Knowledge Base Category -

 Outpatient Services
MMP Logo no Words or Tag
June 2022 Medicare Transmittals and Proposed Rules
Published on Jun 29, 2022
20220629

June 2022 Medicare Transmittals and Proposed Rules

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022
  • Article Release Date: May 9, 2022 – Revised June 21, 2022
  • What You Need to Know: This article details information about newly available codes, separate NCD coding revisions and coding feedback. It was updated on June 21, 2022, to reflect a revised Change Request (CR) 12705. The substance of the article did not change. NCDs updated includes:
    • NCD 20.31 Intensive Cardiac Rehabilitation (ICR) Programs,
    • NCD 20.31.1 Pritikin Program,
    • NCD 20.31.2 Ornish Program for Reversing Heart Disease,
    • NCD 20.31.3 ICR Benson-Henry Program,
    • NCS 90.2 Next Generation Sequencing (NGS),
    • NCD 160.18 Vagus Nerve Stimulation (VNS),
    • NCD 180.1 Medical Nutrition Therapy (MNT), and
    • NCD 270.3 Blood Derived Products for Chronic Non-healing Wounds
  • MLN MM12705: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2021 Update
  • Article Release Date: May 18, 2021 – 2nd Revision June 22, 2022
  • What You Need to Know: This MLN was revised to reflect CR 12124 which changed the business requirements for NCD 90.2, Next Generation Sequencing. This change resulted in a new spreadsheet for this NCD by retaining all ICD-10 Not Otherwise Classified (NOC) diagnosis codes that had been proposed for deletion effective July 1, 2022. CMS advised that “Although we’re not moving forward with deleting the aforementioned ICD-10 NOC diagnosis codes from NCD 90.2, we continue to strongly encourage providers and laboratories to make sure they provide the best possible and most specific code on the claim in accordance with the implementation of ICD-10 in 2015. We’ll be monitoring these laboratory claims and may take future action to reinstate removal of these ICD-10 NOC codes.”
  • MLN MM12124: (link)
July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
  • Article Release Date: June 9, 2022 – Revised June 24, 2022
  • What You Need to Know: This article was revised to remove two HCPCS codes from table 3 of the Change Request 12773 reducing the number of new codes from 16 to 14.
  • MLN MM12773: ((link)

Medicare Proposed Rules

On Tuesday, June 21, 2022, CMS published a Special Edition MLN Connects ((link) spotlighting the release of two Calendar Year (CY) 2023 proposed rules:

  • CY 2023 Home Health Prospective Payment System Rule Update and Home Infusion Therapy Services Requirements Proposed Rule (CMS-176-P), and
  • ESRD Facilities: CY 2023 Proposed Rule.

The MLN connects includes links to Fact Sheets highlighting key provisions in each proposed rule. CMS is accepting comments through August 16, 2022, for the Home Health Proposed Rule and August 22, 2022, for the ESRD Facilities proposed rule.

Beth Cobb

June 2022 Medicare Transmittals and Coverage Updates
Published on Jun 22, 2022
20220622

Medicare MLN Articles & Transmittals

July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • MLN Release Date: May 31, 2022
  • What You Need to Know: This article includes information about new COVID-19 CPT vaccine and administration codes. You will also find details about new CPT proprietary laboratory analyses (PLA) coding changes and new CPT Category III codes effective July 1, 2022.
  • MLN MM127961: (link)
Update to 'J' Drug Code List for Billing Home Infusion Therapy (HIT) Services
  • MLN Release Date: May 31, 2022
  • What You Need to Know: This article provides information about a new HCPCS drug code for payment beginning July 1, 2022, and updates to the list of home infusion drugs.
  • MLN MM12667: (link)
July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
  • MLN Release Date: June 9, 2022
  • What You Need to Know: Effective July 1, 2022, there is a new CPT Category III Code, newly established HCPCS codes for drugs, biologicals and radiopharmaceuticals and new skin substitute products and low-cost/high-cost group assignment.
  • MLN MM12773: (link)

Revised Medicare MLN Articles & Transmittals

July 2022 Updates to the Hospital Outpatient Prospective Payment System (OPPS)
  • Article Release Date: May 31, 2022 – Revised June 16, 2022
  • What You Need to Know: This article was revised due to CMS rescinding Transmittal 11435 and replacing it with Transmittal 11457 to correct Table 1 in the attachment A, because it was missing some codes.
  • MLN MM12761: (link)

Coverage Updates

Surgical Dressings: Medicare Requirements

Excerpt from May 26, 2022 edition of MLN Connects ((link)

“Medicare covers primary or secondary surgical dressings:

  • When used to protect or treat a wound
  • If needed after you debride a wound
  • You must:
  • Include clinical information in patients’ medical records that demonstrates a reasonable and necessary need for the type and quantity of surgical dressings
  • Evaluate the wound monthly and update the record, unless you document why you can't do a monthly evaluation and how you're monitoring the patient's ongoing use of dressings
  • For more information, see the Surgical Dressings – Policy Article.”
Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease Tracking Sheet

On June 16, CMS posted a Tracking Sheet (link) regarding National Coverage Determination (NCD) 220.6.20 Beta Amyloid Positron Tomography in Dementia and Neurodegenerative Disease. CMS generated this NCD analysis based on stakeholder feedback during the finalization of the NCD for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease. The purpose of the NCD reconsideration is to determine if the current policy of one PET scan per patient per lifetime should be revised.

Beth Cobb

May 2022 Medicare MLN Articles and Transmittals Updates
Published on May 25, 2022
20220525

Medicare MLN Articles & Transmittals

Section 127 of the Consolidated Appropriations Act: Graduate Medical Education (GME) Payment for Rural Track Programs (RTPs)
  • Article Release Date: April 28, 2022
  • What You Need to Know: Your billing staff needs to be aware of a new definition for RTPs, changes in Section 127 of the Consolidated Appropriations Act (CAA), 2021, and the documentation requirements for hospitals requesting indirect and direct GME rate increases.
  • MLN MM12709: (link)
Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 15 – Ambulance
  • Article Release Date: April 28, 2022
  • What You Need to Know: This article reports an update to the Medicare Claims Processing Manual. It also provides background guidance on how ambulance providers should bill for Medicare Part B ambulance services when a patient dies before the ambulance arrives and when a patient dies after being loaded on the ambulance.
  • MLN MM12707: (link)
Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as Certain Colorectal Cancer Screening Tests
  • Article Release date: April 29, 2022
  • What You Need to Know: Beginning January 1, 2022, CMS began to gradually reduce the coinsurance for any procedure beyond a planned colorectal cancer screening test until the procedure is completely free for dates of service on or after January 1, 2030.
  • MLN MM12656: (link)
Calendar Year 2023 Modifications/Improvements to Value-Based Insurance Design (VBID) Model – Implementation
  • Article Release Date: April 29, 2022
  • What You Need to Know: Information in this article is for hospices, hospitals, and suppliers billing MACs for services provided to Medicare hospice patients enrolled in Medicare Advantage (MA) plans participating in the voluntary Value-Based Insurance Design (VBID) Model’s Hospice Benefit component.
  • MLN MM12688: (link)
Quarterly Update for Clinical Laboratory Fee Scheduled (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
  • Article Release Date: May 5, 2022
  • What You Need to Know: Links in this article will help you find updates pertaining to Advanced Diagnostic Laboratory Tests (ADLTs) and new codes effective July 1, 2022.
  • MLN MM12737: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)---October 2022
  • Article Release Date: May 9, 2022
  • What You Need to Know: There are no policy changes in this ICD-10 quarterly update. Updates do include newly available codes.
  • MLN MM12705: (link)
Revisions to Medicare Part B Coverage of Pneumococcal Vaccinations for the Medicare Benefit Policy Manual Chapter 15, Section 50.4.42
  • Article Release Date: May 9, 2022
  • What You Need to Know: CMS updated the Medicare coverage for pneumococcal vaccinations to align with the Advisory Committee on Immunization Practices (ACIP) recommendations that vary based on patient age and risk factors.
  • MLN MM12723: (link)
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2022 Update
  • Transmittal 11408 (Change Request 12747) Release Date: May 12, 2022
  • What You Need to Know: CR 12747 details information about new HCPCS and CPT codes, new G codes for the 180-day monitoring period for continuous glucose monitoring (CGM), and codes that are no longer valid.
  • Transmittal 11408 (CR 12747): (link)
Elimination of Certificates of Medical Necessity & Durable Medical Equipment Information Forms
  • MLN Release Date: May 12, 2022
  • What You Need to Know: CMS published this Special Edition (SE) article to alert those that bill Durable Medical Equipment (DME) for services and supplies provided to Medicare patients that effective January 1, 2023, CMS will no longer require Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs)
  • MLN SE22002: (link)

Revised Medicare MLN Articles & Transmittals

New Waived Tests
  • Article Release Date: January 18, 2022 – Revised April 27, 2022
  • What You Need to Know: CR 12581 changed the HCPCS code for the Cardinal Health H. Pylori Rapid Test – Whole Blood/Serum Cassette (Whole Blood) to 86318QW. This MLN article was updated to reflect the code change.
  • MLN MM12581: (link)
Update to Chapter 7, “Home Health Services”, of the Medicare Benefit Policy Manual (Pub 100-02)
  • Article Release Date: March 28, 2022 – Revised April 28, 2022
  • What You Need to Know: CR 12615 changed the background and policy sections of the CR’s business requirements and manual attachment. This MLN article was updated to reflect the changes.
  • MLN MM12615: (link)
Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
  • Article Release Date: March 30, 2022 – Revised May 5, 2022
  • What You Need to Know: This article was revised to show that RHCs must include modifier CG on claims for mental health visits via telecommunications.
  • MLN SE22001: (link)

Beth Cobb

May 2022 Coverage Updates, Education Resources, and COVID-19 Updates
Published on May 25, 2022
20220525

Coverage Updates

National Coverage Determination (NCD) 210.14 Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
  • Article Release Date: May 3, 2022
  • What You Need to Know: This article details changes that have been made to NCD 210.14 including:
    • Lowering the minimum age for screening,
    • Removing the restriction on who can provide counseling and shared decision-making (SDM), and
    • Removing the requirement that facilities participate in a registry.
  • MLN MM12691: (link)
Proposed Decision Memo for Home Use of Oxygen (CAG-00296R3)

NCD 240.2 Home use of Oxygen was issued by CMS on September 27, 2021. On May 12, 2022 CMS issued a Proposed Decision Memo (link). CMS notes in the Decision Summary they are proposing to amend “the period of initial coverage for these patients from 120 days to 90 days, in order to align with the 90-day statutory time period.”

Medicare Educational Resources

MLN Booklet: Medicare Mental Health

This booklet (link)">link) explains Medicare-covered mental health and substance use services, eligible professionals, Medicare Advantage coverage, Medicare drug plan (Part D) coverage, medical record documentation and coding. March 2022 updates to this booklet includes updated information about telehealth services and new payment information specific to Clinical Nurse Specialists (CNS), Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse-Midwifes (CNMs).

MLN Fact Sheet Medical Record Maintenance & Access Requirements (MLN4840534)

This Fact Sheet (link) provides information on updated documentation maintenance and access requirements for billing services to Medicare patients. It also tells you how long to keep the documentation and who is responsible for providing access. CMS updated this Fact Sheet in April to add information on medical records to support home health referrals.

Biosimilars Curriculum: Resources for Teaching Your Students

CMS provided information about the FDA’s Biosimilar Curriculum Toolkit in the May 12, 2022 MLN Connects newsletter (link). This toolkit can be used to instruct students in medicine, nursing, physician assistant and pharmacy programs.

New Comprehensive Error Rate Testing (CERT) Outreach and Education Task Force PowerPoint

On May 4, 2022, the CERT Medicare Administrative Contractor (MAC) Outreach and Education Task Force (link) posted a PowerPoint detailing the role of the MACs and the CERT Contractor in reducing the error rate.

COVID-19 Updates

April 29, 2022: Counterfeit At-Home OTC COVID-19 Diagnostic Tests

The FDA released a notice (link) indicating they are aware of counterfeit at-home over-the-counter (OTC) COVID-19 diagnostic tests being distributed or used in the United States and advises they should not be used or distributed. This notice provides information to help you determine if you have a counterfeit test. To date, the two products that they have identified as counterfeit are:

  • Counterfeit Flowflex COVID-19 Test Kits, and
  • Counterfeit iHealth COVID-19 Antigen Rapid Test Kits.
May 10, 2022: AHA and Others Urge Continuation of the COVID-19 Public Health Emergency (PHE)

In a letter to HHS Secretary Becerra (link), the American Hospital Association along with several other organizations (i.e., AARP, American Diabetes Association, American Medical and Nurses Associations) urge the PHE be maintained “until we experience an extended period of greater stability and, guided by science and data, can safely unwind the resulting flexibilities.” A little over a week later, there were less than 60 days before the end of the current PHE. As the government has indicated they will provided at least 60 days’ notice prior to ending the PHE, it appears it will continue at least to October 2022.

Beth Cobb

April 2022 Medicare Transmittals, Coverage Updates and Education Resources
Published on Apr 27, 2022
20220427

Medicare MLN Articles & Transmittals

Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers
  • Article Release Date: March 30, 2022
  • What You Need to Know: This article provides information about regulatory changes for mental health visits in RHCs and FQHCs, and billing information for mental health visits done via telecommunications.
  • MLN SE22001: (link)
Updates to MS-DRGs Subject to IPPS Replaced Devices Offered Without Cost or With a Credit Policy-Fiscal Years 2021-2022
  • Transmittal Release Date: April 7, 2022
  • What You Need to Know: CMS published this One Time Notification (Change Request 12662 / Transmittal 11346) to implement updates to the list of DRGs subject to the IPPS payment policy for reimbursement of replaced devices offered without cost or with a credit, effective for discharges on or after 10/1/2020.
  • Transmittal 11346/CR 12662: (link)

Revised Medicare MLN Articles & Transmittals

Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting & Reporting Data for the Private Payor Rate-Based Payment System
  • Article Release Date: February 27, 2019 – Most recent revision March 24, 2022
  • What You Need to Know: This article was revised to note that Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLs), the data reporting period has been delayed by 1 year due to the December 10, 2021, Protecting Medicare & American Farmers from Sequester Cuts Act.
  • MLN SE19006: (link)
Claims Processing Instructions for the New Pneumococcal 15-valen Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677
  • Article Release Date: November 1, 2021 – Most recent revision March 30, 2022
  • What You Need to Know: This article was revised for a second time to show the MACs will adjust certain previously processed and rejected claims with HCPCS code 90671 after April 4, 2022.
  • MLN MM12550: (link)

Coverage Updates

April 7, 2022: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease Final Decision Memo (CAG-00460N)

CMS published a final decision memo for the coverage of aducanumab (brand name Aduhelm™) and any future monoclonal antibodies directed against amyloid approved by the FDA with an indication for use in treating Alzheimer’s disease. Of note, CMS incorporated over 10,000 stakeholder comments and more than 250 peer-reviewed documents into the determination.

CMS finalized coverage for therapies that receive traditional approval from the FDA under coverage with evidence development (CED). CMS, as a part of this decision, will provide enhanced access and coverage for people with Medicare participating in CMS-approved studies, such as a data collection through routine clinical practice or registries.

More information:

  • Complete press release
  • Fact sheet on Medicare coverage policy for monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease
  • Final NCD CED decision memorandum

Medicare Educational Resources

MLN Booklet: Advanced Practice Registered Nurses, Anesthesiologist Assistants, & Physician Assistants - Revised

This MLN Booklet (link) was updated in March 2022. A summary of changes is available on page three and substantive content updates highlighted in dark red font throughout the booklet. For example, effective January 1, 2022, Physician Assistants bill the Medicare Program directly for their services and get paid like NPs and CNSs.

April 21, 2022: Medicare Provider Compliance Newsletter

In the Thursday April 21st edition of MLN Connects (link), CMS provided a link to their most recent Medicare Provider Compliance Newsletter. Originally, published on a quarterly basis, this newsletter is now published twice a year. In the most recent edition, you can learn about guidance to address billing errors for three topics:

  • Hospice certification and recertification of terminal illness,
  • Refills of durable medical equipment, prosthetics, orthotics, and supplies: items provided on a recurrent basis, and
  • Total hip arthroplasty: medical necessity and documentation requirements.
    • CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

      April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

      In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

Beth Cobb

April 2022 COVID-19, FY 2023 Proposed Rules and Updates to CMS No Surprises Rule FAQs
Published on Apr 27, 2022
20220427

COVID-19 Updates

March 30, 2022: New COVID.gov website Launched

The Biden Administration announced the launch of COVID.gov. (link), “a new one-stop shop website to help all people in the United States gain even better access to lifesaving tools like vaccines, tests, treatments, and masks, as well as get the latest updates on COVID-19 in their area.”

April 14, 2022: FDA Authorizes First COVID-19 Diagnostic Test Using Breath Samples

The FDA announced the issuance of an emergency use authorization (EUA) for the first COVID-19 diagnostic test that detects chemical compounds in breath samples association with COVID-19 (link). The test is named the InspectIR COVID-19 Breathalyzer.

About the InspectIR COVID-19 Breathalyzer test:

  • Is authorized to be performed in environments where the patient specimen is both collected and analyzed, such as doctor’s offices, hospitals, and mobile testing sites, using an instrument about the size of a piece of carry-on luggage.
  • Is authorized to be performed by a qualified, trained operator under the supervision of a healthcare provider licensed or authorized by state law to prescribe tests and can provide results in less than three minutes.
  • Is for people ages eighteen and older without symptoms or other epidemiological reasons to suspect COVID-19.
April 14, 2022: Update to Publication 100.04, Chapter 18 and Publication 100-02, Chapter 15, Section to Add Data Regarding Novel Coronavirus (COVID-19) and its Administration to Current Claims Processing Requirements and Other General Updates
CDC Call: Evaluating and Supporting Patients Presenting with Cognitive Symptoms Following COVID

The CDC will be holding a Clinician Outreach and Communication Activity (COCA) call on May 5th. During this call, presenters will discuss post-COVID conditions (PCC), that are present four or more weeks after infection. Cognitive symptoms, often described as “brain fog,” are frequently reported following a patient’s COVID-19 illness. If you are interested but unable to attend the live call, you can go to the CDC webpage specific for this call (link), after May 5th to find the call materials.

Other Updates

March 30, 2022: FY 2023 Hospice Payment Rate Update – Proposed Rule

CMS announced, in a special edition MLN connects (link), the issuance of a proposed rule (CMS-1773-P) that would update hospice base payments and the aggregate cap amount for FY 2023. The comment period ends on May 31, 2022.

March 31, 2022: FY 2023 Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules

CMS announced, in a special edition MLN connects (link), the issuance of the Inpatient Psychiatric Facilities and Inpatient Rehabilitation Facilities Proposed Rules. You will find links to a summary of key provisions for each proposed rule as well as the proposed rules in this edition of MLN connects. The comment period for both proposed rules end on May 31, 2022.

April 6, 2022: CMS Updates FAQ Document for Providers about the No Surprises Rules

CMS has updated this FAQ document (link) which contains information on frequently asked questions from provider and facilities regarding No Surprises rules, independent dispute resolution, and exceptions to the new rules and requirements.

April 18, 2022: CMS Issues Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) Proposed Rule

In an MLN Connects Special Edition (link), CMS announced the issuance of the FY 2023 IPPS Proposed Rule. They are proposing a 3.2% increase in operating payment rates for acute care IPPS hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users. You will find links to a complete press release, proposed payment fact sheet, maternal health and health equity measures fact sheet, White House statement on reducing maternal mortality and morbidity, and the proposed rule in the announcement. Comments on the proposed rule must be in by June 17, 2022.

Beth Cobb

March 2022 Education Resources, COVID-19, and Other Updates
Published on Mar 30, 2022
20220330

Medicare Educational Resources

MLN Education Tool: Medicare Payment Systems

CMS alerted readers in the Thursday, March 3, 2022 edition of MLN Connects (link) that the MLN education tool Medicare Payment Systems has been updated to include 2022 regulation changes to payment, quality, and policy across several settings (i.e., acute care hospital, skilled nursing facility, and home health).

MLN Booklet: SBIRT Services Updated

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, early intervention approach for people with non-dependent substance use before they need more extensive or specialized treatment. CMS SBIRT Booklet MLN904084 (link) was recently updated to inform providers that beginning January 1, 2022, CMS covers Naloxone HCPCS Code G1028.

COVID-19 Updates

February 28, 2022: CMS COVID-19 FAQs on Medicare Fee-for-Service Billing Documented Updated
This CMS document (link) includes FAQs for providers and suppliers that bill Medicare (i.e., labs, hospitals, ambulance services, physician services) and was last updated on February 28, 2022. Specifically, on February 16th, CMS updated the answer to the following question:
  • Question: The FDA has expanded the approved indication for the antiviral drug Veklury (remdesivir), and it is now authorized for the treatment of COVID-19 in certain adults and pediatric patients who are not hospitalized in addition to those that are hospitalized. How will CMS pay for remdesivir if it is administered in the outpatient setting?
March 3, 2022: Preliminary Medicare COVID-19 Data Snapshot

Medicare most recently updated their Preliminary Medicare COVID-19 Data Snapshot webpage (link) on March 3rd. The data snapshot reports COVID-19 cases and hospitalization data for Medicare beneficiaries diagnosed with COVID-19. Following are highlights from this data release:

  • There have been 1,636,501 total Medicare COVID-19 hospitalizations,
  • Of those hospitalized, most beneficiaries (38%) were discharged home. The other top three discharge dispositions include home health (17%), skilled nursing facility (17%), and expired (17%),
  • The top five chronic conditions among hospitalized beneficiaries includes hypertension (81%), hyperlipidemia (65%), chronic kidney disease (58%), ischemic heart disease (49%) and diabetes (48%),
  • Total Medicare Fee-for-Service payment to date for COVID-19 hospitalizations is $23.4B, and
  • The average payment per beneficiary hospitalization with COVID-19 is $24,304.
March 10, 2022: MLN Matters Notice Revised Emergency Use Authorization (EUA) for EVUSHELD

CMS published the following information about a revised EUA for the COVID-19 monoclonal antibody cilgavimab (EVUSHELD) in the March 10, 2022, edition of MLN Matters (link):

“On February 24, the FDA revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as pre-exposure prophylaxis of COVID-19 in certain adults and pediatric patients. For more information about dosage and administration, including information about dosing for patients who got the original lower dose, review the fact sheet (ZIP) (link).

  • Long Descriptor: Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
  • Short Descriptor: Tixagev and cilgav, 600mg

Visit the COVID-19 Monoclonal Antibodies webpage for more information (link). Note: you may need to refresh your browser if you recently visited this webpage.”

March 22, 2022: 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)

On March 23rd, CMS updated their COVID-19 Current Emergencies webpage (link) by adding a COVID-19 Medicare Provider Enrollment Relief FAQs document (link). The first question in this document answers the question of how CMS is using its 1135 blanket waiver authority to offer flexibilities with Medicare provider enrollment to support the COVID-19 national emergency.

Other Updates

March 16, 2022: Annual Civil Monetary Penalties Inflation Adjustment Published

The Office of the Assistant Secretary for Financial Resources, Department of Health and Human Services (HHS) published the Annual Civil Monetary Penalties Inflation Adjustment Final Rule (link) on March 17, 2022. Examples of actions that can come under a civil monetary penalty includes:

  • Penalty for knowing of an overpayment and failing to report and return.
  • Penalty for failure to grant timely access to HHS OIG for audits, investigations, evaluations, and other statutory functions of HHS OIG.
  • Penalty for a Medicare Advantage organization that substantially fails to provide medically necessary, required items and services.
  • Penalty for improper billing by Hospitals, Critical Access Hospitals, or Skilled Nursing Facilities.

Beth Cobb

March 2022 Medicare Transmittals and Coverage Updates
Published on Mar 30, 2022
20220330

Medicare MLN Articles & Transmittals

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2020 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs)
  • Article Release Date: February 24, 2022
  • What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
  • MLN MM12628: (link)
April 2022 Update to the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)
  • Article Release Date: March 7, 2022
  • What You Need to Know: This article provides information about coding needs and coding criteria for reprocessing inpatient claims involving Pfizer’s PAXLOVID™ or Merk’s Molnupiravir. Both drugs were granted FDA emergency use authorization in December 2021.
  • MLN MM12631: (link)
One-Time Notification: Correction to Processing When Osteoporosis Drugs are Billed for Other Indications
  • Transmittal Release Date: March 9, 2022
  • What You Need to Know: This Change Request (CR) 12551 permanently removes an edit requiring osteoporosis drugs be billed only by home health agencies.
  • Transmittal 11290 (CR 12551): (link)
April Quarterly Update for 2022 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
  • Article Release Date: March 11, 2022
  • What You Need to Know: This article provides information about the April 2022 quarterly update for the DMEPOS fee schedule and fee schedule amounts for new and existing codes.
  • MLN MM12654: (link)
Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)
  • Article Release Date: March 18, 2022
  • What You Need to Know: Make sure your billing staff knows about how to code for difelikefalin injection and modifier use for code J0879.
  • MLN MM12583: (link)
April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • Transmittal 11305/Change Request 12666 Release Date: March 24, 2022
  • What You Need to Know: The effective date for the updates is April 1, 2022. Examples of items included in this update are:
    • o New COVID-19 CPT vaccines and administration codes,
    • o Changes for COVID-19 monoclonal antibody therapy product and administration codes,
    • o A new HCPCS code describing the InSpace Subacromial Tissue Spacer System procedure to treat irreparably torn rotator cuff tendons, and
    • o New separately payable procedure codes for medical procedures.
  • Link to CR 12666: (link)
April 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
  • Article Release Date: March 24, 2022
  • What You Need to Know: Changes to make your billing staff aware of (updates to payment rates for separately payable procedures, services, drugs, and biologicals and descriptors for newly created CPT and Level II HCPCS codes) are detailed in this MLN article.
  • MLN MM12679: (link)

Revised Medicare MLN Articles & Transmittals

Internet-Only Manual Updated for Critical Care Evaluation and Management Services
  • Article Release Date: Initial article January 22, 2022 – Revised March 2, 2022
  • What You Need to Know: This article was revised to reflect a revised Change Request (CR). All other information is the same. As a reminder, CMS has added language to the definition of a Global Surgical Package to direct you to critical care updates in section 30.6.12.7 of the Medicare Claims Processing Manual, Chapter 12.
  • MLN MM12550: (link)

Coverage Updates

Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache)
  • Article Release Date: February 16, 2022
  • What You Need to Know: You will learn about revisions to NCD 240.2 and 240.2.2. For example, CMS notes that “Medical documentation requirements aren’t contained within the revised NCDs. The absence of medical documentation in these revised NCDs doesn’t otherwise remove or modify Medicare requirements of the Certificate of Medical Necessity (CMN) Form 484 itself or other medical documentation requirements under other existing authorities.”
  • MLN MM12607: (link)
March 1, 2022: CMS Posts New Tracking Sheet for the Cochlear Implantation NCD (50.3)

According to a new Tracking Sheet link), “this NCD analysis will align with the scope of the request and focus on individuals with hearing test scores of > 40% and ≤ 60%, for whom coverage is available only when the provider is participating in, and patients are enrolled in a clinical study.” The initial public comment period is from March 1, 2022, to March 31, 2022.

Beth Cobb

February 2022 Medicare Transmittals and MLN Articles Updates
Published on Feb 23, 2022
20220223

Medicare MLN Articles & Transmittals – Recurring Updates

Expedited Review Process for Hospital Inpatients in Original Medicare
  • Article Release Date: January 21, 2022
  • What You Need to Know: CMS has reformatted the current instructions for delivery of the Important Message from Medicare (IMM) and the beneficiary’s rights to an expedited review. While this MLN article notes in bold to “make sure your staff knows this is a reformatting of the current instructions and there are no policy or instructional changes,” following are three noteworthy clarifications:
    • The effective date for the related Change Request is April 21, 2022.
    • A new exception of who you would not provide an IMM to is the beneficiary that ends care on their own initiative by electing the hospice benefit.
    • A new note indicates “the IM should only be given when an inpatient admission is pending or has occurred. It should not be given ‘just in case,’ such as a hospital delivering to all Medicare patients being treated in a hospital emergency room.”
    • CMS has included a statement that “an IM must be delivered even if the beneficiary agrees with the discharge.”
  • MLN MM12546: (link)
Internet-Only Manual Updates for Critical Care Evaluation and Management Services
  • Article Release Date: January 22, 2022
  • What You Need to Know: You will learn about critical care updates for a patient in a global surgical period and the use of modifier FT.
  • MLN MM12550: (link)
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
  • Article Release Date: January 27, 2022
  • What You Need to Know: This article provides instructions for the April 2022 update to the CLFS and new codes effective April 1, 2022.
  • MLN MM12612: (link)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2022
  • Article Release Date: February 10, 2022
  • What You Need to Know: This article provides information about newly available codes, separate NCD coding revisions, and coding feedback.
  • MLN MM12606: (link)
Gap Billing Between Hospice Transfers
  • Article Release Date: February 10, 2022
  • What You Need to Know: A new CWF edit will no longer allow gaps of care to occur during a transfer.
  • MLN 12619: (link)
Omnibus Change Request to Remove Two NCDs, Updates Medical Nutritional Therapy Policy and Updates to Pulmonary Rehabilitation, (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage
  • Change Request 12613/Transmittal 11272 Release Date: February 18, 2022
  • What You Need to Know: Updates became effective January 1, 2022, by statute with an implementation date of July 5, 2022. Specific to PR, the CY 2022 MPFS final rule removed the requirements for direct physician-patient contact and expanded coverage of PR for beneficiaries with confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least 4 weeks. The two NCDs being removed are:
  • NCD 180.2 Enteral/Parenteral Nutritional Therapy, and
  • NCD 220.6 Positron Emission Tomography (PET) Scans.
  • Transmittal 11272: (link)

Revised Medicare MLN Articles & Transmittals

April 2022 Update to the MS-DRG Group and Medicare Code Editor Version 39.1 for ICD-10 Diagnosis Codes for 2019 COVID-19 Vaccination Status and ICD-10-PCS codes for Introduction or Infusion of Therapeutics and Vaccines for COVID-19 Treatment
  • Article Release Date: Initial article January 19, 2022 – Revised February 8, 2022
  • What You Need to Know: This article was revised to add two new procedure codes describing the introduction or infusion of therapeutics including vaccines for COVID-19 treatment, effective April 1, 2022.
  • MLN MM12578: (link)

Beth Cobb

February 2022 Medicare Coverage Updates and COVID-19 Updates
Published on Feb 23, 2022
20220223

Coverage Updates

National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds
  • Article Release Date: September 15, 2021 – Latest Revision January 24, 2022
  • What You Need to Know: This MLN article was revised to reflect a revised Change Request (CR) 12403. HCPCS G0465 was added and additional information for HCPCS G0460 was also added. Also, the implementation date has been revised to February 14, 2022.
  • MLN MM12403: (link)
CWF Editing – NCD 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds
  • Article Release Date: February 16, 2022
  • What You Need to Know: This article provides information about new edits for autologous Platelet-Rich Plasma (PRP) claims for diabetes and chronic ulcers.
  • MLN MM12611: (link)
Final Decision Memo: Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)

CMS posted a Final Decision Memo ((link) for Lung Cancer Screening with LDCT on February 10, 2022. The eligibility age for screening has decreased from 55 years to 50 years. The tobacco smoking history has decreased from thirty packs per year to at least twenty packs per year. Counseling and shared decision-making are required prior to a beneficiary’s first screening test. Shared Decision Making (SDM) shall “include the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure.”

COVID-19 Updates

January 31, 2022: FDA Approves Second COVID-19 Vaccine

The FDA announced the approval of a second COVID-19 vaccine ((link). The vaccine under emergency use authorization has been known as the Moderna COVID-19 vaccine. The approved vaccine will be marketed as Spikevax. Spikevax has the same formulation as the EUA Moderna COVID-19 Vaccine and is administered as a primary series of two doses, one month apart.

February 18, 2022: FDA Authorized Monoclonal Antibody Bebtelovimab

CMS announced in a special edition of MLN Connects ((link) that the FDA has approved the monoclonal antibody Bebtelovimab for the treatment of mild-to-moderate COVID-19 in adult and pediatric patients when specific criteria apply. CMS has created three new codes for administering this drug. You can find information about this and other monoclonal antibody drugs on the CMS COVID-19 Monoclonal Antibodies webpage (link).

Other Updates

February 1, 2022: DOJ News: False Claims Act Settlements and Judgements Exceed $5.6 Billion in Fiscal Year 2021

In this DOJ announcement ((link) the DOJ reports that over $5 billion of the more than $5.6 billion in settlements in the past fiscal year related to matters involving the health care industry, “including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians.”

Beth Cobb

No Results Found!

Yes! Help me improve my Medicare FFS business.

Thank you! Someone will contact you soon.
Oops! Something went wrong while submitting the form.
Thank you for subscribing!
Oops! Something went wrong while submitting the form.