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Q:

We have ER patients who get intramuscular (I.M.) injections of Rabies Immune Globulin. What CPT code should be billed for the injection of Rabies Immune Globulin?

A:

When an I.M. injection of an immune globulin is administered, use CPT code 96372, representing an intramuscular / subcutaneous injection of a therapeutic drug. This applies to all immune globulins given by I.M. route, such as Rhogam, Hepatitis B immune globulin, and the others listed on the first page of the Medicine section in CPT. This instruction is part of the parenthetical CPT guidelines on the same page, and as such, would apply to all payers.

This week we highlight key updates spanning from February 23rd through March 2nd, 2020.

Resource Spotlight: VaccineFinder

According to the CDC, “VaccineFinder is a free, online service where users can search for pharmacies and providers that offer vaccination. Information about where COVID-19 vaccines are available is provided directly by pharmacies and providers, in collaboration with states, and is updated daily. VaccineFinder is operated by Boston Children’s Hospital, in partnership with CDC.”

At this time VaccineFinder is launching in four states and will expand information for additional states in the coming weeks. If information is not yet available where you live, the CDC has advised that you visit your state health department’s website. Links to State and Territorial Health Department websites are available on the CDC website.  

February 24, 2021: FDA’s New Webpage: COVID-19 Vaccination & the Food and Agriculture Sector

The FDA launched this new webpage to provide information for the food and agriculture sector about the following:

• Safety and effectiveness of COVID-19 vaccines authorized for emergency use by the FDA,
• Benefits of COVID-19 vaccination, and
• Information about the availability of vaccines in your community.

February 25, 2021: FDA Flexibilities for Storing Pfizer-BioNTech COVID-19 Vaccine

In an FDA Bulletin, the FDA announced their decision to allow “undiluted frozen vials of the Pfizer-BioNTech COVID-19 Vaccine to be transported and stored at conventional temperatures commonly found in pharmaceutical freezers for a period of up to two weeks.” This announcement includes an updated Fact Sheet for Health Providers Administering Vaccine.

February 26, 2021: FDA Vaccine Advisory Committee working towards Emergency Use Authorization for Janssen Biotech Inc. COVID-19 Vaccine

Acting Commissioner Janet Woodcock, M.D. and Peter Marks, M.D., Ph.D., director of the FDA’s Center for Biologics Evaluation and Research announced in an FDA bulletin that “Following today’s positive advisory committee meeting outcome regarding the Janssen Biotech Inc. COVID-19 Vaccine, the U.S. Food and Drug Administration has informed the sponsor that it will rapidly work toward finalization and issuance of an emergency use authorization. The agency has also notified our federal partners involved in vaccine allocation and distribution so they can execute their plans for timely vaccine distribution.”

February 27, 2020: Janssen COVID-19 Vaccine Granted Emergency Use Authorization

A little over twenty four hours after the FDA’s Vaccine Advisory Committee met they published a bulletin announcing emergency use authorization for the Janssen COVID-19 vaccine for individuals 18 years of age and older. “The Janssen COVID-19 Vaccine is manufactured using a specific type of virus called adenovirus type 26 (Ad26). The vaccine uses Ad26 to deliver a piece of the DNA, or genetic material that is used to make the distinctive “spike” protein of the SARS-CoV-2 virus. While adenoviruses are a group of viruses that are relatively common, Ad26, which can cause cold symptoms and pink eye, has been modified for the vaccine so that it cannot replicate in the human body to cause illness. After a person receives this vaccine, the body can temporarily make the spike protein, which does not cause disease, but triggers the immune system to learn to react defensively, producing an immune response against SARS-CoV-2.”

February 27, 2020: Johnson & Johnson COVID-19 Vaccine Press Release

Johnson & Johnson announced the EUA for their vaccine indicating that the “vaccine was 85 percent effective in preventing severe disease across all regions studies, and showed protection against COVID-19 related hospitalization and death, beginning 28 days after vaccination.” Unique to this COVID-19 vaccine, it is a single shot vaccine. Side effects that have been reported with the vaccine include:

• Injection site reactions: pain, redness of the skin, and swelling
• General side effects: headache, feeling very tired, muscle aches, nausea, and fever.

Johnson & Johnson indicates that the company has already started shipping the vaccine and “expects to deliver enough single-shot vaccines by the end of March to enable the full vaccination of more than 20 million people in the U.S.”

March 1, 2021: CMS COVID-19 Vaccines and Monoclonal Antibodies Webpage

CMS continues to add to this webpage as additional COVID-19 vaccines and certain monoclonal antibodies receive Emergency Use Authorization. On this page you will find tables for COVID-19 vaccines and monoclonal antibodies detailing the code, CPT descriptor, the vaccine/procedure name, payment allowance and effective dates. There is also a wealth of information available in the Additional Resources section. Most recently added is a Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction download.  This webpage was last modified on March 1, 2021 to include information about the new Janssen COVID-19 vaccine by Johnson & Johnson. I encourage you to check this webpage often for updates.

March 1, 2021: Quidel QuickVue At-Home COVID-19 Test

The FDA issued a EUA for the Quidel QuickVue At-Home COVID-19 Test. Specifically, The QuickVue At-Home COVID-19 Test is authorized for prescription home use with self-collected anterior nasal (nares) swabs from individuals ages 14 and older or individuals ages 8 and older with swabs collected by an adult. The test is authorized for individuals suspected of COVID-19 by their healthcare provider within the first six days of symptom onset.”

March 2, 2021: CDC Call – What Clinicians Need to Know about Johnson & Johnson’s Janssen COVID-19 Vaccine

The CDC hosted a Clinical Outreach and Communication Activity (COCA) call on March 2nd to provide clinicians an overview of the J&J Janssen COVID-19 vaccine including vaccine characteristics and administration, vaccinating special populations, and contraindications. You can access call materials from this presentation on the CDC website. 

MEDICARE MLN ARTICLES & TRANSMITTALS – RECURRING UPDATES

 

April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

• Article Release Date: February 23, 2021
• What You Need to Know: This article informs providers about the Average Sales Price (ASP) methodology, which is based on quarterly data manufacturers submit to CMS.
• MLN Article MM12133: https://www.cms.gov/files/document/mm12133.pdf

Quarterly Updated for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – April 2021

• Article Release Date: February 23, 2021
• What You Need to Know: The DMEPOS CBP files are updated on a quarterly basis to implement necessary changes to HCPCS codes, ZIP codes, single payment amounts, and supplier files.
• MLN Article MM12128: https://www.cms.gov/files/document/mm12128.pdf

 

OTHER MEDICARE MLN ARTICLES & TRANSMITTALS

 

Review of Hospital Compliance with Medicare’s Transfer Policy with Resumption of Home Health Services & Other Information on Patient Discharge Status Codes

• Article Release Date: February 22, 2021
• What You Need to Know: CMS reminds providers that an accurate discharge status code is essential to assure proper payment under the Medicare Severity-Diagnosis Related Group (MS-DRG) payment system. Detailed information regarding the CMS Transfer Policy is included in this article.
• MLN Article SE21001: https://www.cms.gov/files/document/se21001.pdf

Billing for Services when Medicare is a Secondary Payer

• Article Release Date: February 23, 2021
• What You Need to Know: CMS details what to do if you think a claim was inappropriately paid and provides key reminders related to billing for services when Medicare is a secondary payer.
• MLN Article SE21002: https://www.cms.gov/files/document/se21002.pdf

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

• Article Release Date: February 23, 2021
• What You Need to Know: New HCPCS codes for 2021 that are subject to and excluded from CLIA edits are discussed in this article.
• MLN Article MM12131: https://www.cms.gov/files/document/mm12131.pdf

 

MEDICARE EDUCATIONAL RESOURCES

 

MLN Fact Sheet: Intravenous Immune Globulin (IVIG) Demonstration (Demonstration Ends on December 31, 2023)

The IVIG demonstration began in October 2014, has been extended twice, and is now set to end on December 31, 2023. This MLN Fact Sheet, dated February 2021, provides education on the IVIG demonstration and includes information on:

• Supplier eligibility and participation,
• Beneficiary eligibility and participation, and
• Billing and coding requirements.

 

OTHER MEDICARE UPDATES

Medicare Mid-Build Off-Campus Outpatient Department Exception Audit Results

On February 2nd CMS posted a webpage dedicated to their 21st Century Cures Act Mid-Build Audits. In overview, the Cures Act provided the criteria which off-campus departments of a provider must meet to comply with Mid-build exception requirements. CMS completed 334 provider audits that requested the mid-build exception. They found that 202 of the facilities failed to qualify for the exception. They note in the audit findings that “Providers that failed the mid-build exception audit and have been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have received overpayments. Also, providers that have passed the mid-build exception audit and have not been billing for the services provided by their off-campus provider-based departments under the OPPS, likely have been underpaid.

CMS will issue audit determination letters to all affected providers on January 19, 2021. The letter will provide the final determination on meeting the exception, the appropriate point of contact information, and further instructions. The 21st Century Cures Act states that the mid-build exception audit determinations are final and may not be appealed.” The Audit Results and FAQ documents are available on this CMS webpage.

Improving Accuracy of Medicare Payments

CMS shared the following information in the Thursday February 4, 2021 Edition of MLN Connects:  

The U.S. Bureau of Labor Statistics (BLS) conducts numerous surveys of hospitals and health care providers that are used by the government to make economic decisions that affect the entire medical care system. Key users include CMS, the Federal Reserve Bank, and the U.S. Congress.  CMS uses these surveys to adjust Medicare Fee-for-Service payments each year, affecting approximately $300 billion in payments.

If you’re contacted by BLS, please participate in the survey to help ensure the data are as accurate as possible. Recently, many health care providers didn’t complete the survey, which can reduce the representativeness of the data and increase volatility in estimates. Your participation in these surveys helps address these issues and increase the validity of the data. Participation is voluntary, confidential, and the data are only used for statistical purposes.

More Information:

• BLS Survey Respondentswebpage
• BLS Confidentiality Pledge and Lawswebpage
• CMS Market Basket Datawebpage
• BLS Geographic Informationwebpage: Contact a BLS expert or get information on surveys, data, and reports”

February 22, 2021: OIG Report – $4 Million in improper payments for Spinal Facet-Joint Injections

The OIG found that 49 of 100 sampled claims were inappropriately paid by Noridian Healthcare Solutions, LLC to physicians in Jurisdiction E for spinal facet-joint injections. They note that improper payments occurred due to insufficient education to physicians and their billing staff. Based on their findings, the OIG estimated that $4.2 million was improperly paid to physicians. Recommendations for Noridian included recovering the $12,546 in improper payments found in the sampled claims, notify appropriate physicians so they can identify, report, and return any overpayments in accordance with the 60-day rule and provide annual training to physicians and their billing staff. You can read the entire report at https://oig.hhs.gov/oas/reports/region9/92003010.pdf.

This week we highlight key updates spanning from February 16th through February 22nd, 2021.

 

Resource Spotlight: CMS Memorandum – Hospital Survey Priorities Revised

On February 18, 2021, CMS published a revised version of a January 20, 2021 Memorandum regarding Hospital Survey Priorities. This memorandum clarifies expectations of State Survey Agencies and Accrediting Organizations as “CMS is committed to taking critical steps to protect vulnerable individuals to ensure America’s health care facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency PHE.” Specifically, CMS is extending the hospital survey limitations for an additional 30 days from the date of the revised memo (March 22, 2021).

 

February 16, 2021: Moderna Press Release – U.S. COVID-19 Vaccine Supply Update

Moderna, Inc.’s press release opened with the following numbers:

• 4 million – the number of doses the company has supplied to the U.S. Government to date,
• 5 million – the number of doses that have been administered in the U.S. as communicated by the CDC,
• 2 million – The number of additional doses that have been produced and are filled in vials and in the final stages of final production and testing before release,
• 100 million – the number of doses the company expected to deliver to the U.S. Government by the end of March 2021, and
• 100 million – the number of additional doses the company expects to deliver by the end of May 2021 followed by another 100 million by the end of July 2021.

The Press Release goes on to provide information about the Moderna COVID-19 vaccine and important safety information.

 

February 17, 2021: Actions to Expand COVID-19 Testing

HHS announced new actions to expand COVID-19 testing capacity nationwide. They go on to note in the Press Release that “these actions will improve the availability of tests, including for schools and underserved populations; increase domestic manufacturing of tests and testing supplies; and better prepare the nation for the threat of variants by rapidly increasing virus genome sequencing.” Three specific actions outlined includes:

• Expansion of COVID-19 testing for schools and underserved populations,
• Increase domestic manufacturing of testing supplies and materials to address testing shortages, and
• Having the CDC “rapidly increase genomic sequencing of the virus to better prepare for the treat of variants and slow the spread of the disease.”

 

February 18, 2021: CMS MLN Connects News – Further Steps to Provide Wide Access to COVID-19 Antibody Treatment

As reported in last week’s article, the FDA issued an emergency use authorization (EUA) for bamlanivimab and etesevimab being administered together for the treatment of mild to moderate COVID-19 in adults and pediatric patients at risk for progressing to severe COVID-19. Later in the week, CMS published the following information regarding this EUA in the February 18, 2021 edition of MLN Connects:

“The U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab and etesevimab, administered together, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Bamlanivimab and etesevimab, administered together, may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the Emergency Medical System (EMS), as necessary. Review the Fact Sheet for Health Care Providers EUA of Bamlanivimab and Etesevimab regarding the limitations of authorized use when administered together.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).

CMS identified specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment: Eli Lilly and Company’s Antibody Bamlanivimab and Etesevimab, (ZIP) EUA effective February 9, 2021:

Q0245:

• Long descriptor: Injection, bamlanivimab and etesevimab, 2100 mg
• Short descriptor: bamlanivimab and etesevima

M0245:

• Long Descriptor: intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
• Short Descriptor: bamlan and etesev infusion”

 

February 18, 2021 FDA Bulletin: COVID-19 Transmission is not through Food or Food Packaging

In a Bulletin attributed to Acting USDA Secretary Kevin Shea and Acting FDA Commissioner Janet Woodcock, M.D., the authors indicate that “considering the more than 100 million cases of COVID-19, we have not seen epidemiological evidence of food or food packaging as the source of SARS-CoV-2 transmission to humans. Furthermore, transmission has not been attributed to food products or packaging through national and international surveillance systems. Food business operations continue to produce a steady supply of safe food following current Good Manufacturing Practices and preventive controls, focusing on good hygiene practices and keeping workers safe.”

 

February 19, 2021: CDC Morbidity and Mortality Weekly Report (MMWR): COVID-19 Vaccine Safety Monitoring

This CDC MMWR provides insight into the first month (December 14, 2020 – January 13, 2021) of COVID-19 vaccine safety monitoring in the United States. 13.8 million Doses of the Pfizer-BioNTech and Moderna COVID-19 vaccines were administered to the U.S. population in this first month. The most frequently reported symptoms by those vaccinated includes headache, fatigue, dizziness, chills and nausea. The authors of this article (Gee J, Marquez P, Su J, et al.) note in their summary that “monitoring, conducted as part of the U.S. vaccination program, indicates reassuring safety profiles for COVID-19 vaccines. Local and systemic reactions were common; rare reports of anaphylaxis were received. No unusual or unexpected reporting patterns were detected.”

 

CDC COVID Data Tracker – United States COVID-19 Cases

Q:

We have a record with documentation of Recurrent Depression (F33.x) and Bipolar Disorder (F31.x).  The excludes1 note under each code seem to exclude each other.  Do we code both conditions?

A:

Bipolar Disorder includes Depression, so only the code for Bipolar Disorder (F31.9) would be coded and reported.  A separate code for Depression would not be reported in addition.

Reference

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 23

Republished from Kaiser Health News

Jordan Rau, Kaiser Health News 

The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

Subscribe to KHN's free Morning Briefing.

Q:

We had a patient in the ER who was having a miscarriage, and she received an intramuscular injection of Methotrexate.  What CPT code should be used to report the Methotrexate injection in this scenario?

A:

Methotrexate is classified as a chemotherapy drug, specifically an antimetabolite. Therefore, the intramuscular injection of Methotrexate should be reported with CPT code 96401, representing injection of a non-hormonal antineoplastic.  You should not report the injection using CPT code 96372 for a therapeutic drug.

Per CPT guidelines, the CPT codes for chemotherapy administration should be used when an anti-neoplastic drug is given, even if the diagnosis is not related to cancer.

It is unusual for a chemotherapy type drug to be given in the ER, so you may need a new charge code created for those rare circumstances when a drug such as Methotrexate is given by intramuscular route.

This week we highlight key updates spanning from February 9th through February 15th, 2021.

Resource Spotlight: CMS COVID-19 Toolkit for Healthcare Providers & CDC Toolkit for Older Adults & People at Higher Risk

In January “CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the vaccine.  These resources are designed to increase the number of providers that can administer the vaccine and ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. In addition, CMS is taking action to increase reimbursement for any new COVID treatments that are approved by the FDA.” The CMS COVID-10 webpage provides information on several key topics such as Coding for COVID-19 Vaccine shots and Medicare Monoclonal Antibody COVID-19 infusion.

The CDC has developed a Toolkit for Older Adults & People at Higher Risk webpage designed to provide “guidance and tools to help older adults and people at higher risk and those who serve of care for them make decisions, protect their health, and communicate with their communities.” Several resources are available on this CDC webpage, for example, COVID-19 Vaccine Resources, Guidance and Planning Documents, Web Resources, FAQs, Fact Sheets and Posters.

 

February 9, 2021: FDA Authorization for Monoclonal Antibodies Treatment of COVID-19

The FDA announced that they have “issued an emergency use authorization (EUA) for bamlanivimab and etesevimab administered together for the treatment of mild to moderate COVID-19 in adults and pediatric patients (12 years of age or older weighing at least 40 kilograms [about 88 pounds] who test positive for SARS-CoV-2 and who are high risk for progressing to severe COVID-19.” The UEA also authorizes treatment for patients 65 years or older with “certain chronic medical conditions.” As a reminder, the ICD-10-PCS codes for bamlanivimab and etesevimab are included in the list of 21 new procedure codes implemented by CMS with an effective date of January 1, 2021. CMS also has a webpage dedicated to Monoclonal Antibody COVID-19 infusion.

 

February 10, 2021: CDC Morbidity and Mortality Weekly Report (MMWR): Maximizing Masks

In the MMWR titled Maximizing Fit for Cloth and Medical Procedure Masks to Improve Performance and Reduce SARS-CoV-2 Transmission and Exposure, 2021, the authors conducted experiments assessing two ways to improve the fit of medical masks to reduce transmission and exposure of COVID-19. They found that for the user to receive the most benefit from wearing mask(s), a better fit is more effective at slowing the spread of the disease.

The CDC has a dedicated webpage titled Masks Protect You & Me where you can download an educational poster and find links to information about masks (i.e. how to wear masks and how to store and wash masks). 

 

February 10, 2021: CDC Updates Clinical Considerations for Patients who have received COVID-19 Vaccine

The CDC updated their clinical considerations for use of mRNA COVID-19 vaccines currently authorized in the United States. One recent change is for vaccinated persons. Specifically, fully vaccinated persons meeting the following criteria are not required to quarantine when exposed to someone with suspected or confirmed COVID-19:

• A person is fully vaccinated (i.e., ≥ 2 weeks following the receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine),
• A person is within 3 months following receipt of the last dose in a series, and
• A person has remained asymptomatic since the current COVID-19 exposure.

 

February 11, 2021: Alabama Medicaid COVID-19 Emergency Expiration Date Extended

The Alabama Medicaid Agency notes in this Alert that “All previously published expiration dates related to the COVID-19 emergency are once again extended by the Alabama Medicaid Agency (Medicaid). The new expiration date is the earlier of March 31, 2021, the conclusion of the COVID-19 national emergency, or any expiration date noticed by the Alabama Medicaid Agency through a subsequent ALERT.”

 

February 11, 2021: MLN Connects – COVID-19: Revised Clinician Codes Accepted with CS Modifier

CMS included the following information in their Thursday February 11th edition of MLN Connects:

“Effective March 18, 2020, the Families First Coronavirus Response Act requires Medicare Part B to cover beneficiary cost-sharing for provider visits when a COVID-19 diagnostic test is administered or ordered. CMS updated the list of codes (ZIP) that physicians and non-physician practitioners can use with the Cost-Sharing (CS) modifier.

For dates of service on or after January 1, 2021, through the end of the public health emergency, we’ll accept these codes with the CS modifier:

• HCPCS codes G2250, G2251, and G2252
• CPT codes 98970, 98971, and 98972 (These replace HCPCS codes G2061 – G2063, which are accepted for services provided in 2020)  

CPT codes 98966, 98967, and 98968 are accepted for services with the CS modifier provided on or after March 18, 2020.

More information about cost-sharing: Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF) MLN Matters Article”

 

February 12, 2021: CDC Guidance – What to Expect After Getting a COVID-19 Vaccine

This CDC webpage provides COVID-19 vaccine information including the following:  

• Common side effects,
• Helpful tips,
• When to call the doctor,
• Scheduling your second shot,
• About the second shot,
• Additional reminders, and
• A printable handout for vaccine recipients.

 

February 13, 2021: CDC Updates Interim Guidance on Duration of Isolation and Precautions for Adults with COVID-19

The CDC indicates, on this webpage, that “Accumulating evidence supports ending isolation and precautions for adults with laboratory-confirmed COVID-19 using a symptom-based strategy.” Currently, the available data indicates the following:

• Adults with mild to moderate COVID-19 remain infectious no longer than 10 days after symptom onset,
• Most adults with more severe to critical illness “likely remain infectious no longer than 20 days after symptoms onset,
• Severely Immunocompromised patients have been found to remain infectious beyond 20 days,
• Once recovered from the virus, adults can shed detectable but non-infectious COVID-19 in upper respiratory specimens up to 3 months after illness onset.

The CDC notes that “These findings strengthen the justification for relying on a symptom-based rather than test-based strategy for ending isolation of most patients, so that adults who are no longer infectious are not kept unnecessarily isolated and excluded from work or other responsibilities.”

 

CDC COVID Data Tracker – United States COVID-19 Cases

Spotlight: Cigna Updates Authorization Policy for CTA and FFR-CT Analysis

The Society of Cardiovascular Computed Tomography (SCCT) announced in a January 29, 2021 Press Release that effective February 1, 2021, Cigna no longer requires pre-authorization for Computed Tomography Angiogram (CTA) of the heart, coronary arteries and bypass grafts with contrast material, including 3D imaging post-processing.

Cigna also removed pre-authorization, effective February 1, 2021, for Fractional Flow Reserve-Computed Tomography (FFR-CT).

Dustin Thomas, MD, FSCCT, Chair, Advocacy Committee, SCCT indicated in the Press Release that “the favorable policy update shows that Cigna recognized the use of CTA and FFR-CT as front-line test which can lead to improved patient outcomes.”

 

The Local Scene

 

January 25, 2021: CMS Fact Sheet: MAC COVID-19 Test Pricing

CMS notes that “Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates.” Included in this Fact Sheet is a table of newly created COVID-19 Test HCPCS codes and the payment amounts for each of the twelve MAC jurisdictions.

 

January 27, 2021: NGS JK Article: Beneficiaries with Medicare Advantage must Provide Medicare Information to Receive COVID-19 Vaccination

In this NGS News and Alerts article, they discuss the problem Providers are facing in obtaining information needed to bill traditional Medicare when a patient has received the COVID-19 vaccine. They advise that “the provider should inform the beneficiary with MA coverage that the services to be rendered on that DOS must be billed to traditional Medicare. Health care providers who furnish monoclonal antibodies to treat COVID-19 and/or administer a COVID-19 vaccine to a patient enrolled with a MA plan should submit such claims to your traditional Medicare contractor, not the MA plan. Please note that when the provider did not pay for the vaccine then they may only bill Traditional Medicare for the administration.

If the beneficiary with MA refuses to provide their traditional Medicare insurance information for billing purposes, then the provider should inform the patient that their refusal to cooperate so that Medicare can be billed will result in that beneficiary becoming liable for the service(s). If your Medicare patient doesn’t want to give the SSN, tell your patient to log into mymedicare.gov to get the MBI.”

 

February 5, 2021: Novitas JH/JL Notice: New Local Coverage Determinations (LCDs) Effective March 21, 2021

Novitas issued a notice informing providers about the following new LCDs and related billing and coding articles that will become effective March 21, 2021. It is noteworthy that two of the LCDs in the announcement are for procedures that are part of the CMS Hospital Outpatient Prior Authorization Program that began July 1, 2020 (Blepharoplasty and Botulinum Toxins).

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L35004)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
• Botulinum Toxins (L38809)
• Billing and Coding: Botulinum Toxins (A58423)
• Diagnostic Colonoscopy (L38812)
• Billing and Coding: Diagnostic Colonoscopy (A58428)

The following response to comments articles contain summaries of all comments received and Novitas’ responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58586)
• Response to Comments: Botulinum Toxins (A58584)
• Response to Comments: Diagnostic Colonoscopy (A58612)

 

February 4, 2021: First Coast JN - LCD and Article Updates

First Coast has posted new LCDs and related Billing and Coding Articles also effective on March 21, 2021. Similar to Novitas, two of the new LCDs are for procedures that are part of the Hospital Outpatient Prior Authorization Program.

• Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L34028)
• Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
• Botulinum Toxins (L33274)
• Billing and Coding: Botulinum Toxins (A57715)
• Diagnostic Colonoscopy (L33671)
• Billing and Coding: Diagnostic Colonoscopy (A55937)

The following Response to Comments Articles contain summaries of all comments received and First Coast’s responses:

• Response to Comments: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A58587)
• Response to Comments: Botulinum Toxins (A58585)
• Response to Comments: Diagnostic Colonoscopy (A58610)

 

February 4, 2021 Daily Newsletter Palmetto GBA JJ/JM OPD PA Alert!
Palmetto GBA posted the following Alert regarding the hospital Outpatient Department Prior Authorization Program prior authorization requests:

“OPD PAs cannot be sent retroactively, they must be submitted prior to the beneficiary receiving the service. Please review the FAQ on the CMS website.”

 

February 8, 2021: WPS J5/J8 Article – New CERT Contractor Update

WPS shared in an article that “The Comprehensive Error Rate Testing (CERT) contractor has a new website for provider information and resources. Providers can access the new website, the C3HUB at https://c3hub.certrc.cms.gov/.”

 

February 12, 2021: First Coast JN Article: Billing Condition Code (CC) 90 and 91

In this article, First Coast reminds providers that CMS issued MLN Matters® (MM) 12049  to implement two new condition codes (CCs):

• 90 – To allow providers to report when the service is provided as part of an Expanded Access approval
• 91 – To allow providers to report when the service is provided as part of an Emergency Use Authorization (EUA)

They go on to note that while this MLN article was released on November 20, 2020, the implementation date for these codes is February 22, 2021 with an effective date for claims received on or after February 1, 2021.

“First Coast loaded the new CCs on February 10. This means the new codes were not in the Fiscal Intermediary Standard System (FISS) until February 10. Any claims submitted before February 10, with these new condition codes, were rejected prior to entering FISS.

Provider action

If you submitted claims before February 10, with either CC 90 or 91 and received a rejection, you can resubmit the claim.”

Q:

On January 19, 2021, CMS issued a final Decision Memo that included revised criteria for Medicare coverage of Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation formerly known as Transcatheter Mitral Valve Repair (TMVR). When should our hospital start following the new criteria such as the requirements for treatment of functional (secondary) mitral regurgitation?

A:

Medicare is a huge bureaucracy and to change rules is not simply a snap of the fingers – there are manuals to update, Medicare contractors and providers to educate, and electronic systems to tweak. This means changes are not instantaneous and take some time to fully implement.

 

There are differences in the expected compliance with a coverage decision memorandum and a National Coverage Determination (NCD).  CMS addresses this in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

A Decision Memo is not immediately binding on Medicare contractors though they are encouraged to consider it. Here is the language from the Medicare Program Integrity Manual, Chapter 13 concerning decision memos:

“Coverage Decision Memorandum- CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. However, in order to expend MR funds wisely, contractors should consider Coverage Decision Memo posted on the CMS Web site. The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

Providers need to bear in mind however, that the final NCD backdates the effective date of the changes to the date of the decision memo. The issue lies with the implementation date which is communicated in a CMS Transmittal once the NCD changes are finalized. Medicare Administrative Contractors (MACs) will not start enforcing the new rules until the implementation date, but then they will enforce rules for dates of service on and after the date of the decision memo. This means once the final update to the NCD is made and manualized, the effective date will revert to the date of the decision memo but following the new rules will be based on an implementation date.  Claims submitted on and after the implementation date, will follow the new guidelines for dates of service on and after January 19, 2021 (decision memo date).

Best practice is for providers to educate all key stakeholders on the changes in the decision memo and implement new requirements, such as documentation of persistent symptoms in a patient with functional mitral regurgitation despite maximally tolerated guideline-directed-medical therapy (GDMT), as quickly as possible. Until an implementation date is communicated, providers should not stop complying with the requirements of the current NCD if they are continuing to submit claims for the service.  Another option for providers is to follow the new criteria in the Decision Memo and hold claims until after the implementation date of the revised NCD.