Knowledge Base Category -
MMP has been sending out the Wednesday@One since 2012. Over the past decade, I have often shared with our readers my love of fall. Fall means the return of college football, front yards filled with inflatable pumpkins and ghosts, and this year I am seeing the addition of exceptionally large decorative black spiders crawling up the outside walls of homes and strings of glowing witch hats lighting front porches.
Even with pots of chili still to be cooked and caramel apples still to be consumed, it is never too early to prepare for the New Year. Along with the October 1st start of the CMS 2023 Inpatient Prospective Payment System (IPPS) Fiscal Year, this article highlights recent news to help you prepare for the coming year.
2023 Dollar Amount in Controversy Required for Administrative Law Judge (ALJ) Hearing or Federal District Court Review
The fifth level of appeal for Medicare Fee-for-Service appeals is an ALJ hearing or Federal District Court review. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires an annual reevaluation of the dollar amount in controversy (AIC) required to advance to this level of appeal.
On September 30, 2022, the annual adjustment that will be effective on January 1, 2023 was published in the Federal Register (link). The calendar year (CY) 2023 AIC threshold amounts are:
- ALJ hearing requests filed on or after January 1, 2023 remains the same as CY 2022 at $180.
- Federal District Court requests filed on or after January 1, 2023 will increase from the CY 2022 amount of $1,760 to $1,850.
You can learn more about the appeal process in the CMS MLN Booklet Medicare Parts A & B Appeals Process (link).
Inflation Reduction Act
President Biden signed the Inflation Reduction Act (IRA) into law on August 16, 2022. On October 5th, CMS released a Fact Sheet (link) where CMS notes that “this law means millions of Americans across all 50 states, the United States territories, and the District of Columbia will save money from meaningful benefits.” Insulin cost sharing is one of the benefits that will start in 2023 and includes:
- Starting January 1, 2023, people enrolled in a Medicare prescription drug plan will not pay more than $35 for a month’s supply of each insulin that they take and is covered by their Medicare prescription drug plan and dispensed at a pharmacy or through a mail-order pharmacy. Also, Part D deductibles will not apply to the covered insulin product.
- Starting July 1, 2023, people with traditional Medicare who take insulin through a traditional pump will not pay more than $35 for a month’s supply of insulin, and the deductible will not apply to the insulin. This will apply to people using pumps covered through the durable medical equipment benefit under Part B.
COVID-19 PHE Extended
The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency this past Thursday, October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. Sixty days prior to January 11, 2023 is Saturday, November 12th, 2022.
Social Security Benefits in 2023
In an October 13th Press Release (link), the Social Security Administration announced that “approximately 70 million Americans will see a 8.7% increase in their Social Security benefits and Supplemental Security Income (SSI) payments in 2023. On average, Social Security benefits will increase by more than $140 per month starting in January.”
Calendar Year 2023 Medicare Deductible, Coinsurance & Payment Rates
Since writing about the updated Medicare deductible, coinsurance and payment rates in last week’s newsletter (link), CMS has published MLN Matters article MM12903 (link) which includes background information regarding a Medicare beneficiary’s “spell of illness” and Medicare coverage in a skilled nursing facility (SNF) as well as the 2023 payment rate changes.
As we wait for the release of the CY 2023 Outpatient Prospective Payment System (OPPS) Final Rule, the 2022 CERT Report, and the possible notification of the end of the COVID-19 PHE, I wish all our readers a happy fall y’all.
Did You Know?
- An estimated 12.1 million people will have A-Fib in 2030,
- In 2019, A-fib was mentioned on 183,321 death certificates and was the underlying cause of death in 26,535 of those deaths,
- People of European descent are more likely to have A-fib than African Americans, and
- Because the number of A-fib cases increases with age and women generally live longer than men, more women than men experience A-fib.
Why it Matters?
- More than 454,000 hospitalizations with A-fib as the primary diagnosis happen each year in the United States,
- A-fib increases a person’s risk of stroke. In fact, A-fib causes 1 in 7 strokes and strokes caused by A-fib tend to be more severe than strokes with other underlying causes, and
- The death rate from A-fib as the primary or a contributing cause of death has been rising for more than two decades.
What Can I Do?
Know the risk factors for A-fib
- Advancing age,
- Family member with a history of A-fib increases your chances of having A-fib,
- High blood pressure,
- European ancestry,
- Heart failure,
- Ischemic heart disease,
- Chronic Kidney Disease,
- Moderate to heavy alcohol use,
- Enlargement of the chambers on the left side of the heart,
- A-fib is the most common complication after heart surgery,
Know the symptoms of A-fib
- Irregular heartbeat,
- Heart palpitations (rapid, fluttering, or pounding),
- Extreme fatigue,
- Shortness of breath, and
- Chest pain.
Note, it is possible to have no symptoms, or in my mom’s experience, she thought was having panic attacks when on further study by her physician, she was experiencing episodes of A-fib.
Know Common “Triggers” That May Cause an Episode of A-fib
- Caffeine and energy drinks. The American Heart Association notes that “although normal amounts of coffee shouldn’t trigger Afib, further study may be warranted for energy drinks and excessive caffeine intake.”
- Excessive alcohol,
- Stress or anxiety, and
- Poor sleep and/or sleep apnea.
Know the Treatment Options
- Medicines to control your heart’s rhythm and rate,
- Non-surgical procedures (i.e., electrical cardioversion and radiofrequency ablation), and
- Surgical procedures (i.e., pacemaker, left atrial appendage closure implant (Watchman™) for non-valvular A-fib).
While other conditions can cause similar symptoms, if you experience any symptoms of A-fib, contact your doctor. If you are diagnosed with A-fib there is good news. According to the American Heart Association, “people can live long healthy and active lives with AFib. Controlling your risk factors for heart disease and stroke and knowing what can possibly trigger your AFib will help improve your long-term management of AFib.”
- CDC Atrial Fibrillation (A-fib): https://www.cdc.gov/heartdisease/atrial_fibrillation.htm
- American Heart Association: https://www.heart.org/en/health-topics/atrial-fibrillation/who-is-at-risk-for-atrial-fibrillation-af-or-afib
This past weekend my brother and I had the daunting task of downsizing my mom’s living space from an Assisted Living Facility apartment to a long-term care room. While a tough move for my mom, we did find a few hidden treasures and memories. One such memory was finding pictures from a 1976 vacation taken by my grandmother aboard a cruise ship that was part of the 1970s TSS Mardi Gras, The Golden Fleet Carnival Cruise Line. In addition to finding the pictures, there was a packet of daily activities and a map of the different levels of the ship.
In keeping with the cruise ship treasures that we found, this week we celebrate the 12th annual Clinical Documentation Integrity (CDI) Week with the theme Under the Sea-DI. A CDI Week Fact Sheet (link) published by the Association of Clinical Documentation Integrity Specialists (ACDIS), indicates that “CDI specialist review patient medical records and assess whether all conditions and treatments are documented. This documentation helps paint an accurate picture of the severity of the patient’s illness and the extent of the care required. When the documentation is unclear or deficient, CDI specialists prompt (also known as “query”) physicians to provide clarification. CDI specialists serve as the bridge between health information management (HIM) and clinical staff. They must comply with Medicare and/or private payer rules and regulations.”
Just as it takes the entire crew to make a cruise ship run smoothly, it takes the CDI team coordinating with doctors, other departments participating in the care of a patient (i.e., physical therapy, dietician, pharmacy), and coding professionals to find all the hidden treasure in a patient’s medical record.
MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, following are links to key treasure for a successful start to the CMS FY 2023.
FY 2023 IPPS Final Rule Home Page (link)
On this webpage you will find a links to:
- The FY 2023 IPPS Final Rule,
- FY 2023 Final Rule Tables
- Table 5: MS-DRGs, Relative Weighting Factors, Geometric and Arithmetic Mean Lengths of Stay, and Post-Acute Transfer designated MS-DRGs
- Table 6: New Diagnosis Codes,
- Table 6B: New Procedure Codes
- Table 6I: Complete MCC List,
- Table 6I.1: Additions to the MCC List,
- Table 6I.2: Deletions to the MCC List,
- Table 6J: Complete CC list,
- Table 6J.1: Additions to the CC list,
- Table 6J.2: Deletions to the CC list
- FY 2023 MAC Implementation Files
- MAC Implementation File 7: FY 2023 MS-DRGs Subject to the Replaced Devices Policy,
- MAC Implementation File 8: FY 2023 New Technology Add-on Payment
2023 ICD-10-CM Files (link)
Downloads available on this webpage includes:
- 2023 POA Exempt Codes,
- 2023 Conversion Table,
- 2023 Code Description in Tabular Order,
- 2023 Addendum,
- 2023 Code Tables, Tabular and Index, and
- FY 2023 ICD-10-CM Coding Guidelines.
The ICD-10-Files are also available on the CDC’s Comprehensive Listing ICD-10-CM Files webpage (link).
2023 ICD-10-PCS Files (link)
Downloads available on this webpage includes:
- 2023 ICD-10-PCS Order File,
- 2023 Official ICD-10-PCS Coding Guidelines,
- 2023 Version Update Summary,
- 2023 ICD-10-PCS Codes File,
- 2023 ICD-10-PCS Conversion table, 2023 ICD-10-PCS Code Tables and Index, and
- 2023 ICD-10-PCS Addendum.
MS-DRG Definitions Manual and Software
The ICD-10 MS-DRG Version 40 (V40) Grouper Software, ICD-10 MS-DRG Definitions Manual, and the Definitions of Medicare Code Edits V 40 files are publicly available on the CMS MS-DRG Classifications and Software webpage (link).
Again, happy CDI week from our team to yours.
July is UV Safety Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to the treatment costs of Melanoma.
Did You Know?
Anyone can get skin cancer, but people with certain characteristics are at greater risk—
- A lighter natural skin color.
- Skin that burns, freckles, reddens easily, or becomes painful in the sun.
- Blue or green eyes.
- Blond or red hair.
- Certain types and a large number of moles.
- A family history of skin cancer.
- A personal history of skin cancer.
- Older age.
Why Does this Matter?
According to the CDC (link), skin cancer is the most common form of cancer in the United States. The most common types of skin cancer are basal cell and squamous cell and “survey data suggests that each year, about 4.3 million adults are treated for basal cell and squamous cell carcinomas at a cost of about $4.8 billion.”
What Can You Do About It?
Be proactive in lowering your risk for melanoma and other skin cancers by following key sun safety tips from the FDA (link):
- Limit time in the sun, especially between the hours of 10 a.m. and 2 p.m., when the sun’s rays are most intense,
- Wear clothing to cover skin exposed to the sun, such as long-sleeved shirts, pants, sunglasses, and broad-brimmed hats.
- Use broad spectrum sunscreens with SPF values of 15 or higher regularly and as directed.
- Reapply sunscreen at least every two hours, and more often if you are sweating or jumping in and out of the water.
Also, be mindful that certain medications can cause sensitivity to the sun, for example:
- Antibiotics (ciprofloxacin, doxycycline, levofloxacin, ofloxacin, tetracycline, trimethoprim),
- Antihistamines including Diphenhydramine (common brands include Benadryl and Nytol),
- Oral contraceptives and estrogens, and
- Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen).
You can read more about this on the FDA website (link).
Do you know when the COVID-19 Public Health Emergency (PHE) will end?
The COVID-19 PHE declaration was last renewed on January 14, 2022 with an effective date of January 16th (link). When the Secretary of the Department of Health and Human Services (HHS) makes a PHE declaration, it lasts for the duration of the PHE or 90 days but may be extended by the Secretary for as long as the PHE continues to exist. The most recent declaration is set to end April 16, 2022.
Further, in January 2021, acting HHS Secretary Norris Cochran sent a letter to governors across the country to share details about the COVID-19 PHE and indicated in the letter that HHS “has determined that the PHE will likely remain in place for the entirety of 2021, and when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”
The federal government has penalized 764 hospitals — including more than three dozen it simultaneously rates as among the best in the country — for having the highest numbers of patient infections and potentially avoidable complications.
The penalties — a 1% reduction in Medicare payments over 12 months — are based on the experiences of Medicare patients discharged from the hospital between July 2018 and the end of 2019, before the pandemic began in earnest. The punishments, which the Affordable Care Act requires be assessed on the worst-performing 25% of general hospitals each year, are intended to make hospitals focus on reducing bedsores, hip fractures, blood clots, and the cohort of infections that before covid-19 were the biggest scourges in hospitals. Those include surgical infections, urinary tract infections from catheters, and antibiotic-resistant germs like MRSA.
This year’s list of penalized hospitals includes Cedars-Sinai Medical Center in Los Angeles; Northwestern Memorial Hospital in Chicago; a Cleveland Clinic hospital in Avon, Ohio; a Mayo Clinic hospital in Red Wing, Minnesota; and a Mayo hospital in Phoenix. Paradoxically, all those hospitals have five stars, the best rating, on Medicare’s Care Compare website.
Eight years into the Hospital-Acquired Condition Reduction Program, 2,046 hospitals have been penalized at least once, a KHN analysis shows. But researchers have found little evidence that the penalties are getting hospitals to improve their efforts to avert bedsores, falls, infections, and other accidents.
“Unfortunately, pretty much in every regard, the program has been a failure,” said Andrew Ryan, a professor of health care management at the University of Michigan’s School of Public Health, who has published extensively on the program.
“It’s very hard to capture patient safety with the surveillance methods we currently have,” he said. One problem, he added, is “you’re kind of asking hospitals to call out events that are going to have them lose money, so the incentives are really messed up for hospitals to fully disclose” patient injuries. Academic medical centers say the reason nearly half of them are penalized each year is that they are more diligent in finding and reporting infections.
Another issue raised by researchers and the hospital industry is that under the law, the Centers for Medicare & Medicaid Services each year must punish the quarter of general care hospitals with the highest rates of patient safety issues even if they have improved and even if their infection and complication rates are only infinitesimally different from those of some non-penalized hospitals.
In a statement, CMS noted it had limited ability to alter the program. “CMS is committed to ensuring safety and quality of care for hospital patients through a variety of initiatives,” CMS said. “Much of how the Hospital-Acquired Condition (HAC) Reduction Program is structured, including penalty amounts, is determined by law.”
In allotting the penalties, CMS evaluated 3,124 general acute hospitals. Exempted from the evaluation are around 2,000 hospitals. Many of those are critical access hospitals, which are the only hospitals serving a geographic — often rural — area. The law also excuses hospitals that focus on rehabilitation, long-term care, children, psychiatry, or veterans. And Maryland hospitals are excluded because the state has a different method for paying its hospitals for Medicare patients.
For the penalized hospitals, Medicare payments are reduced by 1% for each bill from October 2021 through September 2022. The total amount of the penalties is determined by how much each hospital bills Medicare.
A third of the hospitals penalized in the list released this year had not been punished in the previous year. Some, like UC Davis Medical Center in California, have gone in and out of the penalty box over the program’s eight years. Davis has been penalized four years and not punished four years.
“UC Davis Medical Center is usually within a few points of the [Hospital-Acquired Condition Reduction Program] threshold, so it’s not unusual to move in and out of the program year to year,” UC Davis Health said in an email. It said Davis ranked 38th out of 101 academic medical centers that use a private quality measurement system.
The Cleveland Clinic said that its satellite hospital in Avon has received awards from private groups, such as an “A” grade for patient safety from the nonprofit Leapfrog Group. Both it and Cedars-Sinai touted their five-star ratings. In addition, Cedars said that overall assessment comes even though the hospital deals with large numbers of very sick patients. “This [star] rating is particularly meaningful because of the complexity of the care that many of our patients require,” Cedars said in a statement.
Other hospitals declined to comment or did not respond to emails.
The KHN analysis found that the government penalized 38 of the 404 hospitals that were both included in the hospital-acquired conditions evaluation and had received five stars for “overall quality,” which CMS calculates using dozens of metrics. Those include not just infection and complication rates but also death rates, readmission frequencies, ratings that patients give the hospital after discharge, and hospitals’ consistency in following basic protocols in a timely manner, such as giving patients medicine to break up blood clots in the 30 minutes after they display symptoms of potential heart attacks.
In addition, 138 of 814 hospitals with the next-highest rating of four stars were docked by the program, KHN found.
Lower-rated hospitals were penalized with a higher frequency: Although just 9% of five-star hospitals were punished, 67% of one-star hospitals were.
KHN’s analysis found major discrepancies between the list of penalized hospitals and how Medicare’s Care Compare rated them for virtually the same patient safety infection rates and conditions. On the Medicare site, two-thirds of the penalized hospitals are rated as “no different than average” or “better than average” for the public safety measures CMS uses in assigning star ratings. The major differences center on the time frames for those measures and the structure of the penalty program. The Medicare website, for instance, evaluated only one year of infection rates, rather than the 18 months’ worth that the penalty program examined. And the public ratings are more forgiving than the penalties: Care Compare rates each hospital’s patient safety metric as average unless it’s significantly higher or lower than the scores of most hospitals, while the penalty program always punishes the lowest quartile.
Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, said the penalties would cause more stress to hospitals already struggling to handle the influx of covid patients, staffing shortages, and the extra costs of personal protective equipment. “It is demoralizing to the staff when they see their hospital is deemed unsafe or less safe than other hospitals,” she said.
Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said it was time for Congress and CMS to reevaluate the penalty program. “When this program had started, the thought was that we would get to zero” avoidable complications, she said, “and that hasn’t proven to be the case despite a really good effort on the part of some of these hospitals.”
She said the hospital-acquired conditions penalty program, along with other quality-improvement programs created by the ACA, feels “very ready for a refresh.”
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August 20, 2021: CMS COVID-19 Flexibilities Reminders: Prior Authorization Process, Utilization Management and Medical Necessity
The CMS issued a letter (link) to Medicare Advantage Organizations (MAOs) noting that with the recent COVID-19 delta variant surge resulting in increased hospitalizations, they encourage MA Plans “to waive or relax plan prior authorization requirements and utilization management processes to facilitate the movement of patients from general acute-care hospitals to post-acute care” settings (i.e., skilled nursing facilities, inpatient rehabilitation facilities, inpatient rehabilitation facilities and home health agencies).
Of note, CMS goes on to remind MAOs that “while they and their contract providers are not required to follow Original Medicare’s documentation requirements or policies for establishing medical necessity, the methods implemented…to determine medical necessity cannot result in coverage standards that are more stringent than standards that apply in Fee-For-Service Medicare.”
August 27, 2021: FAQs Regarding ICD-10-CM/PCS Coding for COVID-19 Updated
The FAQ document jointly developed and approved by the American Hospital Association’ Central Office on ICD-10-CM/PCS and the American health Information Management Association provides answers to questions related to Coding COVID-19. This document (link) was most recently revised August 27, 2021.
September 2, 2021: Resumption in Use and Distribution of Bamlanivimab/Etesevimab in all U.S. States, Territories, and Jurisdictions
In late August, use of this COVID-19 monoclonal antibody treatment was revised to authorize use only in areas where the combined frequency of variants resistant to both treatments administered together was less than or equal to 5%. On September 2nd, the FDA announced (link) that based on most recently available data, Bamlanivimab and Etesevimab, administered together, can be used in all U.S. states, territories, and jurisdictions under the condition of authorization for EUA 94.
September 9, 2021: CDC Clinician Outreach and Communications Activity Call: 2021-2022 Influenza Vaccination Recommendations and Guidance on Coadministration with COVID-19 Vaccines
The CDC held this call on Thursday, September 9, 2021. Presenters provided updates on the Advisory Committee on Immunization Practices (ACIP) recommendations for the 2021-2022 influenza vaccination season and guidance for co-administration of influenza and COVID-19 vaccines. One key take away is that COVID-19 vaccines may be administered without regard to timing of other vaccines. For those that missed this call, you can visit the CDC webpage specific to this call (link) to download a copy of the slides.
September 10, 2021: FDA Statement – COVID-19 Vaccines for Young Children
Acting FDA Commissioner Janet Woodcock M.D., and Peter Marks, M.D, Ph.D., director the FDA’s Center for Biologics Research and Education, released a statement (link) providing an update detailing steps being taken to ensure the safety and efficacy of COVID-19 vaccines for young children. The statement ends with the following advice, “Until we authorize or approve a vaccine for this younger population, it’s especially important that parents and others who interact closely with children under 12 years of age get vaccinated, wear masks, and follow other recommended precautions so that we can protect those who cannot yet protect themselves through vaccination.”
September 10, 2021: HHS Announced $25.5 Billion in COVID-19 Provider Funding
The HHS announced (link) that funding from the American Rescue Plan (ARP) and Provider Relief Fund (PFR) totaling $25.5 billion is being made available for health care providers affected by the COVID-19 pandemic. HHS Secretary Xavier Bacerra noted that “this funding critically helps health care providers who have endured demanding workloads and significant financial strains amidst the pandemic…the funding will be distributed with an eye towards equity, to ensure providers who serve our most vulnerable communities will receive the support they need.”
September 30, 2021: CDC COCA Call: Evaluating and Supporting Patients Presenting with Fatigue Following COVID-19
The CDC will be holding a Clinician Outreach and Communication Activity (COCA) call Thursday September 30, 2021, in which presenters will discuss post-COVID conditions (PCC), “an umbrella term for the wide range of health consequences present four or more weeks after infection with SARS-CoV-2, which includes Long-COVID.” If you are unable to attend, call materials will be available on the CDC specific webpage for this call (link).
In case you are not a long-time reader of our newsletter, fall is my favorite time of year. Even though the official start of fall is still a week away, with morning lows in the mid 50’s recently, I have already had my first cup of apple spice tea, first cup of pumpkin spice coffee, and made my first batch of chili in the slow cooker. I have also put out my fall pumpkin themed door mat as we enter the months of celebrating fall, Halloween, Thanksgiving, Christmas.
In the world of Medicare, fall is also a time for new beginnings and celebrations. The new CMS Fiscal Year (FY) starts on October 1st and more importantly this week is all about celebrating the 11th annual Clinical Documentation Integrity (CDI) Week. In keeping with my culinary firsts of the fall, this year’s CDI Week theme is CDI Kitchen: Recipes for a Successful Program. According to a related Association for Clinical Documentation Integrity Specialists (ACDIS) Fact Sheet (link), “the growth of the CDI specialist profession has mirrored the healthcare industry’s increased focus on compliance with regulations, managed care profiles, payment for services rendered, quality of care improvement measurements, and liability exposure. All these factors increasingly depend on the integrity of complete and specific clinical documentation in the medical record.”
MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, following are links to key ingredients for a successful start to the CMS FY 2022.
2022 ICD-10-CM Official Guidelines
- Available on CDC website at: https://www.cdc.gov/nchs/icd/icd10cm.htm
- Available on CMS website at: https://www.cms.gov/medicare/icd-10/2022-icd-10-cm
You can read about changes for FY 2022 in a related MMP article (link).
2022 ICD-10-PCS Official Guidelines
- Available on CMS website at: https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs
2022 CMS IPPS Final Rule
- CMS FY 2022 IPPS Final Rule Home Page: https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page
- Tables 6A-6K are also available on this page in excel format and includes among other things:
- New Diagnosis and Procedure codes,
- “Additions to” and “deletions from” the MCC and CC lists, and
- The complete MCC and CC lists.
FY 2022 ICD-10-CM/PCS Codes, MCCs and CCs
There are 165 new diagnosis codes. Of note, including in this list are:
- 11 new Social Determinants of Health (SDOH) ICD-10-CM codes, and
- 4 new COVID-19 related codes including U09.9 (Post COVID-19 condition, unspecified), Z1152 (Encounter for screening for COVID-19), Z20.822 (Contact with and *suspected) exposure to COVID-19), and Z86.16 (Personal history of COVID-19).
There are 212 new ICD-10-PCS procedure codes, including several new codes related to COVID-19 vaccines and monoclonal antibody treatments for COVID-19.
There are nine additions to the MCC list, including J12.82 (Pneumonia due to coronavirus disease 2019) which was implemented January 1, 2021. There are eleven additions to the CC list, which also include two codes implemented January 1, 2021 (M35.81 (multisystem inflammatory syndrome) and M35.89 (Other specific systemic involvement of connective tissue)).
Again, happy CDI week from our team to yours.
COVID-19 Booster Shots
On August 18, 2021, HHS released a statement, (link), indicating that “the available data make very clear that protection against SARS-CoV-2 infection begins to decrease over time following the initial doses of vaccination, and in association with the dominance of the Delta variant, we are starting to see evidence of reduced protection against mild and moderate disease. Based on our latest assessment, the current protection against severe disease, hospitalization, and death could diminish in the months ahead, especially among those who are at higher risk or were vaccinated during the earlier phases of the vaccination rollout. For that reason, we conclude that a booster shot will be needed to maximize vaccine-induced protection and prolong its durability.” HHS goes on to indicate they have a plan to begin offering booster shots this fall of a third dose of the Pfizer and Moderna mRNA vaccines, “beginning the week of September 20 and starting 8 months after an individual’s second dose.”
HHS also anticipates the need for a booster shot for individuals that received the Johnson & Johnson (J&J) vaccine. They note that “administration of the J&J vaccine did not begin in the U.S. until March 2021, and we expect more data on J&J in the next few weeks. With those data in hand, we will keep the public informed with a timely plan for J&J booster shots as well.”
COVID-19 Third Dose of Moderna and Pfizer-BioNTech CPT Codes
Concurrent to the recommendation that individuals receive a third Moderna or Pfizer-BioNTech COVID-19 vaccine, the AMA published the following CPT codes.
- Moderna Third Dose
- Effective for Emergency Use Authorization (EUA) as of August 12, 2021.
- Administration code 0013A
- Pfizer-BioNTech Third Dose
- Effective for EUA as of August 12, 2021
- Administration code 0003A
You can find a summary of the SARS-CoV-2 related CPT codes on the AMA website (link).
COVID-19 Myths and Facts
The CDC has a webpage (link) dedicated to dispelling myths about COVID-19 vaccines. For example:
- Yes, the Pfizer-BioNTech and Moderna mRNA vaccines trigger an immune response inside your body and are considered vaccines. The CDC notes that “this type of vaccine is new, but research and development on it has been under way for decades.”
- No, COVID-19 vaccines do not contain microchips.
- No, receiving a COVID-19 vaccine will not make you magnetic.
The World Health Organization (WHO) also has a webpage (link) dedicated to dispelling myths about COVID-19 in general by providing the facts, for example:
- COVID-19 is caused by a virus, not by bacteria. The virus that causes COVID-19 is in a family of viruses called Coronaviridae.
- The COVID-19 virus can spread in hot and humid climates, and
- 5G mobile networks DO NOT spread COVID-19. COVID-19 is a virus and is spread through respiratory droplets when an infected person coughs, sneezes or speaks. People can also be infected by touching a contaminated surface and then their eyes, mouth, or nose.
September is Prostate Cancer Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to screening for Prostate Cancer.
Did You Know?
According to the CDC:
- 13 out of every 100 American men will get prostate cancer during their lifetime, and
- 2 to 3 men will die from prostate cancer,
- If you are African American or have a family history of prostate cancer you are at increased risk for getting or dying from prostate cancer.
The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.
Why Does this Matter? Know the Symptoms
The CDC advises that if you are having any of the following symptoms, you need to see your doctor right away:
- Difficulty starting urination.
- Weak or interrupted flow of urine.
- Frequent urination, especially at night.
- Difficulty emptying the bladder completely.
- Pain or burning during urination.
- Blood in the urine or semen.
- Pain in the back, hips, or pelvis that doesn’t go away.
- Painful ejaculation.
The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.
What You Can Do About It? Screening for Prostate Cancer
There are two tests commonly used to screen for prostate cancer:
- A blood test called a prostate specific antigen (PSA) test and
- A digital rectal examination (DRE).
The U.S. Preventive Services Task Force recommendation is that men aged 55 to 69 years should participate in a shared decision making process with their physician by discussing the potential benefits and harms of screening with a PSA test and incorporating their values and preferences in the decision.
This recommendation applies to men who:
- Are at average risk for prostate cancer,
- Are at increased risk for prostate cancer,
- Do not have symptoms of prostate cancer, and
- Have never been diagnosed with prostate cancer.
Medicare Preventive Service: Prostate Cancer Screening – Coverage & Coding
HCPCS & CPT Codes
- G0102 (Prostate cancer screening; digital rectal exam): A patient’s copayment or coinsurance, and deductible will apply.
- G0103 (Prostate cancer screening; prostate specific antigen test): there is no copayment, coinsurance, or deductible for the patient.
- CDC website: https://www.cdc.gov/cancer/prostate/
- NIH National Cancer Institute Cancer Stat Facts: Prostate Cancer: https://seer.cancer.gov/statfacts/html/prost.html
- U.S. Preventive Services Task Force Final Recommendation Statement for Prostate Screening: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
- CMS MLN Educational Tool (MLN006559 May 2021): Medicare Preventive Services at https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventive-services/mps-quickreferencechart-1.html#PNEUMO
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