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June 2022 Medicare Transmittals and Proposed Rules
Published on Jun 29, 2022

June 2022 Medicare Transmittals and Proposed Rules

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022
  • Article Release Date: May 9, 2022 – Revised June 21, 2022
  • What You Need to Know: This article details information about newly available codes, separate NCD coding revisions and coding feedback. It was updated on June 21, 2022, to reflect a revised Change Request (CR) 12705. The substance of the article did not change. NCDs updated includes:
    • NCD 20.31 Intensive Cardiac Rehabilitation (ICR) Programs,
    • NCD 20.31.1 Pritikin Program,
    • NCD 20.31.2 Ornish Program for Reversing Heart Disease,
    • NCD 20.31.3 ICR Benson-Henry Program,
    • NCS 90.2 Next Generation Sequencing (NGS),
    • NCD 160.18 Vagus Nerve Stimulation (VNS),
    • NCD 180.1 Medical Nutrition Therapy (MNT), and
    • NCD 270.3 Blood Derived Products for Chronic Non-healing Wounds
  • MLN MM12705: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2021 Update
  • Article Release Date: May 18, 2021 – 2nd Revision June 22, 2022
  • What You Need to Know: This MLN was revised to reflect CR 12124 which changed the business requirements for NCD 90.2, Next Generation Sequencing. This change resulted in a new spreadsheet for this NCD by retaining all ICD-10 Not Otherwise Classified (NOC) diagnosis codes that had been proposed for deletion effective July 1, 2022. CMS advised that “Although we’re not moving forward with deleting the aforementioned ICD-10 NOC diagnosis codes from NCD 90.2, we continue to strongly encourage providers and laboratories to make sure they provide the best possible and most specific code on the claim in accordance with the implementation of ICD-10 in 2015. We’ll be monitoring these laboratory claims and may take future action to reinstate removal of these ICD-10 NOC codes.”
  • MLN MM12124: (link)
July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
  • Article Release Date: June 9, 2022 – Revised June 24, 2022
  • What You Need to Know: This article was revised to remove two HCPCS codes from table 3 of the Change Request 12773 reducing the number of new codes from 16 to 14.
  • MLN MM12773: ((link)

Medicare Proposed Rules

On Tuesday, June 21, 2022, CMS published a Special Edition MLN Connects ((link) spotlighting the release of two Calendar Year (CY) 2023 proposed rules:

  • CY 2023 Home Health Prospective Payment System Rule Update and Home Infusion Therapy Services Requirements Proposed Rule (CMS-176-P), and
  • ESRD Facilities: CY 2023 Proposed Rule.

The MLN connects includes links to Fact Sheets highlighting key provisions in each proposed rule. CMS is accepting comments through August 16, 2022, for the Home Health Proposed Rule and August 22, 2022, for the ESRD Facilities proposed rule.

Beth Cobb

FY 2023 ICD-10-CM Official Guidelines for Coding and Reporting
Published on Jun 28, 2022
 | Billing 
 | Coding 
 | Quality 

Did You Know?

The 2023 ICD-10-CM Official Guidelines for Coding and Reporting were posted to the CMS website on June 10, 2022 (link). You can also find the guidelines on the CDC ICD-10-CM webpage (link).

Why It Matters?

It is important to annually review the ICD-10-CM Official Guidelines for Coding and Reporting as “these guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. 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.” As of June 29th, there are only 92 days to become familiar with the October 1, 2022, changes.

Narrative Guideline changes appear in bold text in this document. Following are a few examples of new guidance in FY 2023:

Section 1. A.19 Conventions for the ICD-10-CM – Code assignment and Clinical Criteria

Previous guidance states “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

New for FY 2023, coders are advised that “If there is conflicting medical record documentation, query the provider.”

Section 1.B.14 General Coding Guideline - Documentation by Clinicians Other than the Patient’s Provider

The list of diagnosis considered to be one of the “few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider,” continues to expand. Examples of past additions to this list includes:

    • Body Mass Index (BMI) was one of the first exceptions. • NIH stroke scale (NIHSS) was added to the list for FY 2017. • Social Determinants of Health (SDOH) were initially added in FY 2019. In FY 2021, additional guidance was added regarding this group of Z codes (Z55-Z65) indicating that “patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider.” • Blood Alcohol Level was added to the list for FY 2022.

New for FY 2023, “Underimmunization status” has been added to the list and should only be reported as a secondary diagnosis.

Section 1.B. 16. General Coding Guideline - Documentation of Complications of Care

Previous guidance stated “there must be a cause-and-effect relationship between the care provided and the condition. New for FY 2023, this sentence now goes on to add that “the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code.”

You are further advised to query the provider “if documentation is not clear as to the relationship between the condition and the care or procedure.”

Section C.1.d.9 Chapter-Specific Coding Guidelines – Certain Infectious and Parasitic Diseases – Sepsis, Severe Sepsis, and Septic Shock Infections resistant to antibiotics

New to the Guidelines is the following guidance regarding hemolytic-uremic syndrome associated with sepsis: “If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31, Infection-associated hemolytic-uremic syndrome, as the principal diagnosis. Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses.”

What Can You Do?

As mentioned earlier, reading the guidelines annually is important and is one tool to ensure accurate coding. Remember, this article does not detail all that is new for FY 2023. When reading the guidelines, look for what is new and each time the guidelines tell you to query the provider if documentation is unclear. Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1st start of the 2023 CMS Fiscal Year.

Beth Cobb

June 2022 Medicare Transmittals and Coverage Updates
Published on Jun 22, 2022

Medicare MLN Articles & Transmittals

July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • MLN Release Date: May 31, 2022
  • What You Need to Know: This article includes information about new COVID-19 CPT vaccine and administration codes. You will also find details about new CPT proprietary laboratory analyses (PLA) coding changes and new CPT Category III codes effective July 1, 2022.
  • MLN MM127961: (link)
Update to 'J' Drug Code List for Billing Home Infusion Therapy (HIT) Services
  • MLN Release Date: May 31, 2022
  • What You Need to Know: This article provides information about a new HCPCS drug code for payment beginning July 1, 2022, and updates to the list of home infusion drugs.
  • MLN MM12667: (link)
July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
  • MLN Release Date: June 9, 2022
  • What You Need to Know: Effective July 1, 2022, there is a new CPT Category III Code, newly established HCPCS codes for drugs, biologicals and radiopharmaceuticals and new skin substitute products and low-cost/high-cost group assignment.
  • MLN MM12773: (link)

Revised Medicare MLN Articles & Transmittals

July 2022 Updates to the Hospital Outpatient Prospective Payment System (OPPS)
  • Article Release Date: May 31, 2022 – Revised June 16, 2022
  • What You Need to Know: This article was revised due to CMS rescinding Transmittal 11435 and replacing it with Transmittal 11457 to correct Table 1 in the attachment A, because it was missing some codes.
  • MLN MM12761: (link)

Coverage Updates

Surgical Dressings: Medicare Requirements

Excerpt from May 26, 2022 edition of MLN Connects ((link)

“Medicare covers primary or secondary surgical dressings:

  • When used to protect or treat a wound
  • If needed after you debride a wound
  • You must:
  • Include clinical information in patients’ medical records that demonstrates a reasonable and necessary need for the type and quantity of surgical dressings
  • Evaluate the wound monthly and update the record, unless you document why you can't do a monthly evaluation and how you're monitoring the patient's ongoing use of dressings
  • For more information, see the Surgical Dressings – Policy Article.”
Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease Tracking Sheet

On June 16, CMS posted a Tracking Sheet (link) regarding National Coverage Determination (NCD) 220.6.20 Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease. CMS generated this NCD analysis based on stakeholder feedback during the finalization of the NCD for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease. The purpose of the NCD reconsideration is to determine if the current policy of one PET scan per patient per lifetime should be revised.

Beth Cobb

New RAC Issue: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Published on Jun 15, 2022
 | Billing 
 | Coding 
 | Quality 

Did You Know?

About Obstructive Sleep Apnea (OSA)

According to the National Library of Medicine (link), “Obstructive sleep apnea (OSA) is characterized by episodes of complete or partial collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep. Other symptoms include loud, disruptive snoring, witnessed apneas during sleep, and excessive daytime sleepiness. OSA has significant implications for cardiovascular health, mental illness, quality of life, and driving safety.”

“The short-term prognosis of OSA with treatment is good but the long-term prognosis is guarded. The biggest problem is the lack of compliance with CPAP. Almost 50% of patients stop using CPAP within the first month. Many patients are at risk for adverse cardiac events and stroke. Those patients who do use CPAP regularly do have improved survival compared to those who do not. Further, OSA is also associated with pulmonary hypertension, hypercapnia, hypoxemia, and daytime sedation. In addition, there is a high risk of motor vehicle accidents in these individuals. The overall life expectancy of patients with OSA is lower than the general population.”

For patients not tolerating CPAP, Hypoglossal Nerve Stimulation (HNS) is one available alternative treatment strategy.

About the Inspire® Upper Airway Stimulation (UAS)

The position statement from the American Academy of Otolaryngology (AAO) (2016) states 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.”

Currently, the only FDA approved HNS is the Inspire® Upper Airway Stimulation (UAS) (Inspire® Medical Systems, Inc.). This system is comprised of:

  • a stimulation lead that delivers mild stimulation to maintain multilevel airway patency during sleep,
  • a breathing sensor lead that senses breathing patterns, and
  • a generator that monitors breathing patterns.
  • The system battery life for the implantable components is 7 to 10 years.

There are two external components, including:

  • A patient sleep remote providing a noninvasive means for a patient to activate the generator, and
  • A physician programmer allowing the physician to noninvasively interrogate and confiture the generator settings.

In June 2017, Inspire® Medical Systems, Inc. announced the FDA approval for the next-generation device, Inspire 3028 implantable pulse generator, which includes magnetic resonance (MR) conditional labeling to allow patients to undergo MRI safely. The Inspire 3028 device is 40% smaller and 18% thinner than the current Inspire neurostimulator which received FDA approval in April 2014. Patients can undergo MRI on the head and extremities if certain conditions and precautions are met (Inspire® Medical Systems, 2017). Additionally, the AHI range was extended from 20-65 event/hour to 15-65 events per hour.

Why it Matters?

In 2020, every 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.

Coding and Billing

Effective January 1, 2022, there are three new CPT codes related to implantation, revision, or removal of the HNS system:

  • CPT 64582 (Open implantation of hypoglossal nerve stimulator array, pulse generator, and distal respiratory sensor electrode or electrode array).
  • CPT 64583 (Revision or replacement of hypoglossal nerve stimulator array and distal respiratory sensor electrode or electrode array, including connections to existing pulse generator), and
  • CPT 64584 (removal of hypoglossal nerve rose stimulator array pulse generator, and distal respiratory sensor electrode or electrode array).
First New RAC Issue in 2022

On June 7, 2022, the first approved RAC issue in 2022 was posted to the CMS Medicare Fee-for-Service Recovery Audit Program webpage (link):

  • RAC Issue 0201: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements.
  • 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 obstructive sleep apnea (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.

What Can You Do?

As of June 13th, this newly approved RAC Issue has not been added to the list of issues being reviewed by any of the four Recovery Auditor Regions. If your hospital is providing this service, now is the time to review a few medical records against your MACs coverage requirements to ensure you are following the provisions of the policy and billing and coding article. The RAC issue includes a listing of each of the MACs LCDs and Billing and Coding Articles.

For those in the Palmetto MAC jurisdictions J and M, Palmetto has published an article (link) about HNS that includes links to a hypoglossal nerve stimulator checklist and their LCD.

You can also visit Inspire Medical System, Inc’s Inspire Sleep Apnea Innovations webpage (link). Information available for patients includes:

  • Cost and Eligibility,
  • Patient Stories,
  • FAQ,
  • Fee Events, and
  • A four-question assessment to see if you qualify for this system.

Information available for Healthcare Professionals (link) includes:

  • Indications/Contraindications,
  • A Patient Experience Report,
  • Reimbursement information (Hospital, Physician and Sleep Services Billing Guides),
  • Training and Education Tools, and
  • Digital Health Documents.

July 2022 OPPS Code Updates
Published on Jun 08, 2022
 | Billing 
 | Coding 
 | Quality 

Did You Know?

CMS published the July 2022 update of the Outpatient Prospective Payment System (OPPS) (link). The purpose of the change request (CR) is to describe change to and billing instructions for various payment policies effective July 1, 2022.

Why it Matters?

In related MLN matters article MM12761 (link), CMS advises you to let your billing staff know about these changes, including:

  • New COVID-19 CPT vaccines and administration codes,
  • CPT proprietary laboratory analyses (PLA) coding changes,
  • Advanced Diagnostic Laboratory Tests (ADLTs) under the Clinical Laboratory Fee Schedule (CLFS) changes,
  • New CPT Category III codes effective July 1, 2022,
  • Procedures Assigned to New Technology Ambulatory Payment Categories (APCs),
  • The addition of over the counter (OTC) COVID-19 tests being added to the Comprehensive APC (C-APC) Exclusion List,
  • Drugs, Biologicals, and Radiopharmaceuticals updates,
  • Skin Substitutes changes, and
  • The CMS reminder that “The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the OPPS doesn’t imply coverage by the Medicare Program, but indicates only how the product, procedure, or service may be paid if covered by Medicare. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it’s reasonable and necessary to treat the patient’s condition and whether it’s excluded from payment.”

What Can You Do?

Share this information with the appropriate staff at your facility.

Beth Cobb

Cataract Awareness Month
Published on Jun 01, 2022
 | Billing 
 | Coding 
 | Quality 

Did You Know?

June is cataract awareness month and according to the National Eye Institute (link), most cataracts are age-related, there are no early symptoms of cataracts and later symptoms includes blurry vision, colors that seem faded, sensitivity to light, trouble seeing at night and double vision.

A cataract is diagnosed by a dilated eye exam and the treatment is surgery. Cataract surgery is one of the most common operations in the United States. In fact, more than half of all Americans aged eighty or older either have cataracts or have had surgery to get rid of cataracts.

Why it Matters?

Being a high-volume surgery, means scrutiny by CMS and Medicare Contractors to assure documentation in the medical record supports medical necessity of the procedure.

Recovery Audit Contractors

RAC Issue 0002 cataract removal (link) has been an approved complex review for procedures performed in the outpatient hospital setting and ambulatory surgery centers (ASCs) since February 1, 2017. RACs will review documentation to determine if cataract surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) are included in this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2021 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table D1: Top 20 Service Types with Highest Improper Payments: Part B (link).

The improper payment rate for this surgery was 12.7%. The CERT cites two types of errors, insufficient documentation, and incorrect coding, as being the cause of improper payments. Specifically, the insufficient documentation project improper payment was $190,495,888 and the incorrect coding improper payment was $27,844,602.

Medicare Administrative Contractors (MACs)

Jurisdiction 15 (J15) MAC: CGS

Prior to the COVID-19 public health emergency, the J15 MAC CGS’ Targeted Probe and Educate (TPE) activities included cataract removal reviews. Their last results posted (link) was for reviews completed from January 1, 2020, through March 31, 2020, with a claim error rate in Ohio of 30.8%.

CGS’ review results list documentation that should be included to prevent denials. CGS has also published an cataract extraction with intraocular lens ADR checklist (link) for providers who are submitting medical records for review.

JF MAC: Noridian

In May 2021, Noridian, published a notification of their intent to perform a service specific targeted review of cataract removal (link). Noridian published review findings in November and December of 2021.

The review of claims for Arizona, Utah, Montana, North Dakota, South Dakota, and Wyoming included claims from May 3, 2021, through October 26, 2021. The overall claims error rate was 26.6% and payment error rate was 27%.

Their review of claims for Alaska, Idaho, Oregon, and Washington included claims from May 3, 2021, through November 16, 2021. The overall claim error rate was 71.3% and payment error rate was 70.5%.

In both reviews, claims were denied for the following two reasons:

  • Documentation was not received timely in response to the additional documentation request (ADR), and
  • Documentation did not support medical necessity per LCD requirements.

Noridian’s review results articles includes provider education detailing under what circumstances the surgery would be considered medical necessary and the required medical record documentation to support medical necessity.

Noridian also cites the 45-calendar day requirement for timely submission of documentation by providers.

Supplemental Medical Review Contractor (SMRC)

On February 16, 2022, the SMRC published a notification of their intent to review cataract surgeries performed in the physician office, outpatient hospital and specialty facility clinical access hospitals (link). In the background section of the notification, they note that “this type of surgery has been a topic of interest for the Office of Inspector General (OIG) for a number of years. The OIG looked into surgery in both the outpatient facility and ambulatory service center settings. CMS data reflects a potential vulnerability.”

What Can You Do?

With so many entities focused on reviewing cataract surgery claims, moving forward providers should:

  • Respond to ADRs in a timely manner,
  • Become familiar with medical necessity indications and documentation requirements detailed in Medicare coverage documents (NCDs, LCDs, LCAs),
  • Be aware of who is performing cataract surgery reviews,
  • Read published review results to understand reasons for denials and ways to prevent future denials, and
  • Ensure physicians performing these procedures are also aware of Medicare coverage requirements.

Beth Cobb

May 2022 Medicare MLN Articles and Transmittals Updates
Published on May 25, 2022

Medicare MLN Articles & Transmittals

Section 127 of the Consolidated Appropriations Act: Graduate Medical Education (GME) Payment for Rural Track Programs (RTPs)
  • Article Release Date: April 28, 2022
  • What You Need to Know: Your billing staff needs to be aware of a new definition for RTPs, changes in Section 127 of the Consolidated Appropriations Act (CAA), 2021, and the documentation requirements for hospitals requesting indirect and direct GME rate increases.
  • MLN MM12709: (link)
Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 15 – Ambulance
  • Article Release Date: April 28, 2022
  • What You Need to Know: This article reports an update to the Medicare Claims Processing Manual. It also provides background guidance on how ambulance providers should bill for Medicare Part B ambulance services when a patient dies before the ambulance arrives and when a patient dies after being loaded on the ambulance.
  • MLN MM12707: (link)
Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as Certain Colorectal Cancer Screening Tests
  • Article Release date: April 29, 2022
  • What You Need to Know: Beginning January 1, 2022, CMS began to gradually reduce the coinsurance for any procedure beyond a planned colorectal cancer screening test until the procedure is completely free for dates of service on or after January 1, 2030.
  • MLN MM12656: (link)
Calendar Year 2023 Modifications/Improvements to Value-Based Insurance Design (VBID) Model – Implementation
  • Article Release Date: April 29, 2022
  • What You Need to Know: Information in this article is for hospices, hospitals, and suppliers billing MACs for services provided to Medicare hospice patients enrolled in Medicare Advantage (MA) plans participating in the voluntary Value-Based Insurance Design (VBID) Model’s Hospice Benefit component.
  • MLN MM12688: (link)
Quarterly Update for Clinical Laboratory Fee Scheduled (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
  • Article Release Date: May 5, 2022
  • What You Need to Know: Links in this article will help you find updates pertaining to Advanced Diagnostic Laboratory Tests (ADLTs) and new codes effective July 1, 2022.
  • MLN MM12737: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)---October 2022
  • Article Release Date: May 9, 2022
  • What You Need to Know: There are no policy changes in this ICD-10 quarterly update. Updates do include newly available codes.
  • MLN MM12705: (link)
Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.42
  • Article Release Date: May 9, 2022
  • What You Need to Know: CMS updated the Medicare coverage for pneumococcal vaccinations to align with the Advisory Committee on Immunization Practices (ACIP) recommendations that vary based on patient age and risk factors.
  • MLN MM12723: (link)
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2022 Update
  • Transmittal 11408 (Change Request 12747) Release Date: May 12, 2022
  • What You Need to Know: CR 12747 details information about new HCPCS and CPT codes, new G codes for the 180-day monitoring period for continuous glucose monitoring (CGM), and codes that are no longer valid.
  • Transmittal 11408 (CR 12747): (link)
Elimination of Certificates of Medical Necessity & Durable Medical Equipment Information Forms
  • MLN Release Date: May 12, 2022
  • What You Need to Know: CMS published this Special Edition (SE) article to alert those that bill Durable Medical Equipment (DME) for services and supplies provided to Medicare patients that effective January 1, 2023, CMS will no longer require Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs)
  • MLN SE22002: (link)

Revised Medicare MLN Articles & Transmittals

New Waived Tests
  • Article Release Date: January 18, 2022 – Revised April 27, 2022
  • What You Need to Know: CR 12581 changed the HCPCS code for the Cardinal Health H. Pylori Rapid Test – Whole Blood/Serum Cassette (Whole Blood) to 86318QW. This MLN article was updated to reflect the code change.
  • MLN MM12581: (link)
Update to Chapter 7, “Home Health Services”, of the Medicare Benefit Policy Manual (Pub 100-02)
  • Article Release Date: March 28, 2022 – Revised April 28, 2022
  • What You Need to Know: CR 12615 changed the background and policy sections of the CR’s business requirements and manual attachment. This MLN article was updated to reflect the changes.
  • MLN MM12615: (link)
Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
  • Article Release Date: March 30, 2022 – Revised May 5, 2022
  • What You Need to Know: This article was revised to show that RHCs must include modifier CG on claims for mental health visits via telecommunications.
  • MLN SE22001: (link)

Beth Cobb

May 2022 Coverage Updates, Education Resources, and COVID-19 Updates
Published on May 25, 2022

Coverage Updates

National Coverage Determination (NCD) 210.14 Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
  • Article Release Date: May 3, 2022
  • What You Need to Know: This article details changes that have been made to NCD 210.14 including:
    • Lowering the minimum age for screening,
    • Removing the restriction on who can provide counseling and shared decision-making (SDM), and
    • Removing the requirement that facilities participate in a registry.
  • MLN MM12691: (link)
Proposed Decision Memo for Home Use of Oxygen (CAG-00296R3)

NCD 240.2 Home use of Oxygen was issued by CMS on September 27, 2021. On May 12, 2022 CMS issued a Proposed Decision Memo (link). CMS notes in the Decision Summary they are proposing to amend “the period of initial coverage for these patients from 120 days to 90 days, in order to align with the 90-day statutory time period.”

Medicare Educational Resources

MLN Booklet: Medicare Mental Health

This booklet (link)">link) explains Medicare-covered mental health and substance use services, eligible professionals, Medicare Advantage coverage, Medicare drug plan (Part D) coverage, medical record documentation and coding. March 2022 updates to this booklet includes updated information about telehealth services and new payment information specific to Clinical Nurse Specialists (CNS), Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse-Midwifes (CNMs).

MLN Fact Sheet Medical Record Maintenance & Access Requirements (MLN4840534)

This Fact Sheet (link) provides information on updated documentation maintenance and access requirements for billing services to Medicare patients. It also tells you how long to keep the documentation and who is responsible for providing access. CMS updated this Fact Sheet in April to add information on medical records to support home health referrals.

Biosimilars Curriculum: Resources for Teaching Your Students

CMS provided information about the FDA’s Biosimilar Curriculum Toolkit in the May 12, 2022 MLN Connects newsletter (link). This toolkit can be used to instruct students in medicine, nursing, physician assistant and pharmacy programs.

New Comprehensive Error Rate Testing (CERT) Outreach and Education Task Force PowerPoint

On May 4, 2022, the CERT Medicare Administrative Contractor (MAC) Outreach and Education Task Force (link) posted a PowerPoint detailing the role of the MACs and the CERT Contractor in reducing the error rate.

COVID-19 Updates

April 29, 2022: Counterfeit At-Home OTC COVID-19 Diagnostic Tests

The FDA released a notice (link) indicating they are aware of counterfeit at-home over-the-counter (OTC) COVID-19 diagnostic tests being distributed or used in the United States and advises they should not be used or distributed. This notice provides information to help you determine if you have a counterfeit test. To date, the two products that they have identified as counterfeit are:

  • Counterfeit Flowflex COVID-19 Test Kits, and
  • Counterfeit iHealth COVID-19 Antigen Rapid Test Kits.
May 10, 2022: AHA and Others Urge Continuation of the COVID-19 Public Health Emergency (PHE)

In a letter to HHS Secretary Becerra (link), the American Hospital Association along with several other organizations (i.e., AARP, American Diabetes Association, American Medical and Nurses Associations) urge the PHE be maintained “until we experience an extended period of greater stability and, guided by science and data, can safely unwind the resulting flexibilities.” A little over a week later, there were less than 60 days before the end of the current PHE. As the government has indicated they will provided at least 60 days’ notice prior to ending the PHE, it appears it will continue at least to October 2022.

Beth Cobb

FY 2023 IPPS Proposed Rule: Payment Rates, Relative Weights, New ICD-10 Codes and New Technologies
Published on May 11, 2022
 | Billing 
 | Coding 
 | Quality 

CMS issued a display copy of the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) on Monday, April 18, 2022. This article contains a high-level look at the proposed operating payment rate, quality program proposals, COVID-19 claims impact on setting MS-DRG relative weights, new ICD-10 diagnosis and procedure codes, CMS’ request for comments related to Social Determinants of Health (SDOH) and New Technology Add-On Payments.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use is projected to be 3.2%.

Overall, CMS estimates hospitals payments will increase in FY 2023 by $1.6 billion.

Quality Program Proposals

Like FY 2022, CMS is proposing to suppress or refine several measures in the Hospital Readmissions Reduction Program (HRRP), Hospital-Acquired Condition (HAC) Reduction Program, and Hospital Value-Based Purchasing (VBP) Program.

Due to proposed measure suppression for Hospital VBP Program, CMS has proposed to award all hospitals a value-based payment amount for each discharge that is equal to the 2% withheld. They have also proposed to not impose the payment penalty on any hospitals in FY 2023 due to low performance in the HAC Reduction Program.

One or several proposals related to the HRRP is a proposal to modify all six conditions/procedures specific to the readmissions measures to include a covariate adjustment for history of COVID-19 within one year preceding the index admission, beginning with the FY 2024 program year.

Calculating MS-DRG Relative Weights

CMS notes, in a related Fact Sheet, it is reasonable to assume Medicare beneficiaries will continue to be hospitalized with COVID-19 and current information available the volume of hospitalizations will be fewer than are reflected in the FY 2021 data.

Based on these assumptions, CMS is proposing to calculate relative weights for FY 2023 by:

  • Calculating two sets of relative weights, one including and one excluding COVID-19 claims, and
  • Average the two sets of relative weights to determine the final FY 2023 relative weights.

CMS has also proposed a 10% cap on relative weight decrease from the prior fiscal year.

ICD-10 Diagnosis Codes by the Numbers

There are 1,176 new diagnosis codes (Table 6A). Of these codes, thirty-five codes have been designated as an MCC and one hundred thirty-six codes have been designated as an CC. Following are examples of the types of new codes:

  • Three new acidosis codes (E87.20 acidosis, unspecified, E87.21 chronic metabolic acidosis, and E87.29 other acidosis)
  • Sixty-nine new dementia with manifestations codes,
  • Nine new codes for refractory angina pectoris (i.e., I20.2 refractory angina pectoris),
  • Eighteen new methamphetamines codes including poisoning by, adverse effect of and underdosing of codes,
  • Four hundred seventy-four codes describing electric (assisted) bicycle or motorcycle accidents,
  • Three codes related to COVID-19 vaccination and other immunization status that were effective April 1, 2022, and
  • Three new Social Determinants of Health (SDOH) codes (Z59.82 transportation insecurity, Z59.86 financial insecurity, and Z59.87 material hardship).

Request for Information on Social Determinants of Health

The subset of Z codes describing SDOHs are found in categories Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances).

CMS believes reporting of SDOH Z codes may better determine the resource utilization for treating patients experiencing these circumstances to help inform whether a change to the severity designation of these codes would be clinically warranted.

CMS also notes that, if SDOH Z codes are not consistently reported in inpatient claims data, our methodology utilized to mathematically measure the impact on resource use, as described previously, may not adequately reflect what additional resources were expended by the hospital to address these SDOH circumstances in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring or both, and comprehensive discharge planning.

They are seeking public comment on issues related to SDOHs, including the following questions:

  • How the reporting of certain Z codes – and if so, which Z codes - may improve our ability to recognize severity of illness, complexity of illness, and utilization of resources under the MS-DRGs?
  • Whether CMS should require the reporting of certain Z codes – and if so, which ones – to be reported on hospital inpatient claims to strengthen data analysis?
  • What would be the additional provider burden and potential benefits of documenting and reporting of certain Z codes, including potential benefits to beneficiaries?
  • Whether codes in category Z59 (Homelessness) have been underreported and if so, why? We are interested in hearing the perspectives of large urban hospitals, rural hospitals, and other hospital types regarding their experience. We also seek comments on how factors such as hospital size and type might impact a hospital’s ability to develop standardized consistent protocols to better screen, document, and report homelessness.

ICD-10 Procedure Codes by the Numbers

There are fifty-four new procedures codes (Table 6B). Of these codes:

  • thirty-eight have been designated as O.R. procedure codes,
  • twelve have been designated as non-O.R. procedure codes,
  • nine of the twelve non-O.R. procedure codes were implemented April 1, 2022, and includes new technology codes for COVID-19 vaccines and drugs to treat COVID-19, and
  • four have been designated as non-O.R. procedure codes affecting the DRG assignment.

You can find new ICD-10 diagnosis and procedure codes as well as proposed changes to the MCC and CC lists for FY 2023 in tables available on the CMS IPPS Proposed Rule Home Page.

New Technology Add-On Payment (NTAP) Policy

The NTAP policy provides additional payment beyond the MS-DRG for cases where a CMS designated new technology was used and coded on the claim. Note, this “is not budget neutral and is generally limited to the 2-to 3-year period following the date of the FDA approval or clearance for marketing.”

CMS is proposing a one-year extension of new technology add-on payments for fifteen technologies for which the new technology add-on payment would otherwise be discontinued beginning FY 2022. Collectively in FY 2023, the estimated number of cases for the fifteen technologies is 192,455 and the estimated payment impact is $612,910,746.15.

There are twenty-six applications discussed in the proposed rule for new technologies seeking approval for an add-on payment.

I encourage you to submit comments to CMS. The deadline to submit comments is 5 p.m. EDT on June 28, 2021.


Beth Cobb

FY 2023 IPPS Proposed Rule: Proposed Changes to MS-DRG Classifications
Published on May 11, 2022
 | Billing 
 | Coding 
 | Quality 

CMS issued the FY 2023 IPPS Proposed Rule (CMS-1762-IFC) display copy on Monday April 18, 2021. You can find a high level review of what is being proposed in a related MMP article by clicking here. This article focuses on three proposals in section II. Proposed Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Relative Weights, of the Proposed Rule. Each MS-DRG refinement synopsis includes the potential financial impact if the proposal is finalized.

Calculating the potential financial impact was accomplished through a collaboration with RealTime Medicare Data (RTMD). RTMD’s database currently includes Medicare Fee-for-Service paid claims data for all U.S. states and territories except Kentucky and Ohio. RTMD claims analysis in this article represents Medicare Fee-for-Service paid claims data for CY 2021 in the RTMD footprint

Acute Respiratory Distress Syndrome (ARDS)M

CMS received a request to reassign cases reporting diagnois code J80 (Acute respiratory distress syndrome) as the principal diagnosis from MS-DRG 204 (Respiratory Signs and Symptoms) to MS-DRG 189 (Pulmonary Edema and Respiratory Failure). The requestor noted that in the ICD-10-CM Tabular List of Diseases, per the Excludes 1 note under category J96 (Respiratory Failure, not elsewhere classified) only code J80 should be assigned when respiratory failure and ARDs are both documented. Currently, a principal diagnosis of J80 groups to MS-DRG 204.

CMS data analysis supports that cases reporting ARDS (J80) are more appropriately aligned with the average length of stay and average costs of the cases in MS-DRG 189 and they have proposed to reassign cases with ARDS (code J80) as the principal diagnosis from MS-DRG 204 to MS-DRG 189.

RTMD Claims Analysis

In Calendar Year (CY) 2021, in the RTMD database, there were 255 claims sequenced to MS-DRG 204 (Respiratory Signs and Symptoms) with a principal diagnosis of J80 (ARDS). Based on the CMS FY 2022 Final Rule, the shift from MS-DRG 204 to MS-DRG 189 would result in:

  • An increase in the MS-DRG Relative Weight (R.W.) of 0.4325, and
  • An increase in the MS-DRG National Average Payment of $2,612.56.

For the 255 claims with a principal diagnosis of J80 (ARDS) in CY 2021, the reassignment to MS-DRG 189 would results in a $666,202.80 increase in payment for this group of claims.

Cardiac Mapping

CMS identified a replication issue from ICD-9 based MS-DRGs to ICD-10 based MS-DRGs for procedure code 02K80ZZ (Map conduction mechanism, open approach). Cardiac mapping describes the creation of detailed maps to detect how the electrical signals that control the timing of the heart rhythm move between each heartbeat to identify the location of rhythm disorders. Cardiac mapping is generally performed during open-heart surgery or performed via cardiac catheterization.

This code is currently recognized as a non-O.R. procedure that affects the MS-DRG to which it is assigned. CMS is proposing to reassign this code from MS-DRGs 246, 247, 248, 249, 250, and 251 to MS-DRGs 273 and 274 (Percutaneous and Other Intracardiac Procedures with and without MCC, respectively)

RTMD Claims Analysis

There were no claims in the RTMD database for CY 2021 where MS-DRGs 246, 247, 248, 249 and 250 included procedure code 02K80ZZ (Map conduction mechanism, open approach).

Laparoscopic Cholecystectomy with Common Bile Duct Exploration

A requestor noted that when a laparoscopic cholecystectomy is reported with any one of the listed procedure codes with a common bile duct exploration and gallstone removal procedure that is performed laparoscopically and reported with procedure code 0FC94ZZ, the resulting assignment is MS-DRGs 417, 418 and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC, respectively). This MS-DRG assignment does not recognize that a common bile duct exploration (C.D.E.) was performed.

CMS’ clinical advisors agreed that procedure code 0FC94ZZ describes a common bile duct exploration procedure with removal of a gallstone and should be added to the logic for case assignment to MS-DRGs 411, 412, and 413 for clinical coherence with the other procedures that describe a common bile duct exploration. CMS has proposed to redesignate procedure code 0FC94ZZ from a non-O.R. procedure to an O.R. procedure and add it to the logic list for common bile duct exploration (CDE) in MS-DRGs 411, 412, and 413 (Cholecystectomy with C.D.E. with MCC, with CC, and without CC/MCC, respectively).

RTMD Claims Analysis

In CY 2021, in the RTMD database, there were 188 claims that sequenced to the MS-DRG group 417, 418, and 419 (Laparoscopic Cholecystectomy without C.D.E. with MCC, with CC, and without CC/MCC respectively) that included the procedure code 0FC94ZZ describing a common bile duct exploration procedure with removal of a gallstone.

Based on the CMS FY 2022 Final Rule, following are the shifts in R.W. and national average payment by DRG severity levels:

  • The increase from MS-DRG 417 to MS-DRG 411 (Chlecystectomy w/C.D.E. w/MCC) in R.W. is 1.3120 and national average payment of $8,029.19,
  • The increase from MS-DRG 418 to MS-DRG 412 (Cholecystecomy w/C.D.E. w/CC) in R.W. is 0.5885 and national average payment of $3,554.90, and
  • The increase from MS-DRG 419 to MS-DRG 413 (Cholecystecomy w/C.D.E. w/o CC/MCC) in R.W. is 0.4156 and national average payment of $2,510.48.

I encourage key stakeholders take the time to review the proposed rule and remember that CMS is accepting comments on the proposed rule through 5 p.m. EDT on June 17, 2022.


Beth Cobb

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