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Question

In I-10-CM, under J91 there is an Excludes2 instruction that excludes pleural effusion in heart failure (I50.-). Should pleural effusion also be coded any time a patient has congestive heart failure (CHF)?

Answer

No. As coders, we still need to follow all instructions/directions as we have previously been taught. Even though the Excludes2 instruction allows you to code pleural effusion with CHF, it doesn’t mean that it is always appropriate.

Pleural effusion occurs when fluid abnormally accumulates within the pleural spaces and is associated with pulmonary diseases and certain cardiac conditions, but it can also involve other organs.

In ICD-9, pleural effusion with CHF wasn’t to be coded unless it required therapeutic treatment or additional diagnostic studies, etc., e.g., (thoracentesis or decubitus X-ray). The same holds true in ICD-10. If the pleural effusion just shows up on an X-ray, is minimal, and only the CHF is treated, then it is not appropriate to code it; however, if a thoracentesis or additional diagnostic testing/evaluation is performed, then a code for (J91.8) (Pleural effusion in other conditions classified elsewhere) should be assigned in addition to the CHF. Pleural effusion, not elsewhere classified, (NEC) (J90) would not be appropriate in this case since the pleural effusion is associated with CHF.

Pleural effusion in conditions classified elsewhere (J91.x) should also be assigned if the patient has a malignant pleural effusion, filariasis, or influenza.

Pleural effusions that are chronic, have a known underlying cause, and cause no symptoms, are usually not treated with a thoracentesis and/or pleural fluid analysis as it is often not necessary.

Usually, documentation indicates when pleural effusion is related to a patient’s condition. If you can’t determine the cause, query the attending physician for the etiology of the pleural effusion to obtain a more accurate diagnosis code. Pleural effusion, NEC (J90) should seldom be used.

References:

• Coding Clinic, Second Quarter 2015: Page 15
• Coding Clinic, Third Quarter 1991 Page: 19 to 20
• AHA Coding Handbook
• Merck Manual

Did You Know?

According to a National Cancer Institute, bladder cancer:

• Is the fourth most commonly diagnosed malignancy in men in the United States,
• Occurs about four times higher in men than in women,
• Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
• The incidence of bladder cancer increases with age.

Blood in the urine is the most common presenting sign of bladder cancer, occurring in about 90% of cases. Other presenting symptoms include dysuria, urinary frequency or urgency, and less commonly, flank pain secondary to obstruction, and pain from pelvic invasion or bone metastasis.

Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer.

Why it Matters?

There are risk factors related to being diagnosed with bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:

• Having a family history of bladder, cancer,
• Having certain changes in the genes that are linked to bladder cancer,
• Being exposed to paints, dyes, metals, or petroleum products in the workplace,
• Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
• Taking Aristolochia fangchi, a Chinese herb,
• Drinking water from a well that has high levels of arsenic,
• Drinking water that has been treated with chlorine,
• Having a history of bladder infections, and
• Using urinary catheters for a long time.

What Can You Do?

First and foremost, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with you physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current five years relative survival rate is 77.1%.

What Can You Do?

• National Cancer Institute Cancer Stat Facts: Bladder Cancer: (https://seer.cancer.gov/statfacts/html/urinb.html)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDQ®) Patient Version: (https://www.cancer.gov/types/bladder/patient/bladder-screening-pdq)
• National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: (https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq )

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

• Article Release Date: April 14, 2022
• What You Need to Know: Updates have been made to the Medicare Claims Processing Manual (Publication 100-04) and the Benefits Policy Manual (Publication 100-02) to add information for COVID-19 claims for example, CMS has added COVID-19 to the list of preventive vaccines that Medicare Part B covers without coinsurance or deductible. In addition to COVID-19 claims updates, the centralized billing enrollment process has been revised to streamline provider enrollment.
• MLN MM12634: https://www.cms.gov/files/document/mm12634-update-publication-100-04-chapter-18-and-publication-100-02-chapter-15-section-add-data.pdf

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.

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.

Did You Know?

The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:

• For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
• CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.

Why it Matters?

Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.

Current Projects

As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.

Completed Projects

To date, in CY 2022, the SMRC has posted project results for the following five projects:

• 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
• 01-036: Hospice Portfolio: Error Rates 29% and 47%,
• 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
• 01-044: Therapy Reviews: Error Rate 31%, and
• 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.

What Can You Do?

First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide updates and educate resources from the CERT, two MACs and Livanta, the National Medicare Review Contractor.

CMS Q1 2022 Program Scorecard

The U.S. government website PaymentAccuracy (link) publishes program scorecards “to assist the public in understanding what agencies are doing to overcome unique challenges and obstacles to ensure federal funds reach the right recipient.” More specifically, program scorecards are published for high-priority programs such as the Department of Health and Human Services Medicare Fee-for-Service (FFS) program.

The most recent Medicare FFS Program Scorecard published is for Q1 of the CMS fiscal year (FY) 2022 (link). Of note, actions being taken to recover overpayments includes:

• Recovery Audit Contractors reviewing inpatient claims for medical necessity and coding purposes,
• HHS implementation of the Review Choice Demonstration for Home Health Services in the last two states of North Carolina and Florida, and
• HHS providing additional funding to the MACs and the Supplemental Medicare Review Contractor (SMRC) to allow for additional claims review to determine if they had been billed appropriately. You can read more about current SMRC activities in a related article in this week’s newsletter.

Comprehensive Error Rate Testing (CERT) Announcement

The CERT Review Contractor has posted (link) their review year 2022 completion status. As of April 4, 2020, they have completed initial review of 34,400 claims out of 41,974 claims in the 2022 Annual Report (claims submitted to the MAC between July 1, 2020, and June 30, 2021).

Palmetto GBA JJ/JM MAC

New Address Information for CERT Review Contractor

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published an article (link) to alert providers about the CERT Review Contractor’s move to a new location. The new address will be on letters beginning April 11, 2022. You will find the CERT Review Contractor’s new address, fax number, customer service toll free number and email in Palmetto’s article.

Cervical Discectomy Module

Palmetto GBA, has published a Cervical Discectomy module (link) focused on the roles of cervical spine, the differences between discectomy and fusion, and documentation requirements.

Spinal Cord Stimulatory Therapy Module

Palmetto GBA has also recently published a Spinal Cord Stimulator module (link) focused on the purpose of the spinal cord stimulator, coverage requirements for spinal cord stimulatory (SCS) therapy, and documentation requirements.

CERT: Inpatient Psychiatric Facility Checklist

Palmetto GBA posted a checklist (link) for providers to use when your claim(s) are selected for review by the CERT contractor. In this notice, they also provide links to their Psychiatric Inpatient Hospitalization Local Coverage Determination and related Billing and Coding article.

WPS J5/J8 MAC

New YouTube Video

WPS has released a new YouTube Video titled Transcatheter Aortic Valve Replacement (TAVR) CERT Findings (link). This video describes reasons for improper payments identified by the CERT Contractor for WPS claims and provides information on how to avoid these errors.

Therapy Assistants: What They Cannot Do

WPS published an article (link) noting they have identified that physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) have been providing services outside CMS guidelines. The article details what activities that Medicare does not allow PTAs or OTAs to complete.

Livanta National Medicare Review Contractor

Livanta’s focus as the National Medicare Review Contractor is on performing Short Stay Review (SSR) and Higher Weighted DRG (HWDRG) reviews. Monthly, they release a publication titled The Livanta Claims Review Advisor. The March 2022 edition (link) focuses on Exploring Short-Stay Claim Review Guidelines and provides information about:

• The history and background of short stay claim reviews,
• Short stay medical review,
• Step-by-Step guideline for short-stay determinations,
• Example scenarios for short-stay Part A denials, and
• Documentation features.

For those interested in receiving this publication, Livanta provides a link to subscribe at the bottom of the newsletter.

In the early days of the COVID-19 Public Health Emergency (PHE) guidance and information was coming at us fast and furious by the likes of the CMS, CDC, OIG, and the AMA. Early on, MMP provided weekly COVID-19 updates. We later transitioned to including highlights in our end of the month Medicare updates article.

However, with new codes related to COVID-19 becoming effective April 1, 2022, the recent launch of an OIG telehealth webpage, and CMS announcing the end of specific COVID-19 waivers for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities, and end-stage renal disease facilities, updating our readers couldn’t wait until the end of April.

April 1, 2022: Reminder, New COVID-19 Codes Effective April 1, 2022

As a reminder, effective April 1, 2022, there are new ICD-10-CM diagnosis codes for reporting COVID-19 vaccination status as well as new ICD-10-PCS procedure codes describing the introduction or infusion of therapeutics, including vaccines for COVID-19 treatments.

In a related MLN Matters Article MM12578 (link), “CMS notes that for hospitalized patients, Medicare pays for COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. Medicare expects that the appropriate CPT codes will be used when a Medicare patient is administered a vaccine while a hospital inpatient. For details on billing Medicare for the COVID-19 vaccine appropriately, please see this page in our provider toolkit.”

Information about a new Pfizer BioNTech COVDI-19 vaccine code and changes for COVID-19 monoclonal antibody therapy product and administration codes can be found in MLN Matters Article MM12666 (link).

April 4, 2022: New Way for Medicare Beneficiaries to Get Free Over the Counter COVID-19 Tests

In an April 4, 2022, Special Edition of MLN Connects (link), CMS announced that Medicare beneficiaries, including Medicare Advantage enrollees, can now get free COVID-19 tests with a few caveats:

• They must be FDA approved, authorized, or cleared over the counter COVID-19 tests,
• You are limited to up to 8 tests per calendar month from participating pharmacies and health care providers, and
• Free testing is available for the duration of the COVID-19 public health emergency (PHE).

CMS also provided a list of national pharmacy chains participating in this initiative that includes Albertsons Companies, Inc., Costco Pharmacy, CVS, Food Lion, Giant Food, The Giant Company, Hannaford Pharmacies, H-E-B Pharmacy, Hy-Vee Pharmacy, Kroger Family of Pharmacies, Rite Aid Corp., Shop & Stop, Walgreens, and Walmart.

This new option for receiving COVID-19 tests is an addition to the following options outlined in the Special Edition MLN Connects:

• Requesting free over-the-counter tests for home delivery at covidtests.gov. Every home in the U.S. is eligible to order 2 sets of 4 at-home COVID-19 tests.
• Access to no-cost COVID-19 tests through health care providers at over 20,000 testing sites nationwide. A list of community-based testing sites can be found here.
• Access to lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost through Medicare.
• In addition to accessing a COVID-19 laboratory test ordered by a health care professional, people with Medicare can also access one lab-performed test without an order and cost-sharing during the public health emergency.

April 4, 2022: OIG Launches Telehealth Webpage

The OIG announced the launch of a new telehealth webpage (link). In the announcement they note that they are “conducting oversight work assessing telehealth services, including the impact of the public health emergency flexibilities. Once complete, these reviews will provide objective findings and recommendations that can further inform policymakers and other stakeholders considering changes to telehealth policies. This work can help ensure the potential benefits of telehealth are realized for patients, providers, and HHS programs.”

April 6, 2022: CMS to Pay for Second COVID-19 Booster without Cost Sharing

CMS announced (link) that they will pay for a second COVID-19 booster at no cost for people with Medicare or Medicaid coverage. They go on to note that the CDC recently updated their recommendation regarding COVID-19 vaccinations. Specifically, “Certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least 4 months ago are eligible for another booster to increase their protection against severe disease from COVID-19. Additionally, the CDC recommends that adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago can receive a second booster dose of a Pfizer-BioNTech or Moderna COVID-19 vaccine.”

April 7, 2022: CMS Returns to Certain Pre-COVID-19 Policies in Long-term Care and Other Facilities

In a CMS Press Release (link), they note that they have seen steadily increasing vaccination rates for nursing home residents and staff, and improvements in nursing homes’ abilities to respond to COVID-19 outbreaks. This provided the impetus for CMS to announce they will be phasing out certain flexibilities related to the COVID-19 PHE to re-establish certain minimum standards. Some of the same waivers are also being terminated for inpatient hospices, intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), and end-stage renal disease (ESRD) facilities.

Specifically, CMS is ending specific waivers in two groups: one group of waivers will terminate 30 days from the issuance of this new guidance, and the other group will terminate 60 days from issuance. CMS notes in the related memorandum Update to COVID-19 Emergency Declaration Blanket Waivers for Specific Providers (link), that at this time “applicable waivers will remain in effect for hospitals and critical access hospitals (CAH).”

Note, CMS has updated their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (link) document to reflect the dates for when the waivers are to terminated.

Did You Know?

Coding other physicians' diagnosis(es), including consultant’s documentation that were not included in the discharge summary, is permissible and not considered to be conflicting.

Why It Matters?

Hospitals are missing valuable clinical information that could identify an increased Severity of Illness (SOI), increased Risk of Mortality (ROM) and, possibly an increase in reimbursement, when another physician’s documentation of a diagnosis is not reported. You need to show how sick your patients really are.

What Can I Do?

Review the references below and discuss with management if you are coding only the diagnoses listed on the discharge summary.

Resources:

• Coding Clinic, 1ST Quarter 2014, page 11
• MMP Article July 1, 2011: MLN Matters – Number SE1121: Recover Audit Program DRG Coding Vulnerabilities for Inpatient Hospitals
• Medlearn Matters SE1121

Did You Know?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.

Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.

Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.

In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.

Esophageal Cancer Prevalence in the United States in 2021

• New Cases: 19,260
• Deaths: 15,530

Esophageal Cancer Risk Factors

• Tobacco Use,
• Heavy alcohol use,
• Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
• Men are about three times more likely than women to develop esophageal cancer,
• Older age,
• White men develop esophageal cancer at higher rates than Black men in all age groups

Signs and Symptoms of Esophageal Cancer

• Painful or difficult swallowing,
• Weight loss,
• Pain behind the breastbone,
• Hoarseness and cough
• Indigestion and heartburn
• A lump under the skin

Tests Used to Diagnose Esophageal Cancer

• Physical exam and health history,
• Chest x-ray,
• Esophagoscopy
• Biopsy

Why this Matters?

In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.

Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.

Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.

Resources:

• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
• PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
• PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]

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.