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May 2020 MAC Talk

Published on 

Tuesday, June 16, 2020

Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, I wanted to alert readers about Change Request (CR) 11695. This CR was published on May 15, 2020 and provides details regarding revisions to the Targeted Probe and Educate (TPE) Program in the Medicare Program Integrity Manual (IOM 100-08), chapter 3, section 3.2.5.


The TPE review strategy includes instruction to the MACs to refer providers/suppliers failing three rounds of TPE to the CMS for next steps. Prior to the release of CR 11695 there were no references available from CMS to the potential for more than three rounds of TPE review. As a result, CMS is revising the TPE language in section 3.2.5 in Chapter 3 of the Program Integrity Manual (Pub. 100-08) to include the possibility of additional rounds of TPE review.

The following language has been added to the guidance in section 3.2.5D. Post-Probe Activity – Final Results Letter:

“For providers/suppliers who will be released from review due to meeting the established error rate goal, results letters shall indicate that the provider is being released from review for one year, with the caveat that additional review may occur at any time should the MAC identified changes in billing pattern. For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the following language to remind providers of 42 CFR §424.535.

“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.””


May MAC Talk: The Local Scene


May 19, 2020: NGS Botulinum Toxin Injections for Chronic Headaches CERT Findings

This NGS article provides a list of the most common reasons the CERT determined there was insufficient documentation for the service provided.

  • Missing evaluation to support patient is having 15 or more headaches a month for at least three months,
  • Missing documentation to support a significant decrease in the number and frequency of headaches per month,
  • Missing documentation to support the amount of waste for the botulinum toxin, and
  • Missing electronic signature or legible signature.

You can learn more about NGS’ requirements for Botulinum Toxin Injections in their Local Coverage Determination (LCD): Botulinum Toxins (L33646) and related Coverage Article (A52848). As a reminder, Botulinum Toxin Injections is one of the procedures that will require a prior authorization beginning with dates of service on or after July 1, 2020. You can read more about the Prior Authorization Program for certain outpatient department procedures in a related MMP article.

May 20, 2020: First Coast Guidance for Submitting Prior Authorization for Certain Outpatient Department (OPD) Services

First Coast provided guidance in their May 20th eNews about the elements that must be submitted in a Prior Authorization Request (PAR) for services requiring one as part of the new Prior Authorization Program set to begin on July 1, 2020. First Coast is set to begin accepting PARs for these services as of today June 17, 2020, for services to be provided on or after July 1, 2020. You can read the full announcement under the Medical Review tab on the First Coast website.

May 27, 2020: Palmetto GBA Daily Newsletter: Medicare Secondary Payer (MSP) Basics Modules

Palmetto GBA posted information about an educational series available on their website on MSP guidelines. They note in the announcement that “this series provides guidance with condition payment provisions and common MSP billing questions.” They encourage you to review the modules with your staff.

May 28, 2020: CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Open Door Forum (ODF)

The CMS held a special ODF to go over the basics of this program. The presentation was followed by a very robust Q&A session. The slides from this session as well as an Operational Guide and FAQs document have been added to the downloads section of the CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webpage.

June 5, 2020: Noridian Article: SNF PDPM Assessment Diagnosis COVID-19 ICD-10 Code U07.1 and SNF Waiver to Extend Benefit Period

In this article, Noridian offers the following guidance for providers experience claims processing problems related to the April 1, 2020 effective date of applying the new U07.1 – 2019-nCoV acute respiratory disease ICD-10-CM code when the 5-day assessment window overlaps March into April dates of service:

“Based on the following guidance from the CMS PDPM FAQs Question 1.8 that states ‘Is it required that the principal diagnosis on the SNF claim match the primary diagnosis coded in item I0020B? While we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement'. Providers with a 5-Day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification. However, the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and is valid in the month of March.”

This article also provides details regarding the impact on typical billing and assessment processes when a beneficiary qualifies for renewed SNF benefits under the SNF waiver as a result of the COVID-19 pandemic.

June 8, 2020: WPS GBA Medicare eNews: Intravenous Immunoglobulin Therapy (IVIG)

WPS posted the following information regarding IVIG therapy in their June 8th eNews:

“Do you bill for IVIG? Before you bill for these services, read the Local Coverage Article: Billing and Coding: Immune Globulins (A57554). Why read the article? The Centers for Medicare & Medicaid Services (CMS) identified a potential vulnerability in the WPS GHA jurisdictions. Providers should follow the guidance in the local coverage article if they expect payment.”

June 12, 2020: Novitas eNews: Prior Authorization Hospital Outpatient Department Services (OPD) FAQs

Novitas posted this FAQ document in their June 12th eNews indicating the document had been developed to include questions and answers posed during their webinar about the PA program for certain hospital OPD services.

June 15, 2020: WPS GHA Medicare eNews: Appropriate Application of Modifier for Injections to Manage Age-Related Macular Degeneration (AMC)

WPS included the following information in their June 15th Medicare eNews:

“Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss that affects millions of Americans. Medicare Part B covers age-related macular degeneration (AMD) treatments, which include:

  • Aflibercept (Eyelea)
  • Ranibizumab (Lucentis)
  • Brolucizumab (Beovu)
  • Bevacizumab (Avastin)

Recent claim review data showed that claims submitted with anti-vascular endothelial growth factor (anti-VEGF) drug codes did not include an appropriate modifier identifying the eye being treated resulting in claim denials. For more information, see the full article on our website.”

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.