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April 2024 MedCAT Minute: Hypoglossal Nerve Stimulation
Published on Mar 20, 2024
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MMP’s Medicare Compliance Assessment Tool (MedCAT) combines current Medicare Fee-for-Service (FFS) review targets (i.e., MAC, RAC, SMRC) with hospital specific Medicare FFS paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD).

 

In general, MedCAT Minute articles spotlight current contractor review activities. The focus of this article is RAC Issue 0210: Hypoglossal Nerve Stimulation (HNS) for Obstructive Sleep Apnea (OSA).

 

Background

For patients with OSA who are unable to tolerate CPAP, HNS is one available alternative treatment strategy. The American Academy of Otolaryngology (AAO) (2016) position statement indicates that “The AAO considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.” ¹

 

Medicare Coverage Guidance

In 2020, each Medicare Administrative Contractor (MAC) published a Local Coverage Determination (LCD) and related Billing and Coding Article (LCA) for HNS. In general, coverage guidance in each of the LCD’s includes the following statements:

 

“Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

 

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.”

 

In several of the MAC’s Response to Comments Articles, commenters requested that CPAP refusal or non-acceptance should be included with CPAP failure or intolerance as criteria. The refusal/non-acceptance should be clearly documented along with conversations of the benefits of CPAP and the limitations of HNS.

 

In each instance, the MAC responded to this request by noting that failure of conservative therapy should be tried and failed and or not tolerated prior to a surgical approach and no change was made to the LCD.

 

RAC Issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

RAC Issue 0210 was approved for review by CMS on June 7, 2022.

  • Review Type: Complex
  • Provider Type: Outpatient Hospital, Ambulatory Surgical Center, and Professional Services
  • Issue Description: Hypoglossal Nerve Stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe OSA when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.
  • Affected Code: CPT 64582
    • Note: This CPT code was effective on January 1, 2022.
  • Applicable Policy References: The related National Coverage Determination (NCD) 2401.4.1 Sleep Testing for OSA and each of the MACs LCD and related Billing and Coding Articles are included in this section of the RAC Issue.

 

By July 1, 2022, all RACs had added this issue to their list of issues that they would review for all three listed provider types.

 

Meeting Medical Necessity and Documentation Gaps

Palmetto GBA, the Jurisdiction J MAC, has published an article highlighting requirements to meet criteria for HNS and indications when HNS would not be reasonable and necessary.

Beth Cobb

New March 2024 OIG Work Plan Item: Sepsis
Published on Mar 20, 2024
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On Friday, March 15, 2024, the Office of Inspector General (OIG) updated their Work Plan with eight new items. One item that hospitals will want to follow is related to hospital billing for sepsis.

 

OIG Work Plan Item (OEI-02-24-00230): Medicare Inpatient Hospital Billing for Sepsis

“Sepsis is the body’s extreme response to infection. It is a life-threatening, emergency medical issue that often progresses quickly and responds best to early intervention. The definition of and guidance for sepsis have changed over the years in attempts to identify it more accurately. The definition of sepsis was updated in 2016 by an international task force to better differentiate sepsis from a general infection. This narrower definition is widely recognized by groups such as the World Health Organization. However, CMS and CDC currently recognize an older, broader definition. Sepsis is a frequently billed diagnosis in Medicare. There are concerns that hospitals may be taking advantage of this broader definition, as they have a financial incentive to do so. This study will analyze Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how billing of sepsis varied among hospitals. We will also estimate the costs to Medicare associated with using the broader, rather than the narrower, definition of sepsis.” The OIG’s expected report issue date is in Fiscal Year (FY) 2025.

 

Sepsis, Not a New Target

 

OIG and Sepsis

This is not the first time that the OIG has had sepsis MS-DRG’s in their crosshairs. For example, sepsis was mentioned in the February 2021 OIG Report: Trend Toward More Expensive Inpatient Hospitals Stays Emerged Before COVID-19 and Warrant’s further Scrutiny.

 

In their report results, the OIG indicated that “the most frequently billed MS-DRG in FY 2019 was septicemia or severe sepsis with a major complication (MS-DRG 871). Hospitals billed for 581,000 of these stays, for which Medicare paid $7.4 billion.”

 

The following data compares Medicare Fee-for-Service paid claims data by calendar year from pre-COVID 2019 to after then end of the COVID-19 public health emergency (PHE) in May 2023.

 

MS-DRG 871 Medicare Fee-for-Service Paid Claims Data Trend

 

Calendar Year 2019

Claims Volume: 620,927

Claims Payment: $7.992,972,329

 

Calendar Year 2020

Claims Volume: 611,140

Claims Payment: $8,481,178,934

 

Calendar Year 2021

Claims Volume: 556,680

Claims Payment: $8,152,439,134

 

Calendar Year 2022

Claims Volume: 566,387

Claims Payment: $8,392,707,197

 

Calendar Year (January 1 – September 30, 2023) Annualized

Claims Volume: 546,496

Claims Payment: $8,238,024,702

 

The data shows that claims volume and payment has declined since the height of the COVID-19 pandemic in 2020. However, when you annualize calendar year 2023 claims data (January 1 through September 30, 2023), Medicare payment for sepsis continues to be immense at just over $8.2 billion for one MS-DRG. This data was provided by our sister company, RealTime Medicare Data (RTMD).

Beth Cobb

March 2024 National Colorectal Cancer Awareness Month
Published on Mar 06, 2024
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Did You Know?

According to the American Cancer Society, there has been a rise in colorectal diagnoses among people 50 and younger. “In the late 1990s, colorectal cancer was the fourth leading cause of cancer death in both men and women in this age group, and now, it is the first cause of cancer death in men younger than 50 and the second cause in women that age.”

 

In May 2021, the U.S. Preventive Services Task Force changed its colorectal cancer screening recommendation. They lowered the age at which adults at average risk of getting colorectal cancer begin screening from 50 to 45.

 

Why it Matters?

Effective January 1, 2023, CMS lowered the minimum age for colorectal screening (CRC) from age 50 to 45 for certain tests.

 

MLN Matters article MM13017, Removal of a National Coverage Determination and & Expansion of Coverage of Colorectal (CRC) Screening includes:

  • A list of the specific screening tests where the minimum age has decreased from 50 to 45 years and older, and
  • An expanded definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios.

 

Also, National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests was revised to reflect the decrease in minimum age for each of the covered indications listed in this policy.

 

What Can You Do?

As a healthcare provider, be aware of the changes in Medicare’s colorectal screening coverage. Use the Colorectal Cancer Screening Tests information available in MLN Educational Tool Medicare Preventive Services to identify:

  • Applicable HCPCS, CPT and ICD-10 Codes,
  • The specific screening tests that Medicare Covers,
  • The frequency for performing these screening tests for patients not meeting high-risk criteria as well as patients at high-risk,
  • What the patient pays, and
  • Other notes (i.e., CMS pays for anesthesia services provided in conjunction with, and in support of, a screening colonoscopy reported with CPT code 00812.)

 

As a healthcare consumer, I encourage everyone to talk with your doctor about your risk(s) for colorectal cancer and the need for screening tests.

 

References

American Cancer Society article: 2024 – First Year the US Expects More than 2M New Cases of Cancer: https://www.cancer.org/research/acs-research-news/facts-and-figures-2024.html

 

U.S. Preventive Services Task Force May 18, 2021 Final Recommendation Statement for colorectal cancer screening: https://uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

 

MLN MM13017: https://www.cms.gov/files/document/mm13017-removal-national-coverage-determination-expansion-coverage-colorectal-cancer-screening.pdf

 

MLN Educational tool Medicare Preventive Services: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN

Beth Cobb

February 2024 Medicare Coverage and Compliance Updates
Published on Feb 28, 2024
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Coverage Updates

 

February 6, 2024: FAQs Related to Coverage Criteria & Utilization Management Requirements for MA Plans

CMS sent a FAQ document to all Medicare Advantage Organizations and Medicare-Medicaid Plans related to Coverage Criteria and Utilization Management Requirements in the CMS Final Rule (CMS-4201-F) issued on April 5, 2023. They note since this rule has been issued, they have received questions regarding application of the rules. This document is meant to provide clarification about how CMS expects MA plans to comply with the new rules. https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf

 

Compliance Education Updates

 

January 2024: MLN Booklet: Health Equity Services in the 2024 Physician Fee Schedule Final Rule (MLN9201074)

CMS framework on health equity lists 5 priorities for reducing disparities in health. The 2024 Physician Fee Schedule Final Rule has 4 services to help address these priorities including:

  • Caregiver Training Services (CTS),
  • Social Determinants of Health Risk (SDOH) Assessment,
  • Community Health Integration (CHI), and
  • Principal Illness Navigation (PIN).

This MLN booklet reviews all four services including who can provide the service and documentation and billing guidance.

https://www.cms.gov/files/document/mln9201074-health-equity-services-2024-physician-fee-schedule-final-rule.pdf-0

 

January 2024: MLN Booklet: Federally Qualified Health Center (MLN006397)

CMS has added information about marriage and family therapists and mental health counselors or practitioners, added services, updates to mental health in-person visit rules, and COVID-19 and other vaccine billing instructions to this MLN booklet. https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf

 

February 2024: MLN Booklet: Information for Rural Health Clinics (MLN006398)

CMS has made additions to this booklet, for example information about marriage and family therapists and mental health counselors as practitioners and social determinants of health has been added. https://www.cms.gov/files/document/mln006398-information-rural-health-clinics.pdf

 

February 2024: MLN Fact Sheet: Telehealth Services (MLN901705)

Changes made to this MLN product includes adding new CPT and HCPCS codes for CY 2024, adding new and expanded telehealth services, information about extended use of modifier 95 and the CY 2024 originating site facility fee amount which is $29.96. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf

 

February 2024: MLN Fact Sheet: Proper Use of Modifiers 59, XI, XP, XS, & XU (MLN1783722)

This CMS Fact Sheet has been updated to include information on the use of modifier 59 and a single Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC). https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf

Beth Cobb

February 2024 Medicare Potpourri
Published on Feb 28, 2024
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January 17, 2024: Acute Care Hospitals Required to join Joint Commission NHSN Group

Effective July 1, 2024, acute care hospitals with ORYX® performance measurement requirements and that are required through a CMS program to participate in the CDC National Healthcare Safety Network (NHSN) system will be required to join the Joint Commission NHSN Group.

 

The Joint Commission indicated in their announcement that “In April 2024 The Joint Commission will e-mail the primary accreditation contact on file for the organization to determine the appropriate contact person to correspond with regarding the Joint Commission NHSN Group. After the contract has been identified, detailed instructions for joining the Group will be provided, and onboarding will take place May through June 2024.”

 

February 1, 2024: April 1, 2024 ICD-10-CM Updates

CMS notes the ICD-10-CM April 1, 2024 update addresses typographical errors and there are no new diagnosis codes being implemented. You will find downloads for discharges on and after April 1, 2024 on the 2024 ICD-10-CM webpage including an update ICD-10-CM Official Guidelines for Coding and Reporting that includes a few updates, for example on page 29 of this document a new subsection (f) Screening for COVID-19 has been added which provides the following guidance “for screening for COVID-19, including preoperative testing, assign code Z11.52, Encounter for screening for COVID-19.”

 

February 7, 2024: New Steps to Transform the Organ Transplant System

HHS issued a Press Release announcing that the Health Resource and Services Administration (HRSA) “is taking historic steps as part of its Organ Procurement and Transplantation Network (OPTN) Modernization Initiative, leveraging new legal authority…signed into law as part of the Securing the U.S. Organ Procurement and Transplantation Network Act in September 2023.  HRSA actions include:  

  • Releasing a contract solicitation to break up the OPTN monopoly and create an independent OPTN Board of Directors,
  • Issuing a multi-vendor contract solicitation to support broad competition and best-in-class vendors for critical OPTN functions,
  • Launching the discovery and development phase of the transition to a modernized OPTN IT matching system, and
  • Taking action to address “pre-waitlist” inequities in the organ waitlist process and reduce variations in referrals to transplant and in organ procurement practices.

 

February 8, 2024: CMS Reminds Providers about the Jimmo Settlement Agreement

CMS reminded providers in the Thursday, February 8, 2024 edition MLN Connects that “Medicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care to maintain function or to prevent or slow decline, as long as:

  • The beneficiary requires skilled care for the services to be provided safely and effectively.
  • An individualized assessment of the patient's condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are needed for a safe and effective maintenance program.

Note, on February 13, 2024, CMS sent a letter to all Medicare Advantage Organizations reminding them about the Jimmo Settlement Coverage and Training Policies. https://leadingage.org/wp-content/uploads/2024/02/HPMS-Memo_-Jimmo-Settlement_508.pdf

 

February 8, 2024: Accrediting Organization (AO) Proposed Rule

CMS published a proposed rule and related Fact Sheet noting that “CMS’s annual AO oversight Reports to Congress (RTCs) highlight the agency’s significant concerns regarding AO performance that need to be addressed.Comments can be submitted until April 15, 2024.

 

February 8, 2024: Texting of Patient Information and Orders for Hospitals and CAHs Memorandum

This memorandum updates CMS’ current policy for texting patient orders based on current practice and stakeholder feedback. Hospitals and Critical Access Hospitals (CAHs) will now have the flexibility to include text orders, via a secure platform, to be entered into the patient’s medical record or EHR in a manner compliant with the medical record Conditions of Participation (CoPs). https://www.cms.gov/files/document/qso-24-05-hospital-cah.pdf

Beth Cobb

February 2024 Medicare MLN Articles
Published on Feb 28, 2024
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February 5, 2024: MLN MM13507: ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2024 Update

Make sure your staff knows about newly available codes, recent code changes, and NCD coding information. https://www.cms.gov/files/document/mm13507-icd-10-other-coding-revisions-national-coverage-determinations-july-2024-update.pdf

 

February 5, 2024: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

This special edition MLN article was originally released March 26, 2019. With this latest revision, CMS clarified how to hand certain off-campus provider-based departments excepted from Section 603 payment policy. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

 

February 12, 2024: MLN MM13513: Pulmonary Rehabilitation, Cardiac Rehabilitation, & Intensive Cardiac Rehabilitation Expansion of Supervising Practitioners

Make sure your billing staff knows about updates to the above-mentioned rehabilitation services effective January 1, 2024, including expanding the types of practitioners who may supervise these services. https://www.cms.gov/files/document/mm13513-pulmonary-rehabilitation-cardiac-rehabilitation-intensive-cardiac-rehabilitation-expansion.pdf

 

February 15, 2024: Limitation on Recoupment of Medicare Overpayments

Limitation on recoupment of Medicare overpayments is during the first and second level of appeal only. Make sure your staff knows about this limit, when to request an extended repayment plan (ERS) or choose immediate recoupment, and how CMS pays interest on overpayments. https://www.cms.gov/files/document/mm11808-limitation-recoupment-medicare-overpayments.pdf

 

February 21, 2024: MLN MM13485: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: CY 2024 Update

Make sure your billing staff knows about CMS rescinding the AUC program regulations, the program has been paused for reevaluation, and elimination of AUC consultation information on Medicare Fee-for-Service claims. https://www.cms.gov/files/document/mm13485-appropriate-use-criteria-advanced-diagnostic-imaging-cy-2024-update.pdf

 

February 22, 2024: MLN MM13451: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

Make sure your billing staff knows when the next private payor data reporting period is and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13541-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

 

Beth Cobb

Medicare Preventive Services Education Tool Revised
Published on Feb 21, 2024
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Did You Know?

Through the Medicare Learning Network (MLN), CMS has developed an interactive education tool titled Medicare Preventive Services (MLN006559 January 2024). This tool is meant to help providers properly provide and bill Medicare prevention services (i.e., bone mass measurement, colorectal screening, lung cancer screening).

 

For each Preventive Service listed in the tool, you will find the following information as applicable to the service:

  • National Coverage Determination (NCD),
  • HCPCS and CPT codes specific to the service provided,
  • ICD-10-CM diagnosis codes,
  • Telehealth eligibility,
  • Coverage requirements,
  • Frequency requirements, and
  • Medicare Beneficiary (patient) cost sharing.

     

    You will also find answers to the following questions:

  • How do I determine the last date a patient got a preventive service, so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?
  • When can CMS add new Medicare preventive services?
  • My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?
    • CMS provides a link to a Preventive Services Checklist that you can give your patients.
    • Note, CMS also highlights preventive services with an apple in the official U.S. government Medicare Handbook, Medicare and You. You will find information about preventive services in the 2024 Edition of this handbook on pages 30-55.
  • What’s a primary care setting?

     

    Why It Matters?

    This tool was revised in January 2024. Following are two examples of what has been revised:  

     

    Annual Wellness Visit

    New HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes) has been added as well as the following “Other Notes:”

  • The implementation date for SDOH Risk Assessment claims is July 1, 2024,
  • The billing HCPCS code is G0136,
  • Add modifier 33 to an SDOH, G0136, performed on the same day as the Annual Wellness Visit to waive copayment and deductible,
  • G0136 is covered once a year with copayment and deductible waived, and
  • The AWV can be an optional community health integration (CHI) initiating visit when the provider identifies any unmet SDOH needs that prevent the patient from doing the recommended personalized prevention plan.

 

Flu Shot

Starting January 1, 2024, Medicare pays an additional payment for in-home flu shot administration under certain circumstances.

 

What Can You Do?

  • Read all the revisions made to this tool in January in the February 15, 2024 edition of MLN Connects,
  • Use this tool to identify service specific applicable coverage requirements (NCD), HCPCS/CPT codes, and ICD-10-CM diagnosis codes, and
  • Share this tool with key stakeholders at your facility.

Beth Cobb

Electrolyte Abnormalities Short Stay Reviews
Published on Feb 14, 2024
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Did You Know?

Livanta, the National Medicare Claim Review Contractor, samples claims for review monthly for short stay reviews (SSRs) and higher weighted DRG (HWDRG) reviews. As part of their Provider Education efforts, they publish a monthly newsletter called The Livanta Claims Review Advisor.

 

The first Claims Review Advisor newsletter was published two years ago this month in February 2022. Livanta noted in that newsletter that it is meant “to share its review findings and provide guidance to healthcare organizations…each month’s content will highlight areas of interest for medical coders, billing professionals, clinical documentation improvement (CDI) professionals, physicians, and other practitioners.” Topics alternate between SSRs and HWDR reviews each month.

 

Why It Matters?

Livanta recently released the January 2024 edition of The Livanta Claims Review Advisor with a focus on SSRs for electrolyte abnormalities. You will find error rates by MS-DRG, example scenarios of specific electrolyte abnormalities (i.e., hyperglycemic emergencies), and guidance for documenting “the reasonableness of a two-midnight expectation at the time of inpatient admission: regardless of the MS-DRG.

 

Error Rates

Overall, Livanta completed 1,985 reviews for dates of service from October 2021 through December 2023 for the following MS-DRGs:

  • MS-DRG 637: Diabetes with MCC,
  • MS-DRG 638: Diabetes with CC,
  • MS-DRG 639: Diabetes without CC/MCC,
  • MS-DRG 640: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC (error rate 10.20%), and
  • MS-DRG 641: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes without MCC.

 

MS-DRG 641 had the highest reported error rate at 11.60%.

 

How Big is the Pool of Claims?

Based on claims data provided by our sister company RealTime Medicare Data (RTMD), in the CMS FY 2023 (October 1, 2022 through September 30, 2023) for all fifty states and Washington D.C. combined, there were 73,497 claims that grouped to one of the above MS-DRGs. The total payment made to providers for this group of claims was $481,535,832.43.

 

Note, claims with a discharge disposition of expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with planned acute hospital inpatient readmission (82), left against medical advice (07), and hospice election (50 & 51) have been excluded from this data as CMS considers these to be “unforeseen circumstances.” I have included MS-DRG specific claims data in the table at the end of this article.

 

What Can You Do?

 

Resources

Change Request CR10080 and related MLN MM10080: Clarifying Medical Review of Hospital Claims for Part A Payment

 

Beth Cobb

January 2024 Monthly Medicare Updates: MLN Articles
Published on Jan 31, 2024
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Medicare Transmittals & MLN Articles

 

December 21, 2023: MLN MM13496: Billing Requirements for Intensive Outpatient Program Services under New Condition Code 92

Starting January 1, 2024, CMS requires the use of new condition code 92 on all Intensive Outpatient Program (IOP) claims from hospitals and Community Mental Health Centers (CMHCs). Make sure your billing staff knows about billing this new condition code and Medicare manual changes related to providing IOP services. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf

 

December 26, 2023: MLN MM13222: New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services

CMS advises that you make sure your billing staff knows about this new code, that an OPPS provider will get paid per diem payments for this service, the intensity of services required for Medicare to cover and pay for this service, and the outpatient settings this billing requirement is applicable to. https://www.cms.gov/files/document/mm13222-new-condition-code-92-billing-requirements-intensive-outpatient-program-services.pdf

 

January 3, 2024: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update - Revised

This MLN article was revised to change the number of HCPCS codes in Tables 8 and 10 and update the web address of the Change Request (CR) transmittal. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf

 

January 9, 2024: MLN MM13503: Specimen Collection Fees and Travel Allowance: 2024 Update

This MLN article provides updated information about the specimen collection fees and travel allowances for 2024 and other policy updates and reminders. https://www.cms.gov/files/document/mm13503-specimen-collection-fees-and-travel-allowance-2024-update.pdf

 

January 10, 2024: MLN MM13488: Hospital Outpatient Prospective Payment System: January 2024 Update

Make sure your billing staff is aware of the system updates effective January 1, 2024, for example:  

  • COVID-19 vaccine and administration codes,
  • Covered devices for pass-through payments,
  • Inpatient-only list (IPO) updates, and
  • Services: Covered dental rehabilitation procedures, Marriage and Family Therapist (MFT), and Mental health counselor (MHC),

https://www.cms.gov/files/document/mm13488-hospital-outpatient-prospective-payment-system-january-2024-update.pdf

 

January 16, 2024: MLN MM13264: Billing Requirements for Intensive Outpatient Program Services for Federally Qualified Health Centers and Rural Health Clinics

Make sure your billing staff knows about the Intensive Outpatient Program (IOP) scope of benefits, certification and plan of care requirements, payment policies, and coding and billing requirements. https://www.cms.gov/files/document/mm13264-billing-requirements-intensive-outpatient-program-services-federally-qualified-health.pdf

 

January 18, 2024: MLN MM13473: How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

CMS advises that you make sure your billing staff knows about the correct use of HCPCS code G2211 and modifier 25, documentation requirements for G2211, and patient coinsurance and deductible. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

 

Related MLN Matters article MM13272 was revised on December 21, 2023. CMS advises in this article that you make sure your billing staff knows about complexity add-on code G2211. https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf

 

January 18, 2024: MLN MM13480: Refillable DMEPOS Documentation Requirements

Make sure your staff knows about the updated documentation requirements for refillable DMEPOS and the requirement to contact the patient before refilling DMEPOS.  https://www.cms.gov/files/document/mm13480-refillable-dmepos-documentation-requirements.pdf

Beth Cobb

January 2024 Medicare Compliance Education and Other Updates
Published on Jan 31, 2024
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Compliance Education Updates

 

December 2023: MLN Booklet: Global Surgery

CMS has updated this MLN booklet to include the instructions for critical care visits that are unrelated to the surgical procedure and performed post-operatively, report modifier -FY. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

Other Updates

January 18, 2024: CMS Adds Utilization Data on Medicare.gov for the First Time

CMS noted in the Friday January 26 edition of CMS Roundup that they have “added utilization data, specifically procedure volume, for the first time on the Medicare.gov compare tool’s profile pages for doctors and clinicians…this is the latest example of CMS’ transparency efforts to ensure the compare tool on Medicare.gov provides patients and caregivers with information about services they may value as they search for clinicians.”

 

The dataset is currently published in the Provider Data Catalog. The initial list of procedures includes hip and knee replacement, spinal fusion, cataract surgery, colonoscopy, open hernia repair of the groin, minimally invasive hernia repair, mastectomy, CABG, pacemaker insertion or repair, coronary angioplasty and stenting, and prostate resection.

 

You can read more about this data release in a CMS Fact Sheet at https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-195-kb.pdf.

 

January 22, 2024: New EMTALA Resources

CMS announced in a Press Release that they are launching “a series of actions to educate the public about their rights to emergency medical care and to help support the efforts of hospitals to meet their obligations under the Emergency Medical Treatment and Labor Act (EMTALA).” One action CMS has taken is to publish new informational resources on their website at https://www.cms.gov/priorities/your-patient-rights/emergency-room-rights. You can read the entire press release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-actions-help-hospitals-meet-obligations-under-emtala.

 

New Kepro Email Addresses

In the January 2024 edition of Case Review Connections, Kepro lets providers know that Kepro recently became a part of the Acentra health family, and you may notice some changes in email addresses, moving to acentra.com. They do not anticipate any other changes at this time and will provide guidance in the future of any potential required changes. You can sign up for this newsletter on the Kepro website at https://www.keproqio.com/newsletters.

 

January 24, 2024: HHS Releases Voluntary Cybersecurity Goals for the Health Sector & New Gateway Website

HHS announced the release of “voluntary health care specific cybersecurity performance goals (CPGs) and a new gateway website to help Health Care and Public Health (HPH) sector organizations implement these high-impact cybersecurity practices and ease access to the plethora of cybersecurity resources HHS and other federal partners offer.” https://aspr.hhs.gov/newsroom/Pages/HHS-Releases-CPGs-and-Gateway-Website-Jan2024.aspx

Beth Cobb

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