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CY 2023 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center (ASC) Payment Systems Final Rule Highlights
Published on Nov 16, 2022
 | Coding 
 | Billing 

The CMS released the Calendar Year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule on November 1, 2022. Following are highlights from the final rule:

CY 2023 OPPS and ASC Payment Rates

CMS is updating the CY 2023 OPPS and ASC payment rate by 3.8%.

  • The estimated total payments to OPPS providers in CY 2023 would be approximately $86.5 billion, an increase of approximately $6.5 billion compared to CY 2022 OPPS payments.
  • The estimated total payments to ASCs for CY 2023 will be approximately $5.3 billion, an increase of approximately $230 million compared to CY 2022 ASC payments.
Comprehensive Ambulatory Payment Categories (C-APCs) for CY 2023

C-APCs were first implemented on January 1, 2015. A C-APC is defined as “a classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service.”

CMS expanded the C-APC methodology in 2016 to include a “Comprehensive Observation Services” C-APC (C-APC 8011). The payment rate for C-APC 8011 in CY 2023 is $2,439.02.

For CY 2023, CMS finalized one new C-APC, C-APC 5372 (Level 2 Urology and Related Services).

For the duration of the COVID-19 PHE, any new FDA approved drug or biological approved for emergency use authorization (EUA) to treat COVID-19 that is authorized for use in the outpatient setting, or not limited to use in the inpatient setting, will be separately paid and will not package into the C-APC when provided on the same claim as the primary C-APC service.

Rural Emergency Hospital (REH)

REH is a new Medicare Provider type that includes facilities who elect to convert either from a critical access hospital (CAH) or a rural hospital with less than fifty beds to an REH. Policies for this new provider type will take effect January 1, 2023.

By statute REH services include emergency department services and observation care. Specific to observation care, CMS notes “there may be instanced in which REH patients receive observation services at an REH for a period exceeding 24 hours, but REHs are not required to provide required notification under the NOTICE Act, known as the Medicare Outpatient Observation Notice (MOON), because REHs are excluded from the definition of “hospital.”

An REH can also elect to provide other outpatient medical and health services furnished on an outpatient basis. CMS finalized the proposal that REHs may provide outpatient services not otherwise paid under the OPPS (i.e., services paid under the Clinical Lab Fee Schedule, post-hospital extended care services in a distinct part unit licensed as a skilled nursing facility).

REHs will receive a monthly facility payment of $272,866. This payment will increase in subsequent years by the hospital market basket percentage increase.

340B-Acquired Drugs

“CMS notes in the final rule that “for CY 2023, in light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), we are applying the default rate, generally average sales price (ASP) plus 6 percent, to 340B acquired drugs and biologicals in this final rule with comment period for CY 2023 and removing the increase to the conversion factor that was made in CY 2018 to implement the 340B policy in a budget neutral manner.

We are still evaluating how to apply the Supreme Court’s decision to prior calendar years. In the CY 2023 OPPS/ASC proposed rule, we solicited public comments on the best way to craft any potential remedies affecting cost years 2018-2022, and we will take these comments into consideration for separate rulemaking that will be published in advance of the CY 2024 OPPS/ASC proposed rule.”

Reminder, for 2022 claims prior to September 28th, providers will need to submit adjustment claims to recalculate their payments (link).

Medicare Inpatient Only (IPO) List

For CY 2023, CMS is removing 11 services and adding 8 newly created CPT codes to the IPO List. Table 65 of the final rule includes all services to be removed or added to the IPO list.

ASC Covered Procedure Lists

Procedures on the ASC Covered Procedure List (CPL) are surgical procedures that are appropriately performed on an inpatient basis in a hospital but that can also be safely performed in an ASC, a CAH, or an HOPD. Four procedures are being added to this list and can be found in table 80 of the final rule.

Hospital Outpatient Department Prior Authorization Process: New Service Category

Effective for dates of service on or after July 1, 2023, Facet joint interventions will be added to the list of service categories that hospital outpatient departments will be required to get prior authorization to receive payment. Specific Facet Joint CPT codes that will require prior authorization are listed in Table 103 of the final rule.

Outpatient Non-PHP Mental Health Services Furnished Remotely by Hospital Staff to Beneficiaries in Their Homes

CMS finalized its proposal to consider mental health services furnished remotely by hospital staff using communication technology to a beneficiary in his or her home a covered outpatient department service.

An in-person service will be required within 6 months prior to the initiation of remote service and then every 12 months thereafter, exceptions may be made to this requirement based on a beneficiary’s clinical needs and the reason being documented in the medical record. The in-person requirement will not apply to beneficiaries who began receiving mental health telehealth services during the PHE or during the 151-day period after the end of the PHE.

Audio-only interactive telecommunications systems may be used when a beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.


CY 2023 OPPS Final Rule CMS Press Release:

CY 2023 OPPS Final Rule Fact Sheet:

Beth Cobb

November 2022 PAR PRO Tip: Facet Joint Injections to Require Prior Authorization July 1, 2023
Published on Nov 16, 2022
 | Coding 
 | Billing 

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we focus on the new service to be added to the Prior Authorization for Certain Hospital Outpatient (OPD) Services effective July 1, 2023.

Did You Know?

CMS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services through the Calendar Year (CY) 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC).

Initially, effective July 1, 2020 blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation required a prior authorization when performed in the hospital OPD. For claims on or after July 1, 2021, implanted spinal neurostimulators and cervical fusion with disc removal were added to the list.

New for 2023, CMS finalized the addition of facet joint interventions requiring prior authorization for claims on or after July 1, 2023. This service category includes facet joint injections, medial branch blocks, and facet joint nerve destruction. A list of the specific CPT codes that will require prior authorization are listed in Table 103 of the CY 2023 OPPS/ASC Final Rule (CMS-1772-FC).

Why it Matters?

Reviewing facet joint records has been a target by several different entities.

Medicare Administrative Contractors

Noridian Jurisdiction E (JE) Part B MAC has conducted a Targeted and Probe and Educate (TPE) review of CPT 64635 (Destruction by Neurolytic Agent, Paravertebral Facet Joint Nerve). Dates of service reviewed were January 2020 through March 2020. The claims error rate was 75% with the top denial reasons being:

  • Failure to return records,
  • Documentation does not support the medical necessity as listed in the Coverage Requirement, and
  • Duplicate billing.

Noridian indicated in their review results that “Local Coverage Determination L34993 provides an overview of the coverage requirements for these services. Documentation must support the history of pain which has not been responsive to conservative measures. Documentation must also support the conservative measures that have been tried and failed. The LCD also further clarifies that documentation must support a clinical assessment which supports that the pain is a result of the facet joint and that there is no other pathology that may be causing the pain.

Documentation must reflect the patient pre and post procedure pain rating, procedure report, and the injectate used is within the LCD requirements.”

Other Part B MACs that have reviewed or are currently reviewing facet joint injections include Novitas JH and JL and WPS J8.

Office of Inspector General (OIG)

CMS notes in the OPPS/ASC final rule that the OIG has published multiple reports indicating questionable billing practices, improper Medicare payments, and questionable utilization of facet joint interventions. Based on their findings, the OIG recommended that CMS and its contractors provide additional oversight on claims for facet joint injections to prevent additional improper payments.

Supplemental Medical Review Contractor

Just last month on October 10th, the Supplemental Medical Review Contractor (SMRC) posted their review findings of Project 01-304: facet joint injections. The October 2020 OIG report was referenced in the review results. Claims reviewed included hospital outpatient and critical access hospitals with dates of service in CY 2019. The claims error rate was 92% and common denial reasons included:

  • Documentation submitted was insufficient or incomplete,
  • Documentation submitted did not support medical necessity as listed in National and Local Coverage Determinations, and
  • No response to the documentation request by the provider.
What Can I Do?

You can begin to prepare for the July 1, 2023 addition of Facet joint procedures to the Prior Authorization for Certain Hospital OPD Services now by:

  • Identifying applicable Medicare Coverage Documents (Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs)), and
  • Ensuring key stakeholders are aware of the need for prior authorization effective July 1, 2023 (i.e., Outpatient Department Nurse Manager, Scheduling, Physicians performing these procedures) and educate them on applicable documentation requirements found in the LCDs and LCAs.

October 2022 Compliance Education, COVID-19, and Other Updates
Published on Oct 26, 2022

Compliance Education Updates

MLN Educational Tool: Medicare Preventive Services

This MLN tool (link) was updated in September. Updates include pneumococcal shot resources, thirteen new bone mass measurement codes and three new hepatitis B screening codes.

MLN Educational Tool: Medicare Payment Systems

This MLN tool (link) was also updated in September to include updates for FY 2023 for:

  • The Acute Care Hospital Inpatient Prospective Payment System (IPPS),
  • The Hospice Payment System,
  • The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS),
  • The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS),
  • The Long-Term Care Hospital Prospective Payment System (LTCH PPS), and
  • The Skilled Nursing Facility Prospective Payment System (SNF PPS).
MLN Booklet: Chronic Care Management Services

This Booklet (link) has been updated. Substantive content changes are in dark red font and includes:

  • Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same period,
  • In 2021 CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
  • Beginning 2022 CMS replaced G2058 with 99439.

COVID-19 Updates

October 13, 2022: Update to COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

This CMS document (link) was updated on October 13th. The waiver related to the Director of Food and Nutrition Services was terminated on 10/1/2022 per the FY 2023 SNF Prospective Payment System Final Rule (1765-F).

Other Updates

September 23, 2022 Award of Medicare Administrative Contractor (MAC) Contract for Jurisdiction M

On September 23rd, Palmetto GBA, the incumbent MAC for Jurisdiction M (JM) was again awarded the contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the states of North and South Carolina, Virginia, and West Virginia. The claims volume in JM equates to more than $26.4 billion in Medicare benefit payments annually. Palmetto GBA will provide Medicare services to more than three hundred hospitals, approximately 75,000 physicians, and 3.2 million beneficiaries.

CMS Implements Temporary Increase in Payment under Medicare for Qualifying Biosimilars

Section 11403 of the Inflation Reduction Act provides for a temporary increase in the add-on payment for qualifying biosimilars from the current ASP plus an add-on of 6% of the reference biological product’s ASP to ASP plus 8% for a 5-year period. CMS noted in the Thursday, October 6th edition of MLN Matters (link) that “the goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.”

If you are interested in learning more about biosimilars, there are two FDA resources:

  • FDA Biological Product Definition Fact Sheet (link), and
  • A Curriculum Materials for Health Care Degree Programs / Biosimilars (link). The “FDA’s curriculum materials are intended to help educate students in health care professional degree programs, for medicine, nursing, physician assistants, and pharmacy, as well as practicing professionals, to improve understanding of biosimilar and interchangeable biosimilar products and the regulatory approval pathway in the United States.”
CMS Request for Information (RFI): Developing a National Directory of Health Care Providers and Services

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

  • Helping patients locate providers that meet their individual needs and preferences, and
  • A modern NDH “should enable healthcare providers, payers, and others involved in patient care to identify one another’s digital contact information also referred to as digital endpoints, for interoperable electronic data exchange.”

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

    Beth Cobb

    October 2022 Monthly Medicare Transmittals, MLN Articles & Coverage Update
    Published on Oct 26, 2022

    Medicare MLN Articles & Transmittals

    Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data
    • MLN Release Date: September 29, 2022
    • What You Need to Know: Data for the Ninth Circuit’s jurisdiction has been updated based on Supreme Court decision in Azar v. Empire Health Foundation. This includes hospitals in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington. Data for all other hospitals is unchanged.
    • MLN MM12906: (link)
    New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI
    • MLN Release Date: October 6, 2022
    • What You Need to Know: Make sure your billing staff knows about a new consistency edit that validates the attending provider NPI and that organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met.
    • MLN MM12889: (link)
    Medicare Deductible, Coinsurance & Premium Rates: Calendar Year 2023 Update
    • MLN Release Date: October 13, 2022
    • What You Need to Know: CMS advises to make sure your billing staff know about the calendar year 2023 rate changes. I would also encourage you to make sure your case management and social services staff are aware of this information too.
    • MLN MM12903: (link)

    Revised Medicare MLN Articles & Transmittals

    Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests
    • MLN Release Date: April 29, 2022 – Revised September 29, 2022
    • What You Need to Know: The article was revised to add the Other Amount Indicator “B2” for co-insurance reduction amount to the claim, modify edits that affects the co-insurance reduction amount, and report the applied coinsurance amounts in the c-insurance field.
    • MLN MM12656: (link)
    International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)-January 2023 Update – 2 of 2
    • MLN Release Date: August 12, 2022 – Revised October 5, 2022
    • What You Need to Know: This article was revised to reflect a revised Change Request (CR) 12842. The update for NCD 150.3 (Bone Mineral Density Studies) was removed due to ICD-10 diagnosis codes that were added in error and restore ICD-10 diagnosis C91.92 that was removed in error to NCD 110.23 (Stem Cell Transplantation).
    • MLN MM12842: (link)
    October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
    • Transmittal Release Date: Transmittal 11610 released September 23, 2022 is being rescinded and replaced by Transmittal 11661 dated October 23, 2022
    • What You Need to Know: This transmittal has been updated to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11.
    • Transmittal 11661: (link)

    Coverage Updates

    Cochlear Implantation Final Decision Memo (CAG-00107R)

    On September 26, 2022, CMS published a final decision memo (link) for NCD 50.3 Cochlear Implantation. CMS has concluded there is sufficient evidence for cochlear implantation be “be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.” Patient’s must also meet specific criteria detailed in the Decision Memo.

    Beth Cobb

    Coding Non-ischemic Myocardial Injury (Non-traumatic)
    Published on Oct 12, 2022
     | Coding 

    Did You Know?

    A new code has been created to identify a non-ischemic myocardial injury (non-traumatic).

    Why Should I Care?

    Myocardial injury, in the absence of ischemia, is categorized as acute or chronic nonischemic myocardial injury. Previously, non-ischemic, non-traumatic, myocardial injury was assigned to code (I51.89) (Other ill-defined heart diseases). Effective October 1, 2021, non-ischemic, non-traumatic, myocardial injury is assigned to code I5A (CC).

    Non-ischemic myocardial injury (non-traumatic) code (I5A) includes:

    • Acute myocardial injury (non-ischemic)
    • Chronic myocardial injury (non-ischemic)
    • Unspecified myocardial injury (non-ischemic)

    Instructions under I5A:

    • Code first the underlying causes, if known and applicable, such as: acute kidney failure, acute myocarditis, cardiomyopathy, chronic kidney disease, etc.
    • Excludes1: acute myocardial infarction and injury of heart
    • Excludes2: other acute ischemic heart diseases

    Clinicians can now determine whether patients have suffered a non-ischemic myocardial injury or one of the other myocardial injuries: Type 1 MI (myocardial ischemic injury) or Type 2 MI (supply/demand without acute atherothrombosis).

    The new code will allow for the appropriate classification of these patients. Accurate coding of myocardial injury will allow for appropriate reimbursement and support resource costs as well.

    What Should I Do?

    If you see documentation of myocardial injury, remember that this condition is codable, even if the patient doesn’t have a myocardial infarction (ischemic).

    ICD-10-CM Official Coding Book
    Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2021: Page 14
    Coding Clinic for ICD-10-CM/PCS, Second Quarter, 2019: Page 5

    Susie James

    Breast Cancer Awareness - Did You Know?
    Published on Oct 04, 2022

    Did You Know?

    Chances are you; a family member, close friend or acquaintance has been impacted by breast cancer. October is Breast Cancer Awareness Month. According to a CDC (link), each year:

    • About 264,000 women in the United States get breast cancer and 42,000 women die from the disease,
    • Men can also get breast cancer, but it is not common. About one out of every one hundred breast cancers diagnoses in the United States is found in a man, and
    • While most breast cancers are found in women who are 50 years old or older, breast cancer also affects younger women.

    Why Should You Care?

    Even though family history increases the risk of breast cancer, most women diagnosed with breast cancer have no known family history of the disease. Early detection allows for a higher chance of cure. Mammography is used to detect breast cancer and is one of many Preventative Services covered by Medicare.

    A related RealTime Medicare (RTMD) infographic, in this week’s newsletter, highlights the impact of the COVID-19 pandemic on the volume of Medicare Fee-for-Service beneficiaries undergoing screening mammography in RTMD’s footprint.

    NCD 220.4 Mammograms

    The CMS National Coverage Determination (NCD) 220.4 Mammograms (link) distinguishes the difference between diagnostic and screening mammography.

    Diagnostic Mammography

    A radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy - proven benign breast disease and includes a physician's interpretation of the results of the procedure. CMS covers this service if ordered by a Doctor of Medicine or Osteopathy in addition to the following conditions:

    • A patient has distinct signs and symptoms for which a mammogram is indicated,
    • A patient has a history of breast cancer, or
    • A patient is asymptomatic but, based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.
    Screening Mammography

    A radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Routine screening includes:

    • Asymptomatic women 50 years and older, and
    • Asymptomatic women 40 years and older whose mothers or sisters have had the disease, is considered medically appropriate, but would not be covered for Medicare purposes.

    Guidance for coding and billing for screening mammography is available in the MLN Educational Tool: Medicare Preventive Services (link).

    What Can I Do?

    Know Ways to Lower Your Risk for Breast Cancer

    The CDC details thing you can do to help lower your risk of breast cancer including:

    • Keep a health weight and exercise regularly,
    • Choose not to drink alcohol, or dink alcohol in moderation,
    • If you are taking hormone replacement therapy or birth control pills, ask your doctor about the risks, and
    • Breastfeed your children, if possible.

    Know the Warning Signs of Breast Cancer

    While there are different symptoms of breast cancer, and some people have no symptoms at all, symptoms can include:

    • Any change in the size or shape of the breast,
    • Pain in any area of the breast,
    • Nipple discharge other than breast milk (including blood),
    • A new lump in the breast or underarm, thickening or swelling or part of the breast,
    • Irritation or dimpling of the breast,
    • Redness or flaky skin in the nipple area of the breast.

    Be Your Own Patient Advocate

    If you have any signs or symptoms that worry you, follow-up with a health care provider as soon as possible.

    Talk to your health care provider about when and how often to get a screening mammogram. If you are worried about the cost, the CDC’s National Breast Cancer Early Detection Program (NBCCEDP) (link) provides breast and cervical cancer screenings and diagnostic services to women who have low incomes and are uninsured or underinsured.

    Beth Cobb

    September 2022 Medicare Compliance, COVID-19 and Other Updates
    Published on Sep 28, 2022

    Compliance Updates

    MLN Booklet: Chronic Care Management (CCM) Services

    This MLN booklet (link) was updated this month. Changes made to this booklet are highlighted in dark red font and include:

    • Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic CCM and Transitional Care Management (TCM) services for the same patient during the same time period,
    • In 2021, CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
    • Beginning 2022 G2058 was replaced with 99439.

    COVID-19 Updates

    September 12, 2022: COVID-19 Vaccines Providing Protection from Omicron Variant Available at No Cost

    CMS published a special edition MLN Connects (link) announcing that “people with Medicare, Medicaid, Children’s Health Insurance Program coverage, private insurance coverage, or no health coverage can get COVID-19 vaccines, including the updated Moderna and Pfizer-BioNTech COVID-19 vaccines, at no cost, for as long as the federal government continues purchasing and distributing these COVID-19 vaccines.”

    You will also find information in the newsletter about the four new CPT codes effective August 31, 2022, that CMS has issued for the Pfizer-BioNTech and Moderna Bivalent vaccines.

    September 13, 2022: CDC Clinical Outreach and Communication Activity (COCA) Call: Recommendations for Bivalent COVID-19 Booster

    The CDC held a COCA call (link) to discuss their new guidance on bivalent COVID-19 booster doses for people ages 12 years and older, included those who are moderately or severely immunocompromised. In the overview of the call the CDC noted that “Updated COVID-19 vaccines add an Omicron BA.4/5 spike protein component to the previous monovalent composition. These bivalent booster doses help restore protection that has waned since previous vaccination by targeting more transmissible and immune-evading variants. These boosters also broaden the spectrum of variants that the immune system is ready to respond to.” A recording of the call, slides and transcript are now available on this CDC webpage.

    September 20, 2022: CDC COCA Call: Evaluating and Supporting Patients Presenting with Cardiovascular Symptoms Following COVID

    In the “Overview” section on the CDC webpage (link), the CDC notes that of all of the post-COVID conditions (PCC) that people experience “cardiovascular symptoms and complications are among the most common and debilitating.” Presenters during this call outlined “the recommended clinical approach to identifying and managing cardiovascular complications in these patients.” A recording of the call and slides are now available.

    Other Updates

    National Correct Coding Initiative: October Quarterly Update

    In the Thursday, September 15, 2022 edition of MLN Connects (link), CMS encourages you to get the National Correct Coding Initiative (NCCI) fourth quarter edit files, effective October 1, 2022 and provides links to the Procedure-to-Procedure Edits, Medically Unlikely Edits, and Add-on Code Edits webpages.

    CMS Resources by Language

    Did you know that there is a collection of CMS resources categorized by language? This CMS webpage (link) was last modified on September 13th and includes resources in 18 languages “to help people make informed healthcare decisions and be active partners in their healthcare and the healthcare of their families.” These resources can be downloaded or ordered at no cost. A link to additional Medicare resources in 23 languages can also be found on this webpage. .

    Beth Cobb

    September 2022 Medicare Transmittals and MLN Articles
    Published on Sep 28, 2022

    Medicare MLN Articles & Transmittals

    Exceptions to Average Sales Price (ASP) Payment Methodology – Claims Processing Manual Changes
    • MLN Release Date: August 30, 2022
    • What You Need to Know: Your billing staff need to be made aware of updates to Chapter 17 Section 20.1.3 (Exceptions to Average Sales Price (ASP) Payment Methodology) and Section 20.3 (Calculation of the Payment Allowance Limit for DME MAC Drugs) of the Medicare Claims Processing Manual
    • MLN MM12854: link)
    Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023
    • MLN Release Date: September 6, 2022
    • What You Need to Know: This article lists the lab specific NCDs with coding updates effective January 1, 2023.
    • MLN MM12888: link)
    Billing for Hospital Part B Inpatient Services
    • Change Request (CR) 12816 Release Date: September 8, 2022
    • What You Need to Know: The purpose of this CR is to provide billing instructions for hospital Part B inpatient services. Specifically, there are additions to the “Not Allowed Revenue Codes.” No policy change is being made in this CR. You can find more information in the following CMS manuals:
      • Section 10 Medicare Benefit Policy Manual, Chapter 6 (link): when to bill Part B for inpatient services
      • Section 70 Medicare Claims Processing Manual, Chapter 1 (link): time limitations for filing Part B claims
      • Section 240 Medical Claims Processing Manual, Chapter 4 (link): services allowed on inpatient Part B claims
    • CR 12816: link)
    October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
    • MLN Release Date: September 13, 2022
    • What You Need to Know: CMS advises that your billing staff should know about the new COVID-19 CPT vaccine and administration codes, redosing update for EVUSHELD™, and a new procedure to assess coronary disease severity using computed tomography angiography that is detailed in this article.
    • MLN MM12885: link)
    Ambulatory Surgical Center Payment System: October 2022 Update
    • MLN Release Date: September 26, 2022
    • What You Need to Know: Your billing staff needs to know about updates to the ASC payment system, a new OPPS device pass-through code, new HCPCS codes for drugs and biologicals, and new skin substitute products low-cost or high-cost group assignment.
    • MLN MM12915: link)

    Revised Transmittals & MLN Articles

    Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
    • MLN Release Date: August 15, 2022 – Revised September 8, 2022 – Revised September 19, 2022
    • What You Need to Know: The article was revised on September 8th to reflect the change in CR 12870. Specifically, a note was added about code 0340U in dark red font on page 3 of the article. It was once again revised on September 19th to correct an acronym on page three.
    • MLN MM12870: link)

    Beth Cobb

    Chimeric Antigen Receptor (CAR) T-cell Therapy
    Published on Sep 14, 2022
     | Coding 
     | Billing 

    Did You Know?

    CAR T-cell Therapy entails the use of CAR T-cells that have been genetically altered to improve the ability of the T-cells to fight cancer. The genetic modification creating a CAR can enhance the ability of the T-cell to recognize and attach to a specific protein, called an antigen, on the surface of a cancer cell.

    In 2017, the FDA gave approval to two CAR T-cell therapies (Kymriah® and Yescarta®). Effective October 1, 2018, both therapies were approved for new-technology add-on payments with a maximum add-on payment of $186,500.

    Effective for claims with dates of service on or after August 7, 2019, Medicare began covering autologous treatment for cancer with T-cells expressing at least 1 Chimeric Antigen Receptor (CAR) when the treatment is:

    • Administered at healthcare facilities enrolled in the FDA Risk Evaluation and Mitigation Strategies (REMS), and
    • Is used for a medically accepted indication as defined at section 1861(t)(2)-i.e., or
    • Is used for either an FDA-approved indication (according to the FDA-approved label for that product, or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia.

    Not surprisingly, CAR T-cell therapy is expensive. So much so that CMS clinical advisors noted in the Fiscal Year (FY) 2021 IPPS proposed rule that they had found a vast discrepancy in resource consumption and clinical differences warranting the creation of new MS-DRG. Effective October 1, 2020, CAR T-cell therapy had its own MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-cell immunotherapy).

    In the current CMS FY 2022, MS-DRG 018 has a relative weight of 37.4501. On the October 1, 2022, start date of the CMS 2023 FY, MS-DRG 018 will once again have the highest relative weight at 36.1452.

    Since 2017, the FDA has approved additional CAR T-cell therapies. Three of these are eligible for a New Technology Add-On Payment (NTAP) in Fiscal Year 2023:

    • ABECMA® and CARVYKTI ™ to treat patients with relapsed or refractory multiple myeloma with a maximum add-on payment of $289,532.75, and
    • TECARTUS® to treat relapsed or refractory mantle cell lymphoma with a maximum add-on payment of $259,350.00.

    Why it Matters?

    In addition to CMS guidance, several of the Medicare Administrative Contractors (MACs) have published guidance regarding CAR T-cell therapy. If your hospital provides this service, I encourage you to become familiar with both CMS and the MACs guidance.

    CMS Guidance
    • National Coverage Determination Chimeric Antigen Receptor (CAR) T-cell Therapy (NCD 110.24): (link)
    • MLN Matters Article National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell therapy – This CR Rescinds and Fully Replaces CR 11783 (MM12177): (link)
    • MLN Matters Article Chimeric Antigen Receptor (CAR) T-Cell Therapy Revenue Code and HCPCS Setup Revisions (SE19009): (link)
    • MLN Matters Article International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – January 2023 Update: link)
      • Note: Revisions to NCD 110.24 include updated codes and coding guidance for all currently available CAR T-cell therapies.
    MAC Specific Guidance
    • CGS J15 (KY and OH) Article (link)
    • NGS JK (CT, NY, ME, MA, NH, RI, VT) FAQs (link)
    • Novitas JH (AR, CO, LA, MS, MN, OK, TX) Article (link)

    Anita Meyers

    Happy Clinical Documentation Integrity Week 2022
    Published on Sep 14, 2022

    This past weekend my brother and I had the daunting task of downsizing my mom’s living space from an Assisted Living Facility apartment to a long-term care room. While a tough move for my mom, we did find a few hidden treasures and memories. One such memory was finding pictures from a 1976 vacation taken by my grandmother aboard a cruise ship that was part of the 1970s TSS Mardi Gras, The Golden Fleet Carnival Cruise Line. In addition to finding the pictures, there was a packet of daily activities and a map of the different levels of the ship.

    In keeping with the cruise ship treasures that we found, this week we celebrate the 12th annual Clinical Documentation Integrity (CDI) Week with the theme Under the Sea-DI. A CDI Week Fact Sheet (link) published by the Association of Clinical Documentation Integrity Specialists (ACDIS), indicates that “CDI specialist review patient medical records and assess whether all conditions and treatments are documented. This documentation helps paint an accurate picture of the severity of the patient’s illness and the extent of the care required. When the documentation is unclear or deficient, CDI specialists prompt (also known as “query”) physicians to provide clarification. CDI specialists serve as the bridge between health information management (HIM) and clinical staff. They must comply with Medicare and/or private payer rules and regulations.”

    Just as it takes the entire crew to make a cruise ship run smoothly, it takes the CDI team coordinating with doctors, other departments participating in the care of a patient (i.e., physical therapy, dietician, pharmacy), and coding professionals to find all the hidden treasure in a patient’s medical record.

    MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, following are links to key treasure for a successful start to the CMS FY 2023.

    FY 2023 IPPS Final Rule Home Page (link)

    On this webpage you will find a links to:

    • The FY 2023 IPPS Final Rule,
    • FY 2023 Final Rule Tables
      • Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
      • Table 6: New Diagnosis Codes,
      • Table 6B: New Procedure Codes
      • Table 6I: Complete MCC List,
      • Table 6I.1: Additions to the MCC List,
      • Table 6I.2: Deletions to the MCC List,
      • Table 6J: Complete CC list,
      • Table 6J.1: Additions to the CC list,
      • Table 6J.2: Deletions to the CC list
    • FY 2023 MAC Implementation Files
      • MAC Implementation File 7: FY 2023 MS-DRGs Subject to the Replaced Devices Policy,
      • MAC Implementation File 8: FY 2023 New Technology Add-on Payment
    2023 ICD-10-CM Files (link)

    Downloads available on this webpage includes:

    • 2023 POA Exempt Codes,
    • 2023 Conversion Table,
    • 2023 Code Description in Tabular Order,
    • 2023 Addendum,
    • 2023 Code Tables, Tabular and Index, and
    • FY 2023 ICD-10-CM Coding Guidelines.

    The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (link).

    2023 ICD-10-PCS Files (link)

    Downloads available on this webpage includes:

    • 2023 ICD-10-PCS Order File,
    • 2023 Official ICD-10-PCS Coding Guidelines,
    • 2023 Version Update Summary,
    • 2023 ICD-10-PCS Codes File,
    • 2023 ICD-10-PCS Conversion table, 2023 ICD-10-PCS Code Tables and Index, and
    • 2023 ICD-10-PCS Addendum.
    MS-DRG Definitions Manual and Software

    The ICD-10 MS-DRG Version 40 (V40) Grouper Software, ICD-10 MS-DRG Definitions Manual, and the Definitions of Medicare Code Edits V 40 files are publicly available on the CMS MS-DRG Classifications and Software webpage (link).

    Again, happy CDI week from our team to yours.

    Anita Meyers

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