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Question:

A patient came to the ER and a CT of the abdomen and pelvis without contrast (CPT code 74176) was performed. While the patient was still in the ER, the patient went back to CT a second time and a CT abdomen and pelvis with contrast was performed, in other words – two separate scans. Can CPT codes 74176 and 74177 be billed together on the same date of service, and if so, is a modifier needed? Or do we have to report only one CPT code 74178 (CT abdomen and pelvis with and without contrast)?

Answer

If the payer uses Medicare’s National Correct Coding Initiative (NCCI) edits, you can bill CPT codes 74176 and 74177 on the same date of service. A modifier is needed to indicate the scans were separate and distinct from each other, i.e., two separate scans. Depending on the payer, use modifier 59 or XU.

When a patient has only one visit to the CT department for CT abdomen and pelvis with and without contrast as a single study, you must bill CPT code 74178. In this scenario, it would be inappropriate to bill CPT codes 74176 and 74177 with a modifier as this would constitute unbundling.

This week we highlight key updates spanning from May 11h through May 17th, 2021.

Resource Spotlight: Happy Belated National Women’s Health Week

National Women’s Health Week was last week (May 9th – 15th). This effort is led by the U.S. Department of Health and Human Services’ Office on Women’s Health (OWH). According to a related Fact Sheet (link), this year’s week served “as a reminder for women and girls, especially during the outbreak of COVID-19, to make their health a priority and take care of themselves. It is extremely important for all women and girls, especially those with underlying health conditions, such as hypertension, diabetes, obesity, cardiovascular and respiratory conditions and older adults, to take care of your health now.” You can read more about this event on the OWH website by clicking here.

Palmetto Statement in daily newsletter:

“CMS would like to make you aware that the federally supported website (link) that makes it easier for individuals to access COVID-19 vaccines is now live. Vaccines.gov (link) — powered by the trusted VaccineFinder brand — is available in English and Spanish, with high accessibility standard, and will help connect Americans with locations offering vaccines near them. In addition to the website, people in the U.S. are also now able to utilize a text message service, available in both English and Spanish. People can text their ZIP Code to 438829 (GETVAX) and 822862 (VACUNA) to find three locations nearby that have vaccines available.

Vaccines.gov is meant to complement the number of state and pharmacy websites that have been successfully connecting many Americans with vaccinations, by providing a unified federal resource for Americans to use no matter where they are.

In addition to the website and text messaging service, the National COVID-19 Vaccination Assistance Hotline is now available to help those who prefer to get information by phone on where to get a vaccine. Call 1-800-232-0233 to find a location near you.”
Link to announcement

May 11, 2021: CMS Issues Interim Final Rule for Long Term Care Facilities

CMS announced in a Special Edition MLN Connects (link) that they have released an interim final rule “that will ensure long-term care facilities , and residential facilities serving clients with intellectual disabilities, educate and offer the COVID-19 vaccine to residents, clients, and staff.” While the requirements of this rule is for Long-Term Care (LTC) facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID), CMS ends this announcement by indicating they are “seeking comment on opportunities to expand these policies to help encourage vaccine uptake and access in other congregate care settings.”

At the onset of the pandemic, FDA inspections began to be reserved for what they describe as “mission-critical issues” based on the following four factors:

May 13, 2021: CDC Updates Guidance for Fully Vaccinated People

The CDC provided the following two updates on their Guidance for Fully Vaccinated People webpage (link):

• You no longer need to wear a mask or physically distance in any setting, except where required by federal , state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance, and
• You can refrain from testing following a known exposure unless they are residents or employees of a correctional or detention facility or a homeless shelter.

I encourage you to visit this webpage for additional recommendations for indoor and outdoor settings and travel (Domestic and International).

May 14, 2021: CDC Morbidity and Mortality Weekly Report: COVID-19 Vaccine Effectiveness

The CDC posted a report (link) regarding vaccine effectiveness of Pfizer-BioNTech and Moderna COVID-19 vaccines among health care personnel (HCP) at 33 U.S. sites from January to March 2021. In the report summary they indicate what is added by this report is information about COVID-19 effectiveness:

• A single dose of Pfizer-BioNTech or Moderna COVID-19 vaccines is 82% effective against symptomatic COVID-19, and
• Two doses is 94% effective.

May 14, 2021: CDC Call – "What Clinicians Need to Know about Pfizer-BioNTech COVID-19 Vaccination of Adolescents" – In case you missed it, the CDC held a Clinician Outreach and Communication Activity (COCA) call this past Friday, May 14th. This call:

• Provided clinicians with an overview of the Pfizer-BioNTech COVID-19 Vaccination in adolescents who are 12-to-15 years old, and
• Provided information about safety and efficacy of the vaccine, vaccine recommendations, and clinical guidance.

You can access the call materials including slides on this CDC webpage (link).

Over the years, hyperbaric oxygen (HBO) therapy has been and continues to be a review focus by Medicare Review Contractors. Most recently, Palmetto GBA published their findings from a Post-Payment review of claims in their Medicare Administrative Contractor (MAC) Jurisdiction M. But first, let’s take a look back at who else has been reviewing HBO therapy services.

Strategic Health Solutions, LLC: April 2012 to March 31, 2013 Claims Review

In 2014, Strategic Health Solutions, LLC, the first Supplemental Medical Review Contractor (SMRC), completed a review of 2,000 HBO claims with dates of service April 1, 2012 to March 31, 2013. Of the 2,000 claims, 594 were denied for no response and 570 were denied after review resulting in an error rate of 58%. Documentation cited as not being in the record included:

• Specific timelines and goals for therapy. For example, the documentation simply stated “continue HBO” or “until healed”
• Radiology and pathology reports confirming diagnoses such as osteomyelitis or gas gangrene
• Monitoring for improvement or lack of improvement

In addition, when documentation was provided, descriptions of diabetic wounds did not meet Wagner Criteria for Grade three (III) or four (IV) wounds and therapy was provided beyond the 30 days allowed under Medicare coverage guidelines.

OIG: February 2018 Report: Wisconsin Physicians Service Paid Providers for HBO Services that Did Not Comply with Medicare Requirements

For this audit (link), the OIG focused on WPS who is the current Medicare Administrative Contractor for Jurisdictions 5 and 8. Based on their results, the OIG estimated that WPS overpaid providers in Jurisdiction 5 $42.6 million dollars during the audit period of claims paid in 2013 and 2014.

OIG: December 2018 Report: First Coast Options, Inc., Paid Providers for HBO Services that Did Not Comply with Medicare Requirements

Similar to the WPS Audit, the OIG focused on 2013 and 2014 claims and estimated that First Coast overpaid providers in Jurisdiction N $39.7 million (link).

Noridian SMRC: October 2020 Outpatient HBO Notification of Medical Review

In October 2020, the current SMRC announced a post-payment review of HBO therapy with dates of service from January 1, 2018 through December 31, 2018 (link). Noridian indicates in the notification that, “over the years, HBO therapy services formed the basis of several Office of Inspector (OIG) reports. Findings from these OIG reports note that Medicare beneficiaries received treatments for non-covered conditions, medical documentation did not adequately support treatments, and that Medicare beneficiaries received more treatments than were considered medically necessary.”

Palmetto GBA: January to March 2021 Claims Review

As mentioned at the beginning of this article, Palmetto GBA has completed a post-payment service specific probe review of HBO therapy for North Carolina, South Carolina, Virginia and West Virginia (link)). Cumulatively, 285 claims were reviewed and 144 were completely or partially denied resulting in an overall claim denial rate of 50.53 percent. Examples of top denial reasons includes:

• No documentation of medical necessity,
• The recommended protocol was not ordered and/or followed,
• Billing Error,
• Units billed more than ordered, and
• Services not documented,

Based on the “medium to high impact severity errors,” Palmetto plans to continue this targeted medical review.

Moving Forward:

If your facility provides HBO therapy, make sure you are aware of Medicare’s requirements for HBO therapy, which can be found in the National Coverage Determination (NCD) 20.29 for Hyperbaric Oxygen Therapy (link)). Note, this NCD includes a list of covered indications and a longer list of non-covered indications.

Also, I recommend reading Palmetto’s review article as it includes ways to avoid denials. Palmetto GBA has two education resources related to HBO for Providers:

• An HBO Checklist that you can use as an audit tool to assure you are submitting all required documentation (link)), and
• An HBO Module (link)), which provides an overview of HBO therapy and information about physician responsibilities, the treatment plan, and administration of HBO therapy.

Question:

You mentioned in last week’s Wednesday@One outpatient FAQ (link) that Palmetto GBA considers the drug ‘Imitrex’ to be a self-administered drug. Does that apply only to the Imitrex brand, or does it also apply to the other Imitrex formulations / brands?

Answer

All formulations of Imitrex would be considered a self-administered drug under Palmetto. Take a look at Palmetto’s self-administered drug list link and in the Imitrex section, you will see other names of Imitrex listed, which include:

• Imitrex Statdose Pen
• Zembrace Sym touch
• Alsuma
• Sumavel DosePro

Although not listed, this should also include the drug Tosymra, which is another brand name for Imitrex.

This week we highlight key updates spanning from May 4th through May 10th, 2021.

May 3, 2021: New COVID-19 Coverage Assistance Fund: Paying for COVID-19 Vaccine Administration

HHS posted a Press Release (link) announcing the new COVID-19 Coverage Assistance Fund (CAF). This program will cover the cost of administering a COVID-19 vaccine for individuals enrolled in health plans that either do not cover vaccination fees or cover them with patient cost-sharing.

May 4, 2021: Funding to Increase COVID-19 Vaccinations in Underserved & Rural Communities

HHS announced (link) the availability of $250 million, through the American Rescue Plan, “to develop and support a community-based workforce who will serve as trusted voices sharing information about vaccines, increase COVID-19 vaccine confidence, and address any barriers to vaccination for individuals living in vulnerable and medically underserved communities.”

In addition to underserved communities, HHS announced (link) the availability of nearly $1 billion to increase vaccination efforts in rural communities.

May 5, 2021: FDA Issues Roadmap for FDA Inspectional Oversight

The FDA has issued a new report titled “Resiliency Roadmap for FDA Inspectional Oversight” (link). This report outlines their “inspectional activities during the COVID-19 pandemic and its detailed plan to move toward a more consistent state of operations, including the FDA’s priorities related to this work going forward.”

At the onset of the pandemic, FDA inspections began to be reserved for what they describe as “mission-critical issues” based on the following four factors:

• Product received breakthrough therapy or regenerative medicine advanced therapy designation,
• Product is used to treat a serious disease or medical condition and there is no substitute,
• Product required follow-up due to recall, or there is evidence of serious adverse events or outbreaks of a foodborne illness, and
• Product is related to FDA’s COVID-19 response (e.g., drug shortages).

May 6, 2021: Increased Payment for COVID-19 Monoclonal Antibody Infusions & Two New HCPCS Codes

CMS announced (link) an increase in the national average payment rate, for administering monoclonal antibodies to treat COVID-19, from $310 to $450 for most health care settings. Further, “in support of providers’ efforts to prevent the spread of COVID-19, CMS will also establish a higher national payment rate of $750 when monoclonal antibodies are administered in the beneficiary’s home, including the beneficiary’s permanent residence or temporary lodging (e.g., hotel/motel, cruise ship, hostel, or homeless shelter.)” CMS has updated the COVID-19 Vaccines and Monoclonal Antibodies webpage (link) to reflect the payment updates.

Along with CMS establishing a higher national payment rate for monoclonal antibodies in the beneficiary’s home, CMS has added two new HCPCS codes for the administration of the monoclonal antibodies infusion in the home (M0244 and M0246). Note, these will be paid in the same manner as HCPCS codes, M0243 and M0245.

May 7, 2021: CDC Updates SARS-CoV-2 Mode of Transmission

The CDC had updated their Scientific Brief: SARS-CoV-2 Transmission (link). Recent updates to this brief includes:

• Updates have been made to reflect current knowledge about SARS-CoV-2 transmission,
• “Modes of SARS-CoV-2 transmission are now categorized as inhalation of virus, deposition of virus on exposed mucous membranes, and touching mucous membranes with soiled hands contaminated with virus.
• Although how we understand transmission occurs has shifted, the ways to prevent infection with this virus have not. All prevention measures that CDC recommends remain effective for these forms of transmission.”

May 10, 2021: EUA Expanded for Pfizer-BioNTech COVID-19 Vaccine

The FDA announced (link) the expansion of the emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine to include adolescents 12 through 15 years of age. “The most commonly reported side effects in the adolescent clinical trial participants, which typically lasted 1-3 days, were pain at the injection site, tiredness, headache, chills, muscle pain, fever and joint pain. With the exception of pain at the injection site, more adolescents reported these side effects after the second dose than after the first dose, so it is important for vaccination providers and recipients to expect that there may be some side effects after either dose, but even more so after the second dose.”

CMS issued the FY 2022 IPPS Proposed Rule (CMS-1762-IFC) on Tuesday April 27, 2021. Following are highlights from the Proposed Rule.

Proposed Payment Rate Changes

The proposed increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) use is approximately 2.8 percent.

Overall, CMS estimates hospitals payments will increase by $2.5 billion.

COVID-19 Impact on Inpatient Hospitalization Utilization Data

CMS notes, in a related Fact Sheet, that their goal when setting inpatient hospital payment rates is to use the best available data. Given the impact that the COVID-19 Public Health Emergency (PHE) had during FY 2020, CMS is proposing to use the FY 2019 data to approximate the expected FY 2022 inpatient hospital utilization.

New Technology Add-On Payment (NTAP) Policy

There is good news for hospitals regarding the proposal being made related to the New Technology Add-On Payment (NTAP) policy. As background, the NTAP policy provides additional payment beyond the MS-DRG for cases where a CMS designated new technology was used and coded on the claim. Note, this “is not budget neutral and is generally limited to the 2-to 3-year period following the date of the FDA approval or clearance for marketing.”

“CMS is proposing a one-year extension of new technology add-on payments for 14 technologies for which the new technology add-on payment would otherwise be discontinued beginning FY 2022.”

New COVID-19 Treatments Add-on Payment (NCTAP)

CMS established the NCTAP policy for eligible discharges during the PHE. This policy was “designed to mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments. CMS is proposing to extend this policy for eligible products through the end of the fiscal year in which the COVID-19 PHE ends.

The PHE was once again extended in April 2021 and is currently set to expire on July 20, 2021. (link to release) However, in January of this year, HHS sent a letter (link to letter) to governors indicating the likelihood that the PHE will remain in place for all of 2021. If this proposal is finalized, and the PHE ends on December 31, 2021, that would mean the NCTAP policy will be in place until September 30, 2022.

To learn more about the NCTAP policy visit the CMS NCTAP webpage by clicking here.

Quality Program Proposals

CMS is proposing a measure suppression policy that would allow CMS to suppress use of measure data if they determine that the COVID-19 PHE has affected quality measures and resulting quality scores significantly. This measure suppression policy is being proposed for:

• The Hospital Readmission Reduction Program (HRRP),
• The Hospital-Acquired Condition (HAC) Reduction Program, and
• The Hospital Value-Based Purchasing (VBP) Program.

Also, with the Hospital Compare website now being the Care Compare website, CMS is proposing to update regulatory text for the HRRP and HAC Reduction Program to reflect the name change. The new Care Compare webpage ( link to site ) allows you to compare care by providers across the continuum of care (i.e. hospitals, nursing homes, home health, and hospice).

Specific to the HRRP, CMS is “seeking public comment on closing the gap in health equity through possible future stratification of results by race and ethnicity for condition/procedure-specific readmission measures and by expansion of standardized data collection to additional social factors, such as language preference and disability status.”

The Hospital VBP Program is funded by reducing participating hospitals base operating MS-DRG payments by 2%. The total estimated amount is then redistributed to hospitals based on their Total Performance Score (TPS). It is possible for your hospital to earn back a value-based incentive payment percentage that is less than, equal to, or more than the applicable reduction for that FY. The estimated amount available for incentive payments to hospitals in the current FY 2021 is $1.9 billion.

Due to the proposed measure suppression for the Hospital VBP Program, CMS is “proposing to not calculate a TPS for any hospitals based on one domain and to instead award to all hospitals value based payment amount for each discharge that is equal to the amount withheld.”

Graduate Medical Education (GME)

The Consolidated Appropriations Act (CAA), 2021, Section 126, “requires the distribution of an additional 1,000 new Medicare-funded medical residency positions to train physicians. CMS is proposing to distribute the slots to qualifying hospitals, as specified by the law, including those located in rural areas and those serving areas with a shortage of health care professionals.”

The 1,000 new slots would be phased in at no more than 200 per years beginning in FY 2023 (October 1, 2022). The estimated additional funding will total approximately $1.8 billion from FY 2023 through FY 2031.

Repeal of Hospital Negotiated Charges with Medicare Advantage Payers

Tom Nickels, Executive Vice President of the American Hospital Association, indicated in an April 27, 2021 AHA Statement on the release of the Proposed Rule that “based on our initial review, we are very pleased CMS is proposing to repeal the requirement that hospitals and health systems disclose privately negotiated contract terms with payers on the Medicare cost report. We have long said that privately negotiated rates take into account any number of unique circumstances between a private payer and a hospital and their disclosure will not further CMS's goal of paying market rates that reflect the cost of delivering care. We once again urge the agency to focus on transparency efforts that help patients access their specific financial information based on their coverage and care.” (Link to statement)

CMS is accepting comments on the proposed rule through 5 p.m. EDT on June 28, 2021.

Resources

• CMS FY 2022 IPPS Proposed Rule CMS Fact Sheet: Link
• CMS FY 2022 Proposed Rule web page: link

Question:

We have another question about self-administered drugs based on prior outpatient FAQs for Lovenox and insulin. (Click for the Lovenox article and for the insulin article.) Is the drug ‘Imitrex’ a self-administered drug for Medicare? Usually, we see this given to patients in the ER who present with migraine type headaches.

Answer

For Palmetto, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, Imitrex is a self-administered drug when given by subcutaneous route. For Medicare, you would NEVER report a subcutaneous injection (CPT code 96372) for Imitrex. If you are under the jurisdiction of a different MAC, check their respective self-administered drug list as the drugs can vary from one MAC to the next.

Here is a link to Palmetto’s self admin drug list. It is a very handy reference to see which injectable drugs are considered self-administered drugs at least – for hospitals under the jurisdiction of Palmetto GBA.

Local Coverage Article for Self-Administered Drug Exclusion List

This week we highlight key updates spanning from April 27th through May 3rd, 2021.

Spotlight: Noridian JF Ask the Contractor (ACT) Question and Answer: Targeted Probe & Educate during the Pandemic

Noridian JF recently posted Questions and Answers from their January ACT Call (link). Following is an excerpt from one of the Q&A’s regarding the Medicare Administrative Contractors (MACs) Targeted Probe and Educate (TPE) program:

“Q8: Our facility has not received a Targeted Probe and Education (TPE) audit or an Additional Documentation Request (ADR) since the pandemic started. Can Noridian please clarify whether these audits have been restarted?

---

A8: MACs have not received direction from CMS to resume TPE audits. Currently MACs are conducting service specific claim reviews. More information can be found on Noridian’s Medical Review webpage under Post-Pay Reviews. Individual providers will be notified if they have an open, pending TPE file when we have direction from CMS to resume TPE activities.”

April 26, 2021: QW Modifier Added to HCPCS 87636

CMS published MLN MM12269 (link) to inform providers of the addition of the QW modifier to HCPCS code 87636 [Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza type virus types A and B, multiplex amplified probe technique].

CMS ends this MLN article by noting that “claims for tests you perform in facilities having a CLIA certificate of waiver must include the QW modifier. MACs won’t search their files to either retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims you bring to their attention.”

April 27, 2021: CDC Clinical Outreach & Communication Activity Call: Johnson & Johnson/Janssen COVID-19 Vaccine and TTS Update for Clinicians

The CDC conducted an initial call related to the Johnson & Johnson vaccine and Cerebral Venous Sinus Thrombosis with Thrombocytopenia (CVST) on April 15, 2021. The April 27th call provided updates for clinicians about the Johnson & Johnson vaccine and Thrombosis with Thrombocytopenia Syndrome (TTS) (link). For those that missed this call, the CDC webpage for this call includes a video of the session and call materials.

April 27, 2021: Memorandum Update to Interim Final Rule – Additional Policy & Regulatory Revisions in Response to the COVID-19 PHD related to Long-Term care Facility Testing Requirements and Revised COVID-19 Focused Survey Tool e

CMS has updated this Memorandum (link) that was initially provided to State Survey Agency Directors in August of 2020. CMS has revised the COVID-19 Focused Survey Tool for surveyors. They “are also adding to the survey process the assessment of compliance with the requirements for facilities to designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's infection prevention and control program (IPCP) at 42 CFR § 483.80(b).” Additionally, they “are making a number of revisions to the survey tool to reflect other COVID-19 guidance updates.”

April 29, 2021: Expanding COVID-19 Training and Support for Health Centers

HHS announced (link) that 122 organizations, including Primary Care Associations (PCAs), National Training and Technical Assistance Partners (NTTAPs), and Health Center Controlled Networks (HCCNs), have been awarded $32 million to “use the funds to provide health centers with critical COVID-19 related training, technical assistance, and health information technology.” This was made possible through the American Rescue Plan.

This week we highlight key updates spanning from April 20th through April 26th, 2021.

Resource Spotlight: HHS’ COVID-19 Public Education Campaign & Community Corps

HHS has launched a public education campaign “to increase public confidence in and uptake of the COVID-19 vaccines while reinforcing basic prevention measures such as mask wearing and social distancing.” HHS is expanding the campaign through the creation of the COVID-19 Community Corps. Members of this group will receive resources to build vaccine confidence in your community, including:

• Fact Sheets,
• Social Media Content, and
• Regular email updates with the latest vaccine news and resources to share.

You can sign up to be a member of the COVID-19 Community Corps at https://wecandothis.hhs.gov/covidcommunitycorps.

April 20, 2021: I Received the Johnson & Johnson Vaccine, Now What?

The CDC has created a Johnson & Johnson/Janssen COVID-19 vaccine update page (link). The April 20th update highlights the following “What you need to know” information:

• “The use of Johnson & Johnson’s Janssen (J&J/Janssen) COVID-19 Vaccine is paused for now. This is because the safety systems that make sure vaccines are safe received a small number of reports of people who got this vaccine experiencing a rare and severe type of blood clot with low platelets.
• Seek medical care right away if you develop any of the symptoms listed in the question and answer – what if I got the J&J/Janssen COVID-19 vaccine?
• If you have any questions at all, call your doctor, nurse, or clinic.”

April 20, 2021: COVID-19 Update – FDA Revoked EUA for Bamlanivimab When Administered Alone

In last week’s article, I reported that on April 16th, the FDA revoked the Emergency Use Authorization (EUA) for Bamlanivimab when administered alone. CMS released a Special Edition MLN Connects related to this revocation (link). They note that they will cover and pay for Bamlanivimab, when administered alone, for dates of service from November 10, 2020 through April 16, 2021.

April 22, 2021: CDC & Dialysis Organizations Partner to Provide COVID-19 Vaccine

The CDC announced in the Thursday April 22nd MLN Connects newsletter (link) that they are partnering with dialysis organizations nationwide to make the COVID-19 vaccine available to patients and health care personnel in outpatient dialysis clinics. CMS reminds you that there is no copayment, coinsurance or deductible for receiving a COVID-19 vaccine.

April 22, 2021: New Acute Care Delivery at Home Tip Sheet

Also in the April 22nd MLN Connects, CMS provides a link to a new Acute Care Delivery at Home Tip Sheet (link). In addition to the Tip Sheet a link is provided to the CMS Acute Hospital Care at Home webpage where you will find an overview of this program, reporting measures participating hospitals are required to provide, additional resources, and access to past webinars.

April 22, 2021: HHS’ “We Can Do This: Live” Initiative

Building upon the “We Can Do This” public education campaign, HHS announced the launch of their “We Can Do This: Live” series “to pair medical experts with prominent influencers and organizations with large social followings to meet people where they are with the information they need to feel confident about receiving the vaccine. Events will include conversations to answer direct questions about COVID-19, Instagram Live Q&As, and social media account takeovers where doctors, scientists and health officials can provide the public with factual, scientific information about vaccines.” HHS notes in the Press Release (link) that this initiative follows the launch of the COVID-19 Community Corps initiative.

April 23, 2021: Johnson & Johnson (Janssen) COVID-19 Vaccine Pause Lifted

After a “thorough safety review,” the CDC and FDA announced that use of the Johnson & Johnson (Janssen) COVID-19 vaccine should resume. The Fact Sheets related to this vaccine have all been revised to include information about the risk of thrombosis-thrombocytopenia syndrome (TTS). The FDA goes on to note that as of April 23rd they can confirm 15 cases of TTS. All cases were women between 18 and 59 years old, with a median age of 37 years. Symptom onset was between 6 and 15 days after vaccination. (link)

Question:

As a follow-up to last week’s question about Lovenox, (link) we have the same question regarding insulin: We have NOT been charging for insulin administration given in any form (ex. IM, Infusion), but should we?

Answer

Palmetto, GBA considers Insulin to be a self-administered drug when given by subcutaneous route. For Medicare, you would NEVER report a subcutaneous injection for insulin (CPT code 96372). Palmetto says if you give insulin by a different route, it is appropriate to report the administration CPT code, such as IM or IV.

Cahaba, GBA the prior Medicare Administrative Contractor (MAC) for Jurisdiction J, had told Provider that insulin is a self-administered drug regardless of the route. The Palmetto policy is not as strict as Cahaba’s.

Again, here is a link to Palmetto’s self-administered drug list, which includes discussion about drugs on the list given by other than subcutaneous route.
Local Coverage Article for Self-Administered Drug Exclusion List

Remember, insulin is sometimes documented using other names, and it is easy to miss these drugs if you are not familiar with some of the brand names. If you need a reminder, review the Wednesday@One article at the link below from September 2018 which lists some of the more common insulin names and types.

Do You Know When to Code Z79.4?
https://www.mmplusinc.com/kb-articles/do-you-know-when-to-code-z79-4