Knowledge Base Category -
Medicare Transmittals & MLN Articles
June 24, 2024: Changes to the Laboratory National Coverage Determination Edit Software: October 2024 Update
CMS advises providers to make sure your billing staff know about newly available codes, recent coding changes, and how to find NCD coding information.
June 25, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024
Initially released on June 13, 2024, this article was updated to remove HCPCS codes J3393, J3394, J9172, J9322, and J9324 from table of the change request, which now has 12 codes. https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf
June 25, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule
Initially released May 3, 2024, this article was updated to clarify claims processing requirements for ICD-10-CM diagnosis code Z13.1 and previously processed claims. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf
June 27, 2024: Change Request (CR) 13649: Utilization of KX Modifier Medicare Physician Fee Schedule Payment for Dental Services Inextricably Linked to Covered Medical Services
This CR provides instructions to A/B MACs regarding usage of the KX modifier for dental services inextricably linked to covered medical services under the Medicare Physician Fee Schedule. CMS includes four examples of types of evidence that providers must submit to demonstrate the inextricable link between the dental service and covered medical service. https://www.cms.gov/files/document/r12702otn.pdf
July 18, 2024: MLN MM13717: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: October Update
Make sure your billing staff knows about the next private payor data reporting period of January 1, 2025 – March 31, 2025, and new and deleted HCPCS codes.
July 18, 2024: MLN MM13286: Lymphedema Compression Treatment Items: Implementation
Now in it’s fourth iteration, this MLN article was updated on July 18th to add information on how to prevent claims denial due to duplicate payments for compression bandaging systems. https://www.cms.gov/files/document/mm13286-lymphedema-compression-treatment-items-implementation.pdf
Compliance Education Updates
July: CMS’ Oral Health Cross-Cutting Initiative Fact Sheet
In the July 25, 2024, edition of MLN Connects, CMS released this Fact Sheet noting that overall health and well-being are impacted by oral health, affecting individuals, families, and communities. CMS is committed to eliminating barriers to oral health as part of our broader goal of improving quality, equity, and outcomes in the health care system. The CMS Oral Health Cross-Cutting Initiative aligns our programs and policies to better address oral health needs, and the fact sheet highlights this important work and accomplishments to date.
- Link to MLN Connects: https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983
- Link to Fact Sheet: https://www.cms.gov/files/document/oral-health-cci-fact-sheet.pdf
July: CMS Request for Inpatient for Improving the PEPPER
Also, in the July 25, 2024 edition of MLN Connects, CMS noted they are taking steps to improve the effectiveness, accessibility, and design of the Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) and Comparative Billing Reports (CBRs). They note you can help by responding to their Request for Information (RFI) by August 19, 2024. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-07-25-mlnc#_Toc172639983
Other Updates
CMS Publishes CY 2025 Final Rules for Home Health and End-Stage Renal Disease
Links to related Final Rule Fact Sheets:
- June 26, 2024: CY 2025 Home Health Prospective Payment System Proposed Rule Fact Sheet (CMS-1803-P)
- https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1803-p
- June 27, 2024: CY 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule Fact Sheet (CMS-1805-P)
- CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2025-end-stage-renal-disease-esrd-prospective-payment-system-pps-proposed-rule-cms
June 27, 2024: CDC Recommendations Updated 2024-2025 COVID-19 and Flu Vaccines for Fall/Winter Virus Season
The CDC encourages providers to begin their influenza vaccination planning efforts now and to vaccinate patients as indicated once 2024-2025 influenza vaccines become available.
https://www.cdc.gov/media/releases/2024/s-t0627-vaccine-recommendations.htmlBeth Cobb
The FY 2025 IPPS Final Rule (CMS-1808-F) was issued by CMS August 1, 2024. This article focuses on finalized changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications.
MDC 05: Diseases and Disorders of the Circulatory System:
Left Atrial Appendage Closure (LAAC) with Concomitant Ablation
Request: Create a new MS-DRG to better accommodate the cost of concomitant left atrial appendage closure and cardiac ablation for atrial fibrillation. “According to the requester, the manufacturer of the WATCHMAN™ Left Atrial Appendage Closure (LAAC) device, patients who are indicated for a LAAC device can also have symptomatic AF. For these patients performing a cardiac ablation and LAAC procedure at the same time is ideal.”
CMS Proposal: After claims analysis CMS indicated that “taking into consideration that it clinically requires greater resources to perform concomitant left atrial appendage closure and cardiac ablation procedures, we are proposing to create a new base MS-DRG for cases reporting a LAAC procedure and a cardiac ablation procedure in MDC 05. The proposed new MS-DRG is MS-DRG 317 (Concomitant Left Atrial Appendage Closure and Cardiac Ablation).”
CMS has proposed to include the nine ICD-10-PCS procedure codes that describe LAAC procedures and 27 ICD-10-PCS procedure codes describing cardiac ablation for the proposed new MS-DRG.
Final Rule: CMS finalized their proposal to create new MS-DRG 317 (Concomitant Left Atrial Appendage Clouse and Cardiac Ablation) in MDC 05, with modification of the list of procedure codes describing cardiac ablation by removing four codes.
|
FY 2025 Shift in R.W. for LAAC with Concomitant Ablation |
||||
|
DRG |
DRG Description |
R.W. |
GMLOS |
ALOS |
|
273 |
Percutaneous & Other Intracardiac Procedures w/MCC |
3.9100 |
3.4 |
5.4 |
|
274 |
Percutaneous & Other Intracardiac Procedures w/o MCC |
3.1208 |
1.2 |
1.4 |
|
317 |
Concomitant Left Atrial Appendage Closure & Cardiac Ablation |
6.1860 |
2.1 |
3.0 |
|
Source: FY 2025 IPPS Final Rule – Table 5 |
||||
Neuromodulation Device Implant for Heart Failure (Barostim™ Baroreflex Activation Therapy)
The BAROSTIM™ system is the first neuromodulation device system designated to trigger the body’s main cardiovascular reflex to target symptoms of heart failure. The system is indicated for the improvement of symptoms of heart failure in a subset of patients with symptomatic New York Heart Association (NYHA) Class III or Class II heart failure, with a low left ventricular ejection fraction, who also do not benefit from guideline directed pharmacologic therapy or qualify for Cardiac Resynchronization Therapy (CRT).
This system was approved for new technology add-on payments for FY 2021 and FY 2022 and was discontinued in FY 2023.
Request: A request was submitted to reassign the ICD-10-PCS procedure codes describing the BAROSTIM™ system from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without MCC respectively) to MS-DRGs 275 (Cardiac Defibrillator Implant with Cardiac Catheterization with MCC), MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC and without MCC respectively); or to other more clinically coherent MS-DRGs for implantable device procedures indicated for Class III heart failure patients. ICD-10-PCS codes uniquely identifying the implantation of the BAROSTIM™ system includes:
- 0JH60MZ (Insertion of stimulator generator into chest subcutaneous tissue and fascia, open approach)
- in combination with
- 03HK3MZ (Insertion of stimulator lead into right internal carotid artery, percutaneous approach) or
- 03HL3MZ (Insertion of stimulator lead into left internal carotid artery, percutaneous approach).
CMS Response: While there is no intravascular component when implanting a BAROSTIM™ system, they did agree that ICD, CRT-D, and CCM devices and the BAROSTIM™ system are clinically coherent in that they share an indication of heart failure, a major cause of morbidity and mortality in the United States, and that these cases demonstrate comparable resource utilization. As such, they are proposing to reassign the cases reporting procedure codes describing implantation of a BAROSTIM™ system to MS-DRG 276, even if there is no MCC reported, to better reflect the clinical severity and resource use involved.
They are also proposing to change the title of MS-DRG 276 from “Cardiac Defibrillator Implant with MCC” to “Cardiac Defibrillator Implant with MCC or Carotid Sinus Neurostimulator.”
Final Rule: CMS finalized their proposal to reassign the implantation of the BAROSTIM™ system to MS-DRG 276, even if there is no MCC reported. Also, the DRG name was changed to the above proposed name.
|
FY 2025 Shift in R.W. for the BAROSTIM™ System |
||||
|
DRG |
DRG Description |
R.W. |
GMLOS |
ALOS |
|
252 |
Other Vascular Procedures w/MCC |
3.4302 |
5.5 |
8.1 |
|
253 |
Other Vascular Procedures w/CC |
2.5529 |
3.8 |
5.1 |
|
254 |
Other Vascular Procedures w/o CC/MCC |
1.7493 |
1.9 |
2.3 |
|
276 |
Cardiac Defibrillator Implant w/MCC or Carotid Sinus Neurostimulator |
6.1940 |
6.2 |
8.3 |
|
Source: FY 2025 IPPS Final Rule – Table 5 |
||||
Beth Cobb
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.
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).
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
Beth Cobb
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
CMS notes they have identified phishing scams for medical records. In the June 20th edition of MLN Connects they provide an example, signs of a scam to look for in a request. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2024-06-20-mlncBeth Cobb
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:
- For decompression of symptomatic cervical nerve root impingement,
- For decompression of symptomatic cervical canal stenosis, or
- 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 3rd.
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)
Beth Cobb
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.
Beth Cobb
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 25th, 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.
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 3rd, 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 24th 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
Beth Cobb
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 9th 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 9th 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
Beth Cobb
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.
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)
FY 2025 Hospice Payment Rate Update Proposed Rule (CMS-1810-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2025-hospice-payment-rate-update-proposed-rule-cms-1810-p
Beth Cobb
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 15th 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
Beth Cobb
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