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MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 18th – 29th.  

Resource Spotlight This Week: CDC Social Media Toolkit

The CDC Social Media Toolkit was created to help localize efforts in responding to the virus that causes COVID-19. The following messages and graphics are available to help in this effort:

• Ensure current, correct messaging from a trusted source,
• Create collateral materials, and
• Share resources.

“All graphics and suggested messages are available for use on social media profiles and web pages.

Within this guide you will find information and suggested messages from our COVID-19 response. For more images and CDC content you can visit our Communication Resources page. All social media content is public domain and free to use by anyone for any purpose without restriction under copyright law. Please remember to use the #COVID19 hashtag when tweeting out any COVID-19 related content.”

June 18, 2020: JAMA Network Article: Disparities in Coronavirus 2019 Reported Incidence, Knowledge, and Behavior Among US Adults

The authors of this JAMA Network article undertook this endeavor “to determine the association of sociodemographic characteristics with reported incidence, knowledge, and behavior regarding COVID-19 among US adults.”

US National Survey Parameters:

• Survey was conducted electronically from March 29 to April 13, 2020,
• Survey “oversampled COVID-19 hotspot areas,” and
• Participant criterion included age ≥ 18 years old and residence in the US.

Researchers found that African American participants, men, and people younger than 55 years showed less COVID-19-related knowledge than other groups. Survey results detailed in this article also provides insight into the probability of having COVID-19 or knowing someone who does, knowledge about the spread of and symptoms of COVID-19, and factors associated with hand washing and leaving the house.

 

June 19, 2020: MLN MM11742 Long Term Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer Revised

MLN article MM11742 was revised to reflect a revised Change Request (CR) 11742 also issued on June 19th. CMS made the following revisions to CR 11742:

• Revise the COVID-19 blanket waiver for the LTCH ALOS policy,
• To include revising the effective date and policy section, and
• Revise the CR release date, transmittal number, and web address of the CR.

June 19, 2020: American Hospital Association (AHA) urges HHS to extend Public Health Emergency (PHE)

In a letter to the Secretary of Health and Human Services (HHS), AHA President and Chief Executive Officer, Richard J. Pollack urged “to extend the public health emergency beyond its current July 25, 2020 expiration date so health care providers can continue to offer the most efficient and effective care possible during the continuing COVID-19 pandemic.” Mr. Pollack urged for the continuance of the PHE until four criteria outlined in the letter are met.

June 22, 2020: CMS Press Release: Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries

In a June 22nd Press Release, CMS is calling for a renewed commitment to value-based care based on Medicare claims data providing an early look at the impact of COVID-19 on the Medicare population. The initial data reflects claims with a COVID-19 diagnosis (B97.29 from 1/1/2020 – 3/31/2020) and U07.1 (starting 4/1/2020) billed in any of the 25 diagnosis code fields on the claim or encounter record with a date of service from January 1st through May 16, 2020. Data is broken down by Medicare beneficiaries’ state, race/ethnicity, age, gender, dual eligibility for Medicare and Medicaid, and urban/rural locations. Moving forward, CMS indicates that this data will be updated monthly.

“The data shows that older Americans and those with chronic health conditions are at the highest risk for COVID-19 and confirms long-understood disparities in health outcomes for racial and ethnic minority groups and among low-income populations.” This Press Release includes a link to more information on the Medicare COVID-19 data, an FAQ document related to the data release, and a blog by CMS Administrator Seema Verma.

June 25, 2020: Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star Quality Rating System Due to the COVID-19 PHE

CMS announced the following changes in a Memorandum Summary:

• “Staffing Measures and Ratings Domain: On July 29, 2020, Staffing measures and star ratings will be held constant, and based on data submitted for Calendar Quarter 4 2019.
• Also, CMS is ending the waiver of the requirement for nursing homes to submit staffing data through the Payroll-Based Journal System. Nursing homes must submit data for Calendar Quarter 2 by August 14, 2020.
• Quality Measures: On July 29, 2020, quality measures based on a data collection period ending December 31, 2019 will be held constant.”

 

June 25, 2020: CDC Revises Who is at Risk for Severe Illness from COVID-19

On June 25th, the CDC made revisions to the list of people at increased risk of severe illness from COVID-19. They noted that revisions were made to reflect data available as of May 29, 2020, and as new information becomes available, they will again update the information.

With this update comes several changes to the list of conditions. Prior to this update the CDC had indicated that “older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19:

• People aged 65 years and older,
• People living in a nursing home or long-term care facility,
• Other high-risk conditions include:
• People with chronic lung disease or moderate to severe asthma,
• People who have serious heart conditions,
• People who are immunocompromised including cancer treatment,
• People of any age with severe obesity (Body Mass Index [BMI] >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk,
• People who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk,
• Many conditions can cause a person to be immunocompromised, including cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDs, and prolonged use of corticosteroids and other immune weakening medications.

The June 25th revisions indicate that people of any age with the following conditions are at increased risk of severe illness from COVID-19:

• Chronic Kidney Disease,
• Chronic Obstructive Pulmonary Disease,
• Immunocompromised state (weakened immune system) from solid organ transplant,
• Obesity (body mass index {BMI} of 30 or higher),
• Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies,
• Sickle cell disease,
• Type 2 Diabetes, and
• Children who are medically complex, who have neurologic, genetic, metabolic conditions, or who have congenital heart disease are at higher risk for severe illness from COVID-19 than other children.

June 26, 2020: Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on COVID-19 MLN Article Revised Again

MLN Article SE20011 initially released on March 16, 2020 has been updated twice in the past week and is now in its eight iteration. First, on June 19th, a revision added the section, “Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients.” Following is an excerpt from the information added to this MLN article:

“Starting on July 6, 2020, and for the duration of the public health emergency, consistent with sections listed below of CDC guidelines titled, “Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel,” Original Medicare and Medicare Advantage plans will cover diagnostic COVID-19 lab tests and non-cover tests not considered diagnostic.

• Viral Testing of Residents for SARS-CoV-2
• Initial Viral Testing in Response to an Outbreak
• Recommended testing to determine resolution of infection with SARS-CoV-2
• Public health surveillance for SARS-CoV-2

Tests that are considered non-diagnostic are not covered.”

This article was again updated on June 26th to add a section titled Skilled Nursing Facility (SNF) Benefit Period Waiver – Provider Information and Billing Instruction. In this update CMS provides examples of when to document on the claims that a patient meets the requirement SNF requirement waiver.

June 28, 2020: CDC Updates Considerations for Wearing Cloth Face Coverings

On June 28th the CDC updated this webpage and is recommending people wear cloth face coverings in public settings and when around people outside of their household, especially when other social distancing measures are difficult to maintain. You will find information about the following on this webpage:

• Evidence for effectiveness of cloth face coverings,
• Who should wear a cloth face covering,
• Who should not wear a cloth face covering,
• Feasibility and Adaptations,
• Face shields,
• Surgical Masks, and
• Links to recent studies.

June 29, 2020: New Supplies of Remdesivir for the United States

The Department of Health and Human Services (HHS) announced an agreement to secure more than 500, 000 treatment courses of Remdesivir for the US from Gilead Sciences through September. Per the announcement “hospitals will receive the product shipped by AmerisourceBergen and will pay no more than Gilead’s Wholesale Acquisition Price (WAC), which amounts to approximately $3,200 per treatment course.”

Daniel O’Day, Chairman and CEO of Gilead Sciences indicated in a related Open Letter that normal pricing of a medicine is according to the value provided and cites an approximately $12,000 hospital savings per patient. He went on to indicate that “We have decided to price remdesivir well below this value. To ensure broad and equitable access at a time of urgent global need, we have set a price for governments of developed countries of $390 per vial. Based on current treatment patterns, the vast majority of patients are expected to receive a 5-day treatment course using 6 vials of remdesivir, which equates to $2,340 per patient.”

Q:

Can you help me understand what a provisional affirmation prior authorization (PA) decision is as it pertains to the Outpatient Prior Authorization Program set to begin on July 1, 2020? 

 

A:

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M posted the following information about the Outpatient Department Prior Authorization in their June 22, 2020 Daily Newsletter:

“A provisional affirmation prior authorization (PA) decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. The provisional affirmation PA decision is valid for 120 days from the date decision was rendered.

Palmetto GBA's Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires. Just enter the date of the Prior Authorization Affirmation and click Calculate. The tool will tell you the last date your authorization will be valid.”

• Jurisdiction J Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction J Part B Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part A Outpatient Department Prior Authorization Calculator
• Jurisdiction M Part B Outpatient Department Prior Authorization Calculator

Q:

What recourse do we have when a claim has been denied by the SMRC for no receipt of documentation requested?

 

A:

Noridian is the nationwide SMRC who conducts medical reviews as directed by CMS. If you have received a denial for no receipt of documentation requested you would need to do the following:

• Submit documentation to the Medicare Administrative Contractor (MAC), who issued the demand letter for overpayment within 120 calendar days of the demand letter.
• This situation is considered a reopening and the MAC will send the submitted information to the SMRC for a re-review decision.
• The SMRC has 60 days to make a decision and will mail a letter to the supplier with their findings to pay the claim or outline why the claim is being denied.
• The SMRC will also notify the MAC of the payment or denial decision.
• The MAC will then adjust the claim and a remittance advice with the adjustment results will be generated.
• If a claim remains denied, you have the right to appeal the SMRC decision.

The SMRC website can provide you with additional information about their medical review process and how to respond to an Additional Documentation Request (ADR).

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 15th – 22nd.

Resource Spotlight This Week:

This week’s COVID-19 resource spotlight is on the HHS Coronavirus (COVID-19) Home webpage. The HHS indicates that they and their federal partners “are working together with state, local, tribal and territorial governments, public health officials, health care providers, researchers, private sector organizations and the public to execute a whole-of-America response to the COVID-19 pandemic to protect the health and safety of the American people.” Following is a list of a few of the topics related to COVID-19 available on this webpage:

• CARES Act Provider Relief Fund,
• Testing,
• Telehealth, and
• Mental Health and Coping.

June 15, 2020: FDA Revokes Emergency Use Authorization for Chloroquine and Hydroxychloroquine

The FDA has revoked the Emergency Use Authorization (EUA) for the use of these two drugs in treating COVID-19. They indicated in a News Release that “Based on its ongoing analysis of the EUA and emerging scientific data, the FDA determined that chloroquine and hydroxychloroquine are unlikely to be effective in treating COVID-19 for the authorized uses in the EUA. Additionally, in light of ongoing serious cardiac adverse events and other potential serious side effects, the known and potential benefits of chloroquine and hydroxychloroquine no longer outweigh the known and potential risks for the authorized use.” At the same time of the News Release, the FDA posted a related FAQ Document.

June 15, 2020: FDA Warns of Newly Discovered Potential Drug Interaction Related to Remdesiver

On June 15th, in addition to revoking the EUA for Chloroquine and Hydroxychloroquine, the FDA posted another News Release warning health care providers that “Based on a recently completed non-clinical laboratory study, the FDA is revising the fact sheet for health care providers that accompanies the drug to state that co-administration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not recommended as it may result in reduced antiviral activity of remdesivir. The agency is not aware of instances of this reduced activity occurring in the clinical setting but is continuing to evaluate all data related to remdesivir.”

June 16, 2020: Applying COVID-19 Infection Prevention and Control Strategies in Nursing Homes

On Tuesday June 16th, the CDC hosted a webinar where presenters used case-based scenarios to discuss how to apply infection prevention and control guidance for nursing home and other long-term care facilities. A recording of the call and slide deck are available on the CDC Clinical Outreach and Communications (COCA) Calls/Webinars webpage.

June 17, 2020: Senate Health Committee Chair: Make the Two Most Important COVID-19 Telehealth Policy Changes Permanent

A June 17, 2020 Press Release provides remarks made by Senate health committee Chairman Lamar Alexander (R-TN) during the “Telehealth: Lessons from the COVID-19 Pandemic” committee hearing.

Senator Alexander noted that “As dark as this pandemic event has been, it creates an opportunity to learn from and act upon these three months of intensive telehealth experiences, specifically what permanent changes need to be made in federal and state policies.” Specifically, Alexander said the following two changes should be permanent:

• Permanently extend policy changes allowing physicians to be reimbursed for telehealth appointment wherever the patient is located, including the patient’s home, and
• Permanently extent the policy change that nearly doubled the number of telehealth services that could be reimbursed by Medicare.

He also indicated that there are 29 other temporary federal policy changes that could also be considered for being made permanent. You can view the entire Press Release at https://www.help.senate.gov/chair/newsroom/press/alexander-make-the-two-most-important-covid-19-telehealth-policy-changes-permanent.

Link to White Paper: Preparing for the Next Pandemic by Senator Lamar Alexander: https://www.alexander.senate.gov/public/_cache/files/0b0ca611-05c0-4555-97a1-5dfd3fa2efa4/preparing-for-the-next-pandemic.pdf

June 18, 2020: COVID-19 Diagnostic Laboratory Tests: Billing for Clinician Services

CMS provided the following reminders in the June 18, 2020 edition of their weekly MLNConnects eNewsletter:

“Physicians and Non-Physician Practitioners (NPPs): Here are several reminders related to billing for COVID-19 symptom and exposure assessment and specimen collection performed on and after March 1, 2020:

• Use CPT Code 99211 to bill for assessment and collection provided by clinical staff (such as pharmacists) incident to your services, unless you are reporting another Evaluation and Management (E/M) code for concurrent services. This applies to all patients, not just established patients.
• Submit the CS modifier with 99211 (or other E/M code for assessment and collection) to waive cost sharing.
• Contact your Medicare Administrative Contractor if you did not include the CS modifier when you submitted 99211 so they can reopen and reprocess the claim.
• We will automatically reprocess claims billed for 99211 that we denied due to place of service editing.”

June 19, 2020: Weekly Update of Nursing Home COVID-19 Data as of June 7, 2020

CMS has posted the second set of COVID-19 Nursing Home Data as of June 7th and is available at https://data.cms.gov/stories/s/bkwz-xpvg.

Residents Cases and Deaths as of June 7, 2020:

• 107,389 total confirmed cases of COVID-19,
• 71,278 total suspected cases of COVID-19, and
• 29,497 total deaths attributed to COVID-19.

Moving forward this data will be updated weekly. In addition to the data release, CMS has released additional FAQs on Nursing Home COVID-19 data at  https://data.cms.gov/api/views/b62a-ieuz/files/e883f38f-77da-4f58-975f-390b858ccf9f?filename=NH%20COVID-19%20data%20FAQ%206-18-2020.pdf.

June 19, 2020: Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

CMS announced in a June 19th, 2020 Special Edition MLNConnects that they have instructed Medicare Administrative Contractors and notified Medicare Advantage plans that they “must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.”

June 19, 2020: FDA Letter: Stop Using COVID-19 Antibody Tests on the FDA’s “Removed” Test List

On June 19th, the FDA issued a Letter to Clinical Laboratory Staff and Health Care Providers with the recommendation to stop using COVID-19 antibody tests listed on their “removed” test list.” “The “removed” test list includes tests in which significant clinical performance problems were identified that cannot be or have not been addressed by the commercial manufacturer in a timely manner, tests for which an Emergency Use Authorization request has not been submitted by a commercial manufacturer of a serology test within a reasonable period of time as outlined in the FDA’s guidance, and tests voluntarily withdrawn by the respective commercial manufacturers.”

MEDICARE TRANSMITTALS – RECURRING UPDATES

 

Quarterly Influenza Virus Vaccine Code Update – July 2020

• Article Release Date: January 31, 2020
• What You Need to Know: The influenza virus vaccine code set is updated on a quarterly basis. Reminder, effective for claims processed with dated of service on or after July 1, 2020, influenza virus vaccine code 90694 (influenza virus vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use) is payable by Medicare.
• MLN MM11603: https://www.cms.gov/files/document/mm11603.pdf

July 2020 Integrated Outpatient Code Editor (I/OCE) Specification Version 21.2

• Article Release Date: June 5, 2020
• What You Need to Know: This article provides the I/OCE instructions and specifications for the I/OCE employed under the Outpatient Prospective Payment System (OPPS) and non-OPPS. The specifications are for:
• Hospital outpatient departments
• Community mental health centers
• All non-OPPS hospital providers
• For limited services when provided in a Home Health Agency (HHA) not under the HH Prospective Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/.
• MLN Matters MM11792: https://www.cms.gov/files/document/mm11792.pdf

July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Article Release Date: June 5, 2020
• What You Need to Know: The following list highlights the main topics included in this document:
• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update,
• Status Indicator Changes for Certain Virtual Services,
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinical (RHC) or Federally Qualified Health Center (FQHC) Only,
• New CPT Category III Codes Effective July 1, 2020,
• CPT Proprietary Laboratory Analysis (PLA) Coding Changes Effective July 1, 2020,
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755,
• Device Pass-Through Updates,
• Changes to Certain Device Offsets for 2020,
• Drugs, Biologicals, and Radiopharmaceuticals,
• Skin Substitutes – New Products,
• New Separately Payable Procedure Codes – Surgical Procedures,
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI),
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy,
• Supervision of Outpatient Therapeutic Services,
• MLN MM11814: https://www.cms.gov/files/document/mm11814.pdf

July Quarterly Update for the 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

• Article Release Date: June 5, 2020
• What You Need to Know: This article informs DME MACs about changes to the DMEPOS fee schedules that are updated quarterly, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies.

Note, this update includes guidance from the interim final rule with comment period (CMS-5531-IFC) entitled “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” published in the Federal Register May 8, 2020. This final rule implements a section of the Coronavirus Aid, Relief, and Economic Security (CARES) Act regarding fee schedule adjustments.

• MLN MM11810: https://www.cms.gov/files/document/mm11810.pdf
  

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2020

• Article Release Date: June 5, 2020
• What You Need to Know: Medicare Updates the DMEPOS CBP files on a quarterly basis to implement necessary changes to HCPCS, ZIP code, and supplier files. Related Change Request CR 11819 provides specific instruction for implementing the DMEPOS CBP files.
• MLN MM11819: https://www.cms.gov/files/document/mm11819.pdf

Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

• Article Release Date: June 12, 2020
• What You Need to Know: This article informs labs about changes in the quarterly update. Several of the updates are specific to guidance regarding lab testing related to COVID-19.
• MLN MM11815: https://www.cms.gov/files/document/mm11815.pdf

 

OTHER MEDICARE TRANSMITTALS

 

Implement Operating Rules – Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advise Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Healthcare (CAQH) CORE

• Article Release Date: May 22, 2020
• What You Need to Know: Informs you of updates the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, CAGC rule publications. Updates are based on the CORE Combination Codes List to be published on or about June 1, 2020.
• MLN Matters MM11709: https://www.cms.gov/files/document/mm11709.pdf

New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

• Article Release Date: June 12, 2020
• What You Need to Know: Code “G” is a new Point of Origin (PoO) code to indicate a “transfer from a Designated Disaster Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency (PHE).
• MLN MM11836: https://www.cms.gov/files/document/mm11836.pdf

 

REVISED MEDICARE TRANSMITTALS

 

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—October 2020 Update

• Article Release Date: May 1, 2020 – Rescinded May 26, 2020
• What You Need to Know: This article was rescinded on May 26, 2020, as the related Change Request (CR) 11749, Transmittal 10092, dated May 1, 2020, was rescinded in its entirety. Therefore, any coding changes to NCD 90.2, Next Generation Sequencing are null and void.
• MLN MM11749: https://www.cms.gov/files/document/mm11749.pdf

 

Supplier Education on Use of Upgrades for Multi-Function Ventilators

• Article Release Date: May 29, 2020
• What You Need to Know: This article was revised to show that the policy on use of multi-function ventilators, as discussed in the “What You Need to Know” section, is a permanent change.
• MLN SE20012: https://www.cms.gov/files/document/se20012.pdf

 

Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component

• Article Release Date: May 29, 2020 – Revised June 9, 2020
• What You Need to Know: This article provides information about the hospice benefit component associated with the VBID Model being tested by the CMS Innovation Center and starting in Calendar Year (CY) 2021. CMS highlights that “providers MUST still submit claims for these services to Medicare.” CMS revised this MLN article on June 9th to reflect a revised CR 11754 issued on June 9th.
• MLN Matters MM11754: https://www.cms.gov/files/document/mm11754.pdf

NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)

• Article Release Date: March 24, 2020 – Revised June 10, 2020
• What You Need to Know: This article was revised to reflect formatting revisions in Change Request 11660. The substance of the article was not altered.
• MLN MM11660: https://www.cms.gov/files/document/mm11660.pdf

 

MEDICARE COVERAGE UPDATES

 

National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)

• Article Release Date: June 1, 2020
• What You Need to Know: Change Request (CR) 11461 was published on May 22, 2020 highlighting that new to NCD 160.16, for claims with a date of service on or after February 15, 2019, the CMS covers FDA-approved VNS devices for treatment-resistant depression through Coverage with Evidence Development (CED) when all reasonable and necessary criteria are met. The accompanying MLN article was released on June 1, 2020.
• MLN MM11461: https://www.cms.gov/files/document/mm11461.pdf

Other Medicare Updates

 

Prior Authorization (PA) Program for Certain Hospital Outpatient Department (ODP) Services CMS Operational Guide and FAQs

In last May CMS released an Operational Guide and FAQs related to this Program set to begin July 1, 2020.

• Operation Guide: https://www.cms.gov/files/document/opd-operational-guide.pdf
• Frequently Asked Questions: https://www.cms.gov/files/document/opd-frequently-asked-questions.pdf

2021 ICD-10-PCS Codes for Discharges Occurring from October 1, 2020 through September 30, 2021

On May 28, 2020, CMS posted the 2021 Official ICD-10-PCS Coding Guidelines, Code Tables, and Addendum on the 2021 ICD-10-PCD CMS webpage.

• Link to CMS webpage: https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs

KEPRO Case Review Connections: Acute Care Edition: Summer 2020

KEPRO published their Summer 2020 Case Review Connections e-newsletter. Topics included in this newsletter includes:

• Medical Director’s Corner,
• A Reminder About Appeals Cases,
• Updates from CMS Related to COVID-19,
• An Immediate Advocacy Success Story,
• Frequently Asked Questions, and
• Staff Education about BFCC-QIO Services.

June 17, 2020 CMS Proposed Rule: Establishing Minimum Standards in Medicaid State Drug Utilization (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS 2482-P)

CMS Administrator Seema Verma noted in a Press Release that “CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models…by modernizing our rules, we are creating opportunities for drug manufacturers to have skin in the game through payment arrangement that challenge them to put their money where their mouth is.”

The Press Release includes links to a related Fact Sheet and the Proposed Rule. CMS is accepting comments no later than 5 p.m. on July 20, 2020. 

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 8th – June 15th

Weekly COVID-19 Resource Spotlight: CDC Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations

According to the CDC, the Toolkit Communication Toolkit was created to help public health professionals, health departments, community organizations, and healthcare systems and providers reach populations who may need COVID-19 prevention messaging in their native languages. Currently there are materials available in 28 languages ranging from Amharic to Vietnamese. The toolkit provides:

• Current messaging from a trusted source.
• Information in plain language available for downloading and sharing.
• Translated materials to help communities disseminate messages to a wider audience.

June 8, 2020: Addressing the Disparate Impact of COVID-19 on African Americans and Other Racial and Ethnic Minorities.

This HHS Office of Civil Rights Fact Sheet details initiatives underway to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities. A link to this document as well as other COVID-19 Announcements can be found on the HHS Civil Rights and COVID-19 webpage.

June 8, 2020: New FDA Webpages: Innovation to Respond to COVID-19 and Education Resources

In their June 8th COVID-19 Update: Daily Roundup, the FDA announced that they had published two new web pages to help the public access information:

• Innovation to Respond to COVID-19 provides an overview of FDA’s innovative approaches to respond to COVID-19 as quickly and safely as possible, and
• Educational Resources provides links to FDA-produced COVID-19-related resources that help explain FDA’s work.

June 9, 2020: CMS Recommendations for Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare and a Guide for Patients as they consider In-Person Care Options

As the country moves towards “re-opening our towns” CMS has provided two documents for consideration during this transition. First is a guide for patients and beneficiaries as they consider “in-person” care options. Recommendations for the following topics can be found in this guide:

• Do Not Postpone Necessary Care.
• Is It Safe to Go to your Doctor or Hospital?
• Consider Telehealth or Virtual Visits.
• What to Expect when you Seek Healthcare.
• Should I get tested for COVID-19 before seeking healthcare?
• Vulnerable Populations: When Possible, Stay Home.

This new guide is available in English and Spanish.

Second, is CMS’ document providing recommendations for re-opening facilities to provide non-emergent, Non-COVID-19 healthcare. The recommendations are intended for states or regions who have determined with their public health officials that they have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, proceeded to Phase I, and are now ready for Phase II of re-opening. In this document, CMS recommends:

• Optimization of telehealth services, when available and appropriate, to minimize the need for in-person services.
• All individuals at higher risk for severe COVID-19 illness should continue to shelter in place unless an in-person healthcare visit is warranted.
• The phased recommendations in this document “may guide healthcare systems, providers, and facilities as they consider delivering in-person care to non-COVID-19 patients in regions with lower or declining-without-rebound, levels of COVID-19.”

You can read more in a June 9th Press Release that includes links to both of these documents.

June 10, 2020: COVID-19 FAQs for Non Long-Term Care Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IIDs)

CMS released this FAQ Document on June 10th and indicates that “The purpose of this FAQs document is to clarify existing guidance and flexibilities and provide stakeholders with additional information based on questions received regarding the following entities:

• Ambulatory Surgical Centers (ASCs)
• Hospitals & Critical Access Hospitals (CAHs)
• Hospice
• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)
• Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs).”

June 10, 2020: Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic

The CDC has created a webpage dedicated to the use of telehealth. Their purpose in providing this guidance is “to describe the landscape of telehealth services and provide considerations for healthcare systems, practices, and providers using telehealth services to provide virtual care during and beyond the COVID-19 pandemic. As of June 10th, you will find the following on this webpage:

• Telehealth background,
• Telehealth modalities,
• Benefits and Potential Uses for Telehealth,
• Strategies to Increase Telehealth Update,
• Telehealth Reimbursement,
• Safeguards for Telehealth Services,
• Potential Limitations of Telehealth, and

June 12, 2020: CMS One-Time Notification: New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site

This Change Request (CR) 11836 implements a new Point of Origin (PoO) Code “G” to indicate a “Transfer from a Designated Disease Alternative Care Site (ACS),” due to changes relative to the COVID-19 Public Health Emergency.

“Background: The National Uniform Billing Committee (NUBC) practice is to align Discharge Status Codes and Point of Origin (PoO) Codes whenever possible. It came to the Committee's attention that there is a Discharge Status Code for Alternate Care Sites (ACS) but no specific matching PoO Code. Relative to the COVID-19 Public Health Emergency, NUBC created a new Point of Origin (PoO) Code "G" to be effective 07/01/2020, and defined as "Transfer From a Designated Disaster Alternate Care Site."

June 12, 2020: OCR Issues Guidance on HIPAA and Contacting Former COVID-19 Patients about Blood and Plasma Donation

The OCR has released a document answering the question of whether or not covered healthcare providers are permitted to use protected health information (PHI) to identify and contact patients who have recovered from COVID-19 to provide them with information about donating blood and plasma that could help other COVID-19 patients. The short answer is yes. As the late Andy Rooney would say, you can find the entire two page document for “the rest of the story” on the HHS.gov HIPAA and COVID-19 webpage.

June 13, 2020: HHS Awards $15 Million to Support Telehealth Providers During the COVID-19 Pandemic

The Department of Health and Human Services (HHS) announced that they have awarded $15 million to 159 organizations across five health workforce programs to increase telehealth capabilities in response to the COVID-19 pandemic. These awards are funded through the Coronavirus Aid, Relief and Economic Security (CARES) Act.

HHS indicated in the announcement that “these investments will train students, physicians, nurses, physician assistants, allied health and other high-demand professionals in telehealth. This will enable these professionals to maximize telehealth for COVID-19 referrals for screening and testing, case management, outpatient care, and other essential care during the crisis.”

This announcement provides a link to the complete list of award recipients.

Q:

Has CMS released information about the July 2020 Hospital Outpatient Prospective Payment System update? 

A:

Yes. On June 5th CMS released Change Request 11814 - Transmittal R10166CP and related MLN Article MM1184. This recurring update notification describing changes to and billing instructions for various payment policies implemented in the July 2020 OPPS update. This update includes changes in response to the COVID-19 pandemic and the secretary declaring a public health emergency (PHE). Following is a list of key updates for July 1, 2020:

• COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update
• Status Indicator Changes for Certain Virtual Services (Telephone services)
• New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only
• Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE
• New CPT Category III Codes Effective July 1, 2020
• The American Medical Association (AMA) released CPT Category III codes twice a year: In January, for implementation beginning the following July, and in July, for implementation beginning the following January. CMS is implementing 25 CPT Category III codes on July 1, 2020.
• CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020
• The AMA CPT Editorial Panel deleted five PLA codes (CPT codes 0124U through 0128U) and established 30 new PLA codes (CPT codes 0172U through 0201U)
• Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755
• New Device Pass-Through Categories
• New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status
• There are eleven new HCPCS codes for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available (i.e., C9059 Injection, meloxicam, 1mg).
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status
• Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020
• Drugs and Biologicals that have Changes to Status Indicators 
• Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020
• Skin Substitutes – New Products
• New Separately Payable Procedure Codes – Surgical Procedures
• New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI)
• New HCPCS Codes Describing Peripheral Intravascular Lithotripsy
• Supervision of Outpatient Therapeutic Services
• This section discusses several changes that have been made in response to the COVID-19 outbreak and the Secretary declaring the existence of a public health emergency (PDE).

Finally, CMS reminds providers that “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

Resources:

Link to Transmittal: https://www.cms.gov/files/document/r10166cp.pdf

Link to MLN Article MM11814: https://www.cms.gov/files/document/mm11814.pdf

Welcome to this month’s MAC Talk article. This month before diving into updates from the MACs, I wanted to alert readers about Change Request (CR) 11695. This CR was published on May 15, 2020 and provides details regarding revisions to the Targeted Probe and Educate (TPE) Program in the Medicare Program Integrity Manual (IOM 100-08), chapter 3, section 3.2.5.

Background

The TPE review strategy includes instruction to the MACs to refer providers/suppliers failing three rounds of TPE to the CMS for next steps. Prior to the release of CR 11695 there were no references available from CMS to the potential for more than three rounds of TPE review. As a result, CMS is revising the TPE language in section 3.2.5 in Chapter 3 of the Program Integrity Manual (Pub. 100-08) to include the possibility of additional rounds of TPE review.

The following language has been added to the guidance in section 3.2.5D. Post-Probe Activity – Final Results Letter:

“For providers/suppliers who will be released from review due to meeting the established error rate goal, results letters shall indicate that the provider is being released from review for one year, with the caveat that additional review may occur at any time should the MAC identified changes in billing pattern. For providers/suppliers who continue to have high error rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the following language to remind providers of 42 CFR §424.535.

“In addition, we remind you that the regulation at 42 CFR §424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.””

 

May MAC Talk: The Local Scene

 

May 19, 2020: NGS Botulinum Toxin Injections for Chronic Headaches CERT Findings

This NGS article provides a list of the most common reasons the CERT determined there was insufficient documentation for the service provided.

• Missing evaluation to support patient is having 15 or more headaches a month for at least three months,
• Missing documentation to support a significant decrease in the number and frequency of headaches per month,
• Missing documentation to support the amount of waste for the botulinum toxin, and
• Missing electronic signature or legible signature.

You can learn more about NGS’ requirements for Botulinum Toxin Injections in their Local Coverage Determination (LCD): Botulinum Toxins (L33646) and related Coverage Article (A52848). As a reminder, Botulinum Toxin Injections is one of the procedures that will require a prior authorization beginning with dates of service on or after July 1, 2020. You can read more about the Prior Authorization Program for certain outpatient department procedures in a related MMP article.

May 20, 2020: First Coast Guidance for Submitting Prior Authorization for Certain Outpatient Department (OPD) Services

First Coast provided guidance in their May 20th eNews about the elements that must be submitted in a Prior Authorization Request (PAR) for services requiring one as part of the new Prior Authorization Program set to begin on July 1, 2020. First Coast is set to begin accepting PARs for these services as of today June 17, 2020, for services to be provided on or after July 1, 2020. You can read the full announcement under the Medical Review tab on the First Coast website.

May 27, 2020: Palmetto GBA Daily Newsletter: Medicare Secondary Payer (MSP) Basics Modules

Palmetto GBA posted information about an educational series available on their website on MSP guidelines. They note in the announcement that “this series provides guidance with condition payment provisions and common MSP billing questions.” They encourage you to review the modules with your staff.

May 28, 2020: CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Open Door Forum (ODF)

The CMS held a special ODF to go over the basics of this program. The presentation was followed by a very robust Q&A session. The slides from this session as well as an Operational Guide and FAQs document have been added to the downloads section of the CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services webpage.

June 5, 2020: Noridian Article: SNF PDPM Assessment Diagnosis COVID-19 ICD-10 Code U07.1 and SNF Waiver to Extend Benefit Period

In this article, Noridian offers the following guidance for providers experience claims processing problems related to the April 1, 2020 effective date of applying the new U07.1 – 2019-nCoV acute respiratory disease ICD-10-CM code when the 5-day assessment window overlaps March into April dates of service:

“Based on the following guidance from the CMS PDPM FAQs Question 1.8 that states ‘Is it required that the principal diagnosis on the SNF claim match the primary diagnosis coded in item I0020B? While we expect that these diagnoses should match, there is no claims edit that will enforce such a requirement'. Providers with a 5-Day PPS MDS with an April 2020 ARD, but a lookback period that extends into March 2020, when applicable, they can use the COVID 19 ICD-10 code U07.1 in MDS item I0020B to obtain the appropriate PDPM case-mix classification. However, the claim associated with March DOS must contain a different ICD-10 code that applies to the beneficiary and is valid in the month of March.”

This article also provides details regarding the impact on typical billing and assessment processes when a beneficiary qualifies for renewed SNF benefits under the SNF waiver as a result of the COVID-19 pandemic.

June 8, 2020: WPS GBA Medicare eNews: Intravenous Immunoglobulin Therapy (IVIG)

WPS posted the following information regarding IVIG therapy in their June 8th eNews:

“Do you bill for IVIG? Before you bill for these services, read the Local Coverage Article: Billing and Coding: Immune Globulins (A57554). Why read the article? The Centers for Medicare & Medicaid Services (CMS) identified a potential vulnerability in the WPS GHA jurisdictions. Providers should follow the guidance in the local coverage article if they expect payment.”

June 12, 2020: Novitas eNews: Prior Authorization Hospital Outpatient Department Services (OPD) FAQs

Novitas posted this FAQ document in their June 12th eNews indicating the document had been developed to include questions and answers posed during their webinar about the PA program for certain hospital OPD services.

June 15, 2020: WPS GHA Medicare eNews: Appropriate Application of Modifier for Injections to Manage Age-Related Macular Degeneration (AMC)

WPS included the following information in their June 15th Medicare eNews:

“Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss that affects millions of Americans. Medicare Part B covers age-related macular degeneration (AMD) treatments, which include:

• Aflibercept (Eyelea)
• Ranibizumab (Lucentis)
• Brolucizumab (Beovu)
• Bevacizumab (Avastin)

Recent claim review data showed that claims submitted with anti-vascular endothelial growth factor (anti-VEGF) drug codes did not include an appropriate modifier identifying the eye being treated resulting in claim denials. For more information, see the full article on our website.”

MMP remains committed to continuing to monitor for COVID-19 updates specific to our reader base. This week we highlight key updates spanning from June 1st through June 8th.

Resource Spotlight This Week:

As our nation works to “re-open” and move forward towards a “new normal,” it is important to understand Policy Actions in your state and states you may be traveling to. This week’s spotlight resource can help provide that information. On June 3rd the Kaiser Family Foundation (KFF) published the State Data and Policy Actions to Address Coronavirus. Following is a list of key information that is available on this webpage:

• COVID-19: Confirmed cases & Deaths by State,
• State Social Distancing Actions,
• State COVID-19 Health Policy Actions,
• State Actions on Telehealth,
• State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (as of May 28, 2020),
• Guidance for Long-Term Care Facilities Related to COVID-19 (as of May 7, 2020),
• Adults at Higher Risk of Serious Illness if Infected with Coronavirus,
• Medicaid Expansion Status and Health Insurance Coverage,
• Private Insurance Deductibles and Self-Insured Plans,
• Health Care Provider Capacity, and
• Influenza and Pneumonia Deaths and Vaccinations

This publication was authored by Jennifer Tolbert, Cornelia Hall, Kendral Orgera, Natalie Singer, Salem Mengisut, and Marina Tian.

June 1, 2020: Nursing Home COVID-19 Data and Inspection Results leads to Enhanced Enforcement Actions

In a June 1st Press Release, the CMS announced enhanced enforcement directed towards nursing homes with violations of longstanding infection control practices.

A couple of key points in a related State Survey Memo summary are as follows:

• “Following the March 6, 2020 survey prioritization, CMS has relied on State Survey Agencies to perform Focused Infection Control surveys of nursing homes across the country. We are now initiating a performance-based funding requirement tied to the Coronavirus Aid, Relief and Economic Security (CARES) Act supplemental grants for State Survey Agencies. Further, we are providing guidance for the limited resumption of routine survey activities.
• CMS is also enhancing the penalties for noncompliance with infection control to provide greater accountability and consequence for failures to meet these basic requirements... The enhanced enforcement actions are more significant for nursing homes with a history of past infection control deficiencies, or that cause actual harm to residents or Immediate Jeopardy.”

CMS also provided link to the following information in the Press Release:

• Letter to the Governors (PDF)
• State breakdown of the Nursing Home COVID-19 data (PDF).

 

June 3, 2020: CMS Innovation Center Models COVID-19 Related Flexibilities

CMS posted an announcement on the CMS Innovation Center COVID-19 Flexibilities webpage regarding flexibilities being made to several CMS Innovation Center Value-Based Payment Models in response to COVID-19. For example, the Comprehensive Care for Joint Replacement (CJR) Model performance year 5 has been extended through March 2021.

In a news blog CMS indicated the Innovation Center will work “directly with model participants on the specific model changes and the processes for implanting them. CMS will also continue to review the data from our models during this COVID-19 pandemic, to identify short-term and long-term lessons learned.”

June 4, 2020: PEPPER Q1 FY 2020 Release Delayed

The PEPPER Team sent out a notice alerting providers that in keeping with the CMS effort to take measures to free up the attention of providers during the COVID-19 pandemic, the release of the Q1FY20 PEPPER for short-term (ST) acute care hospitals has been delayed. When information becomes available, the PEPPER Team will notify providers about the rescheduled release date.

June 4, 2020: FDA Video – Explaining Different Categories of Tests in Fight against COVID-19

The FDA has released a new video to provide information about the diagnostic tests and antibody tests used in the fight against COVID-19.

June 4, 2020: OCR Alert: HHS Awards More than a Half Billion Dollars to Help Vulnerable and Underserved Communities Gain Access to COVID-19 Testing

The OCR indicates in this alert that they are “sharing this update to promote awareness about COVID-19 testing and testing-related availability to people who are geographically isolated, economically disadvantaged, or medically vulnerable, including people with HIV, pregnant women, people experiencing homelessness, agricultural workers, residents of public housing, older persons and our nation’s veterans.

‎In case you missed it: On ‎May ‎7, ‎2020, the U.S. Department of Health and Human Services, through the Health Resources and Services Administration (HRSA), awarded nearly $583 million to 1,385 HRSA-funded health centers in all 50 states, the District of Columbia, and eight U.S. territories to expand COVID-19 testing. Nearly 88 percent of HRSA-funded health centers report testing patients, with more than 65 percent offering walk-up or drive-up testing. Health centers are currently providing more than 100,000 weekly COVID-19 tests in their local communities.

This Alert provided the following links:

• The Full Press Release may be found on HHS’s website here.
• For a list of award recipients, visit https://bphc.hrsa.gov/emergency-response/expanding-capacity-coronavirus-testing-FY2020-awards. 
• To learn more about health center capacity and the impact of COVID-19 on health center operations, patients and staff, visit https://bphc.hrsa.gov/emergency-response/coronavirus-health-center-data.
• For more information about COVID-19, visit http://coronavirus.gov
• For more information about COVID-19 and civil rights, visit https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/index.html

June 4, 2020: CMS News Alert – Nursing Home COVID-19 Data and Inspection Results Available on Nursing Home Compare

CMS announced in a June 4, 2020 Press Release that they are posting the first set of underlying COVID-19 nursing home data as well as posting results from targeted inspections announced on March 4, 2020 that allowed inspectors to focus on the most serious health and safety threats like infectious disease and abuse during the pandemic.

COVID-19 Nursing Home Data

As of May 31, 2020

• About 13,600 (approximately 88%) of Medicare and Medicaid Nursing Homes had reported the required data to the CDC.
• These facilities reported 95,000 confirmed COVID-19 cases and almost 32,000 deaths.

The CMS announced the next set of data will be released in two weeks and then plans to update the data weekly.

June 4, 2020: New Laboratory Data Reporting Guidance for COVID-19 Testing

The U.S. Department of Health and Human Services (HHS) announced new guidance specifying what additional data must be reported to HHS by laboratories along with COVID-19 test results. “The requirement to include demographic data like race, ethnicity, age, and sex will enable us to ensure that all groups have equitable access to testing, and allow us to accurately determine the burden of infection on vulnerable groups,” said ADM Brett P. Giroir, MD, Assistant Secretary for Health. “With these data we will be able to improve decision-making and better prevent or mitigate further illnesses among Americans.”

Q:

What is the Prior Authorization for Certain Outpatient Department (OPD) Services Program and what resources are available to learn more about the program?

A:

The 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. A Prior Authorization will be required for the following five procedures:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

You can access a list of the specific HCPCS codes for each of these procedures on the CMS Prior Authorization for Certain Hospital OPD Services webpage.

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.

As required by CMS, Medicare Administrative Contractors have been educating providers about this program by posting information on their websites and webinars. Likewise, CMS has created a webpage with information specific to this program and held a Special Open Door Forum on May 28, 2020.

This program is set to begin July 1, 2020. However, a week from today on June 17, 2020, hospitals can begin submitting prior authorization requests (PARs) to Medicare Administrative Contractors for services to be provided on or after July 1, 2020.   

Following are links to resources to assist you as you prepare for this new program:

• CMS Prior Authorization for Certain Hospital OPD Services webpage https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
• Note, this page includes a link to the list of applicable HCPCS codes for the program, the ODF slides, an FAQ document about the program and an Operational Guide.
• Calendar Year 2020 Outpatient Prospective Payment System Final Rule https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf
• Note, information about this program starts on page 61446
• Palmetto GBA Outpatient Department PA https://www.palmettogba.com/palmetto/providers.nsf/docsr/Providers"JJ%20Part%20A"Medical%20Review"Outpatient%20Department%20PA
• Note, this page include articles about the program. The last article was posted on June 3rd and is an OPD eServices Submission Guide.