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February 2024 Medicare MLN Articles
Published on Feb 28, 2024
20240228

February 5, 2024: MLN MM13507: ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2024 Update

Make sure your staff knows about newly available codes, recent code changes, and NCD coding information. https://www.cms.gov/files/document/mm13507-icd-10-other-coding-revisions-national-coverage-determinations-july-2024-update.pdf

 

February 5, 2024: MLN SE19007: Activation of Validation Edits for Providers with Multiple Service Locations – Revised

This special edition MLN article was originally released March 26, 2019. With this latest revision, CMS clarified how to hand certain off-campus provider-based departments excepted from Section 603 payment policy. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se19007.pdf

 

February 12, 2024: MLN MM13513: Pulmonary Rehabilitation, Cardiac Rehabilitation, & Intensive Cardiac Rehabilitation Expansion of Supervising Practitioners

Make sure your billing staff knows about updates to the above-mentioned rehabilitation services effective January 1, 2024, including expanding the types of practitioners who may supervise these services. https://www.cms.gov/files/document/mm13513-pulmonary-rehabilitation-cardiac-rehabilitation-intensive-cardiac-rehabilitation-expansion.pdf

 

February 15, 2024: Limitation on Recoupment of Medicare Overpayments

Limitation on recoupment of Medicare overpayments is during the first and second level of appeal only. Make sure your staff knows about this limit, when to request an extended repayment plan (ERS) or choose immediate recoupment, and how CMS pays interest on overpayments. https://www.cms.gov/files/document/mm11808-limitation-recoupment-medicare-overpayments.pdf

 

February 21, 2024: MLN MM13485: Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging: CY 2024 Update

Make sure your billing staff knows about CMS rescinding the AUC program regulations, the program has been paused for reevaluation, and elimination of AUC consultation information on Medicare Fee-for-Service claims. https://www.cms.gov/files/document/mm13485-appropriate-use-criteria-advanced-diagnostic-imaging-cy-2024-update.pdf

 

February 22, 2024: MLN MM13451: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

Make sure your billing staff knows when the next private payor data reporting period is and new and deleted HCPCS codes. https://www.cms.gov/files/document/mm13541-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

 

Beth Cobb

Medicare Preventive Services Education Tool Revised
Published on Feb 21, 2024
20240221

Did You Know?

Through the Medicare Learning Network (MLN), CMS has developed an interactive education tool titled Medicare Preventive Services (MLN006559 January 2024). This tool is meant to help providers properly provide and bill Medicare prevention services (i.e., bone mass measurement, colorectal screening, lung cancer screening).

 

For each Preventive Service listed in the tool, you will find the following information as applicable to the service:

  • National Coverage Determination (NCD),
  • HCPCS and CPT codes specific to the service provided,
  • ICD-10-CM diagnosis codes,
  • Telehealth eligibility,
  • Coverage requirements,
  • Frequency requirements, and
  • Medicare Beneficiary (patient) cost sharing.

     

    You will also find answers to the following questions:

  • How do I determine the last date a patient got a preventive service, so I know if they’re eligible to get the next service and it won’t deny due to frequency edits?
  • When can CMS add new Medicare preventive services?
  • My patients don’t follow up on routine preventive care. How can I help them remember when they’re due for their next preventive service?
    • CMS provides a link to a Preventive Services Checklist that you can give your patients.
    • Note, CMS also highlights preventive services with an apple in the official U.S. government Medicare Handbook, Medicare and You. You will find information about preventive services in the 2024 Edition of this handbook on pages 30-55.
  • What’s a primary care setting?

     

    Why It Matters?

    This tool was revised in January 2024. Following are two examples of what has been revised:  

     

    Annual Wellness Visit

    New HCPCS code G0136 (Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes) has been added as well as the following “Other Notes:”

  • The implementation date for SDOH Risk Assessment claims is July 1, 2024,
  • The billing HCPCS code is G0136,
  • Add modifier 33 to an SDOH, G0136, performed on the same day as the Annual Wellness Visit to waive copayment and deductible,
  • G0136 is covered once a year with copayment and deductible waived, and
  • The AWV can be an optional community health integration (CHI) initiating visit when the provider identifies any unmet SDOH needs that prevent the patient from doing the recommended personalized prevention plan.

 

Flu Shot

Starting January 1, 2024, Medicare pays an additional payment for in-home flu shot administration under certain circumstances.

 

What Can You Do?

  • Read all the revisions made to this tool in January in the February 15, 2024 edition of MLN Connects,
  • Use this tool to identify service specific applicable coverage requirements (NCD), HCPCS/CPT codes, and ICD-10-CM diagnosis codes, and
  • Share this tool with key stakeholders at your facility.

Beth Cobb

FAQ: Coding Celiac Artery Stenosis
Published on Feb 07, 2024
20240207
 | Coding 

Question

Documentation in the record revealed the patient had Celiac Artery Stenosis. The encoder assigned Celiac Artery Compression Syndrome (I77.4) which was not documented in the record. Is code I77.4 the correct code for Celiac Artery Stenosis?

Answer

No, because Celiac Artery Compression Syndrome is compression caused by a fibrous band of the diaphragm and is not the same as Celiac Artery Stenosis.  The appropriate code for Celiac Artery Stenosis is Stricture of an Artery (I77.1). Coding Clinic advises to search for the more appropriate code if the code title assigned from the Index does not correctly describe the condition.

 

 

Resources:

National Library of Medicine

Coding Clinic, 3Q 2021, page 12

Anita Meyers

January 2024 Monthly Medicare Updates: MLN Articles
Published on Jan 31, 2024
20240131

Medicare Transmittals & MLN Articles

 

December 21, 2023: MLN MM13496: Billing Requirements for Intensive Outpatient Program Services under New Condition Code 92

Starting January 1, 2024, CMS requires the use of new condition code 92 on all Intensive Outpatient Program (IOP) claims from hospitals and Community Mental Health Centers (CMHCs). Make sure your billing staff knows about billing this new condition code and Medicare manual changes related to providing IOP services. https://www.cms.gov/files/document/mm13496-billing-requirements-intensive-outpatient-program-services-new-condition-code-92.pdf

 

December 26, 2023: MLN MM13222: New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services

CMS advises that you make sure your billing staff knows about this new code, that an OPPS provider will get paid per diem payments for this service, the intensity of services required for Medicare to cover and pay for this service, and the outpatient settings this billing requirement is applicable to. https://www.cms.gov/files/document/mm13222-new-condition-code-92-billing-requirements-intensive-outpatient-program-services.pdf

 

January 3, 2024: MLN MM13481: Ambulatory Surgical Center Payment System: January 2024 Update - Revised

This MLN article was revised to change the number of HCPCS codes in Tables 8 and 10 and update the web address of the Change Request (CR) transmittal. https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf

 

January 9, 2024: MLN MM13503: Specimen Collection Fees and Travel Allowance: 2024 Update

This MLN article provides updated information about the specimen collection fees and travel allowances for 2024 and other policy updates and reminders. https://www.cms.gov/files/document/mm13503-specimen-collection-fees-and-travel-allowance-2024-update.pdf

 

January 10, 2024: MLN MM13488: Hospital Outpatient Prospective Payment System: January 2024 Update

Make sure your billing staff is aware of the system updates effective January 1, 2024, for example:  

  • COVID-19 vaccine and administration codes,
  • Covered devices for pass-through payments,
  • Inpatient-only list (IPO) updates, and
  • Services: Covered dental rehabilitation procedures, Marriage and Family Therapist (MFT), and Mental health counselor (MHC),

https://www.cms.gov/files/document/mm13488-hospital-outpatient-prospective-payment-system-january-2024-update.pdf

 

January 16, 2024: MLN MM13264: Billing Requirements for Intensive Outpatient Program Services for Federally Qualified Health Centers and Rural Health Clinics

Make sure your billing staff knows about the Intensive Outpatient Program (IOP) scope of benefits, certification and plan of care requirements, payment policies, and coding and billing requirements. https://www.cms.gov/files/document/mm13264-billing-requirements-intensive-outpatient-program-services-federally-qualified-health.pdf

 

January 18, 2024: MLN MM13473: How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

CMS advises that you make sure your billing staff knows about the correct use of HCPCS code G2211 and modifier 25, documentation requirements for G2211, and patient coinsurance and deductible. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

 

Related MLN Matters article MM13272 was revised on December 21, 2023. CMS advises in this article that you make sure your billing staff knows about complexity add-on code G2211. https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf

 

January 18, 2024: MLN MM13480: Refillable DMEPOS Documentation Requirements

Make sure your staff knows about the updated documentation requirements for refillable DMEPOS and the requirement to contact the patient before refilling DMEPOS.  https://www.cms.gov/files/document/mm13480-refillable-dmepos-documentation-requirements.pdf

Beth Cobb

January 2024 Medicare Compliance Education and Other Updates
Published on Jan 31, 2024
20240131

Compliance Education Updates

 

December 2023: MLN Booklet: Global Surgery

CMS has updated this MLN booklet to include the instructions for critical care visits that are unrelated to the surgical procedure and performed post-operatively, report modifier -FY. https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

Other Updates

January 18, 2024: CMS Adds Utilization Data on Medicare.gov for the First Time

CMS noted in the Friday January 26 edition of CMS Roundup that they have “added utilization data, specifically procedure volume, for the first time on the Medicare.gov compare tool’s profile pages for doctors and clinicians…this is the latest example of CMS’ transparency efforts to ensure the compare tool on Medicare.gov provides patients and caregivers with information about services they may value as they search for clinicians.”

 

The dataset is currently published in the Provider Data Catalog. The initial list of procedures includes hip and knee replacement, spinal fusion, cataract surgery, colonoscopy, open hernia repair of the groin, minimally invasive hernia repair, mastectomy, CABG, pacemaker insertion or repair, coronary angioplasty and stenting, and prostate resection.

 

You can read more about this data release in a CMS Fact Sheet at https://www.cms.gov/files/document/utilization-procedure-volume-data-published-compare-tool-medicaregov-fact-sheet-195-kb.pdf.

 

January 22, 2024: New EMTALA Resources

CMS announced in a Press Release that they are launching “a series of actions to educate the public about their rights to emergency medical care and to help support the efforts of hospitals to meet their obligations under the Emergency Medical Treatment and Labor Act (EMTALA).” One action CMS has taken is to publish new informational resources on their website at https://www.cms.gov/priorities/your-patient-rights/emergency-room-rights. You can read the entire press release at https://www.cms.gov/newsroom/press-releases/cms-announces-new-actions-help-hospitals-meet-obligations-under-emtala.

 

New Kepro Email Addresses

In the January 2024 edition of Case Review Connections, Kepro lets providers know that Kepro recently became a part of the Acentra health family, and you may notice some changes in email addresses, moving to acentra.com. They do not anticipate any other changes at this time and will provide guidance in the future of any potential required changes. You can sign up for this newsletter on the Kepro website at https://www.keproqio.com/newsletters.

 

January 24, 2024: HHS Releases Voluntary Cybersecurity Goals for the Health Sector & New Gateway Website

HHS announced the release of “voluntary health care specific cybersecurity performance goals (CPGs) and a new gateway website to help Health Care and Public Health (HPH) sector organizations implement these high-impact cybersecurity practices and ease access to the plethora of cybersecurity resources HHS and other federal partners offer.” https://aspr.hhs.gov/newsroom/Pages/HHS-Releases-CPGs-and-Gateway-Website-Jan2024.aspx

Beth Cobb

Inpatient FAQ: UTI and Indwelling Catheter/Device
Published on Jan 17, 2024
20240117
 | Coding 

Question

A patient was transferred from a nursing home with a Foley and was found to have a UTI upon admission.  Should we always query to see if the UTI was caused by the Foley catheter?

 

Answer

Yes.  Patients that have an indwelling catheter are susceptible to bacteria in the urine and UTIs.  If the UTI was caused by the Foley, code T83.511A (Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter) should be assigned as the principal diagnosis.  A code for the UTI should also be assigned as a secondary diagnosis.  A catheter-associated urinary tract infection is also called a (CAUTI).  Coding the CAUTI as the principal diagnosis may also affect the DRG assignment.

 

It’s good practice to review the chart for supporting evidence of the presence of a Foley catheter or another kind of urinary catheter/device, when a UTI is diagnosed. 

 

References:

Merck Manual

AHA Coding Handbook

 

Susie James

A Pause in PEPPER and CBRs
Published on Jan 17, 2024
20240117

The Program for Evaluating Payment Patterns Electronic Report or PEPPER is one resource available to providers to help guide your selection of meaningful review targets for audits. According to the PEPPER User’s Guide for Short-Term Acute Care, this report “contains a single hospital’s claims data statistics for Medicare-Severity Diagnosis-Related Groups (MS-DRGs) and discharges at risk for improper payment due to billing, coding, and/or admission necessity issues…All of the data tables, graphs, and reports in PEPPER were designed to assist the hospital in identifying potential overpayments as well as potential underpayments.”

If you attempted to access the PEPPER Resources website in December 2023, you were directed to a blank page. This week I once again checked this website and the following notice has been posted:

“Updates to the Program for Comparative Billing Reports (CBRs) and Evaluating Payment Patterns Electronic Report (PEPPERs) Coming Soon

There will be a temporary pause in distributing CBRs and PEPPERs as CMS works to improve and update the program and reporting system. This pause will remain in effect through the fall of 2024. We recognized the importance of these reports to your practice. Therefore, during this time, CMS will be working diligently to enhance the quality and accessibility of the reports. In fulfilling this commitment, your feedback is requested. In the near future, CMS will release a Request for Information (RFI) to obtain information from you, the provider community, about how the program can better serve you.

Please visit CBR and PEPPER website for periodic updates. If you have further questions please send them to Medicaremedicalreview@cms.hhs.gov.”

About CBRs

In addition to PEPPERs, CMS has paused CBRs. According to the CMS webpage Data Analysis Support and Tracking, “a Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider. CBR’s contain actual data-driven tables and graphs with an explanation of findings that compare provider’s billing and payment patterns to those of their peers on both a national and state level. Graphic presentations contained in these reports help to communicate a provider’s billing pattern more clearly. CBR study topic(s) are selected because they are prone to improper payments. For additional information and examples of CBRs, you can access the eGlobalTech website at http://www.cbrinfo.net/.” Note, this website currently can’t be reached.

Beth Cobb

Outpatient FAQ: Coding Urine Creatinine and Modifier 59
Published on Jan 10, 2024
20240110
 | Coding 

Question

We have outpatient lab orders on patients that frequently have a host of lab tests performed including Microalbumin/Creatinine Ratio and Urine Drug Screen, CPT® codes 82570, 82043, 80307. There are separate orders & results for all 3 tests.  All may have the same diagnoses or different diagnoses.

 

I have read the NCCI edit about specimen validity, but in this case, these tests appear to be ordered for specific diagnoses, they have separate orders and results. Would 59 be appropriate on 82570?

 

Answer

Yes, modifier 59 can be used when CPT® code 82570 (urine creatinine) is ordered and resulted separately, and when the urine creatinine is “not” performed for specimen validity testing.

 

To support this opinion, we used the NCCI policy statement you referenced above (NCCI Policy Manual, chapter X, section E.2, page X-7) Link

 

 

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2023 American Medical Association. All rights reserved.  CPT® is a registered trademark of the American Medical Association.

 

Jeffery Gordon

New Resources to Address Social Determinants of Health
Published on Dec 13, 2023
20231213

In a November 16th Press Release HHS announced three new key resources to “build on the Administration’s work to advance health equity by acknowledging that peoples’ social and economic conditions play an important role in their health and wellbeing.”

 

White House Resource: U.S. Playbook to Address Social Determinants of Health (SDOH)

HHS defines SDOH as “the conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

 

The White House’s vision is for every American to lead full and healthy lives within their community. “This Playbook lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.” The playbook groups actions into the following three pillars:

 

  • Pillar 1: Expanding Data Gathering and Sharing,
  • Pillar 2: Support Flexible Funding to Address Social Needs,
  • Pillar 3: Support Backbone Organization.

     

    HHS Resource: Medicaid and Children’s Health Insurance Program (CHIP) Health-Related Social Needs (HRSN) Framework

    In a related Press Release HHS notes “the Playbook highlights ongoing and new actions that federal agencies are taking to support health by improving the social circumstances of individuals…The second resource provides guidance “to structure programs that address housing and nutritional insecurity for enrollees in high need populations.”

     

    HHS Resource: HHS’s Call to Action to Address Health Related Social Needs

    The third document is meant to “encourage cross-sector partnerships among those working in health care, social services, public and environmental health, government, and health information technology to create a stronger, more integrated health and social care system through shared decision making and by leveraging community resources, to address unmet health related social needs.”

     

    Z-Codes: Identifying and Coding Social Determinates of Health

    Identifying and coding SDOH supports quality measurement, planning, and implementation of social needs, and identifying community population needs. This data can be used to advocate for updating and creating new policies. For example, effective October 1, 2023, the severity designation for three Z codes was changed to a CC (comorbidity or complication) for purposes of MS-DRG assignment:

  • Z59.00: Homelessness, unspecified,
  • Z59.01: Sheltered homelessness (due to economic difficulties, currently living in a shelter, motel, temporary or transitional living situation, scattered site housing, or not having a consistent place to sleep at night), and
  • Z59.02: Unsheltered homelessness (residing in a place not meant for human habitation, such as cars, parks, sidewalks, or abandoned buildings (on the street)).

CMS noted in a FY 2024 IPPS Final Rule Fact Sheet that as SDOH codes are increasingly added to billed claims, they plan “to continue to analyze the effects of SDOH on severity of illness, complexity of services, and consumption of resources.” 

 

To help with understanding and coding Z Codes, CMS has published an infographic titled Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes. This document defines Z codes, explains the importance of collecting them and includes recent SDOH Z Code Categories and new codes effective October 1, 2023.

 

A related Journey Map walks you through five steps to using Z codes and how using these codes can enhance your quality improvement initiatives.

 

Beth Cobb

FAQ: Acute Renal Failure After Kidney Transplant
Published on Dec 13, 2023
20231213
 | Coding 

Question

A patient was admitted to the hospital with acute renal failure and has a history of a kidney transplant.  Is acute renal failure a complication of the kidney transplant?

 

Answer

Acute renal failure is affecting the function of the transplanted kidney, but it doesn’t mean that the transplant itself has failed.  Assign T86.19 (Other complication of kidney transplant) along with N17.9 (Acute renal failure) to correctly code this case.

 

  • Pre-existing conditions or conditions that develop after an organ transplant are not coded as complications unless it affects the function of the transplanted organ.

 

References:

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019:  Page 7

AHA Coding Handbook

Susie James

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