Knowledge Base - Full Library

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).

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.”

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 8th – June 15th

Weekly COVID-19 Resource Spotlight: CDC Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations

According to the CDC, the Toolkit Communication Toolkit was created to help public health professionals, health departments, community organizations, and healthcare systems and providers reach populations who may need COVID-19 prevention messaging in their native languages. Currently there are materials available in 28 languages ranging from Amharic to Vietnamese. The toolkit provides:

• Current messaging from a trusted source.
• Information in plain language available for downloading and sharing.
• Translated materials to help communities disseminate messages to a wider audience.

June 8, 2020: Addressing the Disparate Impact of COVID-19 on African Americans and Other Racial and Ethnic Minorities.

This HHS Office of Civil Rights Fact Sheet details initiatives underway to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities. A link to this document as well as other COVID-19 Announcements can be found on the HHS Civil Rights and COVID-19 webpage.

June 8, 2020: New FDA Webpages: Innovation to Respond to COVID-19 and Education Resources

In their June 8th COVID-19 Update: Daily Roundup, the FDA announced that they had published two new web pages to help the public access information:

• Innovation to Respond to COVID-19 provides an overview of FDA’s innovative approaches to respond to COVID-19 as quickly and safely as possible, and
• Educational Resources provides links to FDA-produced COVID-19-related resources that help explain FDA’s work.

June 9, 2020: CMS Recommendations for Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare and a Guide for Patients as they consider In-Person Care Options

As the country moves towards “re-opening our towns” CMS has provided two documents for consideration during this transition. First is a guide for patients and beneficiaries as they consider “in-person” care options. Recommendations for the following topics can be found in this guide:

• Do Not Postpone Necessary Care.
• Is It Safe to Go to your Doctor or Hospital?
• Consider Telehealth or Virtual Visits.
• What to Expect when you Seek Healthcare.
• Should I get tested for COVID-19 before seeking healthcare?
• Vulnerable Populations: When Possible, Stay Home.

This new guide is available in English and Spanish.

Second, is CMS’ document providing recommendations for re-opening facilities to provide non-emergent, Non-COVID-19 healthcare. The recommendations are intended for states or regions who have determined with their public health officials that they have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, proceeded to Phase I, and are now ready for Phase II of re-opening. In this document, CMS recommends:

• Optimization of telehealth services, when available and appropriate, to minimize the need for in-person services.
• All individuals at higher risk for severe COVID-19 illness should continue to shelter in place unless an in-person healthcare visit is warranted.
• The phased recommendations in this document “may guide healthcare systems, providers, and facilities as they consider delivering in-person care to non-COVID-19 patients in regions with lower or declining-without-rebound, levels of COVID-19.”

You can read more in a June 9th Press Release that includes links to both of these documents.

June 10, 2020: COVID-19 FAQs for Non Long-Term Care Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IIDs)

CMS released this FAQ Document on June 10th and indicates that “The purpose of this FAQs document is to clarify existing guidance and flexibilities and provide stakeholders with additional information based on questions received regarding the following entities:

• Ambulatory Surgical Centers (ASCs)
• Hospitals & Critical Access Hospitals (CAHs)
• Hospice
• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)
• Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs).”

June 10, 2020: Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic

The CDC has created a webpage dedicated to the use of telehealth. Their purpose in providing this guidance is “to describe the landscape of telehealth services and provide considerations for healthcare systems, practices, and providers using telehealth services to provide virtual care during and beyond the COVID-19 pandemic. As of June 10th, you will find the following on this webpage:

• Telehealth background,
• Telehealth modalities,
• Benefits and Potential Uses for Telehealth,
• Strategies to Increase Telehealth Update,
• Telehealth Reimbursement,
• Safeguards for Telehealth Services,
• Potential Limitations of Telehealth, and

June 12, 2020: CMS One-Time Notification: New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

This Change Request (CR) 11836 implements a new Point of Origin (PoO) Code “G” to indicate a “Transfer from a Designated Disease Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency.

“Background: The National Uniform Billing Committee (NUBC) practice is to align Discharge Status Codes and Point of Origin (PoO) Codes whenever possible. It came to the Committee's attention that there is a Discharge Status Code for Alternate Care Sites (ACS) but no specific matching PoO Code. Relative to the COVID-19 Public Health Emergency, NUBC created a new Point of Origin (PoO) Code "G" to be effective 07/01/2020, and defined as "Transfer From a Designated Disaster Alternate Care Site."

June 12, 2020: OCR Issues Guidance on HIPAA and Contacting Former COVID-19 Patients about Blood and Plasma Donation

The OCR has released a document answering the question of whether or not covered healthcare providers are permitted to use protected health information (PHI) to identify and contact patients who have recovered from COVID-19 to provide them with information about donating blood and plasma that could help other COVID-19 patients. The short answer is yes. As the late Andy Rooney would say, you can find the entire two page document for “the rest of the story” on the HHS.gov HIPAA and COVID-19 webpage.

June 13, 2020: HHS Awards $15 Million to Support Telehealth Providers During the COVID-19 Pandemic

The Department of Health and Human Services (HHS) announced that they have awarded $15 million to 159 organizations across five health workforce programs to increase telehealth capabilities in response to the COVID-19 pandemic. These awards are funded through the Coronavirus Aid, Relief and Economic Security (CARES) Act.

HHS indicated in the announcement that “these investments will train students, physicians, nurses, physician assistants, allied health and other high-demand professionals in telehealth. This will enable these professionals to maximize telehealth for COVID-19 referrals for screening and testing, case management, outpatient care, and other essential care during the crisis.”

This announcement provides a link to the complete list of award recipients.

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

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.”

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 1st through June 8th.

Resource Spotlight This Week:

As our nation works to “re-open” and move forward towards a “new normal,” it is important to understand Policy Actions in your state and states you may be traveling to. This week’s spotlight resource can help provide that information. On June 3rd the Kaiser Family Foundation (KFF) published the State Data and Policy Actions to Address Coronavirus. Following is a list of key information that is available on this webpage:

• COVID-19: Confirmed cases & Deaths by State,
• State Social Distancing Actions,
• State COVID-19 Health Policy Actions,
• State Actions on Telehealth,
• State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (as of May 28, 2020),
• Guidance for Long-Term Care Facilities Related to COVID-19 (as of May 7, 2020),
• Adults at Higher Risk of Serious Illness if Infected with Coronavirus,
• Medicaid Expansion Status and Health Insurance Coverage,
• Private Insurance Deductibles and Self-Insured Plans,
• Health Care Provider Capacity, and
• Influenza and Pneumonia Deaths and Vaccinations

This publication was authored by Jennifer Tolbert, Cornelia Hall, Kendral Orgera, Natalie Singer, Salem Mengisut, and Marina Tian.

June 1, 2020: Nursing Home COVID-19 Data and Inspection Results leads to Enhanced Enforcement Actions

In a June 1st Press Release, the CMS announced enhanced enforcement directed towards nursing homes with violations of longstanding infection control practices.

A couple of key points in a related State Survey Memo summary are as follows:

• “Following the March 6, 2020 survey prioritization, CMS has relied on State Survey Agencies to perform Focused Infection Control surveys of nursing homes across the country. We are now initiating a performance-based funding requirement tied to the Coronavirus Aid, Relief and Economic Security (CARES) Act supplemental grants for State Survey Agencies. Further, we are providing guidance for the limited resumption of routine survey activities.
• CMS is also enhancing the penalties for noncompliance with infection control to provide greater accountability and consequence for failures to meet these basic requirements... The enhanced enforcement actions are more significant for nursing homes with a history of past infection control deficiencies, or that cause actual harm to residents or Immediate Jeopardy.”

CMS also provided link to the following information in the Press Release:

• Letter to the Governors (PDF)
• State breakdown of the Nursing Home COVID-19 data (PDF).

June 3, 2020: CMS Innovation Center Models COVID-19 Related Flexibilities

CMS posted an announcement on the CMS Innovation Center COVID-19 Flexibilities webpage regarding flexibilities being made to several CMS Innovation Center Value-Based Payment Models in response to COVID-19. For example, the Comprehensive Care for Joint Replacement (CJR) Model performance year 5 has been extended through March 2021.

In a news blog CMS indicated the Innovation Center will work “directly with model participants on the specific model changes and the processes for implanting them. CMS will also continue to review the data from our models during this COVID-19 pandemic, to identify short-term and long-term lessons learned.”

June 4, 2020: PEPPER Q1 FY 2020 Release Delayed

The PEPPER Team sent out a notice alerting providers that in keeping with the CMS effort to take measures to free up the attention of providers during the COVID-19 pandemic, the release of the Q1FY20 PEPPER for short-term (ST) acute care hospitals has been delayed. When information becomes available, the PEPPER Team will notify providers about the rescheduled release date.

June 4, 2020: FDA Video – Explaining Different Categories of Tests in Fight against COVID-19

The FDA has released a new video to provide information about the diagnostic tests and antibody tests used in the fight against COVID-19.

June 4, 2020: OCR Alert: HHS Awards More than a Half Billion Dollars to Help Vulnerable and Underserved Communities Gain Access to COVID-19 Testing

The OCR indicates in this alert that they are “sharing this update to promote awareness about COVID-19 testing and testing-related availability to people who are geographically isolated, economically disadvantaged, or medically vulnerable, including people with HIV, pregnant women, people experiencing homelessness, agricultural workers, residents of public housing, older persons and our nation’s veterans.

‎In case you missed it: On ‎May ‎7, ‎2020, the U.S. Department of Health and Human Services, through the Health Resources and Services Administration (HRSA), awarded nearly $583 million to 1,385 HRSA-funded health centers in all 50 states, the District of Columbia, and eight U.S. territories to expand COVID-19 testing. Nearly 88 percent of HRSA-funded health centers report testing patients, with more than 65 percent offering walk-up or drive-up testing. Health centers are currently providing more than 100,000 weekly COVID-19 tests in their local communities.

This Alert provided the following links:

• The Full Press Release may be found on HHS’s website here.
• For a list of award recipients, visit https://bphc.hrsa.gov/emergency-response/expanding-capacity-coronavirus-testing-FY2020-awards. 
• To learn more about health center capacity and the impact of COVID-19 on health center operations, patients and staff, visit https://bphc.hrsa.gov/emergency-response/coronavirus-health-center-data.
• For more information about COVID-19, visit http://coronavirus.gov
• For more information about COVID-19 and civil rights, visit https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/index.html

June 4, 2020: CMS News Alert – Nursing Home COVID-19 Data and Inspection Results Available on Nursing Home Compare

CMS announced in a June 4, 2020 Press Release that they are posting the first set of underlying COVID-19 nursing home data as well as posting results from targeted inspections announced on March 4, 2020 that allowed inspectors to focus on the most serious health and safety threats like infectious disease and abuse during the pandemic.

COVID-19 Nursing Home Data

As of May 31, 2020

• About 13,600 (approximately 88%) of Medicare and Medicaid Nursing Homes had reported the required data to the CDC.
• These facilities reported 95,000 confirmed COVID-19 cases and almost 32,000 deaths.

The CMS announced the next set of data will be released in two weeks and then plans to update the data weekly.

June 4, 2020: New Laboratory Data Reporting Guidance for COVID-19 Testing

The U.S. Department of Health and Human Services (HHS) announced new guidance specifying what additional data must be reported to HHS by laboratories along with COVID-19 test results. “The requirement to include demographic data like race, ethnicity, age, and sex will enable us to ensure that all groups have equitable access to testing, and allow us to accurately determine the burden of infection on vulnerable groups,” said ADM Brett P. Giroir, MD, Assistant Secretary for Health. “With these data we will be able to improve decision-making and better prevent or mitigate further illnesses among Americans.”

Q:

What is the Prior Authorization for Certain Outpatient Department (OPD) Services Program and what resources are available to learn more about the program?

A:

The program was finalized in the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) Final Rule and is specific to the Hospital Outpatient Department setting. A Prior Authorization will be required for the following five procedures:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

You can access a list of the specific HCPCS codes for each of these procedures on the CMS Prior Authorization for Certain Hospital OPD Services webpage.

CMS believes this program will be an effective tool in controlling unnecessary increases in volume by ensuring payments are only being made for medically necessary services.

As required by CMS, Medicare Administrative Contractors have been educating providers about this program by posting information on their websites and webinars. Likewise, CMS has created a webpage with information specific to this program and held a Special Open Door Forum on May 28, 2020.

This program is set to begin July 1, 2020. However, a week from today on June 17, 2020, hospitals can begin submitting prior authorization requests (PARs) to Medicare Administrative Contractors for services to be provided on or after July 1, 2020.   

Following are links to resources to assist you as you prepare for this new program:

• CMS Prior Authorization for Certain Hospital OPD Services webpage https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
• Note, this page includes a link to the list of applicable HCPCS codes for the program, the ODF slides, an FAQ document about the program and an Operational Guide.
• Calendar Year 2020 Outpatient Prospective Payment System Final Rule https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf
• Note, information about this program starts on page 61446
• Palmetto GBA Outpatient Department PA https://www.palmettogba.com/palmetto/providers.nsf/docsr/Providers"JJ%20Part%20A"Medical%20Review"Outpatient%20Department%20PA
• Note, this page include articles about the program. The last article was posted on June 3rd and is an OPD eServices Submission Guide.

At least annually, MS-DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources. This week is the first article in a series of article about the 2021 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications.

Pre-MDC: Bone Marrow Transplants

Surgical vs. Medical MS-DRGs

Currently, the Bone Marrow Transplant (BMT) MS-DRGs (MS-DRG 014 (Allogeneic Bone Marrow Transplant), MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell Immunotherapy), and MS-DRG 017 (Autologous Bone Marrow Transplant without CC/MCC) are designated as surgical MS-DRGs.

A request was made to re-designate these three MS-DRGs as medical MS-DRGs as a Bone Marrow Transplant does not involve a surgical procedure or require the use of an O.R. The requestor noted that this change “would clinically align with the resources utilized in the performance of these procedures.

CMS clinical advisors agreed and the proposal has been made to re-designate MS-DRGs 014, 016, and 017 as medical MS-DRGs effective October 1, 2020.

BMT Procedures Designation O.R. vs. Non-O.R.

The requestor also noted that MS-DRGs 016 and 017 includes ICD-10-PCS procedures codes designated as Non-O.R. while the following eight procedures are designated as O.R. Procedures:

• 30230AZ: Transfusion of embryonic stem cells into peripheral vein, open approach
• 30230G0: Transfusion of autologous bone marrow into peripheral vein, open approach
• 30230X0: Transfusion of autologous cord blood stem cells into peripheral vein, open approach
• 30230Y0: Transfusion of autologous hematopoietic stem cells into peripheral vein, open approach
• 30240AZ: Transfusion of embryonic stem cells into central vein, open approach
• 30240G0: Transfusion of autologous bone marrow into central vein, open approach
• 30240X0: Transfusion of autologous cord blood stem cells into central vein, open approach
• 30240Y0: Transfusion of autologous hematopoietic stem cells into central vein, open approach.

CMS is proposing to re-designate these codes from O.R. to Non-O.R. procedures effective October 1, 2020.

Chimeric Antigen Receptor (CAR) T-Cell Therapies: New MS-DRG

In the FY 2020 IPPS Proposed Rule, a request was made to create new MS-DRGs for CAR T-cell therapy. The requestor noted this would improve payment in the inpatient setting. CMS did not believe enough data was available to make a change at that time. However, CMS did seek comments on payment alternatives for CAR-T cell therapies.

In the FY 2020 Final Rule CMS finalized the continuation of the new technology status and add-on payments for FY 2020 for this therapy.

There were several requests made, in the FY 2021 proposed rule, to create a new MS-DRG as this therapy will no longer be eligible for the new technology add-on payment (NTAP) for FY 2021. CMS has responded by noting they now have enough data to consider the development of a new MS-DRG. Further, CMS clinical advisors found a vast discrepancy in resource consumption and clinical differences warranting the creation of new MS-DRG.

CMS is proposing to do the following:

• Create new MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell immunotherapy, and
• Revise the MS-DRG 016 title to “Autologous Bone Marrow Transplant with CC/MCC.”

The following table highlights the proposed MS-DRG relative weight (RW) and geometric mean length of stay (GMLOS) for the BMT MS-DRGs and the proposed new CAR T-Cell MS-DRG:

‍MDC 1: Diseases and Disorders of the Nervous System

Carotid Artery Stent Procedures: Background

In FY 2020 CMS finalized their proposal to reassign 96 ICD-10-PCS procedures describing dilation of carotid artery with an intraluminal device(s):

• From MS-DRGs 037, 038, and 039 (Extracranial Procedures with MCC, with CC, and without CC/MCC respectively)
• To MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC respectively)

Carotid Artery Stent Procedures: FY 2021 Proposals

In response to a request, CMS is proposing to reassign the following six ICD-10-PCS codes describing dilation of carotid artery with drug eluting intraluminal device(s) using an open approach from MS-DRGs 037, 038, and 039 to MS-DRGs 034, 035, and 036:

• 037H04Z: Dilation of right common carotid artery with drug-eluting intraluminal device, open approach
• 037J04Z: Dilation of left common carotid artery with drug-eluting intraluminal device, open approach
• 037K04Z: Dilation of right internal carotid artery with drug-eluting intraluminal device, open approach
• 037L04Z: Dilation of left internal carotid artery with drug-eluting intraluminal device, open approach
• 037M04Z: Dilation of right external carotid artery with drug-eluting intraluminal device, open approach
• 037N04Z: Dilation of left external carotid artery with drug-eluting intraluminal device, open approach

CMS further reviewed to see if any of the six codes were included in MS-DRGs outside of MDC 1. They found a total of 36 ICD-10 PCS codes for procedures describing dilation of the carotid artery with an intraluminal device with an open approach that are currently assigned to MS-DRG 252 (Other Vascular Procedures with MCC) in MDC 5 (Diseases and Disorders of the Circulatory System). Interestingly, they found 8 claims with one of these 36 ICD-10-PCS codes and a Principal Diagnosis in MDC 1 causing the claims to group to the Extensive O.R. Procedure Unrelated to Principal Diagnosis MS-DRG Group (981, 982, and 983).

CMS is proposing to add the 36 ICD-10-PCS codes currently in MDC 5 to the GROUPER logic for MS-DRGs 034, 035, 036 in MDC 1. As my instructor told me when first learning about the MS-DRG system, this change will permit cases with a Principal Diagnosis in MDC 1 to “remain in the family.”

MDC 3: Diseases and Disorders of Ear, Nose, and Throat

Temporomandibular Joint Replacements

A request was made to reassign ICD-10-PCS procedures 0RRC0JZ (Replacement of right temporomandibular joint with synthetic substitute, open approach), and 0RRD0JZ (Replacement of left temporomandibular joint with synthetic substitute, open approach):

• From MS-DRGs 133 and 134 (Other Ear, Nose, Mouth and Throat O.R. Procedures with and without CC/MCC, respectively)
• To MS-DRGs 131 and 132 (Cranial and Facial Procedures with and without CC/MCC, respectively) in MDC 03.

The requestor stated that it is inaccurate for these two codes that involve the excision of the TMJ and replacement with a prosthesis to Group to MS-DRGs 133 and 134 when the codes for the TMJ excision alone (0RBC0ZZ (Excision of right temporomandibular joint, open approach) and 0RBD0ZZ (Excision of left temporomandibular joint, open approach) group to the higher weighted MS-DRGs 131 and 132.

The requestor also recommended analysis of all procedures involving the mandible and maxilla and consider reassignment of these procedures codes describing procedure performed on facial and cranial structure:

• From MS-DRGs 129 (Major Head and Neck Procedures with CC/MCC or Major Device) and 130 (Major Head and Neck Procedures without CC/MCC)
• To MS-DRGs 131 and 132.

CMS undertook a comprehensive review of all procedures currently assigned to MS-DRGs 129, 130, 131, 132, 133, and 134. Based on data analysis and this comprehensive review, the Clinical Advisors support restructuring of these MS-DRGs by assigning procedures currently assigned to these MS-DRGs based on clinical intensity, complexity of service and resource utilization.

Additional Findings as a result of this comprehensive review included:

• CMS noting the current special logic defined as “Major Device Implant” for MS-DRG 129 that identified procedures describing the insertion of a cochlear implant or other hearing device. “Clinical advisors supported the removal of this special logic from the definition for assignment to any proposed modifications to the MSDRGs, noting the costs of the device have stabilized over time and the procedures can be appropriately grouped along with other procedures involving devices in any restructured proposed MS-DRGs.”
• CMS identified 338 procedure codes that were inadvertently assigned to MS-DRGs 133 and 134 as a result of replication during the transition from ICD-9 to ICD-10 based MS-DRGs. This list of codes is available in Table 6P.2c.

As a result of their review, CMS has proposed the following:

• Delete the three MS-DRGs groups with a two-way severity level subgroup (129 & 130, 131 & 132, and 133 & 134)
• Create two new base MS-DRGs with a three-way severity level split:
• MS-DRGs 140, 141, and 142 (Major head and Neck Procedures with MCC, with CC, without CC/MCC respectively), and
• MS-DRGs 143, 144, and 145 (Other Ear, Nose, Mouth, and Throat O.R. Procedures with MCC, with CC, without CC/MCC respectively).

MDC 5: Diseases and Disorders of the Circulatory System

Left Atrial Appendage Closure (LAAC)

Requests were made to create a new MS-DRG for the LAAC procedure or to map all LAAC procedures to a different MS-DRG with payment rates aligned with procedural costs.  The following table shows the current corresponding MS-DRGs for the 9 ICD-10-PCS codes describing LAAC Procedures

As detailed in the table, ICD-10-PCS procedures currently map to an MS-DRG based on the approach. CMS has proposed to reassign the ICD-10-PCS procedure codes for an open approach to MS-DRGs 273 and 274. “Clinical advisors stated this reassignment would allow all LAAC procedures to be grouped to the same MS-DRGs and improve clinical coherence. The following table highlights the difference in R.W., GMLOS and national average payment in FY 2020:

‍Potential Impact by the Numbers

With the national payment rate for MS-DRGs 273 and 274 being significantly higher than MS-DRG 250 and 251, I wanted to see what the potential volume of claims and payment impact this change might have. To answer these questions I pulled Medicare fee-for-service paid claims data from RealTime Medicare Data (RTMD). Specifically, all claims with one of the 9 ICD-10-PCS procedure codes for LAAC for Alabama, Georgia and Tennessee in Calendar Year (CY) 2019. Following is what I found “by the numbers:”

• 314: The number of LAAC procedures performed in CY 2019.
• 1: The volume of claims grouping to MS-DRG 250.
• 8: The volume of claims grouping to MS-DRG 251.
• $74,166.95: The increase in payment for this group of 9 MS-DRGs based on FY 2020 national average payment.

Insertion of Cardiac Contractility Modulation Device

A request was made to review the MS-DRG assignment for cases identifying patients receiving a cardiac contractility modulation (CCM) device system for CHF. “CCM is indicated for patients with moderate to severe heart failure resulting from either ischemic or non-ischemic cardiomyopathy. CCM utilizes electrical signals which are intended to enhance the strength of the heart and overall cardiac performance. CCM delivery device systems consist of a programmable implantable pulse generator (IPG) and three leads which are implanted in the heart. One lead is implanted into the right atrium and the other two leads are inserted into the right ventricle.”

Reasons for this request:

• MS-DRGs 222, 223, 224, 225, 226, and 227 (Cardiac Defibrillator Implant with and without Cardiac Catheterization with and without AMI/HF/Shock with and without MCC, respectively include “code pairs” describing the insertion of contractility modulation devices.
• Currently, GROUPER logic requires the combination of the CCM device codes and a left ventricular lead to map to this group of MS-DRGs.
• Per the requestor, a CCM device is contraindicated in patients with a left ventricular lead. Consequently, no case involving insertion of the CCM system can be appropriately mapped to this group of MS-DRGs.
• Currently, CCM system insertion maps to MS-DRG 245 (AICD Generator Procedures).
• Requester noted to date this procedure has been performed on an outpatient bases but expects that some Medicare patients will receive CCM devices as an inpatient.

CMS analysis found that the ICD-10-PCS procedure code combinations for right ventricular and/or right atrial lead insertion with insertion of CCM devices were inadvertently excludes from this group of MS-DRGs as a result of replicating the ICD-9 based MS-DRGs. Based on their analysis, CMS is making the following two proposals:

• Add 24 ICD-10-PCS code combinations for CCM devices to this group of MS-DRGs, and
• Delete the 12 clinically invalid code combinations from the GROUPER logic of this MS-DRG group describing the insertion of CCM device and the insertion of a cardiac lead into the left ventricle.

MDC 6: Diseases and Disorders of the Digestive System

Acute Appendicitis

A request was made to add K35.20 (Acute appendicitis with generalized peritonitis, without abscess) to the list of complicated Principal Diagnoses grouping to MS-DRGs 338, 339, and 340 (Appendectomy with Complicated Principal Diagnosis with MCC, with CC, without CC/MCC, respectively) so that all ruptured/perforated appendicitis codes in MDC 6 would groups to these MS-DRGs.

Clinical Advisors agreed that the “presence of an abscess would clinically determine whether a diagnosis of acute appendicitis would be considered a complicated principal diagnosis.” However, since K35.20 is “without an abscess,” CMS did not make a proposal to add K35.20 to this MS-DRG group.

The requestor had also noted that K35.32 (Acute appendicitis with perforation and localized peritonitis, without abscess) currently groups to MS-DRGs 338, 339, and 340. Subsequently, CMS identified all diagnosis codes describing acute appendicitis under subcategory K35.2 and K35.3 to review MS-DRG assignments for clinical coherence. As a result of this review, CMS is making the following proposals specific to diagnosis code K35.32:

• Reassign diagnosis code from MS-DRGs 338, 339 and 340 to MS-DRGs 341, 342, and 343; and
• Remove diagnosis code from the complicated principal diagnosis list in MS-DRGs 338, 339, and 340.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Hip and Knee Joint Replacements

A requestor recommended restructuring MS-DRGs for total joint arthroplasty that utilize oxidized zirconium bearing surface implants in total hip and total knee replacements. They went on to offer three options for restructuring the MS-DRGs. Based this request and lengthy data analysis by CMS, CMS is proposing to create two new MS-DRGs for FY 2021:

• MS-DRG 521: Hip Replacement with Principal Diagnosis of Hip Fracture with MCC, and
• MS-DRG 522: Hip Replacement with Principal Diagnosis of Hip Fracture without MCC.

Request for Comment

CMS noted that the Comprehensive Care for Joint Replacement (CJR) model includes episodes triggered by MS-DRG 469 with hip fracture and MS-DRG 470 with hip fracture. Given the proposal for new MS-DRGs for hip fracture, CMS is seeking comments on the effect this proposal would have on the CJR model and whether to incorporate the new MS-DRGs into the model if finalized.

MDC 11: Diseases and Disorders of the Kidney and Urinary Tract

Kidney Transplants

Currently, Kidney Transplants group to MS-DRG 652 (Kidney Transplant) in MDC 11. There was a request to designate kidney transplants as Pre-MDC MS-DRGs similar to other organ transplants. CMS analysis found that all kidney transplants in MS-DRGs 981 and 982 reported a principal diagnosis in MDC 5 (Diseases and Disorders of the Circulatory System). CMS is proposing an alternate option “to modify the GROUPER logic for MS-DRG 652 by allowing the presence of a procedure code describing transplantation of the kidney to determine the MS-DRG assignment independent of the MDC of the principal diagnosis in most instances.”

CMS goes on to discuss how the Pre-MDCs came into existence and that the proposal for kidney transplant represent a “first step in investigating” how they may consider shifting transplants out of Pre-MDCs as their clinical advisors have noted that while once considered as being very resource intensive, “treatment practices have shifted since the inception of Pre-MDCs.”

Kidney Transplants and Dialysis during an Inpatient Stay

An additional request was made to create a new MS-DRG for kidney transplant cases where a patient receives dialysis during the inpatient stay and after the date of the transplant. The following three ICD-10-PCS procedure codes identify the performance of hemodialysis:

• 5A1D70Z: Performance of urinary filtration, intermittent, less than 6 hours per day
• 5A1D80Z: Performance of urinary filtration, prolonged intermittent, 6-18 hours per day
• 5A1D90Z: Performance of urinary filtration, continuous, greater than 18 hours per day

CMS believes that creating separate MS-DRGs when hemodialysis is performed either before or after a kidney transplant or simultaneous pancreas/kidney transplant “would appropriately address the differential in resource consumption consistent with the President’s Executive Order on Advancing American Kidney Health (see https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/). CMS is proposing the following three new MS-DRGs:

• Proposed new Pre-MDC MS-DRG 019 (Simultaneous Pancreas/Kidney Transplant with Hemodialysis),
• CMS is proposing to add the procedure codes from current Pre-MDC MS-DRG 008 to the proposed new Pre-MDC MS-DRG 019 with the procedure codes describing a hemodialysis procedure.
• Proposed new MS-DRG 650 (Kidney Transplant with Hemodialysis with MCC) and
• Proposed new MS-DRG 651 (Kidney Transplant with Hemodialysis without MCC).
• Similarly, CMS is also proposing to add the procedure codes from current MS-DRG 652 to the proposed new MS-DRGs 650 and 651 with the procedure codes describing a hemodialysis procedure.

Hemodialysis procedure codes are currently “designated as Non-O.R. procedure, therefore, as part of the logic for these proposed new MS-DRGs, we are also proposing to designate these codes as non-O.R. procedures affecting the MS-DRG.”

Proposed Addition of Diagnoses to MS-DRGs 673, 674, and 675 (Other Kidney and Urinary Tract Procedure Logic

In response to a request, CMS reviewed the GROUPER logic for this MS-DRG group including the special logic for certain MDC 11 diagnoses reported with procedures codes for the insertion of tunneled or totally implantable vascular access devices. Based on their review, CMS is making several proposals for code reassignment to this MS-DRG group.

MDC 17: Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasms

Inferior Vena Cava Filters

A requestor noted that currently when the procedure code describing the placement of an inferior vena cava (IVC) filter (06H03DZ – Insertion of intraluminal device into inferior vena cava, percutaneous approach) is also reported with the codes describing the introduction of a high dose chemotherapy agent or report a chemotherapy principal diagnosis with a secondary diagnosis describing acute leukemia, the cases are assigned to a lower weighted MS-DRG group than when the IVC filter code is not on the claim.

CMS notes in the proposed rule that “our clinical advisors believe that, given the similarity in factors such as complexity, resource utilization, and lack of a requirement for anesthesia administration between all procedures describing insertion of a device into the inferior vena cava, it would be more appropriate to designate these three ICD-10-PCS codes describing the insertion of an intraluminal device into the inferior vena cava as Non-O.R. procedures. Therefore, we are proposing to remove ICD-10-PCS procedure codes 06H00DZ, 06H03DZ, and 06H04DZ from the FY 2021 ICD-10 MS-DRG Version 38 Definitions Manual in Appendix E--Operating Room Procedures and Procedure Code/MS-DRG Index as O.R. procedures. Under this proposal, these procedures would no longer impact MS-DRG assignment.”

Review of Procedure Codes in MS-DRGS 981 through 983 and 987 through 989

Adding Procedures Codes Currently Grouping to MS-DRGS 981 – 983 and 987 – 989 into MDCs

Annually, CMS conducts a review of procedures resulting in assignment to the O.R. and non-extensive O.R. Procedures Unrelated to Principal Diagnosis MS-DRG Groups (981-983 and 987-989). This review is done on the basis of volume, by procedure, to see if it is more appropriate to move a procedure to a surgical MS-DRG for the MDC where the Principal Diagnosis falls.

There are several proposals being made to move diagnosis and procedures codes back into a specific MDC for FY 2021. For those interested, you can find these proposals on pages 32526 – 32542 of the Proposed Rule.

MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on July 10, 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 May 26th – June 1st 2020.   

Resource Spotlight This Week:

This week’s spotlight is the CDC’s CDC COVID Data Tracker. The Data Tracker includes maps, charts, and data on the following:

• S. Cases of COVID-19,
• S. COVID Testing,
• S. Forecasting,
• S. Trends,
• S. Cases and Deaths by County,
• Social Impact,
• School Closures, Mobility, and
• A “Learn More” tab covering topics ranging from COVID-19 FAQs and hospitalization rates to information on the use of cloth face coverings to daily life and coping.

May 26, 2020: Fact Sheet for State and Local Governments – CMS Programs & Payment for Care in Hospital Alternate Care Sites (ACS)

In order to expand capacity to care for patients during the COVID-19 Public Health Emergency (PHE) alternate care sites are being developed. CMS indicates that the purpose of this Fact Sheet is to provide “state and local governments developing alternate care sites with information on how to seek payments through CMS programs – Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) – for acute inpatient and outpatient care furnished at the site.”

May 27, 2020: The Joint Commission to Resume some Survey and Review Activities in June

The Joint Commission announced in their Wednesday May 27 Edition of Joint Commission Online that they are “committed to working closely with organizations, with safety being the first and foremost priority. As we start to resume some of these survey and review activities, account executives will begin to contact organizations due for a survey to assess the impact that the coronavirus pandemic had on their operations and their current state.”

They go on to note “our survey will focus on a thorough assessment but will not retroactively review compliance…rather, we will work to understand how you have adapted to the pandemic and review your current practices to assure you are providing safe care and working in a safe environment.”

May 27, 2020: COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

CMS has once again updated this now seventy-one page FAQ document. In addition to now containing a table of contents, new FAQS have been posted for the following topics:

• Hospital IPPS Payments under the CARES Act,
• Expansion of Virtual Communication Services for FQHCs/RHCs,
• Medicare telehealth,
• General Billing Requirements, specifically related to COVID-19 testing administered prior to and in association with a procedure.

Also, the following three new sections have been added to this document:

• Diagnosis Coding under ICD-10-CM,
• Chronic Care Management Services, and
• Outpatient Therapy Services

May 29, 2020: Alabama Medicaid Alert: Additional Laboratory Testing for COVID-19

Alabama Medicaid announced in a May 29th Alert that Providers may begin submitting claims on June 1, 2020, for dates of service on or after April 1, 2020 for the following testing procedure codes:

• 86328 Immunoassay for infectious agent antibody (ies), qualitative or semi quantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).

June 1, 2020: CDC Updates COVID-19 Transmission Webpage to Clarify Information about Types of Spread

The CDC announced in an email update that “after media reports appeared that suggested a change in CDC’s view on transmissibility, it became clear that these edits were confusion. Therefore, CDC has once again edited the page to provide clarity. 

The primary and most important mode of transmission for COVID-19 is through close contact from person-to-person. Based on data from lab studies on COVID-19 and what we know about similar respiratory diseases, it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this isn’t thought to be the main way the virus spreads.” This page also includes a link to a video titled “How does COVID-19 Spread?”

June 1, 2020: Medicare Fee-for-Service Response to the Public Emergency on COVID-19 MLN Article Revised

CMS revised MLN SE20011 on June 1st to add a section on Clarifications for using the “CR” Modifier and “DR” Condition Code. All other information remained the same.

• MLN SE20011: https://www.cms.gov/files/document/se20011.pdf