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November 2020 MAC Talk

Published on 

Wednesday, November 18, 2020

October 26, 2020: Novitas Article – Billing Outpatient Observation Services

Novitas Solutions posted the article Billing Outpatient Observation Services which defines outpatient observation, clarifies that observation is a service not a status, discusses the physician order for observation, reminds providers about delivery of the Medicare Outpatient Observation Notice (MOON), covers observation hours and billing requirements, and general reminders about observation.


October 29, 2020: CGS Article – Use of Human Amniotic Based Products

CGS posted the following information about the use of human amniotic based products:

“CGS has seen multiple claims where cellular and/or tissue-based products (CTPs), specially micronized or particulated human amniotic membrane and/or placental tissue matrix, are being injected into joints and tissues for osteoarthritis, plantar fasciitis, and other complaints. The labeled indications for these products are to treat non-healing wounds and burn injuries and are intended for external application to the wound. CGS covers the application of CTPs for ulcers or wounds as outlined in the LCD L36690 Wound Application of Cellular and/or Tissue-Based Products, Lower extremities. Use of these products topically or as an injection outside of the labeled use and as defined in L36690 is considered off-labeled and may not be a covered service.

Off label usage may be reviewed pre-pay or on appeal. The appeal request should include medical record documentation supporting the unique usage and include full-text copies of evidence-based, peer-reviewed articles from core medical journals supporting such use. Such articles should include the results of robust CMS and/or FDA approved clinical trials and/or meta-analysis that support any additional indications.”


November 2, 2020: First Coast Service Options Prior Authorization Program Q&As Modified

First Coast most recently modified their list of Q&A's related to the CMS Prior Authorization (PA) program for certain hospital outpatient department (OPD) services that went into effect in July. They note the document consists of questions and answers posed during their educational webinars.


November 3, 2020: Noridian JE and JF Local Coverage Determination (LCD) for Treatment of Osteoporotic Vertebral Compression Fracture Finalized

Noridian announced that their LCD and Local Coverage Article (LCA) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) has completed the Open Public Meeting and Contractor Advisory Committee (CAC) comment period and is now final.

  • Noridian JE
  • LCD L34228 / Article A56572
  • Effective Date: January 10, 2021
  • Noridian JF
  • LCD L34160 / Article A56573
  • Effective Date: January 10, 2021


November 5, 2020: Noridian JF Article: Hospital Discharge Status Assistance

Nordian JF reminds providers in this article that “overpayment or underpayment of Medicare claims may result when facilities incorrectly bill a discharge status code.” Included in this article are tips to getting the discharge status correct and links to a quick reference guide of patient status codes and MLN Article SE1411 – Clarification of Patient Discharge Status Codes and Hospital Transfer Policies.


November 6, 2020: Noridian Article: Computed Tomography Cerebral Perfusion Analysis (CTP) Final LCD and Billing and Coding Article

Effective December 13, 2020, Noridian’s LCD and related Coverage Article will be effective meaning that CTP will be considered medically reasonable and necessary in patients with small acute ischemic stroke (AIS) caused by unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers.

  • Noridian JE
  • LCD L38709 / Article A58223
  • Effective Date: December 13, 2020
  • Noridian JF
  • LCD L38700 / Article A58225
  • Effective Date: December 13, 2020


November 6, 2020: The SMRC Goes Green

Noridian announced that the Supplemental Medical Review Contractor (SMRC) has started mailing additional documentation requests in green envelopes to assist with proper notification review. Noridian advises providers to let you mail department know of this change to allow requests be received by the appropriate departments and handled timely. Palmetto GBA also included a similar announcement in their November 10th Daily Newsletter.

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.