Knowledge Base Category -
Did You Know?
Noridian Healthcare Solutions, LLC (Noridian) is the current Supplemental Medical Review Contractor (SMRC). “With CMS directed topic selections and timeframes, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices.”
Reviews are assigned to the SMRC based on analysis of national claims data issues identified by other Federal agencies (i.e., OIG, Government Accountability Office (GAO), the Comprehensive Error Rate Testing Program (CERT), and Program for Evaluating Payment Patterns Electronic Report (PEPPER)).
Why It Matters?
As of August 15, 2023, the SMRC has thirteen current projects. Examples of current projects includes hyperbaric oxygen of lower extremities diabetic wounds, hospice general inpatient (GIP) level of care, cryosurgery of the prostate, and Mohs surgery.
Also, as of August 15, 2023, Noridian has completed sixty projects since being awarded the $227 million SMRC contract by CMS in 2018. Error rates for their completed projects range from 1% to 98%.
The 1% error rate was for a sample of claims reviewed related to the 20% add-on payment for COVID-19 that was in place during the COVID-19 Public Health Emergency. The 98% error rate was for a review of claims for Medicare Part B emergency ambulance services.
In July of this year, in addition to reporting an error rate for the reviewed claims, Noridian began reporting an error rate for the number of claims denied due to no response to an Additional Documentation Request (ADR). To date, SMRC medical review findings that include the no response error rate, includes:
Project 01-080: Vitamin B12 with Modifier 25 Findings of Medical Review
Error Rate for Reviewed Claims: 43%
No Response to ADR Denials: 39%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-080/
Project 01-081: Outpatient Dental Services CPT 41899 Findings of Medical Review
Error Rate for Reviewed Claims: 95%
No Response to ADR: 20%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-081/
Project 01-093: Overlapping Claims – Hospital Transfers During the PHE Findings of Medical Review
Error Rate for Reviewed Claims: 12%
No Response to ADR: 8%
Results Published July 18, 2023
https://noridiansmrc.com/completed-projects/01-093/
Project 01-050: Podiatry Findings of Medical Review
Error Rate for Reviewed Claims: 45%
No Response to ADR Denials: 29%
Published August 8, 2023
https://noridiansmrc.com/completed-projects/01-050/
Project 01-072: Neurostimulator Implantation Findings of Medical Review
Error Rate for Reviewed Claims: 39%
No Response to ADR Denials: 23%
Results Published August 15, 2023
https://noridiansmrc.com/completed-projects/01-072/
Noridian notes they must notify CMS of identified improper payments and noncompliance with documentation requests. They will initiate claims adjustments and/or overpayment recoupment by the standard overpayment recovery process.
What Can I Do?
First and foremost, make sure you have a process to receive and respond to ADR requests from the SMRC and other review contractors (i.e., CERT).
If a claim is denied for no receipt of documentation, you can complete the following steps posted to the Noridian Jurisdiction E (JE) MAC website:
SMRC Reviews Denied for No Documentation
“When a claim is denied for no receipt of documentation requested by the SMRC, the next step is to submit the documentation to the MAC that issued the demand letter for the overpayment. This must occur within 120 calendar days of the demand letter.
This situation is considered a reopening and the MAC will send the submitted documentation to the SMRC for a re-review decision. The SMRC has up to 60 calendar days to make this decision. The SMRC will then mail a letter to the supplier with their findings, either to pay the claim or they will outline the reasons for denial.
The SMRC will next notify the MAC of the payment or denial decision. The MAC will adjust the claim and a remittance advice with the adjustment results will be generated. The provider has the right to appeal the SMRC decision, if the claim remains denied.
Based on the timeframes and steps listed above, please call the MAC about the status of the SMRC re-review only after at least 140 days have passed from when documentation was sent.”
Last, become familiar with information available on the SMRC website (https://noridiansmrc.com/).
Beth Cobb
July 21, 2023: MLN MM13240: Patient Driven Payment Model Claim Edits
CMS advises that Skilled Nursing Facilities (SNFs) and Hospitals need to make sure your billing staff knows about edits for SNFs billing on Type of Bill (TOB) 21X and Swing Bed TOB 18X, and hospitals billing during an interrupted stay. https://www.cms.gov/files/document/mm13240-patient-driven-payment-model-claim-edits.pdf
July 21, 2023: MLN MM13248: Processing Services During Disenrollment from the Program of All-Inclusive Care for the Elderly (PACE)
Hospitals, SNFs and other providers billing Medicare Administrative Contractors (MACs) for inpatient services they provide to PACE-eligible Medicare patients need to make sure your billing staff knows how CMS handles payment for Medicare patients disenrolling from PACE and condition codes and value code (VC) CMS requires to prevent claims denials. https://www.cms.gov/files/document/mm13248-processing-services-during-disenrollment-program-all-inclusive-care-elderly.pdf
July 27, 2023: MLN MM13275: ESRD Prospective Payment System: October 2023 Update
Make sure your billing staff knows about billing J0889 for daprodustat and new ICD-10-CM codes for comorbidity payment adjustment and acute kidney injury. https://www.cms.gov/files/document/mm13275-esrd-prospective-payment-system-october-2023-update.pdf
Augst 3, 2032: MLN MM13299: HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement: October 2023 Update
Make sure billing staff knows about updates to the lists of HCPCS codes that are subject to the CB provision of the SNF prospective payment system (PPS), and additions and deletions of certain chemotherapy, blood clotting factors, and therapies inclusion codes from the Medicare Part A SNF files. https://www.cms.gov/files/document/mm13299-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-october-2023.pdf
August 10, 2023: MLN MM13289: Hospice Payments: FY 2024 Update
This article provides information about payment rates, inpatient and aggregate caps and wage index update effective October 1, 2023 for hospices and providers billing for hospice services. https://www.cms.gov/files/document/mm13289-hospice-payments-fy-2024-update.pdf
August 16, 2023: SE19007 Revised: Activation of Validation Edits for Providers with Multiple Service Locations
This special edition MLN article was originally published on March 26, 2019 and recently updated for the fifth time on August 16th. CMS has added information about the practice location address screen for round 3 testing Substantive changes are in dark red on pages 3 and 4.
Effective August 1, 2023, CMS started deploying the systematic validation edits requirements in Section 170 of the Medicare Claims Processing Manual, Chapter 1. MACs have been told to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t exactly match.
CMS notes in the MLN article that they “expect that the almost 7-year time frame that the edits haven’t been active gave you ample time to validate your claims submission system and the PECOS information for your off-campus provider departments are exact matches.” https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
August 17, 2023: MLN MM13321: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Make sure your billing staff know about private payor data reporting (you must report data between January – March 2024), general specimen collection fee increase, and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13321-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
August 24, 2023: Transmittal 12222: Inpatient Psychiatric Facilities Prospective Payment System Updates for Fiscal Year 2024
This Change Request (CR) 13335 identifies changes that are required as part of the annual IPF PPS update and applicable to discharges occurring from October 1, 2023 through September 30, 2024. https://www.cms.gov/files/document/r12222cp.pdf
Beth Cobb
Coverage Updates
August 9, 2023: MLN MM13278: ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2024 Update
Relevant National Coverage Determinations (NCDs) include NCD 50.3 (Cochlear Implants), NCD 90.2. (Next Generation Sequencing (NGS), and NCD 210.1 (Prostate Screening Tests). Make sure your billing staff are aware of newly available codes, recent coding changes, and how to find NCD coding information. https://www.cms.gov/files/document/mm13278-icd-10-other-coding-revisions-national-coverage-determinations-january-2024-update.pdf
August 9, 2023: MLN MM13288: National Coverage Determination 30.3.3 – Acupuncture for Chronic Low Back Pain
Make sure your billing staff knows about updated frequency edits for acupuncture for chronic low back pain (cLBP) and relevant codes for acupuncture and dry needling services starting January 1, 2024. Reminder, CMS won’t cover more than 20 acupuncture treatments annually. https://www.cms.gov/files/document/mm13288-national-coverage-determination-3033-acupuncture-chronic-low-back-pain.pdf
Compliance Education Updates
August 2023: MLN Booklet Federally Qualified Health Center Revised
There have been several updates made to this MLN booklet. For example, CMS clarified the definition of telehealth and added consent for information for care management and virtual communications services. https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf
Other Updates
July 27, 2023: MLN Connects Notification: CMS Updated the Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy FAQs
In the July 27, 2023 edition of MLN Connects, CMS notes that they have updated the Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy FAQs to clarify the applicability of the reporting requirements to various outpatient settings and certain not otherwise classified billing codes. They also clarify how to use the JW and JZ modifiers when you prepare the dose with more than 1 single-dose container.
Finally, they remind providers that they use the JW and JZ Modifiers to collect information on discarded drug amounts from drugs that are packaged in single-dose containers that are separately payable under Part B.
Starting July 1, 2023, report the JZ modifier when there are no discarded amounts and report the JQ modifier when there are discarded amounts. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/1368246344/2023-07-27-mlnc
August 16, 2023: CMS Fact Sheet: Anniversary of the Inflation Reduction Act: Update on CMS Implementation
In this Fact Sheet, CMS details Milestones that they have met for implementing the provisions in this Act. You will also find links to public education resources that CMS has produced to help people with Medicare and those who assist them understand the changes under the new drug law (i.e., Frequently Asked Questions: Medicare Part B & D Insulin Benefit). https://www.cms.gov/newsroom/fact-sheets/anniversary-inflation-reduction-act-update-cms-implementationBeth Cobb
Did You Know?
It has been almost two years since the October 2021 release of the CMS Change Request (CR) 12471 (https://www.cms.gov/files/document/R11059CP.pdf). There were two stated purposes for this CR noted in the Summary of Changes:
- Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
- Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason why laterality could not be determined.
Why this Matters?
In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”
Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.
You will find the initial complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page).
This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”
Mechanism to Bypass new MCE Edit 20-
The provider may enter a remark:
- Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
- “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality.
Entering this language will enable your MAC to systematically bypass the edit and process your claim.
However, “if there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”
New Unspecified Codes Subject to MCE Edit 20-
In the FY 2024 IPPS Final Rule, CMS finalized the addition of six new diagnosis codes that are designated as a CC to the Unspecified code edit code list and four diagnosis codes that were inadvertently omitted from the Unspecified code edit list effective with discharges on or after April 1, 2022.
New FY 2024 Unspecified ICD-10-CM Diagnosis Codes
- M80.0B9A: Age-related osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
- M80.0B9K: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
- M80.0B9P: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
- M80.8B9A: Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
- M80.8B9K: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
- M80.8B9P: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
- L89.103: Pressure ulcer of unspecified part of back, stage 3
- L89.104: Pressure ulcer of unspecified part of back, stage 4
- L89.93: Pressure ulcer of unspecified site, stage 3
- L89.94: Pressure ulcer of unspecified site, stage 4
What Can You Do?
Share this information with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists) including background information found in CR 12471 and related MLN Matters article MM12471 (https://www.cms.gov/files/document/mm12471-april-2022-update-java-medicare-code-editor-mce.pdf).Beth Cobb
Medicare Transmittals & MLN Articles
June 30, 2023: MLN MM13269: ICD-10 & Other Revisions to Laboratory National Coverage Determinations: October 2023 Update
CMS advises that you make sure your billing staff is aware of newly available codes, recent coding changes, and how to find NCD coding information. https://www.cms.gov/files/document/mm13269-icd-10-other-coding-revisions-laboratory-ncds-october-2023-update.pdf
July 5, 2023: MLN Matters MM13216: Ambulatory Surgical Center Payment System: July 2023 Update - Revised
Now in it’s fourth iteration, CMS has revised this MLN article to change the number of separately payable drugs in Section 5.a to 18 to agree with the change for HCPCS J9322 in Table 3 of Change Request (CR) 13216. Substantive changes are in dark red on page 3. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdf
July 11, 2023: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised
Now in its fifth iteration, CMS has revised this special edition MLN article to add information on Round 5 testing and national implementation of edits. Substantive changes are in dark red on pages 1 and 4. Note that these are not new requirements, but CMS did announce a delay of activation of these edits on March 24, 2022 until further notice. On August 1, 2023, CMS will start deploying editing into full procedure and have told the MACs to develop implementation plans to permanently turn on the Reason Codes and set them up to RTP claims that don’t match exactly. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf
Coverage Updates
July 17, 2023: Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease Proposed Decision Memo
CMS is proposing to remove National Coverage Determination (NCD) 220.6.20, ending coverage with evidence development (CED) from positron emission tomography (PET) beta amyloid imaging and permitting Medicare coverage determinations for PET beta amyloid imaging be made by the Medicare Administrative Contractors (MACs). https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=308
July 20, 2023: HCPCS Modifier JZ Reminder
Palmetto GBA JJ Part B published a reminder that “the JZ HCPCS modifier is reports on a claim to attest that no amount of drug was discarded and eligible for payment. The modifier should only be used for claims that bill for single-dose container drugs. Effective July 1, 2023 providers are required to use the JZ modifier on applicable claims. https://www.palmettogba.com/palmetto/jjb.nsf/DID/1HF9LYKONE#ls
Compliance Education Updates
June 2023: Medicare’s Home Health Benefit Brochure Revised
CMS has revised their Medicare home health brochure. This brochure includes information about a beneficiary knowing their rights, where to get more information, what is covered, who can get covered home health care, what to pay, and how to protect yourself and Medicare from fraud. https://tinyurl.com/yc2ej3sv
June 2023: MLN Fact Sheet Telehealth Services Revised
CMS has recently updated this Fact Sheet and notes that they have made significant updates to explain recent policy changes. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf
Beth Cobb
Medicare Transmittals & MLN Articles
April 27, 2023: MLN MM12889: New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI
This MLN article issued October 6, 2022 has been revised to add information to explain how to verify attending physician information. https://www.cms.gov/files/document/mm12889-new-fiscal-intermediary-shared-system-edit-validate-attending-provider-npi.pdf
May 4, 2023: MLN MM13195: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
This article includes information the COVID-19 PHE expiration, the next Clinical Laboratory Fee Schedule data reporting period, the general specimen collection fee increase, and new and discontinued HCPCS codes. https://www.cms.gov/files/document/mm13195-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
May 4, 2023: MLN MM13180: Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process
Billing staff for physicians and End Stage Renal Disease (ESRD) facilities assigned to the ESRD Treatment Choices (ETC) Model should know about adjustments to claim lines on type of bill 072X with condition codes 74 or 76. They also need to know about monthly capitation payment (MCP) claims on claim lines with CPT codes 90957-90962 and 90965-90966. https://www.cms.gov/files/document/mm13180-home-dialysis-payment-adjustment-performance-payment-adjustment-esrd-treatment-choices-model.pdf
May 16, 2023: MLN MM13071: Travel Allowance Fees for Specimen Collection: 2023 Updates
Initially released January 9, 2023, this article was revised May 16, 2023 to delete the phrase “including Medicare Advantage” from the Travel Allowance Policy section of this article. https://www.cms.gov/files/document/mm13071-travel-allowance-fees-specimen-collection-2023-updates.pdf
May 17, 2023: MLN MM13064: Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2023 Final Rules
Billing staff for physicians, hospitals, suppliers, and other providers billing MACs for services provided to Medicare patients need to be aware of the updated billing instructions for nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit. https://www.cms.gov/files/document/mm13064-updating-medicare-manual-policy-changes-cy-2020-cy-2021-final-rules.pdf
May 18, 2023: Transmittal 12047: Educational Instructions for the Implementation of the Medicare Payment Provisions for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule
The Change Request (CR 13190) provides further clarity to and directs the A/B MACs to develop educational materials to aid in the implementation of the Medicare payment policies for dental services as described in Section II.L of the CY 2023 PFS final rule. This guidance is intended to facilitate a consistent application of the payment policy nationally, with MACs providing payment for more types of dental services associated with a broader set of medical services than before CY 2023. https://www.cms.gov/files/document/r12047bp.pdf
May 19, 2023: MLN MM13192: HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update
Information in this MLN article includes updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS) as well as additions and deletions of certain chemotherapy and vaccine codes from the Medicare Part B SNF files. https://www.cms.gov/files/document/mm13192-hcpcs-codes-used-skilled-nursing-facility-consolidated-billing-enforcement-july-2023.pdf
May 23, 2023: MLN MM13210: Hospital Outpatient Prospective Payment System: July 2023 Update
This article describes coding changes and policy effective July 1, 2023, for the hospital OPPS including payment system updates and new codes for COVID-19, drugs, biologicals, and radiopharmaceuticals, devices and other items and services. https://www.cms.gov/files/document/mm13210-hospital-outpatient-prospective-payment-system-july-2023-update.pdf
May 23, 2023: MLN SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
First released March 30, 2022, in this fourth iteration, CMS revised the article to show a legislative change about in-person visits and added modifier 93 for reporting audio-only mental health visits. For RHCs and FQHCs, CMS will not require in-person visits until January 1, 2025. https://www.cms.gov/files/document/se22001-mental-health-visits-telecommunications-rural-health-clinics-federally-qualified-health.pdf
May 25, 2023: MLN MM13216: Ambulatory Surgical Center Payment System: 2023 Update
CMS advises that providers make sure your billing staff know about payment system updates, including new drug biological and procedure codes, an ASC Payment Indicator (PI) correction for CPT code 0698T, and additional skin substitute products. https://www.cms.gov/files/document/mm13216-ambulatory-surgical-center-payment-system-july-2023-update.pdfBeth Cobb
Over the years, my mom has taken joy in sharing that when I was young, I told her “I wish I was two inches taller so that when I get old, I won’t be short.” To the best of my recollection, this wish came from watching my grandmother get shorter as she aged.
Osteoporosis is a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to broken bones and getting shorter as we age.
My mother has had osteoporosis for several years and like my grandmother, over the years has gotten shorter. In the spring of 2022, she suffered a hip fracture requiring surgery. In November 2022, with a diagnosis of osteopenia, my primary doctor ordered a bone density scan.
While just under a decade shy of Medicare eligibility, I felt my family history supported the indications for coverage of this test. Much to my surprise, in early 2023 I received a bill from the performing facility. I was told by customer service this was because I was not 65 years old. I disagreed with the reasoning for a denial and promptly sent an appeal letter to BlueCross Blue Shield (BCBS) of Alabama.
In BCBS’s redetermination, I was informed that my contract complies with healthcare reform (HCR) benefits and provides coverage for in-network mandated preventive services at 100 percent of the allowed amount with no deductible or copayment. Further, the procedure code billed (77080) is included in the HCR preventive services when performed for a diagnosis code that meets the HCR coverage guidelines.
The diagnosis code that had been submitted on my claim was the unspecified osteopenia code M85.80 (other specified disorders of bone density and structure, unspecified site) and is not a code that meets the HCR coverage guidelines.
My next step was to review the CMS National Coverage Determination (NCD) 150.3 Bone (Mineral) Density Studies and related transmittal to determine a more appropriate ICD-10 diagnosis code. Diagnosis code M85.88 (Other specified disorders of bone density and structure, other site) is a covered diagnosis code. I worked with my physician’s billing staff to resubmit my claim with a corrected diagnosis code.
I share my story with you as a cautionary note that a non-covered code can result in a patient having to pay for a covered service.
With the advent of ICD-10, CMS has released several change requests and associated documents as part of its ICD-10 conversion activities related to NCDs. You can find this information on the CMS ICD-10 webpage at
https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10. The most recent code revisions to NCD 150.3 was in an April 12, 2023 transmittal and related MLN Matters Article MM13070 (https://www.cms.gov/files/document/mm13070-icd-10-other-coding-revisions-national-coverage-determinations-july-2023-update.pdf) effective July 1, 2023.
As we celebrate Osteoporosis Awareness and Prevention Month, here are some steps you can take to improve your bone health:
- Eat foods that support bone health. Get enough calcium, vitamin D, and protein each day. Low-fat dairy; leafy green vegetables; fish; and fortified juices, milk, and grains are good sources of calcium. If your vitamin D level is low, talk with your doctor about taking a supplement.
- Get active. Choose weight-bearing exercise, such as strength training, walking, hiking, jogging, climbing stairs, tennis, and dancing. This type of physical activity can help build and strengthen your bones.
- Don’t smoke. Smoking increases your risk of weakened bones. If you do smoke, here are tips for how to quit smoking.
- Limit alcohol consumption. Too much alcohol can harm your bones. Drink in moderation or not at all. Learn more about alcohol and aging.
Resources
National Osteoporosis Foundation (NOF) May 1, 2023 Press Release: https://www.bonehealthandosteoporosis.org/news/osteoporosis-awareness-and-prevention-month-2023-healthy-bones-are-always-in-style/
NOF Osteoporosis Fast Facts: https://www.bonehealthandosteoporosis.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf
National Institute on Aging: https://www.nia.nih.gov/health/osteoporosisBeth Cobb
Medicare Transmittals & MLN Articles
March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update – Article Revised April 3, 2023
This article was revised to reflect a revision to Change Request (CR) 13136 which changed a reference to average sales price (ASP) calculations based on sales price submissions from the third quarter of CY 2022 to the fourth quarter. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf
April 6, 2023: MLN MM13162: New Waived Tests
CMS advises that your billing staff know about Clinical Laboratory Improvement Amendments (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13162-new-waived-tests.pdf
April 21, 2023: Transmittal 11995, Change Request (CR) 13181: Medicare Policy Updates for Dental Services as Finalized in the CY 2023 Physician Fee Schedule (MPFS) Final Rule
The purpose of CR 13181 is to update the Internet Only Manual (IOM) Medicare benefit policy for dental services as finalized in the CY 2023 MPFS final rule. CMS provides four scenarios in which Medicare payment for dental services is not excluded. They also note these policies do not prevent a MAC from deciding that payment can be made for dental services in other circumstances under which the dental services are inextricably linked to, and substantially related and integral to the clinical success of, certain covered medical services, but are not specifically addressed in final rules, manual provisions, and the finalized amendment to §411.14(i). https://www.cms.gov/files/document/r11995bp.pdf
April 21, 2023: MLN MM13149: Skilled Nursing Facility Prospective Payment System: Updates to Current Claims Editing
Information in this article is for SNFs and hospital swing bed providers. Action needed is to make sure your staff knows about improved editing of claims that have interrupted stays that span two months and modified editing for occurrence span code (OSC) edits allowing for proper claims decisions.
Compliance Education Updates
February 2023: MLN Booklet: Information for Critical Access Hospitals
CMS has updated the MLN Booklet. Changes to the booklet are highlighted in dark red, for example, information about the new provider type call rural emergency hospitals (REHs) starting January 1, 2023 has been added to this document. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CritAccessHospfctsht.pdf
April 13, 2023: MLN Connects: Hospital Outpatient Departments: Prior Authorization for Facet Joint Interventions Starts July 1
CMS reminds hospitals in the April 13th edition of MLN Connects that hospital outpatient departments must submit prior authorization requests for facet joint interventions starting on or after July 1, 2023. The Prior Authorization CMS webpage was updated on April 12, 2023 with the addition of this notice and access to a complete list of all HCPCS codes requiring prior authorization as part of this initiative. In general, the Medicare Administrative Contractors (MACs) will begin accepting prior authorization requests for facet joint interventions on or around June 15th. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-04-13-mlnc#_Toc132203902
April 27, 2023: New OMB approved Medicare Outpatient Observation Notice
Reminder
The Medicare Outpatient Observation Notice (MOON) and Important Message from Medicare (IM)/Detailed Notice of Discharge (DND) forms received OMB approval on January 23, 2023. The new versions must be used no later than April 27, 2023. All updated forms are available on the CMS Beneficiary Notices Initiative webpage at https://www.cms.gov/Medicare/Medicare-General-Information/BNI.
MLN Fact Sheet: Intravenous Immune Globulin Demonstration Fact Sheet
This demonstration began in October 2014 and will end on December 31, 2023. A related MLN Fact Sheet has been updated this month with updated 2022 and 2023 payment rates for Q2052 and claims adjustment language for updated payment rates. https://www.cms.gov/files/document/mln3191598-intravenous-immune-globulin-demonstration.pdfBeth Cobb
Medicare Transmittals & MLN Articles
February 27, 2023: MLN MM12103: Extension of Changes to the Low-Volume Hospital Payment Adjustment & the Medicare Dependent Hospital Program
Affected Providers includes Low-volume hospitals and Medicare-dependent hospitals (MDHs). This article includes information and criteria and payment adjustments for FY 2023 and the extension of the MDH program through September 30, 2023. https://www.cms.gov/files/document/mm13103-extension-changes-low-volume-hospital-payment-adjustment-medicare-dependent-hospital-program.pdf
March 16, 2023: Pub 100-20 One Time Notification: Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital Reimbursement
The purpose of this Change Request (CR) 12669 is to provide updated direction related to the evaluation of Section 1115 Waiver days in the calculation of Disproportionate Share Hospital (DSH) reimbursement for open cost reports and cost reports currently under administrative appeal. https://www.cms.gov/files/document/r11912otn.pdf
March 16, 2023: MLN MM13143: Ambulatory Surgical Center Payment System: April 2023 Update
Make sure your billing staff know about the new HCPCS codes for drugs and biologicals, corrected 2023 ASC code pair file, and skin substitute product coding updates. This article was revised on March 24, 2023 to remove a code paid from Table 1 and corrected language associated with this code pair. https://www.cms.gov/files/document/mm13143-ambulatory-surgical-center-payment-system-april-2023-update.pdf
March 17, 2023: MLN MM13136: Hospital Outpatient Prospective Payment System: April 2023 Update
This article highlights payment system updates and new codes for COVID-19, drugs, biologicals, radiopharmaceuticals, devices, and other items and services. Of note, once the COVID-19 PHE ends, CMS instructs that they will package payment for COVID-19 treatments into the payment for a comprehensive APC (C-APC) when services are billed on the same outpatient claim, subject to standard exclusions under the C-APC policy. https://www.cms.gov/files/document/mm13136-hospital-outpatient-prospective-payment-system-april-2023-update.pdf
March 17, 2023: MLN MM13153: DMEPOS Fee Schedule: April 2023 Update
The DMEPOS fee schedule is updated on a quarterly basis, when necessary to implement fee schedule amounts for new and existing codes as applicable and apply changes to payment policies. In this update, pay close attention to guidance regarding payment policies as the COVID-19 PHE ends. https://www.cms.gov/files/document/mm13153-dmepos-fee-schedule-april-2023-update.pdf
March 17, 2023: MLN MM13118: Medicare Part B Coverage of Pneumococcal Vaccinations
Effective October 19, 2022, CMS updated the part B requirements to align with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. This MLN article details the updated recommendations. https://www.cms.gov/files/document/mm13118-medicare-part-b-coverage-pneumococcal-vaccinations.pdf
March 20, 2023: MLN MM13094: Supervision Requirements for Diagnostic Tests: Manual Update
This article provides information about the expanded list of provider types authorized to supervise diagnostic tests and updates to the Medicare Benefit Policy Manual. https://www.cms.gov/files/document/mm13094-supervision-requirements-diagnostic-tests-manual-update.pdf
Coverage Updates
March 1, 2023: MLN Matters MM13073: National Coverage Determination: Cochlear Implantation
This article provides information about the expanded coverage for cochlear implantation services that was effective September 26, 2022 and an implementation date of March 24, 2023. https://www.cms.gov/files/document/mm13073-national-coverage-determination-cochlear-implantation.pdf
March 22, 2023: OIG Report: Medicare Improperly Paid Physicians an Estimated $30 Million for Spinal Facet-Joint Interventions
The OIG performed this audit due to prior audits revealing that facet-joint interventions are at risk for overutilization and improper payments for these services. Of the 120 sampled sessions, 66 sessions did not comply with 1 or more of the requirements. Based on audit results, the OIG estimated that Medicare improperly paid physicians $29.6 million.
In calendar year 2023, all 12 MACs updated their Local Coverage Determination (LCD) and Local Coverage Article (LCA) for facet-joint interventions. Updated policies include new guidance not in the prior versions (i.e., updated LCAs state a physician should append modifier KX to a claim line if a diagnostic face-joint injection was administered – to distinguish the injection from a therapeutic facet-joint injection). https://oig.hhs.gov/oas/reports/region9/92203006.pdfBeth Cobb
Compliance Education
March 9, 2023: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier – Revised
In the March 9th edition of MLN Connects CMS encouraged readers to learn about the requirement to include a modifier on claims for separately payable Part B drugs and biologicals acquired under the 340B Program. Along with the announcement, CMS provided links to an updated MLN Fact Sheet and Updated FAQs. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlnc
March 27, 2023: The Livanta Claims Review Advisor: Short Stay Review (SSR) – Review Findings from Year One
In Livanta’s March 2023 edition of their Claims Review Advisor newsletter, they report findings from the first year of reviews, noting that Medicare short stay reviews were paused in May 2019 and resumed in October 2021. Of the 18,672 claims reviewed, 2,663 (14%) were admission denials. The first common reason cited by Livanta for denials was insufficient documentation to support a two-midnight expectation at the time of the admission order. You can find past issues of the Livanta Claims Review Advisor as well as the full Review Findings from Year One report on Livanta’s website at https://www.livantaqio.com/en/ClaimReview/Provider/provider_education.html.
COVID-19 Updates
February 27, 2023: CMS PHE Fact Sheet: What Do I Need to Know? Waivers, Flexibilities, and the Transition Forward
CMS published a fact sheet covering COVID-19 vaccines, testing, and treatments; telehealth services; continuing flexibilities for health care professionals; and inpatient hospital care at home when the PHE expires at the end of the day on May 11, 2023. https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf
March 10, 2023: OIG’s COVID-19 PHE Flexibilities End May 11, 2023
The OIG published a notice to describe the flexibilities they had implemented in response to the COVID-19 PHE (i.e., their March 17, 2020 Telehealth Policy Statement), and to remind the health care community said flexibilities will end on May 11, 2023. https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp
March 13, 2023: FDA’s Guidance Documents related to COVID-19
The FDA published this notice in the Federal Register “to provide clarity to stakeholders with respect to the guidance documents that will no longer be effective with the expiration of the PHE declaration and the guidance’s that FDA is revising to continue in effect after the expiration of the PHE declaration.” Specifically, there are 72 COVID-19 related guidance documents currently in effect addressed in this notice. Twenty-two will expire at the end of the COVID-19 PHE, another twenty-two will continued for 180 days after the PHE ends, twenty-four will remain in effect with plans to revise (i.e., guidance related to emergency use authorization for vaccines to prevent COVID-19), and the remaining four will also remain in effect. https://www.federalregister.gov/documents/2023/03/13/2023-05094/guidance-documents-related-to-coronavirus-disease-2019-covid-19
March 16, 2023: MLN Connects: Do not Report CR Modifier & DR Condition Code After Public Health Emergency
CMS included the following in the March 13th edition of MLN Connects: “The end of the COVID-19 public health emergency (PHE) is expected to occur on May 11, 2023. Since the CR modifier and DR condition code should only be reported during a PHE when a formal waiver is in place, plan to discontinue using them for claims with dates of service on or after May 12, 2023.” https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-16-mlnc#_Toc129789600
Other Updates
February 28, 2023: New Region 2 Recovery Auditor
On February 28th, Performant posted a general program update alerting providers that on February 7, 2023, CMS approved Performant to begin performing on their new Region 2 contract. Coming soon to their website will be Provider Outreach and education plans. https://performantrac.com/cms-rac/cms-rac-resources/cms-rac-provider-resources/default.aspx
March 9, 2023: MLN Connects: New Inflation Reduction Act Resources
This addition of MLN Connects includes information about the Inflation Reduction Act (IRA), including a recently issues social media toolkit that stakeholders can use to educate people with Medicare about the new insulin benefit and additional vaccines available at no cost and additional resources to provide to your patients that need it. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-03-09-mlncBeth Cobb
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