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July 2021 Medicare Transmittals and Coverage Updates
Published on Jul 28, 2021
20210728

Medicare MLN Articles & Transmittals – Recurring Updates

July Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
  • Article Release Date: July 2, 2021
  • What You Need to Know: This article provides information about changes to the DMEPOS fee schedule that is updated on a quarterly basis. Key points in Change Request 12345 are related to The Coronavirus Aid, Relief, and Economic Security (CAREs) Act, 2020 as it relates to DMEPOS.
  • MLN MM12345: (link)
October 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
  • Article Release Date: July 15, 2021
  • What You Need to Know: This article talks about the ASP methodology, which CMS bases on quarterly data submitted to them by manufacturers.
  • MLN MM12342: (link)
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2021
  • Article Release Date: July 15, 2021
  • What You Need to Know: This article is related to Change Request 12384 which announced the changes that will be included in the October 2021 quarterly release of the edit module for clinical diagnostic laboratory services.
  • MLN MM12384: (link)
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.3, Effective October 1, 2021
  • Article Release Date: July 14, 2021
  • What You Need to Know: Change Request (CR) 12340 provides quarterly updated to the NCCI PTP edits.
  • MLN MM12340: (link)

Other Medicare MLN Articles & Transmittals

Section 50 in Chapter 30 of Publication (Pub.) 100-04 Manual Updates: ABNs
  • Article Release Date: July 14, 2021
  • What You Need to Know: This article alerts providers about key changes being made to Chapter 30, Section 50 of the Medicare Claims Processing Manual related to Advance Beneficiary Notices of Non-coverage (ABNs). One key revision listed is the period of effectiveness of the ABN for repetitive or continuous non-covered care.
  • MLN MM12242: (link)

Revised Medicare MLN Articles & Transmittals

National Coverage Determination (NCD 110.24): Chimeric Antigen Receptor (CAR) T-cell Therapy – This CR Rescinds and Fully Replaces CR 11783
  • Article Release Date: Initial article May 24, 2021 – 2nd Revision July 21, 2021
  • What You Need to Know: The revised change request added CPT code C9076 (Breyanz). The implementation date was also revised to September 20, 2021. Breyanz joins a list of other CAR T-cell therapies including Kymriah®, Yescarta®, Tecartus™, and ABECMA®.
  • MLN MM12177: (link)

Medicare Coverage Updates

July 12, 2021: National Coverage Analysis (NCA) for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

July 12, 2021: National Coverage Analysis (NCA) for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease On June 7, 2021, The FDA approved, using accelerated approval, aducanumab (brand name Aduhelm™) with an indication for the treatment of Alzheimer’s disease. Aducanumab is a monoclonal antibody directed against amyloid beta to reduce amyloid accumulations. CMS has initiated a national coverage determination (NCD) analysis (link) and is requesting public comments to several questions.

Medicare Educational Resources

Critical Access Hospital MLN Booklet Revised

JCMS recently revised the MLN Booklet (link) to include changes related to the COVID-19 Public Health Emergency (PHE). Specifically:

  • CAH temporary emergency coverage without a qualifying hospital stay due to COVID-19 PHE, and
  • Waiving the limitation on number of swing beds (25) and Length of Stay of 96 hours during the COVID-19 PHE.

COVID-19 Updates

Medicare COVID-19 Snapshot Updates

CMS updated their Medicare COVID-19 Data Snapshot slides (link) on June 30, 2021, to provide insight on the Medicare population from January 1, 2020 – April 24, 2021. With this update, data shows that there have been over 4.3 million COVID-19 cases and over 1.2 million COVID-19 hospitalizations.

OIG Fraud Alert: COVID-19 Scams

On July 21, 2021, the OIG updated their Fraud Alert: COVID-19 Scam’s webpage (link). You can find a short YouTube video highlighting 5 things about COVID-19 fraud and tips to protect yourself. For example, “offers to purchase COVID-19 vaccination cards are scams. Valid proof of COVID-19 vaccination can only be provided to individuals by legitimate providers administering vaccines.”

July 19, 2021: COVID-19 PHE Extended

In case you missed it in a recent Wednesday@One article, On July 19, 2021, Xavier Becerra, Secretary of Health and Human Services, renewed the PHE effective July 20, 2021 (link).

Other Updates

CY 2022 Medicare Physician Fee Schedule Proposed Rule

CMS issued this proposed rule on July 13, 2020 (link). Examples of what is being proposed includes:

  • Proposals related to telehealth services added during the COVID-19 PHE and a proposal to require use of a new modifier for telehealth services furnished using audio-only communications,
  • Proposal to make direct payments to Physician Assistants (PAs) for professional services furnished under Part B beginning January 1, 2022, and
  • Proposal to begin the payment penalty phase of the Appropriate Use Criteria (AUC) Program on the later of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19.

You can read additional highlights from the proposed rule in a related CMS Fact Sheet (link).

Beth Cobb

July 2021 Pro Tips: Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
Published on Jul 21, 2021
20210721

Welcome to the second monthly edition of MMP’s P.A.R. Pro Tips. For those new to the Wednesday@One, MMP has collaborated with RealTime Medicare Data (RTMD), to develop a proprietary Protection Assessment Report (P.A.R.). This report is a combination of current Medicare Fee-for-Service review targets with hospital specific Medicare Fee-For-Service paid claims data. As a bonus to our Wednesday@One readers, we have begun to provide useful “Did You Know” information that we come across in our ongoing review of key websites (i.e., Medicare Administrative Contractors (MACs), OIG, Recovery Auditors, etc.)

Did You Know?

The Prior Authorization for Certain Hospital OPD Services was implemented effective July 1, 2020. On July 1, 2021, two additional services were added to the list of services requiring prior authorization (Spinal Neurostimlators and Cervical Fusion with Disc Removal). The full list of HCPCS codes requiring prior authorization is available on the CMS webpage dedicated to this process (link).

Pro Tip: MAC Education

MACs nationwide have been providing education to providers regarding this program and more specifically the two new services that have been added to the list of services requiring prior authorization. Following is a sampling of information available for hospital outpatient departments:

CGS (Jurisdiction 15)

CGS’ OPD Prior Authorization webpage (link) walks providers through the process of submitting a prior authorization request, outlines medical record documentation requirements to meet coverage criteria, provides a detailed exemption process timeline, and information about claims submission and appeals. There are also several “NOTES” included throughout this webpage, for example:

  • “Although other providers, such as a physician/staff may submit a PAR on the hospital OPD’s behalf, departmental collaboration is crucial.”
  • “A PAR is valid for one claim/date of service.” Unlike MMP’s Protection Assessment Report (P.A.R.), the PAR related to this CMS program is an acronym for Prior Authorization Request.

    First Coast Service Options, Inc. (Jurisdiction N)

    In late June, First Coast modified their article Vein ablation and related services (link). This article includes:

    • Clinical definitions of veins, varicose veins, endovenous ablation, and chronic venous insufficiency,
    • Applicable HCPCS codes,
    • Documentation requirements,
    • Best practice/documentation feedback/tips and help,
    • Billing and coding alerts, and
    • References, including links to applicable Local Coverage Determination (LCD) and related Local Coverage Article (LCA).

    First Coast also released an updated Prior Authorization (PA) program Q&A document (link) on July 15th.

    National Government Services (NGS Jurisdiction K)

    On July 7, 2021, NGS posted an Outpatient Department Prior Authorization for Implanted Neurostimulators Alert (link). The alert begins by reminding providers that HCPCS 63650 is the only code that needs to be prior authorized for trial and permanent placement. The alert goes on to provide documentation requirements and links to related content.

    Noridian (Jurisdiction E)

    Noridian has created a Prior Authorization Lookup Tool to help providers determine which HCPSC codes require a prior authorization (link). They are also providing Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webinars (link). One is scheduled for today July 21, 2021, and another one is scheduled for August 12, 2021.

    Novitas Solutions Jurisdiction (Jurisdiction H)

    On the Novitas webpage that is dedicated to this program (link), you will find the following:

    • Program background information,
    • Quick links to key documents,
    • General information,
    • Upcoming Education events,
    • Links to all applicable LCDs and LCAs,
    • Information about expedited requests, and
    • Contact Information.

    Palmetto GBA (Jurisdiction J)

    Palmetto has made available a Cervical Disc Spinal Fusion and Spinal Cord Stimulator On-Demand Webcast (link). On July 15th, Palmetto also posted an article detailing the Prior Authorization Exemption Process (link).

    WPS (Jurisdiction 5)

    On Monday, July 19th, WPS posted the following notice about spinal neurostimulators prior authorization requests:

    “Providers who perform and bill CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) must remember to request prior authorization (PA) for both the trial and permanent placement.

    Providers should submit a PA for the trial placement only if the plan is to perform the procedure in a hospital outpatient department (HOPD). Providers should submit one prior authorization request (PAR) when both the trial and the permanent placement will be in the same HOPD. WPS will only assign one Unique Tracking Number (UTN) that the provider should use to bill for both claims.

    If the trial and permanent placement are to occur at two separate HOPDs, then the provider will need two separate UTNs as each HOPD has their own Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI).”

    What Can You Do?

    For those involved in the Prior Authorization process at your hospital, be sure and check out available resources on your MAC specific webpage. CMS’s Review Contractor Directory – Interactive Map (link) among other Medicare Contractors, provides links to your state specific MAC.

  • Beth Cobb

    What Code to report for the Drug Romidepsin
    Published on Jul 14, 2021
    20210714
    Did you know?

    Romidepsin was first approved by the FDA November 5, 2009, for the treatment of cutaneous T-cell lymphoma (CTCL) and then approved in June 2011 for other peripheral T-cell lymphomas (PTCLs). HCPCS code C9065 was established as a temporary code to report the drug Romidepsin in the outpatient prospective payment system (OPPS) until a permanent J code was established.

    Why it matters.

    This code was to be terminated on June 30, 2021. However, on June 21, 2021, MLN article MM12289 (Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update (link) was revised to reflect that HCPCS J9314 (Injection, romidepsin, non-lyophilized (e.g., liquid), 0.1mg) was removed from the table of new HCPCS codes for July 1, 2021 and after.

    Shortly after the release of the revised MLN article, Medicare Administrative Contractors (MACs) posted announcements on how to report administration of this drug. For example, the JN MAC, First Coast’s June 29, 2021 announcement (link), indicated “HCPCS code C9065 was set to be terminated on June 30; however, a permanent J code has not yet been established. For services on or after July 1, please continue using HCPCS code C9065 on your OPPS claims to report the drug Romidepsin.”

    What can You do?

    Make sure you billing staff is aware of this update.

    Beth Cobb

    Coding Outpatient Surgery without the Pathology Report
    Published on Jul 14, 2021
    20210714
    Question

    Is it appropriate for hospitals to code and submit an outpatient surgery claim before the pathology report is available? At our hospital we do a lot of skin excisions, but we code the record and bill the claim before we have the pathology report. Therefore, there are times when the malignant skin cancers are not reported on the claim since we do not know about it at the time of coding.

    Answer

    Yes, it is appropriate / allowed for hospitals to code and submit a claim before the pathology report is available to the coder for review. It is up to the individual hospital to determine this process. For additional discussion, refer to Coding Clinic, 1st quarter 2017, page 15.

    Jeffery Gordon

    June 2021 Medicare Educational Resources, COVID-19, and Other Medicare Updates
    Published on Jul 07, 2021
    20210707

    Medicare Educational Resources

    Revised MLN Fact Sheet: Medicare Disproportionate Share Hospital

    CMS issued a revised edition of the Medicare Disproportionate Share Hospital MLN Fact Sheet (link). Specifically, the Fact Sheet includes information about how CMS calculates uncompensated care payments for FY 2021 and FY 2022.

    Revised MLN Fact Sheet: Medicare Billing for Cardiac Device Credits

    This revised Fact Sheet (link) includes the following two changes highlighted in dark red font in the text:

    • When a hospital gets a replaced device credit 50% or greater than the device’s cost, report the amount in the claim’s FD code value portion.
    • Beginning in 2020, Medicare applies a device offset cap to the Ambulatory Payment Classification (APC) claims that require implantable devices and have significant device offset (greater than 30%) based on the FD value code’s listed credit amount.”
    MLN Educational Tool: Medicare Preventive Services Revised

    CMS updated this Education Tool (link) in May. Information available in this tool includes:

    • Link to National Coverage Determination (NCD) services webpage when applicable to a service,
    • HCPCS and CPT codes,
    • Prolonger Prevention Services information,
    • ICD-10-CM diagnosis codes,
    • Billing for telehealth during COVID-19,
    • Coverage Requirement,
    • Frequency Requirements,
    • Patient liability, and
    • Telehealth eligibility.

    COVID-19 Updates

    June 3, 2021: Myths and Facts about COVID-19 Vaccines

    The CDC developed this webpage (link) to help stop common myths and rumors such as:

    • The COVID-19 vaccine can make you be magnetic,
    • The COVID-19 vaccine will alter my DNA, or
    • The COVID-19 vaccine will make me sick with COVID-19.
    June 9, 2021: Medicare to Increase Payment for Medicare Vaccination Administration in the Home

    In a Special Edition MLN Connects, CMS announced additional payment for administering in-home COVID-19 vaccinations to Medicare beneficiaries (link). A related infographic (link) was also updated to include this information.

    June 17, 2021: CMS MLN Connects – Emergency Use Authorization (EUA) for Monoclonal Antibody Updates

    CMS noted that on May 26, 2021, the FDA released an EUA for the COVID-19 monoclonal antibody product sotrovimab. Coinciding with the FDA release, CMS created new HCPCS codes also effective May 26th for sotrovimab. This drug can be administered in health care setting and the home. The following is an excerpt from the MLN Connects newsletter:

    Q0247

    • Long descriptor: Injection, sotrovimab, 500 mg
    • Short descriptor: Sotrovimab
    • Price: The government won’t provide this drug for free; visit the COVID-19 Vaccines and Monoclonal Antibodies webpage for pricing information (available soon)

    M0247

    • Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
    • Short Descriptor: Sotrovimab infusion
    • Price: $450.00 per infusion

    M0248

    • Long Descriptor: Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
    • Short Descriptor: Sotrovimab inf, home admin
    • Price: $750.00 per infusion

    On June 3rd, the FDA released a revised EUA for Regnereon’s COVID-19 monoclonal antibody combination product casirivimab and imdevimab. Updates includes new dosing regimen and allows a new route of administration. “In response to this change, CMS created a new HCPCS code, effective June 3, and updated the short and long code descriptors. This information is detailed in the MLN Connects newsletter (link).

    Other Medicare Updates

    July 1, 2021: Interim Final Rule Banning Surprise Billing and Certain Out-of-Network Charges

    HHS issued the interim final rule, “Requirements Related to Surprise Billing: Part 1,” that will restrict surprise billing for insured patients that receive emergency care, non-emergency care from out-of-network providers at their in-network facility, and air ambulance services from out-of-network providers. One way this helps patient, as noted in a Related CMS Fact Sheet (link), is that “if your health plan provides or covers any benefits for emergency services, this rule requires emergency services to be covered:

    • Without any prior authorization (meaning you no not need to get approval beforehand).
    • Regardless of whether a provider or facility is in-network.”

    This rule will take effect on January 1, 2022. CMS is excepting written comments through 5 p.m. 60 days after the rule is displayed in the Federal Register. At the time of this article, the interim final rule had not been published in the Federal Register. You can learn more about the interim rule requirements in another CMS Fact Sheet (link).

    Beth Cobb

    June 2021 Medicare Transmittals and Coverage Updates
    Published on Jul 07, 2021
    20210707

    Medicare MLN Articles & Transmittals – Recurring Updates

    Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 0240U, 0231U and 87637
    • Article Release Date: June 11, 2021
    • What You Need to Know: The FDA has issued Emergency Use Authorizations (EUAs) for the COVID-19 tests represented by these three HCPCS codes. “For Medicare to recognize these tests performed under a CLIA certificate of waiver or a CLIA certificate for provider-performed microscopy procedures, you must add the modifier QW.”
    • MLN MM12318: (link)
    July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
    • Article Release Date: June 14, 2021
    • What You Need to Know: This article provides a summary of changes to and billing instructions for payment policies to be implemented by CMS on July 1, 2021.
    • MLN MM12316: (link)
    July 2021 Update of the Ambulatory Surgical Center [ASC] Payment System
    • Article Release Date: June 25, 2021
    • What You Need to Know: For the July 2021 Update there are 8 new CPT Category III codes, a new device pass through code, new HCPCS codes for drugs and biologicals, a change to a skin substitute HCPCS code from the low to the high-cost skin substitute group and a new technology HCPCS code as been established to describe the technology associated with vaginal colpopexy by sacrospinous ligation fixation.
    • MLN MM12341: (link)

    Revised Medicare MLN Articles & Transmittals

    Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update
    • Article Release Date: February 23, 2021 – Most recent revision June 3, 2021
    • What You Need to Know: In the third iteration of this MLN article, important information about the use of the QW modifier was added in red print on page 10 of this document.
    • MLN MM12131: (link)
    International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2021
    • Article Release Date: May 18, 2021 – Revised June 3, 2021
    • What You Need to Know: This article was revised to reflect NCD specific changes made in a revised Change Request (CR) 12124.
    • MLN MM12124: (link)
    July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
    • Article Release Date: April 27, 2021 – Revised June 8, 2021
    • What You Need to Know: This article was revised to reflect a revised CR 12244 which added language about Section 405 of the Consolidated Appropriates Act, 2021.
    • MLN MM12244: (link)
    Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Amount
    • Article Release Date: May 24, 2021 – Revised June 15, 2021
    • What You Need to Know: This article was revised due to a revised Change Request (CR) 12885 which included the addition of new codes to the national HCPCS file.
    • MLN MM12285: (link)

    Medicare Coverage Updates

    June 10, 2021: NGS Reminder Regarding General Anesthesia, Conscious Sedation and Facet Joint Interventions

    NGS posted a reminder regarding the recent revision to Local Coverage Determination (LCD) (L35936) “Facet Joint Interventions for Pain Management” and Local Coverage Article (LCA) (A57826) “Billing and Coding: Facet Joint Interventions for Pain Management.” As of April 25, 2021, one Limitation of LCD L359356 (link) indicates that “general anesthesia is considered not reasonable and necessary for facet joint interventions.” Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.”

    National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs)
    • Article Release Date: June 11, 2021
    • What You Need to Know: Effective December 1, 2020, CMS covers VADs under certain criteria. Change Request (CR) 12290 revises NCD 20.9 in the Medicare NCD Manual and Chapter 32, Section 320 of the Medicare Claims Processing Manual.
    • MLN MM12290: (link)
    July 2, 2021: Proposed Decision Memo for Home Use of Oxygen and Home Oxygen Use to Treat Cluster Headaches

    CMS issued Proposed Decision Memo CAG-00296R2 (link). Two changes being proposed includes:

    • Remove NCD 240.2.2 of the Medicare NCD Manual, ending coverage with evidence development, and allow the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for cluster headaches (CH), and
    • Modify NCD 240.2 Home Use of Oxygen to expand patient access to oxygen and oxygen equipment in the home, and to permit MACs to cover the use of home oxygen and equipment in order to treat CH and other acute conditions.

    You can submit comments through August 1, 2021. The related National Coverage Analysis (NCA) Tracking Sheet for this Decision Memo CAG-00296R2 (link) will enable you to follow the progress of this proposal.

    May 2021 Medicare Coverage Updates and Education Resources
    Published on Jun 02, 2021
    20210602

    Medicare Coverage Updates

    May 18, 2021: CMS Initiates National Coverage Analysis for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
    • Coverage Analysis Issue: The United States Preventive Services Task Force (USPSTF) recently published an updated recommendation for certain persons at high risk for lung cancer based on age and smoking history for screening for lung cancer with LDCT.
    • CMS Actions: CMS received a complete, formal request to reconsider the National Coverage Determination 210.14 and are soliciting public comment. The public comment period ends on June 17, 2021.
    • Resources
      • March 9, 2021 USPSTF Lung Cancer Screening Recommendation Statement: (link)
      • Coverage Analysis (CAG-00439R): (link)
      • NCD 210.14: (link)
    National Coverage Determination (NCD) Removal
    • Article Release Date: May 24, 2021
    • What You Need to Know: 6 NCDs are being removed from the NCD Manual based on rulemaking in the Calendar Year 2021 Medicare Physician Fee Schedule.
      • NCD 20.5 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
      • NCD 20.5 Extracorporeal Immunoadsorption (ECI) Using Protein A Columns,
      • NCD 100.9 Implantation of Gastrointestinal Reflux Devices,
      • NCD 110.19 Abarelix for the Treatment of Prostate Cancer,
      • NCD 220.2.1 Magnetic Resonance Spectroscopy, and
      • NCD 220.6.16 FDG PET for Inflammation and Infection.
    • MLN MM12254: (link)
    National Coverage Determination (NCD 110.24) Chimeric Antigen Receptor (CAR) T-cell Therapy
    • Article Release Date: May 24, 2021
    • What You Need to Know: Effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cells expressing at least 1 CAR when administered at healthcare facilities:
    • MLN MM12177: (link)
    National Coverage Determination (NCD) 210.3 – Screening for Colorectal Cancer (CRC) – Blood-Based Biomarker Tests
    • Article Release Date: May 26, 2021
    • What You Need to Know: Effective January 19, 2021, CMS determined that the blood-based biomarker test is an appropriate CRC screening test once every three years for Medicare patients when performed in a CLIA certified lab, ordered by a treating physician, and the patient is:
      • Aged 50-85 years, and
      • Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test); and, • At average risk of developing CRC (no personal history of adenomatous polyps, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of CRCs or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis CRC).
    • MLN MM12280: (link)

    Medicare Educational Resources

    Revised MLN Booklet: Behavioral Health Integration Services

    CMS issued a revised version of this MLN Booklet (link) to add CY 2021 MPFS Final Rule CMS-1734-F Updates and add new HCPCS code G2214 (Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional).

    Revised MLN Booklet: Medicare Mental Health

    CMS issued a revised version of this MLN Booklet (link) to include a new outpatient psychiatric services medical records checklist, an acute care hospital section, and CPT codes updates and additions.

    Revised MLN Fact Sheet: Complying with Medicare Signature Requirements

    CMS issued a revised version of this MLN Fact Sheet (link) to include information about signing documentation written by a medical student.

    Revised MLN Booklet: Medicare Diabetes Prevention & Diabetes Self-Management Training

    CMS issued a revised version of this MLN Booklet (link) to add information about flexibilities extended in the March 1, 2020, COVID-19 Interim Final Rule and the CY 2021 Physician Fee Schedule Final Rule to all patients receiving services as of March 31, 2020. They also spotlight that in January 2020, the American Association of Diabetes Educator (AADE) changed their name to the Association of Diabetes Care & Education Specialists (ADCES).

    National Osteoporosis Month

    National Osteoporosis Month falls in May each year. Following is information CMS provided in their Thursday May 6th edition of MLN Connects:

    “Medicare covers bone mass measurements, and your patients pay nothing if you accept assignment. During National Osteoporosis Month, talk to your Medicare patients about their risk factors and bone health.

    More Information:

    • Medicare Preventive Services educational tool (link)
    • Preventive Services webpage (link)
    • CDC Osteoporosis webpage (link)
    • National Osteoporosis Foundation website (link)
    • Information for your patients on bone mass measurements” (link)
    MLN Booklet: Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements

    The Thursday May 13, 2021 edition of the CMS e-newsletter, MLN Connects (link), included the following information related to complying with Medicare billing requirements for outpatient rehabilitation therapy services:

    “An Office of Inspector General report (link) found that payments for physical therapy services didn’t comply with Medicare billing requirements. Review the Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements (PDF) (link) booklet to help you bill correctly, reduce common errors, and avoid overpayments. CMS listed additional resources in the newsletter.

    April 2021 MLN Fact Sheet: Medical Record Maintenance & Access Requirements

    This MLN Fact Sheet (link) provides information on updated documentation maintenance and access requirements for billing services to Medicare patients. It also includes how long providers are to keep the documentation and who is responsible for providing access.

    Beth Cobb

    May 2021 Medicare Transmittals and Other Updates
    Published on Jun 02, 2021
    20210602

    Medicare MLN Articles & Transmittals – Recurring Updates

    July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
    • Article Release Date: April 27, 2021
    • What You Need to Know: This article includes quarterly updates effective July 1, 2021 for ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs.
    • MLN MM12244: (link)
    International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2021
    • Article Release Date: May 18, 2021
    • What You Need to Know: You will find information about updated ICD-10 conversions and coding updates specific to NCDs as a result of newly available code, coding revisions to NCDs released separately and coding feedback received.
    • MLN MM12124: (link)
    Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update
    • Article Release Date: May 21, 2021
    • What You Need to Know: July 2021 updates to the 2021 MPFS are detailed in this MLN article.
    • MLN MM12289: (link)
    Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
    • Article Release Date: May 21, 2021
    • What You Need to Know: MACs perform updates to the RARC and CARC based on the code update schedule and occur around March 1, July 1, and November 1.
    • MLN MM12220: (link)
    Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
    • Change Request Release Date: May 21, 2021
    • What You Need to Know: This recurring transmittal is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. Two NCDs specific to this update are NCD 30.3.3 Acupuncture for Chronic Low-Back Pain (cLBP), and NCD 20.33 Transcatheter Mitral Valve Repair/Transcatheter Edge-to-Edge Repair (TMVR/TEER).
    • Change Request (CR) 12279: (link)

    Other Medicare MLN Articles & Transmittals

    New Waived Tests
    • Article Release Date: April 27, 2021
    • What You Need to Know: This article highlights newly FDA approved Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests.
    • MLN MM12204: (link)
    Waiver of Coinsurance and Deductible for Hepatitis B Preventive Service Vaccine Code, Section 4104 of the Patient Protection and Affordable Health Care Act (the Affordable Care Act), Removal of Barriers to Preventive Services in Medicare
    • Article Release Date: May 11, 2021
    • What You Need to Know: The Hepatitis B vaccine (HCPCS 90739) has been added to the preventive services recommended by the U.S. Preventive Services Task Force. Consequently, coinsurance and deductibles won’t apply for this code. Medicare will make a reasonable cost reimbursement for Types of Bill (TOB) 012X, 013X, 022X, and 034X.
    • MLN MM12230: (link)
    Addition of the Shared System CWF to the Business Requirements for the Healthcare Common Procedure Coding System (HCPCS) Codes U0002QW and 87635QW Mentioned in Change Request 11765
    • Article Release Date: May 20, 2021
    • What You Need to Know: For labs billing MACs for COVID-19 testing services, this article informs you about a revision to CR 11765 that requires changes to Medicare Common Working File (CWF) for:
      • o HCPCS U0002QW [2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC], and
      • o 87635 [Infectious agent detection by nucleic acid (DNC or RNA0; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique].
    • MLN MM12294: (link)

    Other Medicare Updates

    New CMS Hospital Star Ratings

    On April 28th, CMS updated the Hospital Compare Overall Hospital Quality Ratings (link). Hospital specific scores are based on performance for 5 measure groups (Mortality, Safety of Care, Readmission, Patient Experience and Timely & Effective Care). April 2021 results:

    • 455 hospitals received the highest rating of 5 stars,
    • 1,018 hospitals received 3 stars, and
    • 204 hospitals received a 1 star rating.
    Clinical Diagnostic Laboratory Resources about the Private Payor Rate-Based CLFS

    CMS posted the following information in the Thursday April 29, 2021 edition of MLN Connects (link): “If you’re a laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS), you must report information, including laboratory test HCPCS codes, associated private payor rates, and volume data.” You can find links to updated resources and the data collection and reporting timeline in the MLN Connects post.

    April 29, 2021: CJR Three-Year Extension Final Rule

    CMS released the Comprehensive Care for Joint Replacement Model Final Rule which extends the model through December 31, 2021 by adding an additional 3 performance years (PYs). This final rule also revises the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements and the appeals process. The episode of care definition was revised to include outpatient Total Knee and Total Hip Arthroplasty (TKA/THA) procedures. You can read more about this Model on the CJR CMS webpage (link).

    May 7, 2021: Advance Copy of Hospital Interpretive Guidelines for Admission, Discharge and Transfer Notification Requirements

    CMS issued a memorandum (link) to State Survey Agency Directors providing an advance copy of the hospital interpretive guidelines for the admission, discharge, and transfer notification requirements outlined in the Interoperability and Patient Access final rule. This guidance is for Hospitals, Psychiatric Hospitals and Critical Access Hospitals and it will also be published in an updated Appendix A of the State Operations Manual.

    May 2021: United Healthcare Sepsis Claims Review Change Effective July 1, 2021

    While this article focuses on Medicare updates, I believe it is important for Clinical Documentation Integrity Specialists and Utilization Review staff to be aware of this notice. United Healthcare (UHC) has announced (link) that “effective July 1, 2021, Medicare Advantage and commercial claims for sepsis-related treatment may be reviewed on a pre-payment or post payment basis.” UHC will use their Sepsis Clinical Guidelines which includes using Sepsis-3.

    May 10, 2021: University of Miami to Pay $22 Million to Settle Claims Involving Medically Unnecessary Laboratory Tests and Fraudulent Billing Practices

    This Department of Justice release (link) indicates that the University of Miami (UM):

    • Knowingly engaged in improper billing relating to its Hospital Facilities,
    • Billed federal health care programs for medically unnecessary laboratory tests for patients who received kidney transplants at the Miami Transplant Institute (MTI) – a transplant program operate by UM and Jackson Memorial Hospital (JMH) and
    • Caused JMH to submit inflated claims for reimbursement for pre-transplant laboratory testing conducted at the MTI.

    This settlement resolves allegations made in three lawsuits filed under the qui tam (whistleblower) provisions of the False Claims Act.

    May 18, 2021: CMS Delays Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule

    MMP first wrote about this Proposed Rule in October 2020 (link). CMS published a notice further delaying this final rule until December 15, 2021 (link). They note this additional time provides “an opportunity to address all of the issues raised by stakeholders, especially Medicare patient protections, evidence criteria and lack of coordination between coverage, coding and payment.”

    Beth Cobb

    Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Updates for July 1, 2021
    Published on Jun 02, 2021
    20210602

    For most students, the school year has come to an end. However, for those of you that are involved in the Prior Authorization for Certain Hospital Outpatient Department (ODP) process at your hospital, there is some essential summer reading requirements that you need to complete in the next couple of weeks. p>

    Background

    This program was finalized in the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) Final Rule and is specific to the Hospital Outpatient Department setting. Effective July 1, 2020, a Prior Authorization was required for the following five procedures:

    • Blepharoplasty
    • Botulinum toxin injections
    • Panniculectomy
    • Rhinoplasty
    • Vein ablation
    CMS believes this program will be an effective tool in controlling unnecessary increases in volume by ensuring payments are only being made for medically necessary services. You will find additional resource information and updates on the CMS webpage created for this program (link) .

    2021 Program Updates

    Two New Procedures to Require Prior Authorization

    CMS has added Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to this process, effective July 1, 2021. These two services are not replacing, but are being added to the list of procedures currently requiring prior authorization.

    Note: MACs will begin accepting Prior Authorization Requests (PARs) for these two new services on June 17, 2021, for services rendered on or after July 1, 2021.

    February 26, 2021: Exemption(s)

    CMS noted that “MACs are in the process of identifying those hospital OPDs that will be exempt from the prior authorization process. Starting February 1, 2021 MACs began calculating the affirmation rate of initial prior authorization requests submitted. Hospital OPD providers who met the affirmation rate threshold of 90% or greater will receive a written Notice of Exemption no later than March 1, 2021. Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021.”

    CMS’ Prior Authorization Program Operational Guide was updated on May 13, 2020. Updates are highlighted in red. There are a couple of specific updates to hospitals exempted from having to submit a Prior Authorization Request (PAR):

    • The exemption will include PARs for the two new services being added to the program effective July 1, 2021.
    • A word of caution, if you have been exempted from this process, you must continue to ensure documentation supports medical necessity of the procedure being performed. CMS has advised that they will be sending post-payment Additional Documentation Requests (ADRs) for a 10-claim sample from the time period you were exempted to determine compliance. Note, the sample may include claims for the two new services (cervical fusion with disc removal and implanted spinal neurostimulators).

    May 13, 2021: Change to Implanted Spinal Neurostimulators

    “CMS is temporarily removing CPT codes 63685 and 63688 from the list of OPD services that require prior authorization. The only service that will require prior authorization for implanted spinal neurostimulators is CPT code 63650. Providers who plan to perform both the trial and permanent implantation procedures using CPT code 63650 in the OPD will only require prior authorization for the trial procedure. When the trial is rendered in a setting other than the OPD, providers will need to request prior authorization for CPT code 63650 as part of the permanent implantation procedure in the hospital OPD.”

    CMS has added the following paragraph to the program Operational Guide related to when a PAR is required:

    “Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.”

    May 14, 2021: MAC Educating Providers

    CMS released Change Request (CR) 12214 (link) to instruct Medicare Administrative Contractors (MACs) to provide education regarding the prior authorization (PA) process for cervical fusion with disc removal and implanted spinal neurostimulators in the hospital OPD setting. One part of this education will be MACs sending introductory letters detailing the July 1, 2021 updates and general “What You Need to Know” information to physicians and providers. Templates of these letters are included in this CR.

    Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators by the Numbers

    In an effort to quantify the volume and payment related to the two new procedures, I worked with RealTime Medicare Data (RTMD). For those who may be new readers of our newsletter, RTMD’s current data base consists of Medicare Fee-for-Service paid claims data for hospital inpatient discharges, outpatient hospital services, and CMS 1500 professional services for 48 states and territories. The following data is specific to U.S. states for calendar years (CY) 2019 and 2020. Since COVID-19 had an impact on planned surgical procedures, I believe it is important to view both years of data

    Cervical Fusion with Disc Removal

    CY2019

    • Procedure Volume: 20,203
    • Paid Claims Amount: $163,592,946.40

    CY2020

    • Procedure Volume: 17,569
    • Paid Claims Amount: $164,226,275.35
    Implanted Spinal Neurostimulators

    CY2019

    • Procedure Volume: 27,056
    • Paid Claims Amount: $43,991,713.02

    CY2020

    • Procedure Volume: 19,853
    • Paid Claims Amount: $34,603,818.02

    Moving Forward

    This is where the urgent summer reading comes in. For those actively involved in this process, I encourage you:

    • To read CMS’ OPD Operational Guide and Frequently Asked Questions, both of which were last updated on May 13, 2021,
    • Review your MACs website for education offering related to updates to this program. You will find contact information for all of the MACs in the OPD Operational Guide.
    • Make sure your Physicians performing these procedures are aware of the documentation requirements supporting medical necessity of the procedure. In addition to MAC contact information, the OPD Operational Guide includes “Required Documentation” for each of the procedure.
    • Finally, if you are currently exempt from the PAR process, be on the lookout for ADR requests from your MAC in the not too distant future.

    April 2021 Medicare Transmittals and Other Updates
    Published on Apr 28, 2021
    20210428

    Medicare MLN Articles & Transmittals – Recurring Updates

    Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.2, Effective July 1, 2021

    • Article Release Date: March 31, 2021
    • What You Need to Know: NCCI edits were developed to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims. This article alerts providers about the quarterly updates to the NCCI PTP edits in Change Request (CR) 12226 effective July 1, 2021. CMS includes the following bolded statement in the CR, “the edits previously contained in the Mutually Exclusive edit file are NOT being deleted but are being moved to the Column One/Column Two Correct Coding edit file.”
    • MLN MM12226: link

    April 2021 Update of the Ambulatory Surgical Center (ASC) Payment System

    • Article Release Date: April 1, 2021
    • What You Need to Know: Billing instructions for various payment policies CMS made in the April 2021 ACS payment system update are referenced in this article.
    • MLN MM12183: link

    Other Medicare MLN Articles&Transmittals

    Updated to the Payment for Grandfathered Tribal Federally Qualified Health Centers (FQHCs) for Calendar Year (CY) 2021

    • Article Release Date: March 31, 2021
    • What You Need to Know: This article is for FQHCs billing MACs for services provided to Medicare patients.
    • MLN MM12202: link

    Revised Medicare MLN Articles&Transmittals

    Penalty for Delayed Request for Anticipated (RAP) Submission – Implementation

    • Article Release Date: July 31, 2020 – Most recent revision April 1, 2021
    • What You Need to Know: This is the third revision to the original July 31, 2020 MLN article. Information in the article is for Home Health Agencies (HHA) who bill MACs for services provided. The April 1, 2021 revision reflects the revised CR 11855. The revised CR changes the principal diagnosis code reporting instructions in Chapter 10, Section 40.1 and the service date reporting instructions in Chapter 10, Section 40.2 of the Medicare Claims Processing Manual. The changes make sure claims successfully match their corresponding RAP. Changes in the text of the document are in red print.
    • MLN MM11855: link

    Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update

    • Article Release Date: March 18, 2021 – Revised April 6, 2021
    • What You Need to Know: This article reflects a revised Change Request CR 12068. The substance of the article did not change.
    • MLN MM12068: link

    Medicare Coverage Updates

    April 13, 2021: Final Decision Memo for AlloMap® Molecular Expression Testing for Detection of Reject of Cardiac Allografts

    CMS indicates in the background section of this Decision Memo (link), that the “AlloMap is intended to give physicians information on the risk of acute cellular rejection in their patients following heart transplant.” CMS received a request in January of 2013 to non-cover this assay as the requester felt this particular assay “does not perform adequately,” has “poor sensitivity,” and “no intrinsic predictive capability.” A national coverage analysis was issued October 16, 2020. CMS received three comments. CMS did not issue a National Coverage Determination for this testing and notes in the Final Decision Memo that, “in the absence of an NCD, coverage determinations for AlloMap® Molecular Expression Testing for Detection of Rejection of Cardiac Allografts…will continue to be made by the local Medicare Administrative Contractors (MACs).”

    April 13, 2021: Final Decision Memo for Autologous Blood-Derived Products for Chronic Non-Healing Wounds

    CMS indicates in this Decision Memo (link) that they “will cover autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds under section 1862(a)(1)(A) of the Social Security Act (the Act) for a duration of 20 weeks, when prepared by devices whose FDA cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers. Coverage of autologous PRP for the treatment of chronic non-healing diabetic wounds beyond 20 weeks will be determined by local Medicare Administrative Contractors (MACs). Coverage of autologous PRP for the treatment of all other chronic non-healing wounds will be determined by local Medicare Administrative Contractors (MACs) under section 1862(a)(1)(A) of the Act.”

    April 13, 2021: National Coverage Analysis (NCA) Tracking Sheet for Transvenous (Catheter) Pulmonary Embolectomy

    Currently, this procedure is non-covered. CMS internally generated this NCA reconsideration (link) based on stakeholder feedback and have had several requests for this NCD to be removed. The public comment period is from April 13, 2021 through May 13, 2021. The proposed decision memo due date is October 13, 2021.

    Medicare Educational Resources

    New MLN Booklet: How to Use the Medicaid National Correct Coding Initiative (NCCI) Tools

    CMS has issued a new Medicare Learning Network booklet titled How to Use the Medicaid National Correct Coding Initiative (NCCI) Tools (link). This publication is aimed at helping providers learn to navigate the CMS Medicaid NCCI webpages, work with Medicaid Procedure-to-Procedure edits, and manually unlikely edits. CMS notes that the Medicare NCCI Program has significant differences from the Medicaid NCCI initiative and provides related links to the Medicaid NCCI Initiative and Medicare NCCI Program.

    Revised MLN Booklet: Behavioral Health Integration Services

    CMS has issued a revised version of the Behavioral Health Integration Services MLN Booklet (link) to add CY 2021 MPFS Final Rule CMS-1734-F Updates and add new HCPCS code G2214 (Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional).

    CMS’ Diagnosis Coding: Using ICD-10-CM and ICD-10-PCS Web-Based Training Courses Revised

    CMS has updated their ICD-10-CM and PCS web-based training courses. These courses can help you learn how to identify structure and format, recognize features and find codes. You can access both revised courses on the CMS MLN Web-Based Training webpage at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.

    Revised MLN Booklet: Medicare Billing: Form CMS-1450 and the 837 Institutional

    In mid-April, CMS published a revised version of this MLN Booklet (link. In the revised version, CMS updated MSP information in the Medicare Claims Submission section of the booklet and added a new Where to Submit FFS Claims section.

    Medicare Wellness Visits Educational Tool Revised

    CMS noted in the April 22, 2021 edition of MLN Connects (link) that their Medicare Wellness Visit Education Tool has been revised. Providers can use this tool to learn about the annual wellness visit (AWV) and Initial preventive physical exam (IPPE).

    Other Medicare Updates

    April 8, 2021: CMS Issues FY 2022 Proposed Rules

    In a Special Edition MLN Connects (link), CMS issued Proposed Rules for:

    • SNF Prospective Payment System: FY 2022 Proposed Rule
    • Hospice Payment Rate Update for FY 2022,
    • IRF Prospective Payment System: FY 2022 Proposed Rule, and
    • IPF: Proposed Medicare Payment&Quality Reporting Updates.

    Links to each proposed rule and a related Fact Sheet are available in this announcement. CMS is accepting comments on all four proposed rules until June 7, 2021.

    Beth Cobb

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