Medicare News and Web Updates for JH Part B (2020)

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* Coronavirus (COVID-19) Information

June 1, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11754 – Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component
This article informs you of the implementation of the hospice benefit component associated with the VBID Model, being tested by the Centers for Medicare & Medicaid Services Innovation Center and starting in calendar year (CY) 2021. The hospice benefit component of the model will be tested through CY 2024. Please make sure your billing staffs are aware of this update as providers must still submit claims for these services to Medicare. Non-contracting providers must also submit the same billing forms used to bill original Medicare to plans participating in the VBID model’s hospice benefit component for payment.

May 29, 2020

Special Edition – Friday, May 29, 2020

Provider Education Message:

New COVID-19 FAQs on Medicare Fee-for-Service Billing

CMS released additional Frequently Asked Questions (FAQs) on our recent COVID-19-related waivers to help providers, including physicians, hospitals, and rural health clinics. Find more answers to questions on:

Outpatient therapy
Telehealth and appropriate coding
Federally qualified health centers

Bookmark this document and check back for additional updates.

For More Information:

Coronavirus.gov
CMS Current Emergencies website

Opioid treatment program claim submission errors

A new article was added to the OTP Specialty Page to provide guidance on how to resolve top claim submission errors.  Simple changes will ensure that claims are billed and paid correctly. 


May 28, 2020

CMS Provider Education Message:

COVID-19: Adjusting Operations to Manage Patient Surge

MLN Connects® for Thursday, May 28, 2020

View this edition as a PDF

News

COVID-19: Adjusting Operations to Manage Patient Surge
PECOS/NPPES/EHR Identity & Access Management System: Role Renamed
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

COVID-19: Lessons from the Front Lines Call — May 29

MLN Matters® Articles

Medicare Continues to Modernize Payment Software

Publications

Acute Care Hospital Inpatient Prospective Payment System — Revised

The following Local Coverage Determinations (LCDs) posted for comment on December 26, 2019 have been posted for notice. The LCDs and related Billing and Coding Articles will become effective July 12, 2020:

Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495)
Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (A57839)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (L35130)
Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57752)

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

Response to Comments: Magnetic-Resonance-Guided-Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (A58049)
Response to Comments: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A58195)

Prior authorization (PA) program for certain hospital outpatient department (OPD) services

The Centers for Medicare & Medicaid Services (CMS) is implementing a PA program for certain hospital OPD services, effective June 17, 2020, for dates of service (DOS) on or after July 1, 2020, nationwide. As a condition of payment for DOS on or after July 1, 2020, a prior authorization request (PAR) is required for the following hospital OPD services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

CMS recently issued an OPD Frequently Asked Questions document and the OPD Operational Guide. Find these documents and more on our dedicated webpage for the OPD PA program.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11709 – 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 Healthcare (CAQH) CORE
This article informs you of updates that the Medicare Administrative Contractors and Shared System Maintainers will make to systems based on the CORE 360 uniform use of CARC, RARC, and CAGC rule publications. These system updates are based on the CORE code combination list to be published on or about June 1, 2020. Make sure that your billing staffs are aware of these updates.

Rescinded:

MM11749 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2020 Update
This article was rescinded on May 26, 2020, as the related change request (CR) 11749, transmittal 10092, dated May 1, 2020, was rescinded in its entirety. Therefore, any coding changes to NCD 90.2, Next generation sequencing, contained in CR 11749 are null and void.

May 27, 2020

Coronavirus disease 2019 (COVID-19): Telehealth and telephone-only services during the emergency

Updates have been made to the article.  Please review to ensure that you are current with the guidance outlined in the article. 


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11699 – Claim Status Category Codes and Claim Status Codes Update
Change request 11699 updates the claim status and claim status category codes used for the accredited standards committee (ASC) X12 276/277 health care claim status request and response and ASC X12 277 health care claim acknowledgment transactions. Make sure your billing staff is aware of this update.
MM11708 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Change request 11708 updates the RARC and CARC lists and instructs the viable information processing system Medicare system and the fiscal intermediary shared system to update MREP and PC Print. Make sure your billing staffs are aware of these updates. If they use the MREP or PC Print software, they will need to get the updates of that software.
MM11805 – Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules
This article provides a summary of policies in the CY 2020 MPFS PHE interim final rule with comment (IFC) entitled, “Medicare and Medicaid programs; policy and regulatory revisions in response to the COVID-19 public health emergency (CMS-1744-IFC) and Medicare and Medicaid programs, basic health program, and exchanges; additional policy and regulatory revisions in response to the COVID-19 public health emergency and delay of certain reporting requirements for the skilled nursing facility quality reporting program (CMS-5531-IFC).” Please make sure your billing staffs are aware of these changes.

Revised:

MM11791 – Therapy Codes Update
The Centers for Medicare & Medicaid Services (CMS) revised this article to reflect a revised Change request (CR) 11791. The CR revision changed the implementation date for the Medicare administrative contractors in the article. The CR release date, transmittal number, and the web address were also revised. All other information is the same.

May 26, 2020

The following Local Coverage Determination (LCD) posted for notice on April 9, 2020 became effective May 24, 2020. The related Billing and Coding Article also became effective May 24, 2020.

Thrombolytic Agents (L35428)
Billing and Coding: Thrombolytic Agents (A55237)

May 21, 2020

CMS Provider Education Message:

Join Upcoming COVID-19 Calls

MLN Connects® for Thursday, May 21, 2020

View this edition as a PDF

News

CMS Releases Additional Waivers for Hospitals and Ground Ambulance Organizations
Hospice Quality Reporting Program: Quarterly Update for January - March
Nursing Home Quality Initiative: Updated MDS 3.0 Item Sets
Hospitals: Submit Medicare GME Affiliation Agreements by October 1 During the COVID-19 PHE

Events

COVID-19: Lessons from the Front Lines Calls — May 22 and 29
COVID-19: Home Health and Hospice Call — May 26
COVID-19: Office Hours Call — May 26
COVID-19: Nursing Home Call — May 27
COVID-19: Dialysis Organization Call — May 27
COVID-19: Nurses Call — May 28
Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services Special Open Door Forum — May 28

MLN Matters® Articles

COVID-19 Blanket Swing Bed Waiver for Addressing Barriers to Nursing Home Placement for Hospitalized Individuals
Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section
National Coverage Determination (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)
National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)
New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2020 Update
Therapy Codes Update

Multimedia

Procedure Coding: Using the ICD-10-PCS Web-Based Training Course — Revised

Prior Authorization Program for Certain Hospital Outpatient Department Services Webinar – Date Change

Due to CMS hosting a Special Open Door Forum call to discuss the Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services on Thursday, May 28, from 1:30 p.m. to 3:00 p.m. ET, Novitas must change the date and time of the JH JL Part A/B webinar Prior Authorization (PA) Program for Certain Hospital Outpatient Department Services previously scheduled for Thursday, May 28, 2020.  The new date and time for the Novitas webinar is Friday, May 29, 2020 at 10:00 a.m. ET/9:00 a.m. CT. We sincerely apologize for any inconvenience this may cause; If you were previously enrolled in this webinar, we have automatically enrolled you into the rescheduled webinar. If you would like to register for this webinar, please visit our Learning Center to register (JH) (JL).

Novitas will be presenting this webinar on the prior authorization program being implemented by the Centers for Medicare & Medicaid Services (CMS) for certain hospital outpatient department (OPD) services on June 17, 2020, for dates of service on or after July 1, 2020. If your facility bills these services, or you are a provider that performs these services on Medicare beneficiaries, join us for this webinar. We’ll review the guidelines for submitting a Prior Authorization Request (PAR) and the potential results and options available, with specialists present to answer questions relating to the process.

As a condition of payment for DOS on or after July 1, 2020, a Prior Authorization Request (PAR) is required for the following hospital OPD services:

Blepharoplasty, eyelid surgery, brow lift, and related services
Botulinum toxin injections
Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
Rhinoplasty and related services
Vein ablation and related services

The following Billing and Coding Article has been revised. It will become effective on May 24, 2020 with its corresponding Local Coverage Determination L35428 which was posted for notice on April 9, 2020.

Billing and Coding: Thrombolytic Agents (A55237)

May 19, 2020

Special Edition – Tuesday, May 19, 2020

Provider Education Message:

COVID-19: Payment for Lab Tests, Safely Reopening Nursing Homes, Lab & Ambulance Claims

COVID-19: Payment for Diagnostic Laboratory Tests
Trump Administration Issues Guidance to Ensure States Have a Plan in Place to Safely Reopen Nursing Homes
COVID-19: Which Laboratory Claims Require the NPI of the Ordering/Referring Professional?
COVID-19: Ambulance Claims for Alternative Sites.

COVID-19: Payment for Diagnostic Laboratory Tests

Earlier this year, CMS took action to ensure America’s patients, health care facilities, and clinical laboratories were prepared to respond to the 2019-Novel Coronavirus (COVID-19). To help increase testing and track new cases, CMS developed two HCPCS codes that laboratories can use to bill for certain COVID-19 diagnostic tests. Health care providers and laboratories may bill Medicare and other health insurers for SARS-CoV2 tests performed on or after February 4 using:  

HCPCS code U0001 for tests developed by the Centers for Disease Control and Prevention (CDC)
HCPCS code U0002 for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)

Laboratories and other health providers can also bill Medicare for tests using CPT codes created by the American Medical Association, provided testing uses the method specified by each CPT code:

CPT code 87635 for infectious agent detection by nucleic acid tests for dates of service on or after March 13
CPT codes 86769 and 86328 for serology tests for dates of service on or after April 10

Finally, for dates of service on or after April 14, 2020, Medicare pays $100 for laboratory tests for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 making use of high throughput technologies. Laboratories can bill Medicare for these tests using:

U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.

Neither U0003 nor U0004 should be used to bill for tests that detect COVID-19 antibodies.

For COVID-19 tests that do not use high throughput technology, Medicare Administrative Contractors developed payment amounts for claims in their jurisdictions that will be used until we establish national payment rates though the annual laboratory meeting process. There is no cost-sharing for Medicare patients.


Trump Administration Issues Guidance to Ensure States Have a Plan in Place to Safely Reopen Nursing Homes

On May 18, under the leadership of President Trump, CMS announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country. The guidance released is part of President Trump’s Guidelines for Opening Up America Again. The recommendations issued would allow states to make sure nursing homes are continuing to take the appropriate and necessary steps to ensure resident safety and are opening their doors when the time is right. This also serves to help states and nursing homes reunite families with their loved ones in a safe, phased manner.

Press Release


COVID-19: Which Laboratory Claims Require the NPI of the Ordering/Referring Professional?

During the COVID-19 Public Health Emergency, CMS is relaxing billing requirements for a limited number of laboratory tests required for a COVID-19 diagnosis. Any health care professional authorized under state law may order these tests. Medicare will pay for these tests without a written order from the treating physician or other practitioner:

If an order is not written, you do not need to provide the National Provider Identifier (NPI) of the ordering or referring professional on the claim  
If an order is written, include the NPI of the ordering or referring professional, consistent with current billing guidelines

For More Information:

Laboratory Tests with modified requirements
Interim Final Rule

COVID-19: Ambulance Claims for Alternative Sites

During the COVID-19 Public Health Emergency, Medicare covers medically necessary emergency and non-emergency ground ambulance transportation from any point of origin to a destination that is equipped to treat the condition of the patient consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished.

Medicare Administrative Contractors are now processing claims  according to the details provided in the April 7 message. If you believe that your previously processed claims were denied in error, contact your Medicare Administrative Contractor to have these claims reprocessed.


Laboratory - Part B Specialty Page

A new article has been added on the Proper Billing of Laboratory Tests.  Please review the article to ensure you are billing correctly.   


As a reminder, the comment period for the following Proposed Local Coverage Determination (LCD) is currently open and will close on June 13, 2020. We encourage you to submit your comments as soon as possible to allow ample time for us to review them thoroughly.

Implantable Continuous Glucose Monitors (I-CGM) (DL38617)

Submit Comments


May 18, 2020

Special Edition – Friday, May 15, 2020

Provider Education Message:

COVID-19: Deadlines, New Releases, and Important Calls

Deadline Approaching: Notification Requirements of Confirmed and Suspected COVID-19 Cases Among Nursing Home Residents and Staff
CMS Releases Nursing Home Toolkit with Best Practices and Additional Resources
Telephone Evaluation and Management Visits
Hospitals: Physician Time Studies During the COVID-19 PHE
Trump Administration Announces Call for Nominations for Nursing Home Commission
COVID-19: Home Health and Hospice Call — May 19
COVID-19: Nursing Home Call — May 20
COVID-19: Dialysis Organization Call — May 20
COVID-19: Nurses Call — May 21
COVID-19: Office Hours Call — May 21
COVID-19: Lessons from the Front Lines Call — May 22

Deadline Approaching: Notification Requirements of Confirmed and Suspected COVID-19 Cases Among Nursing Home Residents and Staff

On April 19, CMS announced the agency will be requiring facilities to report COVID-19 information to the CDC and to families. Within three weeks of that announcement, on April 30, CMS issued an Interim Final Rule with Comment Period with new regulatory requirements. With the new regulatory requirements, nursing homes are required to report the first week of data to the CDC beginning May 8 but no later than May 17. For the first time, all 15,000 nursing homes will be reporting this data directly to the CDC through its reporting tool.

In order to report, facilities must enroll in the CDC’s National Healthcare Safety Network (NHSN). Information on how to enroll is available here. As nursing homes report this data to the CDC, CMS will be taking swift action and publicly posting this information so all Americans have access to accurate and timely information on COVID-19 in nursing homes. More information on the CDC’s NHSN COVID-19 module can be found here.


CMS Releases Nursing Home Toolkit with Best Practices and Additional Resources

CMS released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities. These additional resources will help in the fight against the COVID-19 pandemic within nursing homes. The toolkit builds on previous actions taken by CMS, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

Press Release
Toolkit


Telephone Evaluation and Management Visits

The March 30 Interim Final Rule with Comment Period added coverage during the Public Health Emergency for audio-only telephone evaluation and management visits (CPT codes 99441, 99442, and 99443) retroactive to March 1. On April 30, a new Physician Fee Schedule was implemented increasing the payment rate for these codes. Medicare Administrative Contractors (MACs) will reprocess claims for those services that they previously denied and/or paid at the lower rate.

There are also a number of add on services (CPT codes 90785, 90833, 90836, 90838, 96160, 96161, 99354, 99355, and G0506) which Medicare may have denied during this Public Health Emergency. MACs will reprocess those claims for dates of service on or after March 1.

You do not need to do anything.


Hospitals: Physician Time Studies During the COVID-19 PHE

Hospitals that incur physician compensation costs must allocate those costs based on the percentage of total time spent furnishing:

Part A services
Part B services

Non-Medicare allowable activities

Hospitals must submit physician allocation agreements annually as part of the cost report filing process. During the Public Health Emergency (PHE), any one of these time study options is acceptable:

One week time study every 6 months (two weeks per year)
Time studies completed in the cost report period prior to January 27, the PHE effective date (e.g. hospital with a 7/1/2019 -- 6/30/2020 cost reporting period, could use the time studies collected 7/1/2019 through 1/26/2020; no time studies needed for 1/27/2020 -- 6/30/2020)
Time studies from the same period in CY 2019 (e.g., if unable to complete time studies during February through July 2020, use time studies completed February through July 2019)

For more information, see the Provider Reimbursement Manual:

Chapter 21, section 2182.3.E.3  - allocation agreements
Chapter 23, section 2313.2.E and Chapter 21, section 212182.3.E - instructions for time studies

Trump Administration Announces Call for Nominations for Nursing Home Commission

CMS announced a call for nominations for the new contractor-led Coronavirus Commission on Safety and Quality in Nursing Homes. The commission’s work will build on the Trump Administration’s long history of decisive actions to protect nursing home residents. The commission will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing homes and will inform immediate and future actions to safeguard the health and quality of life for an especially vulnerable population of Americans.

Press Release
Nursing Home Commission Nominations


COVID-19: Home Health and Hospice Call — May 19

Tuesdays from 3 to 3:30 pm ET

These calls provide targeted updates on the agency’s latest COVID-19 guidance. Leaders in the field also share best practices. There is an opportunity to ask questions if time allows.

To Participate on May 19:

Conference lines are limited; we encourage you to join via audio webcast
Or, call 833-614-0820; Access Passcode: 6477704

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Home health and hospice providers


COVID-19: Nursing Home Call — May 20

Wednesdays from 4:30 to 5 pm ET

These calls provide targeted updates on the agency’s latest COVID-19 guidance. Leaders in the field also share best practices. There is an opportunity to ask questions if time allows.

To Participate on May 20:

Conference lines are limited; we encourage you to join via audio webcast

Or, call 833-614-0820; Access Passcode: 4879622

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Nursing home providers


COVID-19: Dialysis Organization Call — May 20

Wednesdays from 5:30 to 6 pm ET

These calls provide targeted updates on the agency’s latest COVID-19 guidance. Leaders in the field also share best practices. There is an opportunity to ask questions if time allows.

To Participate on May 20:

Conference lines are limited; we encourage you to join via audio webcast

Or, call 833-614-0820; Access Passcode: 3287645

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Dialysis organizations


COVID-19: Nurses Call — May 21

Thursdays from 3 to 3:30 pm ET

These calls provide targeted updates on the agency’s latest COVID-19 guidance. Leaders in the field also share best practices. There is an opportunity to ask questions if time allows.

To Participate on May 21:

Conference lines are limited; we encourage you to join via audio webcast
Or, call 833-614-0820; Access Passcode: 2874976

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Nurses


COVID-19: Office Hours Call — May 21

Tuesdays and Thursdays from 5 to 6 pm ET

Hospitals, health systems, and providers: Ask CMS questions about our temporary actions that empower you to:

Increase hospital capacity – CMS Hospitals Without Walls
Rapidly expand the health care workforce
Put patients over paperwork
Promote telehealth

To Participate on May 21:

Conference lines are limited; we encourage you to join via audio webcast
Or, call 833-614-0820; Access Passcode: 9984433

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Physicians and other clinicians


COVID-19: Lessons from the Front Lines Call — May 22

Fridays from 12:30 to 2 pm ET

These weekly calls are a joint effort between CMS Administrator Seema Verma, Food and Drug Administration Commissioner Stephen Hahn, MD, and the White House Coronavirus Task Force. Physicians and other clinicians: Share your experience, ideas, strategies, and insights related to your COVID-19 response. There is an opportunity to ask questions.

To Participate on May 22:

Conference lines are limited; we encourage you to join via audio webcast
Or, call 877-251-0301; Access Code: 6086125

For More Information:

Coronavirus.gov
CMS Current Emergencies website
Podcast and Transcripts webpage: Audio recordings and transcripts

Target Audience: Physicians and other clinicians


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11791 – Therapy Codes Update
This article informs you of updates to the list of codes that sometimes or always describe therapy services. The additions to the therapy code list reflect those made in the Calendar Year 2020 for the COVID-19 Public Health Emergency. Please make sure your billing staffs are aware of these changes.
MM11778 – Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section
This article informs you that Medicare will remove section 20 (and all of its subsections) of the Medicare Claims Processing Manual (Identification of items or services related to the 2010 oil spill in the Gulf of Mexico). The key impact is that modifier CS is no longer to be used to denote services related to the 2010 oil spill.

May 15, 2020

Prior Authorization Program for Certain Hospital Outpatient Department Services Webinars

Novitas will be presenting a webinar on the prior authorization program being implemented by the Centers for Medicare & Medicaid Services (CMS) for certain hospital outpatient department (OPD) services on June 17, 2020, for dates of service on or after July 1, 2020. The webinar will be presented on Thursday, May 28, 2020, at 1:00 p.m. ET/12:00 p.m. ET and repeated on Thursday, June 11, 2020, at 10:00 a.m. ET/9:00 a.m. ET. If your facility bills these services, or you are a provider that performs these services on Medicare beneficiaries, join us for this webinar. We’ll review the guidelines for submitting a Prior Authorization Request (PAR) and the potential results and options available, with specialists present to answer questions relating to the process. To participate in this webinar, please visit our Learning Center to register (JH) (JL).

As a condition of payment for DOS on or after July 1, 2020, a Prior Authorization Request (PAR) is required for the following hospital OPD services:

Blepharoplasty, eyelid surgery, brow lift, and related services
Botulinum toxin injections
Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
Rhinoplasty and related services
Vein ablation and related services

Prior authorization (PA) program for certain hospital outpatient department (OPD) services - submitting the prior authorization request (PAR) 

The Centers for Medicare & Medicaid Services (CMS) is implementing a Prior Authorization (PA) program for certain hospital outpatient department (OPD) services effective June 17, 2020, for dates of service (DOS) on or after July 1, 2020, nationwide. The hospital OPD provider must submit the PAR to Novitas before the service is provided to the beneficiary and before the claim is submitted for processing.  The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules. Please review this article for additional information.


Proper Billing of Laboratory Tests

A new article has been added to the website.  Physicians who order or refer a laboratory test are not permitted to bill the Medicare program for the service they didn't perform.  Please review the article to ensure that services are billed correctly. 


May 14, 2020

CMS Provider Education Message:

MLN Connects® for Thursday, May 14, 2020

View this edition as PDF

News

IPPS and LTCH PPS: FY 2021 Proposed Rule
Medicare FFS 2nd Level Appeals: Submission Options

Events

COVID-19: Office Hours Call — May 14
COVID-19: Lessons from the Front Lines Call — May 15

MLN Matters® Articles

Medicare Clarifies Recognition of Interstate License Compacts
Extension of Payment for Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2020 Update
Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised

Publications

How to Use the Medicare Coverage Database — Revised

Medicare Administrative Contractors (MACs) will host a Multi-Jurisdictional Contractor Advisory Committee (CAC) Meeting regarding Facet Joint and Medial Nerve Branch Procedures on May 28, 2020, from 1-3 pm CST

The purpose of the meeting is to obtain advice from CAC members and subject matter experts (SMEs) regarding the strength of published evidence on Facet Joint and Medial Nerve Branch Procedures. In addition to discussion, the CAC and SME panel will vote on pre-distributed questions. The public is invited to attend as observers.

The meeting will be hosted by seven Medicare Administrative Contractors (MACs) and there will be a panel of experts discussing the Facet Joint and Medial Nerve Branch Procedures. CAC panels do not make coverage determinations, but MACs benefit from their advice.

The meeting agenda, bibliography, and voting questions are now available. Please refer to our Multi-Jurisdictional CAC website for additional information.

Teleconference/webinar link for registration hereExternal Website .


The following Billing and Coding Article has been revised:

Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11755 – National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)
This article informs you that the Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for cLBP effective for claims with dates of service on and after January 21, 2020. Note that CMS still determines that acupuncture for treatment of fibromyalgia or osteoarthritis is still not considered reasonable and necessary and remain non-covered by Medicare. Make sure your billing staffs are aware of these changes.

May 13, 2020

Special Edition – Tuesday, May 12, 2020

Provider Education Message:

COVID-19: Additional Waivers, Price Transparency, and CMS Letter to Nursing Homes

CMS Releases Additional Waivers for Hospitals and Other Facilities
Price Transparency: Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing
CMS Letter to Nursing Home Facility Management and Staff

CMS Releases Additional Waivers for Hospitals and Other Facilities

CMS continues to release waivers for the health care community that provide the flexibilities needed to take care of patients during the COVID-19 Public Health Emergency (PHE). CMS recently provided additional blanket waivers for the duration of the PHE that:

Expand hospitals’ ability to offer long-term care services (“swing beds”)

Waive distance requirements, market share, and bed requirements for Sole Community Hospitals

Waive certain eligibility requirements for Medicare-Dependent, Small Rural Hospitals (MDHs)

Update specific life safety code requirements for hospitals, hospice, and long-term care facilities

For more information, see Emergency Declaration Blanket Waivers.


Price Transparency: Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing

The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes a number of provisions to provide relief to the public from issues caused by the pandemic, including price transparency for COVID -19 testing. Section 3202(b) of the CARES Act requires providers of diagnostic tests for COVID-19 to post the cash price for a COVID-19 diagnostic test on their website from March 27 through the end of the public health emergency. For more information, see the FAQs.


CMS Letter to Nursing Home Facility Management and Staff

On May 11, CMS Administrator Seema Verma penned a letter to nursing home management and staff. Administrator Verma shared her gratitude for the unwavering dedication and commitment of nursing home management and staff in keeping residents safe and for continuing to compassionately care for those who rely on them during this unprecedented time. The letter also provides links to previously shared infection control resources.


Opioid Treatment Program (OTP) Frequently Asked Questions

Updated information has been added relating to COVID-19.  Please take some time to review the information. 


A/B MAC and DME MAC Collaborative Nebulizer Webinar

Do some of your patients require inhalation medication with a nebulizer?  The Provider Outreach and Education staff from your A/B and DME MACs has scheduled a national webinar to address Medicare’s coverage criteria and documentation requirements for medications and the related nebulizer equipment.  The webinar will take place at 2:00 PM Eastern (1:00 PM Central) on May 21, 2020.  The webinar moderators will leave time for your questions after the presentation portion of the webinar. 

Register today


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11650 – National Coverage Determination (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)
This article informs you that, for dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid Services will cover ABPM for the diagnosis of hypertension in Medicare beneficiaries under updated criteria.
MM11788 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2020 Update
This article informs you that the Centers for Medicare & Medicaid Services issued payment files to the Medicare administrative contractors based upon the 2020 MPFS Final Rule. Change request 11788 amends those payment files. Make sure your billing staffs are aware of these changes.

April 2020 Part B Newsletter

The April Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


May 12, 2020

A/B MAC and DME MAC Collaborative Nebulizer Webinar

Do some of your patients require inhalation medication with a nebulizer?  The Provider Outreach and Education staff from your A/B and DME MACs has scheduled a national webinar to address Medicare’s coverage criteria and documentation requirements for medications and the related nebulizer equipment.  The webinar will take place at 2:00 PM Eastern (1:00 PM Central) on May 21, 2020.  The webinar moderators will leave time for your questions after the presentation portion of the webinar. 

Register today!


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20017 – Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing
Pharmacies and other suppliers currently enrolled in Medicare may also enroll temporarily as independent clinical diagnostic laboratories during the COVID-19 public health emergency via the provider enrollment hotline. This will provide additional laboratory resources to meet the urgent need to increase COVID-19 testing capability. Pharmacies and other suppliers who are not currently enrolled in Medicare and want to enroll as an Independent Clinical Diagnostic Laboratory, must submit a CMS-855B enrollment application to the Medicare Administrative Contractor serving your geographic area.
MM11750 – New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services
This article informs you of new physician specialty codes for MDS (D7), and ACHD (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6). Make sure that your billing staffs are aware of these changes.

May 11, 2020

April 2020 top claim submission errors

The April 2020 Part B top claim submission errors and resolutions for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


May 8, 2020

Special Edition – Friday, May 8, 2020

Provider Education Message:

COVID-19: Nursing Home Reporting, Updated Telehealth Video, Pharmacies & Other Suppliers Can Enroll as Labs, IRF Flexibilities

New Guidance Available on Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes
Telehealth Video: Medicare Coverage and Payment of Virtual Services
Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing MLN Matters® Article
COVID-19: IRF Flexibilities During the PHE
COVID-19: IRF Interdisciplinary Team Meetings During the Pandemic

New Guidance Available on Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes

Nursing homes are now required to report the first week of COVID-19 data to the Centers for Disease Control and Prevention (CDC) beginning May 8 but no later than May 17. For the first time, all 15,000 nursing homes will be reporting this data directly to the CDC through its reporting tool. This reporting requirement is the first action of its kind in the agency’s history. On April 19, CMS announced the agency would be requiring facilities to report COVID-19 information to the CDC and to families. Within three weeks of that announcement, on April 30, CMS issued an Interim Final Rule with Comment Period with the new regulatory requirements. As nursing homes report this data to the CDC, we will be taking swift action and publicly posting this information so all Americans have access to accurate and timely information on COVID-19 in nursing homes.

CMS has a longstanding requirement for nursing homes to report cases of communicable diseases, such as COVID-19, to the appropriate state or local health department. This new requirement not only helps health departments intervene when needed but serves to provide awareness to the public (e.g., families) and surveillance for public health agencies and the CDC. The importance of ongoing transparency and information sharing has proven to be one of the keys to the battle against this pandemic. Building upon the successes of the Trump Administration prior to COVID-19, CMS has strongly supported transparency, such as the work done over the past several years to improve public access and understanding of nursing home inspection reports and expand the information available to consumers on Nursing Home Compare. The agency remains committed to greater transparency and plans to publicly release new data by the end of May. CMS will never stop working to give patients, residents, and families the clearest and most accurate information possible.

Guidance and Frequently Asked Questions


Telehealth Video: Medicare Coverage and Payment of Virtual Services

This updated video provides answers to common questions about the expanded Medicare telehealth services benefit under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.


Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing MLN Matters® Article

A new MLN Matters Special Edition Article SE20017 on Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing is available. Learn how to temporarily enroll to be an additional laboratory resource to meet the urgent need to increase COVID-19 testing capability.


COVID-19: IRF Flexibilities During the PHE

CMS is exercising regulatory flexibilities for Inpatient Rehabilitation Facilities (IRFs) during the COVID-19 Public Health Emergency (PHE) to waive the 60 percent rule.

We are also waiving IRF coverage and classification requirements if all of these criteria are satisfied:

Patient is admitted to a freestanding IRF to alleviate acute care hospital bed capacity issues
IRF is located in an area that is in Phase 1 or has not entered Phase 1; see Guidelines for Opening Up America Again

Add the following letters at the end of your unique hospital patient identification number (the number that identifies the patient’s medical record in the IRF) to identify patients eligible for each waiver:

D- 60 percent rule
DS- Coverage and classification requirements
DDS- Both 60 percent rule and coverage and classification requirements

For More Information:

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers: See page 10 for 60 percent rule
Interim Final Rule: Coverage and classification requirements

COVID-19: IRF Interdisciplinary Team Meetings During the Pandemic

CMS expects Inpatient Rehabilitation Facilities (IRFs) to hold in-person weekly interdisciplinary team meetings to discuss Medicare Part A fee-for-service patients. During the public health emergency, it may be safest to conduct meetings electronically. We will accept all appropriate forms of social distancing precautions.


May 7, 2020

CMS Provider Education Message:

More COVID-19 Updates

MLN Connects® for Thursday, May 7, 2020

View this edition as a PDF

News

CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes
Home Health Plans of Care: NPs, CNSs and PAs Allowed to Certify
Health Care Supply Chain, Provider Self-Care, and Emergency Preparedness Resources

Claims, Pricers & Codes

COVID-19: Modified Ordering Requirements for Laboratory Billing
Hospital OPPS: New Coronavirus Specimen Collection Code

Events

COVID-19: Office Hours Call — May 7
COVID-19: Lessons from the Front Lines Calls — May 8

MLN Matters® Articles

Addition of the QW modifier to Healthcare Common Procedure Coding System (HCPCS) code U0002 and 87635
Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan
New Codes for Therapist Assistants Providing Maintenance Programs in the Home Health Setting
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy — Revised

Publications

Evaluation and Management Services — Revised

The following Billing and Coding Article has been revised:

Billing and Coding: Services That Are Not Reasonable and Necessary (A56967)

April 2020 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

The April 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review.


May 6, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20008 – Medicare Clarifies Recognition of Interstate License Compacts
This MLN Matters article clarifies the Centers for Medicare & Medicaid Services recognition of interstate license compacts as valid and full licenses for purposes of meeting federal license requirements.

Revised:

MM11661 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update
The Centers for Medicare & Medicaid Services revised this article on May 4, 2020, to reflect the revised Change request (CR) 11661, issued on May 1, 2020, to revise the relative value units for codes 99441, 99442, and 99443, and add information for codes G2025 and G0071, listed in the CR attachment. The statement at the end of page 4 was updated. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

May 5, 2020

Limited systems availability

There will be a Common Working File "dark day" on May 8, 2020, to perform a history archive.

Due to this systems upgrade, Novitasphere portal, our interactive voice response unit, and customer service will have limited availability.

Customer service representatives will not be able to assist providers with the following:

Eligibility inquiries
Claim status inquiries related to eligibility
Claim denial inquiries related to eligibility

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11749 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2020 Update
Change request 11749 informs providers about updated ICD-10 conversions as well as coding updates specific to NCDs. Please make sure your billing staffs are aware of these updates.

May 1, 2020

Special Edition – Thursday, April 30, 2020

Provider Education Message:

COVID-19: Second Round of Sweeping Changes, RHC & FQHC Flexibilities, EMTALA

Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic
New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) MLN Matters Article
New Frequently Asked Questions on EMTALA

Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic

At President Trump’s direction, and building on its recent historic efforts to help the U.S. healthcare system manage the 2019 Novel Coronavirus (COVID-19) pandemic, on April 30, 2020, the Centers for Medicare & Medicaid Services, issued another round of sweeping regulatory waivers and rule changes to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system as America reopens. These changes include making it easier for Medicare and Medicaid beneficiaries to get tested for COVID-19 and continuing CMS’s efforts to further expand beneficiaries’ access to telehealth services.

Full press release


New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) MLN Matters Article

A revised MLN Matters Special Edition Article SE20016 on New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) is available. Learn new information on billing for distant site telehealth services during the COVID-19 PHE, including:

New telehealth services that can be provided by RHCs and FQHCs, including audio only telephone evaluation and management services
Revised bed count methodology for determining the exemption to the RHC payment limit for provider-based RHCs

New Frequently Asked Questions on EMTALA

CMS issued Frequently Asked Questions (FAQs) clarifying requirements and considerations for hospitals and other providers related to the Emergency Medical Treatment and Labor Act (EMTALA) during the COVID-19 pandemic. The FAQs address questions around patient presentation to the emergency department, EMTALA applicability across facility types, qualified medical professionals, medical screening exams, patient transfer and stabilization, telehealth, and other topics.

Frequently Asked Questions


Do you bill travel allowance for collection of specimens?

Medicare pays a specimen collection fee when it is medically necessary for a clinical laboratory technician to draw a specimen for a clinical diagnostic laboratory test. In addition, when a technician travels to a nursing facility or homebound patient and a specimen collection fee is payable.

Medicare provides for payment of a travel allowance “to cover the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect the sample.” Prior Office of Inspector General (OIG) work found that travel allowances have the potential to be overpaid when some clinical laboratories claimed travel mileage in excess of the actual miles traveled.

Please review the Travel allowance for collection of specimen article for complete information


April 30, 2020

CMS Provider Education Message:

COVID-19: Lessons from the Front Lines

MLN Connects® for Thursday, April 30, 2020

View this edition as a PDF

News

Infection Control Guidance to Home Health Agencies on COVID-19
Now Available: Nursing Home Five Star Quality Rating System Updates, Nursing Home Staff Counts, and Frequently Asked Questions
CMS Adds New COVID-19 Clinical Trials Improvement Activity to the Quality Payment Program
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

Home Health Claims: Correcting Recoding Errors

Events

COVID-19: Lessons from the Front Lines Calls — May 1 and 8
COVID-19: Home Health and Hospice Call — May 5
COVID-19: Office Hours Call — May 5
COVID-19: Nursing Homes Call — May 6

MLN Matters® Articles

July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer
Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits — Revised
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 Healthcare (CAQH) CORE — Revised

Publications

April 2020 Medicare Quarterly Provider Compliance Newsletter
Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants — Revised
Ambulatory Surgical Center Payment System — Revised
Dual Eligible Beneficiaries Under Medicare and Medicaid — Revised
Hospital Outpatient Prospective Payment System — Revised
How to Use the Searchable Medicare Physician Fee Schedule — Revised
Long-Term Care Hospital Prospective Payment System — Revised

Multimedia

Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training Course — Revised
Medicare Parts C and D General Compliance Training Web-Based Training Course — Revised

DME Specialty Page

A new article for Practitioners ordering Nebulizers and Inhalation Medication has been added. Please review at your leisure.


Online Registration Available for May 15, 2020, Open Meeting and Proposed LCD Now Posted

Online registration for the May 15, 2020, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, May 13, 2020. IMPORTANT: During this unprecedented time, our Open Meeting will be held via teleconference only. The Novitas Solutions Proposed Local Coverage Determination (LCD) is now posted.

Open Meetings are to allow interested parties the opportunity to make presentations of information and offer comments related to new Proposed LCDs and/or the revised portion of a Proposed LCD that are in the 45-day open comment period. Interested parties may also request to attend as an observer. If you are interested in attending as a presenter or observer, please view our Proposed Local Coverage Determination Open Meetings page for specific guidelines and other helpful information.


New codes for laboratory tests for the novel coronavirus (COVID-19)

Allowances are now available for new codes for COVID-19 testing.


The following Proposed Local Coverage Determination (LCD) has been posted for comments. The comment period will end on June 13, 2020, however you are encouraged to submit your comments as soon as possible to allow ample time for us to review them thoroughly.

Implantable Continuous Glucose Monitors (I-CGM) (DL38617)
Submit Comments

The following Draft Billing and Coding Article is related to the above Proposed LCD.

Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58110)

The following LCD has been revised:

Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (L34977)

The following Billing and Coding Articles have been revised:

Billing and Coding: Allergy Testing (A56558)
Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56633)

April 29, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11765 – Addition of the QW modifier to Healthcare Common Procedure Coding System (HCPCS) code U0002 and 87635
This article informs you about the addition of the QW modifier to HCPCS code U0002 (2019- nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC) and 87635 [Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique]. Medicare will permit the use of codes U0002QW and 87635QW for claims submitted by facilities with a valid, current Clinical Laboratory Improvement Amendments certificate of waiver with dates of service on or after March 20, 2020. Make sure your billing staffs are aware of these changes.

April 28, 2020

Tips on How to avoid billing a duplicate claim

Do you often received duplicate denials?  Review our revised article for the most current tips on avoiding duplicate denials. 


April 27, 2020

Special Edition – Monday, April 27, 2020

Provider Education Message:

CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments.

CMS had expanded these temporary loan programs to ensure providers and suppliers had the resources needed to combat the beginning stages of the 2019 Novel Coronavirus (COVID-19). Funding will continue to be available to hospitals and other health care providers on the front lines of the coronavirus response primarily from the Provider Relief Fund. The Accelerated and Advance Payment (AAP) Programs are typically used to give providers emergency funding and address cash flow issues for providers and suppliers when there is disruption in claims submission or claims processing, including during a public health emergency or Presidentially-declared disaster.

Since expanding the AAP programs on March 28, 2020, CMS approved over 21,000 applications totaling $59.6 billion in payments to Part A providers, which includes hospitals. For Part B suppliers, including doctors, non-physician practitioners and durable medical equipment suppliers, CMS approved almost 24,000 applications advancing $40.4 billion in payments. The AAP programs are not a grant, and providers and suppliers are typically required to pay back the funding within one year, or less, depending on provider or supplier type. Beginning today, CMS will not be accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.

Significant additional funding will continue to be available to hospitals and other health care providers through other programs. Congress appropriated $100 billion in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (PL 116-136) and $75 billion through the Paycheck Protection Program and Health Care Enhancement Act (PL 116-139) for health care providers. HHS is distributing this money through the Provider Relief Fund, and these payments do not need to be repaid.

The CARES Act Provider Relief Fund is being administered through HHS and has already released $30 billion to providers and is in the process of releasing an additional $20 billion, with more funding anticipated to be released soon. This funding will be used to support health care-related expenses or lost revenue attributable to the COVID-19 pandemic and to ensure uninsured Americans can get treatment for COVID-19.

For more information on the CARES Act Provider Relief Fund and how to apply, visit: hhs.gov/providerrelief.

For an updated fact sheet on the Accelerated and Advance Payment Programs, visit: https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11490 – 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 Healthcare (CAQH) CORE
The Centers for Medicare & Medicare Services revised this article on April 23, 2020, to reflect the revised change request (CR)11490 issued on April 23, 2020. The CR revision updated the Washington Publishing Company website address and the same change is made to this article. In the article, we also revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

April 23, 2020

CMS Provider Education Message:

Report Clinical Trial  Data to Fight COVID-19 & Earn MIPS Credit

MLN Connects® for Thursday, April 23, 2020

View this edition as a PDF

News

Trump Administration Champions Reporting of COVID-19 Clinical Trial Data through Quality Payment Program, Announces New Clinical Trials Improvement Activity
CMS Releases Additional Blanket Waivers for Long-Term Care Hospitals, Rural Health Clinics, Federally Qualified Health Centers and Intermediate Care Facilities
IRF PPS FY 2021 Proposed Rule
Bill Correctly for Inhalant Drugs

Events

Ground Ambulance Organizations: Data Collection for Medicare Providers Call — May 7

MLN Matters® Articles

New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)
New Waived Tests
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1 — Revised
April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update — Revised
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update — Revised

Publications

Provider Compliance Tips for Nebulizers and Related Drugs Fact Sheet — Revised

Multimedia

Medicare Home Health Benefit Web-Based Training Course — Revised

The following Local Coverage Article has been revised. Due to the current public health emergency the effective date for the addition of Tremfya® (J1628) and Stelara® (J3357) will be deferred until 45 days after the public health emergency ends. Please continue to watch our website for updates.

Self-Administered Drug Exclusion List (A53127)

The Reopening Gateway is available!

The Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process. For those offices working alternate schedules or working remotely due to COVID-19, the Reopening Gateway offers a quick and easy way to update claim data through the internet.

The application is designed to be used in conjunction with the Medicare Remittance Advice, since protected health information will not be retrieved and displayed from the Medicare processing systems. The Reopening Gateway offers a convenient solution to providers, billing services and clearinghouses to correct and reprocess claims.


April 21, 2020

Proper Billing for Inhalation Drugs

The Provider Compliance Tips for Nebulizers and Related Drugs fact sheet has been revised.


April 20, 2020

Special Edition – Monday, April 20, 2020

Provider Education Message:

COVID-19: Nursing Home Transparency, Recommendations for Areas with Low Incidence of Disease

Trump Administration Announces New Nursing Homes COVID-19 Transparency Effort
CMS Issues Recommendations to Re-Open Health Care Systems in Areas with Low Incidence of COVID-19

Trump Administration Announces New Nursing Homes COVID-19 Transparency Effort

Agencies partner with nursing homes to keep nursing home residents safe

On April 19, under the leadership of President Trump, the Centers for Medicare & Medicaid Services (CMS) announced new regulatory requirements that will require nursing homes to inform residents, their families, and representatives of COVID-19 cases in their facilities. In addition, as part of President Trump’s Opening Up America, CMS will now require nursing homes to report cases of COVID-19 directly to the Centers for Disease Control and Prevention (CDC). This information must be reported in accordance with existing privacy regulations and statute. This measure augments longstanding requirements for reporting infectious disease to state and local health departments. Finally, CMS will also require nursing homes to fully cooperate with CDC surveillance efforts around COVID-19 spread.

CDC will be providing a reporting tool to nursing homes that will support federal efforts to collect nationwide data to assist in COVID-19 surveillance and response. This joint effort is a result of the CMS-CDC Work Group on Nursing Home Safety. CMS plans to make the data publicly available. This effort builds on recent recommendations from the American Health Care Association and Leading Age, two large nursing home industry associations, that nursing homes quickly report COVID-19 cases.

This data sharing project is only the most recent in the Trump Administration’s rapid and aggressive response to the COVID-19 pandemic. More details are available in the Press Release and Guidance Memo


CMS Issues Recommendations to Re-Open Health Care Systems in Areas with Low Incidence of COVID-19

On April 19, the Centers for Medicare & Medicaid Services issued new recommendations specifically targeted to communities that are in Phase 1 of the Guidelines for President Trump’s Opening Up America Again with low incidence or relatively low and stable incidence of COVID-19 cases. The recommendations update earlier guidance provided by CMS on limiting non-essential surgeries and medical procedures. The new CMS guidelines recommend a gradual transition and encourage health care providers to coordinate with local and state public health officials and to review the availability of Personal Protective Equipment (PPE) and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to re-start or increase in-person care.

The new recommendations can be found here: https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

The Guidelines for Opening Up America Again can be found here: https://www.whitehouse.gov/openingamerica/#criteria


Frequently Asked Questions (FAQs)

Have questions and not sure where to turn? Check out our FAQs for answers to your questions.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11747 - New Waived Tests
Change request 11747 informs Medicare administrative contractors (MACs) of new Clinical Laboratory Improvement Amendments of 1988 waived tests approved by the Food and Drug Administration. Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services must notify its MACs of the new tests so that they can accurately process claims. Make sure your billing staffs are aware of these newly added waived complexity tests.

Revised:

MM11489 - Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
The Centers for Medicare & Medicaid Services revised this article on April 16, 2020, to reflect an updated change request (CR) 11489 that revised the Washington Publishing Company website address in the background section of the CR (page 2 in this article). All other information remains the same.

April 17, 2020

Special Edition - Wednesday, April 17, 2020

Provider Education Message:

COVID-19: RHC & FQHC Flexibilities, Increased Payment for Lab Tests, Hospital Waivers, Call Audio and Transcript

RHC & FQHC Flexibilities During COVID-19 Public Health Emergency
CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests
CMS Implements CARES Act Hospital Payment and Inpatient Rehabilitation Facility Waivers
COVID-19 Call: Audio Recording and Transcript

RHC & FQHC Flexibilities During COVID-19 Public Health Emergency

To support Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and their patients, Congress and CMS made changes to requirements and payments during the COVID-19 Public Health Emergency. See MLN Matters Special Edition Article 20016 to learn about:

New payment for telehealth services, including how to bill Medicare
Expansion of virtual communication services
Revision of home health agency shortage requirement for visiting nursing services
Consent for care management and virtual communication services
Accelerated/advance payments

CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests

CMS announced that Medicare will nearly double payment for certain lab tests that use high-throughput technologies to rapidly diagnose large numbers of COVID-19 cases. This is another action the Trump Administration is taking to rapidly expand COVID-19 testing. Along with the March 30 announcement that Medicare will pay new specimen collection fees for COVID-19 testing, CMS’s actions will expand capability to test more vulnerable populations, like nursing home patients, quickly and provide results faster. Medicare will pay laboratories for the tests at $100 effective April 14, 2020, through the duration of the COVID-19 national emergency. 

Press Release

CMS Implements CARES Act Hospital Payment and Inpatient Rehabilitation Facility Waivers

The Coronavirus Aid, Relief, and Economic Security (CARES) Act increases payment for Inpatient Prospective Payment System (IPPS) and long-term care hospital (LTCH) inpatient hospital care attributable to COVID-19. CMS provided guidance for IPPS hospitals and LTCHs on how to code claims to receive the higher payment.

The CARES Act also waives the requirement that Medicare Part A fee-for-service patients treated in inpatient rehabilitation facilities receive at least 15 hours of therapy per week.

MLN Matters Article
Emergency Declaration Waivers Summary

COVID-19 Call: Audio Recording and Transcript

An audio recording and transcript are available for the April 7 Medicare Learning Network call on 2019 Novel Coronavirus (COVID-19) Updates. Learn about CMS waivers and COVID-19 response.


Coronavirus disease 2019 (COVID-19): Telehealth and telephone-only services during the emergency

A new article was developed to assist providers with telehealth and telephone services during the emergency. Please review the article to ensure you are keeping up to date with the most current information.


Postponed - Revision of local coverage article A53127 self-administered drug (SAD) exclusion list

Novitas will postpone the May 3, 2020, implementation of Local Coverage Article A53127 Self-Administered Drug Exclusion List due to the COVID-19 Public Health Emergency. The Article will not become effective until after the end of the Public Health Emergency and receipt of CMS technical direction for resuming normal operations.

The effective date for the inclusion of Guselkumab (Tremfya®) (J1628) and Ustekinumab (Stelara®) (J3357) to the SAD exclusion list will be deferred 45 days after the public health emergency ends.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11638 - Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
The Centers for Medicare & Medicaid Services revised this article on April 16, 2020, to reflect an updated Change request (CR) 11638 that revised the Washington Publishing Company website address in the background section of the CR (page 2 in this article). All other information remains the same.

April 16, 2020

CMS Provider Education Message:

3 Proposed Payment Rules

MLN Connects® for Thursday, April 16, 2020

View this edition as a PDF


News

Hospice Payment Rate Update Proposed Rule for FY 2021
IPF Prospective Payment System Proposed Rule for FY 2021
SNF Proposed Payment and Policy Changes for FY 2021

Events

Ground Ambulance Organizations: Data Collection for Medicare Providers Call — May 7

MLN Matters® Articles

April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Quarterly Update to the Fiscal Year 2020 Inpatient Psychiatric Facilities Pricer
Claim Status Category and Claim Status Codes Update — Revised
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Publications

Inpatient Rehabilitation Facility Prospective Payment System — Revised
Medicare Overpayments — Revised
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services— Revised

Multimedia

Medicare Fraud & Abuse: Prevent, Detect, and Report Web-Based Training Course — Revised
Medicare Part C and Part D Data Validation Web-Based Training Course — Revised

The following Local Coverage Determination and related Billing and Coding Article have been revised:

Services That Are Not Reasonable and Necessary (L35094)
Billing and Coding: Services That Are Not Reasonable and Necessary (A56967)

April 15, 2020

Special Edition – Wednesday, April 15, 2020

Provider Education Message:

COVID-19: Reprocessing Hospital Claims, Essential Diagnostic Services, Non-Invasive Ventilators

IPPS Hospitals, LTCHs: Reprocessing Claims for CARES Act
Trump Administration Announces Expanded Coverage for Essential Diagnostic Services Amid COVID-19 Public Health Emergency
Removal of Non-Invasive Ventilator Product Category from DMEPOS Competitive Bidding Program

IPPS Hospitals, LTCHs: Reprocessing Claims for CARES Act

CMS is implementing changes to increase payments to Inpatient Prospective Payment System (IPPS) hospitals and Long-Term Care Hospitals (LTCHs) under Sections 3710 and 3711 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. When you submit an IPPS claim for discharges on or after January 27, 2020, or an LTCH claim for admissions on or after January 27, 2020, and we receive it:

April 20, 2020, and earlier, Medicare will reprocess. You do not need to take any action.
On or after April 21, 2020, Medicare will process in accordance with the CARES Act.

For more information, see MLN Matters Special Edition Article SE20015.


Trump Administration Announces Expanded Coverage for Essential Diagnostic Services Amid COVID-19 Public Health Emergency

CMS, together with the Departments of Labor and the Treasury, issued guidance to ensure Americans with private health insurance have coverage of COVID-19 diagnostic testing and certain other related services, including antibody testing, at no cost. This includes urgent care visits, emergency room visits, and in-person or telehealth visits to the doctor’s office that result in an order for or administration of a COVID-19 test. As part of the effort to slow the spread of the virus, this guidance is another action the Trump Administration is taking to remove financial barriers for Americans to receive necessary COVID-19 tests and health services, as well as encourage the use of antibody testing that may help to enable health care workers and other Americans to get back to work more quickly.

Press Release
Guidance


Removal of Non-Invasive Ventilator Product Category from DMEPOS Competitive Bidding Program

CMS is removing the non-invasive ventilator (NIV) product category from Round 2021 of the DMEPOS Competitive Bidding Program due to the novel COVID-19 pandemic, the President’s exercise of the Defense Production Act, public concern regarding access to ventilators, and the NIV product category being new to the DMEPOS Competitive Bidding Program.

DME Competitive Bidding Program


March 2020 Part B Newsletter

The March Part B monthly newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11694 - April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
The Centers for Medicare & Medicaid Services revised this article on April 14, 2020, due to a revised change request (CR) 11694 that added information on Q4206 to the policy section of the CR (page 6 in this article). All other information remains the same.
MM11661 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update
The Centers for Medicare & Medicaid Services revised this article to reflect the revised change request (CR) 11661, issued on April 6, to make MPFSDB file revisions for COVID-19. In the article, we added updates for codes G2023, G2024, 87635, 98966, 98967, 98968, 99441, 99442, and 99443 to the April 2020 MPFSDB update file. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

April 14, 2020

March 2020 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

The March 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed for February 2020. Please take time to review.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11467 – Claim Status Category and Claim Status Codes Update
The Centers for Medicare & Medicaid Services revised this article on April 10, 2020, to reflect a revised Change Request (CR) 11467. CR 11467 was revised to update the uniform resource locators' references (page 2 in this article) in the background section of the CR. The CR release date, transmittal number and link to the transmittal were also changed. All other information remains the same. All other information remains the same.
SE20011 – Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
The Centers for Medicare & Medicaid Services revised this article on April 10, 2020, to link to all the blanket waivers related to COVID-19 , provide place of service coding guidance for telehealth claims, link to the Telehealth Video for COVID-19, add information on the waiver of coinsurance and deductibles for certain testing and related services, add information on the expanded use of ambulance origin/destination modifiers, provide new specimen collection codes for clinical diagnostic laboratories billing, and add guidance regarding delivering notices to beneficiaries. All other information is the same.

March 2020 top claim submission errors

The March 2020 Part B top claim submission errors and resolutions for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


April 13, 2020

Invoice no longer required

To reduce provider burden, Novitas is implementing a new process for certain Heatlhcare Common Procedure Coding System (HCPCS) codes for Part B. This process allows the provider to enter the invoice information in the narrative field (or Block 19) on a claim.


April 10, 2020

Special Edition – Friday, April 10, 2020

Provider Education Message:

COVID-19: Infection Control, Maximizing Workforce, Updated Q&A, CS Modifier for Cost-Sharing, Payment Adjustment Suspended

CMS Issues New Wave of Infection Control Guidance to Protect Patients and Healthcare Workers from COVID-19
Trump Administration Acts to Ensure U.S. Healthcare Facilities Can Maximize Frontline Workforces to Confront COVID-19 Crisis
Updated Questions and Answers on COVID-19
Using CS Modifier When Cost-Sharing is Waived
Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)

CMS Issues New Wave of Infection Control Guidance to Protect Patients and Healthcare Workers from COVID-19

CMS issued a series of updated guidance documents focused on infection control to prevent the spread of the 2019 Novel Coronavirus (COVID-19) in a variety of inpatient and outpatient care settings. The guidance, based on Centers for Disease Control and Prevention (CDC) guidelines, will help ensure infection control in the context of patient triage, screening and treatment, the use of alternate testing and treatment sites and telehealth, drive-through screenings, limiting visitations, cleaning and disinfection guidelines, staffing, and more.

 Press Release


Trump Administration Acts to Ensure U.S. Healthcare Facilities Can Maximize Frontline Workforces to Confront COVID-19 Crisis

At President Trump’s direction, the Centers for Medicare & Medicaid Services (CMS) today temporarily suspended a number of rules so that hospitals, clinics, and other healthcare facilities can boost their frontline medical staffs as they fight to save lives during the 2019 Novel Coronavirus (COVID-19) pandemic.

These changes affect doctors, nurses, and other clinicians nationwide, and focus on reducing supervision and certification requirements so that practitioners can be hired quickly and perform work to the fullest extent of their licenses. The new waivers sharply expand the workforce flexibilities CMS announced on March 30.

For a fact sheet detailing additional information on the waivers announced today and previously, go to: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf


Updated Questions and Answers on COVID-19

Review CMS’ updated FAQs to equip the American health care system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. Check this resource often as CMS updates it on a regular basis - we insert the date at the end of each FAQ when it is new or updated.


Using CS Modifier When Cost-Sharing is Waived

This clarifies a prior message that appeared in our April 7, 2020 Special Edition.

CMS now waives cost-sharing (coinsurance and deductible amounts) under Medicare Part B for Medicare patients for certain COVID-19 testing-related services.  Previously, CMS made available the CS modifier for the gulf oil spill in 2010; however, CMS recently repurposed the CS modifier for COVID-19 purposes. Now, for services furnished on March 18, 2020, and through the end of the Public Health Emergency, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under specific payment systems outlined in the April 7 message should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services and to get 100% of the Medicare-approved amount.  Additionally, they should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.


Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)

Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.


April 9, 2020

CMS Provider Education Message:

Important COVID-19 Updates

MLN Connects® for Thursday, April 9, 2020

View this edition as a PDF

News

CMS Approves Approximately $34 Billion for Providers with the Accelerated/Advance Payment Program for Medicare Providers in One Week
COVID-19: Dear Clinician Letter
COVID-19: Non-Emergent, Elective Medical Services and Treatment Recommendations
Quality Payment Program: MIPS Extreme and Uncontrollable Circumstances Policy in Response to COVID-19
Multi-Factor Authentication Requirement Delayed for PECOS, I&A, and NPPES
Open Payments: Pre-Publication Review and Dispute through May 15

Claims, Pricers & Codes

Pneumococcal Pneumonia Vaccination: Eligibility Transactions Includes DOS Starting April 13

Events

Ground Ambulance Organizations: Data Collection for Medicare Providers Call — May 7

MLN Matters® Articles

Supplier Education on Use of Upgrades for Multi-Function Ventilators
Second Update to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised

Publications

Civil Rights, HIPAA, and COVID-19
Medicare Advance Written Notices of Noncoverage — Revised
Medicare Preventive Services — Revised
Medicare Preventive Services Poster — Revised

The following Local Coverage Determination (LCD) posted for comment on October 31, 2019 has been posted for notice. The LCD and related Billing and Coding Article will become effective May 24, 2020:

Thrombolytic Agents (L35428)
Billing and Coding: Thrombolytic Agents (A55237)

The following Response to Comments Article contains summaries of all comments received and Novitas’ responses:

Response to Comments: Thrombolytic Agents (A58012)

The following Billing and Coding Articles have been revised:

Billing and Coding: Implantable Automatic Defibrillators (A56355)
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)

Medicare Administrative Contractors (MACs) will host a Multi-Jurisdictional Contractor Advisory Committee (CAC) Meeting regarding Facet Joint and Medial Nerve Branch Procedures on May 28, 2020, from 1-3 pm CST

The purpose of the meeting is to obtain advice from CAC members and subject matter experts (SMEs) regarding the strength of published evidence on Facet Joint and Medial Nerve Branch Procedures. In addition to discussion, the CAC and SME panel will vote on pre-distributed questions. The public is invited to attend as observers.

The meeting will be hosted by seven Medicare Administrative Contractors (MACs) and there will be a panel of experts discussing the Facet Joint and Medial Nerve Branch Procedures. CAC panels do not make coverage determinations, but MACs benefit from their advice.

Complete details will be available by May 14th, 2020 (background material, questions, agenda, time, and place). Teleconference/webinar link for registration hereExternal Website .

Please refer to our Multi-Jurisdictional CAC website for additional information.


April 8, 2020

Quarterly update to the Medicare physician fee schedule database (MPFSDB) - April 2020

The April 2020 quarterly update to the MPFSDB is now available. Certain codes have been revised for January 21, 2020 and March 1, 2020


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11681 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
The Centers for Medicare & Medicaid Services revised this article on April 6, 2020, to reflect revisions to Change request (CR) 11681. The CR revisions added code 87635 to the healthcare common procedure coding system file, effective March 13, 2020, added two new COVID-19 test codes (G2023 and G2024), effective March 1, 2020, and removed the section on the delay of the clinical laboratory fee schedule reporting period. This revised article reflects these revisions. Also, in the article, we revised the CR release date, transmittal number and the web address of the CR. All other information remains the same.

April 7, 2020

Special Edition – Tuesday, April 7, 2020

Provider Education Message:

COVID-19: Telehealth Video, Coinsurance and Deductible Waived, ASC Attestations, Ambulance Modifiers, Lessons From Front Lines, MLN Call Today

New Video Available on Medicare Coverage and Payment of Virtual Services

Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services

Guidance for Processing Attestations from Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals during the COVID-19 Public Health Emergency

COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers

Lessons from The Front Lines: COVID-19

CMS COVID-19 Update Call Today.


New Video Available on Medicare Coverage and Payment of Virtual Services

CMS released a video providing answers to common questions about the Medicare telehealth services benefit. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

Video


Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services

The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services. These services are medical visits for the HCPCS evaluation and management categories described below when an outpatient provider, physician, or other providers and suppliers that bill Medicare for Part B services orders or administers COVID-19 lab test U0001, U0002, or 87635.

Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes:

Office and other outpatient services
Hospital observation services
Emergency department services
Nursing facility services
Domiciliary, rest home, or custodial care services
Home services
Online digital evaluation and management services

Cost-sharing does not apply to the above medical visit services for which payment is made to: 

Hospital Outpatient Departments paid under the Outpatient Prospective Payment System
Physicians and other professionals under the Physician Fee Schedule
Critical Access Hospitals (CAHs)
Rural Health Clinics (RHCs)
Federally Qualified Health Centers (FQHCs)

For services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.

For professional claims, physicians and practitioners who did not initially submit claims with the CS modifier must notify their Medicare Administrative Contractor (MAC) and request to resubmit applicable claims with dates of service on or after 3/18/2020 with the CS modifier to get 100% payment. 

For institutional claims, providers, including hospitals, CAHs, RHCs, and FQHCs, who did not initially submit claims with the CS modifier must resubmit applicable claims submitted on or after 3/18/2020, with the CS modifier to visit lines to get 100% payment.

Additional CMS actions in response to COVID-19, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.


Guidance for Processing Attestations from Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals during the COVID-19 Public Health Emergency

CMS is providing needed flexibility to hospitals to ensure they have the ability to expand capacity and to treat patients during the COVID-19 public health emergency. As part of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers CMS is allowing Medicare-enrolled ASCs to temporarily enroll as hospitals and to provide hospital services to help address the urgent need to increase hospital capacity to take care of patients.

 

Guidance

https://content.govdelivery.com/attachments/fancy_images/USCMS/2014/03/274725/blank-box-15px_original.jpg


COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers

During the COVID-19 Public Health Emergency, Medicare will cover a medically necessary emergency and non-emergency ground ambulance transportation from any point of origin to a destination that is equipped to treat the condition of the patient consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished. On an interim basis, we are expanding the list of destinations that may include but are not limited to:

Any location that is an alternative site determined to be part of a hospital, Critical Access Hospital (CAH), or Skilled Nursing Facility (SNF)
Community mental health centers
Federally Qualified Health Centers (FQHCs)
Rural health clinics (RHCs)
Physicians’ offices
Urgent care facilities
Ambulatory Surgery Centers (ASCs)
Any location furnishing dialysis services outside of an End-Stage Renal Disease (ESRD) facility when an ESRD facility is not available
Beneficiary’s home

CMS expanded the descriptions for these origin and destination claim modifiers to account for the new covered locations:

Modifier D - Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility
Modifier E – Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the beneficiary’s home
Modifier H - Alternative care site for hospital, including CAH, provider-based ASC, or freestanding emergency center
Modifier N - Alternative care site for SNF
Modifier P - Physician’s office
Modifier R - Beneficiary’s home

For the complete list of ambulance origin and destination claim modifiers see Medicare Claims Processing Manual Chapter 15, Section 30 A.


Lessons from The Front Lines: COVID-19

On April 3, CMS Administrator Seema Verma, Deborah Birx, MD, White House Coronavirus Task Force, and officials from the FDA, CDC, and FEMA participated in a call on COVID-19 Flexibilities. Several physician guests on the front lines presented best practices from their COVID-19 experiences. You can listen to the conversation here.

CMS COVID-19 Update Call Today

Tuesday, April 7 from 2 to 3 pm ET

Register for Medicare Learning Network events. Registration closes at 12pm ET.

CMS update on recent actions taken to address the COVID-19 public health emergency.

Target Audience: All Medicare fee-for-service providers and interested stakeholders.


April 6, 2020

Call centers closed Friday, April 10, 2020

Please note that due to the holiday, our offices and call centers will be closed Friday, April 10, 2020. We will reopen Monday, April 13, 2020.


April 3, 2020

Special Edition – Friday, April 3, 2020

Provider Education Message:

COVID-19: Telehealth Billing Correction, Nursing Home Recommendations, Billing for Multi-Function Ventilators, New ICD-10-CM Diagnosis Code

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency — Revised
Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments
Billing for Multi-Function Ventilators (HCPCS Code E0467) under the COVID-19 Public Health Emergency and Otherwise
New ICD-10-CM diagnosis code, U07.1, for COVID-19

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency — Revised

This corrects a prior message that appeared in our March 31, 2020 Special Edition.

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with:

Place of Service (POS) equal to what it would have been had the service been furnished in-person
Modifier 95, indicating that the service rendered was actually performed via telehealth

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier
Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.


Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments

On April 3, at the direction of President Trump, the Centers for Medicare & Medicaid Services (CMS), in consultation with the Centers for Disease Control and Prevention (CDC), issued critical recommendations to state and local governments, as well as nursing homes, to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19) in nursing homes. The recommendations build on and strengthen recent guidance from CMS and CDC related to effective implementation of longstanding infection control procedures.

Press Release

Guidance


Billing for Multi-Function Ventilators (HCPCS Code E0467) under the COVID-19 Public Health Emergency and Otherwise

CMS recognizes that in these important times, in particular, beneficiaries, health care clinicians, suppliers, and manufacturers are looking for the broadest possible access to ventilators for their care needs.  We are taking a number of steps to increase access to and remind suppliers about certain options available to them and beneficiaries regarding multi-function ventilators.

Effective immediately, CMS is suspending claims editing for multi-function ventilators when there are claims for separate devices in history that have not met their reasonable useful lifetime.   

For more information on multi-function ventilators, see MLN Matters Special Edition Article SE20012.

New ICD-10-CM diagnosis code, U07.1, for COVID-19

In response to the national emergency that was declared concerning the COVID-19 outbreak, a new diagnosis code, U07.1, COVID-19, has been implemented, effective April 1, 2020. 

As a result, an updated ICD-10 MS-DRG GROUPER software package to accommodate the new ICD-10-CM diagnosis code, U07.1, COVID-19, effective with discharges on and after April 1, 2020, is available on the CMS MS-DRG Classifications and Software webpage. 

This updated GROUPER software package (V37.1 R1) replaces the GROUPER software package V37.1 that was developed in response to the new ICD-10-CM diagnosis code U07.0, Vaping-related disorder, also effective with discharges on and after April 1, 2020, that is currently available on the MS-DRG Classifications and Software webpage.

Providers should use this new code, U07.1, where appropriate, for discharges on or after April 1, 2020.  Refer to the updated MLN Matters Articles for additional Medicare Fee-For-Service information:

Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder and 2019 Novel Coronavirus (COVID-19)
Update to the Home Health Grouper for New Diagnosis Codes for Vaping Related Disorder and COVID-19
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1 R1

For detailed information regarding the assignment of new diagnosis code U07.1, COVID-19, under the ICD-10 MS-DRGs, visit the MS-DRG Classifications and Software webpage. The announcement is located under the “Latest News” heading.  

For additional information related to the new COVID-19 diagnosis code, visit the CDC website.


April 2, 2020

CMS Provider Education Message:

Interoperability and Patient Access Final Rule Call — April 7

MLN Connects® for Thursday, April 2, 2020

View this edition as a PDF

News

IRF Provider Preview Reports: Review Your Data by April 13
LTCH Provider Preview Reports: Review Your Data by April 13
Hospice Provider Preview Reports: Review Your Data by April 13

Events

Interoperability and Patient Access Final Rule Call — April 7

MLN Matters® Articles

July 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2020
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations – Update — Revised
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020 — Revised

Publications

MLN Catalog – April 2020 Edition

Multimedia

Open Payments Call: Audio Recording and Transcript

Explore Telehealth Service Expansion During the Coronavirus Public Health Emergency Webinar, April 9, 2020

Join us for a combined Part A/B webinar Explore Telehealth Service Expansion During the Coronavirus Public Health Emergency being held Thursday, April 9, 2020, at 10:00 a.m. ET/9:00 a.m. CT. This webinar will address the latest information regarding telehealth coverage expansion specifically related to the COVID-19 pandemic and review waivers to telehealth requirements issued under the Public Health Emergency declaration. Providers should be aware that Novitas may not be able to address all questions on this topic during the webinar; however, we will gather questions requiring further research and clarification following the webinar and distribute responses via our website as more information becomes available.  Access our educational events calendar to register.


March 31, 2020

Special Edition – Tuesday, March 31, 2020

Provider Education Message:

COVID-19: Regulatory Changes, Telehealth Billing, and Specimen Collection Codes

Trump Administration Makes Sweeping Regulatory Changes to Help U.S. Health Care System Address COVID-19 Patient Surge
Billing for Professional Telehealth Services During the Public Health Emergency
New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing

Trump Administration Makes Sweeping Regulatory Changes to Help U.S. Health Care System Address COVID-19 Patient Surge

At President Trump’s direction, the Centers for Medicare & Medicaid Services (CMS) issued an unprecedented array of temporary regulatory waivers and new rules to equip the American health care system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. CMS sets and enforces essential quality and safety standards for the nation’s health care system and is the nation’s largest health insurer serving more than 140 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program, and Federal Exchanges.

Made possible by President Trump’s recent emergency declaration and emergency rule making, these temporary changes will apply immediately across the entire U.S. health care system for the duration of the emergency declaration. This allows hospitals and health systems to deliver services at other locations to make room for COVID-19 patients needing acute care in their main facility.

The changes complement and augment the work of FEMA and state and local public health authorities by empowering local hospitals and health care systems to rapidly expand treatment capacity that allows them to separate patients infected with COVID-19 from those who are not affected. CMS’s waivers and flexibilities will permit hospitals and health care systems to expand capacity by triaging patients to a variety of community-based locales, including ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories. Transferring uninfected patients will help hospital staffs to focus on the most critical COVID-19 patients, maintain infection control protocols, and conserve Personal Protective Equipment (PPE).

“Every day, heroic nurses, doctors, and other health care workers are dedicating long hours to their patients. This means sacrificing time with their families and risking their very lives to care for coronavirus patients,” said CMS Administrator Seema Verma. “Front line health care providers need to be able to focus on patient care in the most flexible and innovative ways possible. This unprecedented temporary relaxation in regulation will help the health care system deal with patient surges by giving it tools and support to create non-traditional care sites and staff them quickly.”

CMS’s announcement will also waive certain requirements to enable and encourage hospitals to hire local physicians and other providers to address potential surges. New rules allow hospitals to support physician practices by transferring critical equipment, including items used for telehealth, as well as providing meals and childcare for their health care workers.

Other temporary CMS waivers and rule changes dramatically lessen administrative burdens, knowing that front line providers will be operating with high volumes and under extraordinary system stresses.

CMS recently approved hundreds of waiver requests from health care providers, state governments, and state hospital associations in the following states: Ohio, Tennessee, Virginia, Missouri, Michigan, New Hampshire, Oregon, California, Washington, Illinois, Iowa, South Dakota, Texas, New Jersey, and North Carolina. With this announcement of blanket waivers, other states and providers do not need to apply for these waivers and can begin using the flexibilities immediately.

Administrator Verma added that she applauds the March 23, 2020, pledge by America’s Health Insurance Plans (AHIP) to match CMS’s waivers for Medicare beneficiaries in areas where in-patient capacity is under strain. “It’s a terrific example of public-private partnership and will expand the impact of Medicare’s changes,” Verma said.

CMS’s temporary actions empower local hospitals and health care systems to:

Increase Hospital Capacity – CMS Hospitals Without Walls

CMS will allow communities to take advantage of local ambulatory surgery centers that have canceled elective surgeries, per federal recommendations. Surgery centers can contract with local health care systems to provide hospital services, or they can enroll and bill as hospitals during the emergency declaration as long as they are not inconsistent with their state’s Emergency Preparedness or Pandemic Plan. The new flexibilities will also leverage these types of sites to decant services typically provided by hospitals such as cancer procedures, trauma surgeries, and other essential surgeries.

CMS will now temporarily permit non-hospital buildings and spaces to be used for patient care and quarantine sites, provided that the location is approved by the state and ensures the safety and comfort of patients and staff. This will expand the capacity of communities to develop a system of care that safely treats patients without COVID-19 and isolate and treat patients with COVID-19.

CMS will also allow hospitals, laboratories, and other entities to perform tests for COVID-19 on people at home and in other community-based settings outside of the hospital. This will both increase access to testing and reduce risks of exposure. The new guidance allows health care systems, hospitals, and communities to set up testing sites exclusively for the purpose of identifying COVID-19-positive patients in a safe environment.

In addition, CMS will allow hospital emergency departments to test and screen patients for COVID-19 at drive-through and off-campus test sites.

During the public health emergency, ambulances can transport patients to a wider range of locations when other transportation is not medically appropriate. These destinations include community mental health centers, federally qualified health centers, physician’s offices, urgent care facilities, ambulatory surgery centers, and any locations furnishing dialysis services when an ESRD facility is not available.

Physician-owned hospitals can temporarily increase the number of their licensed beds, operating rooms, and procedure rooms. For example, a physician-owned hospital may temporarily convert observation beds to inpatient beds to accommodate patient surge during the public health emergency.

In addition, hospitals can bill for services provided outside their four walls. Emergency departments of hospitals can use telehealth services to quickly assess patients to determine the most appropriate site of care, freeing emergency space for those that need it most. New rules ensure that patients can be screened at alternate treatment and testing sites which are not subject to the Emergency Medical Labor and Treatment Act (EMTALA) as long as the national emergency remains in force. This will allow hospitals, psychiatric hospitals, and critical access hospitals to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19.

Rapidly Expand the Health Care Workforce

Local private practice clinicians and their trained staff may be available for temporary employment since nonessential medical and surgical services are postponed during the public health emergency. CMS’s temporary requirements allow hospitals and health care systems to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community, as well as those licensed from other states without violating Medicare rules.

These health care workers can then perform the functions they are qualified and licensed for, while awaiting completion of federal paperwork requirements.

CMS is issuing waivers so that hospitals can use other practitioners, such as physician assistants and nurse practitioners, to the fullest extent possible, in accordance with a state’s emergency preparedness or pandemic plan. These clinicians can perform services such as order tests and medications that may have previously required a physician’s order where this is permitted under state law.

CMS is waiving the requirements that a Certified Registered Nurse Anesthetist (CRNA) is under the supervision of a physician. This will allow CRNAs to function to the fullest extent allowed by the state and free up physicians from the supervisory requirement and expand the capacity of both CRNAs and physicians.

CMS also is issuing a blanket waiver to allow hospitals to provide benefits and support to their medical staffs, such as multiple daily meals, laundry service for personal clothing, or child care services while the physicians and other staff are at the hospital and engaging in activities that benefit the hospital and its patients.

CMS will also allow health care providers (clinicians, hospitals and other institutional providers, and suppliers) to enroll in Medicare temporarily to provide care during the public health emergency.

Put Patients over Paperwork

CMS is temporarily eliminating paperwork requirements and allowing clinicians to spend more time with patients. Medicare will now cover respiratory-related devices and equipment for any medical reason determined by clinicians so that patients can get the care they need; previously Medicare only covered them under certain circumstances.  

During the public health emergency, hospitals will not be required to have written policies on processes and visitation of patients who are in COVID-19 isolation. Hospitals will also have more time to provide patients a copy of their medical record.

CMS is providing temporary relief from many audit and reporting requirements so that providers, health care facilities, Medicare Advantage health plans, Medicare Part D prescription drug plans, and states can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

This is being done by extending reporting deadlines and suspending documentation requests which would take time away from patient care.

Further Promote Telehealth in Medicare

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Providers also can evaluate beneficiaries who have audio phones only.

These temporary changes will ensure that patients have access to physicians and other providers while remaining safely at home.

Providers can bill for telehealth visits at the same rate as in-person visits. Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth. New as well as established patients now may stay at home and have a telehealth visit with their provider.

CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health.

CMS is making it clear that clinicians can provide remote patient monitoring services to patients with acute and chronic conditions and for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.

In addition, CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.

For additional background information on the waivers and rule changes, go to: https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient

For more information on the COVID-19 waivers and guidance, and the Interim Final Rule, please go to the CMS COVID-19 flexibilities webpage: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.

These actions, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov.  For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.


Billing for Professional Telehealth Services During the Public Health Emergency

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service (POS) equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth. As a reminder, CMS is not requiring the “CR” modifier on telehealth services. However, consistent with current rules for traditional telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier
Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

Traditional Medicare telehealth services professional claims should reflect the designated POS code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.


New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing

Clinical diagnostic laboratories: To identify and reimburse specimen collection for COVID-19 testing, CMS established two Level II HCPCS codes, effective with line item date of service on or after March 1, 2020:

G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source               

These codes are billable by clinical diagnostic laboratories.


April 7, 2020, Contractor Advisory Committee (CAC) Meeting Cancelled

The decision has been made to cancel the April 7, 2020, CAC Meeting and our online registration has been closed.

We believe that during this unprecedented time, the primary focus is the care of your patients and families. We will continue to keep you informed of any updates regarding future CAC meetings. Thank you for your dedication to the healthcare community. 


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11734 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020
Change request 11734 provides the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.
MM11745 – July 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Change request 11745 informs Medicare administrative contractors (MACs) about new and revised ASP and ASP not otherwise classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the outpatient prospective payment system are incorporated into the outpatient code editor through separate instructions that are available in chapter 4, section 50 of the Medicare claims processing manual. Make sure your billing staffs are aware of these changes.

Accelerated and Advance Payment Requests

To increase cash flow to providers of services and suppliers impacted by the 2019 Novel Coronavirus (COVID-19) pandemic, CMS expanded their current Accelerated and Advance Payment Program to a broader group of Medicare Part A and Part B providers / suppliers. Learn about accessing and submitting our Payment Request Form.


Update to Qualified Independent Contractor (QIC) Appeal Submission

We are sending this information at the request of the Qualified Independent Contractor (QIC). C2C conducts second-level Medicare Part A Fee-For-Service claims appeals, for claims submitted in your MAC jurisdiction. If you appeal to C2C as the Part A East QIC, as of April 3, 2020, they are limiting their on-site mailroom operations in response to the COVID-19, public health emergency. During this public health emergency, Part A East providers and Medicare beneficiaries are encouraged to submit new second-level Medicare appeals and related correspondence via fax or a portal. For additional information including the QIC fax numbers and a link to their portal, please visit, www.C2Cinc.com


March 30, 2020

Special Edition – Monday, March 30, 2020

Provider Education Message:

COVID-19: Financial Relief, Nursing Home Telehealth, Quality Reporting, Clinical Laboratories, Hospital Data Sharing 

Trump Administration Provides Financial Relief for Medicare Providers
Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit
Quality Payment Program and Quality Reporting Program/Value Based Purchasing Program COVID-19 Relief
Clinical Laboratory Improvement Amendments (CLIA) Guidance During COVID-19 Emergency
Trump Administration Engages America’s Hospitals in Unprecedented Data Sharing

Trump Administration Provides Financial Relief for Medicare Providers

Under the President’s leadership, the Centers for Medicare & Medicaid Services (CMS) is announcing an expansion of its accelerated and advance payment program for Medicare participating health care providers and suppliers, to ensure they have the resources needed to combat the 2019 Novel Coronavirus (COVID-19). This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act, is one way that CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic and ensures the nation’s providers can focus on patient care. There has been significant disruption to the health care industry, with providers being asked to delay non-essential surgeries and procedures, other health care staff unable to work due to childcare demands, and disruption to billing, among the challenges related to the pandemic.

“With our nation’s health care providers on the front lines in the fight against COVID-19, dollars and cents shouldn’t be adding to their worries,” said CMS Administrator Seema Verma. “Unfortunately, the major disruptions to the health care system caused by COVID-19 are a significant financial burden on providers. Today’s action will ensure that they have the resources they need to maintain their all-important focus on patient care during the pandemic.”

Medicare provides coverage for 37.4 million beneficiaries in its Fee for Service (FFS) program, and made $414.7 billion in direct payments to providers during 2019. This effort is part of the Trump Administration’s White House Coronavirus Task Force effort to combat the spread of COVID-19 through a whole-of-America approach, with a focus on strengthening and leveraging public-private relationships.

Accelerated and advance Medicare payments provide emergency funding and address cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. These expedited payments are typically offered in natural disasters to accelerate cash flow to the impacted health care providers and suppliers. In this situation, CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19. The payments can be requested by hospitals, doctors, durable medical equipment suppliers, and other Medicare Part A and Part B providers and suppliers.

To qualify for accelerated or advance payments, the provider or supplier must:

Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/ supplier’s request form,
Not be in bankruptcy,
Not be under active medical review or program integrity investigation, and
Not have any outstanding delinquent Medicare overpayments.

Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.

An informational fact sheet on the accelerated/advance payment process and how to submit a request can be found here: www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf.

This action, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.


Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

On March 27, CMS issued an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities. Under President Trump’s leadership to respond to the need to limit the spread of community COVID-19, CMS has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. This document contains electronic links to reliable sources of information regarding telehealth and telemedicine, including the significant changes made by CMS over the last week in response to the National Health Emergency. Most of the information is directed towards providers who may want to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well. There are specific documents identified that will be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. There is also information that will be useful for providers who intend to care for patients through electronic virtual services that may be temporarily used during the COVID-19 pandemic.

Toolkit


Quality Payment Program and Quality Reporting Program/Value Based Purchasing Program COVID-19 Relief

On March 22, 2020, CMS announced relief for clinicians, providers, hospitals, and facilities participating in quality reporting programs in response to the 2019 Novel Coronavirus (COVID-19). This memorandum and factsheet supplements and provides additional guidance to health care providers with regard to the announcement. CMS has extended the 2019 Merit-based Incentive Payment System (MIPS) data submission deadline from March 31 by 30 days to April 30, 2020. This and other efforts are to provide relief to clinicians responding to the COVID-19 pandemic. In addition, the MIPS automatic extreme and uncontrollable circumstances policy will apply to MIPS eligible clinicians who do not submit their MIPS data by the April 30, 2020 deadline.

You can find a copy of the memo here: Memo

You can find a copy of the fact sheet here: Fact Sheet


Clinical Laboratory Improvement Amendments (CLIA) Guidance During COVID-19 Emergency

CMS issued important guidance ensuring that America’s clinical laboratories are prepared to respond to the threat of the 2019 Novel Coronavirus (COVID-19.) CMS is committed to taking critical steps to ensure America’s clinical laboratories are prepared to respond to the COVID-19 threat and other respiratory illnesses by implementing flexibilities around requirements for a Clinical Laboratory Improvement Amendments (CLIA) certificate during public health emergencies.

While there is no formal waiver authority under CLIA, CMS continue to exercise flexibilities under current regulations and through enforcement discretion to address temporary and remote testing sites, use of alternate specimen collection devices, and implementation of laboratory developed tests.  Our hope is that this guidance provides the steps needed for all U.S. Labs wanting to apply for a CLIA certificate to test for COVID-19.

Guidance

FAQ


Trump Administration Engages America’s Hospitals in Unprecedented Data Sharing

On March 29, the Centers for Medicare & Medicaid Services (CMS) sent a letter to the nation’s hospitals on behalf of Vice President Pence requesting they report data in connection with their efforts to fight the 2019 Novel Coronavirus (COVID-19). Specifically, the Trump Administration is requesting that hospitals report COVID-19 testing data to the U.S. Department of Health and Human Services (HHS), in addition to daily reporting regarding bed capacity and supplies to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) COVID-19 Patient Impact and Hospital Capacity Module. CMS, the federal agency with oversight of America’s Medicare-participating health care providers – including hospitals – is helping the Trump Administration obtain this critical information to help identify supply and bed capacity needs, as well as enhance COVID-19 surveillance efforts. Hospitals will report data without personal identifying information to ensure patient privacy.

“The nation’s nearly 4,700 hospitals have access to testing data that’s updated daily. This data will help us better support hospitals to address their supply and capacity needs, as well as strengthen our surveillance efforts across the country,” said CMS Administrator Seema Verma. “America’s hospitals are demonstrating incredible resilience in this unprecedented situation and we look forward to partnering further with them going forward.”

The White House Coronavirus Task Force is already collecting data from public health labs and private laboratory companies but does not have data from hospital labs that conduct laboratory testing in their hospital. This hospital data is needed at the federal level to support the Federal Emergency Management Agency (FEMA) and CDC in their efforts to support states and localities in addressing and responding to the virus.

Academic, University and Hospital “in-house” labs are performing thousands of COVID-19 tests each day, but unlike private laboratories, the full results are not shared with government agencies working to track and analyze the virus. By sharing this critical data, hospitals can help Federal and state government mitigate the effects of COVID-19 and direct needed resources from Federal Emergency Management Agency (FEMA) and the U.S. Government during this unprecedented crisis.

In Vice President Pence’s letter to America’s hospitals, he asks all hospitals to report data on COVID-19 testing performed in their “in-house” laboratories, which are hospitals’ onsite laboratories. To monitor the rapid emergence of COVID-19 and the impact on the health care system, the White House Coronavirus Task Force is requesting hospitals to report testing data to HHS each day and to the CDC’s NHSN. This new data request by the Trump Administration will help monitor the spread of severe COVID-19 illness and death as well as the impact to our nation’s hospitals. Because private and commercial laboratories already report, this letter is not applicable to them.

This action, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.


Development Requests

You can submit and track your enrollment application through the Provider Enrollment, Chain and Ownership System. If you submitted a paper application, you can view the status in our Provider Enrollment Status Tool.

If we need additional information, a development letter will be sent to the contact person listed in Section 13 of your enrollment application. It is vital that you submit the requested information within the development letter.

Note: There is a 30 day development window from the date on the letter. The quicker we receive the requested information, the faster we can process your application.

If the status shows in development and the contact person didn't receive the letter, please contact our Provider Enrollment Helpdesk to request a copy.

    JH: 1-855-252-8782, Option 4
    JL: 1-877-235-8073, Option 4

For questions regarding the requested information in the letter, please contact your credentialing specialist. The phone number will be at the bottom of the development letter.


March 27, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11628 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020
The Centers for Medicare & Medicaid Services revised this article on March 26, 2020, to reflect a revised change request (CR) 11628 issued on March 25. The CR revision had no impact on the substance of the article. In the article, we revised the CR release date, transmittal number, and the web address. All other information remains the same.

March 26, 2020

Provider Education Message:

Special Edition – Thursday, March 26, 2020

COVID-19: Enrollment Relief, Open Payments, Beneficiary Notices

2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)
Frequently Asked Questions (FAQs) on Enforcing Open Payments Deadlines
Beneficiary Notice Delivery Guidance in light of COVID-19

2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)

CMS released Frequently Asked Questions on Medicare Provider Enrollment Relief related to COVID-19 including the toll-free hotlines available to Medicare Administrative Contractors (MACs). CMS has established toll-free hotlines at each MAC to allow physicians and non-physician practitioners to initiate temporary Medicare billing privileges. These hotlines provide expedited enrollment and answer questions related to COVID-19 enrollment requirements. FAQ


Frequently Asked Questions (FAQs) on Enforcing Open Payments Deadlines

CMS released an updated comprehensive list of Frequently Asked Questions (FAQs) about the Open Payments program. Tuesday, March 31, 2020 is the Open Payments Program Year 2019 data submission deadline for applicable manufacturers and group purchasing organizations (GPOs) to submit and attest to data for the June 2020 publication of Program Year 2019 data. The deadline cannot be extended past March 31, 2020, therefore, CMS will exercise enforcement discretion for submissions completed after the statutory deadline due to circumstances beyond the reporting entity’s control related to the pandemic. FAQ


Beneficiary Notice Delivery Guidance in light of COVID-19

If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:

Important Message from Medicare   (IM)_CMS-10065
Detailed Notices of Discharge   (DND)_CMS-10066
Notice of Medicare Non-Coverage   (NOMNC)_CMS-10123
Detailed Explanation of Non-Coverage   (DENC)_CMS-10124
Medicare Outpatient Observation Notice   (MOON)_CMS-10611
Advance Beneficiary Notice of Non-Coverage   (ABN)_CMS-R-131
Skilled Nursing Advance Beneficiary Notice of Non-Coverage   (SNFABN)_CMS-10055
Hospital Issued Notices of Non-Coverage   (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include: 

Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off, notices to beneficiaries may also delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.
Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

We encourage the provider community to review all of the specifics of notice delivery, as set forth in Chapter 30 of the Medicare Claims Processing Manual. https://www.cms.gov/media/137111

CMS has taken several recent actions in response to the Coronavirus Disease 2019 (COVID-19), as part of the ongoing White House Task Force efforts.  A summary of recent CMS activities can be found here: https://www.cms.gov/newsroom/press-releases/cms-news-alert-march-26-2020

To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For information specific to CMS, please visit the CMS News Room and Current Emergencies Website.


CMS Provider Education Message:

COVID-19: New Targeted Plan for Health Care Facility Inspections

MLN Connects® for Thursday, March 26, 2020

View this edition as a PDF

News

CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Health Care Facility Inspections in light of COVID-19
SNF Quality Reporting Program: MDS 3.0 v1.18.1 Release Delayed
Home Health Quality Reporting Program: Draft OASIS-E Instrument
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

MLN Matters® Articles

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCHs)
April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
New Medicare Beneficiary Identifier (MBI) Get It, Use It — Revised
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS — Revised

Multimedia

Ground Ambulance Data Collection System Call: Audio Recording and Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11660 – NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
Change request (CR) 11660 informs MACs that effective June 21, 2019, the Centers for Medicare & Medicaid Services (CMS) will continue coverage of TAVR under coverage with evidence development when the procedure is provided for the treatment of symptomatic aortic valve stenosis and according to a food & drug administration (FDA)-approved indication for use with an approved device, in addition to the coverage criteria outlined in the Medicare national coverage determinations (NCD) manual (Pub. 100-03). CMS will also continue coverage of TAVR for uses that are not expressly listed as an FDA-approved indication in clinical studies that meet specific requirements and are approved by CMS.
These changes relate to Chapter 1, Part 1, Section 20.32 of the NCD Manual and Chapter 32, Section 290 of the Medicare Claims Processing Manual (Pub. 100-04). Both relevant sections are attached to CR 11660.

Revised:

MM11640 – Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits
The Centers for Medicare & Medicaid Services revised this article on March 24, 2020, to reflect an updated change request (CR) 11640. In the article, we revised the transmittal number, CR release date and link to the transmittal. All other information remains the same.

Filing claims to the proper MAC

We are pleased to bring you an article on filing claims to the proper Medicare administrative contractor (MAC). Please take time to review this article.


March 24, 2020

Provider Education Message:

Special Edition – Monday, March 23, 2020

COVID-19: Relief for Quality Reporting Programs and Provider Enrollment

Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19
COVID-19 Provider Enrollment Relief FAQs

Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19

On March 22, CMS announced it is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. The action comes as part of the Trump Administration’s response to 2019 Novel Coronavirus (COVID-19).

CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines for several CMS programs. For those programs with data submission deadlines in April and May 2020, submission of those data will be optional, based on the facility’s choice to report.

CMS recognizes that quality measure data collection and reporting for services furnished during this time period may not be reflective of their true level of performance on measures such as cost, readmissions, and patient experience during this time of emergency and seeks to hold organizations harmless for not submitting data during this period.

You can find a copy of the press release here: https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting

CMS will continue monitoring the developing COVID-19 situation and assess options to provide additional relief to clinicians, facilities, and their staff so they can focus on caring for patients.

This action, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, please visit the coronavirus.gov webpage. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Webpage on CMS.Gov.

https://content.govdelivery.com/attachments/fancy_images/USCMS/2014/03/274725/blank-box-15px_original.jpg


COVID-19 Provider Enrollment Relief FAQs

On March 22, CMS released Frequently Asked Questions on Medicare Provider Enrollment Relief related to COVID-19, including the toll-free hotlines available to provide expedited enrollment and answer questions related to COVID-19 enrollment requirements.

A copy of the FAQs can be found here: https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

These tools, and earlier CMS actions in response to the COVID-19 emergency, are all part of ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, please visit the coronavirus.gov webpage. For a complete and updated list of CMS actions, guidance, and other information in response to COVID-19, please visit the Current Emergencies Website.


Provider enrollment assistance in response to COVID-19

Novitas Solutions implemented provider enrollment relief for providers impacted by COVID-19, retroactive to March 1, 2020. We have also established a hotline to help healthcare providers that have been impacted by COVID-19. Please visit our full article for further information.


Online Registration Now Available for the April 7, 2020, Contractor Advisory Committee (CAC) Meeting

Online registration for the April 7, 2020, CAC Meeting is now available and will close at 3:00 PM Eastern Time (ET) on Friday, April 3, 2020.

The CAC provides a formal mechanism for healthcare professionals to be informed of the evidence used in developing the Local Coverage Determination (LCD) and promotes communications between the Medicare Administrative Contractor (MAC) and the healthcare community. CAC members will serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of the LCD. The final decision on all issues rests with the Contractor Medical Directors (CMDs). More information regarding CAC meetings is available on Novitas’ website.


March 23, 2020

Provider Education Message:

Special Edition – Friday, March 20, 2020

COVID-19: Telehealth and Non-Essential Procedures

CMS Releases Telehealth Toolkits for General Practitioners and End-Stage Renal Disease (ESRD) Providers
Medicare FFS Response to the Public Health Emergency on the Coronavirus (COVID-19) — Revised
COVID-19 Elective Surgeries and Non-Essential Procedures Recommendations

CMS Releases Telehealth Toolkits for General Practitioners and End-Stage Renal Disease (ESRD) Providers

On March 18, the Centers for Medicare & Medicaid Services (CMS) released two comprehensive toolkits on telehealth that are specific to general practitioners as well as providers treating patients with End-Stage Renal Disease (ESRD).

Under President Trump’s leadership to respond to the need to limit the spread of COVID-19, CMS has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. These benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19 are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.

Each toolkit contains electronic links to reliable sources of information on telehealth and telemedicine, which will reduce the amount of time providers spend searching for answers and increase their time with patients. Many of these links will help providers learn about the general concept of telehealth, choose telemedicine vendors, initiate a telemedicine program, monitor patients remotely, and develop documentation tools. Additionally, the information contained within each toolkit will also outline temporary virtual services that could be used to treat patients during this specific period of time.

You can find the Telehealth Toolkit for General Practitioners here: https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf

You can find the End-Stage Renal Disease Providers Toolkit here: https://www.cms.gov/files/document/esrd-provider-telehealth-telemedicine-toolkit.pdf

CMS continues to monitor the developing COVID-19 situation and assess options to bring relief to clinicians. To keep up with the important work the Task Force is doing in response to COVID-19 visit the coronavirus.gov webpage. For complete and updated information specific to CMS, please visit the Current Emergencies Website.


Medicare FFS Response to the Public Health Emergency on the Coronavirus (COVID-19) — Revised

The MLN Matters Special Edition Article SE20011 on Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF) was updated to cover the use of modifiers on telehealth claims and to explain that the DR condition code is not needed on telehealth claims under the waiver.


COVID-19 Elective Surgeries and Non-Essential Procedures Recommendations

On March 18, at the White House Task Force Press Briefing, the Centers for Medicare & Medicaid Services (CMS) announced that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak.

You can find a copy of the press release here: https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental

You can find a copy of the guidance here: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf

These recommendations, and earlier CMS guidance and actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit the coronavirus.gov webpage for further information. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.


Limited Systems Availability - Friday, April 3, 2020 through Sunday, April 5, 2020

There will be Common Working File (CWF) "Dark" days from Friday, April, 3rd, 2020 through Sunday, April 5th, 2020 due to the April 2020 release upgrades. The Interactive Voice Response (IVR) Unit and our Customer Service representatives will have limited availability. Customer Service Representatives will not be able to assist providers with Eligibility Inquiries, Claim Status Inquiries Relating to Eligibility or Claim Denial Inquiries Relating to Eligibility.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11701 – April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Change request 11701 informs Medicare administrative contractors (MAC) about new and revised Average Sales Price (ASP) and ASP not otherwise classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the outpatient prospective payment system are incorporated into the outpatient code editor through separate instructions that are available in Chapter 4, Section 50 of the Medicare claims processing manual. Make sure your billing staffs are aware of these changes.
MM11702 – April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
Change request 11702 informs durable medical equipment Medicare administrative contractors about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. The update process for the DMEPOS fee schedule is available in the Medicare Claims Processing Manual, Chapter 23, Section 60. Make sure your billing staff is aware of this update.

Revised:

SE20011 – Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
The Centers for Medicare & Medicaid Services revised this article on March 20, 2020, to add a note in the telehealth section to cover the use of modifiers on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same.

March 20, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11335 – Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
The Centers for Medicare & Medicaid Services revised this article on March 19, 2020, and updated the Provider Types Affected, What You Need to Know, and Background sections.
SE18006 – New Medicare Beneficiary Identifier (MBI) Get It, Use It
The Centers for Medicare & Medicaid Services revised the article on March 19, 2020, to clarify that you need the beneficiary’s first name, last name, date of birth, and social security number to use the Medicare beneficiary identifier look-up tool. All other information remains the same

The Reopening Gateway has arrived!  

Novitas Solutions is dedicated to the development of self-service tools to reduce customer burden and to improve the overall customer experience. The Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process. Logging into the Reopening Gateway is a quick and easy way to update claim data through the internet.


March 19, 2020

CMS Provider Education Message:

Interoperability and Patient Access

MLN Connects® for Thursday, March 19, 2020

View this edition as a PDF

News

Quality Payment Program: 2020 Facility-Based Status
Lower Extremity Joint Replacement: Comparative Billing Report in March
IRF Provider Preview Reports: Review Your Data by April 13
LTCH Provider Preview Reports: Review Your Data by April 13
Hospice Provider Preview Reports: Review Your Data by April 13
IRF Compare Refresh
LTCH Compare Refresh
LTCH CARE Data Submission Specifications
Hospital Quality Reporting: Updated 2020 QRDA I Schematron and Sample File

Influenza Activity Continues: Are Your Patients Protected?

Compliance

Provider Minute Video: The Importance of Proper Documentation

Claims, Pricers & Codes

SNF Claims Incorrectly Cancelled

Events

Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2
Interoperability and Patient Access Final Rule Call — April 7

MLN Matters® Articles

Ensure Required Patient Assessment Information for Home Health Claims
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
Medicare FFS Response to the Public Health Emergency on the Coronavirus (COVID-19) — Revised

Publications

Administrative Simplification: Code Set Basics
Medicare Parts A & B Appeals Process — Revised
Clinical Laboratory Fee Schedule — Revised

Multimedia

Part A Appeals Demonstration Call: Audio Recording and Transcript
Introduction to IRF Quality Reporting Program Web-Based Training
Introduction to SNF Quality Reporting Program Web-Based Training

Local Coverage Determination (LCD) and Article Update History

The following Local Coverage Determination (LCD) has been revised:

Ambulance Services (Ground Ambulance) (L35162)

The following Local Coverage Article has been revised and is posted for notice. The article will become effective May 3, 2020:

Self-Administered Drug Exclusion List (A53127)

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

SE20011 – Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
The Centers for Medicare & Medicaid Services revised this article on March 18, 2020, to include information about the telehealth waiver. All other information remains the same.

March 18, 2020

Acupuncturist

Medicare does not recognize acupuncturist as a specialty. The Centers for Medicare & Medicaid Services (CMS) recently issued a decision regarding the coverage of acupuncture for chronic low back pain in certain circumstances. Not all specialty types are able to furnish these services. For additional information, please visit the Decision Memo for Acupuncture for Chronic Low Back Pain on the CMS website.


March 17, 2020

Special Edition – Tuesday, March 17, 2020

Provider Education Message:

President Trump Expands Telehealth Benefits for Medicare Beneficiaries During

COVID-19 Outbreak

CMS Outlines New Flexibilities Available to People with Medicare

The Trump Administration today announced expanded Medicare telehealth coverage that will enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility. Beginning on March 6, 2020, Medicare—administered by the Centers for Medicare & Medicaid Services (CMS)—will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country.

“The Trump Administration is taking swift and bold action to give patients greater access to care through telehealth during the COVID-19 outbreak,” said Administrator Seema Verma. “These changes allow seniors to communicate with their doctors without having to travel to a healthcare facility so that they can limit risk of exposure and spread of this virus. Clinicians on the frontlines will now have greater flexibility to safely treat our beneficiaries.”

On March 13, 2020, President Trump announced an emergency declaration under the Stafford Act and the National Emergencies Act. Consistent with President Trump’s emergency declaration, CMS is expanding Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. This guidance and other recent actions by CMS provide regulatory flexibility to ensure that all Americans—particularly high-risk individuals—are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the spread of coronavirus disease 2019 (COVID-19).

Prior to this announcement, Medicare was only allowed to pay clinicians for telehealth services such as routine visits in certain circumstances. For example, the beneficiary receiving the services must live in a rural area and travel to a local medical facility to get telehealth services from a doctor in a remote location. In addition, the beneficiary would generally not be allowed to receive telehealth services in their home.

The Trump Administration previously expanded telehealth benefits. Over the last two years, Medicare expanded the ability for clinicians to have brief check-ins with their patients through phone, video chat and online patient portals, referred to as “virtual check-ins”. These services are already available to beneficiaries and their physicians, providing a great deal of flexibility, and an easy way for patients who are concerned about illness to remain in their home avoiding exposure to others.

A range of healthcare providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to Medicare beneficiaries. Beneficiaries will be able to receive telehealth services in any healthcare facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.

Medicare beneficiaries will be able to receive various services through telehealth including common office visits, mental health counseling, and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves or others at risk. This change broadens telehealth flexibility without regard to the diagnosis of the beneficiary, because at this critical point it is important to ensure beneficiaries are following guidance from the CDC including practicing social distancing to reduce the risk of COVID-19 transmission. This change will help prevent vulnerable beneficiaries from unnecessarily entering a healthcare facility when their needs can be met remotely.  

President Trump’s announcement comes at a critical time as these flexibilities will help healthcare institutions across the nation offer some medical services to patients remotely, so that healthcare facilities like emergency departments and doctor’s offices are available to deal with the most urgent cases and reduce the risk of additional infections. For example, a Medicare beneficiary can visit with a doctor about their diabetes management or refilling a prescription using telehealth without having to travel to the doctor’s office. As a result, the doctor’s office is available to treat more people who need to be seen in-person and it mitigates the spread of the virus.

As part of this announcement, patients will now be able to access their doctors using a wider range of communication tools including telephones that have audio and video capabilities, making it easier for beneficiaries and doctors to connect.

Clinicians can bill immediately for dates of service starting March 6, 2020. Telehealth services are paid under the Physician Fee Schedule at the same amount as in-person services. Medicare coinsurance and deductible still apply for these services. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Medicaid already provides a great deal of flexibility to states that wish to use telehealth services in their programs. States can cover telehealth using various methods of communication such as telephonic, video technology commonly available on smart phones and other devices. No federal approval is needed for state Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services.

This guidance follows on President Trump’s call for all insurance companies to expand and clarify their policies around telehealth.

To read the Fact Sheet on this announcement visit: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

To read the Frequently Asked Questions on this announcement visit: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

This guidance, and earlier CMS actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19 click here https://protect2.fireeye.com/url?k=1dc3b044-4196b994-1dc3817b-0cc47a6a52de-daff918c3d41b4a0&u=http://www.coronavirus.gov/. For information specific to CMS, please visit the Current Emergencies Website.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20011 – Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
The Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020. The Centers for Medicare & Medicaid Services is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage.
Instructions to request an individual waiver if there is no blanket waiver.

March 16, 2020

Special Edition – Monday, March 16, 2020

Provider Education Message:

COVID-19: FFS Response and Nursing Home Visitor Guidance

Medicare FFS Response to COVID-19

The HHS Secretary declared a public health emergency, which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act. An MLN Matters Special Edition Article SE20011 on Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus is available. Learn about blanket waivers issued by CMS. These waivers prevent gaps in access to care for beneficiaries impacted by the emergency.

See the press release outlining our announcement.

COVID-19 Nursing Home Visitor Guidance

On March 13, as part of the broader Trump Administration announcement, CMS announced critical new measures designed to keep America’s nursing home residents safe from the 2019 Novel Coronavirus (COVID-19). The measures take the form of a memorandum and is based on the newest recommendations from the Centers for Disease Control and Prevention (CDC). It directs nursing homes to significantly restrict visitors and nonessential personnel, as well as restrict communal activities inside nursing homes. The new measures are CMS’s latest action to protect America’s seniors, who are at highest risk for complications from COVID-19. While visitor restrictions may be difficult for residents and families, it is an important temporary measure for their protection.

For More Information:

Press Release
Memo Nursing Home Guidance QSO-20-14 –NH

This guidance, and earlier CMS actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit  the coronavirus.gov webpage.

For information specific to CMS, visit the Current Emergencies website.


Special Edition – Friday, March 13, 2020

Provider Education Message:

COVID-19: Test Pricing, Diagnostic Lab Tests, Pricing & Codes, and EHB Coverage

COVID-19: Test Pricing; Diagnostic Lab Tests, Pricing & Codes; and EHB Coverage
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment MLN Matters® Article
Essential Health Benefits (EHB) Coverage

https://content.govdelivery.com/attachments/fancy_images/USCMS/2014/03/274725/blank-box-15px_original.jpg

COVID-19: Test Pricing; Diagnostic Lab Tests, Pricing & Codes; and EHB Coverage

On March 12, CMS posted a fact sheet with information relating to the pricing of both the Centers for Disease Control and Prevention (CDC) and non-CDC tests.


Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment MLN Matters® Article

A new MLN Matters Article MM 11681 on Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment is available. Learn about Advanced Diagnostic Laboratory Tests, pricing, and new codes. On page 3, we reference new COVID-19 codes.


Essential Health Benefits (EHB) Coverage

On March 12, CMS issued Frequently Asked Questions (FAQs) about EHB to ensure individuals, issuers, and states have clear information on coverage benefits for COVID-19. This action is part of the broader, ongoing effort by the White House Coronavirus Task Force to ensure that all Americans – particularly those at high-risk of complications from the COVID-19 virus – have access to the health benefits that can help keep them healthy while helping to contain the spread of this disease.

These FAQs, and earlier CMS actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19; visit the CDC's Coronavirus Disease 2019 webpage.

For information specific to CMS, please visit the Current Emergencies website.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11681 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Change request 11681 informs Medicare administrative contractors about the changes in the April 2020 quarterly update to the clinical laboratory fee schedule. Make sure that your billing staffs are aware of these changes.
MM11694 – April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
CR 11694 describes changes to and billing instructions for various payment policies implemented in the April 2020 ASC payment system update. This notification also includes updates to the healthcare common procedure coding system. Make sure your billing staffs are aware of these updates.

Local Coverage Determination (LCD) and Article Update History

The following Local Coverage Determination (LCD) which was posted for notice on January 30, 2020 is now effective. The companion article for this LCD is also now effective:

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38385)
Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A56938)

Coming Soon! The March 31, 2020 Deadline for the Completion of the Transport of Portable X-ray Equipment Survey

Time is running out to complete the Reimbursement Survey for Transport of Portable X-ray Equipment (R0070 and R0075). Novitas is requesting your assistance to ensure that the Transport of Portable X-ray Equipment Survey is submitted no later than March 31, 2020, when a final reimbursement determination will be made.


March 13, 2020

The following Billing and Coding Article has been revised:

Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)

March 12, 2020

CMS Provider Education Message:

2019 Novel Coronavirus Guidance

MLN Connects® for Thursday, March 12, 2020

View this edition as a PDF

News

CMS Sends More Detailed Guidance to Providers about COVID-19
HHS Finalizes Historic Rules to Provide Patients More Control of Their Health Data
Quality Payment Program: MIPS 2019 Data Submission Deadline March 31
Hospital Quality Reporting: Comment on Draft QRDA I Implementation Guide by April 1
Inclusion of Lower Limb Prosthetics in DMEPOS Prior Authorization
Clean Hands Count: Prevent and Control Infections
March is National Colorectal Cancer Awareness Month

Compliance

Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type

Events

Open Payments: Your Role in Health Care Transparency Call — March 19
Medicare Promoting Interoperability Program Call for Measures Webinar — March 19
Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2
Interoperability and Patient Access Final Rule Call — April 7
LTCH and IRF Quality Reporting Programs: SPADEs Webinar — April 14

MLN Matters® Articles

NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare
April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1
Proper Use of Modifier 59 — Revised
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised

Publications

Evacuating and Receiving Patients in the Midst of a Wildfire
Administrative Simplification: Eligibility and Benefits Transaction Basics

Multimedia

Dementia Care Call: Audio Recording and Transcript

February 2020 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

February 2020 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX The February 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed for February 2020. Please take time to review.


March 11, 2020

February 2020 top claim submission errors

The February 2020 Part B top claim submission errors and resolutions for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11640 – Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
Change request 11640 informs the Medicare administrative contractors about new HCPCS codes for 2020 that are subject to and excluded from CLIA edits. Please make sure your billing staffs are aware of this update.

March 10, 2020

February 2020 Part B Newsletter

The February Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


March 9, 2020

Special Edition – Monday, March 9, 2020

Provider Education Message:

COVID-19 Response: CMS Issues FAQs to Assist Medicare Providers

On March 6, CMS issued frequently asked questions and answers (FAQs) for health care providers regarding Medicare payment for laboratory tests and other services related to the 2019-Novel Coronavirus (COVID-19). The agency is receiving questions from providers and created this document to be transparent and share answers to some of the most common questions.

Included in the FAQs is:

Guidance on how to bill and receive payment for testing patients at risk of COVID-19.
Details of Medicare’s payment policies for laboratory and diagnostic services, drugs, and vaccines under Medicare Part B, ambulance services, and other medical services delivered by physicians, hospitals, and facilities accepting government resources.
Information on billing for telehealth or in-home provider services. Since 2019, the Trump Administration has expanded flexibilities for CMS to pay providers for virtual check-ins and other digital communications with patients, which will make it easier for sick patients to stay home and lower the risk of spreading the infection.

This FAQ, and earlier CMS actions in response to the COVID-19 virus are part of the ongoing White House Task Force efforts. To keep up with the important work CMS is doing in response to COVID-19, visit the Current Emergencies website.  

Below is an updated list of CMS’ actions to date:

March 5: Issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs 
March 4: Issued a call to action to health care providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare
February 13: Issued a new HCPCS code for providers and laboratories to test patients for COVID-19  
February 6: Gave CLIA-certified laboratories information about how they can test for SARS-CoV-2
February 6: Issued a memo to help the nation’s health care facilities take critical steps to prepare for COVID-19 

March 6, 2020

MLN Connects Special Edition for Friday, March 6, 2020

Provider Education Message:

CMS Develops Additional Code for Coronavirus Lab Tests

Agency Issues Fact Sheets Detailing Coverage under Programs 

On March 6, CMS took additional actions to ensure America’s patients, healthcare facilities and clinical laboratories are prepared to respond to the 2019-Novel Coronavirus (COVID-19). 

CMS has developed a second Healthcare Common Procedure Coding System (HCPCS) code that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children’s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well. 

“CMS continues to leverage every tool at our disposal in responding to COVID-19,” said CMS Administrator Seema Verma. “Our new code will help encourage doctors and laboratories to use these essential tests for patients who need them. At the same time, we are providing critical information to our 130 million beneficiaries, many of whom are understandably wondering what will be covered when it comes to this virus. CMS will continue to devote every available resource to this effort, as we cooperate with other government agencies to keep the American people safe.”

HCPCS is a standardized coding system that Medicare and other health insurers use to submit claims for services provided to patients. Last month, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). On February 29, 2020, the Food and Drug Administration (FDA) issued a new, streamlined policy for certain laboratories to develop their own validated COVID-19 diagnostics. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare or health insurers. CMS expects that having specific codes for these tests will encourage testing and improve tracking. 

The Medicare claims processing systems will be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020. Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. Laboratories may seek guidance from their MAC on payment for these tests prior to billing for them. As with other laboratory tests, there is generally no beneficiary cost sharing under Original Medicare.

To ensure the public has clear information on coverage and benefits under CMS programs, the agency also released three fact sheets that cover diagnostic laboratory tests, immunizations and vaccines, telemedicine, drugs, and cost-sharing policies. 

Medicare Fact Sheet Highlights:  In addition to the diagnostic tests described above, Medicare covers all medically necessary hospitalizations, as well as brief “virtual check-ins,” which allows patients and their doctors to connect by phone or video chat.

Medicaid and Children’s Health Insurance Program (CHIP) Fact Sheet Highlights:  Testing and diagnostic services are commonly covered services, and laboratory and x-ray services are a mandatory benefit covered and reimbursed in all states. States are required to provide both inpatient and outpatient hospital services to beneficiaries. All states provide coverage of hospital care for children and pregnant women enrolled in CHIP. Specific questions on covered benefits should be directed to the respective state Medicaid and CHIP agency.

Individual and Small Group Market Insurance Coverage: Existing federal rules governing health insurance coverage, including with respect to viral infections, apply to the diagnosis and treatment of with Coronavirus (COVID-19). This includes plans purchased through HealthCare.gov. Patients should contact their insurer to determine specific benefits and coverage policies. Benefit and coverage details may vary by state and by plan. States may choose to work with plans and issuers to determine the coverage and cost-sharing parameters for COVID-19 related diagnoses, treatments, equipment, telehealth and home health services, and other related costs.

Summary of CMS Public Health Action on COVID-19 to date:

On March 4, 2020, CMS issued a call to action to healthcare providers nationwide to ensure they are implementing longstanding infection control procedures and issued important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare facilities to focus exclusively on issues related to infection control and other serious health and safety threats. For more information on CMS actions to prepare for and respond to COVID-19, visit: CMS Announces Actions to Address Spread of Coronavirus.

On February 13, 2020, CMS issued a new HCPCS code for healthcare providers and laboratories to test patients for COVID-19 using the CDC-developed test. For more information about this code: Public Health News Alert: CMS Develops New Code for Coronavirus Lab Test.

On February 6, 2020, CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID19.

On February 6, 2020, CMS also gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. Read more: Suspension of Survey Activities memorandum

For the updated information on the range of CMS activities to address COVID-19, visit the Current Emergencies webpage.


March 5, 2020

CMS Provider Education Message:

Ambulance Fee Schedule, Transports & Data Collection

MLN Connects® for Thursday, March 5, 2020

View this edition as a PDF

News

DMEPOS Suppliers: HCPCS Codes Affected by Further Consolidated Appropriations Act
Medicare Promoting Interoperability Program: CAH Reconsideration Forms due March 6
Medicare Promoting Interoperability Program: Submit Proposals for New Measures by July 1
PEPPERs for Short-term Acute Care Hospitals
2018 Geographic Variation Public Use File
Help Your Patients Make Informed Food Choices

Compliance

Ambulance Fee Schedule and Medicare Transports

Claims, Pricers & Codes

Average Sales Price Files: April 2020

Events

Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12
Open Payments: Your Role in Health Care Transparency Call — March 19
Anesthesia Modifiers: Comparative Billing Report Webinar — March 19
Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2
LTCH and IRF Quality Reporting Programs: SPADEs In-Depth Training Event — June 9-10

MLN Matters® Articles

Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - April 2020
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) -- July 2020 Update

Publications

Administrative Simplification: Claim Status Basics
Hospice Quality Reporting Program: Timeliness Compliance Threshold for HIS Submissions
Guide to Reducing Chronic Kidney Disease Disparities in the Primary Care Setting

Multimedia

Ambulance Services Call: Audio Recording and Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20001 – Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type
The Centers for Medicare & Medicaid Services is aware that some providers are submitting claims incorrectly to Medicare using healthcare common procedure code L8679. This article reminds providers of Medicare policy regarding these devices. Make sure your billing staff are aware of the correct policy.

March 4, 2020

Special Edition – Wednesday, March 4, 2020

Provider Education Message:

CMS Announces Actions to Address Spread of Coronavirus

CMS calls on all health care providers to activate infection control practices and issues guidance to inspectors as they inspect facilities affected by Coronavirus

On March 4, the Centers for Medicare & Medicaid Services (CMS) announced several actions aimed at limiting the spread of the Novel Coronavirus 2019 (COVID-19). Specifically, CMS is issuing a call to action to health care providers across the country to ensure they are implementing their infection control procedures, which they are required to maintain at all times. Additionally, CMS is announcing that, effective immediately and, until further notice, State Survey Agencies and Accrediting Organizations will focus their facility inspections exclusively on issues related to infection control and other serious health and safety threats, like allegations of abuse – beginning with nursing homes and hospitals. Critically, this shift in approach, first announced yesterday by Vice President Pence, will allow inspectors to focus their energies on addressing the spread of COVID-19.

As the agency responsible for Medicare and Medicaid, CMS requires facilities to maintain infection control and prevention policies as a condition for participation in the programs. CMS is also issuing three memoranda to State Survey Agencies, State Survey Agency directors and Accrediting Organizations – to inspect thousands of Medicare-participating health care providers across the country, including nursing homes and hospitals.

“Today’s actions, taken together, represent a call to action across the health care system,” said CMS Administrator Seema Verma. “All health care providers must immediately review their procedures to ensure compliance with CMS’ infection control requirements, as well as the guidelines from the Centers for Disease Control and Prevention (CDC). We sincerely appreciate the proactive efforts of the nursing home and hospital associations that have already galvanized to provide up-to-the-minute information to their members. We must continue working together to keep American patients and residents safe and healthy and prevent the spread of COVID-19.”

The first memorandum provides important detail with respect to the temporary focus of surveys on infection control and other emergent issues. Importantly, it notes that, in addition to the focused inspections, statutorily-required inspections will also continue in the 15,000 nursing homes across the country using the approximately 8,200 state survey agency surveyors. Surveys will be conducted according to the following regime:

All immediate jeopardy complaints (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm) and allegations of abuse and neglect;
Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses;
Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities);
Any re-visits necessary to resolve current enforcement actions;
Initial certifications;
Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years;
Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy.

The memorandum also includes protocols for the inspection process in situations in which COVID-19 is identified or suspected. These protocols include working closely with CMS regional offices, coordinating with CDC, and other relevant agencies at all levels of government. The agency is also providing key guidance related to inspectors’ usage of adequate personal protective equipment.

The other two memoranda provide critical answers to common questions that nursing homes and hospitals may have with respect to addressing cases of COVID-19. For example, the memoranda discuss concerns like screening staff and visitors with questions about recent travel to countries with known cases and the severity of infection that would warrant hospitalization instead of self-isolation. They detail the process for transferring patients between nursing homes and hospitals in cases for which COVID-19 is suspected or diagnosed. They also describe the circumstances under which providers should take precautionary measures (like isolation and mask wearing) for patients and residents diagnosed with COVID-19, or showing signs and symptoms of COVID-19.

Finally, the agency is announcing that it has deployed an infection prevention specialist to CDC’s Atlanta headquarters to assist with real-time in guidance development.

These actions from CMS are focused on protecting American patients and residents by ensuring health care facilities have up-to-date information to adequately respond to COVID-19 concerns while also making it clear to providers that as always, CMS will hold them accountable for effective infection control standards. The agency is also supplying inspectors with necessary and timely information to safely and accurately inspect facilities.

To view each memo, please visit:

Suspension of Survey Activities
Guidance for Infection Control and Prevention Concerning Coronavirus Disease (COVID-19): FAQs and Considerations for Patient Triage, Placement and Hospital Discharge
Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes

A/B MAC and DME MAC Collaborative Nebulizer webinar

Your A/B MAC and DME MAC education staff are excited to bring you another collaborative webinar opportunity.  Please join us on March 18, 2020, at 2:00 PM Eastern (1:00 PM Central) as we detail the coverage criteria for inhalation medication and nebulizers.  The standard written order will also be discussed during the webinar.  After the presentation portion of the webinar, the educators will take questions from attendees.

Register today.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20006 – NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
Special Edition (SE) 20006 updates providers on Medicare coverage rules and policies for National Coverage Determination (NCD) 20.4 – Implantable Cardiac Defibrillators (ICDs). SE20006 outlines the coding requirements (including the heart failure codes) and is not more restrictive than the NCD. Please make sure your billing staffs are aware of these updates.
SE20009 – Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare
This Medicare learning network matters article reinforces existing Medicare policy that allows non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.

Revised:

SE1418 – Proper Use of Modifier 59
This special edition article is being provided by the Centers for Medicare & Medicaid Services to clarify the proper use of Modifiers 59 and –X{EPSU}. The article only clarifies existing policy. Make sure that your billing staffs are aware of the proper use of Modifiers 59 and –X{EPSU}.
MM11661 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update
The Centers for Medicare & Medicaid Services revised this article on February 27, 2020, to reflect the revised Change Request (CR)11661 issued on that date. In the article, we changed the MP relative value units for code G2013 in Table 2 to 0.28. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

Care management specialty page

New information has been added the specialty page.  Please review the page to ensure that you are keeping up with the most current information. 


March 3, 2020

The 2020 MSI is Here: Evaluate Our Services!  

The MAC Satisfaction Indicator (MSI) is the best way to share your opinions directly with the Centers for Medicare & Medicaid Services (CMS) about your experience with us. These survey results will help us gain valuable insights and determine process improvements.

https://www.surveygizmo.com/s3/5439699/?MAC_BRNC=7&MAC=JH-Novitas

Thank you for your feedback.


Novitas listened to you and wants to say "Thanks!"

Our Novitas Solutions team would like to take a moment to say ‘thank you’ to our providers. We appreciate the feedback you provided us in the last year through surveys such as the MSI. Your opinion of the service we provide matters to us. Over the past year, we’ve implemented several improvements influenced by how we can better serve you. Here are some of the positive changes:

Customer service: We’re decreasing the time it takes to resolve your complex questions. We reduced our average callback rate by almost 50% for telephone inquiries, providing resolution to your questions at first contact.
Written Inquiries: We reduced our overall processing time by 20%, answering your written inquiries with in an average of 35 days. Our intent is to further improve our response time in 2020.
Provider Outreach and Education: We completed our project to streamline our website’s content centers to allow you to find popular topics and new self-service tools (including a modifier lookup and an enrollment decision tree) even faster.
Website Usability: We enhanced our web search for cleaner results, and upgraded our navigation and layout for easier mouse use on desktops as well as touchscreen tablets and phones.

To these points, as well as others you have brought our way in the past, we say "Thank you!" We look forward to our continued partnership.


March 2, 2020

The Reopening Gateway has arrived!

Novitas Solutions is dedicated to the development of self-service tools to reduce customer burden and to improve the overall customer experience. The Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process. Logging into the Reopening Gateway is a quick and easy way to update claim data through the internet.


February 28, 2020

The 2020 MAC Satisfaction Indicator (MSI): Coming in March

The 2020 Medicare administrative contractor (MAC) Satisfaction Indicator (MSI), a survey administered by the Centers for Medicare & Medicaid Services (CMS), is coming in March. The MSI measures your satisfaction with our processes and service delivery so we can gain valuable insights and determine process improvements.

We appreciate your feedback in 2019. Novitas Solutions used your feedback and survey results to make improvements to our services that better serve you. Watch for an announcement on our website on how you can participate in the 2020 survey.

For additional information on the survey, you may visit the MSI page and the MSI frequently asked questions on the CMS website.


February 27, 2020

CMS Provider Education Message:

COVID-19 Coding Guidance

MLN Connects® for Thursday, February 27, 2020

View this edition as a PDF

News

Quality Payment Program: MIPS 2019 Data Submission Period Open through March 31
Anesthesia Modifiers: Comparative Billing Report in March

Compliance

Inpatient Rehabilitation Facility Services: Follow Medicare Billing Requirements

Claims, Pricers & Codes

COVID-19: New ICD-10-CM Code and Interim Coding Guidance
SNF PDPM Claims Issue
FQHC: Mass Adjustment of Claims

Events

Dementia Care: CMS Toolkits Call — March 3
Part A Providers: QIC Appeals Demonstration Call — March 5
Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12
Open Payments: Your Role in Health Care Transparency Call — March 19

MLN Matters® Articles

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update
Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Claims — Revised
Accepting Payment from Patients with a Medicare Set-Aside Arrangement — Revised
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 — Revised

Publications

Medicare Quarterly Provider Compliance Newsletter, Volume 10, Issue 2
Quality Payment Program: 2020 Resources

February 26, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11655 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) -- July 2020 Update
Change request 11655 informs providers about updated ICD-10 conversions as well as coding updates specific to NCDs. Please make sure your billing staffs are aware of these updates.

February 25, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20007 – Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements
Special Edition 20007 informs providers that the Calendar Year 2020 End Stage Renal Disease Prospective Payment System Final Rule CMS-1713-F (84 Fed. Reg Vol 217) (https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis) goes into effect January 1, 2020.
This rule, in part, streamlines the requirements for ordering DMEPOS items through the identification of a standard set of elements to be included in a written order/prescription. It also develops a new Master List of DMEPOS items potentially subject to a face-to-face encounter, written orders prior to delivery and, or prior authorization requirements as a condition of payment (thereby harmonizing prior lists). This standard written order and Master list will simplify the ordering of DMEPOS items and eliminate multiple lists of DMEPOS items potentially subject to conditions of payment.
MM11638 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Change Request 11638 updates the RARC and CARC lists and instructs the ViPS Medicare System and Fiscal Intermediary Shared System maintainers to update MREP and PC Print software. Be sure your billing staffs are aware of these changes and obtain the updated MREP and PC Print versions if they use that software.

February 21, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

SE17019 – Accepting Payment from Patients with a Medicare Set-Aside Arrangement
The Centers for Medicare & Medicaid services revised this article on February 19, 2020, to add information about submitting electronic attestations via the WCMSAP. This is in the Additional Information Section of the article. We added a note on page 2, regarding workers’ compensation Medicare set-aside arrangement (WCMSA) funds. We also updated the link to an updated version of the WCMSA Reference Guide. All other information remains the same.
SE20002 – Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Claims
The Centers for Medicare & Medicaid services revised this article on February 20, 2020, to include the listing of clinical decision support mechanisms (CDSMs) (page 6) and to update paper billing instruction to direct providers to the National uniform billing committee for instructions on reporting the ordering physician national provider identifier (page 2) and special reporting required for the CDSMs using Healthcare Common Procedure Coding System G1011 on paper claims (page 3). The article release date was also changed. All other information is the same.

2020 Indian Health Services (IHS) Workshop: Improve your IHS Medicare knowledge 

The 2020 Indian Health Services Workshop is coming soon to a location near you. Save the date!
Join Novitas Solutions at an IHS 2020 Workshop! This workshop is held at various locations throughout the country. You will have the opportunity to meet with the Novitas Provider Outreach and Education team and network with your colleagues. This full day workshop is dedicated to help you develop a well-rounded understanding of the Medicare program, review services covered by Medicare, and avoid costly common billing errors.

This instructor-led workshop explores various important Medicare topics for billing IHS services. The topics include: Medicare benefits, provider enrollment requirements, patient screening tools, the Medicare Beneficiary Identifier, billing guidelines for Part A and B services, common claim submission errors, Medicare initiatives and more. The workshop will review the self-service tools available on the Novitas website and in the IHS Training Manual.


February 20, 2020

CMS Provider Education Message:

Bill Correctly for Medicare Telehealth Services

MLN Connects® for Thursday, February 20, 2020

View this edition as a PDF

News

CMS Develops New Code for Coronavirus Lab Test
CMS Program Statistics: 2018 Data
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Compliance

Bill Correctly for Medicare Telehealth Services

Events

Dementia Care: CMS Toolkits Call — March 3
Part A Providers: QIC Appeals Demonstration Call — March 5
Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12
Open Payments: Your Role in Health Care Transparency Call — March 19

MLN Matters® Articles

The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)
Second Update to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
New Medicare Beneficiary Identifier (MBI) Get It, Use It — Revised
What New Home Health Agencies (HHAs) Need to Know about Being Placed in a Provisional Period of Enhanced Oversight — Revised
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) - April 2020 Update — Revised

Publications

Administrative Simplification: EFT and ERA Transactions

February 19, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11661 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update
Change request (CR) 11661 informs you that the Centers for Medicare & Medicaid Services issued payment files to the Medicare administrative contractors based upon the 2020 MPFS Final Rule, published in the Federal register on November 15, 2019. CR 11661 amends those payment files. Make sure your billing staffs are aware of these changes.

February 18, 2020

Claims timely filing calculator

Novitas has developed a Claims Timely Filing Calculator to assist you in determining the timely filing limit for your services. In general, Medicare claims must be filed to the Medicare claims processing contractor no later than 12 months, or 1 calendar year, from the date the services were furnished. For institutional claims that include span dates of service (i.e., a “from” and “through” date span on the claim), the “through” date on the claim is used for determining the date of service for claims filing timeliness. For professional claims submitted by physicians and other suppliers that include span dates of service, the line item “from” date is used for determining the date of service for claims filing timeliness.


Behavioral health specialty

A new Medicare Mental Health Booklet has been added to the Specialty Page.  The booklet contains valuable information regarding covered services, eligible professionals and coding and billing.  Please review our page for the most current information.


February 13, 2020

CMS Provider Education Message:

Protect Your Patients from Influenza

MLN Connects® for Thursday, February 13, 2020

View this edition as a PDF

News

DMEPOS Items Subject to Prior Authorization
Influenza Activity Continues: Are Your Patients Protected?

Compliance

Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing

Events

Substance Use Disorders: Availability of Benefits Listening Session — February 18
Ground Ambulance Organizations: Reporting Volunteer Labor Call — February 20
Dementia Care: CMS Toolkits Call — March 3
Hospice Item Set Data Submission Requirements Webinar — March 3
Part A Providers: QIC Appeals Demonstration Call — March 5
Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12

MLN Matters® Articles

Update to the Home Health Grouper for New Diagnosis Code for Vaping Related Disorder
Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy
Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder — Revised
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

Publications

Diabetes Management Resources
Caring for Medicare Patients is a Partnership — Revised

Multimedia

MAC Listening Session: Audio Recording and Transcript

The following Local Coverage Determinations (LCDs) have been revised:

Hemophilia Factor Products (L35111)
Hyperbaric Oxygen (HBO) Therapy (L35021)

The following Billing and Coding Articles have been revised:

Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
Billing and Coding: Biomarkers Overview (A56541)
Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
Billing and Coding: Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases (A53121)
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Billing and Coding: Non-Coronary Vascular Stents (A56365)

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

SE18006 – New Medicare Beneficiary Identifier (MBI) Get It, Use It
The Centers for Medicare & Medicaid Services revised the article on February 12, 2020, to add a sentence to the Medicare beneficiary identifier (MBI) look-up tool option for getting an MBI to show what happens if the beneficiary record has a date of death. All other information remains the same.

February 12, 2020

Development Requests

You can submit and track your enrollment application through the Provider Enrollment, Chain and Ownership System. If you submitted a paper application, you can view the status in our Provider Enrollment Status Tool.

If we need additional information, a development letter will be sent to the contact person listed in Section 13 of your enrollment application. It is vital that you submit the requested information within the development letter.  

Note: There is a 30 day development window from the date on the letter. The quicker we receive the requested information, the faster we can process your application.

If the status shows in development and the contact person didn't receive the letter, please contact our Provider Enrollment Helpdesk to request a copy.

JH: 1-855-252-8782, Option 4

For questions regarding the requested information in the letter, please contact your credentialing specialist. The phone number will be at the bottom of the development letter.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11491– International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2020 Update
The Centers for Medicare & Medicaid Services (CMS) revised this article on February 10, 2020, to reflect a revised Change Request (CR) 11491, issued on February 4. The CR was revised to amend the spreadsheet for NCD 110.4. This revision did not impact the substance of the article. In the article, CMS revised the CR release date, transmittal number and the web address. All other information remains the same.

February 11, 2020

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for January 2020 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


February 10, 2020

Local Coverage Determination (LCD) and Article Update History

The comment period is now closed for the following Proposed Local Coverage Determinations. Comments received will be reviewed by our Contractor Medical Directors. The Response to Comments Articles and finalized Billing and Coding Articles will be related to the final LCDs when they are posted for notice.

Magnetic-Resonance-Guided-Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (DL38495)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)

February 7, 2020

Punctum plugs and anatomical modifiers

Our article has been updated to include bilateral reporting.  Please review to ensure you are billing and coding correctly. 


Reassignment of Medicare Benefits: Revised CMS-855R Required May 1

Physicians and non-physician practitioners: Use the revised CMS-855R (Reassignment of Benefits) application once it is posted on the CMS Forms List in early February 2020. Medicare Administrative Contractors will accept current and revised versions of the form through April 30, 2020. Starting May 1, 2020 you must use the revised form. Form updates:

Can select Change of Reassignment Information as submission reason
Option to identify a secondary practice address

Visit the Medicare Provider-Supplier Enrollment webpage for more information about Medicare enrollment.


January 2020 Part B Newsletter

The January Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for January 2020. Please take time to review these FAQs for answers to your questions.


February 6, 2020

CMS Provider Education Message:

Medicare Learning Network Celebrates 20 Years

MLN Connects® for Thursday, February 6, 2020

View this edition as a PDF

News

Open Payments Registration
Promoting Interoperability Programs: Deadline to Submit 2019 Data is March 2
Quality Payment Program: Updated Explore Measures Tool
Quality Payment Program: MIPS 2020 Call for Measures and Activities
Medicare Promoting Interoperability Program: Requirements for 2020
SNF Quality Reporting Program: FY 2022 APU Table
Reassignment of Medicare Benefits: Revised CMS-855R Required May 1
February is American Heart Month

Compliance

Outpatient Rehabilitation Therapy Services: Comply with Medicare Billing Requirements

Claims, Pricers & Codes

ICD-10-CM: New Diagnosis Code for Vaping-related Disorders Effective April 1

Events

Substance Use Disorders: Availability of Benefits Listening Session — February 18
Ground Ambulance Organizations: Reporting Volunteer Labor Call — February 20
Dementia Care: CMS Toolkits Call — March 3
Part A Providers: QIC Appeals Demonstration Call — March 5

MLN Matters® Articles

Provider Enrollment Appeals Procedure
Quarterly Influenza Virus Vaccine Code Update - July 2020
2020 Annual Update to the Therapy Code List — Revised
2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List — Revised

Publications

Medicare Mental Health
Medicare Provider Enrollment

Multimedia

MAC Listening Session: Audio Recording and Transcript

February 5, 2020

Opioid Treatment Program (OTP) Specialty

A new tip sheet has added regarding Providers Serving Dually Eligible Individuals. Please review our page for the most current information.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11210 – Provider Enrollment Appeals Procedure
Change Request (CR) 11210 updates the provider enrollment policy that outlines corrective action plans and reconsideration requests. The CR also updates applicable model letters, including initial determinations, the Medicare Administrative Contractors use to advise providers and suppliers of their review rights. Please make sure your billing staffs are aware of these updates.
MM11603 – Quarterly Influenza Virus Vaccine Code Update - July 2020
The influenza virus vaccine code set is updated on a quarterly basis. Change Request (CR) 11603 provides instructions for payment and edits for Medicare’s Common Working File and the Fiscal Intermediary Shared System to include and update new or existing influenza virus vaccine codes. In addition, the CR instructs Medicare Administrative Contractors to modify existing editing to allow influenza and a pneumococcal polysaccharide vaccine vaccination on the same date on separate roster bills. Make sure your billing staffs are aware of these changes.

February 4, 2020

Optical Character Recognition (OCR) 1500 Claim Form Submission Instructions/Helpful Hints

Updates have been made to the our article.  To avoid rejections, please review the article to ensure you are submitting claims correctly.   


Completion of the Centers for Medicare & Medicaid Services, CMS-1500 Claim Form

Updated information has been added to our article relating to Item 11.  Please review to the information to ensuring you are reporting information correctly. 


February 3, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11596 – 2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List
The Centers for Medicare & Medicaid Services revised this article on January 31, 2020, to reflect a revised Change Request (CR) 11596 issued on January 30. The revisions to the CR had no impact on the substance of the article. The CR release date, transmittal number, and the web address of the CR were revised. All other information remains the same.

The comment period will close on February 8, 2020 for the following Proposed Local Coverage Determinations (LCDs):

Magnetic-Resonance-Guided-Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (DL38495)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)

Submit Comments


January 31, 2020

2020 MEDPARD Available Now!

The 2020 MEDPARD (Medicare Participation Physicians / Suppliers Directory) is now available. As in the past, there will be no hardcopy distributions. Beneficiaries can use the Physician Compare website or contact 1-800-MEDICARE for assistance in locating a participating supplier near their home. Please use the following links to access the online MEDPARD Directory (JH) (JL).


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11501 – 2020 Annual Update to the Therapy Code List
The Centers for Medicare & Medicaid Services revised this article on January 29, 2020, to reflect an updated Change Request (CR) 11501.The update removed the sentence (When furnished to hospital outpatients, these two new biofeedback services will continue to be paid under the OPPS.) from the CR policy section (1. below) about how the two new biofeedback codes are paid when furnished to hospital outpatients. Note that the two new biofeedback codes will be paid under the Medicare Physician Fee Schedule. The CR release date, transmittal number and link to the CR also changed. All other information is unchanged.

January 30, 2020

CMS Provider Education Message:

Genetic Testing and Innovative Antibiotics

MLN Connects® for Thursday, January 30, 2020

View this edition as a PDF

News

CMS Expands Coverage of NGS as Diagnostic Tool for Patients with Breast and Ovarian Cancer
Nursing Home Quality Initiative: Draft MDS 3.0 Item Set Change History
Nursing Homes: Use Updated Infection Control Worksheet
Glaucoma Awareness Month: Make a Resolution for Healthy Vision

Compliance

Hospice Care: Safeguards for Medicare Patients

Claims, Pricers & Codes

OPPS Pricer File: January 2020

Events

Ground Ambulance Organizations: Reporting Staff and Labor Costs Open Door Forum — February 6
Ground Ambulance Organizations: Reporting Volunteer Labor Call — February 20

MLN Matters® Articles

Increasing Access to Innovative Antibiotics for Hospital Inpatients Using New Technology Add-On Payments: Frequently Asked Questions
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS — Revised
Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Publications

Safeguards for Medicare Patients in Hospice Care
Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B — Revised
Skilled Nursing Facility Prospective Payment System — Revised

Multimedia

ESRD Quality Incentive Program: Audio Recording and Transcript
MAC Listening Session: Audio Recording and Transcript

The following Local Coverage Determination (LCD) posted for comment on August 29, 2019 has been posted for notice. The LCD and related Billing and Coding Article will become effective March 15, 2020:

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38385)
Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A56938)

The following Response to Comments Article contains summaries of all comments received and Novitas’ responses:

Response to Comments: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A57928)

Reimbursement Survey for Transport of Portable X-ray Equipment (R0070 and R0075)

The opportunity to complete the survey has been extended. Novitas is requesting your assistance to ensure that the Transport of Portable X-ray Equipment Survey is submitted no later than March 31, 2020, when a final reimbursement determination will be made.


January 27, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11598 – Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
The Centers for Medicare & Medicaid Services revised this article on January 23, 2020, due to an updated Change Request (CR) 11598 that changed the policy section. Per the CR, the article notes that “Next Clinical Laboratory Fee Schedule Data Reporting Period — Delayed to January 2021 (page 1).” That is also noted on page 3. The article also has policy changes on page 2. The CR release date, transmittal number and link to the transmittal also changed. All other information remains the same.
MM11335 – Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
The Centers for Medicare & Medicaid Services revised this article on January 23, 2020, due to an updated Change Request (CR) 11335 that deleted references to certain inquiry screens. In the article, we changed the CR release date, transmittal number and link to the transmittal. All other information remains the same.

January 24, 2020

Attention Clinical Lab Providers - Molecular Diagnostic Pathology Survey (archived)

Novitas seeks your input on establishing pricing under the Medicare program for these laboratory test codes. If you have not already done so, please complete our Molecular Diagnostic Pathology Survey by March 3, 2020. Please complete a separate survey for each test you perform.


January 23, 2020

CMS Provider Education Message:

Medicare Learning Network Celebrates 20 Years

MLN Connects® for Thursday, January 23, 2020

View this edition as a PDF

News

Medicare Learning Network Celebrates 20 Years
CMS Updates Open Payments Data
Open Payments Search Tool: New Features
Shoulder Arthroscopy: Comparative Billing Report in January
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
Issues Viewing the CMS Website?
Continue Seasonal Influenza Vaccination through January and Beyond

Compliance

DMEPOS: Bill Correctly for Items Provided During Inpatient Stays

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

Listening Sessions on MAC Opportunities to Enhance Provider Experience — January 29
Shoulder Arthroscopy: Comparative Billing Report Webinar — February 4
CMS Quality Conference — February 25-27
Highly Pathogenic Infectious Disease Training and Exercise Resources Webinar — March 5

MLN Matters® Articles

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020
2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Home Health (HH) Patient-Driven Groupings Model (PDGM) - Split Implementation — Revised
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System — Revised

Publications

Quality Payment Program: 2020 Resources

Multimedia

Quality Payment Program: 2019 Data Submission Videos
Health Care Challenges in Chemical Incidents Webinar Recording
Infection Prevention and Control: Environmental Safety Web-Based Training Course — Revised
Infection Prevention and Control: Hand Hygiene Web-Based Training Course — Revised
Infection Prevention and Control: Injection Safety Web-Based Training Course — Revised

Provider Compliance Tips for Polysomnography (Sleep Studies) - Revised

A revised Provider Compliance Tips for Polysomnography (Sleep Studies) fact sheet is available. Learn about coverage requirements, documentation, and how to prevent claim denials.


Modifier 77 Fact Sheet

Our fact sheet on the proper use of modifier 77 has been updated.  Please take time to review the fact sheet to ensure that you are reporting and documenting the modifier correctly.


January 22, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11628 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020
Change Request 11628 contains the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.
MM11596 – 2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List
Change Request 11596 updates the list of HCPCS codes for Medicare Administrative Contractors (MAC) and Durable Medical Equipment MACs. Please make sure your billing staffs are aware of these updates.
MM11641 – Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Change Request 11641 revises the payment of travel allowances when billed on a per mileage basis using Healthcare Common Procedure Code System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for Calendar Year 2020. Make sure your billing staffs are aware of these changes.

Revised:

MM11003 – Implementation to Exchange the list of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
The Centers for Medicare & Medicaid Services revised this article on January 16, 2020, to link to Change Request 11141, which shows the effective date is now February 3, 2020. All other information remains the same.

January 21, 2020

Independent Diagnostic Testing Facility (IDTF) Specialty Page

New information has been added to our Independent Diagnostic Testing Facility (IDTF) Page relating to Polysomnography Services. Please review our page for the most current information relating to IDTF’s.


January 16, 2020

CMS Provider Education Message:

Quality Payment Program: Learn About the MIPS 2020 Performance Period

MLN Connects® for Thursday, January 16, 2020

View this edition as a PDF

News

CMS Reduces Psychiatric Hospital Burden with New Survey Process
Quality Payment Program: MIPS 2020 Payment Adjustments
Quality Payment Program: New MIPS Participation Framework for 2021 Performance Period
Part A Providers: Talk to a QIC Adjudicator About Your Appeal
Comparative Billing Reports: Access via CBR Portal
January is Cervical Health Awareness Month

Compliance

Bill Correctly for Polysomnography Services

Events

Listening Sessions on MAC Opportunities to Enhance Provider Experience — January 22 or 29
Quality Payment Program: MIPS for 2020 Performance Period Webinar — January 22

MLN Matters® Articles

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Encounters
Medicare Fee-for-Service (FFS) Response to the 2020 Commonwealth of Puerto Rico Earthquakes
January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0
Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System — Revised
Medicare Part B Home Infusion Therapy Services with the Use of Durable Medical Equipment — Revised
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS — Revised
CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule — Revised
Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)

Publications

Provider Compliance Tips for Polysomnography (Sleep Studies) - Revised

The following Local Coverage Determination (LCD) has been revised.

Wound Care (L35125)

The following articles have been revised to reflect the Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2020:

Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (A56530)
Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
Billing and Coding: Barium Swallow Studies, Modified (A56589)
Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Cardiac Rhythm Device Evaluation (A56602)
Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A56615)
Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)
Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993)
Billing and Coding: Pulmonary Function Testing (A57320)
Billing and Coding: Services That Are Not Reasonable and Necessary (A56967)
Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111)
Billing and Coding: Therapy and Rehabilitation Services (PT, OT) (A57703)
Billing and Coding: Wound Care (A53001)

Frequently Asked Questions (FAQs)

Have questions and not sure where to turn? Check out our FAQs for answers to your questions.


January 15, 2020

Ambulatory Surgery Center (ASC) Specialty Page

New information has been added to our ASC Specialty Page. Please review our page for the most current information relating to ASC's.


January 14, 2020

Two New Ways to Communicate with our Website & Portal Teams

We are pleased to announce two new, easy ways to send comments to the Novitas Solutions website and portal teams. 

While accessing our provider website and Novitasphere, you may be invited to complete a satisfaction survey though a message bar that appears across the top of your browsing window. This optional survey gives you the chance to rate your satisfaction with your visit, answer a few questions about why you came to the website or portal today, and if you were able to accomplish your task. This survey is offered at random. 

Additionally, a new “feedback” tab, which appears as a button on the right side of your screen, offers an instant way to leave direct comments on that particular page or function. The Feedback feature is available to all customers at all times. 

Thank you in advance for your participation. Your opinion is important to us, and we look forward to hearing from you soon.


December 2019 Part B Newsletter

The December 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for December 2019. Please take time to review these FAQs for answers to your questions.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE2003– Medicare Fee-for-Service (FFS) Response to the 2020 Commonwealth of Puerto Rico Earthquakes
The Secretary of the Department of Health & Human Services declared a Public Health Emergency in the Commonwealth of Puerto Rico on January 8, 2020, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to December 28, 2019, and are in effect for 90 days.

January 13, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20002 – Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Claims
This article provides guidance for processing claims for certain institutional claims that are subject to the AUC program for advanced diagnostic imaging services. The Centers for Medicare & Medicaid Services (CMS) will begin to accept claims with this information as of January 1, 2020. This is the beginning of the education and operations testing period for the AUC program. While there will not be payment penalties during this period, stakeholders and CMS can use this time to practice reporting and accepting AUC information on claims. The K3 segment will be used to report line level ordering professional information on institutional claims.
For other claims processing information for the AUC program including Healthcare Common Procedure Code System modifiers and codes, please see Medicare Learning Network Matters article MM11268, Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements. For general information regarding the AUC program please visit the CMS website.

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for December 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


January 10, 2020

2020 Complete Fee Schedule Download Files Are Available

Please note that due to legislative changes just before the end of 2019, you may have downloaded previously posted fee schedule files with amounts that have changed since first announced in November.  We are recommending that customers who have saved downloaded files in PDF, Text, or Excel formats visit our Fee Lookup Tool and download current versions of any files to ensure that you have the correct data to reference.


2020 Ambulatory Surgical Center (ASC) Fee Schedule

The 2020 ASC Fee schedule is now available on our website.


January 9, 2020

CMS Provider Education Message:

Read the Latest Quality Payment Program Updates

MLN Connects® for Thursday, January 9, 2020

View this edition as a PDF

News

Quality Payment Program: 2018 Performance Data
Quality Payment Program APM Incentive Payment: Verify Banking Information
Quality Payment Program: Participation Status Tool Includes Third Snapshot of Data
Quality Payment Program: Recheck Your Final 2019 MIPS Eligibility
Quality Payment Program: Check Your Initial 2020 MIPS Eligibility
Quality Payment Program: Qualified Registries and QCDRs for CY 2020
Hospice Provider Preview Reports: Review Your Data by January 15
Feedback on Scope of Practice: Send Recommendations by January 17
Promoting Interoperability Programs: Deadline to Submit 2019 Data is March 2
Quality Payment Program: MIPS 2019 Data Submission Period Open through March 31
Hospitals: New Beneficiary Notices (IM, DND, and MOON) Required April 1
Hospital Outpatient Departments: Prior Authorization Process Begins July 1
Home Health Compare: Preview Reports for April Refresh
Clinical Laboratory Data Reporting Delayed
ICD-10-CM Browser Tool
Provider Enrollment Application Fee Amount for CY 2020
Nursing Home Quality Initiative: Draft 2020 MDS Item Sets
Hospice Quality Reporting Program News
Qualified Medicare Beneficiary Billing Requirements
Get Your Patients Off to a Healthy Start in 2020
Looking for Educational Materials?

Compliance

Chiropractic Services: Comply with Medicare Billing Requirements

Events

Quality Payment Program: QCDR Measures Webinar — January 13
ESRD Quality Incentive Program: CY 2020 ESRD PPS Final Rule Call — January 14
Listening Sessions on MAC Opportunities to Enhance Provider Experience — January 15, 22, or 29

MLN Matters® Articles

Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory Date of Service Policy
IVIG Demonstration: Payment Update for 2020
January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Manual Update to Publication (Pub.) 100-04, Chapter 20, to Revise the Subsection 10 - Where to Bill Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Parenteral and Enteral Nutrition (PEN) Items and Services
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update
New Medicare Beneficiary Identifier (MBI) Get It, Use It — Reissued
Home Health Patient-Driven Groupings Model (PDGM) -Split Implementation — Revised

Publications

MLN Catalog – January 2020 Edition
Quality Payment Program and MIPS Resources
Diabetes Resources
Hospice Payment System — Revised
Medicare Diabetes Prevention and Diabetes Self-Management Training — Revised
Provider Compliance Tips for Hospital Based Hospice — Revised

Multimedia

eCQM: CMS Measure Collaboration Workspace

2020 Complete Fee Schedule Download Files Are Available

Please note that due to legislative changes just before the end of 2019, you may have downloaded previously posted fee schedule files with amounts that have changed since first announced in November.  We are recommending that customers who have saved downloaded files in PDF, Text, or Excel formats visit our Fee Lookup Tool and download current versions of any files to ensure that you have the correct data to reference.


2020 Ambulatory Surgical Center (ASC) Fee Schedule

The 2020 ASC Fee schedule is now available on our website.


Correct Reporting of Positron Emission Tomography (PET) Scan Services with Tracer Elements

A new article has been posted relating to the proper reporting of PET Scans and the tracer codes.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

SE19006 – Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
The Centers for Medicare & Medicaid Services revised this article on January 8, 2020, to note that for Clinical Diagnostic Laboratory Tests that are not Advanced Diagnostic Laboratory Tests, the data reporting is delayed by one year and must now be reported from January 1, 2021 through March 31, 2021 (previously January 1, 2020 through March 31, 2020). All references to the 2020 data reporting period have been changed to 2021. We added the “Clinical Laboratory Fee Schedule Data Reporting Period Delayed” Section on page 24 to summarize the changes. All other information remains the same.

January 8, 2020

Collaborative - Surgical Dressings and Supplies

The DME Specialty page has been updated to include a new tutorial for Collaborative Surgical Dressings and Supplies.


Advanced Diagnostic Imaging Appropriate Use Criteria Modifiers

A new section has been added to our modifier page relating to Advanced Appropriate Use Criteria Modifiers. Please review the information to ensure you are reporting the modifiers correctly. 


January 7, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11570 – CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
The Centers for Medicare & Medicaid Services revised this article on January 3, 2020, to reflect an updated Change request (CR) that corrected the Calendar Year 2020 maintenance and servicing fee for certain oxygen equipment to $73.02 in the CR’ s business requirement 11570.9. The transmittal number, CR release date and link to the transmittal also changed. All other information remains the same.

Reissued:

SE18006 – New Medicare Beneficiary Identifier (MBI) Get It, Use It
The Centers for Medicare & Medicaid Services reissued this article on January 2, 2020, to update certain language to show the use of the MBI is fully implemented.

January 6, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11607 – January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Change Request 11607 informs Medicare Administrative Contractors about updates to the ASC payment system for Calendar Year 2019 and describes changes to and billing instructions for various payment policies in the January 2020 ASC payment system update. This notification also includes updates to the Healthcare Common Procedure Coding System. Be sure your billing staffs are aware of these changes.

January 2, 2020

Online Registration Available for January 16, 2020, Open Meeting and Proposed LCDs Now Posted

Online registration for the January 16, 2020, Open Meeting is now available and will close at 3:00 PM Eastern Time (ET) on Monday, January 13, 2020, or before January 13th if room capacity is filled. The Novitas Solutions Proposed Local Coverage Determinations (LCDs) are now posted. IMPORTANT: The Open Meeting will be held at Novitas Solutions, 2020 Technology Parkway, Mechanicsburg, PA 17050 at 10:00 AM ET. Due to limited room capacity, registered presenters will be given priority for seating and registered observers will be accepted until remaining seats are filled.

Open Meetings are to allow interested parties the opportunity to make presentations of information and offer comments related to new Proposed LCDs and/or the revised portion of a Proposed LCD that are in the 45-day open comment period. Interested parties may also request to attend as an observer. If you are interested in attending as a presenter or observer, please view our Proposed Local Coverage Determination Open Meetings page for specific guidelines and other helpful information.


December 30, 2019

The following Local Coverage Determinations (LCDs) which were posted for notice on November 14, 2019 are now effective. The related Billing and Coding articles for these LCDs are also now effective:

4Kscore Test Algorithm (L37792)
Billing and Coding: 4Kscore Test Algorithm (A56653)
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)( L38229)
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (A56642)
Micro-Invasive Glaucoma Surgery (MIGS) (L38223)
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56633)

Please Note: Billing and Coding: 4Kscore Test Algorithm Article (A56281) will be retired effective 12/29/2019. Please refer to A56653 for services on and after 12/30/2019.


December 26, 2019

The following Local Coverage Determinations (LCDs) has have been posted for comments. The comment period will end on February 8, 2020.

Magnetic-Resonance-Guided-Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (DL38495)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)

Submit Comments

The following Draft Billing and Coding articles are related to the above Proposed LCDs.

Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (DA57839)
Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DA57752)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11574 – Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 – Laboratory Date of Service Policy
Change Request 11574 updates the Laboratory Date of Service Policy in the Medicare Claims Processing Manual, Chapter 16, Section 40.8. Make sure your billing staffs are aware of these updates.
MM11554 – Manual Update to Publication (Pub.) 100-04, Chapter 20, to Revise the Subsection 10 - Where to Bill Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Parenteral and Enteral Nutrition (PEN) Items and Services
Change Request (CR) 11554 updates the Medicare Claims Processing Manual with previously published instructions from CR 5917 Claims Jurisdiction and Enrollment Procedures for Suppliers of Certain Prosthetics, Durable Medical Equipment (DME) and Replacement Parts, Accessories and Supplies (Transmittal 1603, September 26, 2008) and CR 6573 Additional Instructions on Processing Claims for DMEPOS Items Submitted Under the Guidelines Established in CR5917 (Transmittal 531, August 14, 2009). CR 11554 does not convey any Medicare policy changes.

December 23, 2019

Special Edition – Monday, December 23, 2019

Provider Education Message:

New Medicare Card Transition Ends Next Week: Claim Reject Codes Beginning January 1

Get paid. Use Medicare Beneficiary Identifiers (MBIs) now. If you do not use MBIs on claims (with a few exceptions) after January 1, regardless of the date of service, you will get:

Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
Paper claims notices: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

How can you get the MBI? If your patients do not bring their Medicare cards with them:

Give them the Get Your New Medicare Card flyer in English or Spanish.
Use your Medicare Administrative Contractor’s look-up tool. Sign up for the Portal to use the tool.
Check the remittance advice. Until December 31, we return the MBI on the remittance advice for every claim with a valid and active Health Insurance Claim Number (HICN).

See the MLN Matters Article to learn how to get and use MBIs.


Provider Enrollment Application Fee Amount for CY 2020

On November 12, CMS issued a notice: Provider Enrollment Application Fee Amount for Calendar Year 2020 [CMS–6089–N (https://go.usa.gov/xppFM)]. Effective January 1, 2020, the application fee is $595 for institutional providers that are:

Initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP);
Revalidating their Medicare, Medicaid, or CHIP enrollment; or
Adding a new Medicare practice location.

This fee is required with any enrollment application submitted from January 1 through December 31, 2020.


December 20, 2019

New Look to Local Coverage Determinations (LCDs) and Billing and Coding Articles

Consistent with the instruction in Change Request (CR) 10901, the Medical Policy Team has been working to relocate all coding information from our Local Coverage Determinations (LCDs) into related Billing and Coding Articles. This project was completed on November 21, 2019. Therefore, you will now find all coding information in Billing and Coding Articles. In order to better assist you in finding the related Billing and Coding Article, a link has been placed at the bottom of the LCDs.


The Novitas Solutions Medical Policy team has evaluated all active Local Coverage Articles for any impact in response to the 2020 Annual HCPCS/CPT Code Update. The following is a list of the impacted Articles. The revised Articles will be published to the Medicare Coverage Database and on our Website in January. Please continue to watch our website for updates.

A56530 - Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
A54117 - Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
A56589 - Billing and Coding: Barium Swallow Studies, Modified
A52986 - Billing and Coding: Biomarkers for Oncology
A56602 - Billing and Coding: Cardiac Rhythm Device Evaluation
A56615 - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)
A56587 - Billing and Coding: Cosmetic and Reconstructive Surgery
A53124 - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms
A53252 - Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
A53134 - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions
A52993 - Billing and Coding: Non-Invasive Peripheral Venous Studies
A57320 - Billing and Coding: Pulmonary Function Testing
A56967 - Billing and Coding: Services That Are Not Reasonable and Necessary
A54111 - Billing and Coding: Speech-Language Pathology (SLP) Services: Communication Disorders
A57703 - Billing and Coding: Therapy and Rehabilitation Services (PT, OT)
A53001 - Billing and Coding: Wound Care

December 19, 2019

CMS Provider Education Message:

MAC Operations: Provide Feedback at a Listening Session

MLN Connects® for Thursday, December 19, 2019

View this edition as a PDF

News

DMEPOS: Changes to Conditions of Payment Reduce Burden
DMEPOS Competitive Bidding Surveys: Comment by December 20
Mohs Microsurgery: Comparative Billing Report in December
Hospice Provider Preview Reports: Review Your Data by January 15
Hospice Providers: Volunteer for Alpha Testing of HOPE Assessment Instrument
LTCH Compare Refresh
IRF Compare Refresh
2020 Eligible Clinician Electronic Clinical Quality Measure Flows
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Compliance

Provider Minute Video: The Importance of Proper Documentation

Claims, Pricers & Codes

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Updated

Events

Mohs Microsurgery: Comparative Billing Report Webinar — January 7
ESRD Quality Incentive Program: CY 2020 ESRD PPS Final Rule Call — January 14
Listening Sessions on MAC Opportunities to Enhance Provider Experience — January 15, 22, or 29

MLN Matters® Articles

Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2020
Update Inpatient Prospective Payment System (IPPS) Pricer and Related Claims Reprocessing
Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS — Revised
Medicare Part B Home Infusion Therapy Services with the Use of Durable Medical Equipment — Revised
Looking for an MLN Matters Article?

Publications

Hospital Quality Reporting: QRDA I Conformance Statement Resource

Multimedia

Ambulance Services Call: Audio Recording and Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11598 – Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Change Request 11598 provides instructions for the CY 2020 CLFS, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. Make sure your billing staffs are aware of these updates.

December 17, 2019

Provider Education Message:

Special Edition – Tuesday, December 17, 2019

Provider Education Message:

New Medicare Card Transition Ends in 2 Weeks: Use MBIs Now to Get Paid January 1

The 21 month Medicare Beneficiary identifier (MBI) transition period ends in two weeks. Update your patients’ records and use MBIs now. Starting January 1, you must use MBIs to bill Medicare regardless of the date of service:

We will reject claims submitted with Health Insurance Claim Numbers (HICNs) with a few exceptions
We will reject all eligibility transactions submitted with HICNs

Need the MBI?

We encourage people with Medicare to carry their cards with them since we removed the Social Security Number-based number; if your patients do not bring their Medicare cards with them:

Give them the Get Your New Medicare Card flyer in English (PDF) or Spanish (PDF).
Use your Medicare Administrative Contractor’s look-up tool. Sign up (PDF) for the Portal to use the tool.
Check the remittance advice. Until December 31, we return the MBI on the remittance advice for every claim with a valid and active HICN.

MBI on a Patient’s Card Doesn’t work?

Medicare beneficiaries, their authorized representatives, or CMS can ask to change MBIs; for example, if the number is compromised. It is possible your patient will seek care before getting a new card with the new MBI. 

If you get an eligibility transaction error code (AAA 72) of “invalid member ID,” your patient’s MBI may have changed.  

Do a historic eligibility search to get the termination date of the old MBI.
Get the new MBI from your Medicare Administrative Contractor’s secure look-up tool. Sign up (PDF) for the Portal to use the tool.

See the MLN Matters Article (PDF) for answers to your questions on using MBIs.


December 16, 2019

Reopening Gateway - Coming in Early 2020!

Novitas Solutions is dedicated to the development of self-service tools to reduce customer burden and to improve the overall customer experience. The Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process. Logging into the Reopening Gateway is a quick and easy way to update claim data through the internet. 


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11583 – Update Inpatient Prospective Payment System (IPPS) Pricer and Related Claims Reprocessing
Change Request 11583 updates the Fiscal Year 2020 IPPS Pricer with a corrected version of the wage index table and provides direction to reprocess claims affected by the incorrect version. Make sure your billing staff is aware of this change.
MM11593 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2020
Change Request 11593 announces the changes that will be included in the April 2020 quarterly release of the edit module for clinical diagnostic laboratory services. Please be sure your billing staffs are aware of these updates.

Revised:

MM11335 – Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
The Centers for Medicare & Medicaid Services (CMS) revised this article on December 13, 2019, due to an updated Change Request (CR) that added the business requirement 11335.9 in the CR for contractor integration testing. CMS also changed the CR release date, transmittal number and link to the transmittal. All other information remains the same.

The comment period is now closed for the following Proposed Local Coverage Determinations. Comments received will be reviewed by our Contractor Medical Directors. The Response to Comment Articles and finalized Billing and Coding Articles will be related to the final LCDs when they are posted for notice.

Biomarkers for Oncology (DL35396)
Thrombolytic Agents (DL35428)

November 2019 Part B Newsletter

The November 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


December 12, 2019

CMS Provider Education Message:

Quality Payment Program: Your MIPS Eligibility Status

MLN Connects® for Thursday, December 12, 2019

View this edition as a PDF

News

Open Payments: Review and Dispute Data by December 31
LTCH Provider Preview Reports: Review Your Data by January 9
IRF Provider Preview Reports: Review Your Data by January 9
Quality Payment Program: Check Your Final 2019 MIPS Eligibility Status
Quality Payment Program: MIPS Low-Volume Threshold Criteria for 2019
Home Health Agencies: OASIS Considerations for PDGM Transition

Compliance

Bill Correctly for Device Replacement Procedures

Claims, Pricers & Codes

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

Events

ESRD Quality Incentive Program: CY 2020 ESRD PPS Final Rule Call — January 14

MLN Matters® Articles

Medicare Part B Home Infusion Therapy Services with the Use of Durable Medical Equipment
CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements — Revised
Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020 — Revised
Looking for an MLN Matters Article?

Publications

Opioid Treatment Programs (OTPs) Medicare Billing & Payment
Hospice Comprehensive Assessment Measure

Multimedia

Hospital Price Transparency Call: Audio Recording and Transcript


December 11, 2019

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for November 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


December 10, 2019

CMS Provider Education Message:

Provider Education Message:

Most HICN Claims Reject – Regardless of Date Service

Use Medicare Beneficiary Identifiers (MBIs) now to avoid claim and eligibility transaction rejects. Starting January 1, 2020, regardless of the date of service on the Medicare transaction, most Social Security Number – based Health Insurance Claim Number (HICN) Medicare transactions will reject with a few exceptions.

If you do not use MBIs on claims after January 1, you will get:

Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
Paper claims notices: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

Thank you for transitioning to MBIs during the 21 month transition period, protecting your patients from identity theft.

You are currently submitting 87% of claims with MBIs.
If your patient doesn’t have their new card, give them the Get Your New Medicare Card flyer in English or Spanish.
Get MBIs through the MAC portals (sign up (PDF) now and after the transition period. You can also find the MBI on the remittance advice.

See the MLN Matters Article (PDF) for more information on getting and using MBIs.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for November 2019. Please take time to review these FAQs for answers to your questions.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM10882 – Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35
Change Request 10882 revises the “Medicare Claims Processing Manual” Chapters 1 and 35, to add new sections on global billing and separate Technical Component and Professional Component billing instructions. Make sure your billing staffs are aware of these changes.
MM11570 – CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Change Request 11570 provides the Calendar Year 2020 annual update for the Medicare DMEPOS fee schedule. The instructions include information on the data files, update factors, and other information related to the update of the fee schedule. Make sure your billing staffs are aware of these updates.
SE19029 – Medicare Part B Home Infusion Therapy Services With The Use of Durable Medical Equipment
Section 1834(u)(1) of the Social Security Act (the Act), as added by Section 5012 of the 21st Century Cures Act (Pub. L. 144-255), established a new Medicare Home Infusion Therapy (HIT) benefit under Medicare Part B. The Medicare HIT benefit is for coverage of HIT services for certain drugs and biologicals administered intravenously, or subcutaneously for an administration period of 15 minutes or more, in the home of an individual, through a pump that is a Durable Medical Equipment item. This benefit is effective January 1, 2021.
For more information regarding services furnished in calendar years 2019 and 2020, review the Home Infusion Therapy Temporary Transitional Payment Frequently Asked Questions.

Revised:

MM11268 – Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
Change Request (CR) 11268 informs Medicare Administrative Contractors that, effective on January 1, 2020 (the start of the AUC program Educational and Operations Testing Period); they should accept the AUC related Healthcare Common Procedure Coding System modifiers on claims. Please be sure your billing staff and vendors are aware of this update. Subsequent CRs will follow at a later date that will continue AUC program implementation.

December 9, 2019

The comment period will close on December 15, 2019 for the following Proposed Local Coverage Determinations (LCDs):

Biomarkers for Oncology (DL35396)
Thrombolytic Agents (DL35428)

Submit Comments


December 5, 2019

CMS Provider Education Message:

MLN Connects — DMEPOS Competitive Bidding Surveys: Comment by December 20

MLN Connects® for Thursday, December 5, 2019

View this edition as a PDF

News

Direct Contracting Risk-Sharing Options: Submit Letter of Intent by December 10
DMEPOS Competitive Bidding Surveys: Comment by December 20
Quality Payment Program: Technical Expert Panel Nominations due December 20
Quality Payment Program: MIPS Exception Applications due December 31
Clinical Laboratory Fee Schedule: CY 2020 Final Payment Determinations
Quality Payment Program: 2019 APM Incentive Payment Details
PEPPERs for Short-term Acute Care Hospitals
eCQM Reporting: Updated 2020 QRDA III Implementation Guide
National Influenza Vaccination Week
National Handwashing Awareness Week

Compliance

Cardiac Device Credits: Medicare Billing

Claims, Pricers & Codes

Average Sales Price Files: January 2020
Home Health RAPs: Hold Starting January 1, 2020

Events

Hospital Price Transparency Special Open Door Forum — December 10
Medicare Promoting Interoperability Program 2020 Webinar — January 16

MLN Matters® Articles

Overview of the Patient-Driven Groupings Model
Payments and Payment Adjustments under the Patient-Driven Groupings Model
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring File Update

Publications

Disproportionate Share Hospital — Revised
Federally Qualified Health Center — Revised
Medicare Learning Network (MLN) Learning Management System (LMS) FAQs — Revised

Multimedia

Clinical Labs Call: Audio Recording and Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11560 – Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Change Request 11560 provides a summary of the policies in the CY 2020 MPFS Final Rule announces the Telehealth Originating Site Facility Fee payment amount and makes other policy changes related to Medicare Part B payment. These changes are applicable to services furnished in CY 2020. Make sure your billing staffs are aware of these updates.

December 3, 2019

Provider Education Message:

Special Edition – Tuesday, December 3, 2019

MBI Transition Ends This Month: Will You Be Paid On January 1?

The 21 month transition period will end on December 31; use Medicare Beneficiary identifiers (MBIs) now.

You are currently submitting 86% of claims with MBIs.
Get MBIs from your patients and through the MAC portals (sign up) now and after the transition period. You can also find the MBI on the remittance advice.
Protect your patients from identity theft - use MBIs.

Starting January 1, if you do not use the MBI (regardless of the date of service) for Medicare transactions

We will reject your claims with a few exceptions
We will reject all eligibility transactions

See the MLN Matters Article for more information on getting and using MBIs.


December 2, 2019

Provider Education Message:

Special Edition – Monday, December 2, 2019

HHAs: Get Help Registering for iQIES by December 23

Avoid payment delays. You need access to the upgraded Internet Quality Improvement and Evaluation System (iQIES) to submit assessment data beginning January 1. We will return claims that cannot be matched to assessments, delaying your Medicare payments. The first step is to create an account in the Healthcare Quality Information System (HCQIS) Access, Roles and Profile Management (HARP).

Learn how:

HARP Registration Process 5 minute video
HARP Manual Proofing 2 minute video
How to Create an iQIES Account    1.5 minute video
iQIES Onboarding Guide
MLN Connects Special Edition article

Still Need Help?

HARP registration: QTSO Helpdesk at (800) 339-9313 or help@qtso.com  
iQIES: send questions to iQIES_Broadcast@cms.hhs.gov

The following Local Coverage Article which was posted for notice on October 17, 2019 is now effective:

Self-Administered Drug Exclusion List (A53127)

November 27, 2019

CMS Provider Education Message:

Patients Over Paperwork Newsletter
MLN Connects® for Wednesday, November 27, 2019

View this edition as a PDF

 
News

FY 2019 Medicare FFS Improper Payment Rate Lowest Since 2010
Patients Over Paperwork Newsletter
Celebration of National Rural Health Day
November is Home Care and Hospice Month
World AIDS Day is December 1

Compliance

Ambulance Fee Schedule and Medicare Transports

Events

Hospital Price Transparency Final Rule Call — December 3
Ground Ambulance Organizations: Data Collection System Call — December 5

MLN Matters® Articles

Home Health Agencies (HHAs) Urged to Establish Access to the Internet Quality Improvement and Evaluation System (iQIES) By December 23, 2019
Claim Status Category and Claim Status Codes Update
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2020
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 Healthcare (CAQH) CORE
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020
Updating Fiscal Intermediary Shared System (FISS) Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient's Home
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020 — Revised

Publications

Quality Payment Program: MIPS and APM Resources
ACOs: Beneficiary Engagement Toolkit and Case Studies

Multimedia

Physician Fee Schedule and Hospital OPPS/ASC Call: Audio Recording and Transcript

November 26, 2019

Special Edition – Tuesday, November 26, 2019

Provider Education Message:

HHAs: Avoid Payment Delays, Register for iQIES by December 23

Act now. Home Health Agencies (HHAs) need access to the upgraded Internet Quality Improvement and Evaluation System (iQIES) to submit assessment data beginning January 1. We will return claims that cannot be matched to assessments, delaying your Medicare payments. See the MLN Connects Special Edition article SE 19025 for:

Background
Step-by-step instructions
Training videos
Frequently asked questions
How to get help

Special Edition – Tuesday, November 26, 2019

Provider Education Message:

New Medicare Card: Claim Reject Codes After January 1

Get paid. Use Medicare Beneficiary Identifiers (MBIs) now.

If you do not use MBIs on claims (with a few exceptions) after January 1, you will get:

Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)
Paper claims notices: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

We encourage people with Medicare to carry their cards with them since we removed the Social Security Number-based numbers; if your patients do not bring their Medicare cards with them:

Give them the Get Your New Medicare Card flyer in English (PDF) or Spanish (PDF).
Use your Medicare Administrative Contractor’s look-up tool. Sign up for the Portal to use the tool.
Check the remittance advice. Until the end of  December, we return the MBI on the remittance advice for every claim with a valid and active Health Insurance Claim Number.

See the MLN Matters Article to learn how to get and use MBIs.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11485 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
The Centers for Medicare & Medicaid Services revised this article on October 30, 2019, due to an updated Change Request (CR) 11485, which removed an invalid code for NCD 190.14. In the article, the CR Release Date, transmittal number and link to the transmittal were updated. All other information is unchanged.

November 25, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11542 – Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2020
Change Request (CR) 11542 instructs the Medicare Administrative Contractors to update the claims processing system with the new CY 2020 Medicare rates. These updates relate to Chapter 3, sections 10.3, 20.2, and 20.6 of the Medicare General Information, Eligibility, and Entitlement Manual, which are attachments to the CR. Please make sure your billing staffs are aware of these changes.

2020 Medicare Deductibles / Coinsurance / Therapy Thresholds are Now Available

The 2020 Medicare Deductibles / Coinsurance / Therapy Thresholds are now available. Please take a moment to review.


How unsolicted/voluntary refunds are handled

Medicare contractors receive unsolicited/voluntary refunds (i.e., monies received not related to an open account receivable). Part A contractors generally receive unsolicited/voluntary refunds in the form of an adjustment bill, but may receive some unsolicited/voluntary refunds as checks. Part B contractors generally receive checks. Substantial funds are returned to the trust fund each year through such unsolicited/voluntary refunds.

The Centers for Medicare & Medicaid Services reminds providers that:

The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the federal government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

Source: CMS Pub. 100-06, Chapter 5, Section 410.10


November 22, 2019

Special Edition – Thursday, November 21, 2019

Provider Education Message:

HHAs: Avoid Payment Delays, Register for iQIES by December 23

Act now. Home Health Agencies (HHAs) need access to the upgraded Internet Quality Improvement and Evaluation System (iQIES) to submit assessment data beginning January 1. We will return claims that cannot be matched to assessments, delaying your Medicare payments. See the MLN Connects Special Edition article SE 19025 for:

Background
Step-by-step instructions
Training videos
Frequently asked questions
How to get help

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11467 – Claim Status Category and Claim Status Codes Update  
Change Request 11467 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. Make sure your billing staff is aware of this update.
MM11489 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Change Request 11489 updates the RARC and CARC lists and instructs the ViPS Medicare System and Fiscal Intermediary Shared System to update the MREP and PC Print software. Be sure your billing staffs are aware of these changes and obtain the updated MREP and PC Print if they use that software.
MM11490 – 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 Healthcare (CAQH) CORE
Change Request 11490 instructs Medicare Administrative Contractors and Medicare’s Shared System Maintainers to update systems based on the CORE 360 Uniform use of CARC, RARC, and CAGC rule publication. These system updates are based on the CORE Code Combination List scheduled to be published on or about February 1, 2020. Make sure your billing staffs are aware of these updates.

November 21, 2019

CMS Provider Education Message:

MLN Connects — Hospital Price Transparency: Register for Dec 3 Call

MLN Connects® for Thursday, November 21, 2019

View this edition as a PDF

News

Promoting Interoperability Programs: Updated list of eCQMs
MIPS Improvement Activities Technical Expert Panel: Nominations due November 29
DMEPOS Competitive Bidding Surveys: Comment by December 20
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
Modernizing CMS: Organizational Changes Announced

Compliance

Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

Hospital Price Transparency Final Rule Call — December 3
Hospice Quality Reporting Program Forum Webinar — December 4
Ground Ambulance Organizations: Data Collection System Call — December 5

MLN Matters® Articles

2020 Annual Update to the Therapy Code List
2020 Annual Update of Per-Beneficiary Threshold Amounts
Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020
Home Health (HH) Patient-Driven Groupings Model (PDGM) - Revised and Additional Manual Instructions
Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators
Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the Fiscal Intermediary Shared System (FISS)
Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2020

Publications

Medical Privacy of Protected Health Information — Revised
Remittance Advice Resources and FAQs — Revised

Multimedia

Part A Cost Report Webcast: Audio Recording and Transcript
Improving Health Care Quality for LGBTQ People Web-Based Training Course — Updated

The following Local Coverage Determinations have been revised. The related Billing and Coding articles have also been revised or added.

Electroretinography (ERG) (L37371)
Billing and Coding: Electroretinography (ERG) (A56672)
Endovenous Stenting (L37893)
Billing and Coding: Endovenous Stenting (A56414)
Epidural Injections for Pain Management (L36920)
Billing and Coding: Epidural Injections for Pain Management (A56681)
Evaluation and Management Services Provided in a Nursing Facility (L35068)
Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility (A56712)
Facet Joint Interventions for Pain Management (L34892)
Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
Nusinersen (Spinraza) (L37682)
Billing and Coding: Nusinersen (Spinraza) (A56860)
Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (L35035)
Billing and Coding: Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (A56631)
Trigger Point Injections (L35010)
Billing and Coding: Trigger Point Injections (A57751)
Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (L35130)
Billing and Coding: Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (A57752)
Wireless Capsule Endoscopy (L35089)
Billing and Coding: Wireless Capsule Endoscopy (A57753)
Wound Care (L35125)
Billing and Coding: Wound Care (A53001)

The following LCD has been revised:

Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (L38229)

The following Billing and Coding Articles have been revised:

Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240)
Billing and Coding: Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Physician Requirements (A55758)
Billing and Coding: Compounded Drugs Used in an Implantable Infusion Pump (A54100)
Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss (A56440)
Billing and Coding: Isolated Ultrafiltration for Management of Fluid Overload in Cardiac Disease (A53126)
Billing and Coding: Laboratory Panels (A56473)
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions (A53132)
Billing and Coding: Prepackaged Kits (A54515)
Billing and Coding: Prolonged Drug and Biological Infusions Started Incident To a Physician’s Service Using an External Pump (A55134)
Billing and Coding: Rezum® Procedure (A55352)
Billing and Coding: Ventricular Assist Device (VAD) Supply or Accessory (A54910)

The following LCD and the related Billing and Coding Article have been retired for dates of service on and after November 21, 2019:

Sclerotherapy and Endovenous Non-Thermal Treatment of Varicose Veins (L37796)
Sclerotherapy and Endovenous Non-Thermal Treatment of Varicose Veins (A56268)

Processing Instructions to Update the Standard Paper Remit (SPR)

CMS implemented MLN Matters Article MM11112 on July 1, 2019. With the passage and signing of the Social Security Number Fraud Prevention Act of 2017, which became Public Law No. 115-59, the law, restricts the inclusion of SSNs on documents sent by mail by the Federal Government effective not later than 5 years after the date of its enactment.

Based on instruction  MACS updated their systems to ensure that SPRs mailed after July 1, 2019, mask the Health Insurance Claim Number (HICN), so the Social Security Number (SSN) does not show. 

Please ensure your billing staff is aware of this directive. 


November 20, 2019

Modifier 78 Fact Sheet  

Our fact sheet on the proper use of modifier 78 has been updated. Please take time to review the fact sheet to ensure that you are reporting the modifier correctly.


November 19, 2019

CMS Provider Education Message:

Special Edition – Tuesday, November 19, 2019

Provider Education Message:

New Medicare Card: Get Paid January 1, 2020 – Use MBIs Now

Do not wait. Update your patients' records and use Medicare Beneficiary identifiers (MBIs) now, before you are busy with other patient insurance changes in January.

We encourage people with Medicare to carry their cards with them since we removed the Social Security Number-based number; if your patients do not bring their Medicare cards with them:

Give them the Get Your New Medicare Card flyer in English (or Spanish).
Use your Medicare Administrative Contractor’s look-up tool. Sign up for the Portal to use the tool.
Check the remittance advice. Until December 2019, we return the MBI on the remittance advice for every claim with a valid and active Health Insurance Claim Number (HICN).

Starting January 1, you must use MBIs to bill Medicare regardless of the date of service:

We will reject claims submitted with HICNs with a few exceptions
We will reject all eligibility transactions submitted with HICNs

See the MLN Matters Article for answers to your questions on using MBIs.


November 15, 2019

CMS Provider Education Message:

Special Edition – Friday, November 15, 2019

Provider Education Message:

Hospital Price Transparency Requirements
CY 2020 Hospital Outpatient Prospective Payment System Policy Changes

On November 15, CMS finalized policies that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency’s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States. In response to comments, CMS is extending the effective date to January 1, 2021 to ensure hospital compliance with these regulations.

The final rule includes:

Definitions of “hospital,” “standard charges,” and “items and services”
Requirements for making public all standard charges for all items and services in a machine-readable format
Requirements for displaying shoppable services in a consumer-friendly manner
Monitoring and enforcement

For More Information:

View the final rule (CMS-1717-F2): This HHS‐approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS‐approved document.
Press Release
Registration opening soon for December 3 Call

See the full text of this excerpted CMS Fact Sheet (Issued November 15).


November 14, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: If an MBI Changes

MLN Connects® for Thursday, November 14, 2019

View this edition as a PDF

News

New Medicare Card: If an MBI Changes
Medicare Shared Savings Program: Application Deadlines for January 1, 2021, Start Date
Drug Units in Excess of MUE: Comparative Billing Report in November
Person-Centered Planning: Comment on Performance Measurement by December 2
Emergency Preparedness Resources
Raising Awareness of Diabetes in November
Recognizing Lung Cancer Awareness Month and the Great American Smokeout

Compliance

Skilled Nursing Facility 3-Day Rule Billing

Claims, Pricers & Codes

MACRA Patient Relationship Categories and Codes: Reporting HCPCS Level II Modifiers

Events

Kidney Care Choices Model Webinars — November 15 and 22
2020 Quality Payment Program Final Rule Webinar — November 19
Drug Units in Excess of MUE: Comparative Billing Report Webinar — December 4
Ground Ambulance Organizations: Data Collection System Call — December 5

MLN Matters® Articles

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) — April 2020 Update
Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
Display PARHM Claim Payment Amounts — Revised
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update — Revised

The following Local Coverage Determinations (LCDs) posted for comment on June 27, 2019 have been posted for notice. The LCDs and related Billing and Coding Articles will become effective December 30, 2019:

4Kscore Test Algorithm (L37792)
Billing and Coding: 4Kscore Test Algorithm (A56653)
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)( L38229)
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (A56642)
Micro-Invasive Glaucoma Surgery (MIGS) (L38223)
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56633)

The following Response to Comment Articles contain summaries of all comments received and Novitas’ responses:

Response to Comments: 4Kscore Test Algorithm (A57729)
Response to Comments: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (A57732)
Response to Comments: Micro-Invasive Glaucoma Surgery (MIGS) (A57735)

The following Local Coverage Determinations have been revised. The related Billing and Coding articles, if applicable, have been added or revised.

Allergen Immunotherapy (L36240)
Billing and Coding: Allergen Immunotherapy (A56538)
Ambulance Services (Ground Ambulance) (L35162)
Billing and Coding: Ambulance Services (Ground Ambulance) (A54574)
Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (L34977)
Billing and Coding: Anorectal Manometry, Anal Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters (A56530)
Autonomic Function Tests (L35395)
Billing and Coding: Autonomic Function Tests (A54954)
Barium Swallow Studies, Modified (L35433)
Billing and Coding: Barium Swallow Studies, Modified (A56589)
Biomarkers for Oncology (L35396)
Flow Cytometry (L35032)
Billing and Coding: Flow Cytometry (A56676)
Hemophilia Factor Products (L35111)
Billing and Coding: Hemophilia Factor Products (A56433)
Hyperbaric Oxygen (HBO) Therapy (L35021)
Billing and Coding: Hyperbaric Oxygen (HBO) Therapy (A56714)
Implantable Infusion Pump (L35112)
Billing and Coding: Implantable Infusion Pump (A56778)
In Vitro Chemosensitivity & Chemoresistance Assays (L36634)
Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56710)
Intensity Modulated Radiation Therapy (IMRT) (L36711)
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
Intraoperative Neurophysiological Testing (L35003)
Billing and Coding: Intraoperative Neurophysiological Testing (A56722)
Intravenous Immune Globulin (IVIG) (L35093)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Lacrimal Punctum Plugs (L35095)
Billing and Coding: Lacrimal Punctum Plugs (A56780)
Loss-of-Heterozygosity Based Topographic Genotyping with PathfinderTG ® (L34864)
Billing and Coding: Loss-of-Heterozygosity Based Topographic Genotyping with Pathfinder TG® (A56897)
Lower Extremity Major Joint Replacement (Hip and Knee) (L36007)
Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee) (A56796)
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (L34822)
Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A56776)
Microvascular Therapy (L36434)
Billing and Coding: Microvascular Therapy (MVT) (A54343)
Mohs Micrographic Surgery (MMS) (L34961)
Billing and Coding: Mohs Micrographic Surgery (MMS) (A53883)
Multiple Imaging in Oncology (L35391)
Billing and Coding: Multiple Imaging in Oncology (A56848)
Neuromuscular Junction Testing (L34996)
Billing and Coding: Neuromuscular Junction Testing (A56785)
Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (L36419)
Billing and Coding: Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (A56856)
Surgery: Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control (L35011)
Billing and Coding: Surgery: Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control (A57712)
Therapy and Rehabilitation Services (PT, OT) (L35036)
Billing and Coding: Therapy and Rehabilitation Services (PT, OT) (A57703)
Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (L34924)
Billing and Coding: Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities (A55229)

The following Billing and Coding Articles have been revised:

Billing and Coding: 3D Interpretation and Reporting of Imaging Studies (A56526)
Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11501 – 2020 Annual Update to the Therapy Code List
Change Request 11501 updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year 2020 Current Procedural Terminology and Level II HCPCS. Make sure your billing staffs are aware of these updates.

MM11532 – 2020 Annual Update of Per-Beneficiary Threshold Amounts
Change Request (CR) 11532 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for CY 2020. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the Bipartisan Budget Act of 2018 was signed into law repealing the application of the caps.
For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and (b) $2,080 for Occupational Therapy (OT) services. Make sure your billing staffs are aware of these updates.
MM11453 – Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators
Change Request (CR) 11453 informs MACs that Status Indicator Q (therapy functional information code) is no longer effective with the 2020 MPFSDB beginning January 1, 2020. Medicare no longer requires functional therapy reporting. CR 11453 makes change to the Medicare Claims Processing Manual, Chapter 23, Section 30.2.2 to reflect this change for Status Indicator Q. Make sure that your billing staffs are aware of this change.

November 13, 2019

October 2019 Part B Newsletter

The October 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX 

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for October 2019. Please take time to review these FAQs for answers to your questions.


November 12, 2019

CMS Provider Education Message:

Special Edition – Tuesday, November 12, 2019

HICN Claims Reject

We are 50 days out from the end of the Medicare Beneficiary Identifier (MBI) transition period. Use the MBI on Medicare claims and other transactions now. Starting January 1, regardless of the date of service:

We will reject claims submitted with Health Insurance Claim Numbers (HICNs) with a few exceptions
We will reject all eligibility transactions submitted with HICNs

See the MLN Matters Article to learn how to get and use MBIs.


Reimbursement for Transport of Portable X-ray Equipment, Reported with Codes R0070 and R0075

As a result of the 5-year re-evaluation, Novitas will be updating the fees for codes R0070 and R0075 effective January 1, 2020.


Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for October 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


November 11, 2019

2020 Medicare Physician Fee Schedule Payment Rates and Participation Program

The annual physician and supplier participation period begins January 1st of each year, and runs through December 31st. The annual participation enrollment program for calendar year 2020 is scheduled to begin mid-November 2019.

Note: The dates listed for release of the participation enrollment / fee disclosure material are subject to publication of the annual final rule.

The 2020 Medicare Physician Fee Schedule (MPFS) payment rates will be posted to our website after publication of the MPFS final rule in the Federal Register.


November 7, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: HICN Claims Reject January 1, 2020

MLN Connects® for Thursday, November 7, 2019

View this edition as a PDF

News

New Medicare Card: HICN Claims Reject January 1, 2020
IRF/LTCH/SNF Quality Reporting Program: Submission Deadline Extended to November 18
MIPS Heart Failure Measure: Call for Public Comment Closes November 27
CAHs: Hardship Exception Application Deadline December 2
DMEPOS Competitive Bidding Surveys: Comment by December 20
MIPS: Virtual Group Election Period Open Through December 31
Medicare Ground Ambulance Data Collection System: Starts January 1, 2020
Home Health Agency: Final OASIS D-1 Data Submission Specifications
MACRA Patient Relationship Categories and Codes: Learn More
Recommend Influenza Vaccination: Each Office Visit is an Opportunity

Compliance

Bill Correctly for Medicare Telehealth Services

Claims, Pricers & Codes

Skilled Nursing Facility Claims Hold

Events

Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14
Ground Ambulance Organizations: Data Collection System Call — December 5

MLN Matters® Articles

Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy
Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System — Revised

Publications

Opioid Treatment Programs (OTPs) Medicare Enrollment
Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B — Revised

Multimedia

Medicare Telehealth Services Video

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11491 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) -- April 2020 Update
Change Request 11491 constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Make sure that your billing staffs are aware of these changes.

Revised:

MM11422 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
The Centers for Medicare & Medicaid Services revised this article on November 5, 2019, to reflect the revised CR11422 issued on November 4, 2019. In the article, CMS added HCPCS code J0642 and revised the CR release date, transmittal number, and the web address. All other information remains the same.

The following Local Coverage Determinations (LCDs) and related Billing and Coding articles have been revised.

Biomarkers Overview (L35062)
Billing and Coding: Biomarkers Overview (A56541)
Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) (L34834)
Billing and Coding: Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) (A56591)
BRCA1 and BRCA2 Genetic Testing (L36715)
Billing and Coding: BRCA1 and BRCA2 Genetic Testing (A56542)
Cataract Extraction (including Complex Cataract Surgery) (L35091)
Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A56615)
Chiropractic Services (L35424)
Billing and Coding: Chiropractic Services (A52987)
Co-Management of Surgical Procedures (L34862)
Billing and Coding: Co-Management of Surgical Procedures (A52989)
Corus® CAD Test (L36713)
Billing and Coding: Corus® CAD Test (A56608)
Cosmetic and Reconstructive Surgery (L35090)
Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
C-Reactive Protein High Sensitivity Testing (hsCRP) (L34856)
Billing and Coding: C-Reactive Protein High Sensitivity Testing (hsCRP) (A56643)
Diagnostic Abdominal Aortography and Renal Angiography (L35092)
Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
Frequency of Laboratory Tests (L35099)
Billing and Coding: Frequency of Laboratory Tests (A56420)

The following Billing and Coding article has been revised.

Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)

November 5, 2019

Travel Allowance for Collection of Specimens

Our article provides valuable coding and billing information to ensure the correct reporting of travel allowances for the collection of specimens, including a comprehensive review of the following hot topics:

Per Mile Travel Allowance (P9603)
P9603 Billing Examples
Flat Rate (P9604)
P9604 Billing Examples
Place of Service Codes
Modifier LR
Documentation Tips

Please refer to the (2019) MLN Matters Article MM11146 Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens for travel allowances payment amounts.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11327 – Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties
Change Request 11327 informs Medicare Administrative Contractors to update their system to make all psychiatric specialties eligible to receive the mental health bonus. Currently, the claims manual indicates that HPSA bonus payments for mental health services, only specialty 26 is set up to receive the bonus. Make sure that your billing staffs are aware of these changes.

November 4, 2019

Physician Fee Schedule and OPPS/ASC Final Rules Call — November 6

Please join the Centers for Medicare & Medicaid Services on Wednesday, November 6 from 2:15 to 3:45 pm Eastern Time for the Physician Fee Schedule and Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) Final Rules Call. For details and registration, please read this article.


Special Edition – Monday, November 4, 2019

Provider Education Message:

Physician Fee Schedule and OPPS/ASC Final Rules Call — November 6

Wednesday, November 6 from 2:15 to 3:45 pm ET

 Register for Medicare Learning Network events.

 During this call, learn about the provisions in two CMS CY 2020 final rules:

Physician Fee Schedule and Quality Payment Program: Final Rule, Press Release, Physician Fee Schedule Fact Sheet, and Quality Payment Program Fact Sheet
Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment systems: Final Rule and Fact Sheet

 Changes to the Physician Fee Schedule are aimed at reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care. Topics include:

Payment and supervision policy updates
Merit-based Incentive Payment System Value Pathways:  Streamlining the Quality Payment Program to reduce clinician burden
Creating the new Opioid Treatment Program benefit in response to the opioid epidemic

In addition, updates and policy changes under the Medicare OPPS and ASC payment systems lay the foundation for a patient-driven health care system.

A question and answer session follows the presentation. We encourage you to review the final rules prior to the call.

Target Audience: Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent health care providers; all hospitals operating in the United States; and other stakeholders.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11003 – Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
The Centers for Medicare & Medicaid Services revised this article on November 1, 2019, to update and clarify information regarding the eMDR registration/enrollment to indicate the provider and the Health Information Handler roles with more detail. All other information is unchanged.

November 1, 2019

Special Edition – Friday, November 1, 2019

Provider Education Message:

Physician Fee Schedule, Hospital OPPS, and ASC Final Rules

Physician Fee Schedule: Finalized Policy, Payment, and Quality Provisions for CY 2020

Medicare Hospital OPPS and ASC Payment System Final Rule for CY 2020


Physician Fee Schedule: Finalized Policy, Payment, and Quality Provisions for CY 2020

On November 1, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020.

Payment Provisions:

Ratesetting and conversion factor
Medicare telehealth services
Evaluation and management services
Physician supervision requirements for physician assistants
Review and verification of medical record documentation
Care management services
Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs
Bundled payments under the PFS for opioid use disorders
Therapy services

Other Provisions:

Quality Payment Program
Ambulance services
Ground ambulance data collection system
Open Payments Program
Medicare Shared Savings Program

For More Information:

Final Rule
Press Release
Press Release – Treatment for Opioid Use Disorder
Quality Payment Program Fact Sheet
Register for November 6 Call

See the full text of this excerpted CMS Fact Sheet (Issued November 1).


Medicare Hospital OPPS and ASC Payment System Final Rule for CY 2020

On November 1, CMS finalized policies that aim to increase choices, encourage medical innovation, empower patients, and eliminate waste, fraud, and abuse to protect seniors and taxpayers. The changes build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.

In accordance with Medicare law, CMS is updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent. This update is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for Multi-Factor Productivity (MFP).

Using the hospital market basket, CMS is finalizing an update to the ASC rates for CY 2020 equal to 2.6 percent. The update applies to ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.0 percent minus a 0.4 percentage point adjustment for MFP. This change will also help to promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.

The final rule with comment period includes:

Increasing choices and encouraging site neutrality
Method to control for unnecessary increases in utilization of outpatient services
Changes to the inpatient only list
ASC covered procedures list
Payment for procedures involving skin substitutes
Rethinking rural health
Changes in the level of supervision of outpatient therapeutic services in hospitals and critical access hospitals
Addressing wage index disparities
Unleashing innovation
Device pass-through applications
Protecting taxpayer dollars
Meaningful Measures/Patients Over Paperwork
Hospital Outpatient Quality Reporting Program
Ambulatory Surgical Center Quality Reporting Program
OPPS payment methodology for 340B purchased drugs
Partial Hospitalization Program (PHP) rate setting
Update to PHP per diem rates

Revision to the organ procurement organization conditions for certification

For More Information:

Final Rule
Register for November 6 Call

See the full text of this excerpted CMS Fact Sheet (Issued November 1).


October 31, 2019

Special Edition – Thursday, October 31, 2019

Provider Education Message:

Final Payment Rules for HH, ESRD, and DMEPOS

HHAs: CY 2020 Payment and Policy Changes and CY 2021 Home Infusion Therapy Benefit
ESRD and DMEPOS CY 2020 Final Rule

HHAs: CY 2020 Payment and Policy Changes and CY 2021 Home Infusion Therapy Benefit

CMS issued a final rule with comment period that finalizes routine updates to the home health payment rates for CY 2020, in accordance with existing statutory and regulatory requirements. This rule with comment period includes:

Modification to the payment regulations pertaining to the content of the home health plan of care
Allows therapist assistants to furnish maintenance therapy
Finalizes policies related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS)
Final policies related to the implementation of the permanent home infusion therapy benefit in CY 2021, including payment categories, amounts, and required and optional adjustments, and solicits comments on options to enhance future efforts to improve policies related to coverage of eligible drugs for home infusion therapy
Implementation of the Patient-Driven Groupings Model (PDGM), an alternate case-mix adjustment methodology with a 30-day unit of payment, mandated by the Bipartisan Budget Act of 2018 (BBA of 2018)

CMS projects that aggregate Medicare payments to Home Health Agencies (HHAs) in CY 2020 will increase by 1.3 percent, or $250 million. This increase reflects the effects of the 1.5 percent home health payment update percentage ($290 million increase), mandated by the BBA of 2018; and a 0.2 percent aggregate decrease (-$40 million) in payments to HHAs due to the changes in the rural add-on percentages, also mandated by the BBA of 2018. The rate updates also include a budget-neutral adjustment to the CY 2020 30-day payment amount to offset anticipated provider behavior changes upon implementation of the PDGM; the use of updated wage index data for the home health wage index; and updates to the fixed-dollar loss ratio to determine outlier payments. Given the scale of the PDGM payment system changes for CY 2020, it may take HHAs more time before they fully implement the behavior assumed by CMS; therefore, we applied the three previously outlined behavior change assumptions to half of the 30-day periods in our analytic file, resulting in a smaller adjustment to the 30-day payment amount needed to maintain budget neutrality, as required by law. CMS is finalizing a CY 2020 30-day payment amount (for those HHAs that report the required quality data) of $1,864.03.

The final rule also includes:

Enhance and modernize program integrity while reducing regulatory burden
Paraprofessional roles – Improving access to care
Home Health Quality Reporting Program
Home Health Value-Based Purchasing (HHVBP) Model

For More Information:

Final Rule
Press Release
HH PPS website
HHA Center website
PDGM webpage
Home Infusion Therapy Services website
Home Health Quality Reporting Requirements webpage
HHVBP Model webpage

See the full text of this excerpted CMS Fact Sheet (Issued October 31).


ESRD and DMEPOS CY 2020 Final Rule

On October 31, CMS issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2020. This rule also updates the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and finalizes changes to the ESRD Quality Incentive Program.

In addition, this rule includes:

Methodology for calculating fee schedule payment amounts for new Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items and services and making adjustments to the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts

Revises existing policies related to the competitive bidding program for DMEPOS

Streamlines the requirements for ordering DMEPOS items and creates one Master List of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements

Summaries of responses to requests for information on data collection resulting from the ESRD PPS technical expert panel, possible updates and improvements to the ESRD PPS wage index, and new rules for the competitive bidding of diabetic testing strips

CMS projects that the updates for CY 2020 will increase the total payments to all ESRD facilities by 1.6 percent compared with CY 2019. For hospital-based ESRD facilities, CMS projects an increase in total payments of 2.1 percent, while for freestanding facilities, the projected increase in total payments is 1.6 percent.

The final rule also includes:

Update to the outlier policy
Eligibility criteria for the Transitional Drug Add-on Payment Adjustment (TDAPA)
Basis of payment for the TDAPA for calcimimetics
Average sales price conditional policy for the application of the TDAPA
New and innovative renal dialysis equipment and supplies
Discontinuing the erythropoiesis-stimulating agent monitoring policy
Requests for Information

For More Information:

Final Rule
Press Release

See the full text of this excerpted CMS Fact Sheet (Issued October 31).


CMS Provider Education Message:

MLN Connects — Influenza Vaccine: Payment & Resources

MLN Connects® for Thursday, October 31, 2019

View this edition as a PDF

News

Protect Your Patients’ Identities: Use the MBI Now
Hospital Value-Based Purchasing Program Results for FY 2020
IRF/LTCH/SNF Quality Reporting Program Submission Deadline: November 15
Nursing Home Compare Refresh
Influenza Vaccination: Protect Your Patients this Season

Compliance

DMEPOS: Bill Correctly for Items Provided During Inpatient Stays

Claims, Pricers & Codes

Liver Transplant Claims: Possible Overpayment

Events

Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5
Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14
Success with the Hospice Quality Reporting Program Webinar — November 14

MLN Matters® Articles

Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N
Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model — Revised
What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight — Revised

Multimedia

Medicare Fraud & Abuse: Prevent, Detect, and Report Web-Based Training Course
Quality Payment Program: MIPS 2019 Web-Based Training Courses

The following Local Coverage Determinations (LCDs) have been revised in response to reconsideration requests and are now posted as Proposed LCDs. The Proposed LCDs are open for comments related to the current revisions only. Please refer to the Synopsis of Changes, Summary of Evidence and Analysis of Evidence sections for information pertinent to the revisions that are open for comment. The comment period will end on December 15, 2019.

Biomarkers for Oncology (DL35396)
Thrombolytic Agents (DL35428)
Submit Comments

The following draft Billing and Coding articles are related to the above Proposed LCDs. The articles contain the applicable CPT/HCPCS codes, ICD-10 Codes and billing and coding information.

Billing and Coding: Biomarkers for Oncology (DA52986)
Billing and Coding: Thrombolytic Agents (DA55237)

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding articles for these LCDs have been added or revised.

3D Interpretation and Reporting of Imaging Studies (L35408)
Billing and Coding: 3D Interpretation and Reporting of Imaging Studies (A56526)
4Kscore Test Algorithm (L37792)
Billing and Coding: Coding for 4Kscore Test Algorithm (A56281)
Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427)
Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee (A55036)
Nerve Conduction Studies and Electromyography (L35081)
Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
Sacral Nerve Stimulation (L35449)
Billing and Coding: Sacral Nerve Stimulation (A57617)
Scanning Computerized Ophthalmic Diagnostic Imaging (L35038)
Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (A57600)
Speech-Language Pathology (SLP) Services: Communication Disorders (L35070)
Billing and Coding: Speech-Language Pathology (SLP) Services: Communication Disorders (A54111)
Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy (L34891)
Billing and Coding: Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy (A57656)
Surgery: Blepharoplasty (L35004)
Billing and Coding: Surgery: Blepharoplasty (A57618)

The following Billing and Coding article has been revised.

Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11523 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020
Change Request 11523 contains the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.

Online Registration Available for November 15, 2019, Open Meeting and Proposed LCDs Now Posted

Online registration for the November 15, 2019, Open Meeting is now available and will close at 3:00 PM Eastern Time (ET) on Tuesday, November 12, 2019, or before November 12th if room capacity is filled. The Novitas Solutions proposed LCDs are now posted. IMPORTANT: The Open Meeting will be held at Novitas Solutions, 2020 Technology Parkway, Mechanicsburg, PA 17050 at 10:00 AM ET. Due to limited room capacity, registered presenters will be given priority for seating and registered observers will be accepted until remaining seats are filled.

Open Meetings are for the specific purpose of discussing the proposed LCDs. Anyone is welcome to present information related to the proposed LCDs that are in the 45-day draft comment period. Interested parties may also request to attend as an observer. If you are interested in attending as a presenter or observer, please view our Proposed Local Coverage Determination Open Meetings page for specific guidelines and other helpful information.


October 28, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19024 – Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N

This article conveys information on the National Coverage Determination requiring coverage of Chimeric Antigen Receptor (CAR) T-cell therapy for cancer. For more information on the National Coverage Determination, see the decision memorandum.

The Centers for Medicare & Medicaid Services is providing this information for hospitals providing CAR T-cell therapy to beneficiaries enrolled in MA plans. Make sure your billing staff is aware of these instructions.


October 24, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Claim Reject Codes After January 1

MLN Connects® for Thursday, October 24, 2019

View this edition as a PDF

News

New Medicare Card: Claim Reject Codes After January 1
Take Medicare Fraud, Waste and Abuse Fighting Further, Through Innovation
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Compliance

Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing

Claims, Pricers & Codes

ICD-10 Vaping Coding Guidance

Events

Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5
Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14

MLN Matters® Articles

Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates

Multimedia

CDC Opioids Training Module for Nurses
Quality Payment Program: APMs Web-Based Training

Changes to Amount in Controversy (AIC) for Appeals in 2020

The amount that must remain in controversy for ALJ hearing requests filed on or before December 31, 2019 is $160.This amount will increase to $170 for ALJ hearing requests filed on or after January 1, 2020. The amount that must remain in controversy for reviews in Federal District Court requested on or before December 31, 2019 is $1,630. This amount will increase to $1,670 for appeals to Federal District Court filed on or after January 1, 2020.


October 21, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11455 – Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates
Change Request 11455 contains instructions for Medicare Administrative Contractors (MAC) and the Railroad Specialty MAC to update the MDPP Expanded Model payment rates for Calendar Year 2020. Make sure your billing staffs are aware of the update.

October 17, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: MBI Transition Ends in Less Than 10 Weeks

MLN Connects® for Thursday, October 17, 2019

View this edition as a PDF

News

New Medicare Card: MBI Transition Ends in Less Than 10 Weeks
Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use
ICD-10 Coordination and Maintenance: Deadline for Comments November 8
CMS Health Equity Award: Submit Nomination by November 15
Quality Payment Program: Participation Status Tool Includes Second Snapshot of Data
Atherectomy: Comparative Billing Report in October
Protect Your Patients from Influenza this Season

Compliance

Cardiac Device Credits: Medicare Billing

Events

Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5
Atherectomy: Comparative Billing Report Webinar — November 6
Provider Compliance Focus Group Meeting — November 12

MLN Matters® Articles

Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes
Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised
October 2019 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

Publications

Quality Payment Program: MIPS and APM Resources
Roster Billing for Mass Immunizers — Revised
Acute Care Inpatient Hospital Prospective Payment System — Reminder
Hospice Payment System— Reminder
Hospital Outpatient Prospective Payment System— Reminder
Inpatient Psychiatric Facility Prospective Payment System— Reminder
Inpatient Rehabilitation Facility Prospective Payment System— Reminder
Long-Term Care Hospital Prospective Payment System— Reminder
Telehealth Services — Reminder

In response to the annual ICD-10 code update, the following Billing and Coding articles have been added or revised. The related Local Coverage Determinations (LCDs) have been revised to remove the codes and place them into the Billing and Coding articles.

Billing and Coding: Monitored Anesthesia Care (A57361)
Monitored Anesthesia Care (L35049)
Billing and Coding: Oximetry Services (A57205)
Oximetry Services (L35434)
Billing and Coding: Pulmonary Function Testing (A57320)
Pulmonary Function Testing (L35360)
Billing and Coding: Real-Time, Outpatient Cardiac Telemetry (A52995)
Real-Time, Outpatient Cardiac Telemetry (L34997)
Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (A57414)
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350)
Billing and Coding: Vestibular and Audiologic Function Studies (A57434)
Vestibular and Audiologic Function Studies (L35007)

In response to the 2020 annual ICD-10 code update, the following Billing and Coding Articles have been revised. Related LCDs, as applicable, have undergone a system change to remove the coding sections.

Billing and Coding: Allergy Testing (A56558)
Allergy Testing (L36241)
Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)
Assays for Vitamins and Metabolic Function (L34914)
Billing and Coding: Bariatric Surgical Management of Morbid Obesity (A56422)
Bariatric Surgical Management of Morbid Obesity (L35022)
Billing and Coding: Cardiac Event Detection Monitoring (A56600)
Cardiac Event Detection Monitoring (L34953)
Billing and Coding: Cardiac Rhythm Device Evaluation (A56602)
Cardiac Rhythm Device Evaluation (L34833)
Billing and Coding: Cardiovascular Nuclear Medicine (A56423)
Cardiovascular Nuclear Medicine (L35083)
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
Controlled Substance Monitoring and Drugs of Abuse Testing (L35006)
Billing and Coding: Implantable Automatic Defibrillators (A56355)
Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)
Magnetic Resonance Angiography (MRA)( L34865)
Billing and Coding: Molecular Diagnostics: Genitourinary Infectious Disease Testing (A56791)
Molecular Diagnostics: Genitourinary Infectious Disease Testing (L35015)
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)
Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)
Neurophysiology Evoked Potentials (NEPs) (L34975)
Billing and Coding: Non-Coronary Vascular Stents (A56365)
Non-Coronary Vascular Stents (L35084)
Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993)
Non-Invasive Peripheral Venous Studies (L35451)
Billing and Coding: Non-Vascular Extremity Ultrasound (A55037)
Non-Vascular Extremity Ultrasound (L35409)
Billing and Coding: Routine Foot Care (A52996)
Routine Foot Care (L35138)
Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Billing and Coding: Strapping (A56804)
Strapping (L36423)
Billing and Coding: Thrombolytic Agents (A55237)
Thrombolytic Agents (L35428)
Billing and Coding: Transesophageal Echocardiography (TEE) (A56505)
Transesophageal Echocardiography (TEE) (L35016)

The following Billing and Coding Articles have been revised. The related LCDs have been revised to remove the coding sections.

Billing and Coding: Hydration Therapy (A56634)
Hydration Therapy (L34960)
Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies (A52992)
Non-Invasive Cerebrovascular Arterial Studies (L35397)

The Self-Administered Drug Exclusion List, A53127 has been revised and is posted for notice. The article will become effective December 2, 2019

Modifier JB Use for Drugs/Biologicals included on the Self-Administered Drug Exclusion List
Several drugs/biologicals that are considered self-administered and included on the Novitas Self-Administered Drug (SAD) Exclusion List may be administered intravenously or subcutaneously. Effective with claims submitted for dates of service on or after December 2, 2019, Novitas will require the use of the Healthcare Common Procedure Coding System (HCPCS) modifier when reporting subcutaneous administration of a drug/biological that is included on the Novitas Self-Administered Drug (SAD) Exclusion List.
Further information regarding Self-Administered Drugs is found on the Medical Policy Drugs & Biologicals: Self-Administered Drug Exclusions page.

October 15, 2019

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for September 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for September 2019. Please take time to review these FAQs for answers to your questions.


Update to the Open Claims Issue: Procedure Codes Removed from Submitted Claims During Processing

There was a systems error identified in the quarterly release which caused scenarios where procedure codes were being inadvertently removed from submitted claims during processing.  If you have experienced a claim rejection, please resubmit your claim


October 14, 2019

The comment period is now closed for the following Proposed Local Coverage Determination (LCD). Comments received will be reviewed by our Contractor Medical Directors and a Response to Comments Article and a finalized Billing and Coding Article will be posted to our website and related to the LCD when it is posted for notice.

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (DL38385)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11330 – Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model
Change Request 11330 will enable all Medicare-enrolled nurse practitioners in Maryland to certify home health services for Medicare beneficiaries as part of the Maryland Total Cost of Care (TCOC) Model. This will apply to services that the nurse practitioners provide on and after January 1, 2020. Medicare systems will be operational to process claims with dates of service on or after January 1, 2020, at the beginning of the second year of the Maryland TCOC Model. Make sure your billing staffs are aware of these changes.
MM11335 – Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS
Change Request (CR) 11335 instructs Medicare's Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD). This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.

October 11, 2019

Frequently Asked Questions (FAQs)

Have questions and not sure where to turn? Check out our FAQs for answers to your questions.


Medicare Secondary Payer (MSP): MSP Billing Webinars

Join us as we discuss Medicare as a secondary payer (MSP) and the fundamentals of this cost-saving program. During our upcoming webcasts, we will provide an overview of the different Medicare Secondary Payer Billing Options for Medicare Part A on November 5, 2019, and Medicare Part B on November 6, 2019. 


October 10, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: 80% of Claims Submitted with MBI

MLN Connects® for Thursday, October 10, 2019

View this edition as a PDF

News

New Medicare Card: 80% of Claims Submitted with MBI
Nursing Homes: Enhancing Transparency about Abuse and Neglect
Quality Payment Program: MIPS Dates and Deadlines
October is National Breast Cancer Awareness Month

Compliance

Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims

Claims, Pricers & Codes

FY 2020 IPPS and LTCH PPS Claims Hold

Events

Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5

MLN Matters® Articles

Ambulance Inflation Factor for Calendar Year (CY) 2020 and Productivity Adjustment
Provider Enrollment Rebuttal Process
Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update — Revised
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020 — Revised

Publications

Medicare Preventive Services — Revised
Medicare Enrollment for Providers Who Solely Order or Certify — Reminder
Medicare Fraud & Abuse Poster — Reminder
Medicare Fraud & Abuse: Prevent, Detect, Report — Reminder
Medicare Overpayments — Reminder
PECOS for DMEPOS Suppliers — Reminder
PECOS for Physicians and NPPs — Reminder
PECOS for Provider and Supplier Organizations — Reminder

Multimedia

Opioid Treatment Program Listening Session: Audio Recording and Transcript

The following Draft Articles have replaced the Future Effective Articles and have been related to the Proposed LCDs:

Billing and Coding: 4Kscore Test Algorithm (DA56653)
4Kscore Test Algorithm (DL37792)
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (DA56642)
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (DL38229)
Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (DA56938)
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (DL38385)
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (DA56633)
Micro-Invasive Glaucoma Surgery (MIGS) (DL38223)

September 2019 Part B Newsletter

The September 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


October 9, 2019

Special Edition – Wednesday, October 9, 2019

Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule

On October 9, CMS issued a proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989. The proposed rule supports the CMS “Patients over Paperwork” initiative by reducing unnecessary regulatory burden on physicians and other health care providers while reinforcing the Stark Law’s goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest. Through the Patients over Paperwork initiative, the proposed rule opens additional avenues for physicians and other health care providers to coordinate the care of the patients they serve – allowing providers across different health care settings to work together to ensure patients receive the highest quality of care.

For More information:

Proposed Rule: Public comments due by December 31
Press Release

See the full text of this excerpted CMS Fact Sheet (Issued October 9).


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11457 – October 2019 Update of the Ambulatory Surgical Center (ASC) Payment System
The Centers for Medicare & Medicaid Services (CMS) revised this article on October 7, 2019, to reflect the revised Change Request (CR) 11457, issued on October 4. CMS revised the CR to correct table 1 to reinstate C9043 rather than delete it effective October 1, 2019, revise the related footnote 1 for J0641 in table 1, and delete footnote 2 in table 1. The CR release date, transmittal number, and the web address are changed. All other information remains the same.

October 8, 2019

The comment period will close on October 13, 2019 for the following Proposed Local Coverage Determination (LCD):

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (DL38385)

Submit Comments


October 7, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11497 – Ambulance Inflation Factor for Calendar Year (CY) 2020 and Productivity Adjustment
Change Request 11497 furnishes the Calendar Year (CY) 2020 Ambulance Inflation Factor (AIF) for determining the payment limit for ambulance services. The AIF for CY 2020 is 0.9 percent. Make sure that your billing staffs are aware of this change.

October 3, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Do You Refer Patients?

MLN Connects® for Thursday, October 3, 2019

View this edition as a PDF
 
News

New Medicare Card: Do You Refer Patients?
Opioid Treatment Programs: Get Ready to Participate in the New Benefit
Home Health Preview Reports for January 2020 Refresh
LTCH Provider Preview Reports: Review Your Data by October 11
IRF Provider Preview Reports: Review Your Data by October 11
Hospice Provider Preview Reports: Review Your Data by October 11
CLFS CY 2020 Preliminary Payment Determinations: Comment by October 27
MIPS: Virtual Group Election Period Open Through December 31
LTCH Compare Refresh
IRF Compare Refresh
Qualified Medicare Beneficiary Billing Requirements
Ostomies are Life-Savers
Looking for Educational Materials?

Compliance

Outpatient Services Payment: Beneficiaries Who Are Inpatients of Other Facilities

MLN Matters® Articles

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) - January 2020 Update — Revised

Publications

Quality Payment Program: 2019 APM Incentive Payment Fact Sheet
Billing Information for Rural Providers and Suppliers — Revised

Multimedia

Reducing Opioid Misuse Listening Session: Audio Recording and Transcript
SNF PPS: Patient Driven Payment Model Videos

October 2, 2019

Diabetes Self-Management Training (DSMT) Certificate

For providers intending to bill for diabetes self-management training (DSMT) services, a copy of the CMS-approved national accreditation certificate is required. CMS recognizes the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) as approved national accreditation organizations. The certificate can be mailed to one of our mailing addresses (JH) (JL) or faxed to 1-877-439-5479.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM10978 – Provider Enrollment Rebuttal Process
Change Request (CR) 10978 puts into operation the provision under 42 C.F.R. Section 424.545(b), which permits providers/suppliers whose Medicare billing privileges are deactivated to file a rebuttal. CR 10978 provides instructions for Medicare Administrative Contractors to advise providers/suppliers of their rebuttal rights, as well as for receiving and processing rebuttals.
A copy of the rebuttal submission form can be viewed in Attachment 2 of CR 10978. Make sure your billing staffs are aware of these instructions.

October 1, 2019

October is National Breast Cancer Awareness Month

Breast cancer is the second most common cancer in women. Medicare covers a screening mammography for eligible women. This article provides information on coverage you can share with your patients.


Provider Education Message:

New HCPCS Code J0642 for Levoleucovorin Injection

For dates of service on or after October 1, use HCPCS code J0642 for levoleucovorin injection products marketed under the brand name of Khapzory.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11485 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
Change Request 11485 announces changes to be included in the January 2020 quarterly release of the edit module for clinical diagnostic laboratory services. Please make sure your billing staffs are aware of these changes.
MM11495 – January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Change Request 11495 informs Medicare Administrative Contractors (MAC) about new and revised ASP and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after December 16, 2019. CMS gives MACs the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor through separate instructions available in Chapter 4, Section 50 of the Medicare Claims Processing Manual Make sure that your billing staffs are aware of these changes.

September 30, 2019

Durable Medical Equipment (DME) Specialty Page

The DME specialty page has been updated with a number of new Articles and Tutorials. Please visit the page to see the following:

Dear Physician Letters - Documentation Requirements (CGS)
Physicians! Are You Ordering a Spinal Orthosis for Your Patient?
Physicians! Are You Ordering Lower Limb Orthoses for Your Patients?
New Tutorials

September 27, 2019

Local Coverage Determination (LCD) and Article Update History for Jurisdiction H

The Novitas Solutions medical policy team has evaluated all active Local Coverage Determinations (LCDs) and Local Coverage Articles for any impact in response to the 2020 Annual ICD-10 Code Update. On this page is a list of the impacted LCDs and Articles. The revised Articles will be published to the Medicare Coverage Database and on the Novitas Website in the middle of October. Please continue to watch our website for updates.


September 26, 2019

Special Edition – Thursday, September 26, 2019

Provider Education Message:

Omnibus Burden Reduction (Conditions of Participation) Final Rule
Discharge Planning Rule Supports Interoperability and Patient Preferences

Omnibus Burden Reduction (Conditions of Participation) Final Rule

On September 26, CMS took action at President Trump’s direction to “cut the red tape,” by reducing unnecessary burden for American’s health care providers allowing them to focus on their priority – patients. The Omnibus Burden Reduction (Conditions of Participation) Final Rule removes Medicare regulations identified as unnecessary, obsolete, or excessively burdensome on hospitals and other health care providers to reduce inefficiencies and moves the nation closer to a health care system that delivers value, high quality care and better outcomes for patients at the lowest possible cost.

This rule advances the Patients over Paperwork initiative by saving providers an estimated 4.4 million hours of time previously spent on paperwork with an overall total projected savings to providers of $800 million annually.

This rule finalizes the provisions of three proposed rules

Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction (“Omnibus Burden reduction”), published September 20, 2018
Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care, published June 16, 2016
Fire Safety Requirements for Certain Dialysis Facilities, published November 4, 2016.

For More Information:

Final Rule
Press Release

Press release See the full text of this excerpted CMS Fact Sheet (Issued September 26).

Discharge Planning Rule Supports Interoperability and Patient Preferences

On September 26, CMS issued a final rule that empowers patients preparing to move from acute care into Post-Acute Care (PAC), a process called discharge planning. The rule puts patients in the driver’s seat of their care transitions and improves quality by requiring hospitals to provide patients access to information about PAC provider choices, including performance on important quality measures and resource-use measures, including:

Number of pressure ulcers
Proportion of falls that lead to injury
Number of readmissions back to the hospital

The rule also:

Advances CMS’s interoperability efforts by requiring the seamless exchange of patient information between health care settings, and ensuring that a patient’s health care information follows them after discharge from a hospital or PAC provider.
Revises the discharge planning requirements that hospitals (including long-term care hospitals, Critical Access Hospitals (CAHs) psychiatric hospitals, children’s hospitals, and cancer hospitals), inpatient rehabilitation facilities, and home health agencies must meet to participate in Medicare and Medicaid programs. It requires the discharge planning process to focus on a patient’s goals and treatment preferences. Hospitals are mandated to ensure each patient’s right to access their medical records in an electronic format.
Implements requirements from the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) that includes how facilities will account for and document a patient’s goals of care and treatment preferences.

Hospitals and CAHs are already conducting most of the revised discharge planning requirements, with the exception of the discharge planning requirements of the IMPACT Act.

For More Information: 

Fact Sheet
Final Rule

See the full text of this excerpted CMS Press Release (Issued September 26).


CMS Provider Education Message:

MLN Connects — More Questions About Using the MBI?

MLN Connects® for Thursday, September 26, 2019

View this edition as a PDF

News

New Medicare Card: More Questions about Using the MBI?
Quality Payment Program: Submit Comments on 2020 Proposed Rule by September 27
SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1
2019 QRDA I Implementation Guide and Sample File for Hospital Quality Reporting: Updated
Post-Acute Care and Hospice Utilization and Payment Public Use Files
Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
Hospice Quality Reporting Program Quarterly Updates
National Cholesterol Education Month and World Heart Day

Compliance

DME Proof of Delivery Documentation Requirements

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

IRF/LTCH: Reporting Health Care Personnel Influenza Vaccination Data Webinars — October 1, 3, or 9

MLN Matters® Articles

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2020
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files — Revised
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2019 Update — Revised

Publications

Quality Payment Program: Resources for Clinicians New to the Program in 2019
Medicare Enrollment for Physicians and Other Part B Suppliers — Reminder
Medicare Preventive Services Poster — Reminder
Safeguard Your Identity and Privacy Using PECOS — Reminder

Multimedia

Quality Payment Program: All-Payer Combination Option in 2019 Web-Based Training Course
Quality Payment Program Merit-based Incentive Payment System (MIPS): Promoting Interoperability Performance Category in 2019 Web-Based Training Course
Dementia Care Call: Audio Recording and Transcript
Quality Payment Program for Advanced APMs in 2019 Web-Based Training Course — Revised
Quality Payment Program Merit-based Incentive Payment System (MIPS): Participation in 2019 Web-Based Training Course — Revised
Transitioning to an Advanced APM: 2019 Update Web-Based Training Course — Revised

Local Coverage Determination (LCD) and Article Update History

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding Articles for these LCDs have been added or revised.

Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041)
Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
Frequency of Hemodialysis (L35014)
Billing and Coding: Frequency of Hemodialysis (A55723)
Independent Diagnostic Testing Facility (IDTF) (L35448)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Prostate Mapping Biopsy (L35009)
Billing and Coding: Prostate Mapping Biopsy (A56966)
Psychiatric Codes (L35101)
Billing and Coding: Psychiatric Codes (A57130)
Removal of Benign Skin Lesions (L34938)
Billing and Coding: Removal of Benign Skin Lesions (A57113)
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder
(L34998)
Billing and Coding: Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (A57072)
Spinal Cord Stimulation (Dorsal Column Stimulation) (L35450)
Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation) (A57023)
Surgical Treatment of Nails (L34887)
Billing and Coding: Surgical Treatment of Nails (A52998)

September 25, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11392 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update
The Centers for Medicare and Medicaid Services revised this article on September 23, 2019, due the release of an updated Change Request (CR).The update added to the CR:
A revised spreadsheet for NCD110.23, requirement 3
FISS responsibility and new verbiage to NCD150.3, requirement 4 and associated spreadsheet
Revised verbiage to NCD110.21, requirement 11
All other information remains the same.

September 24, 2019

Limited Systems Availability — Friday, October 4, 2019 - Sunday, October 6, 2019  

There will be Common Working File (CWF) "Dark" days from Friday, October 4, 2019 - Sunday, October 6, 2019 due to the October release upgrades. The Interactive Voice Response (IVR) Unit and our Customer Service representatives will have limited availability. Customer Service Representatives will not be able to assist providers with Eligibility Inquiries, Claim Status Inquiries Relating to Eligibility or Claim Denial Inquiries Relating to Eligibility.


September 19, 2019

CMS Provider Education Message:

MLN Connects — Why Use the MBI?

MLN Connects® for Thursday, September 19, 2019

View this edition as a PDF

News

New Medicare Card: Why Use the MBI?
Proposed Opioid Treatment Program Policies: Comment Deadline September 27
Quality Payment Program: MIPS Targeted Review Request Deadline September 30
SNF PPS Patient Driven Payment Model Resources: Get Ready for October 1
Emergency Triage, Treat, and Transport Model: Apply by October 5
LTCH Provider Preview Reports: Review Your Data by October 11
IRF Provider Preview Reports: Review Your Data by October 11
Hospice Provider Preview Reports: Review Your Data by October 11
Prostate Cancer Awareness Month

Compliance

Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

MLN Matters® Articles

2019-2020 Influenza (Flu) Resources for Health Care Professionals
Billing for Hospital Part B Inpatient Services

Publications

Medicare Enrollment for Institutional Providers — Reminder
Medicare Enrollment Resources Educational Tool — Reminder
PECOS FAQs Booklet — Reminder
PECOS Technical Assistance Contact Information Fact Sheet — Reminder

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11343 – October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
The Centers for Medicare and Medicaid Services (CMS) revised this article on September 16, 2019, to reflect the revised Change Request (CR) 11343 issued on September 13. The CR revision had no impact on the substance of the article. CMS did update the release date, transmittal number, and the web address of the CR. All other information remains the same.
MM11422 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2019 Update
The Centers for Medicare and Medicaid Services (CMS) revised this article on September 18, 2019, to reflect the revised Change Request (CR) 11422 issued on September 17. The revised CR did not impact the content of the article. In the article, CMS revised the release date, transmittal number, and the web address of the CR. All other information remains the same.

September 17, 2019

Optical Character Recognition (OCR) 1500 Claim Form Submission Instructions/Helpful Hints

Updates have been made to the article. Effective for claims received on and after October 18, 2019, claims will be returned as unprocessable when a qualifier is not reported to identify the role of the physician and/or valid ICD indicator is not reported on the claim.


Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for August 2019. Please take time to review these FAQs for answers to your questions.


September 16, 2019

Care Management Services

We are pleased to announce the addition of Care Management Services to the  Provider Specialties / Services page of our website.  These services include advanced care planning, chronic care management and transitional care management.  


September 13, 2019

Diabetes Prevention Program (MDPP) Specialty Page

We are pleased to announce the addition of Medicare Diabetes prevention Program (MDPP) to the Provider Specialties / Services page of our website.


September 12, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card Transition Period Ends in Less Than 4 Months

MLN Connects® for Thursday, September 12, 2019

View this edition as a PDF

News

New Medicare Card: Transition Period Ends in Less Than 4 Months
New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP
Different-Day Upper and Lower Endoscopy: Comparative Billing Report in September
Hospices: Call for Panel on Assessment Instrument and Quality Measures — Nominations due September 30
Local Coverage Determination Meetings
Pain Management: CDC Conversation Starters for Patients and Their Doctors
Healthy Aging® Month: Discuss Preventive Services with your Patients

Compliance

Bill Correctly for Device Replacement Procedures

Claims, Pricers & Codes

Average Sales Price Files: October 2019

Events

Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17
Different-Day Upper and Lower Endoscopy: Comparative Billing Report Webinar — September 24

MLN Matters® Articles

Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims
Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004
October 2019 Update of the Ambulatory Surgical Center (ACS) Payment System
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations - Update — Revised
Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System — Revised
2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments — Revised

Publications

Medicare Part A Cost Report Electronic Filing
Quality Payment Program: 2019 MIPS Resources
Advance Care Planning — Revised
Medicare Billing: CMS Form CMS-1500 and the 837 Professional — Revised
Medicare Secondary Payer— Revised
Roadmap to Behavioral Health — Updated

Multimedia

Home Health Call: Audio Recording and Transcript
Radiation Oncology Listening Session: Audio Recording and Transcript
SNF Value-Based Purchasing Call: Audio Recording and Transcript
Medicare Secondary Payer Provisions Web-Based Training Course — Revised
Quality Payment Program for Merit-based Incentive Payment System (MIPS) APMs in 2019 Web-Based Training Course — Revised
SNF PPS: Patient Driven Payment Model Videos

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding Articles for these LCDs have been added or revised:

Debridement of Mycotic Nails (L35013)
Billing and Coding: Debridement of Mycotic Nails (A56640)
Outpatient Sleep Studies (L35050)
Billing and Coding: Outpatient Sleep Studies (A56923)
Reflectance Confocal Microscopy (L37375)
Billing and Coding: Reflectance Confocal Microscopy (A56969)
Services That Are Not Reasonable and Necessary (L35094)
Billing and Coding: Services That Are Not Reasonable and Necessary (A56967)

The following Billing and Coding Articles have been revised:

Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Implantable Automatic Defibrillators (A56355)
Billing and Coding: Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases (A53121)

September 11, 2019

August 2019 Part B Newsletter

The August 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for August 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


September 10, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11457 – October 2019 Update of the Ambulatory Surgical Center (ACS) Payment System
Change Request (CR) 11457 describes changes to and billing instructions for various payment policies implemented in the October 2019 ASC payment system update. The CR also includes Healthcare Common Procedure Coding System updates. Please make sure your billing staffs are aware of these changes.
SE19022 – 2019-2020 Influenza (Flu) Resources for Health Care Professionals
Special Edition (SE) MLN Matters article SE19022 provides information about influenza (flu) resources for health care professionals and providers relevant to the 2019-2020 flu season. Health care professionals should:
Keep this article and refer to it throughout the 2019-2020 flu season.
Take advantage of each office visit as an opportunity to encourage patients to protect themselves from the flu and serious complications by getting a flu shot.
Continue to provide the flu shot if you have vaccine available, even after the New Year.
Remember to immunize yourself and your staff.

September 9, 2019

New Look Coming to Local Coverage Determinations and Billing and Coding Articles

Consistent with the instruction in Change Request (CR) 10901, our Local Coverage Determinations (LCDs) and Billing and Coding Articles will undergo further changes beginning on September 12, 2019.

Due to recent system changes, the entire Coding Information section will no longer appear in Proposed LCDs, Future Effective LCDs and revised LCDs. Additionally all new articles and revised articles will have a new look. The coding section will be rearranged with new fields for CPT/HCPCS Modifiers and Other Coding Information that may be utilized.

All LCDs and Articles will be in the new format by the end of the year.


September 6, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19020 – Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims
The Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the State of North Carolina on September 4, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to September 1, 2019, and are in effect for 90 days.
The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage
Instructions to request an individual waiver if there is no blanket waiver
SE19019 – Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims
The Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the States of Georgia and South Carolina on September 2, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 29, 2019, for Georgia, and retroactive to August 31, 2019, for South Carolina. The PHE is in effect for 90 days.
The Centers for Medicare & Medicaid Services is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage
Instructions to request an individual waiver if there is no blanket waiver

Revised:

SE19006 – Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System
The Centers for Medicare & Medicaid Services revised this article on September 5, 2019, to delete incorrect information in the section titled Only Applicable Information Attributed to non-Hospital Patients is Reported, which is on page 18. All other information remains the same.

September 5, 2019

CMS Provider Education Message:

MLN Connects — September is Pain Awareness Month - Learn Pain Management Options

MLN Connects® for Thursday, September 5, 2019

View this edition as a PDF

News

New Medicare Card: Do You Refer Patients?
IRF Appeals Settlement Option: Deadline September 17
Quality Payment Program: MIPS Targeted Review Request Deadline September 30
SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1
PEPPERs for Short-term Acute Care Hospitals
DME QIC Contract Award
Health Care Supply Chain, Provider Self-Care, and Emergency Preparedness Resources
September is Pain Awareness Month

Compliance

Chiropractic Services: Comply with Medicare Billing Requirements

Events

Dementia Care: Supporting Comfort and Resident Preferences Call — September 10
Health Coaching and Wellness Planning for Self-Management Webinar — September 10
New Medicare Card: Open Door Forum — September 11
Developing a Hospice Patient Assessment Tool Special Open Door Forum — September 12
Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17
CMS Public Meeting: Action Plan to Prevent and Manage Opioid Use Disorder and Substance Use Disorder and Address Pain Management — September 20

MLN Matters® Articles

Hurricane Dorian and Medicare Disaster Related State of Florida Claims
Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims
Hurricane Dorian and Medicare Disaster Related Commonwealth of Puerto Rico Claims
2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Annual Clotting Factor Furnishing Fee Update 2020
Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Multimedia

CMS: Beyond the Policy Podcast: Dispatches from the Blue Button Developers Conference

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11437– 2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
The Centers for Medicare & Medicaid Services revised this article on September 4, 2019, to add: “MACs will continue to accept the AQ modifier on claims for services furnished in a geographic HPSA that is not on the list of ZIP codes for automated payments” (page 2). All other information is unchanged.

September 4, 2019

2019-2020 Flu, Pneumococcal, and Hepatitis B Vaccine Reimbursement

The influenza vaccine payment allowances annual update for the 2019-2020 season is available on the Fee Schedule page of our website.


Medicare Secondary Payer: Gathering MSP Information (A/B) October 8, 2019

Join us as we discuss Medicare as a secondary payer (MSP) and the fundamentals of this cost-saving program. During this webcast, we will discuss gathering information in relation to Medicare as the secondary payer.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19017 – Hurricane Dorian and Medicare Disaster Related Commonwealth of Puerto Rico Claims
The Secretary of the Department of Health & Human Services declared a Public Health Emergency in the Commonwealth of Puerto Rico on August 28, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 26, 2019, and are in effect for 90 days.
The Centers for Medicare & Medicaid Services is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage
Instructions to request an individual waiver if there is no blanket waiver
SE19018 – Hurricane Dorian and Medicare Disaster Related State of Florida Claims
The Secretary of the Department of Health & Human Services declared a Public Health Emergency in the State of Florida on August 30, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 28, 2019, and are in effect for 90 days.
The Centers for Medicare & Medicaid Services is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage
Instructions to request an individual waiver if there is no blanket waiver
MM11441 – 2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Change Request 11441 makes changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that will be used to revise Medicare’s Common Working File edits to allow Medicare Administrative Contractors to make appropriate payments in accordance with policy for SNF Consolidated Billing (CB) in Chapter 6, Section 110.4.1 and Chapter 6, Section 20.6 in the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.
MM11435 – Annual Clotting Factor Furnishing Fee Update 2020
Change Request 11435 announces that the clotting factor furnishing fee for 2020 is $0.226 per unit. Make sure your billing staffs are aware of the update to the annual clotting factor furnishing fee for 2020.
MM11428 – Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
Change Request 11428 informs Medicare Administrative Contractors about payment allowances for influenza virus vaccines, which are updated on August 1 of each year. The Centers for Medicare & Medicaid Services will post the payment allowances for influenza vaccines that are approved after the release of CR 11428 at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html. Make sure your billing staffs are aware of the payment allowances for the 2019-2020 season.
MM11433 – October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Change Request 11433 informs Durable Medical Equipment Medicare Administrative Contractors about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. Make sure your billing staffs are aware of these changes.

September 3, 2019

September is Prostate Cancer Awareness Month

Prostate cancer is the most common nonskin cancer among men in the United States. Prostate cancer is treatable and has a very strong possibility of cure if it is caught early. September is a good time with this focus to speak to your patients, remind them of the concern of prostate cancer, and recommend that they pursue this annual screening service to help them to identify a potential health issue.


August 29, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Open Door Forum — September 11

MLN Connects® for Thursday, August 29, 2019

View this edition as a PDF

News

Promoting Interoperability: 2019 PDMP Bonus Measure
Beneficiary Notices Initiative Mailbox Portal
Promoting Interoperability: 2020 Eligible Hospital eCQM Flows
DMEPOS: Nationwide Expansion of Required PA of Pressure Reducing Support Surfaces

Compliance

IRF Services: Follow Medicare Billing Requirements

Events

MIPS Value Pathways RFI Webinar — September 4
Venipuncture: Comparative Billing Report Webinar — September 5
Dementia Care: Supporting Comfort and Resident Preferences Call — September 10
New Medicare Card: Open Door Forum— September 11
Hospice Outcomes & Patient Evaluation Tool ODF – September 12
Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17
Overall Hospital Star Ratings Listening Session - September 19

MLN Matters® Articles

New Documentation Requirements for Filing Medicare Cost Reports
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020
Claim Status Category and Claim Status Codes Update
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 Healthcare (CAQH) CORE
Home Health (HH) Patient-Driven Groupings Model (PDGM) - Revised and Additional Manual Instructions
2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update
Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System — Revised

Publications

Inpatient Rehabilitation Facility Prospective Payment System Booklet — Revised

Multimedia

Physician Fee Schedule Listening Session: Audio Recording and Transcript
IRF Appeals Settlement Call: Audio Recording and Transcript
OPPS and ASC Listening Session: Audio Recording and Transcript
ESRD QIP Call: Audio Recording and Transcript
SNF PPS: Patient Driven Payment Model Videos
Inpatient Rehabilitation Facilities (IRFs): Improving Documentation Positively Impacts CERT Web-Based Training Course — Revised

The following Proposed Local Coverage Determination (LCD) has been posted for comment. The comment period will end on October 13, 2019:

Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (DL38385)

Submit Comments

The following future effective related billing and coding article has been added:

Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A56938)

Online Registration Available for September 13, 2019, Open Meeting and Proposed LCD Now Posted

Online registration for the September 13, 2019, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, September 11, 2019, or before September 11th if room capacity is filled. The Novitas Solutions’ proposed LCD for one of the June 2019 CAC meeting topics is now posted. IMPORTANT: The Open Meeting will be held at Novitas Solutions, 2020 Technology Parkway, Mechanicsburg, PA 17050 at 10:00 AM ET. Due to limited room capacity, registered presenters will be given priority for seating and registered observers will be accepted until remaining seats are filled.

Open Meetings are for the specific purpose of discussing the proposed LCDs. Anyone is welcome to present information related to the proposed LCDs that are in the 45-day draft comment period. Interested parties may also request to attend as an observer. If you are interested in attending as a presenter or observer, please view our Proposed Local Coverage Determination Open Meetings page for specific guidelines and other helpful information.


August 28, 2019

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update

The October 2019 quarterly update to the MPFSDB is available and effective for services from January 1, 2019, through December 31, 2019. For a summary of changes, please review the Medicare Learning Network Matters Article, MM11402.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11003 – Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System
The Centers for Medicare & Medicaid Services revised this article on August 26, 2019, to reflect changes made to the eMDR registration screens within the National Plan and Provider Enumeration System (NPPES).The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs. In particular, the steps and screens relating to “Create new Endpoint Information in NPPES” and “Delete an existing Endpoint Information in NPPES” have been revised or added. A section discussing “Who should register the endpoint information in NPPES” was also added. The NPPES updates result in no changes to the Change Request. All other information is unchanged. Please make sure your billing staffs are aware of these changes.

August 26, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11393 – Claim Status Category and Claim Status Codes Update
Change Request 11393 updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Make sure your billing staffs are aware of these updates.
MM11394 – 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 Healthcare (CAQH) CORE
Change Request 11394 instructs Medicare Administrative Contractors and Medicare's Shared System Maintainers to update systems based on the CORE 360 Uniform use of CARC, RARC and CAGC rule publication. These system updates are based on the CORE Code Combination List to be published on or about October 1, 2019. Make sure that your billing staffs are aware of these changes.
MM11437 – 2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
Change Request 11437 provides files for the automated payments of HPSA bonuses for dates of service January 1, 2020, through December 31, 2020. Please make sure your billing staffs are aware of these updates.
MM11418 – Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update
Change Request 11418 advises the Medicare Administrative Contractors to obtain the most recent HPTCs code set and use it to update their internal HPTC tables and, or reference files. Please make sure your billing staffs are aware of these changes.

August 22, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Read the Updated MLN Matters Article

MLN Connects® for Thursday, August 22, 2019

View this edition as a PDF

News

Overall Hospital Quality Star Ratings: Upcoming Enhancement
Pneumococcal Vaccine Eligibility Data Issue
Venipuncture: Comparative Billing Report in August
SNF Provider Preview Reports: Review Your Data by September 16
SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1
Promoting Interoperability: 2019 Program Requirements for Hospitals
Quality Payment Program Exception Applications
Hospice Compare Refresh
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
CBRs: We Want Your Feedback

Compliance

Ambulance Fee Schedule and Medicare Transports

Claims, Pricers & Codes

MACRA Patient Relationship Categories and Codes: Reporting HCPCS Level II Modifiers

Events

Understanding Your SNF VBP Program Performance Score Report Call — August 27
Dementia Care: Supporting Comfort and Resident Preferences Call — September 10

MLN Matters® Articles

New Medicare Beneficiary Identifier (MBI) Get It, Use It — Reissued
Medicare Coverable Services for Integrative and Non-pharmacological Chronic Pain Management
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update
Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2020 — Revised

Publications

MLN Catalog September 2019 Edition
Ambulance Fee Schedule and Medicare Transports
QPP: New Resources
Getting Started with Hospice CASPER Review and Correct Reports
Behavioral Health Integration — Revised
Critical Access Hospital — Revised
Swing Bed Services — Revised
Screening Pap Tests and Pelvic Examinations Booklet — Revised
Hospices: CASPER QM Fact Sheet — Updated

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding Articles for these LCDs have been added or revised:

Intravenous Immune Globulin (IVIG) (L35093)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Loss-of-Heterozygosity Based Topographic Genotyping with PathfinderTG ® (L34864)
Billing and Coding: Loss-of-Heterozygosity Based Topographic Genotyping with Pathfinder TG® (A56897)
Microvascular Therapy (L36434)
Billing and Coding: Microvascular Therapy (MVT) (A54343)
Multiple Imaging in Oncology (L35391)
Billing and Coding: Multiple Imaging in Oncology (A56848)
Non-Vascular Extremity Ultrasound (L35409)
Billing and Coding: Non-Vascular Extremity Ultrasound (A55037)
Nusinersen (Spinraza) (L37682)
Billing and Coding: Nusinersen (Spinraza) (A56860)
Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (L36419)
Billing and Coding: Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (A56856)
Strapping (L36423)
Billing and Coding: Strapping (A56804)

The following LCD has been revised:

Facet Joint Interventions for Pain Management (L34892)

The following Billing and Coding Articles have been revised:

Billing and Coding Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases (A53121)
Billing and Coding: Implantable Automatic Defibrillators (A56355)

August 21, 2019

Provider Specialty: Ambulance

The Ambulance Specialty page has been updated to add the Centers for Medicare & Medicaid Services new booklet on Ambulance Fee Schedule and Medicare Transports.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19008 – Medicare Coverable Services for Integrative and Nonpharmacological Chronic Pain Management
Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain. This article is informational only and does not convey any new or revised Medicare policies.

Revised:

SE18006 – New Medicare Beneficiary Identifier (MBI) Get It, Use It
The Centers for Medicare & Medicaid Services reissued this article on August 19, 2019, to show that all new Medicare cards have been mailed. CMS encourages providers to use MBIs now to protect patients’ identities, to emphasize that providers must use MBIs beginning January 1, 2020, and to explain the rejection codes providers will get if they submit a health insurance claim number after January 1, 2020.

August 20, 2019

Electronic Submission of Medical Documentation System (esMD) Split Indicators

Novitas Solutions is experiencing a large number of esMD submissions for Appeals Content Type 9 and Medical Review Content Type 1 medical records. We are observing situations where the records are submitted for one case in separate submissions without a split indicator.

Starting September 1, 2019, the split indicator will be required. In this situation, if documentation is submitted without the split indicator, we will be rejecting the transmission and these records will not be reviewed.


August 19, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11402 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update
Change Request (CR) 11402 informs providers that the Centers for Medicare & Medicaid Services issued payment files to the MACs based on the 2019 Medicare Physician Fee Schedule Final Rule. CR 11402 amends those payment files. Please make sure your billing staffs are aware of these changes.
MM11403 – Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual
Change Request 11403 updates the language in sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual to add a link to the current influenza codes and payment rates. Make sure your billing staffs are aware of these updates. For the Medicare-covered codes for the influenza vaccines approved by Food and Drug Administration for the current influenza vaccine season, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.
MM11422 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update
Change Request 11422 updates the HCPCS code set for codes related to drugs and biologicals. Make sure your billing staffs are aware of these updates.

August 16, 2019

July 2019 Part B Newsletter

The July 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


August 15, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Transition Period Ends in Less Than 5 Months

MLN Connects® for Thursday, August 15, 2019

View this edition as a PDF

News

New Medicare Card: Transition Period Ends in Less Than 5 Months
CAR T-Cell Cancer Therapy Available to Medicare Beneficiaries Nationwide
DMEPOS Competitive Bidding: Round 2021 Deadlines
MACRA Patient Relationship Categories and Codes: Learn More

Compliance

Inpatient Rehabilitation Facility Services: Follow Medicare Billing Requirements

Events

ESRD Quality Incentive Program: CY 2020 ESRD PPS Proposed Rule Call — August 20
IPPS/LTCH PPS FY 2020 Final Rule Special Open Door Forum — August 20
Home Health Patient-Driven Groupings Model: Operational Issues Call — August 21
Self-Direction for Dually Eligible Individuals Utilizing LTSS Webinar — August 21
Radiation Oncology Model Listening Session — August 22
Understanding Your SNF VBP Program Performance Score Report Call — August 27
Dementia Care: Supporting Comfort and Resident Preferences Call — September 10

MLN Matters® Articles

Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
Display PARHM Claim Payment Amounts
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update

Publications

Chronic Care Management Services — Revised
ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets — Revised

Multimedia

I&A Enrollment Webcast: Audio Recording and Transcript
SNF PPS: Patient Driven Payment Model Videos

August 13, 2019

Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for July 2019. Please take time to review these FAQs for answers to your questions.


August 12, 2019

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for July 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


The comment period is now closed for the following Proposed Local Coverage Determinations (LCDs). Comments received will be reviewed by our Contractor Medical Directors and Response to Comments Articles will be posted to our website and related to the LCDs when they are posted for notice.

4Kscore Test Algorithm (DL37792)
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATS) (DL38229)
Micro-Invasive Glaucoma Surgery (MIGS) (DL38223)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11392 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update
Change Request 11392 constitutes a maintenance update of International Classification of Diseases (ICD)-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Please make sure your billing staffs are aware of these updates.
MM11312 – Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
Change Request 11312 directs Medicare Administrative Contractors (MACs) to implement logic that ensures they bypass payment window edits (3-days and 1-day) when processing claims for donor post-kidney transplant complications services. MACs will hold certain claims, as noted below, until Medicare's Common Working File system edits these claims correctly. Please be sure your billing staffs are aware of these changes.

August 8, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Will Your Claims Reject?

MLN Connects® for Thursday, August 8, 2019

View this edition as a PDF

News

New Medicare Card: Will Your Claims Reject?
Securing Access to Life-Saving Antimicrobial Drugs for American Seniors
IRF/LTCH/SNF Quality Reporting Programs: Submission Deadline August 15
Hospice Patient Assessment Instrument Focus Groups: Respond by August 26
Emergency Triage, Treat, and Transport Model: Apply by September 19
SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1
2019 QRDA III Implementation Guide: Updated Addendum
Quality Payment Program: Reporting Patient Relationship Categories

Compliance

Skilled Nursing Facility 3-Day Rule Billing

Events

Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12
IRF Appeals Settlement Initiative Call — August 13
OPPS and ASC Proposed Rule Listening Session — August 14
ESRD Quality Incentive Program: CY 2020 ESRD PPS Proposed Rule Call — August 20
Home Health Patient-Driven Groupings Model: Operational Issues Call — August 21
Radiation Oncology Model Listening Session — August 22
Understanding Your SNF VBP Program Performance Score Report Call — August 27

MLN Matters® Articles

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2020
Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
Medicare Shared Savings Program (Shared Savings Program) Skilled Nursing Facility (SNF) Affiliates’ Requirement to Include Demonstration Code 77 on SNF 3-Day Rule Waiver Claims
Modification to the National Coordination of Benefits Agreement (COBA) Crossover Process
October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Oxygen Policy Update
Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Multimedia

CMS: Beyond the Policy Podcast: Nursing Home Strategy Part 1 – Strengthening Oversight
CLFS Public Meetings: Videos

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding Articles for these LCDs have been added:

Implantable Infusion Pump (L35112)
Billing and Coding: Implantable Infusion Pump (A56778)
Intravenous Immune Globulin (IVIG) (L35093)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Lacrimal Punctum Plugs (L35095)
Billing and Coding: Lacrimal Punctum Plugs (A56780)
Lower Extremity Major Joint Replacement (Hip and Knee) (L36007)
Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee) (A56796)
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (L34822)
Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A56776)
Magnetic Resonance Angiography (MRA) (L34865)
Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)
Molecular Diagnostics: Genitourinary Infectious Disease Testing (L35015)
Billing and Coding: Molecular Diagnostics: Genitourinary Infectious Disease Testing (A56791)
Neuromuscular Junction Testing (L34996)
Billing and Coding: Neuromuscular Junction Testing (A56785)
Neurophysiology Evoked Potentials (NEPs) (L34975)
Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)

The following Billing and Coding Article has been revised:

Billing and Coding: Cardiovascular Nuclear Medicine (A56423)

Durable Medical Equipment (DME) Specialty Page

We are pleased to announce the addition of DME to the Provider Specialties/Services page of our website.


New: Prior Authorization program for Durable Medical Equipment

Please take a moment to read the following letters regarding the Prior Authorization program for Durable Medical Equipment.

Dear Physician – Medicare Prior Authorization Condition of Payment for Certain Power Mobility Devices
Dear Physician – Medicare Prior Authorization Condition of Payment for Group 2 Pressure Reducing Support Surfaces

Physicians! Collaborative Spinal Orthosis Webinar Scheduled for September 19!

Do you order spinal orthoses (back braces) for your Medicare patients? Do you wonder why the Durable Medical Equipment suppliers ask you for documentation of their condition or a detailed written order? These questions and many more will be addressed during the spinal orthosis webinar scheduled for September 19, 2019 at 2:00PM Eastern Time. For details and registration, please read this article.


August 7, 2019

CMS Provider Education Message:

Special Edition – Wednesday, August 7, 2019

Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12
OPPS and ASC Proposed Rule Listening Session — August 14

Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12

Monday, August 12 from 1-2:30 pm ET

Register for Medicare Learning Network events.

Proposed changes to the CY 2020 Physician Fee Schedule are aimed at reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care. During this listening session, CMS experts briefly cover three provisions from the proposed rule and address your clarifying questions to help you formulate your written comments for formal submission:

Increasing value of Evaluation and Management (E/M) payments
Continuing to improve the Quality Payment Program by streamlining the program’s requirement’s in order to reduce clinician burden
Creating the new Opioid Treatment Program benefit in response to the opioid epidemic

We encourage you to review the following materials prior to the call:

Proposed rule
Press release
Physician Fee Schedule proposed rule fact sheet
Quality Payment Program proposed rule fact sheet

Note: Feedback received during this listening session is not a substitute for your formal comments on the rule. See the proposed rule for information on submitting these comments by September 27.

Target Audience: Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent health care providers; and other stakeholders.


OPPS and ASC Proposed Rule Listening Session — August 14

Wednesday, August 14 from 2:30 to 4 pm ET

Register for Medicare Learning Network events.

CMS proposed updates and policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment systems, including price and quality transparency that lay the foundation for a patient-driven health care system. During this listening session, CMS experts briefly cover provisions from the proposed rule and address your clarifying questions to help you formulate your written comments for formal submission. Topics include:

Price transparency: Requirements for all United States hospitals to make their standard charges public
Increasing choices and encouraging site neutrality, including payments for clinic visits

We encourage you to review the proposed rule, press release, and fact sheet prior to the call. Note: Feedback received during this listening session is not a substitute for your formal comments on the rule. See the proposed rule for information on submitting these comments by September 27.

Target Audience: All hospitals operating in the United States and other stakeholders.


August 5, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11406 – Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Change Request 11406 provides instructions for the quarterly update to the Clinical Laboratory Fee Schedule. Make sure your billing staffs are aware of these updates.
MM11381 – October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Change Request (CR) 11381 provides updates to the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).
CR11381 alerts providers of incorrectly categorized CPT codes 29580, 29581, and 29584. CR 11381 provides instructions to categorize these codes correctly on the SNF CB files.
Section 1888 of the Social Security Act codifies SNF PPS and Consolidated Billing (CB). The new coding identified in each update describes the same services that are subject to SNF PPS payment by law. No additional services are in place because of these routine updates; that is, the new updates occur because of changes to the coding system, not because of redefined services subject to SNF CB. There are no other regulatory changes beyond code list updates.
Make sure your billing staffs are aware of these changes.
MM11369 – Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices
Change Request 11369 states, effective January 1, 2020, MACs will include a revised informational Remittance Advice Remark Code Alert Code N817 on all Remittance Advices returned from processed claims containing a laboratory service. Make sure your billing staffs are aware of these changes.
MM11290 – Medicare Shared Savings Program (Shared Savings Program) Skilled Nursing Facility (SNF) Affiliates’ Requirement to Include Demonstration Code 77 on SNF 3-Day Rule Waiver Claims
Change Request 11290 requires SNF affiliates of Accountable Care Organizations (ACOs) participating in the Shared Savings Program to include demonstration code 77 in the treatment authorization field on claims when the SNF affiliate intends for the claim to be subject to the SNF 3-day rule waiver. Beginning with admissions on or after January 1, 2020, ACO SNF affiliates need to submit demonstration code 77 on claims in the treatment authorization field to serve as the SNF affiliate's attestation that the eligibility requirements for using a SNF 3-Day Rule Waiver have been met. Should Medicare systems determine the beneficiary is deemed ineligible for services under the demonstration code 77, MACs will reject the claim with the following messages:
Claim Adjustment Reason Code 272: Coverage/program guidelines were not met.
Remittance Advice Remark Code N564: Patient did not meet the inclusion criteria for the demonstration project or pilot program.
This waiver is only available to ACOs that are eligible and approved to use the SNF 3-day rule waiver. Make sure your SNF billing staffs are aware of the requirement to include demonstration code 77 in the treatment authorization field.

August 2, 2019

CMS Provider Education Message:

Special Edition – Friday, August 2, 2019

IPPS/LTCH: FY 2020 PPS Final Rule
IRF: FY 2020 Payment and Policy Changes
Hospice: FY 2020 Hospice Payment Rate Final Rule

IPPS/LTCH: FY 2020 PPS Final Rule

On August 2, CMS finalized policy changes to spur competition and innovation that will help deliver improved care and outcomes at a better value to patients. The final rule updates Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for FY 2020 and advances two key CMS priorities—“Rethinking Rural Health” and “Unleashing Innovation” by making historic changes to how Medicare pays hospitals. This final rule:

Increases the wage index for certain low-wage index hospitals, including many rural hospitals
Increases Medicare add-on payments for high cost eligible new technologies from 50-65%
Clarifies policies on “substantial clinical improvement” to qualify for new technology add on payments
Provides an alternative pathway where Breakthrough Devices are no longer required to demonstrate evidence of “substantial clinical improvement” to qualify for new technology add-on payments
Provides an alternative pathway where Qualified Infectious Disease Products are no longer required to meet the “substantial clinical improvement” criteria for technology add-on payments, which are increased from 50 to 75% 

For More Information:

Final Rule
Fact Sheet

Press release See the full text of this excerpted CMS Press Release (Issued August 2).
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IRF: FY 2020 Payment and Policy Changes

On July 31, CMS issued a final rule that updates Medicare payment policies and rates for facilities under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program for FY 2020. We are continuing our efforts towards the eventual transition to a unified post-acute care system through updates to the data used for IRF payments, including revising the Case-Mix Groups (CMGs), updating the CMG relative weights and average length of stay values, and using concurrent inpatient prospective payment system wage index data for the IRF PPS to align wage index data across settings of care.  

For FY 2020, CMS is finalizing updates to the IRF PPS payment rates using the most recent data to reflect an estimated 2.5 percent increase factor (reflecting an IRF-specific market basket increase factor of 2.9 percent, reduced by a 0.4 percentage point multifactor productivity adjustment). CMS projects that IRF payments will increase by 2.5 percent (or $210 million) for FY 2020, relative to payments in FY 2019.

This Rule Finalizes:

Rebase and revise the IRF market basket
Clarification of “rehabilitation physician”
Two new quality measures

See the full text of this excerpted CMS Fact Sheet (Issued July 31).


Hospice: FY 2020 Hospice Payment Rate Final Rule

On July 31, CMS issued a final rule that demonstrates continued commitment to strengthening Medicare by better aligning the hospice payment rates with the costs of providing care and increasing transparency so patients can make more informed choices. For FY 2020, hospice payment rates are updated by 2.6 percent ($520 million increase in their payments). The final hospice cap amount for the FY 2020 cap year will be $29,964.78, which is equal to the FY 2019 cap amount ($29,205.44) updated by the final FY 2020 hospice payment update percentage of 2.6 percent. The aggregate cap limits the overall payments per patient made to a hospice annually.

This Rule Finalizes:

Rebasing to more accurately align Medicare payments with the costs of providing care
Modifications to the election statement beginning in FY 2021, increasing coverage transparency for beneficiaries under a hospice election
Hospice Quality Reporting Program updates, including developing a hospice assessment tool for real-time patient assessments

For More Information:

Final Rule
Hospice Center webpage
Hospice Quality Reporting webpage

See the full text of this excerpted CMS Fact Sheet (Issued July 31).


The comment period will close on August 11, 2019 for the following Proposed Local Coverage Determinations (LCDs):

4Kscore Test Algorithm (DL37792)
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATS) (DL38229)
Micro-Invasive Glaucoma Surgery (MIGS) (DL38223)

Submit Comments


August 1, 2019

CMS Provider Education Message:

MLN Connects — Protect Your Patients’ Identities: Use the MBI Now

MLN Connects® for Thursday, August 1, 2019

View this edition as a PDF


News

SNF: FY 2020 Payment and Policy Changes
IPF: FY 2020 Payment and Quality Reporting Updates
Protect Your Patients’ Identities: Use the MBI Now
CMS Advances MyHealthEData with New Pilot to Support Clinicians
Reducing Administrative Burden: Comment by August 12
Medicare Coverage for Treatment Services Furnished by Opioid Treatment Programs
Open Payments Program Expansion
Improve Accessibility of Care for People with Disabilities: New Resources
Part A Providers: Formal Telephone Discussion Demonstration
July – September Quarterly Provider Update
Disaster Preparedness Resources
Vaccines Are Not Just for Kids

Compliance

DMEPOS: Bill Correctly for Items Provided During Inpatient Stays

Events

Emergency Triage, Treat, and Transport Model Application Tutorial Webinar — August 8
Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12
IRF Appeals Settlement Initiative Call — August 13
OPPS and ASC Proposed Rule Listening Session — August 14
ESRD Quality Incentive Program: CY 2020 ESRD PPS Proposed Rule Call — August 20
Home Health Patient-Driven Groupings Model: Operational Issues Call — August 21
Understanding Your SNF VBP Program Performance Score Report Call — August 27

MLN Matters® Articles

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period – Claims Processing Requirements
New Waived Tests
Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment — Revised

Publications

Skilled Nursing Facility 3-Day Rule Billing
Provider Compliance Tips for Glucose Monitors and Diabetic Accessories/Supplies — Revised

Multimedia

Quality Payment Program Merit-based Incentive Payment System (MIPS): Cost Performance Category in 2019 Web-Based Training Course — Revised
Quality Payment Program 2019 Overview Web-Based Training Course — Revised
Quality Payment Program Merit-based Incentive Payment System (MIPS): Quality Performance Category in 2019 Web-Based Training Course — Revised
Quality Payment Program Merit-based Incentive Payment System (MIPS): Improvement Activities in 2019 Web-Based Training Course — Revised

July 29, 2019

CMS Provider Education Message:

Special Edition – Monday, July 29, 2019

PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020
Medicare OPPS and ASC Payment System CY 2020 Proposed Rule
ESRD and DMEPOS CY 2020 Proposed Rule

PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020

On July 29, CMS issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. This proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better accessibility, quality, affordability, empowerment, and innovation. It also includes proposals to streamline the Quality Payment Program with the goal of reducing clinician burden. This includes a new, simple way for clinicians to participate in our pay-for-performance program, the Merit-based Incentive Payment System (MIPS), called the MIPS Value Pathways.

The proposed rule also includes:

CY 2020 PFS rate setting and conversion factor
Medicare telehealth services
Payment for evaluation and management services
Physician supervision requirements for physician assistants
Review and verification of medical record documentation
Care management services
Comment solicitation on opportunities for bundled payments
Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs
Bundled payments for substance use disorders
Therapy services
Ambulance services
Ground ambulance data collection system
Open Payments Program
Medicare Shared Savings Program
Stark advisory opinion process

For More information:

Proposed Rule: Public comments due by September 27
Press Release
PFS Proposed Rule Fact Sheet
Quality Payment Program Proposed Rule Fact Sheet

See the full text of this excerpted Fact Sheet (Issued July 29).


Medicare OPPS and ASC Payment System CY 2020 Proposed Rule

On July 29, CMS proposed policies that follow directives in President Trump’s Executive Order, entitled “Improving Price and Quality Transparency in American Health Care to Put Patients First,” that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The proposed changes also encourage site-neutral payment between certain Medicare sites of services.  Finally, the proposed rule proposes updates and policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed polices in the CY 2020 OPPS/ASC Payment System proposed rule would further advance the agency’s commitment to increasing price transparency, (including proposals for requirements that would apply to each hospital operating in the United States), strengthening Medicare, rethinking rural health, unleashing innovation, reducing provider burden, and strengthening program integrity so that hospitals and ambulatory surgical centers can operate with better flexibility and patients have what they need to become active health care consumers. 

In accordance with Medicare law, CMS is proposing to update OPPS payment rates by 2.7 percent. This update is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for Multi-Factor Productivity (MFP).

In the CY 2019 OPPS/ASC final rule with comment period, we finalized our proposal to apply the hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). CMS is not proposing any changes to its policy to use the hospital market basket update for ASC payment rates for CY 2020-2023. Using the hospital market basket, CMS proposes to update ASC rates for CY 2020 by 2.7 percent for ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for MFP. This change will also help to promote site neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.

The proposed rule also includes:

Proposed definition of ‘hospital,’ ‘standard charges,’ and ‘items and services’
Proposed requirements for making public all standard charges for all items and services
Proposed requirements for making public consumer-friendly standard charges for a limited set of ‘shoppable services’
Proposals for monitoring and enforcement
Method to control for unnecessary increases in utilization of outpatient services
Changes to the Inpatient Only list
ASC covered procedures list
High-cost/low-cost threshold for packaged skin substitutes
Device pass-through applications
Addressing wage index disparities
Changes in the level of supervision of outpatient therapeutic services in hospitals and critical access hospitals
Hospital Outpatient Quality Reporting Program
Ambulatory Surgical Center Quality Reporting Program
CY 2020 OPPS payment methodology for 340B purchased drugs
Partial Hospitalization Program rate setting and update to per diem rates
Revision to the organ procurement organization conditions for certification
Potential changes to the organ procurement organization and transplant center regulations: Request for Information

For More Information:

Proposed Rule: Public comments due by September 27
Press Release

See the full text of this excerpted CMS Fact Sheet (issued July 29).


ESRD and DMEPOS CY 2020 Proposed Rule

On July 29, CMS issued a proposed rule that proposes to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2020. This rule also:

Proposes updates to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI
Proposes changes to the ESRD Quality Incentive Program
Includes requests for information on data collection resulting from the ESRD PPS technical expert panel, on possible updates and improvements to the ESRD PPS wage index, and on new rules for the competitive bidding of diabetic testing strips.

In addition, this rule proposes a methodology for calculating fee schedule payment amounts for new Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items and services and making adjustments to the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts. This rule would also:

Make amendments to revise existing policies related to the competitive bidding program for DMEPOS
Streamline the requirements for ordering DMEPOS items, and create one Master List of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements

The proposed CY 2020 ESRD PPS base rate is $240.27, an increase of $5.00 to the current base rate of $235.27.  This proposed amount reflects a reduced market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (1.7 percent) and application of the wage index budget-neutrality adjustment factor (1.004180).
The proposed rule also includes:

Annual update to the wage index
Update to the outlier policy
Eligibility criteria for the Transitional Drug Add-on Payment Adjustment (TDAPA)
Basis of Payment for the TDAPA for calcimimetics
Average sales price conditional policy for the application of the TDAPA:
New and innovative renal dialysis equipment and supplies
Discontinuing the application of the erythropoiesis-stimulating agent monitoring policy
Impact analysis:  

For More Information:

Proposed Rule: Public comments due by September 27
Press Release

See the full text of this excerpted CMS Fact Sheet (issued July 29).


August is National Immunization Awareness Month

Help protect your Medicare patients from vaccine-preventable diseases by encouraging utilization of Medicare-covered immunizations and ensuring those immunizations are up-to-date.


July 26, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11268 – Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period – Claims Processing Requirements
Change Request (CR) 11268 informs the Medicare Administrative Contractors (MACs) that effective January 1, 2020 (the start of the AUC program Educational and Operations Testing Period), MACs should accept the Appropriate Use Criteria (AUC) related HCPCS modifiers on claims. Please be sure your billing staff and vendors are aware of this update. Subsequent CRs will follow at a later date that will continue AUC program implementation.

July 25, 2019

CMS Provider Education Message:

MLN Connects — Questions about Using the MBI?

MLN Connects® for Thursday, July 25, 2019

View this edition as a PDF

News

New Medicare Card: Questions about Using the MBI?
2020 QRDA III Implementation Guide, Schematron, and Sample Files
Antipsychotic Drug Use in Nursing Homes: Trend Update
Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
World Hepatitis Day: Medicare Coverage for Viral Hepatitis

Compliance

Importance of Proper Documentation: Provider Minute Video

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

Enrollment: Multi–Factor Authentication for I&A System Webcast — July 30
Diagnosing and Treating Dementia: Current Best Practices Webinar — July 30
Quality Payment Program Performance Information on Physician Compare Webinar — July 30/Aug 1
Disability-Competent Care Conversation on Access Webinar — July 31
RF Appeals Settlement Initiative Call — August 13
Home Health Patient-Driven Groupings Model: Operational Issues Call — August 21

MLN Matters® Articles

Medicare Plans to Modernize Payment Grouping and Code Editor Software

Publications

Medicare DMEPOS Improper Inpatient Payments
Medicare Part D Vaccines — Revised
Provider Compliance Tips for Enteral Nutrition Pumps — Revised

Multimedia

Hospital Listening Session: Audio Recording and Transcript
Hospice Quality Reporting Program Web-Based Courses

The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding articles for these LCDs have been added:

Evaluation and Management Services Provided in a Nursing Facility (L35068)
Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility (A56712)
Flow Cytometry (L35032)
Billing and Coding: Flow Cytometry (A56676)
Hyperbaric Oxygen (HBO) Therapy (L35021)
Billing and Coding: Hyperbaric Oxygen (HBO) Therapy (A56714)
Intensity Modulated Radiation Therapy (IMRT) (L36711)
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
Intraoperative Neurophysiological Testing (L35003)
Billing and Coding: Intraoperative Neurophysiological Testing (A56722)
In Vitro Chemosensitivity & Chemoresistance Assays (L36634)
Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56710)

The following Local Coverage Determination (LCD) has been revised

Services That Are Not Reasonable and Necessary (L35094)

The following Local Coverage Article has been revised:

Billing and Coding: Hemophilia Factor Products (A56433)

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11273 – Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment
Change Request 11273 removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit. Also, the Centers for Medicare & Medicaid Services added a new section to chapter 12 of the Medicare Claims Processing Manual regarding Evaluation and Management codes that you may bill with superficial radiation treatment. Make your billing staff aware of these changes.

July 23, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11354 – New Waived Tests
Change Request 11354 informs Medicare Administrative Contractors (MACs) of new Clinical Laboratory Improvement Amendments of 1988(CLIA) waived tests approved by the Food and Drug Administration. Since these tests are marketed immediately after approval, the Centers for Medicare & Medicaid Services must notify the MACs of the new tests so that they can accurately process claims. Make sure your billing staffs are aware of these CLIA-related changes.

July 18, 2019

CMS Provider Education Message:

MLN Connects — DMEPOS Competitive Bidding: Round 2021 Bid Window is Open 

MLN Connects® for Thursday, July 18, 2019

View this edition as a PDF

News

Is Your Vendor/Clearinghouse Submitting Your Claims with the MBI?
DMEPOS Competitive Bidding: Round 2021 Bid Window is Open
Nursing Homes: Updating Requirements for Arbitration Agreements and New Regulations
CMS Proposes to Cover Acupuncture for Chronic Low Back Pain for Medicare Beneficiaries Enrolled in Approved Studies
Quality Payment Program: 2018 MIPS Performance Feedback and Final Score
Quality Payment Program Participation: Preliminary Data on 2018
Physician Compare: 2017 Quality Payment Program Performance Information
PEPPERs for HHAs, PHPs
2017 Physician and Other Supplier PUF
2017 Referring Provider DMEPOS PUF
Qualified Medicare Beneficiary Billing Requirements
Mass Casualty Triage White Paper and June Express
Looking for Educational Materials?

Compliance

Cardiac Device Credits: Medicare Billing

Events

DMEPOS Competitive Bidding: Round 2021 Webcast Series
Enrollment: Multi–Factor Authentication for I&A System Webcast — July 30
IRF Appeals Settlement Initiative Call — August 13

MLN Matters® Articles

Tropical Storm Barry and Medicare Disaster Related Louisiana Claims
Reduce Risk of Opioid Overdose Deaths by Avoiding and Reducing Co-Prescribing Benzodiazepines
Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
Emergency Medical Treatment and Labor Act (EMTALA) and the Born-Alive Infant Protection Act
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - October 2019
Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home
July 2019 Update of the Ambulatory Surgical Center (ASC) Payment System
Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations — Revised

Publications

Provider Compliance Tips for Respiratory Assistive Devices — Revised
Provider Compliance Tips for Enteral Nutrition — Revised

Multimedia

Post-Acute Care Call: Audio Recording and Transcript

July 16, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11328 – July 2019 Update of the Ambulatory Surgical Center (ASC) Payment System
Change Request 11328 contains the changes to and billing instructions for various payment policies implemented in the July 2019 ASC payment system update. This notification also includes updates to HCPCS. Make sure your billing staffs are aware of these updates.

Part B Top Inquiries / Frequently Asked Questions (FAQs) for AR, CO, LA, MS, NM, OK, & TX

The Part B Top Inquiries / FAQs, received by our Customer Contact Center, have been reviewed for June 2019. Please take time to review these FAQs for answers to your questions.


Provider Enrollment Alert - Issues resulting from recent Provider Enrollment, Chain and Ownership System (PECOS) Release

On June 30, 2019, PECOS Release 7.37 was implemented. This release was prescheduled and designed to bring efficiencies to Medicare Administrative Contractors (MACs) and providers who use PECOS. While many aspects of the release were successful, a small component associated to changes made to existing and new group reassignments, was found to be problematic post-implementation. As a result, data flows from PECOS to the Multi-Carrier System (MCS) for these changes have been delayed for all MACs to proactively correct the identified issue.   

The Centers for Medicare & Medicaid Services has assembled a team with accountability for resolving this issue. The team is working tirelessly to resolve the issue(s). While some records are expected to be corrected by Tuesday, July 16, 2019, problems persist for other records. Please be assured that the team is working aggressively for a resolution.  Click here for potential questions and answers that you may have.


July 15, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19014 – Tropical Storm Barry and Medicare Disaster Related Louisiana Claims
The Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the state of Louisiana on July 12, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to July 10, 2019, and are in effect for 90 days.
The Centers for Medicare & Medicaid Services is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
Current Emergencies webpage
Instructions to request an individual waiver if there is no blanket waiver
MM11357 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.3 Effective October 1, 2019
Change Request 11357 updates the NCCI PTP edits, which relate to Chapter 23, Section 20.9 of the Medicare Claims Processing Manual. Please make sure your billing staffs are aware of these updates.
MM11295 – Update to Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home
Change Request 11295 informs MACs about changes which update the list of International Classification of Diseases, Tenth Revision, Clinical Modification codes for the coverage of Intravenous Immune Globin for treatment of Primary Immune Deficiency Diseases in the home. Make sure that your billing staffs are aware of these changes.

Tropical Storm Barry

Our thoughts are with those impacted by this tropical storm. To learn more about the Centers for Medicare & Medicaid Services (CMS) response activities regarding Tropical Storm Barry and find the latest program guidance, please visit the CMS Emergency Preparedness and Response website.


Frequently Asked Questions (FAQs) 

Have questions and not sure where to turn? Check out our FAQs for answers to your questions.


July 12, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11344 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2019
Change Request 11344 announces changes that will be in the October 2019 quarterly release of the edit module for clinical diagnostic laboratory services. Please make sure your billing staffs are aware of these changes.

July 11, 2019

CMS Provider Education Message:

MLN Connects — New Medicare Card: Transition Period Ends in Less Than 6 Months

MLN Connects® for Thursday, July 11, 2019

View this edition as a PDF

News

New Medicare Card: Transition Period Ends in Less Than 6 Months
HHS To Transform Care Delivery for Patients with Chronic Kidney Disease
CMS Expands Coverage of Ambulatory Blood Pressure Monitoring
Open Payments: Program Year 2018 Data
SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1

Events

DMEPOS Competitive Bidding: Round 2021 Webcast Series
Enrollment: Multi–Factor Authentication for I&A System Webcast — July 30

MLN Matters® Articles

Medicare Plans to Modernize Payment Grouping and Code Editor Software
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2020
October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program — Revised
July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2 — Revised
July Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule — Revised
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Publications

Get Your New Medicare Card
Medicare Documentation Job Aid for Doctors of Chiropractic
Medicare Preventive Services — Revised

Multimedia

CMS: Beyond the Policy Podcast: Throwback to HIMSS Conference

CMS Provider Education Message: Home Health Payment and Policy Changes

Special Edition – Thursday, July 11, 2019

HHAs: CY 2020 and 2021 New Home Infusion Therapy Benefit and Payment and Policy Changes

On July 11, CMS issued a proposed rule [CMS-1711-P] that proposes routine updates to the home health payment rates for CY 2020, in accordance with existing statutory and regulatory requirements. This rule will also include:

Proposal to modify the payment regulations pertaining to the content of the home health plan of care
Proposal to allow therapist assistants to furnish maintenance therapy
Proposal related to the split percentage payment approach under the Home Health Prospective Payment System (PPS)
Proposals related to the implementation of the permanent home infusion therapy benefit in 2021

This proposed rule sets forth implementation of the Patient-Driven Groupings Model (PDGM), an alternate case-mix adjustment methodology, and a 30-day unit of payment as mandated by the Bipartisan Budget Act of 2018 (BBA of 2018). CMS projects that Medicare payments to Home Health Agencies (HHAs) in CY 2020 will increase in aggregate by 1.3 percent, or $250 million, based on proposed policies. The increase reflects the effects of the 1.5 percent home health payment update percentage ($290 million increase) mandated by BBA of 2018.  It also reflects a 0.2 percent decrease in aggregate payments due to reductions made by the new rural add-on policy mandated by the BBA of 2018 for CY 2020 (i.e., an estimated $40 million decrease in rural add-on payments). The rate updates also include adjustments for anticipated changes with implementation of the PDGM and a change to a 30-day unit of payment, the use of updated wage index data for the home health wage index, and updates to the fixed-dollar loss ratio to determine outlier payments.

In addition, the proposed rule includes:

Proposed payment rate changes for home infusion therapy temporary transitional payments for CY 2020
Payment proposals for new home infusion therapy benefit for CY 2021
Regulatory burden reduction – Patients over paperwork and enhance and modernize program integrity
Paraprofessional roles – Improving access to care
Home Health Quality Reporting Program – Support MyHealthEData Initiative
Home Health Value-Based Purchasing model

For More Information:

Proposed Rule
Press Release
Home Health PPS website
Home Health Quality Reporting Requirements webpage
Home Health Value-Based Purchasing Model webpage

See the full text of this excerpted CMS Fact Sheet (issued July 11).


The following Local Coverage Determinations (LCDs) have been revised. The related Billing and Coding articles for these LCDs have been added:

Debridement of Mycotic Nails (L35013)
Billing and Coding: Debridement of Mycotic Nails (A56640)
Diagnostic Abdominal Aortography and Renal Angiography (L35092)
Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
Electroretinography (ERG) (L37371)
Billing and Coding: Electroretinography (ERG) (A56672)
Epidural Injections for Pain Management (L36920)
Billing and Coding: Epidural Injections for Pain Management (A56681)
Facet Joint Interventions for Pain Management (L34892)
Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
Hydration Therapy (L34960)
Billing and Coding: Hydration Therapy (A56634)

The following Local Coverage Article has been revised:

Independent Diagnostic Testing Facility (IDTF) (A53252)

Medicare Secondary Payer: Non-Group Health Plans (NGHP) (A/B) September 17, 2019

Join us as we discuss Medicare as a secondary payer (MSP) and the fundamentals of this cost-saving program. During this webcast, we will provide information regarding Non-Group Health Plans in relation to Medicare as the secondary payer.

Medicare secondary payer (MSP) is a term used when Medicare is not the beneficiary's primary health insurance coverage. Providers are responsible to determine whether Medicare is the primary payer or not, as well as billing for the services and/or supplies provided to Medicare beneficiaries. One of the top inquiries we receive every month is regarding a patient's eligibility and MSP. This event is the third in a series of webcasts designed in collaboration with the A/B Medicare Administrative Contractors (MAC) to educate Medicare providers on the fundamentals of the MSP program.


June 2019 Part B Newsletter

The June 2019 Part B Monthly Newsletter is currently available for your reading pleasure. Visit the Publications page of our website for up to date information on the Medicare program.


July 10, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE19001 – Pre-Diabetes Services: Referring Patients to the Medicare Diabetes Prevention Program
This article is for providers who may refer Medicare patients to the Medicare Diabetes Prevention Program (MDPP) for services to reduce diabetes risk.
SE19011 – Reduce Risk of Opioid Overdose Deaths by Avoiding and Reducing Co-Prescribing Benzodiazepines
This article is for physicians, non-physician practitioners (NPPs), other prescribers, and pharmacists who prescribe or dispense opioids and benzodiazepines (BZDs).

Part B Top Claim Submission / Reason Code Errors

The Top Claim Submission / Reason Code Errors and resolutions for June 2019 for Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas are now available. Please take time to review these errors and avoid them on future claims.


July 9, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11343 – October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Change Request 11343 informs MACs about new and revised ASP and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after September 13, 2019.
CMS gives Medicare Administrative Contractors the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System are incorporated into the Outpatient Code Editor through separate instructions available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure that your billing staffs are aware of these changes

Revised:

MM11230 – Medicare Summary Notice (MSN) Changes to Assist Beneficiaries Enrolled in the Qualified Medicare Beneficiary (QMB) Program
The Centers for Medicare & Medicaid Services (CMS) revised this article on July 9, 2019, to reflect the revised Change Request (CR) 11230 issued on July 3. In the article, CMS deleted a reference to the Fiscal Intermediary Standard System rejections that was on page 3. They also revised the release date, transmittal number, and the web address of the CR. All other information remains the same.

Modifier 50 Fact Sheet 

Our fact sheet on the proper use of modifier 50 has been updated. Please take time to review the fact sheet to ensure that you are reporting the modifier correctly. Effective for claims received on and after August 16, 2019, services will be rejected as unprocessable when the procedure code reported is inconsistent with the modifier used.


Bilateral Indicator Article Update

Our Bilateral Indicator article has been updated.  Please take time to review the new information.   Effective for claims received on and after August 16, 2019, services will be rejected as unprocessable when the procedure code reported is inconsistent with the modifier used.


July 8, 2019

Medicare Documentation Job Aid for Doctors of Chiropractic

A new Medicare Documentation Job Aid for Doctors of Chiropractic Medicare Learning Network Educational Tool is available. Learn about:

How to respond to medical records requests
Medical necessity documentation
Medical records which support corrective treatment

July 5, 2019

Revised July 1, 2019 ASC Fee Schedule

The July 1, 2019 ASC Fee Schedule has updated the fee for procedure code 0548T and is effective July 1, 2019 for dates of service 7/1/19 to 12/31/19.


Local Coverage Determination (LCD) and Article Update History

The following Local Coverage Determination (LCD) has been revised. The related billing and coding article has also been revised:

Frequency of Hemodialysis (L35014)
Billing and Coding: Frequency of Hemodialysis (A55723)

July 3, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11280 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
The Centers for Medicare & Medicaid Services (CMS) revised this article on July 3, 2019, to reflect a revised Change Request (CR) that they posted on June 28. In the article, a section was added on page 5 regarding Advanced Diagnostic Laboratory Tests. CMS also revised the CR release date, transmittal number, and the web address. All other information remains the same.

July 2, 2019

Revised:

MM11334 – July Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
The Centers for Medicare & Medicaid Services (CMS) revised this article on July 2, 2019, to reflect the revised Change Request (CR) 11334 issued on June 28. CMS revised the CR to include a correction to the fee schedule amounts for HCPCS codes E1353 and E1355. The article includes this correction information on page 4. CMS also revised the CR release date, transmittal number, and the web address. All other information remains the same.

Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes (PRC)

Medicare Part B Merit-Based Incentive Payment System (MIPS)-eligible clinicians may now report their patient relationships on Medicare claims using the PRC codes.  CMS advises clinicians to participate during the voluntary reporting period.   


July 1, 2019

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11296 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2019 Update
The Centers for Medicare & Medicaid Services (CMS) revised this article on June 19, 2019 to reflect the revised Change Request (CR) 11296 issued on June 12. CMS revised the CR to update the short and long descriptors of Q5115 and revised the article accordingly. The CR release date, transmittal number, and the web address have also been revised. All other information remains the same.