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September 2021 Medicare Rules, Regulations & Enforcement Updates
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September 9, 2021: Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Payment Update

CMS included the following updated information in the Thursday September 9, 2021 edition of MLN Connects (link):

“By November 1, 2021, CMS will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) so they’re paid at the same rate as non-excepted off-campus PBDs for those services under the Physician Fee Schedule (PFS). This affects certain claims with dates of service between January 1 - December 31, 2019. You don’t need to do anything; we’ll reprocess all affected claims. You must refund the coinsurance difference to patients (or payers) who paid the higher coinsurance rates based on new remittance advice information.


  • November 21, 2018: The Calendar Year (CY) 2019 Outpatient Prospective Payment System (OPPS) Rule (link) finalized payment for certain outpatient clinic visit services provided at excepted off-campus PBDs at the same rate that we pay non-excepted off-campus PBDs for those services under the PFS. Previously, CMS and Medicare patients often paid more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.
  • In 2019: We reduced payment to 70% of the full OPPS rate in off-campus PBDs. In 2020, this rate changed to 40%.
  • September 17, 2019: The U.S. District Court for the District of Columbia declared invalid the CY 2019 payment rule that provided for the reduction for clinic visits provided at excepted off-campus PBDs.
  • January 1 – July 2020: We reprocessed CY 2019 claims paid at the reduced payment rate of 70% to restore the 100% payment rate in accordance with the district court decision.
  • July 17, 2020: The U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding our volume control site-neutrality payment policy for off-campus outpatient hospital clinic visits.”
September 13, 2021: Proposal to Fully Repeal the Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” Final Rule

On September 1, 2020, the CMS released the Proposed Rule Medicare Coverage of Innovative Technology (MCIT) and Definition of Reasonable and Necessary Proposed Rule (CMS-3372-P). At that time, then Medicare HHS Secretary Alex Azar stated in a related press release that “this new proposal would give Medicare beneficiaries faster access to the latest lifesaving technologies and provider more support for breakthrough innovations by finally delivering Medicare reimbursement at the same time as FDA approval.” A Final Rule was published in the Federal Register on January 14, 2021, with a stated effective date of March 14, 2021. The effective date has since been delayed until December 15, 2021.

On Wednesday September 15, 2021, the CMS issued a Notice of Proposed Rule Making to fully repeal this final rule. (link). The repeal includes a public comment period through October 15, 2021. CMS’s intent is “to conduct future rulemaking to explore an expedited coverage pathway for innovative technologies (balanced with evidence development to ensure beneficial health outcomes for beneficiaries) and a regulatory definition of the Reasonable and Necessary standard for Medicare coverage.”

September 15, 2021: Department of Justice News: Orlando Cardiologist Pays $6.75 Million to Resolve Allegations

In a recent announcement (link), the DOJ indicated that an Orlando Cardiologist paid $6.75 million to resolve allegations that he performed medically unnecessary ablations and vein stent procedures. Specific allegations included:

  • Ablations and stent procedures were performed on veins that did not qualify for treatment under accepted standards of medical practice,
  • Dr. Pal made misrepresentations in patient records to justify the procedures, including overstating the degree of reflux and diameter of veins, and falsely documenting patient symptoms, and
  • In many instances, the ablations were performed either exclusively or primarily by one or more ultrasound technicians outside their scope of practice.”
September 17, 2021: DOJ News – National Healthcare Fraud Enforcement Action

The DOJ announced (link) criminal charges against 138 defendants, including 42 doctors, nurses, and other licensed medical professionals in 31 federal districts across the U.S. for alleged participation in health care fraud schemes resulting in approximately $1.4 billion in alleged losses. Specifically, charges targeted approximately $1.1 billion in fraud committed using telemedicine, $29 million in COVID-19 health care fraud, $133 million connected to substance abuse treatment facilities, and $160 million connected to other health care fraud and illegal opioid distribution schemes.

Beth Cobb

September 2021 COVID-19 Updates
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 | Billing 
 | Coding 

COVID-19 Updates

August 20, 2021: CMS COVID-19 Flexibilities Reminders: Prior Authorization Process, Utilization Management and Medical Necessity

The CMS issued a letter (link) to Medicare Advantage Organizations (MAOs) noting that with the recent COVID-19 delta variant surge resulting in increased hospitalizations, they encourage MA Plans “to waive or relax plan prior authorization requirements and utilization management processes to facilitate the movement of patients from general acute-care hospitals to post-acute care” settings (i.e., skilled nursing facilities, inpatient rehabilitation facilities, inpatient rehabilitation facilities and home health agencies).

Of note, CMS goes on to remind MAOs that “while they and their contract providers are not required to follow Original Medicare’s documentation requirements or policies for establishing medical necessity, the methods implemented…to determine medical necessity cannot result in coverage standards that are more stringent than standards that apply in Fee-For-Service Medicare.”

August 27, 2021: FAQs Regarding ICD-10-CM/PCS Coding for COVID-19 Updated

The FAQ document jointly developed and approved by the American Hospital Association’ Central Office on ICD-10-CM/PCS and the American health Information Management Association provides answers to questions related to Coding COVID-19. This document (link) was most recently revised August 27, 2021.

September 2, 2021: Resumption in Use and Distribution of Bamlanivimab/Etesevimab in all U.S. States, Territories, and Jurisdictions

In late August, use of this COVID-19 monoclonal antibody treatment was revised to authorize use only in areas where the combined frequency of variants resistant to both treatments administered together was less than or equal to 5%. On September 2nd, the FDA announced (link) that based on most recently available data, Bamlanivimab and Etesevimab, administered together, can be used in all U.S. states, territories, and jurisdictions under the condition of authorization for EUA 94.

September 9, 2021: CDC Clinician Outreach and Communications Activity Call: 2021-2022 Influenza Vaccination Recommendations and Guidance on Coadministration with COVID-19 Vaccines

The CDC held this call on Thursday, September 9, 2021. Presenters provided updates on the Advisory Committee on Immunization Practices (ACIP) recommendations for the 2021-2022 influenza vaccination season and guidance for co-administration of influenza and COVID-19 vaccines. One key take away is that COVID-19 vaccines may be administered without regard to timing of other vaccines. For those that missed this call, you can visit the CDC webpage specific to this call (link) to download a copy of the slides.

September 10, 2021: FDA Statement – COVID-19 Vaccines for Young Children

Acting FDA Commissioner Janet Woodcock M.D., and Peter Marks, M.D, Ph.D., director the FDA’s Center for Biologics Research and Education, released a statement (link) providing an update detailing steps being taken to ensure the safety and efficacy of COVID-19 vaccines for young children. The statement ends with the following advice, “Until we authorize or approve a vaccine for this younger population, it’s especially important that parents and others who interact closely with children under 12 years of age get vaccinated, wear masks, and follow other recommended precautions so that we can protect those who cannot yet protect themselves through vaccination.”

September 10, 2021: HHS Announced $25.5 Billion in COVID-19 Provider Funding

The HHS announced (link) that funding from the American Rescue Plan (ARP) and Provider Relief Fund (PFR) totaling $25.5 billion is being made available for health care providers affected by the COVID-19 pandemic. HHS Secretary Xavier Bacerra noted that “this funding critically helps health care providers who have endured demanding workloads and significant financial strains amidst the pandemic…the funding will be distributed with an eye towards equity, to ensure providers who serve our most vulnerable communities will receive the support they need.”

September 30, 2021: CDC COCA Call: Evaluating and Supporting Patients Presenting with Fatigue Following COVID-19

The CDC will be holding a Clinician Outreach and Communication Activity (COCA) call Thursday September 30, 2021, in which presenters will discuss post-COVID conditions (PCC), “an umbrella term for the wide range of health consequences present four or more weeks after infection with SARS-CoV-2, which includes Long-COVID.” If you are unable to attend, call materials will be available on the CDC specific webpage for this call (link).

Beth Cobb

September 2021 Medicare Transmittals and MLN Articles
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Medicare MLN Articles & Transmittals – Recurring Updates

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—January 2022
  • Article Release Date: August 25, 2021
  • What You Need to Know: This article providers ICD-10 updates specific to NCDs resulting from newly available codes, separate NCD coding revisions and coding feedback received. Note, one of the updated NCDs is 20.4 Implantable Automatic Defibrillator. As CMS has added codes to this NCD, Novitas and First Coast have both retired their AICD Coding and Billing Articles.
  • MLN MM12399: (link)
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 Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule – Update from Council for Affordable Quality Health Care (CAQH) Core
  • Article Release Date: September 8, 2021
  • What You Need to Know: This article alerts billing staff that the next version of the Code Combination List will be published on or about October 1, 2021. Updates are based on a market-based review conducted once every two years to fit in code combinations that Medicare and other health plans are now using.
  • MLN MM12428: (link)
Annual Clotting Factor Furnishing Fee Update 2022
  • Article release date: September 8, 2021
  • What You Need to Know: Make sure your billing staff knows the clotting factor furnishing fee for 2022 is $0.239 per unit.
  • MLN MM12420: (link)
Influenza Vaccine Payment Allowances – Annual Update for 2021-2022 Season
  • Article release date: September 9, 2021
  • What You Need to Know: This article includes a link to the CMS Seasonal Influenza Vaccines Pricing webpage and reminds all physicians, non-physician practitioners, and suppliers who give the flu shot that they must take assignment on the claim for the shot.
  • MLN MM12421: (link)
2022 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
  • Article Release Date: September 9, 2021
  • What You Need to Know: This article informs providers that the MACs will be receiving files for the automated payments of HPSA bonuses for dates of service from January 1, 2022, through December 31, 2022.
  • MLN MM12367: (link)
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2021 Update
  • Change Request (CR) 12422 released: September 8, 2021
  • What You Need to Know: This CR amends the payment files issued to contractors based upon the 2021 Medicare Physician Fee Schedule (MPFS) Final Rule.
  • Related MLN MM12422: (link)
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
  • Article Release Date: September 10, 2021
  • What You Need to Know: This article provides information about quarterly updates to the CLFS, effective October 1, 2021.
  • MLN MM12435: (link)
October 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • Article Release Date: September 16, 2021
  • What You Need to Know: Changes to and billing instructions for various payment policies are included in this Change Request. Information related to COVID-19 in this update includes:
    • New COVID-19 CPT Administration Codes,
    • New COVID-19 HCPCS Vaccine Administration Code for Administering in the Beneficiary’s Home, and
    • Changes for COVID-19 Monoclonal Antibody Therapy Product and Administration Codes.
  • Change Request (CR) 12436: (link)
October 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
  • Article Release Date: September 17, 2021
  • What You Need to Know: This article highlights HCPCS updates included in the October 2021 ASC payment system update.
  • MLN MM12451: (link)

Revised Medicare MLN Articles & Transmittals

Medicare FFS Response to the PHE on COVID-19
  • Article Release Date: Initial article March 16, 2020 – 19th iteration September 8, 2021
  • What You Need to Know: The latest revision to this MLN Special Edition article includes more information about Skilled Nursing Facility (SNF) waivers. Substantive changes are in dark red font on page 13 of this document. Specifically, CMS reminds providers that while the 3-day qualifying hospital stay is being waived prior to transfer to a SNF, “these emergency measures don’t waive or change any other existing requirements for SNF coverage under Part A such as the SNF level of care criteria, which remain in effect under the emergency.”
  • MLN SE20011: (link)

Beth Cobb

September 2021 Pro Tips: Targeted Probe and Educate Program Resumption
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Welcome to this month’s edition of MMP’s P.A.R. Pro Tips. For those new to the Wednesday@One, MMP has collaborated with RealTime Medicare Data (RTMD), to develop a proprietary Protection Assessment Report (P.A.R.). This report is a combination of current Medicare Fee-for-Service review targets with hospital specific Medicare Fee-For-Service paid claims data. As a bonus to our Wednesday@One readers, we have begun to provide useful “Did You Know” information that we come across in our ongoing review of key websites (i.e., Medicare Administrative Contractors (MACs), OIG, Recovery Auditors, etc.)

Did You Know?

Late last month, we reported that CMS had given the green light for Medicare Administrative Contractors (MACs) to resume the Targeted Probe and Educate (TPE) Program. This program had been on hold since March of 2020 due to the COVID-19 Public Health Emergency (PHE).

MACs are now reporting that effective September 1, 2021, they will discontinue sending post-payment additional documentation requests (ADR) and will resume reviews conducted under the TPE Medical Review Strategy.

Pro Tip: MAC Education

MACs nationwide have been releasing information about the resumption of the TPE Program.

CGS (Jurisdiction 15)

CGS has posted a letter to providers (link) walking through the TPE process and providing links to resources. At the time this article was written, CGS Part A Medical Review Activity Log (link) indicated that the TPE review types were still paused.

First Coast Service Options, Inc. (Jurisdiction N)

First Coast’s TPE webpage (link) you will find a link to a Targeted Probe and Educate Manual with guidance ranging from what is TPE to filing appeals.

Noridian (Jurisdiction E)

Noridian held a Targeted Probe and Educate (TPE) A/B webinar this past Friday, September 10, 2021. Topics included in the webinar included the TPE process, initiating reviews, providing notification, and completing and closing files. If you missed it, you can sign up for an October 14, 2021 webinar that will cover the same information (link).

Noridian (Jurisdiction F)

Following is an excerpt from an announcement (link) that Noridian posted on their website on September 8, 2021, “CMS has authorized the Medicare Administrative Contractors (MACs) to conduce a 20-40 claim preview for A/B providers utilizing the normal TPE process. If the Round One results in an acceptable error rate, no further action is required, and the TPE review will be closed.”

Novitas Solutions Jurisdiction (Jurisdiction H)

Novitas most recently updated their TPE webpage (link) on September 7, 2021, where you will find links to TPE Q&As, current TPE activities, historical TPE reviews, and documentation checklists. As of 9/7/2021, the only listed TPE Topic list is Therapy Services.

Palmetto GBA (Jurisdiction J)

Palmetto GBA was one of the first to update their Active Medical Review list (link), they note that TPE cases that remained open during the PHE have been closed.

WPS (Jurisdiction 5)

CMS issued the following notice on August 30, 2021, “CMS has authorized WPS to resume the TPE program effective September 1, 2020. Providers selected for review based on data analysis aberrancies will receive notification prior to the start of their TPE review.” Topics under review listed on their website (link) includes:

  • Inpatient Psychiatric Facility (IPF),
  • Inpatient Rehabilitation Services,
  • Routine Foot Care, and
  • Wound care in a Critical Access Hospital (CAH).

What Can You Do?

Make sure that employees involved with the TPE program at your facility are aware of the resumption of the program and make sure someone is checking your MAC’s websites on an ongoing basis for any updates, new review targets and TPE review results.

Beth Cobb

Happy Clinical Documentation Integrity Week 2021
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In case you are not a long-time reader of our newsletter, fall is my favorite time of year. Even though the official start of fall is still a week away, with morning lows in the mid 50’s recently, I have already had my first cup of apple spice tea, first cup of pumpkin spice coffee, and made my first batch of chili in the slow cooker. I have also put out my fall pumpkin themed door mat as we enter the months of celebrating fall, Halloween, Thanksgiving, Christmas.

In the world of Medicare, fall is also a time for new beginnings and celebrations. The new CMS Fiscal Year (FY) starts on October 1st and more importantly this week is all about celebrating the 11th annual Clinical Documentation Integrity (CDI) Week. In keeping with my culinary firsts of the fall, this year’s CDI Week theme is CDI Kitchen: Recipes for a Successful Program. According to a related Association for Clinical Documentation Integrity Specialists (ACDIS) Fact Sheet (link), “the growth of the CDI specialist profession has mirrored the healthcare industry’s increased focus on compliance with regulations, managed care profiles, payment for services rendered, quality of care improvement measurements, and liability exposure. All these factors increasingly depend on the integrity of complete and specific clinical documentation in the medical record.”

MMP would like to wish all the hard-working CDI Professionals that we have the privilege to work with a happy CDI week. To help you prepare for the new CMS fiscal year, while celebrating this week, following are links to key ingredients for a successful start to the CMS FY 2022.

2022 ICD-10-CM Official Guidelines

You can read about changes for FY 2022 in a related MMP article (link).

2022 ICD-10-PCS Official Guidelines

2022 CMS IPPS Final Rule

FY 2022 ICD-10-CM/PCS Codes, MCCs and CCs

There are 165 new diagnosis codes. Of note, including in this list are:

  • 11 new Social Determinants of Health (SDOH) ICD-10-CM codes, and
  • 4 new COVID-19 related codes including U09.9 (Post COVID-19 condition, unspecified), Z1152 (Encounter for screening for COVID-19), Z20.822 (Contact with and *suspected) exposure to COVID-19), and Z86.16 (Personal history of COVID-19).

There are 212 new ICD-10-PCS procedure codes, including several new codes related to COVID-19 vaccines and monoclonal antibody treatments for COVID-19.

There are nine additions to the MCC list, including J12.82 (Pneumonia due to coronavirus disease 2019) which was implemented January 1, 2021. There are eleven additions to the CC list, which also include two codes implemented January 1, 2021 (M35.81 (multisystem inflammatory syndrome) and M35.89 (Other specific systemic involvement of connective tissue)).

Again, happy CDI week from our team to yours.

Beth Cobb

Prostate awareness
Published on 



We do ultrasound guided prostate biopsies in Radiology and report the ultrasound guidance with CPT code 76742. To report CPT code 76942, should we maintain permanently recorded images?


Yes, per the parenthetical guidelines in the Diagnostic Ultrasound section of the CPT book, permanently recorded images must be maintained for ultrasound guidance. The physician should also document the use of ultrasound guidance. This documentation can be included in the biopsy report or can be documented as a separate report. Typically, we see only one physician’s report that describes both the prostate needle biopsy as well as the ultrasound guidance.

Jeffery Gordon

Coding BiPap via an ETT
Published on 


 | Coding 
 | FAQ 
Did You Know?

When a patient has bi-level positive airway pressure (BiPap) delivered through an endotracheal tube (ETT), the procedure code is different that BiPap (5A09x57), and the case groups to a different DRG.

Why It Matters

When BiPap is delivered through an ETT or tracheostomy, the PCS alpha index sends us to see Performance, Respiratory (5A19###).

Alphabetic Index:

BiPAP – see Assistance, Respiratory 5A09


Endotracheal Tube or Tracheostomy –see Performance, Respiratory

Example: If a patient has a principal diagnosis of pneumonia, unspecified (J18.9), with a secondary diagnosis of acute respiratory failure with hypoxia (J96.01), and the patient is placed on Bipap without an ETT, the case groups to DRG 193 (Simple pneumonia and pleurisy with MCC) with a relative weight of 1.3107.

However, if this same patient is placed on BiPap, via an ETT or tracheostomy, the case groups to DRG 208 (Respiratory system diagnosis with ventilator support) with a relative weight of 2.5423.

Accurate coding of BiPap, via an ETT or tracheostomy, will not only group to a higher-weighted DRG, realizing more appropriate reimbursement, but it will also help to support the resources your facility spends on a patient. p>

What Should I Do?

Thoroughly review the record:

  • Watch for words like “intubation” or “successfully intubated”
  • Review any procedure reports
  • Review all respiratory sheets
  • Review nursing notes
  • ICD-10-PCS Official Coding Book
  • Coding Clinic for ICD-10-CM/PCS, 2014, page 3

Susie James

COVID-19: Vaccine Booster Shot, First FDA Approved Vaccine and Myths & Facts
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COVID-19 Booster Shots

On August 18, 2021, HHS released a statement, (link), indicating that “the available data make very clear that protection against SARS-CoV-2 infection begins to decrease over time following the initial doses of vaccination, and in association with the dominance of the Delta variant, we are starting to see evidence of reduced protection against mild and moderate disease. Based on our latest assessment, the current protection against severe disease, hospitalization, and death could diminish in the months ahead, especially among those who are at higher risk or were vaccinated during the earlier phases of the vaccination rollout. For that reason, we conclude that a booster shot will be needed to maximize vaccine-induced protection and prolong its durability.” HHS goes on to indicate they have a plan to begin offering booster shots this fall of a third dose of the Pfizer and Moderna mRNA vaccines, “beginning the week of September 20 and starting 8 months after an individual’s second dose.”

HHS also anticipates the need for a booster shot for individuals that received the Johnson & Johnson (J&J) vaccine. They note that “administration of the J&J vaccine did not begin in the U.S. until March 2021, and we expect more data on J&J in the next few weeks. With those data in hand, we will keep the public informed with a timely plan for J&J booster shots as well.”

COVID-19 Third Dose of Moderna and Pfizer-BioNTech CPT Codes

Concurrent to the recommendation that individuals receive a third Moderna or Pfizer-BioNTech COVID-19 vaccine, the AMA published the following CPT codes.

  • Moderna Third Dose
    • Effective for Emergency Use Authorization (EUA) as of August 12, 2021.
    • Administration code 0013A
  • Pfizer-BioNTech Third Dose
    • Effective for EUA as of August 12, 2021
    • Administration code 0003A

You can find a summary of the SARS-CoV-2 related CPT codes on the AMA website (link).

COVID-19 Myths and Facts

The CDC has a webpage (link) dedicated to dispelling myths about COVID-19 vaccines. For example:

  • Yes, the Pfizer-BioNTech and Moderna mRNA vaccines trigger an immune response inside your body and are considered vaccines. The CDC notes that “this type of vaccine is new, but research and development on it has been under way for decades.”
  • No, COVID-19 vaccines do not contain microchips.
  • No, receiving a COVID-19 vaccine will not make you magnetic.

The World Health Organization (WHO) also has a webpage (link) dedicated to dispelling myths about COVID-19 in general by providing the facts, for example:

  • COVID-19 is caused by a virus, not by bacteria. The virus that causes COVID-19 is in a family of viruses called Coronaviridae.
  • The COVID-19 virus can spread in hot and humid climates, and
  • 5G mobile networks DO NOT spread COVID-19. COVID-19 is a virus and is spread through respiratory droplets when an infected person coughs, sneezes or speaks. People can also be infected by touching a contaminated surface and then their eyes, mouth, or nose.

Beth Cobb

Prostate Cancer Awareness Month
Published on 



September is Prostate Cancer Awareness Month. A related RealTime Medicare Data (RTMD) infographic in this week’s newsletter focuses on Medicare Fee-for-Service claims data related to screening for Prostate Cancer.

Did You Know?

According to the CDC:

  • 13 out of every 100 American men will get prostate cancer during their lifetime, and
  • 2 to 3 men will die from prostate cancer,
  • If you are African American or have a family history of prostate cancer you are at increased risk for getting or dying from prostate cancer.

The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.

Why Does this Matter? Know the Symptoms

The CDC advises that if you are having any of the following symptoms, you need to see your doctor right away:

  • Difficulty starting urination.
  • Weak or interrupted flow of urine.
  • Frequent urination, especially at night.
  • Difficulty emptying the bladder completely.
  • Pain or burning during urination.
  • Blood in the urine or semen.
  • Pain in the back, hips, or pelvis that doesn’t go away.
  • Painful ejaculation.

The NIH National Cancer Institute indicates that based on 2011-2017 data, there is a 97.5% 5-year relative survival rate for men diagnosed with prostate cancer.

What You Can Do About It? Screening for Prostate Cancer

There are two tests commonly used to screen for prostate cancer:

  • A blood test called a prostate specific antigen (PSA) test and
  • A digital rectal examination (DRE).

The U.S. Preventive Services Task Force recommendation is that men aged 55 to 69 years should participate in a shared decision making process with their physician by discussing the potential benefits and harms of screening with a PSA test and incorporating their values and preferences in the decision.

This recommendation applies to men who:

  • Are at average risk for prostate cancer,
  • Are at increased risk for prostate cancer,
  • Do not have symptoms of prostate cancer, and
  • Have never been diagnosed with prostate cancer.

Medicare Preventive Service: Prostate Cancer Screening – Coverage & Coding

  • G0102 (Prostate cancer screening; digital rectal exam): A patient’s copayment or coinsurance, and deductible will apply.
  • G0103 (Prostate cancer screening; prostate specific antigen test): there is no copayment, coinsurance, or deductible for the patient.


Beth Cobb

Medicare Targeted Probe & Educate, Short Stay & Higher Weighted DRG Reviews to Resume
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CMS Resumes Targeted Probe & Educate Program

In response to the COVID-19 Public Health Emergency (PHE), CMS suspended medical review activities on March 30, 2020. In August 2020, Recovery Auditors, Comprehensive Error Rate Testing Program, and Medicare Administrative Contractor post-payment reviews were resumed. At that time, the Targeted Probe and Educate (TPE) program remained on hold.

On May 8, 2019, CMS put a temporary hold on SSRs and HWDRG reviews as they planned to procure a new contractor to review both types of reviews on a national basis. The expectation was to award the contract by the 3rd quarter of calendar year 2019.

According to a CMS TPE Q&A document (link), when performing medical review as a part of this program, Medicare Administrative Contractors (MACs):

  • Focus on specific providers/suppliers who, through data analysis, have been identified as varying significantly from their peers,
  • Typically review 20-40 claims per provider/supplier, per item or service (round),
  • Provide individualized education based on review results after a round, and
  • Perform up to three rounds of reviews per item or service.

The CMS announced in the Thursday August 12, 2021, edition of MLN Connects (link) that the TPE Program is restarting “to help educate providers and reduce future denials and appeals.”

Livanta to Begin Short Stay Reviews and Higher Weighted DRG Reviews

Kepro and Livanta are the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) that serve all regions across the nation. The BFCC-QIO scope of work, among other things includes performing certain types of medical record reviews. Two specific reviews are Short Stay Reviews (SSRs) and Higher Weight Diagnosis-Related Group (HWDRG) review.

It wasn’t until April of 2021, that Livanta announced they had been awarded this contract. On August 11, 2021, Livanta released a Provider Bulletin (link) to announce the official start of claims reviews. The bulletin includes information on the following topics:

  • What Hospitals Can Expect,
  • Hospital Inpatient Claim Review Types,
  • HWDRG Review Process,
  • SSR Process, and
  • Questions and Education.

The review process for each type of medical review includes the timing of when they will begin requesting records. For HWDRG reviews, they expected to send the first medical record request the week of August 16th. For SSRs, Livanta anticipated sending the first individual medical record requests on or about the week of September 20, 2021. Note, record requests will be sent to your Medical Record point of contact via fax when possible or U.S. mail if fax is not possible. A hospital sample will consist of 30 claims reviewed within a rolling 3-month period and records must be submitted electronically.

I encourage you to visit Livanta’s webpage (link), read the Provider Bulletin and share this information with appropriate staff at your facility.

Beth Cobb

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