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August 2020 MAC Talk

Published on 

Tuesday, August 25, 2020

Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, there have been updates issued about the new ABN form and the resumption of Medicare Contractor Medical reviews since first discussed in the July 2020 MAC Talk article.


New Fee-For-Service (FFS) Advanced Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131

Last month’s MAC Talk article alerted you to the June 24th modification found on the FFS ABN CMS webpage indicating form CMS-R-131 had been approved and use of the form was set to be mandatory on August 31, 2020.

On August 3rd CMS once again modified this CMS webpage further delaying the mandatory implementation date for the new ABN form:

“The ABN, Form CMS-R-131, and instructions have been approved by the Office of Management and Budget (OMB) for renewal.  Due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN, Form CMS-R-131 (exp. 6/30/2023).  At this time, the renewed ABN will be mandatory for use on 1/1/2021.  The renewed form may be implemented prior to the mandatory deadline.  The ABN form and instructions may be found in the download section.”


Medical Review during the COVID-19 Public Health Emergency

On July 6, 2020, CMS released the document Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). The very first FAQ addresses Medicare Fee-for-Service medical reviews indicating CMS’s intent to allow the resumption of medical reviews beginning on August 3, 2020, “regardless of the status of the public health emergency.”

On August 4th Palmetto GBA provided additional detail about the resumption of medical reviews. Specifically,

  • MACs are resuming post-payment reviews of items/services provided prior to March 1, 2020,
  • The Targeted Probe and Educate (TPE) program will restart later, and
  • MACs will continue to offer detailed review decisions and education as appropriate.

On August 19th Palmetto GBA posted a related article Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review. In addition to details about receiving and responding to requests, this article provides a link to active service specific post-payment medical review topics for Part A inpatient and outpatient hospital services and Part B Physician Services.


August MAC Talk: The Local Scene


July 21, 2020: Noridian JE Article: Part B Provider Responsibility for Prior Authorization for Certain Hospital Outpatient Department Services

At the time of this month’s MAC Talk article, the Prior Authorization program is almost into its third month. Here at MMP we have had several clients seeking clarification on who is responsible for obtaining the prior authorization. The following comment and CMS response is excerpted from page 61453 of the Final Rule (CMS-1717-FC):

Who is Responsible for Obtaining Prior Authorization?

“Comment: We received comments with general questions regarding the proposed process such as who will be responsible for obtaining the prior authorization, that is, the physician or the hospital, and whether all related claims will be denied if prior authorization is not obtained. Some commenters expressed concern that physicians could be denied payment for services rendered if a hospital fails to submit a prior authorization request or fails to notify the physician of a denial.

Response: As noted above, this prior authorization process is being adopted under section 1833(t)(2)(F) of the Act, which is specific to OPD services, which provides payment only to hospital outpatient departments. In light of the different arrangements that could exist in different hospitals, we determined that enabling either the physician or the hospital to submit the prior authorization request on behalf of the hospital outpatient department was the best approach, though the hospital ultimately remains responsible for ensuring this condition of payment is met.

In an article posted on July 21, 2020 by Noridian Healthcare Solutions, the JE MAC, they indicated the following regarding the physician’s involvement in the prior authorization process:

“Noridian has been receiving requests for prior authorizations from Part B providers, who bill on the CMS-1500 form.

This program is for outpatient hospital services billed on a UB-04 form, with type of bill 13X. Providers who bill on a CMS-1500 form should not submit prior authorization requests for the OPD services, because it is the facility’s responsibility to send in the request. A valid prior authorization request must contain the Part A Provider Transaction Access Number (PTAN), which is six digits. Requests that come from a physician’s office will be rejected.

It is the physicians’ responsibility to assist the facility by ensuring copies of the patient’s medical records are available for the following services:

  • Blepharoplasty
  • Botulinum Toxin Injections - use for chronic migraine treatment
  • Panniculectomy
  • Rhinoplasty
  • Vein Ablation.”

Noridian published the following subsequent article on August 18, 2020:

“While this prior authorization process is applicable to hospital OPDs, as specified in CMS-1717-FC, CMS allows the PA request to be sent by the physician/practitioner on behalf of the hospital OPD. If a PA request submitted by the physician/practitioner includes all necessary hospital OPD information, it is considered to be sent on behalf of the hospital OPD.

Please visit our Prior Authorization for OPD Services Webpage to learn about submitting requests. Last Updated Aug 18, 2020”  


July 29, 2020: Palmetto GBA JJ Part B Claims Payment Issue (CPI) Regarding Stelara®

Palmetto GBA has identified an issue with Stelara®. Specifically, Stelara® billed with HCPCS codes J3357 denying as a self-administrated drug (SAD) when it should be excluded as indicated in the SAD Exclusion List Article #A53066. The issue affected claims with dates of service on or after April 20, 2020. As of July 29th Providers are asked to hold new claims for this HCPCS code until this CPI is updated, indicating editing has been updated. As of August 24, 2020, the status of this issue was the needed updates and adjustments were still pending.


August 3, 2020: Noridian Telehealth and Virtual Visits – During COVID-19 Webinar – September 17, 2020

Noridian Healthcare Solutions, the Medicare Administrative Contractor for jurisdictions E and F, Provider Outreach and Education (POE) staff will be hosting a webinar on September 17, 2020 at 1 p.m. PT. Topics for this session includes:

  • Telehealth information
  • Service Listings
  • Waiver Changes
  • Eligible Providers
  • Billing Part A and Part B
  • Other Telecommunication Services, and
  • Questions and Answers


August 5, 2020: Who are the Medical Directors for Palmetto GBA?

Palmetto GBA posted an article highlighting their Medical Directors. Information about each of the Medical Directors includes their specific responsibility at Palmetto GBA (i.e. accountable for coverage policy activities, Director of the MolDX program) and details about their professional background.


August 7, 2020: COVID-19 FAQs on Medicare Fee-for-Service (FFS) Billing: Condition Code 44 FAQ

At the time this article was written this CMS FAQ Document was last updated on August 7th when a question regarding the use of Condition Code 44 was answered by CMS.

“Question: CMS is waiving the entire utilization review (UR) condition of participation at 42 CFR 482.30, which requires that a hospital must have a UR committee with a UR plan that provides for review for Medicare and Medicaid patients with respect to the medical necessity of the admissions to the institution, duration of stays, and professional services furnished, including drugs and biologicals. Does that mean that the use of Condition Code 44 is waived as well?

Answer: No, Condition Code 44 still applies. Although CMS has waived the UR condition of participation at 42 CFR 482.30, this does not mean that if a beneficiary’s status is changed from inpatient to outpatient and there is a determination that the inpatient admission does not meet the hospital’s inpatient criteria, that the hospital may bill an inpatient claim. Hospitals should report Condition Code 44 as appropriate.

New: 8/7/20”


August 14, 2020: First Coast Post-Payment Service-Specific Reviews

First Coast posted the following information about post-payment service-specific reviews:

“First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. Medical review of claims helps to ensure that Medicare pays for services that are covered, correctly coded, and medically reasonable and necessary.

First Coast performs data analysis on a regular basis on all services billed to Medicare to identify services that are frequently not billed and coded correctly per Medicare guidelines. Post-pay service-specific reviews are performed based on results of a widespread data analysis that focuses on specific topics. If you bill Medicare for these services, you may receive an additional development request (ADR) letter asking for documentation. This allows First Coast to validate that you have billed the services correctly according to Medicare guidelines. Once the ADR is received, you will have 45 days to respond to the request with the supporting medical record documentation. The review will be completed within 60 days of receipt of the documentation. When the review is completed, you will be notified of the results.”


August 17, 2020: WPS Billing and Coding Article: Nerve Blocks for Peripheral Neuropathy (A57598) Updated

WPS has updated their Local Coverage Article (A57589), “Billing and Coding: Nerve Blocks for Peripheral Neuropathy” to include ICD-10-CM codes that do not support medical necessity effective September 13, 2020. Use the Local Coverage Determination (LCD) and Billing and Coding/Policy Article Lookup to access our Billing and Coding/Policy Articles.


August 18, 2020: Palmetto GBA Posts Part A Ask the Contractor (ACT): Comprehensive Error Rate Testing FAQs from August 13, 2020 Call

Sandra Booker, Senior Provider Education Consultant for Palmetto GBA noted that “the ACT is intended to open the communication channels between the provider community and Palmetto GBA.” The August 13th call focused on providing education to and answering questions from providers regarding the Comprehensive Error Rate Testing (CERT) program.

One question asked during the call was related to whether or not the CERT is currently performing reviews or are reviews on hold due to COVID-19. Palmetto GBA’s response to the question was that “CMS has allowed them to start the process. Palmetto GBA is not doing the TPE process as of yet. We have not been directed by CMS to continue TPE. But all this information should be published on the Palmetto GBA web site. CERT is now sending letters, so you should be receiving those soon.”


August 21, 2020: Palmetto GBA’s Outpatient Department Prior Authorization Teleconference on September 16, 2020

Palmetto GBA posted an article announcing their next teleconference to provide up-to-date information as well as a chance for providers to ask questions about the Outpatient Department Prior Authorization Program. The teleconference is scheduled from 11 a.m. to 12 p.m. ET. You will find the dial in number and conference ID in the article.


August 21, 2020: Noridian Article – Incorrect Patient Status One of Most Common Errors on Part A Claims

Noridian indicates in this article that incorrect patient status is one of the most common errors on Part A claims. This article includes links to a Quick Reference Guide Patient Status webpage and Quick Reference Billing Guide Condition Codes webpage. Also, as a reminder, an incorrect patient status could have a negative impact for patient admissions assigned a DRG that is included in the post-acute care transfer (PACT) policy. You can read more about the PACT Policy in a related MMP article.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
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 Tool.

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.