Knowledge Base Category -

Medicare MLN Articles

May 23, 2024: MLN MM13620: HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: October 2024

This article reviews discontinued HCPCS codes, new HCPCS codes, and HCPCS codes subject to and excluded from CLIA edits as of October 1, 2024. https://www.cms.gov/files/document/mm13620-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-october-2024.pdf

June 3, 2024: MLN MM13632: Hospital Outpatient Prospective Payment System: July 2024 Update

Make sure your billing staff knows about payment system updates for July including new CPT and HCPCS codes, covered devices for OPPS pass-through payments, drugs, biologicals and radiopharmaceutical, and skin substitutes.

https://www.cms.gov/files/document/mm13632-hospital-outpatient-prospective-payment-system-july-2024-update.pdf

June 13, 2024: MLN MM13658: DMEPOS Fee Schedule: July 2024 Quarterly Update

In this article you will find updates to CY 2024 fee schedule amounts for certain DMEPOS codes and information in changes in payment policy and new fee schedule information for HCPCS codes K1007 and E2298.

https://www.cms.gov/files/document/mm13658-dmepos-fee-schedule-july-2024-quarterly-update.pdf

June 13, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024

This article includes July updates for new CPT and HCPCS codes, coverage of Elios System for patients with primary open-angle glaucoma, and information about skin substitutes.

https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf

June 13, 2024: MLN MM13651: Medicare Benefit Policy Manual Update: DMEPOS Benefit Category Determinations

This article highlights updates to Section 110.8, Medicare Benefit Policy Manual, Chapter 15, and information about added DMEPOS items and their national benefit category determination (BCDs).

https://www.cms.gov/files/document/mm13651-medicare-benefit-policy-manual-update-dmepos-benefit-category-determinations.pdf

Coverage Updates

May 24, 2024: MLN MM13598: National Coverage Determination 200.3: Monoclonal Antibodies for the Treatment of Alzheimer's Disease

Make sure your billing staff knows about FDA-approved monoclonal antibodies, criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf

June 20, 2024: National Coverage Analysis (NCA): Transcatheter Tricuspid Valve Replacement (TTVR)

CMS notes that TTVR is a new technology for use in treating tricuspid regurgitation (TR) and they have received a formal request to provide coverage for the EVOQUE tricuspid valve replacement system (EVOQUE system). This NCA will focus on clinical indications for use of TTVR among Medicare beneficiaries. The public comment period for this NCA is from June 20, 2024, to July 20, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=314

June 25, 2024: NCA: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection

CMS updated this NCA noting that they released a Technical Frequently Asked Questions for Pharmacies. In response feedback, this document provides technical detail following the previous posting of the fact sheet on April 15, 2024. CMS also noted the final NCD is expected to be similar to the proposed published July 12, 2023, and pharmacies should prepare not to ready for this transition. They are sharing as much information as possible before issuing the final NCD to avoid disruptions for beneficiaries. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=310&ncacaldoctype=all&status=all&sortBy=status&bc=17

Compliance Education Updates

May 2024: MLN006559: Medicare Preventive Services

This MLN educational tool was revised in May to update the applicable codes for Hepatitis C screening. This tool includes helpful information related to HCPCS & CPT codes, ICD-10 codes, what Medicare covers, the frequency of screening, what the patient pays and additional miscellaneous notes. You will also find applicable coverage requirements when one has been published for the preventive service (i.e., for bone mass measurement you will find a link to national coverage determination 150.3: Bone (Mineral) Density Studies. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#BONE_MASS  

May 28, 2024: CMS Updates to Include Marriage and Family Therapists and Mental Health Counselors for Hospice, Rural Health Clinics, and Federally Qualified Health Centers

In the memorandum summary sent to State Survey Agency Directors, CMS notes the CY 2024 PFS final rule updated the Hospice Conditions of Participation, the Rural Health Clinic (RHC) Conditions for Certification, and the Federally Qualified Health Center (FQHC) Conditions for Coverage to implement provisions of the Consolidated Appropriations Act, 2023.

For Hospices: The interdisciplinary team must now include at least one social worker, marriage and family therapist or mental health counselor as part of the team. The hospice personnel requirements were updated to add these disciplines.

For RHCs and FQHCs: Staffing and personnel requirements were updated to include marriage and family therapists and mental health counselors as part of the collaborative team approach to providing services. Also, definitions of several health care professionals who are already eligible to provide services at RHCs and FQHCs were updated, including the definition of “nurse practitioner,” to align with current standards of professional practice. https://www.cms.gov/files/document/qso-24-12-hospice-fqhc/rhc.pdf

Comprehensive Error Rate Testing Program: Reduced Sample Size Starting Reporting Year (RY) 2025

The CERT selects a stratified random sample of Part A/B claims submitted to the Medicare Administrative Contractors (MACs). The sample size allows CMS to calculate a national improper payment rate and contractor-and-service-specific improper payment rates. The sample size is considered to reflect all claims processed by the Medicare FFS program in the report period. CMS recently announced that beginning with the RY 2025, the sample size will be permanently reduced from 50,000 to 37,500 claims annually. CMS notes on their CERT webpage that “it is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements.”

June 7, 2024: FDA Approves Expanded Age Indication for GSK’s Arexvy

GSK noted in their announcement that “over 13 million US adults aged 50-59 have a medical condition that increased their risk of RSV outcomes.” Further, the US FDA has approved Arexvy (Respiratory Syncytial Virus (RSV) Vaccine, Adjuvanted) for the prevention of RSV lower respiratory tract disease (LRTD) in adults 50 through 59 years who are at increased risk for example, adults with COPD, asthma, heart failure and/or diabetes.

• June 7, 2024 FDA Letter to GlaxoSmithKline (GSK) Biologicals: https://www.fda.gov/media/179248/download?attachment=&utm_medium=email&utm_source=govdelivery

June 10, 2024: OIG Semiannual Report to Congress

OIG released their semiannual report for the 6-month period ending March 31, 2024. Inspector General Christi A. Grim notes that OIG used experts and authorities, highly developed data analysis techniques, and strong partnerships with other law enforcement and oversight entities, OIG identified $2.76 billion in expected recoveries and issued 195 recommendations and completed 60 audits and 18 evaluations in this reporting period. Inspector General Grim went on to indicate that OIG’s health care work consistently yields a positive return on investment of around $10 returned to every $1 invested. https://oig.hhs.gov/documents/sar/9905/Spring_2024_SAR.pdf

June 11, 2024: Long COVID Defined

The National Academies of Sciences, Engineering, and Medicine (NASEM) released a new definition for “Long COVID” – “that it is an infection-associated chronic condition that occurs after COVID-19 infection and is present for at least three months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems.” https://www.nationalacademies.org/news/2024/06/federal-government-clinicians-employers-and-others-should-adopt-new-definition-for-long-covid-to-aid-in-consistent-diagnosis-documentation-and-treatment

June 20, 2024 MLN Connects: Watch out for Medicare Record Request Phishing Scam

Did You Know?

In 2023, the Medicare Administrative Contractors (MACs) came together for a multi-MAC collaboration to provide an evidence-based Local Coverage Determination (LCD) for cervical fusion.

Why it Matters?

Historically, there have been LCDs for back procedures for Cervical Disk Replacement (i.e., Palmetto GBA LCD L38033), Lumbar Artificial Disc Replacement (i.e., Palmetto GBA LCD L37826), and Lumbar Spinal Fusion (i.e., Palmetto GBA LCD L37826).

Cervical Fusion is new to this group of back procedure LCDs, and the original effective date for this new LCD is July 7, 2024.

Per Palmetto’s LCD, cervical fusion surgery is considered medically reasonable and necessary when one of three covered indications:

1. For decompression of symptomatic cervical nerve root impingement,
2. For decompression of symptomatic cervical canal stenosis, or
3. For decompression or stabilization of the cervical spine for one of four indications (traumatic injuries, spinal tumors, infection, deformities that include the cervical spine.)

In addition to meeting one of the above three indications, there are specific requirements for each that also must be met.  

What Can You Do?

Find your MAC specific LCD and related Billing and Coding Article on the Medicare Coverage Database (MCD) and share this information with key stakeholders at your facility. Below are the MAC specific policies and related articles listed on the MCD as of June 3^rd.   

MAC Specific Cervical Fusion LCD and related Billing and Coding Article

CGS J14: L39741 / A59608 (A59738 – Response to Comments Article)

First Coast JN: DL39799

NGS J6/JK: DL39770 / DA59632

Noridian JE: L39758 / A59624 (A59796 – Response to Comments Article)

Noridian JF: L39762 / A59645 (A59797 – Response to Comments Article)

Novitas JH/JL: DL39793

Palmetto JJ/JM: L39773 / A59634 (A59736 – Response to Comments Article)

WPS J5/J8: L39788 / A59664 (A59800 – Response to Comments Article)

Did You Know?

June is cataract awareness month and according to the National Eye Institute (https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts), 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.

In addition to age, you may be at a higher risk of developing cataracts if you:

• Have certain health problems like diabetes
• Smoke
• Drink too much alcohol
• Have a family history of cataracts
• Have had an eye injury, eye surgery, or radiation treatment on your upper body
• Have spent a lot of time in the sun
• Take steroids

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 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 on this RAC issue webpage.

Comprehensive Error Rate Testing (CERT)

In the 2023 CERT Medicare Fee-for-Service supplemental improper payment report, cataract removal and lens insertion is listed in Table G1: Improper Payment Rates by Service Type: Part B. The improper payment rate was 8.2% with the projected improper payment of $149,241,566.

Medicare Administrative Contractors (MACs)

JE and JF MAC: Noridian

Cataract surgery has been a review target for Noridian MAC jurisdictions for a few years. Their most recent review findings were published on April 15, 2024 for claims with dates of service from January 1, 2024 through March 31, 2024:  

• Noridian JE error rate was 22% down from 48.67% in April 2023.
• Noridian JF was 43.6% down from error rate 45.88% in April 2023.

Noridian’s review results articles include top denial reasons, educational resources, and education regarding the medical necessity for cataract surgery.

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.

Medicare Transmittals & MLN Articles

April 25, 2024: MLN MM13449: Stay of Enrollment – Revised

This article provides information about a new provider enrollment status called a stay of enrollment and related updates to the Medicare Program Integrity Manual, Chapter 10. On April 25^th, CMS reissued this article to revise the effective and implementation dates to May 30, 2024 and the web address of Change Request (CR) 13449. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

May 3, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule

CMS advises providers to make sure your billing staff knows about the revised regulatory definition of diabetes, the revised diabetes screening frequency limitations, and coverage of the Hemoglobin A1C (HbA1c) test for diabetes screening.

Prior to January 1, 2024 the HbA1C test (HCPCS code 83036) was covered for the purpose of diabetes management but not for diabetes screening. As of January 1, 2024, CMS now covers the HbA1c test for diabetes screening. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf

May 3, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment

Make sure your billing staff knows that the social determinants of health (SDOH) risk assessment is now an optional annual wellness visit (AWV) element and what the eligibility and billing requirements are for completing the SDOH risk assessment as part of the AWV. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf

May 3, 2024: MLN MM13592: Updates for Split or Shared Evaluation & Management Visits

Information in this article for your billing staff include the definition of split or shared visit and substantive portion, and how to bill appropriately for split or shared evaluation and management (E/M) visits. https://www.cms.gov/files/document/mm13592-updates-split-or-shared-evaluation-management-visits.pdf

May 9, 2024: MLN MM13608: ESRD Prospective Payment System Quarterly Update

Make sure your billing staff knows about the Transitional Drug Add-On Payment Adjustment (TDAPA) for HCPCS code J0911 and the updated list of outlier services under the ESRD PPS. https://www.cms.gov/files/document/mm13608-esrd-prospective-payment-system-quarterly-update.pdf

May 16, 2024: MLN MM13617: Medicare Claims Processing Manual Update: Gap-Filling DMEPOS Fees

Make sure your billing staff knows about the revised Section 60.3 in the Medicare Claims Processing Manual, Chapter 23 and updated factors for gap-filling purposes.

https://www.cms.gov/files/document/mm13617-medicare-claims-processing-manual-update-gap-filling-dmepos-fees.pdf

May 23, 2024: MLN MM13598: NCD 200.3 – Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)

This article includes information about FDA-approved monoclonal antibodies, the criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf

May 24, 2024: MLN MM13613: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update

This article was initially released on May 3^rd, 2024 with guidance from CMS to make sure your billing staff know that the next private payor data reporting period of January 1, 2025 – March 31, 2025 and new and deleted HCPCS codes. No substantive changes were made in the May 24^th revision other than to update the web address of the CR transmittal. https://www.cms.gov/files/document/mm13613-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf

Coverage Updates

April 30, 2024: New National Coverage Analysis (NCA)Tracking Sheet for Implanted Pulmonary Artery Pressure Sensor for Heart Failure Management (CAG-00466N)

CMS posted a National Coverage Analysis (NCA) Tracking Sheet regarding a request from Abbott to provide coverage for the CardioMEMS™ HF System. This device measures Pulmonary artery (PA) pressures by using a combination of an implantable PA pressure sensor and a remote hemodynamic monitoring system that is accessible by the physician. CMS is soliciting public comment until May 30, 2024 and has indicated a proposed Decision Memo due date of October 30, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=313

May 2, 2024: CMS Statement on Proposed LCD for Skin Substitute Grafts/Cellular and Tissue-Based Products for Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

CMS notes in the May 2, 2024 edition of MLN Connects that they are aware of the MACs having issued a collaborative proposed Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Local Coverage Determination (LCD). CMS strongly encourages interested parties to provide comments during the public comment period that is open until June 8, 2024.  

May 10, 2024: MLN MM13596: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2024 Update

This article highlights new codes and recent coding changes related to the Next Generation Sequencing (NGS) (NCD 90.2), Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1), and the Aprepitant for Chemotherapy-Induced Emesis (NCD 110.18). https://www.cms.gov/files/document/mm13596-icd-10-other-coding-revisions-national-coverage-determinations-october-2024-update.pdf

May 13, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation

Make sure your billing staff knows about coverage for HSCT using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients and all other indications for stem cell transplantation not otherwise specified. https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf

Compliance Education Updates

May 2024: MLN Fact Sheet: Swing Bed Services

CMS has updated this fact sheet to include information about covered Critical Access Hospital (CAH) swing bed services.  https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf

Other Updates

May 9, 2024: CMS Publication – Part B Drug Payment Limits Overview

In the Thursday, May 9^th edition of MLN Connects, CMS noted they have published a Part B Drug Payment Limits Overview document to explain the Average Sales Price (ASP) payment limit calculation and other Medicare Part B drug payment methodologies including Wholesale Acquisition Cost (WAC), Average Wholesale Price (AWP), Average Manufacturer Price (AMP), Widely Available Market Price (WAMP), and Contractor Pricing.  

May 9, 2024: Mental Health: It’s Important at Every Stage of Life

Also in the Thursday, May 9^th edition of MLN Connects, CMS noted that mental and physical health are equally important components of overall health, and they provide links to information about appropriate preventive services and preventive services (i.e. Medicare & Mental Health Coverage) covered by Medicare.

May 21, 2024: CMS Launches New Option for Individuals to Report Potential Violations of the Emergency Medical Treatment and Labor Act (EMTALA)

CMS announced the launch of a new web resource to educate the public and promote patients’ access to emergency medical care to which they are entitled under federal law. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-launches-new-option-report-potential-violations-federal-law-and-continue

Compliance Education Updates

March 2024: MLN8659122: MLN Fact Sheet Original Medicare vs. Medicare Advantage Updated

CMS updated the payment rules for patients enrolled in Medicare Advantage Organizations. https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf

April 2024: MLN Educational Tool Medicare Preventive Services Revised

CMS has revised this tool to clarify social determinants of health information, add a link to the most current and comprehensive list of ICD-10 codes for bone mass measurement and colorectal cancer screening, add coding, coverage, and payment information for COVID-19 vaccine and administration, and replace Hepatis B information with a link to the Hepatitis B screening service. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Other Updates

March 26, 2024: GAO Improper Payments: Information on Agencies’ Fiscal Year 2023 Estimates

In this report the Government Accountability Office (GAO) indicates the importance of this information due to the fact that “improper payments – those that should not have been made or were made in the incorrect amount – have consistently been a government-wide issue. Since fiscal year 2003, cumulative improper payment estimated by executive branch agencies have totaled about $2.7 trillion. Reducing improper payments is critical to safeguarding federal funds.” With an estimated $51 billion in estimated improper payments HHC’s Medicare (Medicare Fee-for-Service (Parts A and B), Medicare Advantage (Part C), and Medicare Prescription Drug (Part D)) had the highest estimated improper payments across 14 government agencies.

https://www.gao.gov/assets/d24106927.pdf?emci=4185bdfa-36ed-ee11-aaf0-002248223794&emdi=645794fb-40ed-ee11-aaf0-002248223794&ceid=7931774

March 27, 2024: CMS Releases FY 2025 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1804-P)

CMS is proposing to update payment rates by 2.8 percent. This proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, associated impact analysis, and IRF Quality Reporting Program (QRP). Also included are two requests for information (RFIs) (1) Future Measure Concepts for the IRF QRP, and (2) Creating and IRF QRP Star Rating System.

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1804

CMS Proposed Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/rules-related-files/cms-1804-p

IRF QRP webpage: https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility

March 28, 2024: CMS Issues 3 FY 2025 Proposed Rules: SNF, Inpatient Psych and Hospice

FY 2025 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1802-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-25-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1802-p

FY 2025 Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Quality Reporting (IPFQR) Updates Proposed Rule (CMS-1806-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-medicare-inpatient-psychiatric-facilities-prospective-payment-system-ipf-pps-and

• Of note, CMS has proposed to increase the per treatment amount for electroconvulsive therapy (ECT) from the current FY 2024 payment per treatment of $385.58 to $660.30. CMS believes this increase would help ensure that patients who need ECT are more able to access it. (ECT CPT 90870)

Medicare MLN Articles

March 20, 2024: MLN MM11003: Electronic Medical Documentation Requests via the Electronic Submission of Medical Documentation System – Revised

This MLN was first released February 1, 2019. In the March 20, 2024 revision to this article, CMS has added information about the implementation of a new feature to accept review outcome letters during October 2023 release. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf

April 4, 2024: MLN MM13577: Ambulatory Surgical Center Payment Update – April 2024

Make sure your billing staff knows about new CPT and HCPCS codes, Device code changes, iDose TR (travoprost intracameral implant) for the treatment of glaucoma, Drug and biological code changes, and Skin code updates. https://www.cms.gov/files/document/mm13577-ambulatory-surgical-center-payment-update-april-2024.pdf

April 15, 2024: MLN MM13574: DMEPOS Fee Schedule: April 2024 Quarterly Update – Revised

This MLN article was revised on April 15^th to show the addition of 4 HCPCS Level II codes to Common Working File category 58. CMS also revised the effective date and the web address of Change Request (CR) 13574). https://www.cms.gov/files/document/mm13574-dmepos-fee-schedule-april-2024-quarterly-update.pdf

April 15, 2024: MLN MM13587: Medicare Claims Processing Manual Update: Inpatient Rehabilitation Facility

CMS advised that you make sure your billing staff know that hospitals may open a new IRF unit at any time during the cost reporting year, and any IRF unit excluded during a cost reporting Year will stay excluded for the rest of the cost reporting year. https://www.cms.gov/files/document/mm13587-medicare-claims-processing-manual-update-inpatient-rehabilitation-facility.pdf

Coverage Updates

April 15, 2024: CMS Releases Fact Sheet for Potential NCD for Preexposure Prophylaxis (PrER) Using Antiretroviral Drugs to Prevent HIV

CMS is sharing this information to encourage pharmacies and other interested parties to prepare for a potential National Coverage Determination (NCD) for PrEP Using Antiretroviral Drugs to Prevent HIV.

• National Coverage Analysis (NCA) Tracking Sheet: https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?NCAId=310
• CMS Fact Sheet: https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf

April 16, 2024: MLN MM13512: National Coverage Determination 20.7: Percutaneous Transluminal Angioplasty

This article provides education about the changes in coverage for PTA of the carotid artery concurrent with stenting effective October 11, 2023:

• Patients don’t have to enroll in a clinical trial.
• Facilities don’t need CMS approval to perform this service.
• You must engage in a formal shared decision-making (SDM) process with the patient. This must include documentation of four key elements outlined in this MLN article.
• MACs can decide if this service is covered if it’s not addressed in this NCD.

Note, your MAC will adjust claims processed in error that you bring to their attention. https://www.cms.gov/files/document/mm13215-national-coverage-determination-207-percutaneous-transluminal-angioplasty.pdf

Did You Know?

In mid-February CMS announced a new Prior Authorization Demonstration for certain Ambulatory Surgical Center (ASC) Services.

Why It Matters?

In their announcement, CMS references the nationwide prior authorization process for certain hospital outpatient department (OPD) services that was finalized in the Calendar Year 2020 OPPS Final Rule and implemented on July 1, 2020. The initial services subject to prior authorization in 2020 were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.

This 5-year demonstration project design will include ASC providers that:

• Submit claims with place of service 24 (Ambulatory Surgical Center) for one of the five previously mentioned services,
• Are in one of the ten demonstration states (California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York), and
• Submit claims to Medicare fee-for-service.

CMS plans to implement this demonstration for all ten states in one phase and they do not anticipate beginning the demonstration earlier than the fall of 2024.

Why now? CMS indicates that data from 2019 to 2021 shows there has been a significant increase in utilization in the ASC for the above five services and they were selected “for inclusion in this demonstration, based upon problematic events, data, trends, and potential billing behavior impacts of the OPD Prior Authorization Program which requires prior authorization as a condition of payment for these services.”

What Can You Do?

Take the time to read CMS Form CMS-10884 to learn about details of the demonstration design and justification for the need for this demonstration.

Since “the documentation requirements that MACs already have for the services in the OPD program, including local coverage determinations (LCDs), are applicable to these ASC services as well” visit your MACs website to find related resources. For example, Palmetto GBA Jurisdiction J (JJ), the MAC for Tennessee and Georgia has several resources available on their Medical Review / Outpatient Prior Department Prior Authorization (PA) webpage (i.e., Blepharoplasty and Medical Necessity Module).

Finally, if you are in one of the demonstration states, share this information with key stakeholders at your facility.

MMP’s Medicare Compliance Assessment Tool (MedCAT) combines current Medicare Fee-for-Service (FFS) review targets (i.e., MAC, RAC, SMRC) with hospital specific Medicare FFS paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD).

In general, MedCAT Minute articles spotlight current contractor review activities. The focus of this article is RAC Issue 0210: Hypoglossal Nerve Stimulation (HNS) for Obstructive Sleep Apnea (OSA).

Background

For patients with OSA who are unable to tolerate CPAP, HNS is one available alternative treatment strategy. The American Academy of Otolaryngology (AAO) (2016) position statement indicates 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.” ¹

Medicare Coverage Guidance

In 2020, each 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.

RAC Issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

RAC Issue 0210 was approved for review by CMS on June 7, 2022.

• 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 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.
• Affected Code: CPT 64582
  • Note: This CPT code was effective on January 1, 2022.
• Applicable Policy References: The related National Coverage Determination (NCD) 2401.4.1 Sleep Testing for OSA and each of the MACs LCD and related Billing and Coding Articles are included in this section of the RAC Issue.

By July 1, 2022, all RACs had added this issue to their list of issues that they would review for all three listed provider types.

Meeting Medical Necessity and Documentation Gaps

Palmetto GBA, the Jurisdiction J MAC, has published an article highlighting requirements to meet criteria for HNS and indications when HNS would not be reasonable and necessary.