Knowledge Base - Full Library

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates that span from April 23rd through April 30th.  

Coronavirus.gov Website

This week’s COVID-19 resource spotlight is the Coronavirus.gov website at

https://www.coronavirus.gov/. Specifically, there are two resources available on this website that I want to point out. First is the COVID-19 Screening Tool.  This tool can help you understand what to do next about COVID-19. Second, is the State Information where you can choose a state to see COVID-19 specific guidance from that state’s health department. Both of these resources can be found by clicking “Check for Symptoms” on the homepage.  

April 23, 2020: COVID-19 FAQs on Medicare Fee-for-Service (FFS) Billing – Updated

On April 9, 2020 CMS announced in Special Edition MLN Connects that the COVID-19 FAQs have been updated. They advise that you check this resource often as it is updated on a regular basis. They noted that a date is added at the end of an FAQ when it is new or the content has been updated. As of Thursday April 23th this document is now 41 pages. The following list highlights the newest FAQ topics in the document:

• Payment for specimen collection for purposed of COVID-19 testing,
• Diagnostic laboratory services,
• Hospital services,
• Ambulance services,
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs),
• NEW: Expansion of Virtual Communication Services for FQHCs/RHCs,
• NEW: Revision of the Home Health Agency Shortage Area Requirement for Visiting Nursing Services Furnished by RHCs and FQHCs,
• Medicare telehealth. (CMS notes this document does not include flexibilities that might be exercised under the CARES Act),
• Physician Services
• Home Infusion Services,
• Accountable Care Organizations (ACO),
• Opioid Treatment Programs,
• Inpatient Rehabilitation Facility services,
• Skilled Nursing Facility services,
• General billing requirements,
• Home Health,
• Drugs and Vaccines under Part B,
• NEW: National Coverage Determinations (NCD),
• Medicare payment to facilities accepting government resources,
• Oxygen,
• NEW: Temporary Department of Defense Sites, and
• NEW: Military Treatment Facilities (MTFs).

April 24, 2020: Alabama Medicaid Alert

Alabama Medicaid indicated in a Provider Alert that all previously published expiration dates related to the COVID-19 emergency are being extended with a new expiration date of May 30, 2020 or at the conclusion of the COVID-19 National emergency, whichever occurs first.

Also included in this Alert is the reminder that “during the COVID-19 emergency, it is important to file claims as quickly as possible to ensure payment from Medicaid is made to Medicaid providers close to the date of service. The Centers for Medicare and Medicaid Services has increased the federal matching percentage for the emergency time frame, but states can only receive the increased match on claims that are paid during the emergency. Providers should include appropriate COVID-19 diagnosis code(s) on claims submitted to help with tracking of COVID-19.”

You can view a listing of prior Provider Alerts and all actions in response to the COVID-19 National emergency on the Agency’s COVID-19 at: https://medicaid.alabama.gov/news_detail.aspx?ID=13729

April 27, 2020: HHS Launches COVID-19 Uninsured Program Portal

In an April 27th media release, the U.S. Department of Health and Human Services (HHS) announced that they have “launched a NEW COVID-19 Uninsured Program Portal, allowing health care providers who have conducted COVID-19 testing or provided treatment for uninsured COVID-19 individuals on or after February 4, 2020 to submit claims for reimbursement.”

About the Program

• Where to Access the Portal
• HHS’ Health Resources and Services Administration (HRSA) COVID-19 Claims Reimbursement to Health Care Providers and Facilities Testing and Treatment of the Uninsured webpage at: https://www.hrsa.gov/coviduninsuredclaim
• HHS’ HRSA has contracted with UnitedHealth Group to administer this program.
• Approximately $1 billion is available to reimburse providers. This money was appropriate through the Families First Coronavirus Response Act.
• Program Timeline:
• April 22: Program Details Launch
• April 27: Sign up period begins for the program
• April 29: On Demand training starts
• May 6: Begin submitting claims electronically
• Mid-May: Begin receiving reimbursement
• Services Eligible for reimbursement:
• Specimen collection, diagnostic and antibody testing.
• Testing-related visits including in the following settings: office, urgent care or emergency room or via telehealth.
• Treatment, including office visit (including via telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (e.g., oxygen, ventilator), emergency ground ambulance transportation, non-emergent patient transfers via ground ambulance, and FDA-approved drugs as they become available for COVID-19 treatment and administered as part of an inpatient stay.
• FDA-approved vaccine, when available.
• For inpatient claims, date of admittance must be on or after February 4, 2020.
• How to learn more:
• HRSA has indicated the Program website will be updated with much more information starting April 27 and to check back often.

April 27, 2020: MLN Matters MM11765: Addition of the QW Modifier to HCPCS Code U0002 and 87635

Provider Types affected by information in MLN MM11765 are facilities with a current Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver. Specifically, the article advised the need for the addition of the QW modifier to:

• HCPCS code U0002 (2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC), and
• 87635 [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.]

Medicare will permit the use of Codes U0002QW and 87635QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after March 20, 2020. The official instruction, CR 11765, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10066OTN.pdf.

April, 28 2020: AHA and AHIMA FAQs Regarding ICD-10-CM Coding for COVID-19 Revised

The American Hospital Association and American Health Information Management Association released this joint FAQs regarding ICD-10-CM Coding for COVID-19 document on March 24, 2020. Since then several FAQs have been added with the most recent additions being on April 28, 2020.

MMP encourages you to visit the AHA COVID-19 FAQ webpage often for new information that can be downloaded and shared with your Coders and Clinical Documentation Integrity (CDI) Specialists.

April 28, 2020: Alabama Hospitals allowed to Resume Medical Procedures

Alabama’s Safer At Home Order signed on April 28, 2020 amended the Order of the State Health Officer Suspending Certain Public Gathering Due to the Risk of Infection by COVID-19 document. This is good news for Alabama hospitals as the following information for hospitals regarding resuming medical procedures was included in the amended document:

“Medical procedures. Effective April 30, 2020, at 5:00 P.M., dental, medical, or surgical procedures may proceed unless the State Health Officer or his designee determines that performing such procedures, or any category of them (whether statewide or regionally), would unacceptably reduce access to personal protective equipment or other resources necessary to diagnose and treat COVID-19. Providers performing these procedures shall follow all applicable COVID-19-related rules adopted by a state regulatory board or by the Alabama Department of Public Health. In the absence of such rules, providers should take reasonable steps to comply with applicable COVID-19-related guidelines from the Centers for Medicare and Medicaid Services (CMS) and the CDC, including “Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I” from CMS, available at https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf, and “Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19)” from the CDC, available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html.”

April 28, 2020: CMS Issues Letter to Clinicians Regarding New COVID-19 Clinical Trials Improvement Activity to the MIPS

In a letter thanking clinicians for their efforts to treat patients and combat COVID-19, CMS provided additional details on the new Merit-Based Incentive Payment System (MIPS) improvement activity.

Letter (PDF)

April 29, 2020: First Coast eNews: COVID-19: Allowances for Lab Test Codes U0001-U0004 and 87635

In this announcement, First Coast reminds providers that CMS established new codes for lab tests for the novel coronavirus (COVID-19). Further, CMS provided pricing for codes U0001 and U0002, and instructed MACs to develop the allowance for the remaining codes. The following table highlights the Allowance for each code:

‍April 29, 2020: The HHS Office of Civil Rights (OCR) Webinar on HIPAA Privacy and Security Issues Related to COVID-19

In an April 29th announcement the OCR indicated they had hosted a webinar on April 24, 2020, for health IT stakeholders on HIPAA privacy and security issues related to COVID-19 and recent OCR actions related to the pandemic. The following topics were included in this webinar:

• COVID-19 and Permissible Disclosures under the HIPAA Privacy Rule
• Enforcement Discretion and Guidance for Telehealth Remote Communications
• Guidance for Disclosures to First Responders and Public Health Authorities
• Enforcement Discretion for Business Associates to Use and Disclose PHI for Public Health and Health Oversight Activities
• Enforcement Discretion for Community-Based Testing Sites

A recording of this webinar is now available on YouTube: https://youtu.be/2C6iOdS_FR0. 

The slides from this presentation may be viewed at:  https://go.usa.gov/xvExS. 

For more information related to HIPAA and COVID-19, visit the HIPAA, Civil Rights, and COVID-19 webpage.

April 30, 2020: Second Round Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic

In an April 30th Press Release the CMS announced “another round of sweeping regulatory waivers and rule changes to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system as America reopens.” The CMS indicates “today’s actions are informed by requests from healthcare providers as well as by the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act.”  Included in the Press Release is the reminder that you do need to apply for the blanket waivers and providers and states can begin using the flexibilities immediately. Following are a few of the actions being taken:   

COVID-19 Diagnostic Testing for Medicare and Medicaid Beneficiaries:

• During the Public Health Emergency, COVID-19 test may be covered when ordered by any healthcare professional authorized to do so under state law. To provide broad access to testing related to COVID-19, a written practitioner’s order is no longer required for the COVID-19 test for Medicare payment purposes.
• CMS will pay hospitals and practitioners to assess beneficiaries and collect lab samples for COVID-19 testing, and make separate payment when that is the only service the patient receives.
• CMS announced they will be “covering certain serology (antibody) tests, which may aid in determining whether a person may have developed an immune response and may not be at immediate risk for COVID-19 reinfection. Medicare and Medicaid will cover laboratory processing of certain FDA-authorized tests that beneficiaries self-collect at home.”

CMS Hospitals Without Walls

CMS provided the following examples of ways hospitals are being provided flexibility to increase beds for COVID-19 patients and receive stable Medicare payments:

• Teaching hospitals can increase the number of temporary beds without facing reduced payments for indirect medical education.
• Inpatient Psychiatric and inpatient rehabilitation facilities (IRFs) can admit more patients to alleviate pressure on acute-care hospital capacity without facing reduced teaching status payments.
• Specific for freestanding IRFs, CMS is excepting certain requirements to enable them to accept patients from acute-care hospitals experiencing a surge, even if they do not require rehabilitation care.
• Hospital systems with rural health clinics (RHCs) can increase bed capacity without affecting the RHCs payments.

Outpatient Hospital Services

• Under current law, most provider-based hospital outpatient departments that relocate off-campus are paid at lower rates under the Physician Fee Schedule, rather than the Outpatient Prospective Payment System (OPPS). CMS will allow certain provider-based hospital outpatient departments that relocate off-campus to obtain a temporary exception and continue to be paid under the OPPS. Importantly, hospitals may also relocate outpatient departments to more than one off-campus location, or partially relocate off-campus while still furnishing care at the original site.

Additional flexibilities being made are related to increasing the Healthcare Workforce, decreasing administrative burden for providers, and further expanding telehealth.

You can read more about the new flexibilities and waivers in a related CMS Fact Sheet or the Medicare and Medicaid Interim Final Rule with Comment (IFC): Additional Policy and Regulatory Revisions in Response to COVID-19 Public Health Emergency (CMS-5531 IFC) that can be found on the CMS COVID-19 flexibilities webpage: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers. 

April 30, 2020: MLN SE20016 New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) Revised

MLN SE20016 was revised to provide the following:

• Additional claims submission and processing instructions,
• Information on cost-sharing related to COVID-19 testing,
• Additional information on telehealth flexibilities, and
• Information on provider-based RHCs exemption to the RHC payment limit.

April 30, 2020: New FAQs on the Emergency Medical Treatment and Labor Act (EMTALA)

CMS has issued FAQs to clarify requirements and considerations for hospitals and other providers related to EMTALA during the COVID-19 pandemic. FAQ topics includes the following:

• Patient Presentation to the Emergency Department,
• Where Does EMTALA Apply,
• Qualified Medical Professionals (QMPs),
• Medical Screening Exam (MSE),
• Transfer and Stabilization of a Patient,
• Telehealth,
• Waivers Under Section 1135 of the Social Security Act, and
• FAQs falling under “Other.”

Q:

I know that the new MOON is available for use. What I don’t know is when are we required to use the new form?

A:

The new CMS 10611-MOON has been approved by the Office of Management and Budget (OMB) and has an expiration date of 12/31/2022. The following update was posted to the CMS MOON webpage on April 6, 2020:

“Hospitals are strongly encouraged to begin using the new Medicare Outpatient Observation Notice (MOON) as soon as possible, but no later than May 1, 2020.

Also, keep in mind the following guidance from CMS regarding the delivery of Beneficiary Notices during the COVID-19 public health emergency:

If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:

• Important Message from Medicare (IM)_CMS-10065
• Detailed Notices of Discharge (DND)_CMS-10066
• Notice of Medicare Non-Coverage (NOMNC)_CMS-10123
• Detailed Explanation of Non-Coverage (DENC)_CMS-10124
• Medicare Outpatient Observation Notice (MOON)_CMS-10611
• Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131
• Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055
• Hospital Issued Notices of Non-Coverage (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include:

• Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off, notices to beneficiaries may also be delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.
• Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

Resource: MLN Matters SE20011 at https://www.cms.gov/files/document/se20011.pdf

Q:

How would Anxiety due to a medical condition be coded?

A:

Per Coding Clinic, 4th quarter 1996, page 29, Anxiety due to a medical condition is assigned to Organic anxiety syndrome (293.84), which crosswalks in I-10 to Anxiety Disorder Due to Known Physiological Condition (F06.4).  Per Coding Clinic, “This condition is characterized by clinically significant anxiety that is judged to be due to the direct physiological effects of a general medical condition.”

Below are some organic conditions that can cause Anxiety:

• Hypo and Hyperthyroidism,
• CHF,
• COPD,
• Pneumonia,
• Neoplasms

References:

• Coding Clinic, 4th Quarter 1996, page 29
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743/ 

MEDICARE TRANSMITTALS – RECURRING UPDATES

April 2020 Average Sales Price (AS) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: March 20, 2020
• What You Need to Know: Article informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
• MLN MM11701: https://www.cms.gov/files/document/mm11701.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020

• Article Release Date: March 27, 2020
• What You Need to Know: This MLN article is a companion article to Change Request 11734 which providers the quarterly updated to the NCCI PTP edits. CMS advises making sure your billing staffs know the updates.
• MLN MM11734: https://edit.cms.gov/files/document/mm11734.pdf

July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: March 27, 2020
• What You Need to Know: Related Change Request (CR) 11745 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.
• MLN MM11745: https://www.cms.gov/files/document/mm11745.pdf

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

• Article Release Date: April 7, 2020
• What You Need to Know: Change Request 11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 OPPS update.
• MLN MM11691: https://www.cms.gov/regulations-and-guidanceguidancetransmittals2020-transmittals/r4544cp

Quarterly Update to the Fiscal Year 2020 Inpatient Psychiatric Facilities Pricer

• Article Release Date: April 10, 2020
• What You Need to Know: CR 11759 updates the Inpatient Psychiatric Facilities (IPF) Pricer software used in Medicare claims procession. This update includes updates to the comorbidity tables to include the new ICD-10 diagnosis code for COVID-19 (U01.7) effective for claims with discharges on or after April 1, 2020.
• MLN MM11758: https://www.cms.gov/files/document/mm11759.pdf

Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer

• Article Release Date: April 24, 2020
• What You Need to Know: CT 11742 updates the LTCH Pricer software. The new version include the payment policy for an LTCH that is subject to the Discharge Payment Percentage (DPP) payment adjustment described in CR 11616. CR 11742 also included new payment policy for COVID-19.
• MLN MM11742: https://www.cms.gov/files/document/MM11742.pdf

July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer

• Article Release Date: April 24, 2020
• What You Need to Know: CR 11764 updates the FY 2020 IPPS Pricer software. This new version includes new payment policy for individuals diagnosed with COVID-19.
• MLN MM11764: https://www.cms.gov/files/document/MM11764.pdf

OTHER MEDICARE TRANSMITTALS

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Article Release Date: March 13, 2020
• What You Need to Know: Effective June 21, 2019, CMS will continued coverage of TAVR under Covered with Evidence Development (CED) when the procedure is provided for the treatment of symptomatic aortic valve stenosis and according to a FDA-approved indication for use with an approved device.
• MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitations Facilities (IRFs), and Long Term Care Hospitals (LTCHs)

• Article Release Date: 3/13/2020
• What You Need to Know: This MLN article includes links to hospital specific data for determining adjustments to be made for caring for low-income patients (LIP).
• MLN MM11679: https://www.cms.gov/files/document/MM11679.pdf

Supplier Education on Use of Upgrades for Multi-Function Ventilators

• Article Release Date: April 3, 2020
• What You Need to Know: This article informs DME suppliers that effective immediately, you may provide and bill for multi-function ventilators described by code E0467 as an upgrade in situations where beneficiaries only meet the coverage criteria for a ventilator.
• MLN SE20012: https://www.cms.gov/files/document/se20012.pdf

New Waived Tests

• Article Release Date: April 17, 2020
• What You Need to Know: Change Request 11747 informs MACs of new Clinical Laboratory Amendments of 1988 (CLIA) waived tests by the FDA. These tests are marketed immediately after approval and as such, the CMS must notify MACs of the new tests for accurate claims processing. The following statement is included in the article: “Note: MACs will not search their files to either retract payment or retroactively pay claims; however, MACs should adjust claims if you bring those claims to their attention.”
• MLN MM11747: https://www.cms.gov/files/document/mm11747.pdf

REVISED MEDICARE TRANSMITTALS

New Medicare Beneficiary Identifier (MBI) Get It, Use It – Revised

• Article Release Date: March 19, 2020
• What You Need to Know: This article was revised to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool. All other information remains the same.
• MLN SE18006: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits

• Article Revised: March 24, 2020
• What You Need to Know: This article was revised to reflect an update CR 11604. CR 11640 informs the MACs about new HCPCS codes for 2020 that are subject to and excluded from CLIA Edits.
• MLN MM11640: https://www.cms.gov/files/document/mm11640.pdf

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020

• Article Revised: March 25, 2020
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 11628. This revision had no impact on the substance of the article.
• MLN MM11628: https://www.cms.gov/files/document/mm11628.pdf

Implementation of Additional Requirements to add HCPC and CPT as Paired Items of Service for Prior Authorization and Medicare Claims Processing for Part A, Part B, DME, and Home Health and Hospice

• Change Request revised date: March 27, 2020
• What You Need to Know: Transmittal 2438, dated February 21, 2020 was rescinded and replaced with Transmittal 10021, dated March 27, 2020 to remove business requirement 11516.7 and to change the PA Program Indicator in the attachment Criteria Template. All other information remains the same.
• Transmittal 10021: https://www.cms.gov/files/document/r10021otn.pdf

April 1, 2020: Update to ICD-10-CM for Vaping Related Disorder and 2019 Novel Coronavirus (COVID-19)

• Article Revised: April 1, 2020
• What You Need to Know: This article was revised to reflect the update to Change Request (CR) 11623 where the new ICD-10-CM code for the 2019 Novel Coronavirus (COVDI-19) was added.
• MLN MM11623: https://www.cms.gov/files/document/MM11623.pdf

April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1

• Article Revised: April 1, 2020
• What You Need to Know: CR 11680 provides the I/OCE instruction and specifications for the April 1, 2020 updates. This article was revised to reflect the CR revisions adding information to Table 1, including COVID-19 changes.
• MLN MM11680: https://www.cms.gov/files/document/MM11680.pdf

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

• Article Revised: April 6, 2020
• What You Need to Know: This article was revised to reflect revisions to Change Request 1168 where the section on the delay of the CLFS reporting period was removed and the following codes were added:
• 87635: added to HCPCS file, effective March 13, 2020
• Two new COVID-19 test codes (G2023 and G2024), effective March 1, 2020
• MLN MM11681: https://www.cms.gov/files/document/mm11681.pdf

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

• Article Revised: April 6, 2020
• What You Need to Know: The revision was made to reflect the revised CR 11661 to make MPFSDB file revisions for COVID-19.
• MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf

Claim Status Category and Claim Status Codes Update

• Article Revised: April 10, 2020
• What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 11467. Specifically the Uniform Resource Locators (URLs) references (page 2 in this article) in Background Section in the CR was revised.
• MLN MM11467: https://www.cms.gov/files/document/mm11467.pdf

April 2020 Updated of the Ambulatory Surgical Center (ASC) Payment System - Revised

• Article Revised: April 14, 2020
• What You Need to Know: CR 11694 describes changes to and billing instructions for various payment policies implemented in the April 2020 ASC payment system update. MLN 11694 was revised on April 14th due the revised CR that added information on Q4206 to the policy section of the CR (page 6 in the MLN article).
• MLN MM11694: https://www.cms.gov/files/document/mm11694.pdf

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

• Article Revised: April 16, 2020
• What You Need to Know: This article was updated to reflect a revised WPC website address in the background section of Change Request 11638 on page 2 of the article. All other information remained the same.
• MLN MM11638: https://www.cms.gov/files/document/mm11638.pdf

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

• MLN Article Revised: April 23, 2020
• What You Need to Know: This article was revised to reflect the revised Change Request (CR) 11490. Specifically, the CR updated the WPC website address. This change was made in this Article as well as changing the CR Release Date to April 23, 2020.

MEDICARE COMPLIANCE TIPS

Medicare Advance Written Notices of Non-Coverage MLN Booklet Revised

CMS noted in the April 9, 2020 MLNConnects eNewsletter that a revised Medicare Advance Written Notices of Noncoverage Medicare Learning Network Booklet is now available. This booklet provides guidance on how to complete the form and collect payment.

OTHER MEDICARE UPDATES

Fiscal Year (FY) 2021 Proposed Rules Released April 10, 2020: Skilled Nursing Facilities, Inpatient Psychiatric Facilities, and Hospice

On April 10th CMS released Fact Sheets announcing the FY 2021 Proposed Rules for Skilled Nursing Facilities, Inpatient Psychiatric Facilities and Hospice have been put on display in the Federal Register. In each of the Fact Sheets, CMS notes the proposed rules are being published consistent with legal requirements to update Medicare payment policies. CMS acknowledges that the entire healthcare system is focused on responding to the COVID-19 public health emergency. 

• FY 2021 Proposed Medicare Payment and Policy Changes for Skilled Nursing Facilities (CMS-1737-P) CMS Fact Sheet
• FY 2021 Proposed Medicare Payment and Policy Changes for Inpatient Psychiatric Facilities (CMS-1731-P) CMS Fact Sheet
• FY 2021 Hospice Payment Rate Update Proposed Rule (CMS-1733-P) CMS Fact Sheet

CMS is accepting comments on all three proposed rules through June 9, 2020.

March 18, 2020: Advanced Beneficiary Notice Form Update

CMS put the following announcement on the CMS Fee-for-Service ABN webpage:

“The ABN, Form CMS-R-131, is currently awaiting OMB approval for renewal. CMS will provide instructions when it does get approved.  In the meantime, continue to use the current form until further instruction is provided.”

March 27, 2020: KEPRO Releases Spring 2020, Special COVID-19 Edition Newsletter

The following topics are included in the Spring 2020 edition of KEPRO’s Case Review Connections newsletter:

• COVID-19 Guidance for Providers,
• Beneficiary Notice Delivery Guidance in Light of COVID-19,
• Frequently Asked Questions,
• An Immediate Advocacy Success Story; and
• Staff Education about BFCC-QIO Services.

April 16, 2020: CMS Fact Sheet: Fiscal Year (FY) 2021 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) Proposed Rule (CMS-1729-P)

Similar to the proposed rules released on April 10th, CMS indicates this proposed rule is being published consistent with legal requirements. They go on to indicate that “In recognition of the significant impact of the COVID-19 public health emergency, and limited capacity of health care providers to review and provide comment on extensive proposals, CMS has limited annual IRF rulemaking required by statute to essential policies including Medicare payment to IRFs, as well as proposals that reduce provider burden and may help providers in the COVID-19 response.” CMS is accepting comments on this proposed rule until June 15, 2020.

• FY 2021 IRF PPS Proposed Rule (CMS-1729-P) CMS Fact Sheet

April 21, 2020: CMS Interoperability and Patient Access Final Rule

This Final Rule was initially released on March 9th, 2020. However, it took until April 21st for the

unpublished version to be filed in the Federal Register. The Final Rule is scheduled to be published in the Federal Register on May 1, 2020. Following is an excerpt from a related CMS Press Release detailing how this Rule will impact hospitals:

“To further advance the mission of fostering innovation, the CMS final rule establishes a new Condition of Participation (CoP) for all Medicare and Medicaid participating hospitals, requiring them to send electronic notifications to another healthcare facility or community provider or practitioner when a patient is admitted, discharged, or transferred. These notifications can facilitate better care coordination and improve patient outcomes by allowing a receiving provider, facility, or practitioner to reach out to the patient and deliver appropriate follow-up care in a timely manner.”

Effective Date for New CoP

In the March 9th release of the Final Rule CMS stated the CoPs would be effective 6 months after the Rule was published in the Federal Register. However, the Final Rule currently on display indicates this date has been changed to indicate the new CoPs at 42 CFR Parts 482 and 485 will now be effective 12 months after the Final Rule is published in the Federal Register. This delay is due to CMS recognizing that hospitals, including psychiatric hospitals, and critical access hospitals, are on the front line of the COVID-19 public health emergency. You can learn more about this Final Rule on the CMS Interoperability and Patient Access final rule webpage.

April 24, 2020: 340B Hospital Survey

The 340B hospital survey is now available for hospitals paid under the OPPS, that were enrolled in the 340B program during calendar year Q4 2018 and/or Q1 2019. Both a detailed and "Quick Survey" method are available to submit 340B-acquired drug acquisition cost information to the Centers for Medicare & Medicaid Services through https://www.340bsurvey.com/survey. The survey closes on May 15, 2020.

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates that span from April 20th through April 27th.  

April 20, 2020: FDA’s Daily Roundup: Serological (Antibody) Tests Guidance

On April 20th the Food and Drug Administration (FDA) issued the following information on the use or serological (antibody) tests to help identify people potentially exposed to the SARS-CoV-2 virus or have recovered from the infection:

• Letter to Health Care Providers: Important Information on the use of serological (antibody) tests for COVID-19. This letter opens with the following important statement: “The U.S. Food and Drug Administration (FDA) recommends that health care providers continue to use serological tests intended to detect antibodies to SARS-CoV-2 to help identify people who may have been exposed to the SARS-CoV-2 virus or have recovered from the COVID-19 infection. Health care providers should also be aware of the limitations of these tests and the risks to patients and the community if the test results are used as the sole basis to diagnose COVID-19.”
• FDA Fact Sheet: Serological Testing for Antibodies to SARS-CoV-2 Infection; and
• New Serology/Antibody Test FAQs in the FAQs on Diagnostic Testing for SARS-CoV-2 Infection.

April 20, 2020: CMS Announces Clinicians Can Earn Credit in the Merit-Incentive Payment System (MIPS) when Participating and Attesting to the New COVID-19 Clinical Trials Improvement Activity

In an April 20th Press Release, CMS announced that clinicians who participate in the CMS Quality Payment Program (QPP) may now earn credit in the MIPS for participation in a clinical trial and reporting clinical information by attesting to the new COVID-19 Clinical Trials improvement activity. CMS noted “this action will provide vital data to help drive improvement in patient care and develop innovative best practices to manage the spread of COVID-19 within communities.”

How You Will Receive Credit for Participation

“Clinicians must attest that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study.”

More about this Improvement Activity

• There is flexibility in the type of clinical trial, which could include the traditional double-blind placebo-controlled trial, to an adaptive or pragmatic design that flexes to workflow and clinical practice.
• Clinicians who report this activity will automatically earn half of the total credit needed to earn a maximum score in the MIPS improvement activities performance category, which counts as 15 percent of the MIPS final score.
• You can view a database of privately and publicly funded clinical studies currently being conducted on COVID-19 at https://clinicaltrials.gov/

April 21, 2020: COVID-19 Update: FDA Authorizes First Test for Patient At-Home Sample Collection

The U.S. FDA announced  that they had re-issued the emergency use authorization (EUA) for the LapCorp COVID-10 RT-PCR Test to permit testing of samples self-collected by patients at home using LapCorp’s Pixel by LabCorp COVID-19 Test home collection kit. FDA Commissioner Stephen M. Hahn, M.D., notes they “worked with LapCorp to ensure the data demonstrated from at-home patient sample collection is as safe and accurate as sample collection at a doctor’s office, hospital or other testing site. With this action, there is now a convenient and reliable option for patient sample collection from the comfort and safety of their home.”

The FDA makes it clear this authorization only applies to this LapCorp test and is not a general authorization for at-home collection of patient samples using other collection swabs, media, or tests, or for tests fully conducted at home.

April 21, 2020: CMS Releases Additional Blanket Waivers for Long-Term Care Hospitals, Rural Health Clinics, Federally Qualified Health Center and Intermediate Care Facilities

Additional blanket waivers released on April 21st were related to care for patients in LTCHs, temporary expansion locations of Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), staffing and training modifications in Intermediate Care Facilities for individuals with Intellectual disabilities, and the limit for substitute billing arrangements (locum tenens). Blanket waiver guidance can be found in the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers document.

April 21: Memorandum to State Survey Agency Directors: Guidance for Freestanding EDs during COVID-19 Public Health Emergency

According to the Memorandum Summary, “CMS is creating additional flexibilities to allow licensed independent freestanding emergency departments (EDs) to participate in Medicare and Medicaid to help address the urgent need to increase hospital capacity to provide care to patients. The following ways to participate include:

• Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 emergency waiver.
• Participating in Medicaid under the clinic benefit if permitted by the State, or
• Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services.”

April 22, 2020: New Toolkit to Help States Navigate COVID-19 Health Workforce Challenges

An April 22nd CMS Press Release announced that the CMS and the Assistant Secretary of Preparedness and Response (ASPR) released the COVID-19 Healthcare Workforce Toolkit to help state and local healthcare decision makers maximize workforce flexibilities when confronting COVID-19 in their communities. This work was developed by the Healthcare Resilience Task Force and provides helpful information on funding flexibilities, liability protections, and workforce training. It also provides up-to-date best practices making it a go-to resource for decision makers to find out what has been implemented in the field and how it’s working.

The toolkit is housed on the ASPR Technical Resources, Assistance Center, and Information Exchange (TRACIE). This is a healthcare emergency preparedness information gateway ensuring all stakeholders have access to the information. To view the COVID-19 Healthcare Workforce Toolkit, visit: https://asprtracie.hhs.gov/Workforce-Virtual-Toolkit

April 23, 2020: COVID-19 Telehealth Toolkit to Accelerate State Use of Telehealth in Medicaid and CHIP

The Trump Administration announced in a Press Release the release of a new toolkit for states to help accelerate adoption of broader coverage policies in the Medicaid and Children’s Health Insurance Program (CHIP) during the COVID-19 pandemic. The toolkit includes the following issues for states to consider when evaluating their need to expand telehealth capabilities and coverage policies:

• Patient populations eligible for telehealth,
• Coverage and reimbursement policies,
• Providers and practitioners eligible to provide telehealth,
• Technology requirements,
• Pediatric considerations; and
• A compilation of FAQs.

April 23, 2020: Guidance for Infection Control and Prevention Concerning COVID-19 in Home Health Agencies (HHAs) and Religious Nonmedical Healthcare Institutions (RNHCIs)

This guidance was initially released on March 10, 2020 and was subsequently updated on April 23, 2020 to include RNHCI Guidance on COVID-19. The following information was added to the Memorandum Summary:

• HHA Guidance now includes additional information about CMS waivers and regulations, and CDC guidance was added for optimizing personal protective equipment and return to work criteria for healthcare personnel with confirmed or suspected COVID-19.
• Recommendations for Visitation in Residential Facilities not Certified by Medicare: CMS is providing recommendations to home health care personnel who care for patients in residential settings such as assisted and independent living facilities.
• Medicare Participating Religious Nonmedical Healthcare Institutions (RNHCIs) and Actions – CMS is providing additional guidance for RNHCIs related to addressing potential and confirmed COVID cases and mitigating transmission including screening, treatment, and transfer to higher level of care (when appropriate).

April 24, 2020: Nursing Home Five Star Quality Rating System Updates, Nursing Home Staff Counts, and Frequently Asked Questions

An April 24, 2020 Memorandum to State Survey Agency Directors indicates CMS’ commitment to ensuring nursing homes are prepared to respond to the threat of COVID-19. Specific steps outlined in the memorandum summary includes the following:

• The inspection domain of the Nursing Home Compare Five Star Quality Rating System will be held constant temporarily due to the prioritization and suspension of certain surveys, to ensure the rating system reflects fair consumer information.
• CMS will post a list of the surveys conducted after the prioritization of certain surveys, and findings, through a link on the Nursing Home Compare website.
• CMS is publishing a list of the average number of nursing and total staff that work onsite in each nursing home, each day. This information can be used to help direct adequate (PPE) and testing to nursing homes.
• A list of FAQs is being released to clarify certain actions that CMS has taken related to visitation, survey, waivers, and other guidance.

April 26, 2020: CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments. You can read more about this in the April 26th CMS Press Release.

April 27, 2020: WPS GHA Medicare eNews: Modifier CS and COVID-19 Testing

The following reminder was included in the April 27th edition of WPS’ Medicare eNews:

“A new law waives cost-sharing under Medicare Part B for certain outpatient COVID-19 testing-related services. The CS modified signals the MACs to pay 100% for these services. This applies for claims with dates of service on or after March 18, 2020. Claims submitted without the modifier may be resubmitted.

To learn more, refer to "Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services"   in the CMS MLN Connects Special Edition – Tuesday, April 7, 2020.”

Kaiser Health News and Guardian US Partner to Honor American Health Care Workers Lost on the Frontline of the COVID-19 Pandemic

In recent COVID-19 updates articles MMP has highlighted the Institute for Health Metrics and Education (IHME) COVID-10 Projection Models (link to Project: https://covid19.healthdata.org/projections

) and the Johns Hopkin’s Coronavirus Resource Center where you will find world and U.S. specific numbers as well as critical trends.

This week I want to make our readers aware of the Lost on the Frontline Project that was officially launched on April 15th by KFF’s Kaiser Health News (KHN) and Guardian US. This special project aims to document the life of every health care worker in America who has died from COVID-19 during the pandemic. According to the KHN Announcement, “this includes medical professionals like doctors, nurses and paramedics, and others working at hospitals, nursing homes and other medical facilities, including aides, administrative employees and cleaning and maintenance staff.”

Note, when you go to the Lost on the Frontline website, you are encouraged to share the story of colleagues or loved ones that you know who have died from COVID-19.

KHN and The Guardian are inviting news organizations across the country to partner in the effort. The project will link to local news stories on health care worker deaths, and all content from the series will be available free to other news organizations to republish. The project will reflect the rich diversity of the U.S. health care workforce. The lead partners will translate selected stories into multiple languages and make them available for publication by ethnic media outlets to ensure they reach the many communities in America affected by the pandemic. 

April 10, 2020: AMA Announces Expedited Updates to CPT for COVID-19 Antibody Tests

The CPT Editorial Panel expedited the review of proposed changes and approved them on April 10th. In the Announcement AMA President Patrice A. Harris, M.D., M.A. said that “The expedited approval of new CPT codes for COVID-19 antibody tests is an important step that enhances the reporting of innovative tools now available to advance medicine's overarching goals of reducing the COVID-19 disease burden, improving health outcomes and reducing long-term care costs.”

• Code 86328 has been established for antibody testing using a single step method immunoassay.
• Code 86769 has been established for antibody testing using a multiple step method.

Prior to these two new Category I CPT codes approval, the CPT Editorial Panel approved a new code to report molecular testing to detect the SARS-CoV-2 virus:

• Code 87635 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

Note: All AMA COVID-19 Coding Guidance to date is available on the AMA’s COVID-19 Coding and Guidance webpage. 

April 13, 2020: CMS Provides COVID-19 Long-Term Care Transfer Scenarios

CMS released a Memorandum to State Survey Agency Directors. This memorandum provides supplemental information for transferring or discharging residents between facilities for the purpose of cohorting residents based on COVID-19 status (i.e., positive, negative, unknown/under observation). This guidance includes graphics explaining the various scenarios.

April 14, 2020: Novo Nordisk® Offering Free 90-Day Insulin Supply to People Experiencing Financial Hardship due to COVID-19

Novo Nordisk, Inc. announced on April 14th that diabetics using Novo Nordisk insulin who have lost health insurance coverage because of a change in job status due to the COVID-19 pandemic may now be eligible for enrollment in their Diabetes Patient Assistance Program and receive a 90 day supply of insulin free of charge.

April 15, 2020: Special Edition MLNConnects: IPPS Hospitals, LTCHS: Reprocessing Claims for CARES Act

Sections 3710 and 3711 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act implemented changes to increase payments to IPPS Hospitals and Long-Term Care Hospitals (LTCHs). When you submit an IPPS claim for discharges on or after January 27, 2020, or an LTCH claim for admissions on or after January 27, 2020, and we receive it:

• April 20, 2020, and earlier, Medicare will reprocess. You do not need to take any action.
• On or after April 21, 2020, Medicare will process in accordance with the CARES Act.

For more information, see MLN Matters Special Edition Article SE20015.

April 15, 2020: CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests

In a CMS Press Release CMS announced that Medicare will nearly double payments for certain lab tests that use high-throughput technologies to rapidly diagnose large numbers of COVID-19 cases. CMS Administrator Seema Verma said “this is an absolute game-changer for nursing homes, where the risk of Coronavirus infection is high among our most vulnerable.”

Key Facts from this Announcement

• Medicare will pay the higher payment of $100 for COVID-19 clinical diagnostic lab tests making use of high-throughput technologies developed by the private sector.
• High-throughput lab tests can process more than 200 specimens daily.
• High-throughput lab tests use highly sophisticated equipment requiring specially trained technicians and more time-intensive processes to assure quality.
• This increased payment rate became effective April 14, 2020, through the duration of the COVID-19 National Emergency.
• Local Medicare Administrative Contractors (MACs) will continue to be responsible for other COVID-19 lab tests.
• MACs are currently paying approximately $51 for those tests.

CMS reminds readers that for a complete and updated list of  CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.

For more information on this payment announcement, please visit: https://www.cms.gov/files/document/cms-2020-01-r.pdf

April 17, 2020:  MLN SE20016: New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)

Special Edition Article SE20016 highlights changes made to the RHC and FQHC requirements and payments for the duration of the PHE. Also included in this article is a link to the RHC/FQHC COVID-19 FAQs.

April 17, 2020: CDC’s Clinical Outreach & Communications Activity (COCA) Webinar: COVID-19 in the United States: Insights from Healthcare Systems

This past Friday the CDC provided a webinar focused on insights from healthcare care systems in response to the COVID-19 PHE. Specifically, David Reich, MD, President, and Chief Operating Officer of The Mount Sinai Hospital in New York and Amy Compton-Phillips, MD, Executive Vice President, Chief Clinical Office of Providence St. Joseph Health in Washington shared their healthcare systems experience. A replay of the webinar and the transcript and slide presentation are available on the CDC’s COCA Calls/Webinars - 2020. 

Drug Enforcement Administration: Diversion Control Divisions’ Response to COVID-19

The Diversion Control Division of the DEA has been working closely with “Federal partners, DEA registrants, and their representative association to assure that there is an adequate supply of controlled substances in the United States. The DEA will also work to assure that patients will have access to controlled substances.” All of their actions to date are available on their COVID-19 Information Page. Following is one Q&A available on this page regarding drug distribution to “pop-up” hospitals. 

Question: Distributors are being inundated with requests to deliver to what distributors are referring to as "pop-up" hospital/triage locations that are located in a variety of locations, including parking lots, hotels, and convention centers – essentially wherever additional space can be found to set up treatment centers. Distributors are concerned that these alternate locations do not comply with the CSA and the DEA regulations regarding the delivery of controlled drugs. How can distributors obtain expedited approval to deliver to an alternate address for their customers in the event that a pharmacy or healthcare facility is shut down for quarantine or cleaning?

Answer: Before addressing this question, we wish to emphasize that DEA is making every effort to expeditiously review any application for an emergency DEA registration number and intends to expedite the pre-registration process when warranted. The DEA registrant requesting to establish an alternate site should submit a request to DEA's national disaster email, natural.disaster@usdoj.gov, for an emergency DEA registration number for each designated alternate location. The email must include the following information for the alternate location: physical address; security measures; and, the name and complete contact information of the person who will be responsible for the controlled substances at this location.

Please also see the answer to the question and answer regarding what alternate delivery methods will be considered compliant with 21 CFR 1305.13(c) and 1305.22(f) during the COVID-19 public health emergency. In addition, to address the scenario in which, due to COVID-19 related considerations, the purchaser that has recently set up location for which the purchaser's DEA-222 forms do not yet reflect its new location, DEA is issuing an exception to the regulations. This exception is posted at DEA's COVID-19 guidance webpage

April 19, 2020: New Nursing Homes COVID-19 Transparency Efforts

CMS announced new regulatory requirements for nursing homes in a Sunday April 19th Press Release.

New Requirements:

• Nursing homes will be required to inform residents, their families and representatives of COVID-19 cases in their facilities.
• As part of President Trump’s Opening Up America, nursing home will now be required to report COVID-19 case directly to the CDC in accordance with existing privacy regulations and statute.
• Nursing homes will be required to fully cooperate with CDC surveillance efforts around COVID-19 spread. The CDC will be providing a reporting tool to nursing homes that will support Federal efforts to collect nationwide data to assist in COVID-19 surveillance and response. CMS plans to make the data publicly available.

April 19, 2020: Guidelines for Opening Up America Again

In an April 19th Press Release, the CMS announced the issuance of new recommendations specifically targeted to communities that are in Phase 1 of the Guidelines for President Trump’s Opening Up America Again with low incidence or relatively low and stable incidence of COVID-19 cases. The recommendations update earlier guidance provided by CMS on limiting non-essential surgeries and medical procedures. The new CMS guidelines recommend a gradual transition and encourage health care providers to coordinate with local and state public health officials and to review the availability of Personal Protective Equipment (PPE) and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to re-start or increase in-person care.

The new recommendations can be found here: https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

The Guidelines for Opening Up America Again can be found here: https://www.whitehouse.gov/openingamerica/#criteria 

“I am convinced that acupuncture is going to be one of the greatest contributions that any group of people has made to the future of all medicine, if it is handled correctly by the people of the Western World.”

• 1972 Quote by Dr. W. Kenneth Riland, Personal Physician to President Nixon

Background

In May 1980, CMS issued a national non-coverage determination for acupuncture (NCD30.3). Since then they have issued non-coverage determinations for acupuncture for fibromyalgia (NCD 30.3.1) and acupuncture for osteoarthritis (NCD 30.3.2).

In a July 15, 2019, Press Release, CMS announced their proposal to cover acupuncture for chronic low back pain (cLBP) as a potential alternative to opioid use, while data is collected on patient outcomes. HHS Secretary Alex Azar noted, “Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”

On January 15, 2020, CMS released the Final Decision memo for acupuncture for cLBP (CAG-00452N).

CMS indicated in a related Press Release they had “conducted evidence reviews and examined coverage policies of private payers to inform today’s decision.”

MLN Matters MM11691: April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN MM11691 describes changes to and billing instructions for various payment policies implemented in the April 2020 Hospital OPPS update. Included in the update is guidance about the change in status indicators for acupuncture as a result of NCD 30.3.3. Following is an excerpt from the article specific for Acupuncture:

Effective January 21, 2020, Medicare covers acupuncture and dry needling for beneficiaries with chronic low back pain…Based on this recent coverage determination, CMS revised the OPPS status indicator and APC assignment for the CPT codes describing acupuncture and dry needing services from “E1” (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type) to “S” (Paid under OPPS, separate APC payment) and “N” (Paid under OPPS; payment is packaged into payment for other services. Thus, there is no separate APC payment.)

Table 2 – Acupuncture and Dry Needling CPT Codes for Newly Covered by Medicare

You can learn more about what is covered, what is noncovered, and who can furnish acupuncture for the Medicare Fee-for-Service population as detailed in NCD30.3.3 in a related MMP article.

Medical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) Pandemic

Palmetto GBA has posted the following Notice on their website:

The Centers for Medicare & Medicaid Services (CMS) has authorized nationwide waivers under §1812(f) of the Social Security Act retroactive to March 1, 2020, for those impacted by COVID-19. Medicare Fee-For-Service (FFS) operations will implement the following policies and procedures for all claims, not just for the COVID-19 diagnoses.

Additional Documentation Requests (ADRs)

• For ADRs that have already been issued, Medicare contractors will release the claims for payment and not issue claim denials; providers should not respond to any pending claims as all claims will be released for relief efforts.
• Any claims auto-denied for non-response of an ADR from March 1, 2020, until March 26, 2020, will have the denial reversed and allow payment if an appeal has not been filed. If an appeal has been filed, normal appeals processes will be followed.
• As of March 26, 2020, future ADRs will not be sent until further notice from CMS

Targeted Probe and Education (TPE)

• All current TPE reviews and associated edits are suspended and selected claims released for payment
• MACs will allow TPE medical review education sessions to be rescheduled upon provider request

Note: Providers must resume compliance with normal Medicare fee-for-service rules and regulations as soon as they are able. The waivers or modifications a provider was operating under are no longer available after the termination of the emergency period.

April MAC Talk: The Local Scene

March 17th, 2020: Palmetto GBA JM Posts TPE Progress Updates

It seems a little ironic that in March Palmetto GBA JM began releasing Targeted Probe and Educate (TPE) Progress Updates. Medical Review specific articles include the dates of services reviewed, the volume of probes performed, the charge denial rates, top denial reasons, tips for preventing denials, next steps, and references.

In regards to “Next Steps,” Palmetto GBA indicates that Providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 1 will advance to Probe 2 at least 45 days from completion of the 1:1 post probe education call date. Palmetto GBA offers education at any time for providers. Providers do not have to be identified for TPE to request education.

Following is a list of the specific TPE articles released to date by Palmetto GBA JM:

• March 17, 2020: DRG 682/683 Renal Failure with MCC/CC,
• March 17, 2020: DRG 470 – Major Joint Replacement,
• March 18, 2020: Inpatient Rehab Facility A0604, B0604, C0604 and D0604,
• March 18, 2020: DRG 885 Psychoses,
• March 19, 2020: Therapeutic Exercise 97110,
• March 19, 2020: Skilled Nursing Facility (SNF),
• March 23, 2020: Rituximab J9310/J9312,
• March 23, 2020: Pegfilgrastim J2505,
• March 23, 2020: Neuromuscular Re-education – 97112,
• March 23, 2020: Manual Therapy – 97140,
• March 23, 2020: Infliximab J1745,
• March 23, 2020: HBO Therapy G0277,
• March 23, 2020: DRG 291 Heart Failure and Shock with MCC and DRG 292 Heart Failure and Shock with CC,
• March 23, 2020: Denosumab J0897, and
• March 23, 2020: Bevacizumab J0935.

Links to all of the articles can be found on Palmetto GBA’s JM Target Probe and Educate webpage.

March 20, 2020: First Coast Revises Articles A52571 and A57778

Article A52571: Self-Administered Drug Exclusion List

Effective May 3, 2020, First Coast (JN) has added the following drugs to the self-administered drug (SAD) list:

• Tremfya® (guselkumab) (J1628), and
• Stelara® (ustekinumab) subcutaneous (J3357).

This announcement includes a link to their entire list of SADs.

Article A57778: Billing and Coding Intravenous Immune Globulin

First Coast has added the new FDA approved drug Panzyga® (immune globulin intravenous, human – IFAS) (HCPCS codes C9399 and J1599) to the CPT®/HCPCS Codes/Group 1 Paragraph:/Group 1 codes:” and “ICD-10 Codes that Support Medical Necessity/Group 1 Paragraph:” section.

This change is effective for claims processed on or after March 16, 2020, for services rendered on or after August 2, 2018.

March 24, 2020: Palmetto GBA Daily Newsletter: Self-Administered Drug Exclusion List Article Changes

Palmetto GBA posted information about revisions made to their Self-Administered Drug Exclusion List

Article A53066.

These changes will be effective 4/20/2020. They encourage providers to share this information with their staff.

• Revision 23 (R23): Under Excluded CPT/HCPCS Codes – Table Format the previous revision (R22) that added HCPCS Code J3358 – Stelara®, ustekinumab for intravenous injection, 1mg should be disregarded as this code was inadvertently added. HCPCS code J3557 – Stelara®, ustekinumab for subcutaneous injection, 1mg has been added.

March 25, 2020: Palmetto GBA JJ Posts TPE Progress Updates

A little over a week after Palmetto GBA released TPE Progress Updates for Jurisdiction M they began posting findings for Jurisdiction J. Review specific articles follow the same format as articles released for JM. Following is a list of specific TPE articles released to date by Palmetto GBA JJ:

• March 25, 2020: HBO Therapy G0277,
• March 25, 2020: JJ Part A Skilled Nursing Facility (SNF),
• March 25, 2020: Therapeutic Exercise 97110,
• April 3, 2020: DRG 885 Psychoses; and
• April 3, 2020: DRG 470 Major Joint Replacement,
• April 10, 2020: Manual Therapy 97140,
• April 10, 2020: Inpatient Rehabilitation Facility (IRF) A0604-D0604
• April 10, 2020: Pegfilgrastim J205,
• April 10, 2020: DRGs 291 and 292: Heart Failure and Shock with MCC and with CC,
• April 11, 202: Rituximab J9310,
• April 11, 2020: Infliximab J1745,
• April 11, 2020: Denosumab J0897, and
• April 11, 2020: Bevacizumab J9035.

Links to all of the articles can be found on Palmetto GBA’s JJ Target Probe and Educate webpage.

March 30, 2020: CGS Posts Notice Medical Review Update

On January 31, 2020, Secretary Azar of the Department of Health & Human Services (HHS) declared a nationwide public health emergency.  On March 13, 2020, Secretary Azar authorized waiver and modifications under §1135 of the Social Security Act retroactive to March 1, 2020. CGS understands the effect of COVID-19 on our provider community. In response to questions received regarding Medical Review Additional Document Requests (ADRs) and Targeted Probe and Educate (TPE) activity, at this time, CGS has temporarily suspended TPE reviews. Our medical review and provider outreach and education staff will continue to be available to conduct education sessions and provide answers to questions to ensure that providers understand regulatory guidelines to prevent improper payment. To reschedule a TPE educational session, request an educational session related to medical review topics, or for medical review general TPE questions please contact us at one of the email addresses below or contact the appropriate provider contact center (PCC) at: https://www.cgsmedicare.com/help/index.html.

• Part A Medical Review: J15AprobeandEducation@cgsadmin.com
• Part B Medical Review: J15BPROBEANDEDUCATION@cgsadmin.com
• HHH Medical Review: J15HHprobeandEducation@cgsadmin.com

April 1, 2020: NGS News COVID-19 Update: Important Information Regarding Part A and B Second-Level Appeals
NGS provided the following “information at the request of the Qualified Independent Contractor (QIC), C2C Innovative Solutions, Inc. (C2C). C2C conducts second-level Medicare Part A and B Fee-for-Service claims appeals submitted in Jurisdiction K Part A and B as well as Jurisdiction 6 home health and hospice for New York, New Jersey, Puerto Rico and the U.S. Virgin Islands. If you appeal to C2C as the Part A and B East QIC, they are limiting their on-site mail room operations in response to the COVID-19 public health emergency. During this public health emergency, providers and Medicare beneficiaries falling into the above categories are encouraged to submit new second-level Medicare appeals and related correspondence via fax or the electronic portal. For additional information including the QIC fax numbers and a link to their portal, please visit the C2C website.”

April 6, 2020: NGS Posts Update Regarding Pricing of HCPCS G2066

NGS News and Alerts

On 3/12/2020 NGS posted an article on their website regarding a fee adjustment for HCPCS G2066 (Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results).

While NGS recognizes its authority to periodically review and adjust pricing as warranted of any “Contractor Priced“ codes, the adjustment in payment for HCPCS G2066 will not go into effect during this PHE, as scheduled on April 24, 2020.

HCPCS G2066 was created by the CMS for 2020 to replace the retired code of CPT 93299. Therefore, the fee for G2066 will remain the same as the prior 2019 fee for CPT 93299.

At such time as the PHE is deemed over, HCPCS G2066 will be reviewed for pricing based on other MAC fees; a thorough review of this service; and further input from stakeholders.

April 8, 2020: Palmetto GBA Claims Payment Issue: Medically Unlikely and Procedure-to-Procedure Edit Updates Due to COVID-19

Palmetto GBA identified the following Issue on April 3, 2020:

As a result of the CMS expansion of telehealth services in response to COVID-19, CMS updated certain Medically Unlikely Edits (MUEs) and Procedure-to-Procedure (PTP) edits for CPT and HCPCS codes, retroactive to January 1, 2020. Palmetto GBA advises that they will implement the CMS replacement files and adjust affect claims with dates of service on or after March 6, 2020. Additionally, any appeals already started by Palmetto GBA that related to MUE or PTP denials will be prioritized for review using the replacement files for claims with dates of service on or after March 6, 2020.

April 9, 2020: NGS Daily News: A Message from Our Medical Review Team: Targeted Probe and Educate Medical Reviews
In the wake of the public health emergency related to COVID-19, National Government Services (NGS) is in the process of pausing Targeted Probe and Educate (TPE) Medical Reviews. At this time, they are unable to provide additional clarity on when or how TPE reviews will resume, but will share information as it’s made available. They will work with providers who previously scheduled educational sessions to reschedule them.

NGS is contacting providers to let them know claims were released and there is no need to respond to an additional development request (ADR) for medical records. Effective 3/1/2020, claims that auto-denied for nonresponse or late response to the ADR will be reversed and allowed for payment unless an appeal has already been filed. In that case, the appeal will follow the normal appeals process.

NGS’ dedicated email address remains available for questions specific to medical reviews

• Jurisdiction 6 Part A:  j6probeandeducate@anthem.com
• Jurisdiction 6 Part B: J6Bprobeandeducate@anthem.com
• Jurisdiction K Part A: ngs-jkmedicalreview@anthem.com
• Jurisdiction K Part B: educate@anthem.com">Jkbprobe&educate@anthem.com

April 9, 2020: Palmetto GBA Update: MACs to Host Multi-jurisdictional Contractor Advisory Committee (CAC) Meeting Regarding Facet Joint & Medical Nerve Branch Procedures on May 28, 2020 from 1-3 p.m. CT

Due to the COVID-19 Pandemic, the decision has been made to hold the meeting via Teleconference/Webinar ONLY. All other information remains the same.

The purpose of the meeting is to obtain advice from CAC members and subject matter experts (SMEs) regarding the strength of published evidence on Facet Joint and Medial Nerve Branch Procedures. In addition to discussion, the CAC and SME panel will vote on pre-distributed questions. The public is invited to attend as observers.

The meeting will be hosted by seven Medicare Administrative Contractors and will be held via Teleconference/Webinar. There will be a panel of experts discussing the Facet Joint and Medial Nerve Branch Procedures. CAC panels do not make coverage determinations, but MACs benefit from their advice.

Complete details will be available by May 14, 2020 (background material, questions, and agenda).

Link to Announcement:
https://www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-A"BMYQLA2250

April 13, 2020: WPS J8A Medical Review (MR) Targeted Probe & Educate (TPE) Quarterly Update

WPS provided the common errors identified by their Medical Review staff throughout the first quarter of 2020. Specific for hospitals was the following guidance regarding wound care.

• Wound Care (CPT 11042): Denials for Documentation Not Supporting Sharp Debridement: WPS reminds Providers that documentation should provide a clear rationale for the excisional debridement. Additionally, the documentation should include a certified plan of care that includes the potential to heal and goals. The WPS Local Coverage Determination (LCD) L37228outlines coverage criteria for wound care.

April 13, 2020: WPS eNews: Inpatient Psychiatric Facility (IPF) – CERT Errors

A WPS Announcement indicated that the Comprehensive Error Rate Testing (CERT) Contractor has assessed for errors for IPF services and found that in most cases there was missing documentation to support payment based on Medicare guidelines. The announcement details information that should be submitted in a response to a Medicare request and provides a link to additional information in Chapter 2: Inpatient Psychiatric Hospital Services of the Medicare Benefit Policy Manual.

April 13, 2020: OIG Releases Report : An Estimated 87 Percent of Inpatient Psychiatric Facility Claims with Outlier Payments Did Not Meet Medicare’s Medical Necessity or Documentation Requirements

The OIG focus for this audit was claims resulting in outlier payments with an objective of determining whether Inpatient Psychiatric Facilities (IPFs) complied with Medicare coverage, payment, and participation requirements. OIG Findings from the 160 sampled claims:

• 25 claims did not meet Medicare medical necessity requirements,
• 142 claims had missing or inadequate medical record elements, including physician certification, and
• 12 of the 142 claims did not clearly support that the IPF had protected the patient’s right to make informed decisions regarding care.

Ultimately, the OIG estimated that Medicare overpaid IPFs $93 million for FYs 2014 and 2015 for stays that were non-covered or partially non-covered and resulted in outlier payments. 

April 16, 2020: CGS Announces Retirement of LCD L34093: Chemotherapy and Biologicals

• Effective June 7, 2020: CGS will be retiring LCD L34093: Chemotherapy and Biologicals
• Effective June 8, 2020: LCD L34093 will be replaced with Article A58113: Off-Label Use of Anti-Cancer Drugs and Biologicals
• CGS Notes in the announcement that, “This is a change from how we currently handle chemotherapy and biological drugs. While there will no longer be a local policy in place with attached billing and coding articles, we will be using the coverage indications as listed in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) 100-02, Chapter 15, section 50.4.1 and 50.4.5 which is the basis for the current policy. CGS will cover these types of drugs based on FDA label indications and for off label use if listed in one of the five CMS approved compendia’s (NCCN, Micromedex Drug DEX, Lexi-Drugs, AHFS, or Clinical Pharmacology).”
• You can read the entire announcement at:   https://www.cgsmedicare.com/parta/pubs/news/2020/04/cope16807.html

April 17, 2020: First Coast eNews: TPE Announcement

“Targeted probe and educate (TPE) reviews have been temporarily postponed due to the public health emergency (PHE) declared as a result of the 2019 novel coronavirus (COVID-19). We encourage providers to focus on patient care and defer discussions related to these reviews after the PHE. First Coast will reach out to providers after the pandemic to offer education based upon prior reviews. In the event providers would like to receive education during this time, we are prepared to provide educational sessions. Please feel free to reach out to the nurse assigned to your case to arrange an educational call.”

March 30, 2020: OIG Released Strategic Plan for the Next Five Years (2020-2025)

On March 30th, the OIG published their Strategic Plan for the next five years (2020-2025).  Christi A. Grimm, Principal Deputy Inspector General, notes that this “plan is dynamic to accommodate a rapidly changing health and human services environment, including emergent threats and vulnerabilities. This Strategic Plan is a roadmap to guide our entire multidisciplinary workforce in planning and conducting the most consequential oversight work, optimizing use of our available resources and delivering results for our stakeholders. To support our workforce, OIG will continue to prioritize investment in data analytics, technology, expertise, and training. This strengthens OIG’s modern approach to oversight that allows us to quickly adapt to emerging risks, including the corona virus disease 2019 (COVID-19) pandemic.”

The Strategic Plan includes examples of past accomplishments related to their three stated Goals.

Goal 1: Fight Fraud, Waste and Abuse

Past Accomplishment: Nationwide Brace Scam

• April 2019: With law enforcement partners, OIG dismantled one of the largest fraud schemes involving telemedicine and medically unnecessary back, shoulder, wrist and knee braces.
• Impact: Twenty-four defendants were charged for allegedly participating in the scheme, in which over $1.7 billion in Medicare claims were fraudulently submitted.

Goal 2: Promote Quality, Safety and Value

Past Accomplishment: Identifying and Combating Potential Abuse and Neglect of Beneficiaries

• OIG issued an early alert followed by two June 2019 reports identifying thousands of Medicare claims that indicate abuse and neglect of Medicare beneficiaries.
• Impact: CMS has provided details about actions taken and plans to take ensuring incidents of potential abuse or neglect in SNFs are identified and reported.

Goal 3: Advance Excellence and Innovation

Past Accomplishment: Data at OIG’s Fingertips

• Self-service data and analytics tools empower OIG to use data proactively.
• Impact: OIG has created portals offering access to data analytics tools used to oversee the Medicare programs and also enable grants oversight work.

April 3, 2020: OIG Report – Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23 – 27, 2020

On April 3rd, the OIG provided their findings from a survey they conducted with a goal of being able to provide decision makers “with a national snapshot of hospitals’ challenges and needs in responding to the coronavirus 2019 (COVID-19) pandemic. The information represents brief telephone interview (“pulse surveys”) conducted March 23-27, 2020 with hospital administrators from 323 hospitals across 46 States, the District of Columbia, and Puerto Rico. The rate of contact with this random sample was 85 percent.

If you have been following the barrage of COVID-19 news available via television, radio, internet, it shouldn’t surprise you that the following list represents the most significant challenges reported by hospitals:

• Severe shortages of testing supplies and extended waits for results,
• Widespread shortages of Personal Protective Equipment (PPE),
• Difficulty maintaining adequate staffing and supporting staff,
• Difficulty maintaining and expanding hospital capacity to treat patients,
• Shortages of critical supplies, materials, and logistic support,
• Anticipated shortages of ventilators,
• Increased costs and decreased revenue, and
• Changing and sometimes inconsistent guidance.

It is important to note that there are five different instances in this report where the OIG reminds the reader “the hospital input and suggestions in this report reflect a specific point in time- March 23-27, 2020. We recognize that HHS is also getting input from hospitals and other frontline responders and has already taken and continues to take actions” related to findings in this report. 

On April 6, 2020 Rick Pollack, President and CEO of the American Hospital Association (AHA), released a Statement on HHS OIG Report. In the statement, he opened by noting this report is important and timely and “the HHS Office of the Inspector General accurately captures the crisis that hospitals and health systems, physicians and nurses on the front lines face of not having enough personal protective equipment (PPE), medical supplies and equipment in their fight against COVID-19.” He ends the AHA Statement with the following: “The AHA continues to urge that all possible levers be used by both the government and the private sector to ensure front line heroic providers battling against COVID-19 have what they need for protection and to provide care for their patients and communities -- countless lives are depending on it.”

A Full Summary and the Report are available on the OIG website.

April 8, 2020: OIG Releases Notice of Recently Added OIG Work Plan Items

Just five days after the Pulse Survey Report was released, the OIG updated their OIG Work Plan with the following items related to COVID-19:

You can access the entire OIG Work Plan at: https://go.usa.gov/xvjmP.

COVID-19 Portal

In addition to the Strategic Plan, Survey and Work Plan, the OIG has also created a COVID-19 Portal on their website. The portal provides links to information about COVID-19 Fraud, Infectious Disease Preparedness and Response and Policy Statements and Guidance. Additionally, you can find links to resources, recent new put out by the OIG and the opportunity to submit questions regarding OIG’s authorities during the COVID-19 public health emergency.

Q:

What is the principal diagnosis if a patient presents to the hospital with Sepsis and COVID-19?

A:

If a patient has COVID-19 that has progressed to sepsis, we are instructed to see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock.  If sepsis meets the definition of principal diagnosis, sepsis should be sequenced first, followed by COVID-19. 

When COVID-19 meets the definition of principal diagnosis, and sepsis develops after admission, code U07.1 (COVID-19) should be sequenced first, followed by the appropriate code for sepsis.

Remember:  Code only confirmed cases of COVID-19

If a physician documents “presumed” COVID-19, and has tested positive for the virus, code U07.1 (COVID-19) as confirmed.  A positive test at a local or state level can be coded as COVID-19.  The Center for Disease Control and Prevention (CDC) confirmation of local and state tests for the COVID-19 virus is no longer required.

If a physician documents “suspected”, “possible”, “probable”, or “inconclusive” COVID-19, do not assign code U07.1.  Assign a codes(s) explaining the reason for the encounter such as fever, or contact with and (suspected) exposure to other viral communicable diseases (Z20.828).

Resources:

ICD-10-CM Official Coding and Reporting Guidelines (April 1, 2020 through September 30, 2020)

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-April-1-2020-addenda.pdf

American Hospital Association (AHA) Coding Clinic webinar ICD-10-CM Coding for COVID-19

Watch the FREE AHA webinar on COVID-19 and receive one CEU.  https://www.codingclinicadvisor.com/webinar/icd-10-cm-coding-covid-19