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2/25/2020
MEDICARE TRANSMITTALS – RECURRING UPDATES
Quarterly Influenza Virus Vaccine Code Update – July 2020
Provider Types Affected: Physicians, providers and suppliers billing MACs for influenza vaccine services.
This update includes one new influenza virus code: 90694.
MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – April 2020 Update
Article Release Date: February 14, 2020
What You Need to Know: Change Request 11661 amends payment files based upon the 2020 MPFS Final Rule. Make sure billing staff is aware of these changes.
MLN MM11661: https://www.cms.gov/files/document/mm11661.pdf
OTHER MEDICARE TRANSMITTALS
Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging
Change Request (CR) Release Date: January 31, 2020
CR 11571: https://www.cms.gov/files/document/r2425otn.pdf
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy
Provider Type Affected: Physicians, Hospitals, other Providers, and Suppliers
What You Need to Know: CR11559 informs MACs about changes to CWF edits to ensure the original 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: “Payment Window for Outpatient Services Treated as Inpatient Services,” and
- Chapter 3, Section 40.3: “Outpatient Services Treated as Inpatient Services
MLN Article MM11559: https://www.cms.gov/files/document/mm11559.pdf
Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment
Article Release Date: February 14, 2020
What You Need to Know: This article is for hospitals who submit claims for inpatient services provided to Medicare beneficiaries by LTHCs.
MLN MM11616: https://www.cms.gov/files/document/mm11616.pdf
REVISED MEDICARE TRANSMITTALS
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
MLN 11605 was revised on February 4, 2020 to add a section for radiopharmaceuticals with pass-through status and for Extravascular Implantable Cardioverter Defibrillator (EV ICD).
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
January 2020 Annual Update to the Therapy Code List
Provider Type Affected: Physicians, providers and suppliers billing Medicare for therapy services
Transmittal Change: Two new biofeedback codes will be paid under the Medicare Physician Fee Schedule.
MLN Article: MM11501: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11501.pdf
Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder
Article Release Date: January 31, 2020
What You Need to Know: This article was revised to reflect an updated Change Request (CR), transmittal number and link to transmittal.
MLN Article MM11623: https://www.cms.gov/files/document/mm11623.pdf
International Classification of Disease, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – April 2020 Update
Article Release Date: February 4, 2020
What You Need to Know: This article was revised on February 10, 2020 to reflect a revised CR 11491. This CR was revised to amend the spreadsheet for NCD 110.4. All other information remains the same.
MLN MM11491: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11491.pdf
New Medicare Beneficiary Identifier (MBI) Get It Use It
Article Release Date: February 12, 2020
What You Need to Know: Article was revised to add a sentence to the MBI look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death.
MLN SE18006 Revised: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Article Release Date: February 13, 2020
What You Need to Know: This article was revised due to a Change Request that added two new attachments due to legislation.
MLN Article: MM11564: https://www.cms.gov/files/document/mm11564.pdf
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging-Approval of Using the K3 Segment for Institutional Claims
Article Release Date: February 20, 2020
What You Need to Know: This article was revised to include the listing of Clinical Decision Support Mechanisms (CDSMs) and to update the paper billing instruction.
MLN Article SE20002: https://www.cms.gov/files/document/se20002.pdf
Accepting Payment from Patients with a Medicare Set-Aside Arrangement
Article Release Date: February 19, 2020
What You Need to Know: This article was revised to add information about submitting electronic attestations via the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).
MLN Article: SE17019: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17019.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
Incorrect Billing of HCPCS L8679 – Implantable Neurostimulator, Pulse Generator, Any Type
Article Release Date: January 29, 2020
Issue: CMS has identified that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Please make sure you billing staff are aware of the correct policy.
MLN SE20001: https://www.cms.gov/files/document/se20001.pdf
MEDICARE COVERAGE UPDATES
January 27, 2020: Final Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R)
Policy covers FDA approved or cleared laboratory diagnostic tests using Next Generation Sequencing (NGS) for patients with germline (inherited) ovarian or breast cancer.
Decision Memo: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=296
Related CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-expands-coverage-next-generation-sequencing-diagnostic-tool-patients-breast-and-ovarian-cancer
February 3, 2020: National Coverage Analysis (NCD) Tracking Sheet for Artificial Hearts and related devices, including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy
Issue: Currently, Medicare covers artificial hearts under coverage with evidence development (CED) when a beneficiary is enrolled in a clinical study that meets all the criteria in NCD 20.9. CMS has received two formal requests:
- Request that CMS reconsider CED for artificial hearts based on evidence since the NCD was last updated in 2008.
- A second request asked CMS reconsider Ventricular Assist Devices (VADs) specifically for coverage indications for bridge-to-transplant and destination therapy based on scientific evidence available since the NCD was last reconsidered in 2013.
CMS is soliciting public comment. The initial 30-day public comment period is from 2/3/2020 – 3/4/2020.
February 5, 2020: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)
Issue: Approved Study Posted
On February 15, 2019, CMS issued NCD covering FDA approved VNS devices for TRD through Coverage with Evidence Development (CED) when offered in a CMS approved, double-blind, randomized, placebo-controlled trial. On February 5, 2020, CMS posted a new approved Clinical Study. https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS
MEDICARE EDUCATIONAL RESOURCES
CMS 2020 Medicare Costs Information Product
CMS has published a 2020 Medicare Costs document which includes Beneficiary costs for Medicare Part A and Part B, Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) Premiums
https://www.medicare.gov/Pubs/pdf/11579-Medicare-Costs.pdf
CMS 2020 Your Medicare Benefits Product
This booklet contains important information about the items and services covered by Original Fee-for-Service Medicare.
https://www.medicare.gov/Pubs/pdf/10116-Your-Medicare-Benefits.pdf#
MLN Booklet: Medicare Mental Health
This booklet was released in January and provides information about Medicare mental health services (i.e. Covered and non-covered mental health services, outpatient psychiatric hospital services, and medical record requirements).
ICN MLN1986542 January 2020: https://www.cms.gov/outreach-and-educationmedicare-learning-network-mlnmlnproductsmln-publications/2020-01-3
MLN Booklet: Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B
ICN MLN006799 January 2020: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr-immun-billTextOnly.pdf
MEDICARE COMPLIANCE TIPS
Specimen Validity Testing Billing in Combination with Urine Drug Testing
CMS provided Compliance information in the February 13, 2020 MLNConnects e-newsletter regarding proper coding for specimen validity testing billed in combination with urine drug testing. They reminded providers that “current coding for testing for drugs of abuse relies on a structure of presumptive and definitive testing that identifies the specific drug and quantity in the patient and referenced MLN Matters Special Edition Article SE18001 for descriptors for presumptive and definitive drug testing codes.
OTHER MEDICARE UPDATES
February 6, 2020 Memorandum to State Survey Agency Directors.
Subject: Information Regarding Patients with Possible Coronavirus Illness (2091-nCoV)
Memorandum Summary: Links to information documents issued by the CDC on the respiratory illness cause by the 2019 Novel Coronavirus (2019-nCoV) are included in the memorandum. “CMS strongly urges the review of CDC’s guidance and encourages facilities to review their own infection prevention and control policies and practices to prevent the spread of infection.”
Memorandum Ref: QSO 20-09-ALL: https://www.cms.gov/files/document/qso-20-09-all.pdf
February 6, 2020 Memorandum to State Survey Agency Directors
Subject: Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for use in CDC Qualified Laboratories.
Memorandum Summary: Guidance is being provided to surveyors regarding Authorization for Emergency Use (AEU) for the Diagnostic Panel. These assays remain subject to CLIA regulations. The Panel assay and corresponding protocols have been developed by the CDC for use by CDC qualified labs.
Memorandum Ref: QSO 20-10-CLIA: https://www.cms.gov/files/document/qso-20-10-clia.pdf
Beth Cobb
2/25/2020
Vaping-Related Disorder ICD-10-CM Guidance Timeline
As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.
In last month’s Coding Corner we shared a timeline to date for EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) specific ICD-10-CM guidance. Since then CMS has updated its MS-DRG Grouper Version 37.1 software to include the new Vaping-related disorder code U07.0 effective April 1, 2020.
Diagnosis code U07.0 will be assigned as follows:
- The code is not a CC,
- It falls in Major Diagnostic Category (MDC) 4: Diseases and Disorders of the Respiratory System, and
- This code has been assigned to MS-DRGs 205 and 206: Other Respiratory System Diagnoses with MCC and without MCC respectively.
Additionally, if diagnosis code U07.0 is reported as a principal diagnosis there are five diagnosis codes that will be excluded from acting as a MCC when reported as a secondary diagnosis under the CC Exclusion list. You can read the entire announcement at https://www.cms.gov/files/document/icd-10-ms-drgs-version-371-effective-april-1-2020.pdf.
National Correct Coding Initiative Edits
CMS posted the following notice to their National Correct Coding Initiatives Edits webpage on February 2, 2020:
Replacement Files
The CMS issued replacement files with the following changes:
- Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020.
- CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172
Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.
February 13, 2020 CMS Press Release: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test
The February 20, 2020 MLNConnects e-newsletter provides highlights from a CMS Press Release issued on February 13, 2020. CMS has developed a new Healthcare Common Procedure Coding System (HCPCS) code for providers and laboratories testing patients for SARS-CoV-2. This will allow labs to bill for the specific test instead of an unspecified code.
When a patient is tested using the CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test panel, the provider may bill for the test using the new HCPCS code (U0001). The Medicare claims processing system will be able to accept this code on April 1, 2020, for dates of service on or after February 4, 2020.
Link to CMS Press Release: https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test.
Beth Cobb
2/18/2020
Caring for Medicare Patients is a Partnership
This monthly article highlights information from Medicare Administrative Contractor (MAC) daily e-newsletters and alerts. Before delving into MAC highlights, I want to highlight the December 2019 MLN Fact Sheet (MLN 909340) Caring for Medicare Patients is a Partnership.
This fact sheet reminds Physicians and other health care providers and suppliers providing services to Medicare patients that “understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.”
The fact sheet also includes the Social Security Act definition of medical necessity, what documentation is needed to support medical necessity of services provided, and endorsements from Medical Directors at all of the MACs.
MAC Highlights
January 23, 2020 Palmetto GBA Article: DRG 470 – Major Joint Replacements or Reattachments of Lower Extremity
Palmetto notes that CMS has had multiple auditing entities reviewing claims, including Recovery Auditors, CERT and MACs. Findings have demonstrated very high paid claims error rates for hospitals and professional claims. This article provides Top Denial Reasons, Ways to Avoid Denials, and CMS Resources. https://www.palmettogba.com/palmetto/providers.nsf/DocsR/Providers~JJ%20Part%20A~Medical%20Review~General~BL4KTJ5777?open
January 27, 2020: NGS Self-Service Pulse Newsletter: What, When and How: Advanced Beneficiary Notice of Non-coverage
NGS has a five-video series on YouTube “to get you up to speed or refresh your knowledge on everything you need to know about ABNs.
https://www.youtube.com/playlist?list=PLw4-yeXdND_qzKAMfWEdvKI1lK4Zmne8x
January 31, 2020: Palmetto GBA Daily Newsletter: DRG 056 Degenerative Nervous System Disorders with MCC and DRG 057 – Degenerative Nervous System Disorders without MCC
This article highlights conditions that can cause a neuropathic condition as well as the FY 2020 relative weights and length of stays assigned to MS DRGs 056 and 057. https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BDAJ6A3806?opendocument
February 3, 2020: WPS J5 Hospital Discharge Status Codes – CERT Errors
The Comprehensive Error Rate Testing (CERT) contractor issues errors related to the incorrect use of patient discharge status codes. Incorrect use of these codes may result in the overpayment or underpayment of a Medicare claim. In situations where use of an incorrect code affects claim payment, the Jurisdictional and National CERT error rates for facilities reflect these errors.
For information about the appropriate use of patient discharge status codes, refer to MLN Matters article SE1411, "Clarification of Patient Discharge Status Codes and Hospital Transfer Policies."
February 4, 2020: Noridian Medical Review Frequently Asked Questions
Question: Does Medical Review have review results with trending errors posted for providers to see?
Answer: Part A medical Review will soon be posting review results on the top 2 services with errors notes on our Medical review webpage at med.noridian.com.
https://med.noridianmedicare.com/web/jea/fees-news/faqs/mr
February 5, 2020: Palmetto GBA Medicare Advantage (MA) Plan Overpayments – Update
On February 5th, Palmetto GBA reminded providers who received the Phase III Settlement Offer letters that wish to accept the settlement offer must return their signed and dated settlement letter no later than March 3, 2020.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~AZ9J8M2780?opendocument
CGS J15 Posts Quarterly TPE Update for Probes Completed July 1, 2019 – September 30, 2019
Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)
- Three probes were completed with one provider found to be “non-compliant” after Round 1 Completion.
- CGS noted the documentation should include the following to prevent denials:
- ADL impairment,
- Documentation to support subsequent injections,
- Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injection,
- Documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per LCD L34807,
- Preoperative H&P,
- Imaging Requirements – preoperative lumbar imaging/radiology reports. Imaging must be included and not referenced with the first injection.
This post also includes findings from the following Probe types:
- Review of Cardiac Rehabilitation with continuous ECG Monitoring,
- Review of Skilled Nursing Facility (SNF) RUG codes,
- Review of Inpatient Rehabilitation Facility (IRF) CMGs,
- Outpatient claims for Pulmonary Rehabilitation,
- Review of Inpatient Spinal Fusion Claims, and
- Review of Inpatient Claims for Major Hip and Knee Joint Replacement.
https://www.cgsmedicare.com/parta/mr/tpe_updates/q3_19.html
February 14, 2020: Palmetto GBA OIG Audit Adjustment Process Announcement
The OIG adjustments were incorrectly processed as full denials instead of partial adjustments.
Further review of the OIG report revealed that the adjustment was intended to be a partial adjustment where the patient discharge status code would be updated. This partial adjustment would change the full DRG reimbursement to a per diem reimbursement.
Palmetto GBA is rescinding the demand letters associated with denials that were processed in error. Any collections associated with these overpayments will be issued with payments dated February 18, 2020. New demand letters will be issued based on the patient discharge status change.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A~BLSS3C6531?opendocument
Noridian Outpatient Therapy A/B – Medical Review Top Errors Webinar – March 24, 2020
The Noridian Provider Outreach and Education (POE) staff is hosting this webinar. The event will include examples of errors, how to view and submit Additional Documentation Requests (ADRs), and provide CMS and Noridian resources.
Link to Announcement: https://med.noridianmedicare.com/web/jea/article-detail/-/view/10521/outpatient-therapy-a-b-medical-review-top-errors-webinar-march-24-2020
Beth Cobb
2/5/2020
Q:
We are getting a CCI edit between our nuclear medicine bone scans and the radiopharmaceutical we always use in conjunction with bone scans (technetium medronate / MDP). The edit is telling us we cannot report the bone scan CPT code and HCPCS code A9503 for the MDP on the same date of service – with or without a modifier. Can you explain?
A:
This is a new CCI edit that became effective January 1, 2020. We sent actual patient examples to NCCI asking for clarification. We received notification from NCCI that, after review of the issue, CMS has made a decision to delete the January 1, 2020 edits in the table below. Review the table carefully, as the changes include radiopharmaceuticals besides A9503.
The changes will be retroactive to January 1, 2020 and will be implemented as soon as technically possible. Providers may choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file with retroactive date of January 1, 2020.
Providers may also choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation or resubmit claims denied due to the PTP edits after the implementation of the replacement edit file with January 1, 2020 retroactive date, as permitted by the MAC.
Jeffery Gordon
2/5/2020
In a January 23, 2020 CMS Blog, CMS Administrator Seema Verma shared CMS’ plans to improve tools found at Medicare.gov (Hospital, Nursing Home, Home Health, Dialysis Facility, Long-term Care Hospital, Inpatient Rehabilitation Facility, Physician and Hospice Compare Tools). Administrator Verma notes while the Compare tools are among the most popular, “each one functions independently with varying user interfaces that make them difficult to understand and challenging to navigate.”
CMS plans to improve the customer experience by combining and standardizing the eight existing Compare tools. “The new “Medicare Care Compare” on Medicare.gov will offer Medicare beneficiaries and their caregivers and other users a consistent look and feel, providing a streamlined experience to meet their individual needs in accessing information about health care providers and care settings. In the new, unified experience, patients will be able to easily find the information that is most important to help make health care decisions, like getting quality data by the type of health care provider.”
CMS plans to launch “Medicare Care Compare” this spring, kicking off with a transition period allowing the public to use the new combined Compare alongside the existing tools before they are retired. It just so happens CMS has promised a spring 2020 release of sub-regulatory guidance to the new Discharge Planning Conditions of Participation (CoP) Final Rule that went into effect in November 2019. Updates to both can’t come soon enough as hospitals work to comply with the new CoPs requirement of sharing data from the Compare websites to beneficiaries seeking post-acute care services at the time of discharge.
In the meantime, CMS made data updates to Hospital Compare in January. Among the changes were data updates for the Hospital Readmission Reduction Program (HRRP) and Hospital-Acquired Condition (HAC) Reduction Program.
Hospital Readmissions
CMS began reducing Medicare payments for Inpatient Prospective Payment System Hospitals (IPPS) hospitals with excess readmissions in October 2012. CMS calculates readmission rates for specific conditions through the Hospital Readmission Reduction Program (HRRP). Current specific conditions include:
- Heart Attack (AMI),
- Heart Failure (HF),
- Pneumonia (PNA),
- Chronic Obstructive Pulmonary Disease (COPD),
- Hip/Knee Replacement (THA/TKA), and
- Coronary Artery Bypass Graft Surgery (CABG).
For FY 2020, Medicare estimates hospitals will lose $563 million. A hospitals specific penalty amount will be deducted from each inpatient claim billed during the FY. You can read more about the penalties in an October 1, 2019 Kaiser Health News (KHN) article by Jordan Rau.
Hospital-Acquired Condition (HAC) Reduction Program
The HAC Reduction Program began in FY 2015 and is a Medicare pay-for-performance program supporting the CMS effort to link Medicare payments to quality in the inpatient hospital setting. Hospitals ranking in the worst-performing quartile with respect to risk-adjusted HAC quality measures are subject to a 1 percent payment reduction.
Per a January 31, 2020 Kaiser Health News (KHN) article by Jordan Rau, 786 hospitals will receive lower payments during FY 2020.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Beth Cobb
2/5/2020
Included in the basic format for National Coverage Determinations (NCDs) are Nationally Covered Indications and Nationally Non-Covered Indications sections. In general, NCDs are created to outline covered indications. However, there are NCDs specifically detailing that a service is non-covered such as:
- NCD 280.2 White Cane for Use by a Blind Person,
- NCD 30.5 Transcendental Meditation, and
- NCD 30.3 Acupuncture.
Fortunately, for Medicare beneficiaries, with the January 21, 2020 release of Final Decision Memo (CAG-00452N), acupuncture for chronic low back pain (cLBP) is now a viable treatment option.
Acupuncture NCD Timeline
NCD 30.3 Acupuncture
CMS initially issued a National Non-coverage Determination for Acupuncture (NCD 30.3) in May 1980. This non-coverage determination indicates that “although acupuncture has been used for thousands of years in China and for decades in parts of Europe...Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made.”
Since the initial acupuncture NCD, in 2004, CMS concluded there was no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia or patients with osteoarthritis and published two additional NCDs for non-coverage of acupuncture:
- NCD 30.3.1 – Acupuncture for Fibromyalgia, and
- NCD 30.3.2 – Acupuncture for Osteoarthritis.
CMS Proposes to Cover Acupuncture for Chronic Low Back Pain
In a July 15, 2019 Press Release, CMS announced their proposal to cover acupuncture for 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.”
January 21, 2020: CMS Releases Final Decision Memo for Acupuncture for Chronic Low Back Pain (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.”
NCD 30.3.3 Acupuncture for Medicare Beneficiaries with cLBP
What is covered?
Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:
- For the purpose of this decision, chronic low back pain (cLBP) is defined as:
- Lasting 12 weeks or longer;
- nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
- not associated with surgery; and
- not associated with pregnancy.
- An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
- Treatment must be discontinued if the patient is not improving or is regressing.
What is Non-Covered?
Nationally Non-Covered Indications: “All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.”
Who Can Furnish Acupuncture for Medicare Fee-for-Service Population?
- Physicians (as defined in 1861(r)(1)) may furnish acupuncture in accordance with applicable state requirements.
- Physician assistants, nurse practitioners/clinical nurse specialists (as identified in 1861(aa)(5)), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
- A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
- Current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.
Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by our regulations at 42 CFR §§ 410.26 and 410.27.
Who Can Furnish Acupuncture: Comments & CMS Responses in Final Decision Memo
Comment: Several commenters suggested that acupuncture should only be performed by licensed acupuncturists and not be physicians, physician assistants, or nurse practitioners/clinical nurse specialists who would not have the specialized training a licensed acupuncturist would have.
CMS Response: The coverage criteria defined in section I of this decision memo states that physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must have a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the ACAOM, and language has been added to specify a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. These requirements are consistent either with the requirements of the qualification standards of private payers (which vary as discussed further below) for licensed acupuncturists who treat patients (and also the standards for VA medical centers or the requirements used to identify providers who perform acupuncture paid by the VA in the community). As noted above, licensed acupuncturists cannot directly bill Medicare for services.
Comment: One commenter requested chiropractic doctors who have completed the 100 hour acupuncture course and examination approved by the American Chiropractic Association (ACA) and the National Board of Chiropractic Examiners (NBCE) be included in the list of personnel able to furnish acupuncture in the studies.
CMS Response: CMS notes that the requirements for chiropractic acupuncturists vary widely from state to state. CMS also notes Medicare covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor (or other qualified provider). Medicare does not cover other services or tests ordered by a chiropractor, including acupuncture. However, if a chiropractor fulfills the requirements in section I of this decision memo as auxiliary personnel, they would be eligible to furnish acupuncture “incident to” a physician’s service.
What Benefit Category does Acupuncture Fall Within?
Medicare is a defined benefit program. Items or services must fall within one of the statutorily defined benefit categories outlined in the Social Security Act. According to the Decision Memo, acupuncture qualifies as:
- Incident to a physician’s professional service,
- Inpatient Hospital Services,
- Outpatient Hospital Services Incident to a Physician’s Service, and
- Physician’s Services
Consideration of Benefits and Harms
“We believe that in light of the relative safety of the procedure and the grave consequences of the opioid crisis in the United States, there is sufficient rationale to provide this nonpharmacologic treatment to appropriate beneficiaries with chronic low back pain. Several professional societies and experts (such as the American Pain Association and American College of Physicians) also supported acupuncture as a nonpharmacologic treatment option to consider.
We have reviewed coverage policies of private payers including integrated health systems. A number of other payers such as Aetna, various Blue Cross Blue Shield plans, Cigna, Kaiser Permanente, and United Healthcare provide some coverage of acupuncture for certain indications or offer advantage plans that may provide coverage. There is variation in covered indications and frequency of services.”
NCD 30.3.3 Acupuncture for cLBP
Effective for services performed on or after January 21, 2020, CMS will cover acupuncture for Medicare patients with cLBP when the Nationally Covered Indications are met and will be manualized under NCD 30.3.3, Acupuncture for cLBP.
Beth Cobb
1/29/2020
Background
In November 2019, the Office of Inspector General (OIG) released the Report Medicare Improperly Paid Acute-Care Hospitals $54.4 Million for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy.
The OIG performed this review due to the fact that in prior reviews, they had identified almost $242 million in overpayments to hospitals that did not comply with Medicare’s Post-Acute-Care Transfer (PACT) Policy. In fact, there have been eight prior OIG related reviews dating back to the Implementation of Medicare’s Postacute Care Transfer Policy report issued on October 10, 2001.
Specifically, hospitals transferred patients to a skilled nursing facility setting, but submitted a discharge disposition as if the patient were discharged home resulting in higher reimbursement for the hospital.
Review Approach
- The audit period included claims with dates of service from January 1, 2016, through December 31, 2018.
- The review covered $212 million in Medicare Part A payments for 18,647 inpatient claims subject to the PACT Policy.
- Claims Selection:
- First, the OIG identified claims with a patient discharge status code indicating a discharged to home or certain types of healthcare institutions.
- The OIG then used beneficiary information and services dates to identify services from post-acute-care providers that began on the same date as the inpatient discharge for SNF claims or within three days of the inpatient discharge for home health claims.
Review Findings
Medicare improperly paid acute-care hospitals $54.4 million for 18,647 claims subject to the transfer policy.
Process for Determining Overpayment
Acute care hospitals discharging a Medicare beneficiary to home or certain types of healthcare institutions receive the full MS-DRG payment submitted for the hospitalization. “In contrast, Medicare pays an acute-care hospital that transfers a beneficiary to post-acute care a per diem rate for each day of the beneficiary’s stay in the hospital. The total overpayment of $54.4million represented the difference between the amount of the full MS-DRG payments and the amount that would have been paid if the per diem rates had been applied.”
OIG Recommendations
The OIG recommended that CMS direct Medicare Administrative Contractors (MACs) to do the following:
- Recover the $54.4 million in identified overpayments,
- Identify any claims for transfers to post-acute care in which incorrect patient discharge status codes were used and direct the MACs to recover any overpayments after the audit period, and
- Ensure the MACs are receiving the post-payment edit’s automatic notifications of improperly billed claims and are taking action by adjusting the original inpatient claims to initiate recovery of the overpayments. “If all of the Medicare contractors had received the postpayment edit’s automatic notifications of improperly billed claims and had properly taken action since CY 2013, Medicare could have saved $70,011,503.”
CMS Response
CMS concurred with all of the OIG’s recommendations and provided a plan of action to the OIG to address the recommendations.
January 23, 2020 Palmetto GBA Daily Newsletter: OIG Audit Adjustments
Last week, Palmetto announced that they will be sending letters notifying Jurisdiction J and M hospitals of the OIG Audit Overpayment adjustments. The letters only state the reason for adjustment as “overpayment.” Palmetto GBA identifies the type of bill (TOB) 11K adjustments by entering verbiage in the Remarks field as “OIG AUDIT A-09-19-03007.”
You can read the full Palmetto Article as well as sign up for Article Update Notifications specific to this issue on the Palmetto website.
Beth Cobb
1/29/2020
Vaping-Related Disorder ICD-10-CM Guidance Timeline
As of January 14, 2020, a total of 2,668 hospitalized EVALI (E-Cigarette or Vaping product use-Associated Lung Injury) cases or deaths have been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Sixty deaths have been confirmed in 27 states and the District of Columbia.
In response to the vaping crisis, the Centers for Disease Control and Prevention (CDC) has been proactive by providing guidelines, a new ICD-10-CM code and most recently posting an April 2020 Addenda.
- October 17, 2019: An ICD-10-CM Official Coding Guidelines – Supplement was posted on the CDC website. This supplement is intended to be used with the October 1, 2019 edition of the ICD-10-CM Official Coding Guidelines for Coding and Reporting.
- December 9, 2019: The CDC announced a new emergency code established by the World Health Organization (WHO) for vaping-related disorders. This code became valid for immediate use as of September 24, 2019.
- 0, Vaping-related disorder
- January 15, 2020: The CDC posted an ICD-10-CM Tabular List of Diseases and Injuries Addenda to be implemented April 1, 2020.
- January 24, 2020: CMS released MLN Matters MM11623: Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder
New ICD-10-CM Browser Tool
On January 3, 2020 the CDC posted a new browser tool on their ICD-10-CM webpage. “This user-friendly web-based query application allows users to search for codes….and provides instructional information needed to understand the usage of ICD-10-CM codes. The application provides access to multiple fiscal year version sets that are available with real-time comprehensive results via the search capabilities.”
CDC Specific Vaping Related Disorder information as well as the new Browser Tool are available at https://www.cdc.gov/nchs/icd/icd10cm.htm.
Increasing Access to Innovative Antibiotics for Hospital Inpatients Using New Technology Add-On Payments: Frequently Asked Questions
CMS released MLN Matters SE20004 on January 21, 2020 for hospitals billing for services provided to Medicare beneficiaries. Specifically, this article details changes made by CMS to develop alternative New Technology Add-On Payment (NTAP) to increase access to innovative antibiotics for hospital inpatients and provides a series of frequently asked questions to educate hospitals on changes to the new NTAP policy for Qualified Infectious Disease Products (QIDPs).
Beth Cobb
1/29/2020
MEDICARE TRANSMITTALS – RECURRING UPDATES
Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Provider Type Affected: Clinical Diagnostic Labs
Provider Action Needed: Change Request (CR) 11598 provides instructions for CY 2020, mapping for new codes, and updates for lab costs subject to reasonable charge payment.
MLN Article MM11598: https://www.cms.gov/files/document/mm11598.pdf
January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Provider Type Affected: ASCs billing Medicare Administrative Contractors
Provider Action Needed: CR 11607 informs MACs about updates to the ASC payment system for Calendar Year (CY) 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the HCPCS. Be sure your billing staffs are aware of these changes.
MLN Article MM11607: https://www.cms.gov/files/document/MM11607.pdf
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Provider Type(s) Affected: Hospitals, Other Providers and Suppliers Billing MACs
What You Need to Know: This article is based on CR 11564, informs MACs, including Home Health MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2010.
MLN Article MM11564: https://www.cms.gov/files/document/mm11564.pdf
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
What You Need to Know: This Change Request (CR) revises the payment of travel allowances when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for calendar year 2020.
MLN Article MM11641: https://www.cms.gov/files/document/mm11641.pdf
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective Date: April 1, 2020
MLN Article MM11628: https://www.cms.gov/files/document/mm11628.pdf
OTHER MEDICARE TRANSMITTALS
Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory date of Service Policy
Provider Type Affected: Laboratories & other providers
What You Need to Know: In response to comments, CMS finalized excluding blood banks or centers from the laboratory DOS exception at 42 CFR 414.510(b)(5) in the CY 2020 OPPS/ASC final rule published on November 12, 2019. CMS also adopted a definition of “blood bank or center” and clarified that this policy change categorically excludes molecular pathology testing performed by laboratories that are blood banks or blood centers from the laboratory DOS exception at 42 CFR 414.510(b)(5).
MLN Article MM11574: https://www.cms.gov/files/document/mm11574.pdf
Revised Medicare Transmittals
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Transmittal 266 replaces transmittal 264 released on December 20, 2019. Corrections made include:
- Section 5: change “removing 12 procedures from IPO list” to “removing 11 procedures from IPO list”
- Add a new section, number 18, “Correction of deductible and Coinsurance for HCPCS code, G0404,” and
- Change section 18 “Coverage Determinations” to section 19.
MLN Matters Article MM11605: https://www.cms.gov/files/document/mm11605.pdf
MEDICARE SPECIAL MLN & SPECIAL EDITION ARTICLES
SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It
On January 2, 2020 to update language reflected the use of the MBI number is fully implemented.
SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
Article Release Date: January 8, 2020
The Data Reporting Period has been delayed one year and as such all references to the 2020 data reporting period have been changed to 2021.
SE20002: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Approval of Using the K3 Segment for Institutional Claims
Article Release Date: January 10, 2020
Provider Action Needed: This article provides guidance for processing claims for certain institutional claims that are subject to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services. The CMS will begin to accept claims with this information as of January 1, 2020. This SE article contains an attached advanced diagnostic imaging UB-04 claim examples to help better understand the claims-based reporting concept of the AUC program.
https://www.cms.gov/files/document/se20002.pdf
MEDICARE EDUCATIONAL RESOURCES
January 2020 MLN Catalog
2020 marks the Medicare Learning Network’s® (MLN’s) 20th anniversary and the January 2020 Edition of the MLN Catalog is now available. Resources you will find in the catalog:
- MLN Matters® Articles
- Publications and Educational Tools
- MLN Connects® Newsletter
- Web-based Training Courses, and
- Provider Association Partnerships.
Billing Correctly for Polysomnography
The January 16, 2020 edition of MLN Connects provided Polysomnography Compliance Information, noting in a recent report, the Office of Inspector General (OIG) determined that CMS improperly paid practitioners for some claims associated with polysomnography services that did not meet Medicare requirements. We revised the Provider Compliance Tips for Polysomnography (Sleep Studies) (PDF) Fact Sheet to help you bill correctly. Additional resources:
- Medicare Claims Processing Manual, Chapter 15 (PDF) , Section 70
- Questionable Billing for Polysomnography Services OIG Report
- Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report
OTHER MEDICARE UPDATES
2020 OPPS Correction Notice
On January 3, 2020, CMS published a correction notice in the Federal Register. This document corrects technical errors that appeared in the final rule that appeared in the November 12, 2019 issue of the Federal Register. Included in the notice is the inadvertent omission of two additional botulinum toxin injection codes J0586 and J0588 that have now been added to the codes in Table 65 – Final List of Outpatient Services That Require Prior Authorization.
You can read more about the new Prior Authorization requirement in a related MMP article at http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations.
Palmetto GBA Jurisdiction J Medicare Advantage (MA) Plan Overpayments Update
On January 3, 2020, Phase III Settlement Offer Letters were mailed to affected providers. The settlement offer is intended to address all remaining unresolved “MA overpayment” claims.
https://www.palmettogba.com/palmetto/providers.nsf/ls/JJ%20Part%20A"AZ9J8M2780?opendocument
New Important Message from Medicare (IM) and Detailed Notice of Discharge
The Office of Management and Budget (OMB) has renewed the IM (CMS-10065) and DND (CMS-10066). The revised IM has a new CMS Form number (CMS-10065). It was formerly CMS-R-193. Hospitals are required to use the new forms as of April 1, 2020. Until then the previous and new versions are acceptable for use. You can access the forms at the following links:
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Important-Message-English-and-Spanish.zip
- https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Detailed-Notice-English-and-Spanish.zip
New Medicare Outpatient Observation Notice (MOON)
The OMB has renewed the MOON (CMS-10611). The only change made was the expiration date is now 12/31/2022. Similar to the IM and DND, hospitals are required to use the new MOON beginning April 1, 2020. Both previous and new versions are acceptable for use through March 31, 2020. You can access the MOON at the following link:
January 13, 2020 Memorandum: Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes
Aims of Memorandum:
- To improve the identification of quality issues, the CMS is in the process of integrating the psychiatric hospital program survey into the hospital program survey,
- Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals, and
- Develop training to provide the necessary competencies for all State Survey Agency surveyors to evaluate compliance with the psychiatric hospital CoPs.
Link to Memorandum: https://www.cms.gov/files/document/admin-info-20-05-hospitalpsych.pdf
Link to Related CMS Newsroom Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-reduces-psychiatric-hospital-burden-new-survey-process
2020 Updates to OIG Work Plan
OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Beginning in January 2020, completed Work Plan items will remain in the active Work Plan for one month, after which they will be moved into the Archive. Recently completed reports can be found on OIG's What's New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.
January 2020 Medicare Quarterly Provider Compliance Newsletter
The January 2020 edition of this newsletter includes CERT review findings specific to the provision of Lumbar Sacral Orthosis (LSO) and Recovery Auditor findings from a review of Trastuzumab (Herceptin), J9355.
1/21/2020
“I hope that in this year to come, you make mistakes. Because if you are making mistakes, then you are making new things, trying new things, learning, living, pushing yourself, changing yourself, changing your world. You’re doing things you’ve never done before, and more importantly, you’re doing something.”
So that’s my wish for you, and all of us, and my wish for myself. Make New Mistakes. Make glorious, amazing mistakes. Make mistakes nobody’s ever made before. Don’t freeze, don’t stop, don’t worry that it isn’t good enough, or it isn’t perfect, whatever it is: art, or love, or work or family or life.”
- Neil Gaiman, author
The Appropriate Use Criteria (AUC) Program is complex. So much so, that this is the fourth article in the last six months that MMP has dedicated to this topic and January 1st, 2020 kicked off an entire year of Education and Testing before claims for advanced diagnostic imaging services may be denied.
AUC Program Background
The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries.
Examples of such advanced imaging services include
- Computed tomography (CT),
- Positron Emission Tomography (PET),
- Nuclear Imaging, and
- Magnetic Resonance Imaging (MRI).
Settings this program applies to include
- Physician Offices
- Hospital Outpatient Departments (including emergency department)
- Ambulatory Surgical Centers (ASCs)
- Independent Diagnostic Testing Facilities
Program Applies to services paid under the following
- Medicare Physician Fee Schedule (MPFS),
- Hospital Outpatient Prospective Payment System (OPPS), and
- The Ambulatory Surgical Center (ASC) fee schedule.
CMS Allowed Exceptions to Participation in the Program
CMS does allow exceptions to participation in the program to the following:
- Ordering professionals with a significant hardship (such as limited access to the internet, etc.),
- Patients with an emergency medical condition (note, you can read more about what is considered to be an emergency medical condition in a related MMP article), and
- Inpatient paid under Medicare Part A.
Qualified Decision Support Mechanisms
Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. The CDSM will determine whether or not the imaging order adheres to the AUC, or if there is no AUC available to address a patient’s clinical condition. The CMS AUC Program Webpage includes a table of the current Qualified CDSMs available.
AUC Program Purpose
Per CMS, the purpose of this program is to enable physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to order the most appropriate test for their patient. CMS will use data collected from the program to identify outlier ordering professionals who will become subject to prior authorization.
Hospital Compare: Use of Medical Imaging Measure
AUC Program Priority Clinical Areas are defined in 42 CFR 414.94(b) as clinical conditions, diseases or symptom complexes and associated advanced diagnostic imaging services identified by CMS through annual rulemaking and in consultation with stakeholders. Priority Clinical Areas as of November 2016 includes:
- Coronary Artery Disease (suspected or diagnosed),
- Suspected Pulmonary Embolism,
- Headache (traumatic and nontraumatic),
- Hip pain,
- Low Back Pain,
- Shoulder Pain (to include suspected rotator cuff injury),
- Cancer of the lung (primary or metastatic, suspected or diagnoses), and
- Cervical or neck pain.
Hospital Compare’s Use of Medical Imaging Measure is an outpatient imaging efficiency measure providing information about hospitals’ use of medical imaging tests (like mammograms, MRIs, and CT scans) for outpatients. One goal of this measure is to avoid risk, stress, and cost of doing imaging tests that patients may not need.
The AUC Program Priority Clinical Area of Low Back Pain is also a Use of Medical Imaging Measure on Hospital Compare. More specifically, outpatients with low back pain who had an MRI without trying recommended treatments (like physical therapy) first.
The standard of care in patients with low back pain is to start with treatment like physical therapy or chiropractic care, and have MRI only if the treatment doesn’t help. CMS notes if the number of MRIs is high, it may mean the facility is doing too many unnecessary MRIs for low back pain. Below is a screen shot of three hospitals in the Birmingham market highlighting how they compare to each other, the state of Alabama and the Nation. Findings in this table reflect Medicare Fee-For-Service outpatient claims from July 1, 2017 through June 30, 2018.
As evidenced in this graph, the entire state of Alabama is above the National Average, meaning facilities may be doing too many unnecessary MRIs for low-back pain.
January 1, 2020: Education and Operations Testing Period Begins
Providers are encouraged to participate during the testing period, but claims will not be denied for lack of AUC claim elements. Earlier this month CMS released MLN Article SE20002 specifically for institutional providers providing guidance for processing claims subject to the AUC program. The K3 segment will be used to report line level ordering professional information on institutional claims.
In 2020, CMS expects ordering professionals to begin consulting CDSMs and provide this information to furnishing practitioners and providers for reporting on their claims. Note, modifier MH can be utilized by furnishing practitioners and providers when they do not receive AUC-related information from the ordering professional.
I strongly encourage key stakeholders to read this MLN article as it includes advanced diagnostic imaging UB-04 examples.
Additional Resources
While mistakes will invariably happen with such a complex process, I leave you with a few additional resources to hopefully prevent too many truly glorious, amazing mistakes.
- MMP September 24, 2019 Article: Tips on Implementing Appropriate Use Criteria http://www.mmplusinc.com/news-articles/item/tips-on-implementing-appropriate-use-criteria
- MLN Fact Sheet: Appropriate Use Criteria for Advanced Diagnostic Imaging https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AUCDiagnosticImaging-909377.pdf
- MLN MM11268: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educations and Operations Testing Period – Claims Processing Requirements https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11268.pdf
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