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MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from 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:

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.

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:

How do you code Type 2 Diabetes Mellitus with Peripheral Neuropathy?  Is Polyneuropathy the same as Peripheral Neuropathy in Diabetes?

A:

Yes.  According to the ICD-10-CM Code Book, Type 2 Diabetes Mellitus with Peripheral Neuropathy codes to Type 2 Diabetes Mellitus with Polyneuropathy (E11.42).  Let’s follow the alphabetic index:

Neuropathy

                        peripheral (nerve) (see also Polyneuropathy) G62.9

            In order to capture Diabetes Mellitus, we need to ‘see also Polyneuropathy’.

                Polyneuropathy (peripheral) G62.9

                Notice that (peripheral) is a modifier for polyneuropathy

                                diabetic - see Diabetes, polyneuropathy

                When we ‘see Diabetes, polyneuropathy’, it takes us to:

                Diabetes, diabetic; due to underlying condition; with; polyneuropathy E08.42

                Under the code category for E08, there is an Excludes1 note for several conditions, including type 2 diabetes mellitus.

                type 2 diabetes mellitus (E11.-)

Go to E11 Type 2 diabetes mellitus

                                E11.4 Type 2 diabetes mellitus with neurological complications

                                                E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy

Polyneuropathy means multiple nerve damage is causing peripheral neuropathy.  These are the nerves that connect your spinal cord to the rest of your body.  Both these terms are often used at the same time and generally mean the same thing.

References

ICD-10-CM Official Code Set

https://www.empowher.com/community/ask/what-difference-between-peripheral-neuropathy-and-poly-neuropathy

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

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 18th through May 26th.   

Resource Spotlight This Week:

This week’s spotlight is the CDCs COVIDView. This is a weekly surveillance summary of U.S. COVID-19 activity. Each week you can download a weekly summary. The summary includes information about the following:

Key Updates for the week,

• Virus,
• Outpatient and Emergency Department Visits,
• Severe Disease: Hospitalizations and Mortality, and
• Surveillance activity included graphs.

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

May 18, 2020: Guidance to Safely Reopen Nursing Homes

New guidance for the safe reopening of nursing homes was announced in a CMS Press Release as part of Guidelines for Opening Up America Again. This guidance details critical steps to be taken prior to relaxing nursing home restriction including “rigorous infection prevention and control, adequate testing, and surveillance.” CMS further recommends the following steps:

• Do not advance through any phase of reopening or relax restrictions until all residents and staff have received results from a baseline test,
• Have State survey agencies inspect nursing homes experiencing a significant outbreak prior to reopening, and
• Nursing homes should remain in the current state of highest restriction and be among the last to reopen within the community.

“Nursing homes may receive visitors during phase three, which is when there has been a sustained decrease in COVID-19 cases.” This Press Release provides links to the Guidance (Memorandum QSO-20-30-NH), an FAQ document and a full list of CMS Public Health Actions for Nursing Home on COVID-19 to date.

May 19, 2020: Re-entry Guidance for Health Care Facilities and Medical Device Representatives

The release of this Guidance is a joint effort of the American Hospital Association (AHA), the Association of perioperative Registered Nurses (AORN), and the Advanced Medical Technology Association (AdvaMed).

An AdvaMed Press Release indicates that “the guidance for re-entry builds on the April 17 joint statement by AHA, AORN, the American College of Surgeons, and the American Society of Anesthesiologists – entitled “Roadmap for Resuming Elective Surgery” – with expanded, clinically based recommendations supporting the safe return of medical device representatives into health care facilities, consistent with the AdvaMed Code of Ethics. The guidance seeks to align access standards and processes across health care facilities, with principles and considerations rooted in health authority guidance, including from the CDC, FDA, and state and local authorities.”

May 19, 2020: CDC Clinical Outreach and Communication Activity (COCA) Webinar: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19)

Discussion during this call included clinical characteristics of this syndrome, how cases have been diagnosed and treated, and how clinicians have been responding to recently reported cases associated with COVID-19. A video and slides from this presentation are available on the CDC website at https://emergency.cdc.gov/coca/calls/2020/callinfo_051920.asp?deliveryName=USCDC_1052-DM28705.

May 19, 2020: Special Edition MLNConnects: COVID-19: Payment for Diagnostic Laboratory Tests

“Earlier this year, CMS took action to ensure America’s patients, health care facilities, and clinical laboratories were prepared to respond to the 2019-Novel Coronavirus (COVID-19). To help increase testing and track new cases, CMS developed two HCPCS codes that laboratories can use to bill for certain COVID-19 diagnostic tests. Health care providers and laboratories may bill Medicare and other health insurers for SARS-CoV2 tests performed on or after February 4 using:  

• HCPCS code U0001 for tests developed by the Centers for Disease Control and Prevention (CDC)
• HCPCS code U0002 for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)

Laboratories and other health providers can also bill Medicare for tests using CPT codes created by the American Medical Association, provided testing uses the method specified by each CPT code:

• CPT code 87635 for infectious agent detection by nucleic acid tests for dates of service on or after March 13
• CPT codes 86769 and 86328 for serology tests for dates of service on or after April 10

Finally, for dates of service on or after April 14, 2020, Medicare pays $100 for laboratory tests for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 making use of high throughput technologies (PDF). Laboratories can bill Medicare for these tests using:

• U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
• U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.

Neither U0003 nor U0004 should be used to bill for tests that detect COVID-19 antibodies.

For COVID-19 tests that do not use high throughput technology, Medicare Administrative Contractors developed payment amounts (PDF) for claims in their jurisdictions that will be used until we establish national payment rates though the annual laboratory meeting process. There is no cost-sharing for Medicare patients.”

May 19, 2020: Special Edition MLNConnects: COVID-19: Which Laboratory Claims Require the NPI of the Ordering/Referring Professional?

“During the COVID-19 Public Health Emergency, CMS is relaxing billing requirements for a limited number of laboratory tests (PDF) required for a COVID-19 diagnosis. Any health care professional authorized under state law may order these tests. Medicare will pay for these tests without a written order from the treating physician or other practitioner:

• If an order is not written, you do not need to provide the National Provider Identifier (NPI) of the ordering or referring professional on the claim
• If an order is written, include the NPI of the ordering or referring professional, consistent with current billing guidelines

For More Information:

• Laboratory Tests (PDF)with modified requirements

• Interim Final Rule”

May 20, 2020: COVID-19 Blanket Swing Bed Waiver for Addressing Barriers to Nursing Home Placement for Hospitalized Individuals

MLN Matters SE20018 provides answers to questions hospitals may have when looking at the option to provide post-hospital Skilled Nursing Facility (SNF) swing-bed services for non-acute care patients in your hospital. Q&A’s fall into the following topics in this eight page document:

• Swing Beds and Hospitals,
• Swing Bed Waiver during the Public Health Emergency (PHE),
• Swing Beds and the Required MDS,
• Billing and Payment for Swing Bed Services, and
• Additional Information.

May 21, 2020: FDA COVID-19 Response At-A-Glance Summary as of May 21, 2020

This document highlights the FDA’s Activities, Recent Actions and Provides links to resources for further information about COVID-19.

May 22, 2020: Alabama Medicaid Alert: COVID-19 Emergency Expiration Date Extended to June 30

The Alabama Medicaid Agency provided the following information in a May 22nd Alert:

“All previously published expiration dates related to the Coronavirus (COVID-19) emergency are once again extended by the Alabama Medicaid Agency (Medicaid). The new expiration date is the earlier of June 30, 2020, the conclusion of the COVID-19 National emergency, or any expiration date noticed by the Alabama Medicaid Agency through a subsequent ALERT.

A listing of previous Provider Alerts and notices related to the health emergency is available by selecting the Agency’s COVID-19 page in the link below:  https://medicaid.alabama.gov/news_detail.aspx?ID=13729.”

May 22, 2020: Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules

MLN Matters MM11805 provides a summary of policies in the following legislation:

• Interim Final Rule with Comment (IFC) titled “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC), and
• Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-129 Public Health Emergency and Delay for Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program (CMS-5531-IFC).”

The implementation date is June 12, 2020.

May 22, 2020: New OIG Work Plan Item Related to COVID-19: Audit of Nursing Home Infection Prevention and Control Program Deficiencies

The OIG announced the addition of the following new Active Work Plan Item related to COVID-19:

“The Centers for Disease Control and Prevention has indicated that individuals at high risk for severe illness from coronavirus disease 2019 (COVID-19) are people aged 65 years and older and those who live in a nursing home. Currently, more than 1.3 million residents live in approximately 15,450 Medicare- and Medicaid-certified nursing homes in the United States. As of February 2020, State Survey Agencies have cited more than 6,600 of these nursing homes (nearly 43 percent) for infection prevention and control program deficiencies, including lack of a correction plan in place for these deficiencies. To reduce the likelihood of contracting and spreading COVID-19 at these nursing homes, effective internal controls must be in place. Our objective is to determine whether selected nursing homes have programs for infection prevention and control and emergency preparedness in accordance with Federal requirements.”

The expected issue date for a report is 2020.

May 26, 2020: Transmittal 10161: Therapy Codes Update

CMS rescinded One-Time Notification Transmittal 10139, dated May 15, 2020 and has replaced it with One-Time Notification Transmittal 10161, dated May 26, 2020 to revise the implementation date for the MACs. Policies implemented in this notification are reflective of policies related to the following legislation:

• Interim final rule with comment (IFC) Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC).
• IFC Medicare and Medicaid Programs Additional Policy and Regulatory Revision in Response to the COVID-19 Public Health Emergency (CMS-5531-IFC); and
• The Coronavirus Aid, Relief, and Economic Security Act (CARES Act). This CR updates the therapy code list and associated policies effective March 1, 2020, for the duration of the COVID-19 PHE.

The revised implementation date for the MACs is June 16, 2020 and July 6, 2020 for FISS.

May 26, 2020: OIG Strategic Plan: Oversight of COVID-19 Response and Recovery

As part of their Strategic Plan, the OIG will be “using risk assessment and data analytics to identify, monitor, and target potential fraud, waste, and abuse affecting HHS programs and beneficiaries and to promote the effectiveness of HHS’s COVID-19 response and recovery programs." The plan incorporates the following four goals:

• Goal 1: Protect People,
• Goal 2: Protect Funds,
• Goal 3: Protect Infrastructure, and
• Goal 4: Promote Effectiveness of HHS Programs – Now and into the Future.

MEDICARE TRANSMITTALS – RECURRING UPDATES

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
• What You Need to Know: Change Request (CR) 11749 provides information about updated ICD-10 conversions as well as coding updates specific to NCDs. In this update new ICD-10-CM codes have been added to NCD 90.2 Next Generation Sequencing.
• MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2020 Update

• Article Release Date: May 12, 2020
• What You Need to Know: CMS has issued payment files to the MACs based on the 2020 MPFS Final Rule.
• MLN MM11788: https://www.cms.gov/files/document/mm11788.pdf

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

• Article Release Date: May 22, 2020
• What You Need to Know: CR 11708 is a code update notification indicating when updates to the CARC and RARC lists are made available at the official Accredited Standards Committee (ASC) X12 website.
• MLN MM11708: https://www.cms.gov/files/document/mm11708.pdf

October 2020 Healthcare Common Procedure Coding System (HCPCS) Quarterly Update Reminder

• Transmittal Release Date: May 22, 2020
• What You Need to Know: The complete HCPCS file is updated and released quarterly to the Medicare contractors. The file contains existing, new, revised and discontinued HCPCS codes for the October 2020 quarter. Contractors must download the file via the CMS mainframe in September 2020. The recurring update notification applies to chapter 23, section 20 of the Medicare Claims Processing Manual.
• Transmittal 10153: https://www.cms.gov/files/document/r10153cp.pdf

OTHER MEDICARE TRANSMITTALS

 Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

• Article Release Date: May 1, 2020
• What You Need to Know:
• Change Request (CR) 11580 modifies Medicare system edits on inpatient claims when a beneficiary’s MA plan becomes effective during the inpatient admission.
• The CMS is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered significant cost. FFS Medicare will pay for services obtained by beneficiaries enrolled in MA plans in this circumstance.
• MACs will allow Condition Code (CC) 78 on inpatient and outpatient claims for MA beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost. An update will occur to any current editing that does not allow this scenario.
• Condition Code 78 = newly covered Medicare service for which a HMO does not pay.
• MLN MM11580: https://www.cms.gov/files/document/mm11580.pdf

New Codes for Therapist Assistants Providing Maintenance Programs in the Home Health Setting

• Article Release Date: May 1, 2020
• What You Need to Know: CR 11721 details changes to Home Health (HH) billing and processing instructions, including new G-codes describing therapy assistant services. Also included is a correction to the processing of HH claims that receive episode sequence edits.
• MLN MM11721: https://www.cms.gov/files/document/mm11721.pdf

Medicare Clarifies Recognition of Interstate License Compacts

• Special Edition Article Release Date: May 5, 2020
• What You Need to Know: This article clarifies the CMS recognition of interstate license compacts. CMS acknowledges that more compacts may be underway as new legislation is passed but at this time they have determined that interstate license compact for the following provider types will be treated as valid and full licenses for purposes of meeting federal license requirements:
• Physicians,
• Physical and Occupational Therapists,
• Speech Language Therapists,
• Nurse Practitioners, and
• MLN Article SE20008: https://www.cms.gov/files/document/SE20008.pdf

Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process

• Article Release Date: May 8, 2020
• What You Need to Know: Change Request 11727 contains updates to Medicare’s claims processing systems to make corrections to processing of adjustments and other billing issues for SNF Patient Driven Payment Model (PDPM) claims. CMS advises you to make sure your billing staffs are aware of these updates.
• MLN Article MM11727: https://www.cms.gov/2020-mln-matters-articles-0

New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services

• Article Release Date: May 11, 2020
• What You Need to Know: This article highlights new physician specialty codes for MDS (D7) and ACHD (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6).
• MLN MM11750: https://www.cms.gov/files/document/MM11750.pdf

Therapy Codes Update

• Article Release Date: May 15, 2020
• What You Need to Know: This article includes updates to the list of codes that sometimes or always describe therapy services. Additions to the list reflect changes made in Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE).
• MLN MM11791: https://www.cms.gov/files/document/MM11791.pdf

Manual Update Pub. 100.-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section

• Article Release Date: May 15, 2020
• What You Need to Know: Medicare is removing section 20 (and all of its subsections) of chapter 38 of the Medicare Claims Processing Manual (Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico). The key impact of this notification is that modifier CS will no longer be used to denote services related to the 2010 oil spill. The effective and implementation date for this change is June 16, 2020.
• MLN Matters MM11778: https://www.cms.gov/files/document/MM11778.pdf

REVISED MEDICARE TRANSMITTALS

Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy

• Date Article Revised: April 30, 2020
• What You Need to Know: This article was revised to reflect revised Change Request 11559. The CR informs MACs about changes to Medicare Common Working File (CWF) edits to ensure the original 1-Day and 3-Day Payment Window edits’ set and bypass conditions are consistent with current policy. There are no policy changes. Current policy is in the Medicare Claims Processing Manual, Chapter 4, Section 10.12 and Section 40.3.
• MLN Article MM1159: https://www.cms.gov/files/document/mm11559.pdf

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update

• Date Article Revised: May 4, 2020
• What You Need to Know: This article was revised to reflect revisions in CR 11661 issued on May 1, 2020. The following changes were made:
• The relative value units for codes 99441-99442, and 99443 were revised,
• Information for codes G2025 and G0071 was added, and
• The statement at the end of page was updated.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Medicare Continues to Modernize Payment Software

• Article Release Date: May 19, 2020
• What You Need to Know: This articles provides information about the CMS efforts to modernize payment grouping and code edit software. Specifically, this article is meant to inform providers that in October 2020, CMS will expand this effort to include the following additional software products:
• The IRF Case-Mix Group (CMG) Grouper, and
• The IRF Pricer and PC Pricer.
• MLN SE20019: https://www.cms.gov/files/document/SE20019.pdf

Claim Status Category Codes and Claim Status Codes Updates

• Article Release Date: May 22, 2020
• What You Need to Know: CR 11699 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.
• MLN MM11699: https://www.cms.gov/files/document/mm11699.pdf

MEDICARE COVERAGE UPDATES

National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)

• Article Release Date: May 13, 2020
• What Your Need to Know: This article informs you that CMS will cover acupuncture for cLBP effective for claims with dates of service on or after January 21, 2020. The article reminds you that acupuncture for fibromyalgia or osteoarthritis is still non-covered by Medicare.
• MLN MM11755: https://www.cms.gov/files/document/MM11755.pdf
  

National Coverage Determinations (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)

• Date Article Released: May 12, 2020
• What You Need to Know: For dates of service on and after July 2, 2019, the CMS will cover ABPM for the diagnosis of hypertension in Medicare under updated criteria detailed in this article. The Effective Date was July 2, 2019. The Implementation Date for Local MAC edits is June 16, 2020.
• MLN MM11650: https://www.cms.gov/files/document/MM11650.pdf

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

• Date Transmittal Released: May 22, 2020
• What You Need to Know: NCD 160.18, Vagus Nerve Stimulation was initially issued in 1999 to provide coverage for VNS for patients with medically refractory partial onset seizures, for whom surgery is not recommended or for whom surgery had failed. New to this NCD, 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.
• Transmittal 10145: https://www.cms.gov/files/document/r10145ncd.pdf

OTHER MEDICARE UPDATES

MLN Booklet (ICN MLN901623) April 2020: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants

This MLN Booklet outlines the required healthcare practitioner qualifications and coverage, billing, and payment criteria for Medicare services furnished by:

• Advanced Practice Registered Nurses (APRNs), including:
• Certified Registered Nurse Anesthetists (CRNAs)
• Nurse Practitioners (NPs)
• Certified Nurse-Midwives (CNMs)
• Clinical Nurse Specialists (CNSs)
• Anesthesiology Assistants (AAs), and
• Physician Assistants (PAs)

Fiscal Year 2021 IPPS and LTCH PPS Proposed Rule

CMS released the FY 2021 IPPS and LTCH PPR Proposed Rule. In a related Fact Sheet CMS indicates the agency’s singular objective is “transforming the healthcare delivery system through competition and innovation to provide patients with better value and results.” CMS is accepting comments on the Proposed Rule through 5 pm EDT on July 10, 2020.

May 7, 2020: Original Medicare (Fee-for-Service) Appeals: Enhanced Opportunity for Submission of 2nd Level of Appeals, Reconsiderations

CMS posted the following announcement on their Original Medicare (Fee-for-Service) Appeals webpage on May 7th: Qualified Independent Contractors (QICs) that process 2nd level Medicare Fee-For-Service (FFS) claim appeals, reconsiderations, on behalf of the Centers for Medicare & Medicaid Services (CMS) have established alternative communication mediums for CMS stakeholders to submit reconsideration requests and related documentation to the QIC. The websites for the respective QIC jurisdictions contain instructions to stakeholders for electronic (e.g., fax or portal) submission of reconsideration requests or documentation.” A table on this page provides guidance regarding the options for submitting reconsiderations and related documentation by QIC jurisdiction.

May 8, 2020: Hospital Outpatient Therapeutic Services That Have Been Evaluated for a Change in Supervision Level

On May 8th, CMS added this document to the available downloads on the CMS Hospital Outpatient PPS 

Webpage. Included in the download is a table providing the level of supervision required for hospital outpatient therapeutic services. Information prior to the table highlights changes made in an interim final rule addressing supervision requirements for non-surgical extended duration services (NSEDTS) and pulmonary rehabilitation services, cardiac rehabilitation services, and intensive cardiac rehabilitation services during the COVID-19 Public Health Emergency (PHE).

For the past two weeks the Wednesday@One has included an article about the CMS Prior Authorization Program for Certain Outpatient Department (OPD) Services Program set to begin July 1, 2020.

• May 12, 2020 Article: Prior Authorization for Certain Procedures to Begin July 1, 2020
• May 19, 2020 Article: Prior Authorization for Certain Hospital Outpatient Department (OPD) Services: MAC Provider Education and Coverage Determinations http://www.mmplusinc.com/news-articles/item/prior-authorization-for-certain-hospital-outpatient-department-opd-services-mac-provider-education-and-coverage

The May 19th article included MAC specific details about when they would be holding education sessions for Providers. This week’s article is meant to inform you about a CMS Open Door Forum related to the prior authorization program, provide highlights from Palmetto GBA’s education sessions in the form of Q&A’s and discuss the change CMS has made in the timeline for Provider Education from the MACs.

CMS Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services Special Open Door Forum (ODF)

The CMS will be hosting a Special ODF tomorrow Thursday May 28 from 1:30 to 3pm ET.

The ODF announcement can be found in the Thursday May 21, 2020 MLNConnects newsletter.

In the announcement CMS invites hospitals, physicians, practitioners, and other Medicare stakeholders to discuss the prior authorization of certain outpatient hospital department services from the following categories:

• Blepharoplasty,
• Botulinum toxin injections,
• Panniculectomy,
• Rhinoplasty, and
• Vein ablation.

Participation Instructions:

• Participant Dial-in-Number: 888-455-1397
• Conference ID#: 9375124

I advise those interested in participating to call in five to ten minutes prior to the start time to ensure you hear the entire session.

Palmetto GBA Outpatient Prior Authorization (PA) May 26, 2020 Education Sessions

Question: When can I start submitting PA’s?
Answer: You can begin to submit PA’s on June 17, 2020 for services on or after July 1, 2020.

Question: How should a PA be submitted to Palmetto (i.e., fax)?
Answer: On June 17 you will be able to submit a PA via fax or mail. You will be able to submit a PA via eServices on or after July 6, 2020.

Question: What happens if a Prior Authorization Request (PAR) does not contain all of the required information?
Answer: You will receive an “error message.”

Question: Will there be a paper form available for Providers to use?
Answer: At this time there is not a paper form available. A form will be made available in the near future. The form will contain the fax number that it should be sent. However, Palmetto GBA recommends that Providers use eServices once this option is available.

Question: Once I submit a PAR, how will I receive the Decision Letter back from Palmetto GBA?
Answer: The Decision Letter will be processed within 10 days and be sent in the same way that the PA was received. (i.e., if you send the PA by fax you will receive a Decision Letter via fax.)

Question: Once you receive a Provisional Affirmation, how long is it valid?
Answer: It is valid for 120 calendar days from the date the decision was made.

Question: Does this Program apply to the Ambulatory Surgery Center (ASC) setting?
Answer: This question was asked in the first session of the day and then clarified in the section session that no, this program is not applicable to the ASC setting.

In addition to the May 26 Education Sessions, Palmetto GBA has added an Outpatient Department PA webpage to their website where you will find articles related to this program. Also, at the end of the May 26 afternoon session the presenter indicated that Palmetto GBA plans to hold monthly teleconferences once this program has started to be available to answer questions from Providers.

CMS Extends MAC Provider Education Deadline

On April 24, 2020 CMS released Transmittal 10061 entitled One-Time Notification: Provider Education for Required Prior Authorization (PA) of Hospital Outpatient Department (OPD) Services. The purpose of this Change Request (CR 11671) is to provide instructions to the MACs regarding provider education on the PA process.

On May 21, 2020 this Transmittal was rescinded and replaced with Transmittal 10155 . The transmittal was updated to change the effective and implementation date from May 26, 2020 to June 17, 2020. All other information remained the same.

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 12th through May 15th.  

Resource Spotlight This Week:

This week’s spotlight is on a May 4th pdf document titled COVID-19 Regulations & Waivers to Enable Health System Expansion highlighting how CMS has enabled significant health system flexibility during the COVID-19 Public Health Emergency (PHE) through Medicare 1135 blanket waivers and the passage of two interim final rules. You can also find this presentation on the CMS Coronavirus Waivers and Flexibilities webpage. 

May 12, 2020: Price Transparency Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing

In a May 12 Special Edition MLNConnects newsletter, CMS noted the following regarding Price Transparency Requirements:

“The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes a number of provisions to provide relief to the public from issues caused by the pandemic, including price transparency for COVID -19 testing. Section 3202(b) of the CARES Act requires providers of diagnostic tests for COVID-19 to post the cash price for a COVID-19 diagnostic test on their website from March 27 through the end of the public health emergency. For more information, see the FAQs. (PDF).”

CMS has also posted a Q&A Document specific to the Price Transparency Requirement.

May 13, 2020: CMS Issues Nursing Homes Best Practices Toolkit to Combat COVID-19

This Toolkit includes recommendations and best practices from front line health care providers, governors’ COVID-19 task forces, associations, organizations and experts. It is intended to provide a catalogue of resources dedicated to address challenges facing nursing homes in the fight against COVID-19. You can read more in a related CMS Press Release.

May 14, 2020: FDA Informs Public about Possible Accuracy Concerns with Abbott ID NOW Point-of-Care Test for COVID-19

The FDA Alert indicates that early data suggests potential inaccurate results from using this point-of-care to diagnose COVID-19. Specifically, the test may return false negative results. They will continue to work with Abbott and communicate any updates publicly.

May 14, 2020: FDA Health Advisory Issued: Multisystem Inflammatory Syndrome in Children (MIS-C) Association with COVID-19

The CDC issued an official Health Advisory alert providing background information on several cases of a recently reported MIS-C associated with COVID-19 and a case definition of the syndrome. “CDC recommends healthcare providers report any patient who meets the case definition to local, state, and territorial health departments to enhance knowledge of risk factors, pathogenesis, clinical course, and treatment of this syndrome.”

The Case Definition for MIS-C includes the following:

• An individual aged <21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
• No alternative plausible diagnoses; AND
• Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

May 14, 2020: Health Affairs Research Article: Strong Social Distancing Measures in the United States Reduced the COVID-19 Growth Rate

Economists at the University of Kentucky evaluated the impact of imposed social distancing measures on growth rate of confirmed COVID-19 cases across US counties in March and April of 2020. The end date of this study was April 27 as this date coincided with the re-opening of restaurants and other entertainment facilities in Georgia. Results of this study imply there would have been more than 35 times greater spread of the disease without any of the social distancing measures having been put into place.

May 15, 2020: American College of Surgeons (ACS) Post-COVID-19 Readiness Checklist for Resuming Surgery

The ACS developed this checklist “to help surgeons ultimately communicate to their patients the important items they want to know. You can read the full announcement and download a print-friendly version of the checklist on the ACS website at https://www.facs.org/covid-19/checklist.

May 15, 2020: OCR Bulletin: Ensuring the Rights of Persons with Limited English Proficiency (LEP) in Health Care During COVID-19

This OCR Bulletin reminds health care providers that they “must take reasonable steps to provide meaningful access to individuals with LEP eligible to be served or likely to be encountered in their health programs and activities. This longstanding obligation is not waived during a National Emergency.” You will find suggestions for providing meaningful access for persons with LEP and links to several available resources.

May 15, 2020: Special Edition MLNConnects: Deadline Approaching for Nursing Homes to Report Confirmed and Suspected COVID-19 Cases

The April 30th Interim Final Rule with Comment Period requires nursing homes to begin reporting data to the CDC no later than Sunday May 17th. Facilities have to enroll in the CDC’s National Healthcare Safety Network (NHSN) to report data. “As nursing homes report this data to the CDC, CMS will be taking swift action and publicly posting this information so all Americans have access to accurate and timely information on COVID-19 in nursing homes. More information on the CDC’s NHSN COVID-19 module can be found here.”

May 15, 2020: Special Edition MLNConnects: Telephone Evaluation and Management Visits

“The March 30 Interim Final Rule with Comment Period added coverage during the Public Health Emergency for audio-only telephone evaluation and management visits (CPT codes 99441, 99442, and 99443) retroactive to March 1. On April 30, a new Physician Fee Schedule was implemented increasing the payment rate for these codes. Medicare Administrative Contractors (MACs) will reprocess claims for those services that they previously denied and/or paid at the lower rate.

There are also a number of add on services (CPT codes 90785, 90833, 90836, 90838, 96160, 96161, 99354, 99355, and G0506) which Medicare may have denied during this Public Health Emergency. MACs will reprocess those claims for dates of service on or after March 1.

You do not need to do anything.”

May 17, 2020: New CDC Activities and Initiatives Supporting the COVID-19 Response and the President’s Plan for Opening America Up Again – May 2020

This CDC Document was posted to the CDC website on May 17th. In addition to highlighting CDC activities and initiatives, this document includes the following appendices:

• Appendix A: Surveillance for COVID-19,
• Appendix B:Healthcare System Surveillance,
• Appendix C: Guidance on Infection Control and Contact Tracing,
• Appendix D: Guidance on Test Usage (Asymptomatic Populations and Serology),
• Appendix E: Assessing Surveillance and Hospital Gating Indicators, and
• Appendix F: Setting Specific Guidance.

Appendix F offers interim guidance for child care programs, interim guidance for schools and day camps, interim guidance for employers with workers at high risk, interim guidance for restaurants and bars, and interim guidance for mass transit administrators. The CDC notes the guidance in Appendix F is meant to assist establishments as they open. Further, they will update guidance as more is learned about COVID-19 and best practices to prevent its spread.