercept (Eyelea)
• Ranibizumab (Lucentis)
• Brolucizumab (Beovu)
• Bevacizumab (Avastin)

Recent claim review data showed that claims submitted with anti-vascular endothelial growth factor (anti-VEGF) drug codes did not include an appropriate modifier identifying the eye being treated resulting in claim denials. For more information, see the full article on our website.”

Q:

Has CMS released information about the July 2020 Hospital Outpatient Prospective Payment System update? 

A:

Yes. On June 5th CMS released Change Request 11814 - Transmittal R10166CP and related MLN Article MM1184. This recurring update notification describing changes to and billing instructions for various payment policies implemented in the July 2020 OPPS update. This update includes changes in response to the COVID-19 pandemic and the secretary declaring a public health emergency (PHE). Following is a list of key updates for July 1, 2020:

• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update
• Status Indicator Changes for Certain Virtual Services (Telephone services)
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only
• Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE
• New CPT Category III Codes Effective July 1, 2020
• The American Medical Association (AMA) released CPT Category III codes twice a year: In January, for implementation beginning the following July, and in July, for implementation beginning the following January. CMS is implementing 25 CPT Category III codes on July 1, 2020.
• CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020
• The AMA CPT Editorial Panel deleted five PLA codes (CPT codes 0124U through 0128U) and established 30 new PLA codes (CPT codes 0172U through 0201U)
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755
• New Device Pass-Through Categories
• New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status
• There are eleven new HCPCS codes for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available (i.e., C9059 Injection, meloxicam, 1mg).
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020
• Drugs and Biologicals that have Changes to Status Indicators 
• Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020
• Skin Substitutes – New Products
• New Separately Payable Procedure Codes – Surgical Procedures
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy
• Supervision of Outpatient Therapeutic Services
• This section discusses several changes that have been made in response to the COVID-19 outbreak and the Secretary declaring the existence of a public health emergency (PDE).

Finally, CMS reminds providers that “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

Resources:

Link to Transmittal: https://www.cms.gov/files/document/r10166cp.pdf

Link to MLN Article MM11814: https://www.cms.gov/files/document/mm11814.pdf