A Look Back at 2019

on Monday, 06 January 2020. All News Items | Medicare Coverage | Documentation | Billing

Out with the Old, In with the New

Annually, one of my goals is to write in a daily journal where I focus on things to be grateful for, important events from the previous day, and prayer requests. Unfortunately, life gets in the way and here I am at the start of 2020 journaling in the same notebook that I started on January 1st, 2017. Amazingly enough, in reading back through, I had journaled enough to recall forgotten simple pleasures and adventures with friends and family. It also reminded me of the ongoing health issue struggles of family members. Whether changes in the world of Medicare in 2019 were positive or negative, it is definitely worthwhile to take a look back.  


1st - Outpatient Prospective Payment System Quarterly Update Effective Date

MLN Matters Number: MM11099

In addition to describing changes to and billing instructions for various payment policies implemented in January, CMS provides the following reminder at the end of the MLN article: “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

January 2019 Edition Medicare Quarterly Compliance Newsletter

Guidance to address billing errors. This edition includes information on Observation and Inpatient Care and Billing for DME during an inpatient stay.



1st – CMS Expands Covered List of Diagnosis codes for Supervised Exercise Therapy (SET)

On February 1, 2019, CMS issued a new transmittal that clarified the payment rules and expanded the list of covered diagnosis codes for supervised exercise therapy (SET). You can read more about this in the transmittal and related MMP article at http://www.mmplusinc.com/news-articles/item/supervised-exercise-therapy-for-pad.

6th – National Transitions of Care Standards

The American Case Management Association (ACMA) announced the first multi-setting, inter-professional National Transitions of Care Standards endorsed by an Executive Steering Committee composed of payer, provider, and other organizations representation.

The ACMA as an organization has a mission “To be THE Association for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals.” Transitions of Care (TOC) describe a process of transferring a patient’s care from one setting or level of care to another (i.e. transition from hospital to skilled nursing facility or hospital to home with home health services). Annually, $26 Billion is spent on poor transitions of acute care Medicare patients.

You can assess how your organization is doing when it comes to executing patient level of care transitions by visiting transitionsofcare.org and taking the Transitions of Care Standards self-assessment.

13th – Guidelines for Achieving a Compliant Query Practice – 2019 Update

The Association of Clinical Documentation Integrity Specialists (ACDIS) posted an updated brief noting it was a joint effort of ACDIS and the American Health Information Management Association (AHIMA). Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries. This practice brief supersedes all previous versions.

15th – Implementation Date for Implantable Cardiac Defibrillator (ICD) National Coverage Determination changed from February 26, 2019 to March 26, 2019.

On November 21, 2018, CMS issued Transmittal 211 regarding revisions made to the Implantable Cardiac Defibrillator (ICD) National Coverage Determination (NCD 20.4) through a February 15, 2018 Final Decision Memo.

On February 15th, CMS rescinded Transmitted 211 and replaced it with Transmittal 213. The only change made in the Transmittal was to change the implementation date from February 26, 2019 to March 26, 2019 (for MAC local edits). All other information remained the same.

The delay in implementation afforded providers an opportunity to make last minute adjustments to their systems and/or provide additional education to key stakeholders to ensure compliance with the NCD revisions. Following is a summary review of the significant changes in the NCD revision:

  • MRI has been added to the list of imaging studies that can be performed to evaluate left ventricular ejection fraction (LVEF);
  • At least three months of Optimal Medical Therapy (OMT) is a new requirement for patients who have severe non-ischemic dilated cardiomyopathy and no personal history of sustained ventricular tachyarrhythmia or cardiac arrest due to ventricular fibrillation;
  • A Shared Decision Making (SDM) interaction must happen prior to ICD implantation for certain patients. (Note: This includes all patients receiving an ICD for primary prevention);
  • The Class IV heart failure requirement for cardiac resynchronization therapy (CRT) has been removed,
  • An exception to the waiting period has been added for patients meeting CMS coverage requirements for cardiac pacemakers, and who meet the criteria for an ICD;
  • An exception to the waiting period has also been added for patients with an existing ICD and qualifying replacement; and
  • There is no longer a data collection requirement (e.g. a registry).

Additional information about the NCD Revisions and Effective and Implementation dates can be found in related Wednesday@One articles (http://mmplusinc.com/news-articles/item/ncd-20-4-implantable-cardiac-defibrillators-icds and http://mmplusinc.com/news-articles/item/effective-dates-of-new-icd-ncd-rules).



22nd – MLN Article: Billing for Hospital Part B Inpatient Services

CMS released MLN Matters Article MM11181 titled “Billing for Part B Hospital Inpatient Services” on March 22, 2019. This is not a new rule at all, but has been around since 2013. In the 2014 Inpatient Prospective Payment System (IPPS) Final Rule CMS-1599-R, effective October 1, 2013, CMS first allowed the billing of certain Part B services when an inpatient hospital admission is determined to not be reasonable and necessary for payment under Medicare Part A. Prior to this rule change, the billing of Part B inpatient services on a 12x type of bill (TOB) was limited to those occasions when the Medicare beneficiary did not have Part A coverage or the Part A benefits were exhausted.

You can read more about this rule at http://www.mmplusinc.com/news-articles/item/billing-for-part-b-hospital-inpatient-services.

 22nd – Palmetto GBA Published Lumbar Spinal Fusion Local Coverage Determination (LCD L37848)

The Jurisdiction J MAC (Alabama, Georgia and Tennessee) transition from Cahaba GBA to Palmetto GBA was complete as of February 26, 2018. Prior to the transition, Cahaba GBA had a Spinal Fusion LCD. LCDs from both MACs were consolidated during the transition. Cahaba’s Spinal Fusion LCD (L35942) did not make the cut leaving the Jurisdiction J MAC without a Spinal Fusion LCD, until now.

Palmetto GBA announced a new Lumbar Spinal Fusion LCD (L37848) in their March 22nd Daily e-Newsletter. This LCD’s original effective date is for services performed on or after May 6, 2019.

You can find a compare of Cahaba’s and Palmetto’s Spinal Fusion LCDs in a related article at http://www.mmplusinc.com/news-articles/item/palmetto-gba-publishes-new-spinal-fusion-lcd.

26th – Transcatheter Aortic Valve Replacement (TAVR) Proposed Decision Memo (CAG-00430R)

On March 26, 2019 CMS published a Proposed Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430R). In a related CMS Press Release CMS noted they would continue to cover TAVR under Coverage with Evidence Development (CED) when furnished according to an FDA-approved indication.





Patients over Paperwork Newsletter includes Modernization Update for Local Coverage Determinations

Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.  In carrying out this internal process, CMS is moving the needle and removing regulatory obstacles that get in the way of providers spending time with patients.

The April 2019 Newsletter includes steps taken to Modernize the Local Coverage Determination (LCD) Process.

16th - National Healthcare Decisions Day (NHDD)

NHDD is an initiative of The Conversion Project. This Project is “dedicated to helping people talk about their wishes for end-of-life care.” According to the NHDD website, this day “exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.”

Effective January 1, 2016, the CMS began paying for Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). ACP is a face-to-face service between a physician (or other qualified health professional) and the patient discussing advance directives with or without completing relevant legal forms.

16th - First National Care Transitions Awareness (NCTA) Day

April 16, 2019 marked the first National Care Transitions Awareness (NCTA) Day. This day is meant to raise awareness about the importance and value of care transitions and care coordination. In an FAQ Session posted on the CMS Quality Improvement Organization (QIO) website, Jean Moody-Williams and Dr. Adebola Adeleye shared the inspiration behind NCTA Day.

30th – Beneficiary and Family Centered Care Quality Improvement Organization 12th Scope of Work Contract Awards

On April 30th KEPRO and LIVANTA were again awarded the Beneficiary and Family Centered Care (BFCC-QIO) contracts for the 12th Scope of Work (SOW) that will run from 2019-2023. You can read more about the new SOW in a related article at http://www.mmplusinc.com/news-articles/item/bfcc-qio-updates-2.



8th – Temporary Pause of BFCC-QIO Short Stay and Higher Weighted DRG Reviews

The Centers for Medicare & Medicaid Services (CMS) temporarily paused the performance of both Short Stay reviews and Higher Weighted Diagnosis-Related Group (HWDRG) reviews by the BFCC-QIOs. Short Stay reviews and HWDRG reviews will stop for a brief time beginning on May 8, 2019.

CMS took this action to procure a new BFCC-QIO contractor. Two BFCC-QIOs have done HWDRG reviews since 2014 and Short Stay reviews since 2015 for all 50 states and 3 territories. Going forward, Short Stay reviews and HWDRG reviews will resume with one national contractor. CMS anticipates a contract award to be issued by the 3rd quarter of calendar year 2019.

Note: As of January 8, 2020, CMS has yet to announce the new national contractor award.

May - CMS Posts LCD Process Modernization Qs & As

This Q&A document describes recent changes to the LCD process.



8th – BFCC-QIO 12th Scope of Work Begins

Effective June 8th the BFCC-QIOs, KEPRO and Livanta transitioned to the 12th SOW.

21st – New TAVR Decision Memo Released

CMS released the new TAVR Coverage Decision Memo. As always with Decision Memos, the requirements are not yet effective until the NCD is updated and implemented. However, NCD revisions generally revert to the effective date of the Decision Memo, which in this case is June 21, 2019. You can read about the changes in a related article at http://www.mmplusinc.com/news-articles/item/cms-releases-new-tavr-decision-memo.



MLN Fact Sheet: Skilled Nursing Facility 3-Day Rule Billing

In July 2019, CMS released this Fact Sheet (ICN MLN9730256.pdf). This Fact Sheet is meant to educate provider about and how to apply the 3-day rule and includes the following information:

  • Background about the 3-day rule,
  • Communicating Medicare SNF Services Coverage Rules,
  • Medicare SNF Claims Processing,
  • Financial Responsibility for SNF Services When There is No 3-Day Qualifying Inpatient Stay, and
  • Available Resources.


2nd – FY 2020 IPPS Final Rule Released

CMS posted a Fact Sheet indicating the CY 2020 IPPS Final Rule (CMS-1716-F) had been finalized. The following table highlights key policy changes and provides links to related MMP articles.

Finalized Policy ChangesLink to Related MMP, Inc. Article
MS-DRG Changes http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-final-rule-part-2-ms-drgs
ICD-10-CM Diagnosis Code Severity Changes http://www.mmplusinc.com/news-articles/item/fy-2020-ipps-final-rule-part-1
New Technology Add-On Payments http://www.mmplusinc.com/news-articles/item/ipps-fy-2020-final-rule-part-3-new-technology-add-on-payments

7th – Chimeric Antigen Receptor (CAR) T-Cell Therapy Final Decision Memorandum

On August 7, 2019, CMS released a Final Coverage Decision Memorandum concerning CAR-T Therapy for Cancers.  Per the memo, CMS covers autologous treatment for cancer with T-cells expressing at least one chimeric antigen receptor (CAR) when:

  • Administered at healthcare facilities enrolled in the FDA risk evaluation and mitigation strategies (REMS), and
  • Used for either an FDA-approved indication (according to the FDA-approved label for that product), or
  • Used for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

The policy also continues coverage for routine costs in clinical trials that use CAR T-cell therapy as an investigational agent that meet the requirements listed in NCD 310.1.

8th – FY 2020 ICD-10-CM Official Guidelines for Coding and Reporting Now Available

“These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself… The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

The Guidelines are available on the CDC website at https://www.cdc.gov/nchs/icd/icd10cm.htm or the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM. Also, you can read about specific changes in a related article at http://www.mmplusinc.com/news-articles/item/happy-9th-clinical-documentation-integrity-week.



24th – New ICD-10-CM Code for Vaping-Related Disorder to be implemented April 1, 2020

In response to the recent occurrences of vaping related disorders and in consultation with the World Health Organization (WHO) Framework Convention on Tobacco Control, the WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) was convened to discuss a diagnosis code for vaping related illness for immediate use.

As a result of this meeting, a new International Classification of Diseases, Tenth Revision (ICD-10) emergency code has been established by WHO. The code became valid for immediate use as of September 24, 2019.

  • U07.0, Vaping-related disorder

The full announcement as well as the ICD-10-CM Official Coding Guidelines Supplement Vaping Coding Guidance 2019 can be found on the CDC website at https://www.cdc.gov/nchs/icd/icd10cm.htm.

26th – CMS Releases Discharge Planning Conditions of Participation (CoP) Final Rule

Almost four years after the Proposed Rule and over 200 public comments later, CMS finally released this Final Rule. The rule became effective on Friday November 29, 2019. To date, hospitals nationwide are still waiting on the sub-regulatory guidance that CMS instructed several times in the Final Rule would be provided.

MMP wrote the following three articles related to the Final Rule:  



1st – New Round of Medicare Readmission Penalties His 2,583 Hospitals

Will your hospital be subject to a Readmission Penalty in FY 2020? Kaiser Health News (KHN) is a nonprofit national health policy news service and on October 1st, Jordan Rau of KHN released an article discussing the Medicare Hospital Readmission Penalties for FY 2020. The article includes a link enabling you to trend a hospitals Readmission Penalties from 2015 through 2020. You can access the article at https://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals/.

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.

17th – VAPING Coding Guidance from the CDC

The first possible cases of a vaping related illness were reported to the CDC on August 1st, 2019. In response to reports of illness, the CDC, FDA, State and Local Health Departments, Clinical and Public Health Partners have been actively investigating a multi-state outbreak of lung injury associated with use of e-cigarettes, or vaping, products. The vaping related illness has been named EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury).

On October 17, 2019, the CDC released a supplement to the ICD-10-CM Official Coding Guidelines. This supplement:

  • Provides guidance related to the 2019 health care encounters and deaths related to EVALI.
  • Is intended to be used in conjunction with current ICD-10-CM classifications and the ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2019.
  • May not represent all possible reasons for health care encounters related to e-cigarette, or vaping, product use.

24th – Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N

On October 24, 2019, CMS released MLN Matters Article SE19024 concerning billing instructions for beneficiaries enrolled in MA plans for CAR T-cell therapy. As a result of the significant cost of this therapy, effective August 7, 2019, original fee-for-service Medicare will pay for CAR T-cell therapy for cancer obtained by beneficiaries enrolled in Medicare Advantage (MA) plans when the coverage criteria outlined in the decision memorandum is met. This applies for Calendar Years (CYs) 2019 and 2020 only.

29th – Hospital Value-Based Purchasing Program Results for FY 2020

The law requires CMS to reduce a portion of the base operating Diagnosis-Related Group (DRG) payment amounts otherwise applicable to a participating hospital for each Medicare Fee-for-Service discharge by two percent (2%). The estimated sum total of these reductions is redistributed to participating hospitals based on their performance. CMS estimates the total amount available for FY 2020 is approximately $1.9 billion. In an October 29th Fact Sheet, CMS announced they had posted the adjustment factor for each participating hospital in Table 16B for FY 2020.

30th – Detailed Notice of Discharge (Hospital Notice) Form October 31, 2019 Expiration Date

CMS provided the following update on the Hospital Discharge Appeal Notices webpage:

  • October 30, 2019: The currently available Detailed Notice of Discharge (hospital notice) has an expiration date of October 31, 2019. This notice is now going through the Paperwork Reduction Act clearance process. The currently available hospital notice is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice. Hospitals following this direction are fully compliant with our requirements.



1st – OPPS Final Rule for Calendar Year 2019 Released

CMS posted a Fact Sheet indicating the CY 2020 OPPS Final Rule (CMS-1717-FC) had been finalized. The following table highlights key policy changes and provides links to related MMP articles.

Finalized Policy ChangesLink to Related MMP, Inc. Article
Clinic Visits and Drug Payment Policies http://www.mmplusinc.com/news-articles/item/the-2020-opps-final-rule-clinic-visits-and-drug-payment-policies
Inpatient Only List, the 2-Midnight Rule & ASC Covered Surgical Procedures http://www.mmplusinc.com/news-articles/item/calendar-year-2020-opps-final-rule
Supervision of Therapeutic Services and Prior Authorizations http://www.mmplusinc.com/news-articles/item/2020-opps-final-rule-supervision-of-therapeutic-services-and-prior-authorizations

8th – 2020 Medicare Parts A & B Premiums and Deductibles

A CMS Fact Sheet released the 2020 premiums and deductibles. The following table compares 2020 deductible amounts to 2019.

 CY 2019CY 2020
Standard Monthly Premium for Medicare Part B enrollees $135.50 $144.60
Annual Deductible for Medicare Part B Beneficiaries $185 $198
Inpatient Hospital Deductible $1,364 $1,408
Daily Co-Insurance for 61st – 90th Day $341 $352
Daily Co-Insurance for Lifetime Reserve Days $682 $704
Skilled Nursing Facility Co-Insurance $170.50 $176
Source: CMS November 8, 2019 Fact Sheet at https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-deductibles

15th – Hospital Price Transparency Requirements

In a CMS Fact Sheet, CMS announced that “the policies in the final rule will further advance the agency’s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States.” You can read more about the Final Rule in two related MMP articles:


2nd – Palmetto GBA Medical Review Targeted Probe & Educate (TPE) Q&As

Palmetto GBA posted Q&A's from their most recent TPE Teleconference. Following is one Q&A that we have been asked by some our clients:

“Question: What is the established threshold for determining if the provider should move on to the next round?

Answer: We establish TPE rates based upon our interactions with CMS and some other demonstrations that we've done. We chose a 20 percent threshold because it's in line with those demonstrations. We have some other MAC partners who are using a much lower percent threshold, but we feel 20 percent is agreeable for both the MAC and the provider community. The Results Letter at the end of the round alert a provider whether they are going to be removed or advance to the next round. The report contains your claim and charge determination rates and the claim(s) outcomes table attached to letter. You may look at each individual claim reviewed and look in your system to see the actions that were taken. All that information composed in education letter lets you know how the round went for you, if you're going to be progressed to the next round or not, and you will receive a follow-up notification before the second and third round begin.”

3rd – Medicare Outpatient Observation Notice (MOON) Form Expiration Date December 31, 2019

CMS provided the following update on the CMS MOON webpage:

  • December 3, 2019:The currently available MOON has an expiration date of December 31, 2019. This notice is now going through the Paperwork Reduction Act clearance process. The currently available MOON is covered under an extension and hospitals should continue using the current notice until CMS publishes the updated notice. Hospitals following this direction are fully compliant with our requirements.

3rd – CMS Hospital Price Transparency Final Rule Call

CMS held a Final Rule call on Tuesday December 3rd. You can access the presentation slide deck, an audio recording of the call and transcript on the CMS website at https://www.cms.gov/outreach-and-educationoutreachnpcnational-provider-calls-and-events/2019-12-03.


HAPPY 2020!

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment (PAT) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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