Medicare News and Web Updates for JH Part B (2021)

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* Coronavirus (COVID-19) Information

April 21, 2021

March 2021 top claim submission errors

The March 2021 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.


2021 COVID-19 monoclonal antibodies reimbursement

Please take the time to review updates to this article. Information was added about the revocation of the Emergency Use Authorization (EUA) that allowed payment for the monoclonal antibody therapy bamlanivimab (HCPCS codes M0239 or Q0239) effective with dates of service after 4/16/2021.


COVID-19 vaccine and monoclonal antibody billing for Part B providers

Please take the time to review updates to this article. Information was added about the revocation of the Emergency Use Authorization (EUA) that allowed payment for the monoclonal antibody therapy bamlanivimab (HCPCS codes M0239 or Q0239) effective with dates of service after 4/16/2021.


Medically necessary services and prior authorization

CMS supports efforts to safeguard beneficiaries’ access to medically necessary items and services while reducing improper Medicare billing and payments. Please review our revised article on medically necessary services and prior authorization.


April 20, 2021

Special Edition – Tuesday, April 20, 2021

Provider Education Message:

COVID-19 Update: FDA Revoked the EUA for Bamlanivimab When Administered Alone

On April 16, the FDA revoked the Emergency Use Authorization (EUA) for bamlanivimab, when administered alone, due to a sustained increase in COVID-19 viral variants in the U.S. that are resistant to this antibody therapy. The FDA determined that the known and potential benefits of bamlanivimab, when administered alone, no longer outweigh the known and potential risks.

Medicare will cover and pay for bamlanivimab, when administered alone, for dates of service from November 10, 2020 – April 16, 2021.

The FDA indicates that alternative monoclonal antibody therapies remain appropriate to treat COVID-19 patients, and health care providers may continue using these authorized therapies when administered together:

Casirivimab & imdevimab
Bamlanivimab & etesevimab

More Information:

Fact Sheet for Health Care Providers EUA of Casirivimab and Imdevimab Section 15, Antiviral Resistance
Fact Sheet for Health Care Providers EUA of Bamlanivimab and Etesevimab Section 15, Antiviral Resistance
Monoclonal Antibody COVID-19 Infusion webpage

Person(s) with Medicare

Please take time to review new articles added titled for COVID-19 vaccine scams poster and HHS OIG alert about COVID-19 scams.


Provider specialty: COVID-19 vaccine and monoclonal antibodies

Please review the new article titled HHS OIG COVID-19 vaccination program and provider compliance.


April 19, 2021

Provider specialty: Radiology services

New information has been added to the radiology specialty page regarding the appropriate use criteria program.  Please ensure that you carefully review the this information. 


April 16, 2021

CMS Provider Education Message:

2% Payment Adjustment (Sequestration) Suspended Through December

MLN Connects newsletter for Friday, April 16, 2021

View this edition as a: Webpage | PDF

News

Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through December
COVID-19 Vaccine: Check Medicare Eligibility Starting April 16
Johnson & Johnson COVID-19 Vaccine: Information for Long Term Care Facilities
Medicare Telehealth Services: Updated List
Medicare Pays to Help Patients Plan
Sexual Health: Medicare Covers Preventive Services

Compliance

Telehealth Services: Bill Correctly

Events

Medicare Part A Cost Report: Easier File Uploads for e-Filing in MCReF Webcast — April 29

Multimedia

IRF Providers: Assessment of Cognitive Function Web-Based Training
Diagnosis Coding: Using the ICD-10-CM Web-Based Training — Revised
Procedure Coding: Using the ICD-10-PCS Web-Based Training — Revised

Appropriate use criteria (AUC) program for advanced diagnostic imaging services

During the AUC program educational and operations testing period, CMS expects ordering providers to begin consulting qualified clinical decision support mechanisms (CDSMs) prior to ordering advanced imaging services in applicable settings for Medicare patients and providing information to the furnishing provider for reporting on their claims. Please review this new article for the guidelines.


Frequently Asked Questions (FAQs)

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


April 14, 2021

Special Edition – Wednesday, April 14, 2021

Provider Education Message:

J&J COVID-19 Vaccine: Health Alert

The CDC issued a Health Alert, about the CDC and FDA’s recommended pause in the use of the J&J COVID-19 vaccine, in part, to ensure that the health care provider community is aware of the potential for adverse events and can provide proper management due to the unique treatment required with this type of blood clot. This alert includes specific recommendations for clinicians.


Registration and meeting materials available for May 12, 2021, Amniotic Product Injections for Musculoskeletal Indications-Non-Wound Multi-Jurisdictional Contractor Advisory Committee (CAC) Meeting

This meeting will be held via Teleconference ONLY.

On May 12, 2021, seven Medicare Administrative Contractors (MACs); lead by Noridian Healthcare Solutions, will host a multi-jurisdictional CAC meeting from 1:30 p.m. - 4:30 p.m. CT.

The CAC panel will discuss the clinical literature related to Amniotic Product Injections for Musculoskeletal Indications, Non-Wound and rate their confidence in a series of key questions. Discussions will occur between CAC panelists and Contractor Medical Directors (CMDs). The public may attend; however, questions from the public will not be entertained.

Interested stakeholders are invited to listen via teleconference; however, advance registration is required. Note: Registration deadline is May 11, 2021, 11:59 p.m. CT

Once registered you will receive the teleconference information via email prior to the meeting. Lines will remain muted throughout the conference except for the invited CAC panelists and the MAC hosts.   

View meeting details and register now from the Noridian Healthcare Solutions CAC Meeting web page or the Novitas Multi-Jurisdictional CAC Meeting web page.


April 12, 2021

March 2021 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

The March 2021 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


April 10, 2021

Part B Physician’s Fee Schedule: Pricing Updates for 93241, 93243, 93245, and 93247

Pricing has been updated for the following codes: 93241, 93243, 93245, and 93247. This pricing is for 2021 and effective retroactively to January 1, 2021. Please note that our download files and lookup tool currently reflect the old pricing. Until these have been updated, please reference this table to review the currently effective pricing. We will update you when our fee download files and lookup tools have been adjusted to include this new pricing.

 

93241

93243

93245

93247

Arkansas Locality 13

121.30

85.05

132.80

94.21

Colorado Locality 01

146.11

105.19

159.92

116.52

Louisiana Locality 01

132.53

93.43

144.95

103.46

Louisiana Locality 99

125.52

87.84

137.31

97.28

Mississippi Locality 00

120.99

84.62

132.43

93.73

New Mexico Locality 05

128.25

90.20

140.32

99.90

Oklahoma Locality 00

125.88

88.56

137.78

98.10

Texas Locality 09

143.32

102.71

157.01

113.78

Texas Locality 11

143.62

103.01

157.22

114.11

Texas Locality 15

143.79

103.01

157.42

114.12

Texas Locality 18

144.64

103.44

158.29

114.57

Texas Locality 20

133.25

94.80

145.86

105.01

Texas Locality 28

139.72

99.90

152.96

110.67

Texas Locality 31

147.24

106.32

161.19

117.78

Texas Locality 99

134.63

95.91

147.37

106.24

April 9, 2021

Self-paced education is now available!

Novitas Solutions On-Demand education is growing! Did you know that we now offer the following free On-Demand education? Continue to monitor the pages below for updates!

Webinar Recordings

Webinar recordings are now available! Continue to monitor our Webinar Recordings page for additional recording options! A Novitas Learning Center account is required to view the recording.

New release! 4/1/2021 Medicare Part A/B Presents: Overpayment and Recoupment Process

Click and Play Videos

Looking for help now? Novitas Solutions offers a variety of tutorials aimed at helping you navigate forms, billing, enrollment and so much more. A Novitas Learning Center account is not needed to view these videos. Visit our Training Videos page or our YouTube channel to see a full list of videos.

Online Training Courses

Want to learn about a Medicare topic, but want to do it on your time? Participate in our self-paced, free online courses when and where it is most convenient for you! View the full course listing on our Online Course Catalogue. A Novitas Learning Center account is required to participate.

New release! Billing Part B Laboratory Services
New release! Opioid Treatment Program (OTP) Billing and Coding
Coming soon! Skilled Nursing Facility (SNF) Part B Consolidated Billing (CB)

If you need additional help logging in to the Novitas Learning Center, making changes to your account, or finding what you need inside the Learning Center, email us at NovitasLearningCenterHelpDesk@novitas-solutions.com. Include your contact information, username (if you know it), and a detailed description of your issue in the body of the email. 


April 8, 2021

Special Edition – Thursday, April 8, 2021

Provider Education Message:

4 Proposed FY 2020 Payment Rules

SNF Prospective Payment System: FY 2022 Proposed Rule
Hospice Payment Rate Update for FY 2022
IRF Prospective Payment System: FY 2022 Proposed Rule
IPF: Proposed Medicare Payment & Quality Reporting Updates

SNF Prospective Payment System: FY 2022 Proposed Rule

On April 8, CMS issued a proposed rule that would update Medicare payment policies and rates for Skilled Nursing Facilities (SNFs) under the SNF Prospective Payment System (PPS) for Fiscal Year (FY) 2022. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program and the SNF Value-Based Program (VBP) for FY 2022.

CMS estimates that the aggregate impact of the payment policies in this proposed rule would result in an increase of approximately $444 million in Medicare Part A payments to SNFs in FY 2022. This estimate reflects a $445 million increase from the update to the payment rates of 1.3 percent, which is based on a 2.3 percent SNF market basket update, less a 0.8 percentage point forecast error adjustment and a 0.2 percentage point multifactor productivity adjustment, and a $1.2 million decrease due to the proposed reduction to the SNF PPS rates to account for the recent blood-clotting factors exclusion. These impact figures do not incorporate the SNF VBP reductions that are estimated to be $184.25 million in FY 2022.

Proposed updates to the Patient Driven Payment Model:

Methodology for recalibrating the parity adjustment
Proposed changes in ICD-10 code mappings

More Information:

Full fact sheet
Proposed rule: CMS will accept comments until June 7

Hospice Payment Rate Update for FY 2022

On April 8, CMS issued a proposed rule that would provide routine updates to hospice base payments and the aggregate cap amount for Fiscal Year (FY) 2022. This proposed rule also includes a comment solicitation regarding hospice utilization. In addition, this rule proposes to rebase the hospice labor shares and clarify certain aspects of the hospice election statement addendum requirements.

This rule proposes changes to the hospice conditions of participation and Hospice Quality Reporting Program (HQRP). The proposed rule also includes a Home Health Quality Reporting Program proposal to display publicly 3 quarters of certain outcome and assessment information set data due to the COVID-19 public health emergency exemptions of the 2020 first and second quarter data. 

As proposed, hospices would see a 2.3 percent ($530 million) increase in their payments for FY 2022. The proposed 2.3 percent hospice payment update for FY 2022 is based on the estimated 2.5 percent inpatient hospital market basket reduced by the multifactor productivity adjustment (0.2 percentage point). Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual market basket update for FY 2022.

Proposed updates:

Hospice labor shares
Fast health care interoperability resources in support of the HQRP – Request for Information (RFI)
Closing the health equity gap in the HQRP - RFI

More Information:

Full fact sheet
Proposed rule: CMS will accept comments until June 7

IRF Prospective Payment System: FY 2022 Proposed Rule

On April 7, CMS issued a proposed rule that would update Medicare payment policies and rates for facilities under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program for Fiscal Year (FY) 2022.

CMS is proposing to update the IRF PPS payment rates by 2.2% based on the proposed IRF market basket update of 2.4%, less a 0.2 percentage point Multi-Factor Productivity (MFP) adjustment. CMS is proposing that if more recent data becomes available, we would use these data, if appropriate, to determine the FY 2022 market basket update and MFP adjustment in the final rule. In addition, the proposed rule contains an adjustment to the outlier threshold to maintain outlier payments at 3.0% of total payments. This adjustment would result in a 0.3 percentage point decrease in outlier payments. We estimate that the overall increase to IRF payments for FY 2022 would be 1.8% (or $160 million), relative to payments in FY 2021. 

Proposed updates to quality reporting:

Closing the health equity gap – Request for Information (RFI)
COVID-19 Vaccination Coverage among Health Care Personnel measure
Transfer of Health Information to the Patient Post-Acute Care quality measure
Public reporting of quality measures with fewer than standard numbers of quarters due to COVID-19 public health emergency exemptions
Fast health care interoperability resources in support of digital quality measurement in post-acute care quality reporting programs – RFI

More Information:

Full fact sheet
Proposed rule: CMS will accept comments until June 7
IRF PPS webpage

IPF: Proposed Medicare Payment & Quality Reporting Updates

On April 7, CMS issued a proposed rule that would update Medicare payment policies and rates for the Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS) for Fiscal Year (FY) 2022 and propose changes to the IPF Quality Reporting (IPFQR) Program. We’re soliciting comments on addressing health equity in the IPFQR Program.

Total estimated payments to IPFs are estimated to increase by 2.3% or $90 million in FY 2022 relative to IPF payments in FY 2021. For FY 2022, CMS is proposing to update the IPF PPS payment rates by 2.1% based on the proposed IPF market basket update of 2.3%, less a 0.2 percentage point productivity adjustment. CMS is proposing that if more recent data becomes available, we would use these data, if appropriate, to determine the FY 2022 market basket update and multi-factor productivity adjustment in the final rule. Accounting for an additional update to the outlier threshold so that estimated outlier payments remain at 2.0% of total payments, results in a 0.2% overall increase to aggregate payments due to updating the outlier threshold results.

More Information:

Full fact sheet
Proposed rule: CMS will accept comments until June 7

CMS Provider Education Message:

More FY20 PEPPERs Available

MLN Connects newsletter for Thursday, April 8, 2021

View this edition as a: Webpage | PDF

News

PEPPERs for LTCHs, CAHs, IRFs, IPFs, Hospices, & SNFs
Preparedness Resources: Cybersecurity & Post-Acute Sequelae of SARS-CoV-2
Minority Health: Medicare Covers Preventive Services

Compliance

Hospice Aide Services: Enhancing RN Supervision

Claims, Pricers, & Codes

OPPS Pricer File: April 2021

Events

Changes in the Hospice Item Set Manual V3.00 Webinar — April 15
Medicare Part A Cost Report: Easier File Uploads for e-Filing in MCReF Webcast — April 29

MLN Matters® Articles

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2021
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.2, Effective July 1, 2021
Update to the Payment for Grandfathered Tribal Federally Qualified Health Centers (FQHCs) for Calendar Year (CY) 2021
April 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation — Revised

Publications

How to Use the Medicaid NCCI Tools
Hospital Value-Based Purchasing — Revised

Multimedia

Dementia Care Call: Audio Recording & Transcript
Open Payments Call: Audio Recording & Transcript
SNF Resident Mood Interview Video
2021 Medicare Part C & Part D Reporting Requirements & Data Validation Web-Based Training — Revised

The new FastTrack to Medicare Coverage Policy tool is here!

Do you find it challenging to identify a Medicare coverage policy concerning a particular item or service? Not sure what to do if a Medicare coverage policy doesn’t exist?

Novitas has the answer: the FastTrack to Medicare Coverage Policies tool. This new tool provides a hierarchy of critical resources to determine if a Medicare policy exists, and if not, what to do next. We know this tool will help you find your Medicare coverage answers.

Start using the FastTrack to Medicare Coverage Policies on the Novitas website today.


The following Billing and Coding Article has been revised:

Billing and Coding: Hemophilia Factor Products (A56433)

Ventricular assist device (VAD) supplies

Please take a minute to review our new article and ensure that you are providing an invoice with your claim submission.   


April 7, 2021

HCPCS codes no longer requiring invoice

New information has been added to the article regarding important narrative information required.  Please ensure that you carefully review the article. 


Medicare Learning Network® MLN Matters® Articles from CMS

Revision:

MM12068 - Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update
CMS revised this article to reflect a revised change request (CR) 12068. The CR revision didn’t change the substance of this article. CMS changed the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

April 6, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12183 - April 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
This article describes changes to and billing instructions for various payment policies CMS is making in the April 2021 ASC payment system update. Change request 12183 also includes updates to HCPCS. Make sure that your billing staffs are aware of these changes.

April 5, 2021

May 2021 Novitas Solutions Virtual Symposium

The Novitas Solutions Virtual Symposium is now open for registration! New classes have been added to our agenda. There are 31 webinars available to choose from with this event. Please visit our Symposium page to view the full agenda and to register.

Event Dates: May 19 – 21, 2021
Event Times: 9:00 AM, 11:30 AM, 2:00 PM CST

To register and participate in an educational event, you must have an account in the Novitas Learning Center. If you do not have one, request an account. For additional assistance with registering or with your account, please contact NovitasLearningCenterHelpDesk@novitas-solutions.com.


The following Local Coverage Article which was revised and  posted on February 18, 2021 is now effective:

Self-Administered Drug Exclusion List (A53127)

April 1, 2021

CMS Provider Education Message:

Repayment of COVID-19 Accelerated and Advance Payments

MLN Connects newsletter for Thursday, April 1, 2021

View this edition as a: Webpage | PDF

News

Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021
COVID-19 Vaccine Administration – No Out-of-Pocket Cost to Patients
Alcohol Misuse: Medicare Covers Screening & Counseling

Compliance

DMEPOS: Bill Correctly for Items Provided During Inpatient Stays

Claims, Pricers, & Codes

COVID-19: RHC & FQHC Lump Sum Payments

Events

Medicare Part A Cost Report: Easier File Uploads for e-Filing in MCReF Webcast — April 29

MLN Matters® Articles

New Provider Enrollment Administrative Action Authorities
April 2021 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2021
Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
Update to the Manual for Telephone Services, Physician Assistant (PA) Supervision, and Medical Record Documentation for Part B Services

Multimedia

Medicare Part A Cost Report Appeals Listening Session: Audio Recording & Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE21004 - Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021
This article informs all Medicare providers and suppliers who requested and received COVID-19 accelerated and advance payments (CAAPs) that we began recovering those payments as early as March 30, 2021, depending upon the 1-year anniversary of when you received your first payment. It also gives information on how to identify recovered payments. Please be sure your billing staff are aware that the recovery has begun or will begin soon but no sooner than 1 year from the date we issued the CAAP to you.

The following Billing and Coding Article has been revised:

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

March 31, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12226 - Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.2, Effective July 1, 2021
Change Request 12226 provides the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.

#StayConnected Workshop Series: New Provider Roadmap

Stay connected with Medicare updates and requirements by attending the Novitas Solutions New Provider Roadmap Workshop Series. Novitas Solutions is dedicated to providing you with the knowledge necessary to be a successful Medicare provider. We are hosting a free webinar series that highlights important information for new providers and support staff. This six-part webinar series provides an overview of the Medicare program, basic billing instructions, an overview of the appeal process and a tour of the resources available on the Novitas Solutions and Centers for Medicare and Medicaid Services (CMS) websites. Feel free to attend all classes in the series or an individual class based on your schedule and area of interest.

Monday, April 19, 2021, at 10:00 AM EST “Understanding the Basics of the Medicare Program”
Tuesday, April 20, 2021, at 10:00 AM EST “Introduction to Part B Medicare Billing”
Tuesday, April 20, 2021, at 1:00 PM EST “Introduction to Part A Medicare Billing”
Wednesday, April 21, 2021, at 10:00 AM EST “Introduction to the Part B Medicare Appeal and Claim Correction Process”
Wednesday, April 21, 2021, at 1:00 PM EST “Introduction to the Part A Medicare Appeal and Claim Correction Process”
Thursday, April 22, 2021, at 10:00 AM EST “Exploring the Novitas and Centers for Medicare & Medicaid Services (CMS) Websites”

Register for this event or check out our full listing of upcoming Workshop events by visiting our Event Calendar.


COVID-19 vaccine and monoclonal antibody (mAb) infusion billing alerts 

The billing tip for Medicare secondary payer has been revised. Information has been added to clarify that you must gather information both from patients with Original Medicare and from patients enrolled in Medicare Advantage plans. Please carefully review the article for additional information.


March 30, 2021

Special Edition – Tuesday, March 30, 2021

Provider Education Message:

Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension

In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, we instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess if Congress extends the suspension; the MACs will automatically reprocess any claims paid with the reduction applied if necessary. 


March 29, 2021

Roster billing for Part B providers

Please ensure you are reporting the rendering provider's NPI when submitting the modified claim form for roster billing.   

Providers are highly encourage to submit roster bills electronically.  Please review the ABILTY PC-ACE user guide:  Section 5 flu, pneumonia, COVID-19, or Monoclonal Antibody Infusion Injection roster billing for additional information.


The following Local Coverage Determination (LCD) which was posted for notice on February 11, 2021 is now effective. The related billing and coding article for this LCD is also now effective.

Colon Capsule Endoscopy (CCE) (L38807)
Billing and Coding: Colon Capsule Endoscopy (CCE) (A58414)

March 25, 2021

CMS Provider Education Message:

Home Health Payment Corrections

MLN Connects newsletter for Thursday, March 25, 2021

View this edition as a: Webpage | PDF

News

Medicare Shared Savings Program: Application Deadlines for January 1, 2022, Start Date
Repetitive, Scheduled Non-Emergent Ambulance Transport: Documentation Requirements
PT During COVID-19 & Response to Texas Storm

Compliance

Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly

Claims, Pricers, & Codes

Home Health Payment Corrections

MLN Matters® Articles

Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update
Correction to Period Sequence Edits on Home Health Claims
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) 2021
Updated Billing Requirements for Home Infusion Therapy (HIT) Services on or After January 1, 2021
Update to Rural Health Clinic (RHC) Payment Limits

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12212 - April 2021 Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement
This article informs you about updates to the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS). Specifically, this quarterly update includes revisions to the Part B SNF CB files for 2021, 2020, 2019, and 2017.
These changes to HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing. This policy is contained in the Medicare Claims Processing Manual, Chapter 6, Section 20.6. Make sure your billing staffs are aware of these changes.

Limited Systems Availability - Friday, April 2, 2021 through Sunday, April 4, 2021

There will be Common Working File (CWF) "Dark" days from Friday, April 2, 2021, through Sunday, April 4, 2021 due to the April 2021 release upgrades. The Interactive Voice Response (IVR) will have limited availability. Additionally, the Customer Contact Center will be closed on Friday, April 2, 2021.


March 24, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11862 - Update to the Manual for Telephone Services, Physician Assistant (PA) Supervision, and Medical Record Documentation for Part B Services
This article informs you about updates to Chapter 15 of the Medicare Benefit Policy Manual for Physician Supervision for PA services and Medical Record Documentation for Part B services. These updates clarify existing manual language and bring the manual in line with current payment policy for PA supervision and medical record documentation for Part B services. Make sure that your billing staffs are aware of these changes.
MM12104 - Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
This article informs you about Medicare claims processing system changes for ICDs with dates of service on or after February 15, 2018. Make sure your billing staffs are aware of these instructions.
MM12171 - Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2021
This article announces the changes in the July 2021 quarterly release of the edit module for clinical diagnostic laboratory services. Please be sure your billing staffs are aware of these updates.
SE21003 - New Provider Enrollment Administrative Action Authorities
This article gives you important information about recently issued regulatory authorities. These authorities affect currently enrolled Medicare providers and suppliers, or prospective providers and suppliers. You and your staff should be aware of these new authorities.

March 23, 2021

Your feedback matters

Novitas Solutions values and appreciates your feedback regarding the services we provide to you.  We continue to make additions and improvements to our provider website and provider portal as a result of your surveys. 

This week, we are pleased to announce additional ways you can reach us to provide feedback, this time relating directly to the educational materials and events from our Provider Outreach & Education department:

Our Provider Outreach website survey targets content and materials you find in our Education Center, including areas such as our event calendar and Novitas Learning Center.
Our Video on Demand survey invites you to let us know how we are doing with our “click and play” content you find via on-demand videos page and on our YouTube Channel. You can find the survey links in the description for each product video.
If you have recently listened to a prior event recording or taken an online self-paced course within the Novitas Learning Center, we also now offer specific feedback opportunities for each of them.  You’ll find an invitation to complete these at the end of the course descriptor for the recordings and self-paced course.

Additionally, starting in April, you will notice a small change in the surveys that we provide to you following our live events.  We appreciate your participation in those surveys, and look forward to continuing to receive your feedback on these educational events after they are conducted.

We look forward to hearing from you, and appreciate our ongoing opportunities to serve you as your Medicare Administrative Contractor.


March 22, 2021

The following Local Coverage Determination (LCDs) which were posted for notice on February 4, 2021 are now effective. The related billing and coding articles for these LCDs are also now effective:

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

February 2021 top claim submission errors

The February 2021 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.


March 19, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12068 - Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update
This article informs you about claims frequency editing changes that Medicare’s CWF performs based on relevant policy limitations for subsequent nursing facility care services. The article also informs you of updates to the Medicare Claims Processing Manual to reflect these changes. Make sure that your billing staffs are aware of these changes.

March 18, 2021

CMS Provider Education Message:

Open Payments & You – Register for March 25 Call

MLN Connects newsletter for Thursday, March 18, 2021

View this edition as a: Webpage | PDF

News

Clinical Laboratory Data Reporting Delayed Until 2022: Reminder
Comprehensive Eye Examinations: Comparative Billing Report in March

Compliance

Polysomnography Services: Bill Correctly

Events

Long-Term Care: Dementia-related Psychosis Call — March 23
Open Payments & You Call — March 25
SNF Quality Reporting Program: Achieving a Full APU Webinar- March 30

MLN Matters® Articles

April 2021 Update to the Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS)
April Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) & PC Print Update

Publications

Medicare Quarterly Provider Compliance Newsletter

Provider specialty: COVID-19 vaccine and monoclonal antibodies

New articles have been added under the reimbursement section for centralized billers, Indian Health Services, and Veterans Affairs with the geographically-adjusted payment rates for the COVID-19 vaccine and monoclonal antibodies infusion administrations.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12108 - Updated Billing Requirements for Home Infusion Therapy (HIT) Services on or After January 1, 2021
This article informs you of new changes to Medicare claims processing for HIT services on or after January 1, 2021. Make sure your billing staffs are aware of this change.

New Medicare #StayConnected Workshops are coming soon!

Novitas Solutions is offering new topic-focused workshops starting April 2021. Each workshop consists of multiple webinars addressing the Medicare topics that are most important to you. Stay connected to Medicare with these workshops to receive the most current information and regulations and have your Medicare questions answered live by a Medicare Education Specialist.

Medicare Secondary Payer (MSP) Series: April 6 – 8, 2021
Medicare Coverage Series: April 13 – 15, 2021
New Provider Roadmap Series: April 19 – 22, 2021

Continue to monitor our event calendar for registration!


March 17, 2021

Caring for Medicare Patients is a Partnership

The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates.

Understanding the Medicare coverage criteria, medical necessity and documentation guidelines is very important since physicians and nonphysician practitioners play a key role in providing health care services to Medicare patients.

The Medicare Learning Network (MLN) Fact Sheet, Caring for Medicare Patients is a Partnership provides additional guidance on documentation supporting medical necessity and helpful resources to keep you current on these and other guidelines.


Prior authorization: Hospital outpatient department services frequently asked questions

New information has been added to our frequently asked questions article for prior authorization. Please carefully review the article for additional information.


March 16, 2021

February 2021 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

The February 2021 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


Counting units for therapy codes

New information has been added to the article which may impact reporting requirements. Please review the article to ensure you are billing correctly


2021 COVID-19 vaccine reimbursement

CMS updated the geographically- adjusted payment rates for claims with dates of service on or after March 15, 2021. This article has been updated to reflect the change in payment rates.


March 15, 2021

Special Edition – Monday, March 15, 2021

Provider Education Message:

Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine

On March 15, CMS increased the Medicare payment amount for administering the COVID-19 vaccine. This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. At a time when vaccine supply is growing, CMS is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

These updates to the Medicare payment rate for COVID-19 vaccine administration reflect new information about the costs involved in administering the vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare, or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

Coverage of COVID-19 Vaccines:

As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance, or deductible.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

Medicaid: State Medicaid and Children’s Health Insurance Program agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the Public Health Emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit.

Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the PHE. Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More Information:

Medicare COVID-19 Vaccine Shot Payment webpage: Payment for COVID-19 vaccine administration, including a list of billing codes, payment allowances, and effective dates
CDC COVID-19 Vaccination Program Provider Requirements and Support webpage: How the COVID-19 vaccine is provided at 100% no cost to recipients
HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured webpage

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12102 - Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) & PC Print Update
This article informs you of updates to the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare’s Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print. Make sure billing staffs are aware of these updates. If you use the MREP or PC Print software, be sure to get the updated software.
MM12193 - April Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
This article informs you about the changes to the DMEPOS fee schedules that Medicare updates on a quarterly basis, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Make sure your billing staffs are aware of these changes.

March 12, 2021

Accelerated and Advance Payment (AAP) Repayment Reminder

In October of 2020 CMS announced amended terms for payments issued under the Accelerated and Advance Payment (AAP) Program to extend repayment to start one year after loan payment. As many of the initial loans were started in April of 2020 providers who received these payments should prepare for recoupments to begin. Please review our article, Learn about CMS' amended repayment process, for accelerated and advance repayments for details on the repayment terms as well as FAQs.


March 11, 2021

CMS Provider Education Message:

Hospitals: Are You Using Your PEPPER Data? 

MLN Connects newsletter for Thursday, March 11, 2021

View this edition as a: Webpage | PDF

News

PEPPERs for Short-term Acute Care Hospitals
Colorectal Cancer: Medicare Covers Screening

Compliance

Ambulance Services & SNF Consolidated Billing Requirements: Avoid Improper Payments

Claims, Pricers, & Codes

Average Sales Price Files: April 2021

Events

Medicare Part A Cost Report Appeals Listening Session — March 16
Long-Term Care: Dementia-related Psychosis Call — March 23
Open Payments & You Call — March 25

MLN Matters® Articles

April 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1
April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes — Revised

The following Local Coverage Determinations (LCDs) posted for comment on October 29, 2020 have been posted for notice. The LCDs and related Billing and Coding Articles will become effective April 25, 2021:

Cardiology Non-emergent Outpatient Stress Testing (L35083)
Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
Facet Joint Interventions for Pain Management (L34892)
Billing and Coding: Facet Joint Interventions for Pain Management (A56670)

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

Response to Comments: Cardiology Non-emergent Outpatient Stress Testing (A58661)
Response to Comments: Facet Joint Interventions for Pain Management (A58667)

The following Billing and Coding articles have been revised:

Billing and Coding: Hydration Therapy (A56634)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12155 - Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update
This article informs you of the issuance of April 2021 updates of the 2021 MPFS. Make sure your billing staffs are aware of these updates.
MM12140 - Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
This article informs you about the Calendar Year (CY) 2021 changes to travel allowances when billed:
On a per mileage basis using HCPCS code P9603.
On a flat rate basis using HCPCS code P9604.
Medicare Part B allows payment for a specimen collection fee and travel allowance, when medically necessary, for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Act. Payment for these services is made based on the Clinical Laboratory Fee Schedule (CLFS).
Make sure that your billing staffs are aware of these changes.
MM12178 - Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
This article gives you details of the quarterly update to the Clinical Laboratory Fee Schedule (CLFS). Please be sure your billing staff is aware of these updates.

Revised:

MM12131 - Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
CMS revised this article to reflect a revised CR12131. The CR revision changed the date that CMS added HCPCS code 87428. The correct date is November 10, 2020. (See bullet 13 on page 7.) CMS revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

Appropriate Use of Not Otherwise Classified Codes when Billing Drugs and Biologicals 

New information has been added to the article. Please be sure you are in compliance by reviewing the article.


March 10, 2021

Special Edition – Wednesday, March 10, 2021

Provider Education Message:

CMS Updates Nursing Home Guidance with Revised Visitation Recommendations

On March 10, CMS, in collaboration with the CDC, issued updated guidance for nursing homes to safely expand visitation options during the COVID-19 pandemic public health emergency.

This latest guidance comes as more than 3 million doses of vaccines have been administered within nursing homes, thanks in part to the CDC’s Pharmacy Partnership for Long-Term Care Program, following the FDA authorization for emergency use of COVID-19 vaccines.  

According to the updated guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation for:

Unvaccinated residents, if the COVID-19 county positivity rate is greater than 10 percent and less than 70 percent of residents in the facility are fully vaccinated,
Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue transmission-based precautions, or
Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine

The updated guidance also emphasizes that “compassionate care” visits should be allowed at all times, regardless of a resident’s vaccination status, the county’s COVID-19 positivity rate, or an outbreak. Compassionate care visits include visits for a resident whose health has sharply declined or is experiencing a significant change in circumstances.

CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated.

“CMS recognizes the psychological, emotional, and physical toll that prolonged isolation and separation from family have taken on nursing home residents and their families,” said Dr. Lee Fleisher, MD, CMS Chief Medical Officer and Director of CMS’ Center for Clinical Standards and Quality. “That is why, now that millions of vaccines have been administered to nursing home residents and staff, and the number of COVID cases in nursing homes has dropped significantly, CMS is updating its visitation guidance to bring more families together safely. This is an important step that we are taking, as we continue to emphasize the importance of maintaining infection prevention practices, given the continued risk of transmission of COVID-19.”

High vaccination rates among nursing home residents, and the diligence of committed nursing home staff to adhere to infection control protocols, which are enforced by CMS, have helped significantly reduce COVID-19 positivity rates and the risk of transmission in nursing homes.

Although outbreaks increase the risk of COVID-19 transmission, as long as there is evidence that the outbreak is contained to a single unit or separate area of the facility, visitation can still occur.

More Information:

Nursing Home Visitation - COVID-19 webpage
Fact sheet

COVID-19 Webinar

Join us on Friday, March 19, 2021, 10:00 am ET or 9:00 am CT for an informative webinar to learn about billing and coding for the COVID-19 vaccine and mAb infusion administration. This educational session will include the guidelines for billing COVID-19 vaccines and mAb infusions. This webinar will review the process for enrollment to bill for the COVID-19 vaccine and mAb infusion and outline available resources to assist in providing these important services during the public health emergency (PHE).  Visit our Calendar of Events to register for this event.

Please visit our COVID-19 resource pages for additional information.


March 9, 2021

Register now for our restructured Ask-the-Contractor (ACT) webinar!

"Ask-the-Contractor" (ACT) webinars provide a venue for providers to ask Novitas Solutions their specific questions concerning billing and Medicare policies or procedures. Novitas Solutions hosts ACTs on a quarterly basis.

The format of the ACT will now be conducted in a roundtable forum. We will provide background information and relevant Medicare guidelines and then open the floor to questions from our audience regarding the presentation topic. We invite you to attend to have your Part A and B Medicare questions answered about the topics listed below

The next quarterly JH Part A ACT is scheduled for March 17, 2021. Topics that will be discussed at this meeting include:

Part A East (PAE) Qualified Independent Contractor (QIC) Demonstration
Overview of the January 2021 Outpatient Payment System Updates

The next quarterly JH Part B ACT is scheduled for March 18, 2021. Topics that will be discussed at this meeting include:

Modifiers, Modifiers and more Modifiers

Novitas Solutions wants to hear from you and answer your questions about these topics. Register now to participate by visiting our Event Calendar!

To view a full topic listing for this event, click here.


March 5, 2021

Exemption process for hospital outpatient department (OPD) providers 

CMS may elect to exempt a hospital OPD provider from the hospital OPD prior authorization process upon a provider's demonstration of compliance with Medicare coverage, coding, and payment rules. Please review this new article for more information.


Attention Clinical Lab Providers - Molecular Diagnostic Pathology Survey

Novitas seeks your input on establishing pricing under the Medicare program for the 2021 Gap-fill laboratory test codes. Due to the low volume of responses received thus far, we are extending the due date for completing the survey. If you have not already done so, please complete our Molecular Diagnostic Pathology Survey by March 29, 2021. Please complete a separate survey for each test you perform.


March 4, 2021

CMS Provider Education Message:

COVID-19 Vaccine Codes: EUA for Janssen Biotech

MLN Connects® newsletter for Thursday, March 4, 2021

View this edition as a: Webpage | PDF

News

COVID-19 Vaccine Codes: EUA Effective Date for Janssen Biotech Inc.
COVID-19 Vaccine Administration: Insurance Coverage, MBI, & MSP
COVID-19 FAQs on Medicare FFS Billing to Administer Vaccines
COVID Vaccine Resources for Hard to Reach Patients
Cybersecurity Resources
Nutrition-related Health Conditions: Medicare Covers Preventive Services

Compliance

IRF Services: Follow Medicare Billing Requirements

Claims, Pricers, & Codes

DMEPOS: Corrected 2021 Fee Schedule Amounts

Events

Medicare Part A Cost Report Appeals Listening Session — March 16
Long-Term Care: Dementia-related Psychosis Call — March 23
Open Payments & You Call — March 25

Publications

Intravenous Immune Globulin Demonstration

Multimedia

Section J: Health Conditions: Coding the SPADEs Related to Falls Web-Based Training

March 2, 2021

Clinical Diagnostic Laboratory Tests for COVID-19

Updates have been made to the reimbursement for U0003, U0004 and add-on code U0005. 


March 1, 2021

2021 MEDPARD Available Now!

The 2021 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 link to access the online MEDPARD Directory.


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 Article and finalized Billing and Coding Article will be related to the final LCD when it is posted for notice.

Allergen Immunotherapy (DL36240)
Allergy Testing (DL36241)
Cataract Extraction (including Complex Cataract Surgery) (DL35091)
Cosmetic and Reconstructive Surgery (DL35090)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)
Respiratory Pathogen Panel Testing (DL38916)

Anatomical modifiers

An update was made to the article relating to bilateral procedures. Please review the article to ensure you are billing these services correctly.


February 25, 2021

CMS Provider Education Message:

Medicare Secondary Payer: Billing for Services

MLN Connects® newsletter for Thursday, February 25, 2021

View this edition as a: Webpage | PDF

News

CMS Offers Comprehensive Support to the State of Texas to Combat Winter Storm

Compliance

Post-Acute Care Transfers: Bill Correctly

MLN Matters® Articles

Billing for Services when Medicare is a Secondary Payer
April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - April 2021

From the Desk of the MAC Medical Directors: Caring for Medicare Patients is a Partnership

The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates.

Understanding the Medicare coverage criteria, medical necessity and documentation guidelines is very important since physicians and nonphysician practitioners play a key role in providing health care services to Medicare patients. The Medicare Learning Network (MLN) Fact Sheet: Caring for Medicare Patients is a Partnership provides additional guidance on documentation supporting medical necessity and helpful resources to keep you current on these and other guidelines.


The following LCDs have been revised:

Intensity Modulated Radiation Therapy (IMRT) (L36711)
Outpatient Sleep Studies (L35050)

The following Billing and Coding Articles have been revised:

Billing and Coding: Non-Invasive Peripheral Venous Studies (A52993)
Billing and Coding: Non-Vascular Extremity Ultrasound (A55037)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12131 - Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits
This article tells you about the new HCPCS codes for 2021 that are subject to and excluded from CLIA edits. Make sure your billing staffs are aware of these updates.
MM12133 - April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
This article informs you about the ASP methodology, which is based on quarterly data manufacturers submit to CMS. CMS gives the MACs ASP and Not Otherwise Classified 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 in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Please make sure your billing staffs are aware of these updates.
SE21002 - Billing for Services when Medicare is a Secondary Payer
Don’t deny treatment, entry to a SNF or hospital, or services based on an open or closed liability, no-fault or Workers’ Compensation Medicare secondary payer (MSP) record on the beneficiary’s Medicare file or if a claim was inappropriately denied. You should appeal the inappropriately denied claim with your MAC. You must provide an explanation or a reason code to justify the services aren’t related to the accident or injury on record.
You must continue to see or provide services to the beneficiary. If services relate to an open MSP accident or injury incident, first bill the other insurer as primary.

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM12129 - January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
CMS revised this article to reflect the revised CR12129. The revisions to the CR did not change the substance of this article. CMS changed the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

February 24, 2021

Evaluation and management FAQs

Please review our consolidated FAQs on evaluation and management services. They are listed by category and can be easily navigated by clicking the category at the top of the page.


Opioid treatment program claim submission errors

New information has been added relating to patient eligibility. Help to avoid future denials by reviewing the information.


February 23, 2021

New Feature: The Claims Denial/Rejection Tool

Novitas Solutions is launching our newest self-service tool: The Claims Denial/Rejection Tool. Located under the Self-Service Tools drop down on our website, this tool has been developed to provide guidance on how to address claim denials and rejections in the most efficient manner.

Searching in the tool is quick and easy: 

Locate your Claim Adjustment Reason Code (CARC) or Remittance Advice Remark Code (RARC) on the remittance advice
Enter your CARC or RARC or a keyword
Reasons for the denial and/or rejection will appear with the resolution as well as valuable references to learn more regarding the claim denial or rejection reason

View the tool on our website and start using it today!


Subscribe to Our New YouTube Channel

Novitas Solutions is excited to share the launch of our new YouTube channel. We understand how busy providers are caring for patients. We’ve created multiple videos outlining critical instructions and resources that are most important to you regarding billing, provider enrollment, website features and tutorials, and our Novitasphere provider portal.

Please subscribe to our channel today. By subscribing, you will be automatically notified when additional videos are released to our channel.

Access to our videos can also be found on our Training Videos - Click and Play webpage.


Prior authorization (PA) program for certain hospital outpatient department (OPD) services - general documentation requirements

New information has been updated to our current documentation requirements article.  Please carefully review the article for additional information.


Hospital outpatient department (OPD) services – medical record checklist

New information has been updated to our current medical record checklist article.  Please carefully review the article for additional information.


January 2021 top claim submission errors

The January 2021 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.


February 19, 2021

New! The Claims Denial/Rejection Tool

Please take a minute to look at our new Claims Denial/Rejection Tool. Located under the Self-Service Tools located on the left-hand side our website, this tool provides guidance on how to address claim denials and rejections.


2020 COVID-19 vaccine reimbursement 

New information has been updated to our current article.  Please carefully review the article for additional information.


2021 COVID-19 vaccine reimbursement

New information has been updated to our current article.  Please carefully review the article for additional information.


2020 COVID-19 monoclonal antibodies reimbursement

New information has been updated to our current article.  Please carefully review the article for additional information.


2021 COVID-19 monoclonal antibodies reimbursement

New information has been updated to our current article.  Please carefully review the article for additional information.


February 18, 2021

CMS Provider Education Message:

COVID-19: EUA for Antibody Treatment

MLN Connects® for Thursday, February 18, 2021

View this edition as a: Webpage | PDF

News

CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment
IPPEs & AWVs: Comparative Billing Report in February
American Heart Month & Black History Month

Compliance

Hospice Aide Services: Enhancing RN Supervision

Claims, Pricers, & Codes

FQHC & RHC Claims: Retroactive Rate Adjustment for Code G2025

Multimedia

Section N: Medications – Drug Regimen Review Web-Based Training

The following Billing and Coding Article has been revised:

Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)

The following Local Coverage Article has been revised effective for dates of service on and after April 5, 2021:

Self-Administered Drug Exclusion List (A53127)

As a reminder, the comment period for the following Proposed Local Coverage Determinations (LCDs) is currently open and will close on February 27, 2021. We encourage you to submit your comments as soon as possible.

Allergen Immunotherapy (DL36240)
Allergy Testing (DL36241)
Cataract Extraction (including Complex Cataract Surgery) (DL35091)
Cosmetic and Reconstructive Surgery (DL35090)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)
Respiratory Pathogen Panel Testing (DL38916)
Submit Comments

February 17, 2021

January 2021 top inquiries FAQs for AR, CO, LA, MS, NM, OK, & TX

The January 2021 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


February 15, 2021

COVID-19 vaccine and monoclonal antibody billing for Part B providers

New information has been added to the article. Please take time to review the information to ensure proper billing.


COVID-19 vaccine and monoclonal antibody (mAb) infusion billing alerts

Novitas is working to ensure minimal impacts to claims processing for COVID-19 vaccine and infusion administrations. We are actively reviewing data from claim errors and providing education to prevent claim payment delays. A new claim issue was added relating to multiple PTANs linked to single NPI.


February 11, 2021

CMS Provider Education Message:

PFS Payment for Office & Outpatient E/M Visits

MLN Connects® for Thursday, February 11, 2021

View this edition as a: Webpage | PDF

News

Flu & Pneumococcal Shots: Protect Your Patients

Compliance

Hospices: Create an Effective Plan of Care

Claims, Pricers, & Codes

COVID-19: Revised Clinician Codes Accepted with CS Modifier
PFS Payment for Office & Outpatient E/M Visits
ESRD: Claims Processing Issues for Type of Bill 072X

The following LCD which was posted for comment on August 27, 2020, has been posted for notice. The LCD and related Billing and Coding Article will become effective March 28, 2021:

Colon Capsule Endoscopy (CCE) (L38807)
Billing and Coding: Colon Capsule Endoscopy (CCE) (A58414)

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

Response to Comments: Colon Capsule Endoscopy (A58606)

The following articles have been revised to reflect the 2021 Annual CPT/HCPCS Code updates effective for dates of service on and after January 1, 2021:

Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985)
Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
Billing and Coding: Epidural Injections for Pain Management (A56681)
Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss (A56440)
Billing and Coding: Hemophilia Factor Products (A56433)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Billing and Coding: Multiple Imaging in Oncology (A56848)
Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)
Billing and Coding: Pulmonary Function Testing (A57320)
Billing and Coding: Vestibular and Audiologic Function Studies (A57434)

February 10, 2021

COVID-19 vaccine and monoclonal antibody (mAb) infusion questions and answers

New information has been updated to our current article.  Please carefully review the article for additional information.


February 9,2021

Are you ready to provide the COVID-19 vaccine and/or the monoclonal antibody infusion treatment?

Join us on Thursday, February 11, 2021, 10 a.m. ET or 9 a.m. CT for an informative webinar to learn about billing and coding for the COVID-19 vaccine and mAb infusion administration. This educational session will include the guidelines for billing COVID-19 vaccines and mAb infusions. We will review the process for enrollment to bill for the COVID-19 vaccine and mAb infusion and outline available resources to assist in providing these important services during the public health emergency. Visit our Calendar of Events to register.


February 8, 2021

Medicare secondary payer (MSP) educational series

The questions and answers have been updated from the educational series.  Please carefully review the information. 


February 5, 2021

COVID-19 vaccine and monoclonal antibody (mAb) infusion billing alerts

Novitas is working to ensure minimal impacts to claims processing for COVID-19 vaccine and infusion administrations. We are actively reviewing data from claim errors and providing education to prevent claim payment delays. New billing tips have been added on place of service (POS) for Part B claims.


Bilateral Indicators

New information has been updated to our current article.  Please carefully review the article for additional information.


February 4, 2021

CMS Provider Education Message:

Improving Accuracy of Medicare Payments

MLN Connects® for Thursday, February 4, 2021

View this edition as a: Webpage | PDF

News

Improving Accuracy of Medicare Payments
Cardiovascular Health: Medicare Covers Screening & Therapy

Claims, Pricers, & Codes

OPPS Pricer File: January 2021
FQHC Claims: Retroactive Adjustment for Geographic Adjustment Factor
HCPCS Code G2211 is a Bundled Service & Not Separately Paid

Events

ICD-10 Coordination & Maintenance Committee Meeting — March 9-10

The following Local Coverage Determinations (LCDs) posted for comment on September 24, 2020 have been posted for notice. The LCDs and related Billing and Coding Articles will become effective March 21, 2021:

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

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

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

Attention Clinical Lab Providers - Molecular Diagnostic Pathology Survey

Novitas seeks your input on establishing pricing under the Medicare program for the 2021 Gap-fill laboratory test codes. If you have not already done so, please complete our Molecular Diagnostic Pathology Survey by March 8, 2021. Please complete a separate survey for each test you perform.


February 3, 2021

Provider specialty: Opioid treatment program (OTP)

A link was added under the OTP billing and payment section for the CY2021 Payment rates. 


February 2, 2021

Are you ready to provide the COVID-19 vaccine and/or the monoclonal antibody infusion treatment?

Join us on Thursday, February 11, 2021, 10 a.m. ET or 9 a.m. CT for an informative webinar to learn about billing and coding for the COVID-19 vaccine and mAb infusion administration. This educational session will include the guidelines for billing COVID-19 vaccines and mAb infusions. We will review the process for enrollment to bill for the COVID-19 vaccine and mAb infusion and outline available resources to assist in providing these important services during the public health emergency. Visit our Calendar of Events to register.


January 29, 2021

Part B reimbursement rates: Contractor-priced reimbursement rates for new External Electrocardiographic Recording codes

The 2021 Contractor-priced rates are effective January 1, 2021. For details, please review this article.


January 28, 2021

CMS Provider Education Message:

Medicare Wellness Visits: Get Your Patients Off to a Heathy Start

MLN Connects® for Thursday, January 28, 2021

View this edition as a: Webpage | PDF

News

Care Compare: 2019 Preview Period Open through March 25
Open Payments Data
Medicare Wellness Visits: Get Your Patients Off to a Heathy Start

Compliance

Hospice Care: Safeguards for Medicare Patients

Claims, Pricers, & Codes

Drug Claims Rejected in Error

MLN Matters® Articles

Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Are you ready to provide the COVID-19 vaccine and/or the monoclonal antibody infusion treatment?

Join us on Thursday, February 11, 2021, 10:00 am ET or 9:00 am CT for an informative webinar to learn about billing and coding for the COVID-19 vaccine and mAb infusion administration. This educational session will include the guidelines for billing COVID-19 vaccines and mAb infusions. This webinar will review the process for enrollment to bill for the COVID-19 vaccine and mAb infusion and outline available resources to assist in providing these important services during the public health emergency (PHE). Visit our Calendar of Events to register for this event.


Registration and meeting materials now available for February 11, 2021, Multi-Jurisdictional Contractor Advisory Committee (CAC)/Subject Matter Expert Meeting regarding Epidural Interventions for Chronic Pain Management

Due to the public health crisis this meeting will be held via Teleconference/Webinar ONLY.

On February 11, 2021, seven Medicare Administrative Contractors (MACs); lead by Novitas Solutions (Jurisdictions H and L) and First Coast Service Options (Jurisdiction N), will host a multi-jurisdictional CAC/subject matter expert meeting.

The purpose of the meeting is to obtain advice from CAC members and a subject matter expert panel regarding the strength of published evidence on epidural interventions for chronic pain management. In addition to discussion during the meeting, the expert panel will vote on pre-distributed questions. CAC and expert panels do not make coverage determinations, but MACs benefit from their advice.

All compliant CAC members as well as the expert panelists will be given the opportunity to submit their answers to the voting questions and/or any written comments within one week of the meeting. The public is invited to attend as observers.

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 here.


January 27, 2021

COVID-19 vaccine and monoclonal antibody (mAb) infusion FAQs

New information has been updated to our current article.  Please carefully review the article for additional information.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM12080 - Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
CMS revised this article to reflect a revised CR12080, issued on January 20, 2021. In the CR, CMS changed the payment determination for code 0177U in the crosswalk from 81310 to 81309. The same change is shown in red print on page 6. Also, CMS changed the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

COVID-19 vaccine and monoclonal antibody (mAb) infusion billing alerts

We are working to ensure minimal impacts to claims processing for COVID-19 vaccine and infusion administrations. We are actively reviewing data from claim errors and providing education to prevent claim payment delays. New billing tip has been added on administering the COVID-19 vaccine or mAb infusions, Medicare Advantage beneficiaries, the Medicare secondary payer questionnaire, and Part B entitlement.


COVID-19 vaccine and monoclonal antibody billing for Part B providers

New information has been updated to our current article.  Please carefully review the article for additional information.


December 2020 top claim submission errors

The December 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.


January 22, 2021

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

The December 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


January 21, 2021

CMS Provider Education Message:

Give Flu Shots through January & Beyond

MLN Connects® for Thursday, January 21, 2021

View this edition as a: Webpage | PDF

News

Hospital IPPS: FAQs on Market-Based MS-DRG Relative Weights
MLN Web-Based Training: Complete Training & Save Certificates by January 31
Intensity-Modulated Radiation Therapy: Comparative Billing Report in January
2020 MIPS Extreme & Uncontrollable Circumstances Exception Application: Deadline February 1
Give Flu Shots through January & Beyond

Compliance

SNF 3-Day Rule: Bill Correctly

Events

COVID-19 Listening Sessions with CMS Office of Minority Health — January 22, 26, & 28
Physicians, Nurses & Allied Health Professionals Open Door Forum — January 27

Claims, Pricers, & Codes

ESRD Facilities: Machine Reported Dialysis Treatment Time on the 072X Bill Type
Therapy Claims: Reprocessing Dates of Service from January 1 through February 15
Home Health RAP Workaround

MLN Matters® Articles

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) 2021 — Revised

Multimedia

Quality Reporting Programs: From Data Elements to Quality Measures Web-Based Training
Section M: Assessment and Coding of Pressure Ulcers & Injuries Web-Based Training

The following Billing and Coding article has been revised:

Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111).

January 20, 2021

COVID-19 vaccine and monoclonal antibody (mAb) infusion FAQs

The COVID-19 vaccine and mAb infusion FAQ document has been developed to include questions and answers posed during our webinars on the COVID-19 vaccine and mAb infusion.


January 19, 2021

COVID-19 and Monoclonal antibody infusion administrations

Billing reminder: When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free. Please carefully review the article for additional information.


January 15, 2021

Roster billing for Part B providers

New Roster forms have been added for the influenza and pneumonia vaccines. Please ensure you are using the most current version. 


January 14, 2021

CMS Provider Education Message:

Ensuring our Nation’s Seniors Have Access to Latest Advancements

MLN Connects® for Thursday, January 14, 2021

View this edition as a: Webpage | PDF

News

Ensuring our Nation’s Seniors Have Access to Latest Advancements
Opioid Treatment Programs: New for 2021
Electronic Funds Transfer: Revised CMS-588 Required on February 28
Recommend Glaucoma Screening for High-Risk Patients

Compliance

Inhalant Drugs: Bill Correctly

Claims, Pricers & Codes

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments
ASC Payment System Update Effective January 1, 2021

MLN Matters® Articles

January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.0
January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Publications

Clinical Laboratory Fee Schedule — Revised

Multimedia

Achieving Health Equity Web-Based Training Course

The following Proposed Local Coverage Determinations (LCDs) have been posted for comments. The comment period will end on February 27, 2021; however, you are encouraged to submit your comments as soon as possible.

Allergen Immunotherapy (DL36240)
Allergy Testing (DL36241)
Cataract Extraction (including Complex Cataract Surgery) (DL35091)
Cosmetic and Reconstructive Surgery (DL35090)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (DL35130)
Respiratory Pathogen Panel Testing (DL38916)
Submit Comments

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

Billing and Coding: Allergen Immunotherapy (DA56538)
Billing and Coding: Allergy Testing (DA56558)
Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (DA56615)
Billing and Coding: Cosmetic and Reconstructive Surgery (DA56587)
Billing and Coding: Respiratory Pathogen Panel Testing (DA58575)

Webinar: Understanding COVID-19 Vaccine and Monoclonal Antibody Infusion (mAb) Billing and Coding

Join us on Thursday, January 21, 2021, for an informative webinar to learn about billing and coding for the COVID-19 vaccine and mAb infusion administration. This educational session will include the guidelines for roster billing COVID-19 vaccines and mAb infusions and the forms to be completed. This webinar will review the process for enrollment to bill for the COVID-19 vaccine and mAb infusion and available resources to assist in providing these important services during the public health emergency (PHE).  Visit our Calendar of Events to register for this event.


Online Registration Available for January 29, 2021, Open Meeting and Proposed LCDs Now Posted

Online registration for the January 29, 2021, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, January 27, 2021. IMPORTANT: During this unprecedented time, our Open Meeting will be held via teleconference only. The Novitas Solutions Proposed Local Coverage Determinations (LCDs) are 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.


January 13, 2021

2021 COVID-19 monoclonal antibodies reimbursement 

The geographically adjusted payment allowances for the COVID-19 monoclonal antibody infusion administration fees have been updated due to changes made by the Consolidated Appropriations Act, 2021.


2021 COVID-19 vaccine reimbursement 

The geographically adjusted payment allowances for the COVID-19 vaccine administration fees have been updated due to changes made by the Consolidated Appropriations Act, 2021.


January 7, 2021

Special Edition – Thursday, January 7, 2021

Provider Education Message:

Physician Fee Schedule Update

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

Provided a 3.75% increase in MPFS payments for CY 2021
Suspended the 2% payment adjustment (sequestration) through March 31, 2021
Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.


CMS Provider Education Message:

COVID-19 Vaccines: CDC Long-Term Care Facility Toolkit

MLN Connects® for Thursday, January 7, 2020

View this edition as a: Webpage | PDF

News

COVID-19 Vaccines: CDC Long-Term Care Facility Toolkit
MLN Web-Based Training: Complete Training & Save Certificates by January 31
2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1
Extension of Medicare IVIG Demonstration through December 31, 2023
Teaching Hospitals Receiving FTE Resident Caps Under Section 5506 of the Affordable Care Act
Cervical Health: Medicare Covers Screening Services

Compliance

Importance of Proper Documentation: Provider Minute Video

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — January 7

MLN Matters® Articles

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 87811 and 87428
2021 Annual Update to the Therapy Code List
Instructions to Medicare Administrative Contractors (MACs) on COVID-19 Emergency Declaration Blanket Waivers for Medicare-Dependent, Small Rural Hospitals and Sole Community Hospitals
Quarterly Update to Home Health (HH) Grouper
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.1, Effective April 1, 2021
Updating Calendar Year (CY) 2021 Medicare Diabetes Prevention Program (MDPP) Payment Rates
Billing for Home Infusion Therapy Services on or After January 1, 2021 — Revised
Telehealth Expansion Benefit Enhancement under the Pennsylvania Rural Health Model (PARHM) – Implementation — Revised

Publications

Complying with Laboratory Services Documentation Requirements — Revised

Multimedia

Enroll in Medicare to Administer COVID-19 Vaccine Shots: Information for Health Care Providers Video
Hospital Price Transparency Webcast: Audio Recording & Transcript
Promoting Interoperability Listening Session: Audio Recording & Transcript
Information for Medicare Patients
From Coverage to Care Resources Help Navigate Health Coverage

The following Billing and Coding Article has been revised:

Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (A57600)

The following Local Coverage Article has been revised:

Self-Administered Drug Exclusion List (A53127)

COVID-19 and Monoclonal antibody infusion administrations

New information has been added to our article on the proper billing of the administration fees. When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free. Please carefully review the article for additional information.


New COVID-19 vaccines or monoclonal antibody infusion roster form

A new roster form for COVID-19 vaccines and monoclonal antibody infusion is now available. For more information on COVID-19 vaccine and monoclonal antibody infusion billing, please visit our Provider Specialty page.


January 6, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12129 – January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
This article describes changes to and billing instructions for various payment policies implemented in the January 2021 ASC payment system update. Change request 12129 also includes updates to HCPCS. Make sure that your billing staffs are aware of these changes.

Immunizations: COVID-19 roster billing collaborative webinar

Join us on Tuesday, January 12, 2021, for the Novitas and First Coast Service Options multi-contractor collaborative webinar to learn about coding and billing mass immunization services for COVID-19 vaccines and monoclonal antibody (mAb) infusions This educational session will focus on the guidelines for roster billing COVID-19 vaccines and mAb infusions by mass immunizers, the forms to be completed, and available resources to assist in providing these important services during the public health emergency (PHE). Visit our calendar of events to register for this event.


January 5, 2021

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11880 – Billing for Home Infusion Therapy Services on or After January 1, 2021
CMS revised this article to reflect a revised change request (CR) 11880 issued on December 31. In the article, CMS added two codes (J1559 JB and J7799 JB) shown in red print in Table 3.2 on page 7. CMS also revised the CR release date, transmittal numbers, and the web addresses of the transmittals. All other information remains the same.

January 4, 2021

Part B reimbursement fees: Transportation of portable x-ray equipment (R0070/R0075)

The portable X-ray transportation fees are changing as the result of the cost analysis of the survey data. The 2021 fees will become effective after a 45-day notice period on February 23, 2021, for dates of service on or after January 1, 2021. For details, please review this article


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12126 – 2021 Annual Update to the Therapy Code List
This article informs you of updates to 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 2021 CPT and Level II HCPCS. Make sure your billing staffs are aware of these updates.

December 29, 2020

Due to extenuating circumstances, the Annual HCPCS/CPT Code Update has been delayed. The following is a preliminary list of Billing and Coding Articles that will be revised in response to the update. Due to the delay, it is anticipated that the revisions will be published to the Medicare Coverage Database (MCD) and our website in early February. Please continue to watch our website for further updates. 

Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985)
Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss (A56440)
Billing and Coding: Hemophilia Factor Products (A56433)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)
Billing and Coding: Vestibular and Audiologic Function Studies (A57434)

November 2020 top claim submission errors

The November 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.


December 28, 2020

Special Edition – Monday, December 28, 2020

Provider Education Message:

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

The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31.  The Consolidated Appropriations Act, 2021, signed into law on December 27, extends the suspension period to March 31, 2021.  w


The following Local Coverage Determinations (LCDs) are now effective:

Endovenous Stenting (L37893) 
Transurethral Waterjet Ablation of the Prostate (L38712)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924)

The following Billing and Coding Articles are now effective:

Billing and Coding: Transurethral Waterjet Ablation of the Prostate (A58243)
Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12030 - Updating Calendar Year (CY) 2021 Medicare Diabetes Prevention Program (MDPP) Payment Rates
Change request 12030 contains instructions for Medicare administrative contractors (MACs) and the Railroad specialty MAC to update the MDPP expanded model payment rates for CY 2021. Make sure your billing staffs are aware of the update.
MM12093 - Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 87811 and 87428
This article informs you of the addition of the QW modifier to the following CMS HCPCS codes:
87811 [Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])] and code.
87428 [Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B].
Make sure your billing staffs are aware of these changes.
MM12110 - Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.1, Effective April 1, 2021
Change request 12110 provides the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.

December 23, 2020

CMS Provider Education Message:

ICD-10 Code Files for FY 2021

MLN Connects® for Wednesday, December 23, 2020

View this edition as a: Webpage | PDF

News

Redesign of Medicare Supplier Directory Improves Beneficiary Decision-making
Proposed Updates to Coverage Policy for Autologous Blood-Derived Products for Chronic Non-Healing Wounds
Open Payments: Review & Dispute Data by December 31
Hospital Price Transparency: Requirements Effective January 1
DMEPOS Competitive Bidding Program: Round 2021 Begins January 1
Clinics/Group Practices & Certain Other Suppliers: Revised CMS-855B Required January 4
Acute Hospital Care at Home: Increasing Capacity through Hospital without Walls Program
Orthoses Referring Providers: Comparative Billing Report in December
National Correct Coding Initiative Medicare Policy Manual: Annual Update

Compliance

Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly

Claims, Pricers & Codes

ICD-10 Code Files for FY 2021
COVID-19: PC-ACE Software Vaccine Roster Billing Issue

MLN Matters® Articles

FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients
Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Services Subject to Reasonable Charge

Publications

Medicare Preventive Services — Revised

Multimedia

Promoting Interoperability Call: Audio Recording & Transcript
Physician Fee Schedule Call: Audio Recording & Transcript

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11870 – Telehealth Expansion Benefit Enhancement Under the Pennsylvania Rural Health Model (PARHM) - Implementation
CMS revised this article due to a revised change request (CR) 11870, issued on December 22. The CR revision updated some denial edits. CMS added that information starting near the bottom of page 3 of this article. The CR release date, transmittal number, and web address of the CR were also updated. All other information remains the same.

December 22, 2020

Special Edition – Tuesday, December 22, 2020

Provider Education Message:

COVID-19 Vaccine Codes: Updated Effective Date for Moderna

On December 18, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Moderna COVID-19 Vaccine for the prevention of COVID-19 for individuals 18 years of age and older. Review Moderna’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when the vaccines are free.

Related links:

CMS COVID-19 Provider Toolkit
CMS COVID-19 FAQs
CDC COVID-19 Vaccination Communication Toolkit for medical centers, clinics, and clinicians
FDA COVID-19 Vaccines webpage

Limited Systems Availability - Thursday, December 31, 2020 through Sunday, January 3, 2021

There will be Common Working File (CWF) "Dark" days from Thursday, December 31, 2020 through Sunday, January 3, 2021 due to the January 2021 release upgrades. The Interactive Voice Response (IVR) 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.    


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

The PA program for certain hospital OPD services webpage had been updated to include announce the upcoming webinar Understanding the Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services on Wednesday, January 13, 2020.  Please visit our educational event calendar to register for this event.


December 21, 2020

Reopening Gateway: History corrections now available

The “history correction” feature is now available on our Reopening Gateway! The Reopening Gateway currently allows claim corrections and billed in error requests. The new history correction feature allows you to easily reprocess claims that previously denied based on the beneficiary’s file and due to the file being updated, can now be considered for payment. This feature is specific to file updates for the beneficiary’s Medicare Part B entitlement, Medicare secondary payer, health maintenance organization/Medicare Advantage plan and hospice periods. This feature also allows a claim to be reprocessed that is denied for Medically Unlikely Edits due to a claim being submitted to Medicare twice in error. As a reminder, our Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process.


Provider specialty: COVID-19 vaccine and monoclonal antibodies

We are pleased to announce the addition of COVID-19 vaccine and monoclonal antibodies to the Provider Specialties / Service page of our website. This is a central location for all COVID-19 vaccine and monoclonal antibody infusion billing information, including links to related CMS resources and references. These services include information on the COVID-19 vaccine, monoclonal antibodies, and their administration.


COVID-19 vaccine and monoclonal antibodies billing for Part B

This billing article was created to assist Medicare Part B providers with proper billing relating to COVID-19 vaccine and monoclonal antibody infusion. When COVID-19 vaccine and monoclonal antibody doses are provided by the government without charge, only bill for the vaccine administration. Don’t include the vaccine codes on the claim when the vaccines are free.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12080 – Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Services Subject to Reasonable Charge
Related CR 12080 provides instructions for the Calendar Year (CY) 2021 Clinical Laboratory Fee Schedule (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 18, 2020

Special Edition – Friday, December 18, 2020

Provider Education Message:

COVID-19: Add-on Payment for New Treatments

CMS issued an Interim Final Rule with Comment Period, which established the New COVID-19 Treatments Add-on Payment (NCTAP) under the Medicare Inpatient Prospective Payment System (IPPS), effective from November 2, 2020, until the end of the Public Health Emergency (PHE) for COVID-19. To mitigate potential financial disincentives for hospitals to provide new COVID-19 treatments during the COVID-19 PHE, the Medicare program will provide an enhanced payment for eligible inpatient cases that involve use of certain new products with current Food and Drug Administration approval or emergency use authorization to treat COVID-19. Visit the NCTAP webpage for more information.


Special Edition – Friday, December 18, 2020

Provider Education Message:

Monitoring for Hospital Price Transparency

Hospital Price Transparency requirements go into effect January 1, 2021.  CMS plans to audit a sample of hospitals for compliance starting in January, in addition to investigating complaints that are submitted to CMS and reviewing analyses of non-compliance, and hospitals may face civil monetary penalties for noncompliance. 

Is your institution prepared to comply with the requirements of the Hospital Price Transparency Final Rule? Effective January 1, 2021, each hospital operating in the United States is required to provide publicly accessible standard charge information online about the items and services they provide in 2 ways:

Comprehensive machine-readable file with all items and services
Display of 300 shoppable services in a consumer-friendly format

In the final rule, CMS outlined a monitoring and enforcement plan to ensure compliance with the requirements.  We finalized a policy that CMS monitoring activities may include, but would not be limited to, the following, as appropriate:

Evaluation of complaints made by individuals or entities to CMS
Review of individuals’ or entities’ analysis of noncompliance
Audit of hospital websites

If we conclude a hospital is noncompliant with one or more of the requirements to make public standard charges, we may take any of the following actions, which generally, but not necessarily, will occur in the following order:

Provide a written warning notice to the hospital of the specific violation(s)
Request a Corrective Action Plan (CAP) if noncompliance constitutes a material violation of one or more requirements
Impose a civil monetary penalty not in excess of $300 per day and publicize the penalty on a CMS website if the hospital fails to respond to our request to submit a CAP or comply with the requirements of a CAP

See 45 CFR part 180 Subpart C- Monitoring and Penalties for Noncompliance.

Visit the Hospital Price Transparency website for additional information and resources to help hospitals prepare for compliance, including:

FAQs (PDF)
8 Steps to a Machine-Readable File (PDF)
10 Steps to a Consumer-Friendly Display (PDF)
Quick Reference Checklists (PDF)

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

The November 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


COVID-19 vaccine and monoclonal antibody infusion fees

CMS has established new codes and fees based on the geographically-adjusted payment allowances for the COVID-19 vaccine and the monoclonal antibody infusion. Fees for 2020 and 2021 are now available on the fee schedule homepage.


December 17, 2020

CMS Provider Education Message:

Physician Fee Schedule Final Rule Summary: Telehealth, Preventive Services & More

MLN Connects® for Thursday, December 17, 2020

View this edition as a: Webpage | PDF

News

MLN Web-Based Training: Complete Training & Save Certificates by January 31
IRF Quality Reporting Program: December Refresh
LTCH Quality Reporting Program: December Refresh
COVID-19: Stress & Resilience, Crisis Standards of Care
COVID-19: Designated Hospitals Lessons Learned and Patient Surge Management Strategies

Compliance

Ambulance Fee Schedule and Medicare Transports

MLN Matters® Articles

2021 Annual Update of Per-Beneficiary Threshold Amounts
CY 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Summary of Policies in the Calendar Year (CY) 2021 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
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2021 — Revised

Publications

Opioid Treatment Programs (OTPs) Medicare Enrollment — Revised
Opioid Treatment Programs (OTPs) Medicare Billing and Payment — Revised

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

Non-Invasive Peripheral Venous Studies (L35451)

The following Billing and Coding Article has been revised:

Billing and Coding: Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Physician Requirements (A55758)

Medicare Administrative Contractors (MACs) will host a Multi-Jurisdictional Contractor Advisory Committee (CAC) Meeting regarding Epidural Interventions for Chronic Pain Management on February 11, 2021, from 1-4 p.m. Central Time

Due to the public health crisis this meeting will be held via Teleconference/Webinar ONLY.

On February 11, 2021, seven Medicare Administrative Contractors (MACs); lead by Novitas Solutions (Jurisdictions H and L) and First Coast Service Options (Jurisdiction N), will host a multi-jurisdictional CAC meeting.

The purpose of the meeting is to obtain advice from CAC members and subject matter experts (SMEs) regarding the strength of published evidence on epidural interventions for chronic pain management. In addition to discussion, the SME panel will vote on pre-distributed questions during the meeting. CAC panels do not make coverage determinations, but MACs benefit from their advice.

All compliant CAC members will be given the opportunity to submit their answers to the voting questions and/or any written comments within one week of the meeting. The public is invited to attend as observers.

Complete details, including background material, voting questions, agenda, and registration will be available on our website by January 28, 2021.


December 14, 2020

Provider Education Message:

Special Edition – Monday, December 14, 2020

COVID-19 Vaccine Codes: Updated Effective Date for Pfizer-BioNTech

On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine for the prevention of COVID-19 for individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when vaccines are free.

Related links:

CMS COVID-19 Provider Toolkit
CMS COVID-19 FAQs
CDC COVID-19 Vaccination Communication Toolkit for medical centers, clinics, and clinicians
FDA COVID-19 Vaccines webpage

The following Local Coverage Determination (LCD) which was posted for notice on October 29, 2020 is now effective. The companion article for this LCD is also now effective:

Biomarkers for Oncology (L35396)
Billing and Coding: Biomarkers for Oncology (A52986)

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 Article and finalized Billing and Coding Article will be related to the final LCD when it is posted for notice.

Cardiology Non-emergent Outpatient Stress Testing (DL35083)
Facet Joint Interventions for Pain Management (DL34892)

Reopening Gateway: History corrections coming soon

The “history correction” feature is coming soon to our Reopening Gateway! The Reopening Gateway currently allows claim corrections and billed in error requests. The new history correction feature will allow you to easily reprocess claims that previously denied based on the beneficiary’s file and due to the file being updated, can now be considered for payment. This feature is specific to file updates for the beneficiary’s Medicare Part B entitlement, Medicare secondary payer, health maintenance organization/Medicare Advantage plan and hospice periods. This feature will also allow a claim to be reprocessed that is denied for Medically Unlikely Edits due to a claim being submitted to Medicare twice in error. As a reminder, our Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process.


December 11, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM12027 – International Classification of Diseases, 10th Revision (ICD10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2021
CMS revised this article due to a revised change request (CR)12027 that they issued on December 10, 2020. The CR revision didn’t impact the substance of this article. We revised the CR's release date, transmittal number, and web address. All other information remains the same.

Fee schedule for 2021

The 2021 fees will be placed on our website after the calendar year 2021 physician fee schedule regulation is put on display.


December 10, 2020

Special Edition – Thursday, December 10, 2020

Provider Education Message:

CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers

On December 10, under President Trump’s leadership, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients and streamline processes related to prior authorization to reduce burden on providers and patients. By both increasing data flow and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care.

For More Information:

Proposed Rule: Comment period closes January 4
Full press release
Fact sheet
Blog
CMS Interoperability and Patient Access Final Rule webpage
Register for December 16 listening session

CMS Provider Education Message:

Flu & Pneumonia Vaccines: Protect Your Patients

MLN Connects® for Thursday, December 10, 2020

View this edition as a: Webpage | PDF

News

Flu & Pneumonia Vaccines: Protect Your Patients
VBID Model: Hospice Benefit Component
Open Payments: Review and Dispute Data by December 31
Hospital Price Transparency: Requirements Effective January 1
Annual Participation Enrollment Period Extended to January 31
2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1
COVID-19: Hospital Operations Toolkit

Compliance

Telehealth Services: Bill Correctly

Claims, Pricers & Codes

ICD-10 MS-DRG Grouper V38.1 & 2021 ICD-10-PCS Code Files
Average Sales Price Files: January 2021

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — December 10 & January 7

MLN Matters® Articles

Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2021
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2021 - Recurring File Update
New & Expanded Flexibilities for RHCs & FQHCs during the COVID-19 PHE — Revised
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020 — Revised
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) 2021 — Revised

Publications

Medicare Provider Enrollment — Revised
Provider Compliance Tips — Revised

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

BRCA1 and BRCA2 Genetic Testing (L36715)
Billing and Coding: BRCA1 and BRCA2 Genetic Testing (A56542)

The following Billing and Coding Article has been revised:

Billing and Coding: Hydration Therapy (A56634)

December 9, 2020

Special Edition – Wednesday, December 9, 2020

Provider Education Message:

In Case You Missed It: CMS Announces Guidance for Medicare Coverage of COVID-19 Antibody Treatment

On December 9, CMS posted updates to FAQs and an infographic about coverage and payment for monoclonal antibodies to treat COVID-19. The FAQs include general payment and billing guidance for these products, including questions on different setting types. The infographic has key facts about expected Medicare payment to providers and information about how Medicare beneficiaries can receive these innovative COVID-19 treatments with no cost-sharing during the public health emergency (PHE). CMS’ November 10, 2020 announcement about coverage of monoclonal antibody therapies allows a broad range of providers and suppliers, including freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract, to administer this treatment in accordance with the Food & Drug Administration’s Emergency Use Authorization (EUA), and bill Medicare to administer these infusions. Currently, two monoclonal antibody therapies have received EUA’s for treatment of COVID-19.

For More Information:

Therapeutics Coverage Infographic
Section BB of the FAQs: billing and payment for COVID-19 monoclonal antibody treatments
Monoclonal toolkit and program guidance

Physicians/Practitioners! Medical records play a vital role in ordering and providing DMEPOS to your patients!

For any durable medical equipment, prosthetic, orthotic and supply (DMEPOS) item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type of equipment or supply, quantity and/or frequency of use or replacement, if applicable. For more information view the full article on our website.


December 8, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12014 – 2021 Annual Update of Per-Beneficiary Threshold Amounts
Related change request 12014 updates the annual per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for calendar year (CY) 2021. These amounts were previously associated with the financial limitation amounts that Medicare more commonly referred to as “therapy caps.” The Bipartisan Budget Act of 2018 repealed those caps while also retaining and adding limitations to ensure appropriate therapy. For CY 2021, the KX modifier threshold amounts are:
a) $2,110 for physical therapy and speech-language pathology services combined, and
b) $2,110 for occupational therapy services.
Please make sure your billing staffs are aware of these updates.
MM12063 – CY 2021 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
This article provides the calendar year (CY) 2021 annual update for the Medicare DMEPOS fee schedule. The article includes 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.
MM12071 – Summary of Policies in the Calendar Year (CY) 2021 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 12071 provides a summary of the policies in the CY 2021 MPFS Final Rule and makes other policy changes that apply to Medicare Part B. These changes are effective January 1, 2021, and applicable to services you provide throughout CY 2021. Make sure your billing staffs are aware of these updates.

December 4, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

SE20024 – FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients
This article further explains the billing procedures and provides additional resources to avoid incorrect billing for outpatient services within 3 days before date of admission and on the date of admission. This is in response to an Office of Inspector General May 2020 report, Medicare Made $11.7 Million in Overpayments for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient Stays. Make sure that your billing staffs are aware of this information to avoid billing errors that may lead to overpayments.

December 3, 2020

CMS Provider Education Message:

Register for Physician Fee Schedule Call on 12/10

MLN Connects® for Thursday, December 3, 2020

View this edition as a: Webpage | PDF

News

Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge
CMS Updates Coverage Policies for Artificial Hearts and Ventricular Assist Devices
PEPPERs for Short-term Acute Care Hospitals: Download December 4 through 14
Provider Enrollment Application Fee Amount for CY 2021

Compliance

Hospices: Create an Effective Plan of Care

Events

Hospital Price Transparency Webcast — December 8
Interoperability and Patient Access Final Rule Call — December 9
Physician Fee Schedule Final Rule: Understanding 4 Key Topics Call — December 10

MLN Matters® Articles

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) 2021 — Revised

Publications

Major Joint Replacement (Hip or Knee) — Revised
Provider Compliance Tips for Tracheostomy Supplies — Revised

Multimedia

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

Special Edition – Thursday, December 3, 2020

Provider Education Message:

COVID-19 Antibody Treatment and Enforcement Discretion Reminder

CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment
COVID-19 Vaccines and Monoclonal Antibody Infusion: Enforcement Discretion Relating to SNF Consolidated Billing

CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment

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

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

CMS identified specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment: Regeneron’s Antibody Casirivimab and Imdevimab (REGN-COV2) , EUA effective November 21, 2020.

Q0243:

Long descriptor: Injection, casirivimab and imdevimab, 2400 mg

Short descriptor: casirivimab and imdevimab

M0243:

Long Descriptor: intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring

Short Descriptor: casirivi and imdevi infusion

Additional Resources: 

List COVID-19 monoclonal antibody infusion billing codes, payment allowances and effective dates
Monoclonal Antibody COVID-19 Infusion Program Instruction
CMS COVID-19 Vaccine Provider Toolkit

COVID-19 Vaccines and Monoclonal Antibody Infusion: Enforcement Discretion Relating to SNF Consolidated Billing

To facilitate the efficient administration of COVID-19 vaccines to Skilled Nursing Facility (SNF) residents, CMS is exercising enforcement discretion with respect to statutory provisions requiring consolidated billing by SNFs as well as any associated statutory references and implementing regulations, including as interpreted in pertinent guidance. Through the exercise of this discretion, we will allow Medicare-enrolled immunizers working within their scope of practice and subject to applicable state law, including, but not limited to, pharmacies working with the United States, as well as infusion centers, and home health agencies, to bill directly and receive direct reimbursement from the Medicare program for vaccinating Medicare Part A SNF residents. This enforcement discretion, and accordingly the ability for entities other than the SNF to submit claims for these monoclonal antibody products and their administration furnished to Medicare Part A SNF residents, is limited to the period described in the above-cited enforcement discretion notice.


As a reminder, the comment period for the following Proposed Local Coverage Determinations (LCDs) is currently open and will close on December 12, 2020. We encourage you to submit your comments as soon as possible.

Cardiology Non-emergent Outpatient Stress Testing (DL35083)
Facet Joint Interventions for Pain Management (DL34892)
Submit Comments

December 2, 2020

Special Edition – Wednesday, December 2, 2020

Provider Education Message:

Trump Administration Finalizes Policies to Give Medicare Beneficiaries More Choices around Surgery

Outpatient Prospective Payment System and Ambulatory Surgical Center final rule empowers beneficiary choices and unleashes competition to lower costs and improve innovation

On December 2, CMS finalized policy changes that will give Medicare patients and their doctors greater choices to get care at a lower cost in an outpatient setting. The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rules will increase value for Medicare beneficiaries and reflect the agency’s efforts to transform the health care delivery system through competition and innovation. These changes implement the Trump Administration’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, and will take effect on January 1, 2021.

“President Trump’s term in office has been marked by an unrelenting drive to level the playing field and boost competition at every turn,” said CMS Administrator Seema Verma. “Today’s rule is no different. It allows doctors and patients to make decisions about the most appropriate site of care, based on what makes the most sense for the course of treatment and the patient without micromanagement from Washington.”

In this final rule, CMS will begin eliminating the Inpatient Only (IPO) list of 1,700 procedures for which Medicare will only pay when performed in the hospital inpatient setting over a three-year transitional period, beginning with some 300 primarily musculoskeletal-related services. The IPO list will be completely phased out by CY 2024. This will make these procedures eligible to be paid by Medicare when furnished in the hospital outpatient setting when outpatient care is appropriate, as well as continuing to be payable when furnished in the hospital inpatient setting when inpatient care is appropriate, as determined by the physician. In the short term, as hospitals face surges in patients with complications from COVID-19, being able to provide treatment in outpatient settings will allow non-COVID-19 patients to get the care they need.

In addition to putting decisions on the best site of care in the hands of physicians, allowing more procedures to be done in an outpatient setting also provides for lower-cost options that benefit the patient.

For example, thromboendarterectomy (HCPCS code 35372) is a surgical procedure that removes chronic blood clots from the arteries in the lung. If this procedure is performed in an inpatient setting, a patient who has not had other health care expenses that year would have a deductible of about $1500. In contrast, the copayment for this procedure for the same patient in the outpatient setting would be about $1150. Patient safety and quality of care will be safeguarded by the doctor’s assessment of the risk of a procedure or service to the individual beneficiary and their selection of the most appropriate setting of care based on this risk. This is in addition to state and local licensure requirements, accreditation requirements, hospital conditions of participation, medical malpractice laws, and CMS quality and monitoring initiatives and programs.

Beginning January 1, 2021, we are adding eleven procedures to the ASC Covered Procedures List (CPL), including total hip arthroplasty (CPT 27130), under our standard review process. Additionally, we are revising the criteria we use to add surgical procedures to the ASC CPL, providing that certain criteria we used to add surgical procedures to the ASC CPL in the past will now be factors for physicians to consider in deciding whether a specific beneficiary should receive a covered surgical procedure in an ASC. Using our revised criteria, we are adding an additional 267 surgical procedures to the ASC CPL beginning January 1, 2021. Finally, we are adopting a notification process for surgical procedures the public believes can be added to the ASC CPL under the criteria we are retaining.

CMS is announcing that it will continue its policy of paying for 340B-acquired drugs at average sales price minus 22.5% after the July 31, 2020, decision of the Court of Appeals for the D.C. Circuit upholding the current policy. This policy lowers out-of-pocket drug costs for Medicare beneficiaries by letting them share in the discount that hospitals receive under the 340B program. Since this policy went into effect in 2018, Medicare beneficiaries have saved nearly $1 billion on drug costs, with expected Medicare beneficiary drug cost savings of over $300 million in CY 2021.

As part of the agency’s Patients Over Paperwork Initiative, which is aimed at reducing burden for health care providers, CMS is establishing a simple updated methodology to calculate the Overall Hospital Quality Star Rating (Overall Star Rating). The Overall Star Rating summarizes a variety of quality measures published on the Medicare.gov Care Compare tool (the successor to Hospital Compare) for common conditions that hospitals treat, such as heart attacks or pneumonia. Along with publicly reported data on Care Compare, the Overall Star Rating helps patients make better-informed health care decisions. Veterans Health Administration hospitals will be added to CMS’ Care Compare, which will help veterans understand hospital quality within the VA system. Overall, these changes will reduce provider burden, improve the predictability of the star ratings, and make it easier for patients to compare ratings between similar hospitals.

In response to stakeholder feedback about the current methodology used to calculate the Overall Star Rating, CMS is not finalizing its proposal to stratify readmission measures under the new methodology based on dually eligible patients, but will continue to study the issue to find the best way to convey quality of care for this vulnerable population.

Finally, in order to address the ongoing public health emergency, CMS is finalizing a new requirement for the nation’s 6,200 hospitals and critical access hospitals to report information about their inventory of therapeutics to treat COVID-19. This reporting will provide the information needed to track and accurately allocate therapeutics to the hospitals that need additional inventory to care for patients and meet surge needs.

For More Information:

Final Rule
Fact Sheet

December 1, 2020

Provider Education Message:

Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients  

On December 1, CMS released the annual Physician Fee Schedule (PFS) final rule, prioritizing CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions. The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. This final rule takes steps to further implement President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors including prioritizing the expansion of proven alternatives like telehealth.

“During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”

“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”

Finalizing Telehealth Expansion and Improving Rural Health

Before the COVID-19 Public Health Emergency (PHE), only 15,000 Fee-for-Service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE.

This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE, and we will continue to gather more data and evaluate whether more services should be added in the future. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.

Additionally, CMS is announcing a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE. The study will explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.

Payment for Office/Outpatient Evaluation and Management (E/M) and Comparable Visits

Last year, CMS finalized a historic increase in payment rates for office/outpatient face-to-face E/M visits that goes into effect in 2021. The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary health care needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions. These payment increases, informed by recommendations from the American Medical Association (AMA), support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home. 

Under this final rule, CMS continues to prioritize this investment in primary care and chronic disease management by similarly increasing the value of many services that are similar to E/M office visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. These adjustments ensure CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” Administrator Verma added. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. The changes modernize documentation and coding guidelines developed in the 1990s, and come after extensive stakeholder collaboration with the AMA and others. These changes will significantly reduce the burden of documentation for all clinicians, giving them greater discretion to choose the visit level based on either guidelines for medical decision-making (the process by which a clinician formulates a course of treatment based on a patient’s information, i.e., through performing a physical exam, reviewing history, conducting tests, etc.) or time dedicated with patients. These changes are expected to save clinicians 2.3 million hours per year in administrative burden so that clinicians can spend more time with their patients.

Professional Scope of Practice and Supervision

As part of the Patients Over Paperwork Initiative, the Trump Administration is cutting red tape so that health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. The PFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program.

Specifically, CMS is finalizing the following changes:

Certain non-physician practitioners, such as nurse practitioners and physician assistants, can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.

For More Information:

Final Rule
Physician Fee Schedule Final Rule fact sheet
Quality Payment Program Final Rule fact sheet and FAQs
Medicare Diabetes Prevention Program fact sheet

October 2020 top claim submission errors

The October 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

Revised:

MM11889 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020
CMS revised this article to reflect the revised change request (CR) 11889 issued on August 14, 2020. The CR revision updated the codes in the CR spreadsheet for NCD 190.15. That change did not impact the article. In the article, we revised the CR release date, transmittal number, and the web address of the CR. All other information is the same.

November 25, 2020

CMS Provider Education Message:

Hospital Price Transparency Webcast on 12/8

MLN Connects® for Wednesday, November 25, 2020

View this edition as a: Webpage | PDF

News

CMS Announces Historic Changes to Physician Self-Referral Regulations
Policy Will Increase Number of Lifesaving Organs by Holding OPAs Accountable through Transparency and Competition
Prescription Drug Payment Model to Put American Patients First
DMEPOS Competitive Bidding Program: Contract Suppliers for Round 2021
Quality Payment Program APMs: Extended Deadline to Update Billing information — December 13
Clinical Laboratory Fee Schedule: CY 2021 Final Payment Determinations
Hospice Quality Reporting Program: November Refresh
November is Home Care & Hospice Month
World AIDS Day is December 1

Compliance

Polysomnography Services: Bill Correctly

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

Long-Term Services and Supports Open Door Forum — December 1
Hospital Price Transparency Webcast — December 8
Interoperability and Patient Access Final Rule Call — December 9

MLN Matters® Articles

Changes to the End-Stage Renal Disease (ESRD) PRICER to Accept the New Outpatient Provider Specific File Supplemental Wage Index Fields, the Network Reduction Calculation and New Value Code for Time on Machine
Claim Status Category and Claim Status Codes Update
Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)”
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
National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy
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) 2021
Update to Vaccine Services Editing
Overview of the Repetitive Scheduled Non-emergent Ambulance Prior Authorization Model — Revised
Billing for Home Infusion Therapy Services on or After January 1, 2021 — Revised
Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021 — Revised
Update to Chapter 10 of Publication (Pub.) 100-08 - Enrollment Policies for Home Infusion Therapy (HIT) Suppliers — Revised

Publications

DMEPOS Information for Pharmacies — Revised
DMEPOS Quality Standards — Revised

Advance Care Planning — Revised

November 24, 2020

How unsolicited/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


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11943 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
This article updates the RARC and CARC lists and instructs the Medicare’s system maintainers to update MREP and PC print. Make sure billing staffs are aware of these updates. If you use the MREP or PC print software, be sure to get the updated software.
MM11957 – Claim Status Category and Claim Status Codes Update
This article informs you of updates, as needed, to 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 staffs are aware of this update.
MM11988 – 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 Medicare system updates based on 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 February 1, 2021. Please make sure your billing staffs are aware of these updates.
MM12024 – Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2021
This article informs you of the new CY 2021 Medicare premium, coinsurance, and deductible rates.

Revised:

SE1514 – Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model
CMS revised the article to show that the model will not end on December 1, 2020. The model no longer has an end date and will remain in effect for the nine model states. All other information is unchanged.

November 19, 2020

CMS Provider Education Message:

MLN Connects® for Thursday, November 19, 2020

View this edition as a: Webpage | PDF

News

CMS Releases Nursing Home COVID-19 Training Data with Urgent Call to Action
Medicare FFS Estimated Improper Payments Decline by $15 Billion Since 2016
CMS Retiring Original Compare Tools on December 1
COVID-19: Health Care Operations Lessons and Fostering Professional Resilience
Medicare Diabetes Prevention Program: Become a Medicare-Enrolled Supplier
Recognizing Lung Cancer Awareness Month and the Great American Smokeout

Compliance

Hospice Care: Safeguards for Medicare Patients

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — November 19
Hospital Price Transparency Webcast — December 8

Multimedia

Part A Cost Report Webcast: Audio Recording and Transcript

November 18, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11783 – National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy
This article informs you that effective for claims with dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cells expressing at least one CAR when administered at healthcare facilities enrolled in the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategies and meets specified FDA conditions. Make sure your billing staffs are aware of these changes.

Revised:

MM11880 – Billing for Home Infusion Therapy Services on or After January 1, 2021
CMS revised this article to reflect a revised CR 11880 issued on November 13. In the article, CMS added statements related to the status indicator for the G codes on the Physician Fee Schedule and noting that MACs will post the HIT fees on their websites as soon as possible. Also, we revised the CR release date, transmittal numbers, and the web addresses of the transmittals. All other information remains the same.
MM11954 – Update to Chapter 10 of Publication (Pub.) 100-08 - Enrollment Policies for Home Infusion Therapy (HIT) Suppliers
CMS revised the article to reflect the revised change request (CR) 11954 issued on November 13. In the article, CMS revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

November 17, 2020

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

The October 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


November 12, 2020

CMS Provider Education Message:

COVID-19: Non-Physician Practitioner Billing for Audio Services

MLN Connects® for Thursday, November 12, 2020

View this edition as a: Webpage | PDF

News

Critical Care: Comparative Billing Report in November
Raising Awareness of Diabetes in November

Compliance

SNF 3-Day Rule Billing

Claims, Pricers & Codes

COVID-19: Non-Physician Practitioner Billing for CPT Codes 98966-98968

MLN Matters® Articles

Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2021
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) 2021
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2021
Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum
Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims

Publications

Provider Compliance Tips — Revised

Information for Medicare Patients

2021 Medicare Part B Premiums Remain Steady

Special Edition – Thursday, November 12, 2020

Provider Education Message:

COVID-19 Vaccine Codes and PC-ACE Software Update

In anticipation of the availability of a vaccine(s), for the novel coronavirus (SARS-CoV-2) in response to the coronavirus disease 2019 (COVID-19), the American Medical Association (AMA), working with the Centers for Medicare & Medicaid Services (CMS), created new codes for the vaccine and the administration of the vaccine.  To prepare for the vaccine administration claims, the PC-ACE software is also updated and ready for providers to download.

If you intend to administer the COVID-19 vaccines when they become available, or the new monoclonal antibody bamlanivimab, especially if you intend to roster bill these codes, please download and install the new release of PC-ACE. This release includes the coding structure, currently comprised of both a HCPCS Level I CPT code structure issued by the American Medical Association (AMA) and a HCPCS Level II code structure issued by CMS. Together, these codes support the administration of the COVID-19 vaccines and the monoclonal antibody infusions, as they become available; this structure includes the codes for bamlanivimab. This code structure was developed to facilitate efficient claims processing for any COVID-19 vaccines and monoclonal antibody infusions that receive FDA EUA or approval. CMS and the AMA are working collaboratively regarding which codes to submit for COVID-19 vaccines and administration.  Most of these codes are not currently effective and not all codes will be used.  We will issue specific code descriptors in the future.  Effective dates for the codes for Medicare purposes will coincide with the date of the FDA EUA or approval.


The following Local Coverage Determinations (LCDs) posted for comment on June 25, 2020 have been posted for notice. The LCDs and related Billing and Coding Articles will become effective December 27, 2020:

Transurethral Waterjet Ablation of the Prostate (L38712)
Billing and Coding: Transurethral Waterjet Ablation of the Prostate (A58243)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (L34924)
Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)

The following LCD posted for comment on June 25, 2020 has been posted for notice and will become effective December 27, 2020.

Endovenous Stenting (L37893)

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

Response to Comments: Endovenous Stenting (A58394)
Response to Comments: Transurethral Waterjet Ablation of the Prostate (A58377)
Response to Comments: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58378)

The following Billing and Coding Article has been revised:

Billing and Coding: Thrombolytic Agents (A55237)

The following Billing and Coding Article has been added:

Billing and Coding: Urodynamic Services - Non-invasive (A58541)

November 10, 2020

Provider Education Message:

CMS Takes Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment

Coverage Available at No Cost to Beneficiaries Across Variety of Settings in Health Care System

CMS announced that starting November 10, Medicare beneficiaries can receive coverage of monoclonal antibodies to treat COVID-19 with no cost-sharing during the Public Health Emergency (PHE). CMS’ coverage of monoclonal antibody infusions applies to bamlanivimab, which received an Emergency Use Authorization (EUA) from the FDA on November 9.

“Today, CMS is announcing a historic, first-of-its kind policy that drastically expands access to COVID-19 monoclonal antibodies to beneficiaries without cost sharing,” said CMS Administrator Seema Verma. “Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings – such as in a doctor’s office, nursing home, infusion centers, as long as safety precautions can be met. This aggressive action and innovative approach will undoubtedly save lives.”

CMS anticipates that this monoclonal antibody product will initially be given to health care providers at no charge. Medicare will not pay for the monoclonal antibody products that providers receive for free but this action provides for reimbursement for the infusion of the product. When health care providers begin to purchase monoclonal antibody products, Medicare anticipates setting the payment rate in the same way it set the payment rates for COVID-19 vaccines, such as based on 95% of the average wholesale price for COVID-19 vaccines in many provider settings. CMS will issue billing and coding instructions for health care providers in the coming days.

CMS anticipates the announcement will allow for a broad range of providers and suppliers, including freestanding and hospital-based infusion centers, home health agencies, nursing homes, and entities with whom nursing homes contract, to administer this treatment in accordance with the EUA, and bill Medicare to administer these infusions.

Under section 6008 of the Families First Coronavirus Response Act (FFCRA), state and territorial Medicaid programs may receive a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP), through the end of the quarter in which the COVID-19 PHE ends. A condition for receipt of this enhanced federal match is that a state or territory must cover COVID-19 testing services and treatments, including vaccines and their administration, specialized equipment, and therapies for Medicaid enrollees without cost sharing. This means that this monoclonal antibody infusion is expected to be covered when furnished to Medicaid beneficiaries, in accordance with the EUA, during this period, with limited exceptions. 

View the Monoclonal Antibody COVID-19 Infusion Program Instruction.


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)
CMS revised the article to clarify the billing instructions in the Skilled Nursing Facility Benefit Period Waiver - Provider Information section. All other information remains the same.

November 9, 2020

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

Blepharoplasty and Surgical Procedures of the Brow (DL35004)
Botulinum Toxins (DL38809)
Diagnostic Colonoscopy (DL38812)

The comment period remains open until December 12, 2020 for the following proposed LCDs.

Cardiology Non-emergent Outpatient Stress Testing (DL35083)
Facet Joint Interventions for Pain Management (DL34892)
Submit Comments

November 6, 2020

Reopening Gateway: Billed in error is here!

The “billed in error” feature is now available in our Reopening Gateway! This new feature allows you to easily correct a claim or individual lines of a claim that were billed in error and allows overpayment letters to be issued much faster than the traditional method. No paper required! As a reminder, our Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process.


Repetitive Non-Emergent Ambulance Prior Authorization Nationwide Expansion Model Update

The Centers for Medicare & Medicaid Services (CMS) began operating the Repetitive, Scheduled, Non-Emergent Ambulance Transportation (RSNAT) Prior Authorization Model in New Jersey, Pennsylvania, and South Carolina in December 2014 under the authority of Section 1115A of the Social Security Act (the Act). Section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) added Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia to the model in January 2016.

On September 23, 2020, CMS announced that the model has met all nationwide expansion criteria, as described in paragraphs (1) through (3) of Section 1115A(c) of the Act. The current pilot model will end under Section 1115A authority on December 1, 2020 and will transition to nationwide authority under section 1834(l)(16) of the Act, as added by Section 515(b) of MACRA on December 2, 2020. The nationwide model does not change any program requirements for providers.

If you have any questions or concerns regarding this update or the Prior Authorization program, please visit our Novitas Prior Authorization Webpage or call Prior Authorization Customer Service 855-340-5975.


November 5, 2020

CMS Provider Education Message:

COVID-19 Vaccine: Find Out How to Prepare

MLN Connects® for Thursday, November 5, 2020

View this edition as a: Webpage | PDF

News

COVID-19 Vaccine: Find Out How to Prepare
Hospital Price Transparency: Requirements Effective January 1
SNF Quality Reporting Program: October Refresh
Flu Shots: Each Visit is an Opportunity

Compliance

Inhalant Drugs: Bill Correctly

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — November 5

MLN Matters® Articles

Special Provisions for Radiology Additional Documentation Requests
Update to Chapter 10 of Publication (Pub.) 100-08 - Enrollment Policies for Home Infusion Therapy (HIT) Suppliers
October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule — Revised
Penalty for Delayed Request for Anticipated Payment (RAP) Submission -- Implementation — Revised
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update — Revised

Publications

Medicare Wellness Visits

Multimedia

SNF Quality Reporting Program: Confusion Assessment Method Video Tutorial
SNF Quality Reporting Program: Brief Interview for Mental Status Video Tutorial

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12027 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--April 2021
This article informs you about updated ICD-10 conversions as well as 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. Any policy-related changes to NCDs continue to be implemented via the current, longstanding NCD process. There are no policy related changes with these updates. Make sure your billing staffs are aware of these updates.

Updated: Avastin for ophthalmological use, J7999

Novitas would like to provide the following information to assist with the billing of the compounded form of Avastin for ophthalmological use to ensure the drug is reported accurately. The not otherwise classified (NOC) code, J7999, from the American Medical Association Healthcare Common Procedure Coding System (HCPCS) is to be billed for the compounded form of Avastin administered through an intravitreal injection. Find out more.


November 3, 2020

Special Edition – Tuesday, November 3, 2020

Provider Education Message:

ESRD & Home Health Payment Rules

ESRD PPS: CY 2021 Payment Policies and Rates
Home Health Agencies: CY 2021 Payment and Policy Changes and Home Infusion Therapy Benefit
CMS’ New One-Stop Nursing Home Resource Center Assists Providers, Caregivers, Residents

ESRD PPS: CY 2021 Payment Policies and Rates

On November 2, 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 enrolled in Original Medicare on or after January 1, 2021. 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.

The final CY 2021 ESRD PPS base rate is $253.13, which represents an increase of $13.80 to the current base rate of $239.33. This amount reflects the application of the updated wage index budget-neutrality adjustment factor (.999485), the addition to the base rate of $9.93 to include calcimimetics, and a productivity-adjusted market basket increase, as required by section 1881(b)(14)(F)(i)(I) of the Act (1.6 percent), equaling $253.13 (($239.33 x .999485) + $9.93 x 1.016 = $253.13).

CMS finalized the following:

Update to the ESRD PPS wage index to adopt the 2018 Office of Management and Budget delineations with a transition period
Changes to the eligibility criteria and determination process for the Transitional add-on Payment adjustment for New and Innovative Equipment and Supplies (TPNIES)
Expansion of the TPNIES to include new and innovative capital-related assets that are home dialysis machines
Change to the low-volume payment adjustment eligibility criteria and attestation requirement to account for the COVID-19 public health emergency

For More Information:

Final rule
Press release
Full text of fact sheet

Home Health Agencies: CY 2021 Payment and Policy Changes and Home Infusion Therapy Benefit

On October 29, CMS issued a final rule that finalizes routine updates to the home health payment rates for Calendar Year (CY) 2021 in accordance with existing statutory and regulatory requirements. This rule also finalizes the regulatory changes related to the use of telecommunications technology in providing care under the Medicare home health benefit.

CMS estimates that Medicare payments to Home Health Agencies (HHAs) in CY 2021 will increase in the aggregate by 1.9 percent, or $390 million, based on the finalized policies. This increase reflects the effects of the 2.0 percent home health payment update percentage ($410 million increase) and a 0.1 percent decrease in payments due to reductions in the rural add-on percentages mandated by the Bipartisan Budget Act of 2018 for CY 2021 ($20 million decrease). This rule also updates the home health wage index including the adoption of revised Office of Management and Budget statistical area delineations and limiting any decreases in a geographic area’s wage index value to no more than 5 percent in CY 2021.

This final rule also:

Finalizes Medicare enrollment policies for qualified home infusion therapy suppliers
Updates the home infusion therapy services payment rates for CY 2021
Finalizes a policy excluding home infusion therapy services from home health services as required by law
Finalizes policies under the Home Health Value Based Purchasing Model published in the interim final rule with comment period, as required by law

For More Information:

Final rule
Home Health Prospective Payment System website
HHA Center webpage
Home Health Patient-Driven Groupings Model webpage
Home Infusion Therapy Services website
Full text of Fact Sheet

CMS’ New One-Stop Nursing Home Resource Center Assists Providers, Caregivers, Residents

On October 30, CMS launched a new online platform - the Nursing Home Resource Center - to serve as a centralized hub bringing together the latest information, guidance, and data on nursing homes that is important to facilities, frontline providers, residents, and their families, especially as the fight against COVID-19 continues.

The Resource Center consolidates all nursing home information, guidance, and resources into a user-friendly, one-stop-shop that is easily navigable so providers and caregivers can spend less time searching for critical answers and more time caring for residents. Moreover, the new platform contains features specific to residents and their families, ensuring they have the information needed to make empowered decisions about their health care.

 With the new page, people can efficiently navigate all facility inspection reports and data – including COVID-19 pandemic and Public Health Emergency (PHE) information. This tool will remain active through and beyond the COVID-19 PHE.

Full text of News Alert.


November 2, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11954 – Update to Chapter 10 of Publication (Pub.) 100-08 - Enrollment Policies for Home Infusion Therapy (HIT) Suppliers
Change request 11954 informs MACs of the policies and procedures for enrolling HIT suppliers in Medicare. MACs will accept enrollment applications from HIT suppliers beginning on or after November 1, 2020. Payments will begin for dates of service on or after January 1, 2021. Please make sure your billing staffs are aware of these policies.
MM11659 – Special Provisions for Radiology Additional Documentation Requests
This article discusses a pilot process enabling MACs to request pertinent documentation from the treating/ordering provider during medical review, in an effort to support the necessity and payment for radiology service(s)/item(s) billed to Medicare. Make sure that your billing staffs are aware of these changes.

Revised:

MM11939 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update
CMS revised the article to reflect the revised change request (CR) 11939, issued on October 27, 2020. We added information about codes 3170F, 0599T, A4226, and the new codes 86408, 86409, 86413, and 99072. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

October 30, 2020

Opioid treatment program specialty update

New information has been regarding Office-Based Opioid Use Disorder (OUD) Treatment Billing.    


October 29, 2020

CMS Provider Education Message:

Quality Payment Program APMs: Update Billing Information to Get Paid

MLN Connects® for Thursday, October 29, 2020

View this edition as a: Webpage | PDF

News

Quality Payment Program APMs: Update Billing information by November 13

Compliance

Hospice Aide Services: Enhancing RN Supervision

MLN Matters® Articles

Change to the Payment of Allogeneic Stem Cell Acquisition Services — Revised

Publications

Medicare Quarterly Provider Compliance Newsletter

The following Proposed Local Coverage Determinations (LCDs) have been posted for comments. The comment period will end on December 12, 2020; however, you are encouraged to submit your comments as soon as possible.

Cardiology Non-emergent Outpatient Stress Testing (DL35083)
Facet Joint Interventions for Pain Management (DL34892)
Submit Comments

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

Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (DA56423)
Billing and Coding: Facet Joint Interventions for Pain Management (DA56670)

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 December 13, 2020:

Biomarkers for Oncology (L35396)
Billing and Coding: Biomarkers for Oncology (A52986)

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

Response to Comments: Biomarkers for Oncology (A58529)

As a reminder, the comment period for the following Proposed Local Coverage Determinations (LCDs) is currently open and will close on November 7, 2020. We encourage you to submit your comments as soon as possible.

Blepharoplasty and Surgical Procedures of the Brow (DL35004)
Botulinum Toxins (DL38809)
Diagnostic Colonoscopy (DL38812)
Submit Comments

2021 evaluation & management (E/M) changes FAQs

We are pleased to announce a new FAQ document to assist you with understanding the AMA CPT® E/M code and guideline changes for 2021.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11956 – October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
CMS revised this article to reflect the revised change request (CR) 11956, issued on October 27, 2020. The CR revision clarified the claims processing jurisdiction for code K1009. CMS also revised the release date, transmittal number, and the web address of the CR. All other information remains the same.

Online Registration Available for November 13, 2020, Open Meeting and Proposed LCDs Now Posted

Online registration for the November 13, 2020, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, November 11, 2020. IMPORTANT: During this unprecedented time, our Open Meeting will be held via teleconference only. The Novitas Solutions Proposed Local Coverage Determinations (LCDs) are 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.


Special Edition – Wednesday, October 28, 2020

Provider Education Message:

Trump Administration Acts to Ensure Coverage of Life-Saving COVID-19 Vaccines & Therapeutics

Under President Trump’s leadership, CMS is taking steps to ensure all Americans, including the nation’s seniors, have access to the coronavirus disease 2019 (COVID-19) vaccine at no cost when it becomes available. On October 28, the agency released a comprehensive plan with proactive measures to remove regulatory barriers and ensure consistent coverage and payment for the administration of an eventual vaccine for millions of Americans. CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to swiftly administer the vaccine once it is available. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. In addition, CMS is taking action to increase reimbursement for any new COVID-19 treatments that are approved or authorized by the FDA.

“Under President Trump’s leadership, we have developed a comprehensive plan to support the swift and successful distribution of a safe and effective vaccine for COVID-19,” said CMS Administrator Seema Verma. “As Operation Warp Speed nears its goal of delivering the vaccine in record time, CMS is acting now to remove bureaucratic barriers while ensuring that states, providers and health plans have the information and direction they need to ensure broad vaccine access and coverage for all Americans.”

To ensure broad access to a vaccine for America’s seniors, CMS released an Interim Final Rule with Comment Period (IFC) that establishes that any vaccine that receives Food and Drug Administration (FDA) authorization, either through an Emergency Use Authorization (EUA) or licensed under a Biologics License Application (BLA), will be covered under Medicare as a preventive vaccine at no cost to beneficiaries. The IFC also implements provisions of the CARES Act that ensure swift coverage of a COVID-19 vaccine by most private health insurance plans without cost sharing from both in and out-of-network providers during the course of the public health emergency (PHE).

In anticipation of the availability of new COVID-19 treatments, the IFC also establishes additional Medicare hospital payment to support Medicare patients’ access to these potentially life-saving COVID-19 therapies.  In Medicare, hospitals are generally reimbursed a fixed payment amount for the services they provide during an inpatient stay, even if their costs exceed that amount. Under current rules, hospitals may qualify for additional “outlier payments,” but only when their costs for a particular patient exceed a certain threshold. Under this IFC, hospitals would qualify for additional payments when they treat patients with innovative new products approved or authorized to treat COVID-19 to mitigate any losses they may experience from making these therapies available, even if they do not reach the current outlier threshold. The IFC also makes changes to reimbursement for outpatient hospital services to ensure payment for certain innovative treatments for COVID-19 that occur outside of bundled arrangements and are paid separately. In addition, CMS released information to prepare hospitals to bill for the outpatient administration of a monoclonal antibody product in the event one is approved under an emergency use authorization (EUA).

This rule also allows states to employ a broad range of strategies - based on local needs - to appropriately manage their Medicaid program costs. The guidance and flexibility provided to states in the IFC will help them maintain Medicaid beneficiary enrollment while receiving the temporary increase in federal funding in the Families First Coronavirus Response Act (FFCRA).

CMS is also taking continued steps to ensure that price transparency extends to COVID-19 testing during the PHE. Provisions in the IFC require that any provider who performs a COVID-19 diagnostic test post their cash prices online. Providers that are non-compliant may face civil monetary penalties.

In addition to these provisions, the IFC:

Provides an extension of Performance Year 5 for the Comprehensive Care for Joint Replacement (CJR) model; and
Creates flexibilities in the public notice requirements and post-award public participation requirements for a State Innovation Waiver under Section 1332 of the Patient Protection and Affordable Care Act during the COVID-19 PHE.

Along with these regulatory changes, CMS is issuing three toolkits aimed at state Medicaid agencies, providers who will administer the vaccine, and health insurance plans. Together, these toolkits will help ensure the health care system is prepared to successfully administer a safe and effective vaccine by addressing issues related to access, billing and payment, and coverage.

Increasing Access to Vaccines for Medicare & Medicaid Beneficiaries

The toolkits issued today give health care providers not currently enrolled in Medicare the information needed to administer and bill vaccines to Medicare patients. CMS is working to increase the number of providers that will administer a COVID-19 vaccine to Medicare beneficiaries when it becomes available, to make it as convenient as possible for America’s seniors. New providers are now able to enroll as a “Medicare mass immunizers” through an expedited 24-hour process. The ability to easily enroll as a mass immunizer is important for some pharmacies, schools, and other entities that may be non-traditional providers or otherwise not eligible for Medicare enrollment. To further increase the number of providers who can administer the COVID -19 vaccine, CMS will continue to share approved Medicare provider information with states to assist with Medicaid provider enrollment efforts. CMS is also making it easier for newly enrolled Medicare providers to also enroll in state Medicaid programs to support state administration of vaccines for Medicaid recipients.

Coverage

As a condition of receiving free COVID-19 vaccines from the federal government, providers will be prohibited from charging consumers for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay directly for the COVID-19 vaccine and its administration for beneficiaries enrolled in MA plans. MA plans would not be responsible for reimbursing providers to administer the vaccine during this time. Medicare Advantage beneficiaries also pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.

Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for most beneficiaries during the public health emergency. Following the public health emergency, depending on the population, states may have to evaluate cost sharing policies and may have to submit state plan amendments if updates are needed.

Private Plans: CMS, along with the Departments of Labor and the Treasury, is requiring that most private health plans and issuers cover a recommended COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing. The rule also provides that out-of-network rates cannot be unreasonably low, and references CMS’s reimbursement rates as a potential guideline for insurance companies.

Uninsured: For individuals who are uninsured, providers will be able to be reimbursed for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

Billing and Payment

The toolkits also address issues related to billing and payment. After the FDA either approves or authorizes a vaccine for COVID-19, CMS will identify the specific vaccine codes, by dose if necessary, and specific vaccine administration codes for each dose for Medicare payment. CMS and the American Medical Association (AMA) are working collaboratively on finalizing a new approach to report use of COVID-19 vaccines, which include separate vaccine-specific codes. Providers and insurance companies will be able to use these to bill for and track vaccinations for the different vaccines that are provided to their enrollees.

Medicare Payment

CMS also released new Medicare payment rates for COVID-19 vaccine administration. The Medicare payment rates will be $28.39 to administer single-dose vaccines. For a COVID-19 vaccine requiring a series of two or more doses, the initial dose(s) administration payment rate will be $16.94, and $28.39 for the administration of the final dose in the series. These rates will be geographically adjusted and recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine. Medicare beneficiaries, those in Original Medicare or enrolled in Medicare Advantage, will be able to get the vaccine at no cost.

CMS is encouraging state policymakers and other private insurance agencies to utilize the information on the Medicare reimbursement strategy to develop their vaccine administration payment plan in the Medicaid program, CHIP, the Basic Health Program (BHP), and private plans. Using the Medicare strategy as a model would allow states to match federal efforts in successfully administering the full vaccine to the most vulnerable populations.

The IFC (CMS-9912-IFC) is scheduled to display at the Federal Register as soon as possible with an immediate effective date and a 30-day comment period.

For More Information:

Fact Sheet
COVID-19 vaccine resources for providers, health plans and State Medicaid programs
FAQs on billing for therapeutics

October 27, 2020

Special Edition – Tuesday, October 27, 2020

Provider Education Message:

New CMS Proposals Streamline Medicare Coverage, Payment, and Coding for Innovative New Technologies and Provide Beneficiaries with Diabetes Access to More Therapy Choices

Durable Medical Equipment (DME) proposed rule would reduce administrative burden for new innovative technologies

On October 27, under the leadership of President Trump, CMS proposed new changes to Medicare Durable Medical Equipment, Prosthetics, Orthotic Devices, and Supplies (DMEPOS) coverage and payment policies. This rule would provide more choices for beneficiaries with diabetes, while streamlining the process for innovators in getting their technologies approved for coverage, payment, and coding by Medicare.

The proposed rule would expand the interpretation regarding when external infusion pumps are appropriate for use in the home and can be covered as DME under Medicare Part B, increasing access to drug infusion therapy services in the home. The proposed rule also drastically reduces administrative burdens – such as complicated government coverage, payment, and coding processes – that block innovators from getting their products to Medicare beneficiaries in a timely manner. This action aligns with President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors.

“With the policies outlined in this proposed rule, innovators have a much more predictable path to understanding the kinds of products that Medicare will pay for,” said CMS Administrator Seema Verma. “For manufacturers, bringing a new product to market will mean they can get a Medicare payment amount and billing code right off the bat, resulting in quicker access for Medicare beneficiaries to the latest technological advances and the most, cutting-edge devices available. It’s clearly a win-win for patients and innovators alike.”

Due to administrative constraints, the process for making Medicare benefit classifications, pricing determinations, and creating billing codes for DMEPOS used to routinely take up to 18 months to complete. Last year, CMS changed this process through sub-regulatory guidance to reduce that timeframe to six months in many cases, and is now proposing to establish a streamlined process for coding, coverage, and payment in regulation. Under this accelerated process, benefit classification and pricing decisions could happen on the same day the billing codes used for payment of new items take effect, which would facilitate seamless coverage and payment for new DMEPOS and services. If finalized, this proposed rule would allow innovators to bring their products to Medicare beneficiaries quicker giving them more choices and increased access to the latest, cutting-edge devices.

If finalized, this proposed rule will also expand Medicare coverage and payment for Continuous Glucose Monitors (CGMs) that provide critical information on blood glucose levels to help patients with diabetes manage their disease. Currently, CMS only covers therapeutic CGMs or those approved by the FDA for use in making diabetes treatment decisions, such as changing one's diet or insulin dosage based solely on the readings of the CGM.

CMS is proposing to classify all CGMs (not just limited to therapeutic CGMs) as DME and establish payment amounts for these items and related supplies and accessories. CGMs that are not approved for use in making diabetes treatment decisions can be used to alert beneficiaries about potentially dangerous glucose levels while they sleep and that they should further test their glucose levels using a blood glucose monitor. With one in every three Medicare beneficiaries having diabetes, this proposal would give Medicare beneficiaries and their physicians a wider range of technology and devices to choose from in managing diabetes. This proposal will improve access to these medical technologies and empower patients to make the best health care decisions for themselves.

In addition, the proposed rule would expand classification of external infusion pumps under the DME benefit making home infusion of more drugs possible for beneficiaries. An external infusion pump is a medical device used to deliver fluids such as nutrients or medications into a patient’s body in a controlled manner. The proposal would expand classification of external infusion pumps as DME in cases where assistance from a skilled home infusion therapy supplier is necessary for safe infusion in the home, allowing beneficiaries more choices to get therapies at home instead of traveling to a health care facility. 

Lastly, in the proposed rule, CMS proposes to continue to pay higher amounts to suppliers for DMEPOS items and services furnished in rural and non-contiguous areas to encourage suppliers to provide access and choices for beneficiaries living in those areas. CMS is making this proposal based on previous stakeholder feedback that indicate unique challenges and higher costs for providing for DMEPOS items for beneficiaries in rural and remote areas.

For More Information:

Proposed Rule
Fact Sheet

October 22, 2020

CMS Provider Education Message:

Medicare Coverage for Opioid Use Disorder Treatment

MLN Connects® for Thursday, October 22, 2020

View this edition as a: Webpage | PDF

News

Opioid Use Disorder Treatment: Medicare Coverage
Clinical Diagnostic Laboratory Tests Advisory Panel: Request for Nominations
Medicare Diabetes Prevention Program: Become a Medicare-Enrolled Supplier

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — October 22
Medicare Part A Cost Report: New Bulk e-Filing Feature Webcast — October 29

MLN Matters® Articles

Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 and Productivity Adjustment
Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) — Revised
New Waived Tests — Revised

Multimedia

Nursing Home COVID-19 Preparedness for Fall & Winter Web-Based Training

Information for Medicare Patients

Diabetes Management Resources

September 2020 top claim submission errors

The September 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.


October 20, 2020

Retroactive prior authorization for certain outpatient department (OPD) services in the emergency department (ED)

CMS will allow exclusions for certain PARs to be submitted retroactively when those services were rendered in the Emergency Department (ED) and obtaining a prior authorization was not possible given the timing of the emergency and conditions when service(s) cannot be delayed. Such a PAR must be submitted no more than two business days (excluding federal holidays and weekends) after the service was rendered in the ED using the expedited PAR cover sheet.


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

The September 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


October 19, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12031 – Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 and Productivity Adjustment
This article gives you the CY 2021 AIF for determining the payment limit for ambulance services. The AIF for CY 2021 is 0.2 percent. Make sure that your billing staffs are aware of this change.

Revised:

SE20011 – Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
CMS revised the article to clarify the HCPCS codes that critical access hospitals (CAHs) should use in the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section. Also, we clarified the skilled nursing facility (SNF) benefit period waiver - provider information section to show the SNF waiver applies to swing-bed services in rural hospitals and CAHs. All other information remains the same.

October 16, 2020

Special Edition – Friday, October 16, 2020

Provider Education Message:

Enforcement Discretion Relating to Certain Pharmacy Billing

The Centers for Medicare & Medicaid Services (“CMS”) appreciates its long-standing partnership with immunizers, including pharmacies, to facilitate the efficient administration of vaccinations, particularly for vulnerable populations in long-term care facilities and other congregate care settings across America. Leveraging immunizers’ capabilities and expertise will play an important role in the Department’s ability to broadly distribute and administer COVID-19 vaccinations, including Medicare beneficiaries.

America is facing an unprecedented challenge. Quickly, safely, and effectively vaccinating our most vulnerable citizens in settings that have accounted for about 30 percent of U.S. COVID-19 deaths is a top-priority mission for the Trump Administration. Unfortunately, many long-term care facilities may not have sufficient capacity to receive, store, and administer vaccines. And some long-term care facility residents cannot safely leave the facility to receive vaccinations.

Outside immunizers can help fill that urgent need and provide onsite vaccinations at skilled nursing facilities (“SNFs”). But to do so during this global emergency, Medicare-enrolled vaccinators must be able to bill directly and receive direct reimbursement from the Medicare program. However, the Social Security Act requires SNFs to bill for certain services, including vaccine administration, even when SNFs rely on an outside vendor to perform the service. See Social Security Act §§ 1862(a)(18), 1842(b)(6)(E).

Therefore, in order to facilitate the efficient administration of COVID-19 vaccines to SNF residents, CMS will exercise enforcement discretion with respect to these statutory provisions as well as any associated statutory references and implementing regulations, including as interpreted in pertinent guidance (collectively, “SNF Consolidated Billing Provisions”). Through the exercise of that discretion, CMS will allow Medicare-enrolled immunizers, including but not limited to pharmacies working with the United States, to bill directly and receive direct reimbursement from the Medicare program for vaccinating Medicare SNF residents.

CMS will exercise such discretion (1) during the emergency period defined in paragraph (1)(B) of section 1135(g) of the Social Security Act (42 U.S.C. § 1320b-5(g)) and ending on the last day of the calendar quarter in which the last day of such emergency period occurs; or (2) so long as CMS determines that there is a public health need for mass COVID-19 vaccinations in congregate care settings—whichever is later. While CMS exercises this enforcement discretion, compliance with SNF Consolidated Billing Provisions is not material to CMS’ decision to reimburse for COVID-19 vaccine administration. If CMS decides in the future to cease exercising this enforcement discretion, CMS will provide public notice in advance and allow at least 60 days for affected outside immunizers to modify their business practices.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11982 – New Waived Tests
CMS revised this article to reflect a revised change request (CR)11982, issued on October 15, 2020. The CR revised an incorrect date for one of the codes for 87804QW. The date in the article was correct already. In the article, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

October 15, 2020

Special Edition – Thursday, October 15, 2020

Provider Education Message:

Trump Administration Drives Telehealth Services in Medicaid and Medicare

On October 14, CMS expanded the list of telehealth services that Medicare Fee-for-Service will pay for during the COVID-19 Public Health Emergency (PHE). CMS is also providing additional support to state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their efforts to expand access to telehealth. The actions reinforce President Trump’s Executive Order on Improving Rural Health and Telehealth Access to improve the health of all Americans by increasing access to better care.

“Responding to President Trump’s Executive Order, CMS is taking action to increase telehealth adoption across the country,” said CMS Administrator Seema Verma. “Medicaid patients should not be forgotten, and today’s announcement promotes telehealth for them as well. This revolutionary method of improving access to care is transforming health care delivery in America. President Trump will not let the genie go back into the bottle.”

Expanding Medicare Telehealth Services:

For the first time using a new expedited process, CMS added 11 new services to the Medicare telehealth services list since the publication of the May 1 COVID-19 Interim Final Rule with comment period (IFC). Medicare will begin paying eligible practitioners who furnish these newly added telehealth services effective immediately and for the duration of the PHE. These new telehealth services include certain neurostimulator analysis and programming services, and cardiac and pulmonary rehabilitation services. The list of these newly added services is available on the List of Telehealth Services webpage.

In the May 1 COVID-19 IFC, CMS modified the process for adding or deleting services from the Medicare telehealth services list to allow for expedited consideration of additional telehealth services during the PHE outside of rulemaking. This update to the Medicare telehealth services list builds on the efforts CMS has already taken to increase Medicare beneficiaries’ access to telehealth services during the COVID-19 PHE.

Since the beginning of the PHE, CMS added over 135 services to the Medicare telehealth services list – such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services. With this action, Medicare will pay for 144 services performed via telehealth. Between mid-March and mid-August, over 12.1 million Medicare beneficiaries – over 36% – of people with Medicare Fee-for-Service received a telemedicine service.

Preliminary Medicaid and CHIP Data Snapshot on Telehealth Utilization and Medicaid & CHIP Telehealth Toolkit Supplement:

In an effort to provide greater transparency on telehealth access in Medicaid and CHIP, CMS released, for the first time, a preliminary Medicaid and CHIP data snapshot on telehealth utilization during the PHE. This snapshot shows, among other things, that there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and June of this year, representing an increase of more than 2,600% when compared to the same period from the prior year. The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states.

To further drive telehealth, CMS released a new supplement to its State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 Version that provides numerous new examples and insights into lessons learned from states that implemented telehealth changes. The updated supplemental information is intended to help states strategically think through how they explain and clarify to providers and other stakeholders which policies are temporary or permanent. It also helps states identify services that can be accessed through telehealth, which providers may deliver those services, the ways providers may use in order to deliver services through telehealth, as well as the circumstances under which telehealth can be reimbursed once the PHE expires.

The toolkit includes approaches and tools states can use to communicate with providers on utilizing telehealth for patient care. It updates and consolidates in one place the FAQs and resources for states to consider as they begin planning beyond the temporary flexibilities provided in response to the pandemic.

View the Medicaid and CHIP data snapshot on telehealth utilization during the PHE.


CMS Provider Education Message:

COVID-19 Testing: Protecting Integrity

MLN Connects® for Thursday, October 15, 2020

View this edition as a: Webpage | PDF

News

CMS Takes Action to Protect Integrity of COVID-19 Testing
Protect Your Patients: Give Them a Flu Shot

Events

Medicare Part A Cost Report: New Bulk e-Filing Feature Webcast — October 29

MLN Matters® Articles

New Waived Tests
January 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3 — Revised
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2021 — Revised

Publications

Provider Compliance Tips for Glucose Monitors and Diabetic Accessories/Supplies — Revised

Multimedia

Coverage of an Annual Wellness Visit Video

Information for Medicare Patients

Medicare Health and Drug Plans Receive Star Ratings

Frequently Asked Questions (FAQs)

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


The following Billing and Coding Article has been revised:

Billing and Coding: Psychiatric Codes (A57130)

Avastin for ophthalmological use, J7999

Novitas would like to provide the following information to assist with the billing of the compounded form of Avastin for ophthalmological use to ensure the drug administration is reported accurately. The not otherwise classified (NOC) code, J7999, from the American Medical Association Healthcare Common Procedure Coding System (HCPCS) is to be billed for the intravitreal administration of the compounded form of Avastin.


October 12, 2020

The following Local Coverage Determination (LCD) which was posted for notice on August 27, 2020 is now effective. The companion article for this LCD is also now effective:

Implantable Continuous Glucose Monitors (I-CGM) (L38617)
Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58110)

The comment period is now closed for the following Proposed Local Coverage Determination. Comments received will be reviewed by our Contractor Medical Directors. The Response to Comments Article and finalized Billing and Coding Article will be related to the final LCD when it is posted for notice.

Colon Capsule Endoscopy (CCE) (DL38807)
Billing and Coding: Colon Capsule Endoscopy (CCE) (DA58414)

Accelerated and Advance Repayments

The Centers for Medicare & Medicaid Services (CMS) expedited payments to increase cash flow to providers/suppliers due to a disruption in claim submission and/or claims processing.  As these funds were temporary they will need to be refunded to Medicare through the recoupment process. If you are a provider or supplier who had received these payments we encourage you to review our article Learn about CMS' amended repayment process for accelerated and advance repayments to learn how to prepare for the recoupment of these funds.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM12020 – January 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
This article informs you of updates to the quarterly ASP Medicare Part B pricing files and informs providers of revisions, if needed, to prior quarterly pricing files. Please make sure your billing staffs are aware of these updates and revisions.

October 8, 2020

Special Edition – Thursday, October 8, 2020

Provider Education Message:

CMS Announces New Repayment Terms for Medicare Loans Made to Providers During COVID-19

New recoupment terms allow providers and suppliers one additional year to start loan payments

CMS announced amended terms for payments issued under the Accelerated and Advance Payment (AAP) Program as required by recent action by President Trump and Congress. This Medicare loan program allows CMS to make advance payments to providers, which are typically used in emergency situations. Under the Continuing Appropriations Act, 2021 and Other Extensions Act, repayment will now begin one year from the issuance date of each provider or supplier’s accelerated or advance payment. CMS issued $106 billion in payments to providers and suppliers in order to alleviate the financial burden health care providers faced while experiencing cash flow issues in the early stages of combating the Coronavirus Disease 2019 (COVID-19) public health emergency.

“In the throes of an unprecedented pandemic, providers and suppliers on the frontlines needed a lifeline to help keep them afloat,” said CMS Administrator Seema Verma. “CMS’ advanced payments were loans given to providers and suppliers to avoid having to close their doors and potentially causing a disruption in service for seniors. While we are seeing patients return to hospitals and doctors providing care we are not yet back to normal,” she added.

CMS expanded the AAP Program on March 28, 2020, and gave these loans to health care providers and suppliers in order to combat the financial burden of the pandemic. CMS successfully paid more than 22,000 Part A providers, totaling more than $98 billion in accelerated payments. This included payments to Part A providers for Part B items and services they furnished. In addition, more than 28,000 Part B suppliers, including doctors, non-physician practitioners, and durable medical equipment suppliers received advance payments totaling more than $8.5 billion.

Providers were required to make payments starting in August of this year, but with this action, repayment will be delayed until one year after payment was issued. After that first year, Medicare will automatically recoup 25% of Medicare payments otherwise owed to the provider or supplier for 11 months. At the end of the 11-month period, recoupment will increase to 50% for another 6 months. If the provider or supplier is unable to repay the total amount of the AAP during this time-period (a total of 29 months), CMS will issue letters requiring repayment of any outstanding balance, subject to an interest rate of 4%.

The letter also provides guidance on how to request an Extended Repayment Schedule (ERS) for providers and suppliers who are experiencing financial hardships. An ERS is a debt installment payment plan that allows a provider or supplier to pay debts over the course of 3 years, or, up to 5 years in the case of extreme hardship. Providers and suppliers are encouraged to contact their MAC for information on how to request an ERS. To allow even more flexibility in paying back the loans, the $175 billion issued in Provider Relief funds can be used towards repayment of these Medicare loans. CMS will be communicating with each provider and supplier in the coming weeks as to the repayment terms and amounts owed as applicable for any accelerated or advance payment issued.

For More Information:

Fact Sheet
FAQs

CMS Provider Education Message:

17 Provider Compliance Tips Fact Sheets

MLN Connects® for Thursday, October 8, 2020

View this edition as a:  Webpage | PDF 

News

Hospice Quality Reporting Program: Successful Facilities for FY 2021
Laboratories: Pay Your CLIA Certification Fees Online
Institutional Providers: Give Us Your Feedback on the Provider Specific File by November 1
Submit Medicare GME Affiliation Agreements during COVID-19 PHE by January 1
COVID-19: Optimizing PPEand Child Health and Wellness
Ostomies are Life-Savers

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — October 8

Publications

Laboratory Quick Start Guide for CLIA Certification
Provider Compliance Tips — Revised
ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets — Revised
DMEPOS Accreditation — Revised
SNF and LTCH Quality Reporting Programs: COVID-19 Public Reporting — Revised

Multimedia

Dementia Care Call: Audio Recording and Transcript

October 6, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11982 – New Waived Tests
This article tells you 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 the MACs of the new tests so that they can accurately process claims. There are five newly added waived complexity tests listed in the table below.

Changes to amount in controversy for appeals in 2021

The Centers for Medicare & Medicaid Services has announced the dollar amount that must remain in controversy to sustain appeal rights beginning January 1, 2021. Please read this article for details.


October 1, 2020

CMS Provider Education Message:

Hospital Price Transparency: Requirements Effective January 1

MLN Connects® for Thursday, October 1, 2020

View this edition as a: Webpage | PDF

News

Hospital Price Transparency: Requirements Effective January 1
IRF Provider Preview Reports: Review Your Data by October 26
LTCH Provider Preview Reports: Review Your Data by October 26
Therapeutic Injections and Infusions: Comparative Billing Report
SNF Healthcare-Associated Infections Confidential Dry Run Report
COVID-19: Optimizing Health Care PPE and Supplies
Hospice Quality Reporting Program News
October is National Breast Cancer Awareness Month

MLN Matters® Articles

Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021
Change to the Payment of Allogeneic Stem Cell Acquisition Services — Revised
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 — Revised
October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised
October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised
Penalty for Delayed Request for Anticipated Payment (RAP) Submission -- Implementation — Revised
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Multimedia

ICD-10 Coordination and Maintenance Committee Meeting Materials
SNF Consolidated Billing Web-Based Training Course — Revised

Information for Medicare Patients

Making Insulin More Affordable for Medicare Patients Beginning January 1

The following Billing and Coding Articles have been revised to reflect the Annual ICD-10 Code Updates effective for dates of service on and after October 1, 2020.

Billing and Coding: Allergen Immunotherapy (A56538)
Billing and Coding: Allergy Testing (A56558)
Billing and Coding: Ambulance Services (Ground Ambulance) (A54574)
Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)
Billing and Coding: Bariatric Surgical Management of Morbid Obesity (A56422)
Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
Billing and Coding: Epidural Injections for Pain Management (A56681)
Billing and Coding: Flow Cytometry (A56676)
Billing and Coding: Hydration Therapy (A56634)
Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A56938)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)
Billing and Coding: Monitored Anesthesia Care (A57361)
Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)
Billing and Coding: Oximetry Services (A57205)
Billing and Coding: Psychiatric Codes (A57130)
Billing and Coding: Pulmonary Function Testing (A57320)
Billing and Coding: Routine Foot Care (A52996)
Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (A57600)
Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (A57414)

The following LCD and related Billing and Coding Article have been retired:

Chiropractic Services (L35424)
Billing and Coding: Chiropractic Services (A52987)

The following Billing and Coding Article that was published on August 27, 2020 is now effective:

Billing and Coding: Chiropractic Services (A58345)

Prior authorization (PA) for hospital outpatient department (OPD) tips and reminders

We have been processing prior authorization requests (PARs) since the implementation of the program and have found errors and omissions in these requests. These errors and omissions can result in delays or dismissals of the PAR. This article provides tips and reminders that will assist you in avoiding a delay or dismissal of a PAR.


September 28, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11984 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.0, Effective January 1, 2021
Change request 11984 provides the quarterly update to the NCCI PTP edits. Please be sure your billing staffs know of the updates.

Revised:

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
CMS revised this article to reflect the revised change request (CR) 11750, issued on September 25, 2020. CMS also revised the CR release date, transmittal number, and web address. All other information remains the same.

September 25, 2020

Reporting Bevacizumab for ophthalmological use

Novitas revised Local Coverage Article A53121 Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases on February 13, 2020 to provide clarification to the billing instruction for Bevacizumab. Physicians providing Bevacizumab for ophthalmological use should report HCPCS code J7999 (Compounded drug, not otherwise classified). Each 1.25mg dose administered is considered one unit. The total dosage administered should be noted in the "Remarks" section of the claim.


Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11937 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
CMS revised the article to add a new COVID 19 code (86413) and advanced diagnostic laboratory test code (0090U). CMS also revised the change request (CR) release date, transmittal number, and web address of the CR. All other information remains the same.
MM11963 – October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
CMS revised this article due to an updated change request (CR) 11963 that revised HCPCS code C9066 in Table 2 in the CR. That change is reflected in the article on page 3 (Table 2). CMS also revised the CR release date, transmittal number and link to the transmittal. All other information remains the same.

Reopening Gateway: Billed in error coming soon!

The “billed in error” feature is coming soon to our Reopening Gateway! This new feature will allow you to easily correct a claim or individual lines of a claim that were billed in error, and overpayment letters will be issued much faster than the traditional method. No paper required! As a reminder, our Reopening Gateway is a free, web-based application that allows for automated submission of claim corrections with no enrollment process.


September 24, 2020

CMS Provider Education Message:

Need Help Checking Medicare Eligibility?

MLN Connects® for Thursday, September 24, 2020

View this edition as a PDF

News

CMS to Expand Successful Ambulance Program Integrity Payment Model Nationwide
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
COVID-19: Maintaining Safety, Critical Care Load-Balancing, & Behavioral Health
National Cholesterol Education Month & World Heart Day

Claims, Pricers & Codes

Medicare Diabetes Prevention Program: Valid Claims

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — September 24

MLN Matters® Articles

2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer
Update to the Medicare Claims Processing Manual
Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries — Revised

Publications

Checking Medicare Eligibility

The following Proposed Local Coverage Determinations (LCDs) have been posted for comments. The comment period will end on November 7, 2020, however you are encouraged to submit your comments as soon as possible.

Blepharoplasty and Surgical Procedures of the Brow (DL35004)
Botulinum Toxins (DL38809)
Diagnostic Colonoscopy (DL38812)
Submit Comments

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

Billing and Coding: Blepharoplasty and Surgical Procedures of the Brow (DA57618)
Billing and Coding: Botulinum Toxins (DA58423)
Billing and Coding: Diagnostic Colonoscopy (DA58428)

The following Billing and Coding article has been revised:

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

The following LCD and related Billing and Coding Article have been retired:

Corus® CAD Test  (L36713)
Billing and Coding: Corus® CAD Test (A56608)

Online Registration Available for October 9, 2020, Open Meeting and Proposed LCD Now Posted

Online registration for the October 9, 2020, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, October 7, 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.


September 23, 2020

Limited Systems Availability - Friday, October 2, 2020 through Sunday, October 4, 2020

There will be Common Working File (CWF) "Dark" days from Friday, October 2, 2020 through Sunday, October 4, 2020 due to the October 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.


September 21, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11958 – Update to the Medicare Claims Processing Manual
Change request 11958 updates the Medicare Claims Processing Manual, Chapters 12 and 23. The list of non-facility place of service (POS) codes in the Medicare Claims Processing Manual, Chapter 12, Section 20.4.2, is updated to reflect previous updates to the POS list in Chapter 26, Section 10.5. Therefore, the Non-Residential Opioid Treatment Facility (POS code 58) setting is now included in Chapter 12, Section 20.4.2. Also, the Medicare Physician Fee Schedule Database (MPFSDB) file layout in the Chapter 23 Addendum is updated to show the procedure code series that are not included on the MPFSDB file. There are no policy changes, and no changes to the function of the MPFSDB file.

September 17, 2020

Provider Education Message:

Nursing Home COVID-19 Commission Findings, Oregon Wildfires, & Flu

Independent Nursing Home COVID-19 Commission Findings Validate Unprecedented Federal Response
CMS Offers Comprehensive Support for Oregon due to Wildfires
Protect Yourself & Your Patients from Flu this Season

Independent Nursing Home COVID-19 Commission Findings Validate Unprecedented Federal Response

On September 16, CMS received the final report from the independent Coronavirus Commission for Safety and Quality in Nursing Homes (Commission), which was facilitated by MITRE. CMS also released an overview of the robust public health actions the agency has taken to date to combat the spread of the Coronavirus Disease 2019 (COVID-19) in nursing homes. The Commission’s findings align with the actions the Trump Administration and CMS have taken to contain the spread of the virus and to safeguard nursing home residents from the ongoing threat of the COVID-19 pandemic. This announcement delivers on the Administration’s commitments to keeping nursing home residents safe and to transparency for the American people in the face of this unprecedented pandemic.

“The Trump Administration’s effort to protect the uniquely vulnerable residents of nursing homes from COVID-19 is nothing short of unprecedented,” said CMS Administrator Seema Verma. “In tasking a contractor to convene this independent Commission comprised of a broad range of experts and stakeholders, President Trump sought to refine our approach still further as we continue to battle the virus in the months to come. Its findings represent both an invaluable action plan for the future and a resounding vindication of our overall approach to date. We are grateful for the Commission’s important contribution.”

As the capstone to the Commission’s extensive report, on September 17, Administrator Verma will join Vice President Mike Pence and CDC Director Dr. Robert R. Redfield, some members of the Commission, and other public health and elder care experts at the White House. The Vice President, Dr. Redfield, and Administrator Verma will lead the group in a discussion regarding the Commission’s findings and general issues facing the nation’s elder care system.

Nursing homes and other shared or congregate living facilities have been severely affected by COVID-19, as these facilities often house older individuals who suffer from multiple medical conditions, making them particularly susceptible to complications from the virus. To help CMS inform immediate and future actions as well as identify opportunities for improvement, the Commission was created to conduct an independent review and comprehensive assessments of confronting COVID-19. The Commission’s report contains best practices that emphasize and reinforce CMS strategies and initiatives to ensure nursing home residents are protected from COVID-19.

As outlined in the overview released on September 16, the Trump Administration has already taken significant steps to implement many of the Commission’s findings. The Administration has worked to support nursing homes financially during this challenging time, distributing over $21 billion to America’s nursing homes – more than $1.5 million each on average. To ensure nursing homes had access to supplies, the Trump Administration shipped a 14-day supply of personal protective equipment to more than 15,000 nursing homes across the Nation in May.

The Administration has also required facilities to report data about COVID-19 cases, deaths, and supply levels, with 99.3 percent of facilities currently reporting. CMS took action to keep COVID-19 out of nursing homes by requiring them to test staff, a requirement that was paired with the Administration’s distribution of 13,850 point-of-care testing devices to America’s nursing homes. The Administration has also deployed federal Task Force Strike Teams in six waves, in 18 states so far, to 61 facilities particularly affected by COVID-19 to share best practices and gain a deeper understanding of how the virus spreads. CMS also required states to conduct focused infection control inspections at their nursing homes; between June and July, states completed these inspections at 99.8 percent of Medicare and Medicaid certified nursing homes.

Additionally, since March, CMS has conducted weekly calls with nursing homes, issued over 22 guidance documents and established a National Nursing Home COVID-19 Training program focused on infection control and best practices. CMS is also using COVID-19 data to target support to the highest risk nursing homes. In May, CMS released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to nursing homes. The toolkit is a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19. CMS updates the toolkit on a biweekly basis.

For More Information:

Coronavirus Commission for Safety and Quality in Nursing Homes Report

Trump Administration Response to Commission findings

COVID-19 Guidance and Updates for Nursing Homes during COVID-19

See the full text of this excerpted CMS Press Release (issued September 16), including a list of CMS public health actions for nursing homes on COVID-19 to date..

CMS Offers Comprehensive Support for Oregon due to Wildfires

On September 17, CMS announced efforts underway to support Oregon in response to wildfires across the state. On September 16, HHS Secretary Alex Azar declared a Public Health Emergency (PHE) in Oregon, retroactive to September 8. CMS is working to ensure hospitals and other facilities can continue operations and provide access to care despite the effects of the wildfires. CMS provided numerous waivers to health care providers during the current Coronavirus Disease 2019 (COVID-19) pandemic to meet the needs of beneficiaries and providers. These waivers will continue be available to health care providers to use for the duration of the COVID-19 PHE and for the wildfires PHEs. CMS will be waiving certain Medicare, Medicaid, and Children’s Health Insurance Program requirements; creating special enrollment opportunities for individuals to access health care quickly; and taking steps to ensure dialysis patients obtain critical life-saving services.

For More Information, visit www.cms.gov/emergency. See the full text of this excerpted CMS Press Release (issued September 17).https://content.govdelivery.com/attachments/fancy_images/USCMS/2014/03/274725/blank-box-15px_original.jpg

Protect Yourself & Your Patients from Flu this Season

Do your part to prevent the spread of seasonal flu. The CDC published flu vaccine recommendations for the 2020-2021 season. Because of the COVID-19 pandemic, reducing the spread of respiratory illness, like flu, this fall and winter is more important than ever.

Frequency and Coverage:

Medicare Part B covers one flu shot per flu season and additional flu shots if medically necessary
Flu shots are free for your Medicare patients if you accept assignment

You can give pneumonia and flu shots during the same office visit; see CDC recommendations.

The CDC, the Advisory Committee on Immunization Practices, and the Healthcare Infection Control Practices Advisory Committee recommend that all U.S. health care workers get annual flu shots.

For More Information:

CMS Flu Shot webpage
CDC Flu website
CDC Information for Health Professionals webpage
CDC Fight Flu Toolkit webpage
Vaccines.gov

CMS Provider Education Message:

Participate in Medical Documentation Interoperability Pilot

MLN Connects® for Thursday, September 17, 2020

View this edition as a PDF

News

SNF Healthcare-Associated Infections Measure: Submit Comments by October 14
Participate in Medical Documentation Interoperability Pilot
COVID-19 Lessons Learned & Infectious Disease Surge Annex Template
Healthy Aging® Month: Discuss Preventive Services with Your Patients
Prostate Cancer Awareness Month

Events

Dementia Care Call — September 22

MLN Matters® Articles

October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act — Revised
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2021 — Revised

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11968 – 2021 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
CR 11968 makes changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that Medicare uses to revise its Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF 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.

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

The August 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


September 16, 2020

Open Claims Issues

Two new issues have been added relating to 99441-99443 for Skilled Nursing Facility (SNF) Consolidated Billing (CB) edits and development letters providers received regarding the influenza procedure codes 90672 and 90694.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11837– National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer
Effective for dates of service on and after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician, and when specific requirements are met. Make sure that your billing staffs are aware of these changes.

September 15, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11963 – October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
This article is based on change request 11963 that informs you about the changes to and billing instructions for various payment policies implemented in the October 2020 ASC payment system update. As appropriate, this notification also includes updates to the HCPCS. Make sure that your billing staffs are aware of these changes.

September 11, 2020

Special Edition – Friday, September 11, 2020

Provider Education Message:

Community Health Access and Rural Transformation Model

The CMS Innovation Center announced the Community Health Access and Rural Transformation (CHART) Model.

The approximately 57 million Americans living in rural communities, including millions of Medicare and Medicaid beneficiaries, face unique challenges when seeking health care services, such as limited transportation options, shortages of health care services, and an inability to fully benefit from technological and care-delivery innovations.

Current regulations and volume-based payment structures perpetuate these challenges, with unsustainable financial models leading to over 130 rural hospitals closing since 2010. The constellation of reduced access to care and patients not seeking or delaying care leads to rural Americans facing worse health outcomes and having higher rates of preventable diseases than those living in urban areas.

CMS remains focused on the transformation of rural health care delivery and enabling local community collaboration to redesign their systems of care and align across providers and payers based on their unique needs. As part of that rural transformation, including transforming a system built on fee-for-service and volume to one based on value, CMS is testing the CHART Model.

Through the Model, CMS is directly providing a pool of $75M in upfront, seed funding, with 15 rural communities applying for up to $5M to develop local transformation plans. With this upfront seed funding, CMS is also providing regulatory and operational flexibility for updated service delivery models as well as changing how participating hospitals in these communities are paid, from a system based on volume to stable, monthly payments. In additional to supporting these 15 rural communities, CMS is also looking for 20 rural Accountable Care Organizations (ACOs) to participate in the model, paying shared savings upfront so that ACOs have infrastructure funding to be successful on the move towards achieving better outcomes. Taken together, these are substantial and tangible actions to support health care in our rural communities.

Specifically, the CHART Model will:

Increase financial stability for rural health care providers through multiple new funding approaches, including the use of up-front investments and predictable, capitated payments that pay for quality and patient outcomes over volume
Provide the necessary operational and regulatory flexibilities to allow health care providers and CMS to test the Model in their local communities and successfully transform themselves
Support local rural communities’ transformation efforts by being directly engaged at CMS, offering real-time technical expertise and other learning when needed to foster success

If successful, beneficiaries’ access to health care services should be improved, rural provider’s financial sustainability should increase for years to come, and communities can align with payers and other stakeholders to address both their health care service delivery ecosystem and the necessary social support structures, such as food and housing, to deliver improved health. Ultimately, the CHART Model aims to improve quality and health, while reducing Medicare and Medicaid expenditures, in rural communities over the long-term.

CMS is providing funding, regulatory and operational flexibilities, and technical assistance for rural communities to transform their systems of care through a Community Transformation Track. Further, CMS is enabling providers to participate in value-based payment models where they are paid for quality and outcomes, instead of volume, through an ACO Transformation Track.

CMS anticipates the Notice of Funding Opportunity for the Community Transformation Track will be available in September on the Model website. The Request for Application for the ACO Transformation Track will be available in early 2021 on the CHART Model website.

See the full text of this excerpted CMS Fact Sheet (issued August 11).


September 10, 2020

CMS Provider Education Message:

CMS Care Compare Empowers Patients

MLN Connects® for Thursday, September 10, 2020

View this edition as a PDF

News

CMS Care Compare Empowers Patients When Making Important Health Care Decisions
Open Payments: Adding 5 Provider Types in 2021
Breast Re-Excision: Comparative Billing Report in September

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call — September 10
Dementia Care Call — September 22

MLN Matters® Articles

October 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2021
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2021
Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19
Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries
National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP) — Revised

Publications

Understanding Your Remittance Advice Reports
Home Health, Hospice, IRF, LTCH, & SNF Quality Reporting Programs: COVID-19 Public Reporting

Multimedia

Pain Management Listening Session: Audio Recording & Transcript
Introduction to the LTCH Quality Reporting Program Web-Based Training
Introduction to the Home Health Quality Reporting Program Web-Based Training

August 2020 top claim submission errors

The August 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.


September 8, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11935 – Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19
Change request 11935 removes the reference to Electrocardiogram services in the Medicare Claims Processing Manual, chapter 16, section 60.1.2 and, chapter 26, section 10.4, item 19. This change only clarifies existing content and no policy, processing, or system changes are anticipated.

September 3, 2020

CMS Provider Education Message:

CMS Acts to Spur Innovation for America’s Seniors

MLN Connects® for Thursday, September 3, 2020

View this edition as a PDF

News

CMS Acts to Spur Innovation for America’s Seniors
Hospital Opioid Toolkit
CMS Offers Comprehensive Support for California due to Wildfires
PEPPERs for Short-term Acute Care Hospitals
Office Visits by Nurse Practitioners: Comparative Billing Report

Events

Dementia Care Call — September 22

MLN Matters® Articles

2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
Annual Clotting Factor Furnishing Fee Update 2021
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
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2021
The Intravenous Immune Globulin (IVIG) Demonstration: Demonstration is ending on December 31, 2020
October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3
October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised
Update to the International Classification of Diseases, Tenth Revision (ICD-10) Diagnosis Codes for Vaping Related Disorder and Diagnosis and Procedure Codes for the 2019 Novel Coronavirus (COVID-19) — Revised

Publications

Medicare Preventive Services — Revised
Medicare Preventive Services Poster — Revised

September 2, 2020

Special Edition – Wednesday, September 2, 2020

Provider Education Message:

CMS Advancing Seniors’ Access to Cutting-edge Therapies and Technology in Medicare Hospital Rule

Finalized policy changes expand new technology add-on payment pathway for certain antimicrobials

On September 2, CMS issued the FY 2021 Medicare Hospital Inpatient Prospective Payment System and Long Term Acute Care Hospital (LTCH) final rule, which includes important provisions designed to ensure access to potentially life-saving diagnostics and therapies for hospitalized Medicare beneficiaries. The changes will affect approximately 3,200 acute care hospitals and approximately 360 LTCHs. CMS estimates that total Medicare spending on acute care inpatient hospital services will increase by about $3.5 billion in FY 2021, or 2.7 percent.

“President Trump is committed to ensuring that seniors on Medicare have access to the latest life-saving diagnostics and therapies,” said CMS Administrator Seema Verma. “This rule is another critical step in our effort to modernize the program and strip away bureaucratic barriers between our seniors and the latest innovative treatments.”  

CMS’ rule creates a new Medicare Severity Diagnostic Related Group (MS-DRG) that provides a predictable payment to help adequately compensate hospitals for administering Chimeric Antigen Receptor (CAR) T-cell therapies. The current FDA-approved CAR-T-cell cancer therapies use a patient’s genetically modified immune cells to treat specific types of cancer.

Also in the final rule, CMS approved a record number of 24 New Technology Add-on Payments (NTAPs), which is an additional payment to hospitals for cases involving eligible new and relatively high cost technologies. Last year, to remove barriers to innovation, CMS established alternative streamlined pathways for FDA Breakthrough Devices and FDA Qualified Infectious Disease Products (QIDPs) to qualify for NTAPs. Among CMS’ approval of these 24 additional NTAPs are two technologies for new medical devices that are part of the FDA’s Breakthrough Devices Program and six technologies that received FDA QIDP designation. This will provide additional Medicare payment for these technologies while real-world evidence is emerging, giving Medicare beneficiaries timely access to the latest innovations.

CMS is also expanding the add-on payment alternative pathway for antimicrobial products approved under FDA’s Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD pathway), which encourages the development of safe and effective drug products that address unmet needs of patients with serious bacterial and fungal infections. Specifically, an antibacterial or antifungal drug approved under the LPAD pathway is used to treat a serious or life-threatening infection in a limited population of patients with unmet needs.

CMS is also taking steps to ensure that the Medicare Fee-for-Service (FFS) program adopts pricing strategies based on real world market forces. Medicare generally pays hospitals a rate that is weighted by the relative cost of providing certain services based on a patient's diagnosis. These weights are currently based in large part on the charges that hospitals report to the federal government, which often have little relevancy to the actual rates paid by insurance companies. Hospitals are already required to report these negotiated rates as part of the Trump Administration’s efforts to promote price transparency, and CMS is now finalizing a requirement for hospitals to report to CMS the median rate negotiated with Medicare Advantage Organizations for inpatient services to use instead of the charge based data. CMS will begin to collect this data in 2021 and will use it in the methodology for calculating inpatient hospital payments beginning in 2024. These provisions will introduce the influences of market competition into hospital payment and help advance CMS's goal of utilizing market- based pricing strategies in the Medicare FFS program.

For More Information:

Final Rule
Fact Sheet

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11755 – National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)
The Centers for Medicare & Medicaid Services revised this article on August 28, 2020, to reflect an updated change request 11755 that provides revised messaging (page 3 in this article). It also revised the Claims Processing Manual at Section 410.4. All other information remains the same.

September 1, 2020

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

Join us for our upcoming webinars to learn more about the PA for certain hospital OPD services program and to review common issues that have contributed to dismissal or nonaffirmation of PA requests. In addition, each webinar will focus on one of the five categories below requiring the PA as a condition of payment for dates of service (DOS) on or after July 1, 2020, by reviewing documentation and medical necessity guidelines.

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

To register for the upcoming webinars, visit our Educational Event Calendar (JH ) (JL).


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11796 – Claim Status Category and Claim Status Codes Updates
This article informs you of updates to 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. Please make sure your billing staffs are aware of these updates.
MM11852 – 2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
This article informs you that the Centers for Medicare & Medicaid Services will provide Medicare administrative contractors with files for the automated payments of HPSA bonuses for dates of service January 1, 2021, through December 31, 2021. Make sure that your billing staffs are aware of these changes.
MM11881 – 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 that Medicare will update its claims processing 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, which will be published on or about October 1, 2020. Make sure that your billing staffs are aware of these updates.
MM11932 – Annual Clotting Factor Furnishing Fee Update 2021
This article informs you that the clotting factor furnishing fee for 2021 is $0.238 per unit. Make sure your billing staffs are aware of the update to the annual clotting factor furnishing fee for 2021, which pertains to Chapter 17, Section 80.4.1 of the Medicare Claims Processing Manual.
MM11944 – October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3
This article discusses changes to the October 2020 version of the I/OCE instructions and specifications for the Integrated OCE that Medicare uses:
Under the outpatient prospective payment system (OPPS) and non-OPPS for hospital outpatient departments, community mental health centers and all non-OPPS providers.
For limited services when provided in a home health agency not under the home health prospective payment system.
For a hospice patient for the treatment of a non-terminal illness.
Make sure your billing staffs are aware of these changes.
MM11956 – October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
CR 11956 informs Durable Medical Equipment MACs about the changes to the DMEPOS fee schedules that Medicare updates quarterly, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Make sure your billing staffs are aware of these changes.

August 28, 2020

Special Edition – Friday, August 28, 2020

Provider Education Message:

CMS Offers Comprehensive Support for Louisiana and Texas with Hurricane Laura

On August 27, CMS announced efforts underway to support Louisiana and Texas in response to Hurricane Laura. On August 26, 2020, Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies (PHEs) in these states, retroactive to August 22, 2020 for the state of Louisiana and to August 23, 2020 for the state of Texas. CMS is working to ensure hospitals and other facilities can continue operations and provide access to care despite the effects of Hurricane Laura.

CMS provided numerous waivers to health care providers during the current coronavirus disease 2019 (COVID-19) pandemic to meet the needs of beneficiaries and providers. The waivers already in place will be available to health care providers to use during the duration of the COVID-19 PHE determination timeframe and for the Hurricane Laura PHE. CMS may waive certain additional Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements, create special enrollment opportunities for individuals to access healthcare quickly, and take steps to ensure dialysis patients obtain critical life-saving services.

“Our thoughts are with everyone who is in the path of this powerful and dangerous hurricane and CMS is doing everything within its authority to provide assistance and relief to all who are affected,” said CMS Administrator Seema Verma. “We will partner and coordinate with state, federal, and local officials to make sure that in the midst of all of the uncertainty a natural disaster can bring, our beneficiaries will not have to worry about access to healthcare and other crucial life-saving and sustaining services they may need.”

Below are key administrative actions CMS will be taking in response to the PHEs declared in Louisiana and Texas: 

Waivers and Flexibilities for Hospitals and Other Healthcare Facilities: CMS has already waived many Medicare, Medicaid, and CHIP requirements for facilities. The CMS Dallas Survey & Enforcement Division, under the Survey Operations Group, will grant other provider-specific requests for specific types of hospitals and other facilities in Louisiana and Texas. These waivers, once issued, will help provide continued access to care for beneficiaries. For more information on the waivers CMS has granted, visit www.cms.gov/emergency.

Special Enrollment Opportunities for Hurricane Victims: CMS will make available special enrollment periods for certain Medicare beneficiaries and certain individuals seeking health plans offered through the Federal Health Insurance Exchange. This gives people impacted by the hurricane the opportunity to change their Medicare health and prescription drug plans and gain access to health coverage on the Exchange if eligible for the special enrollment period. For more information, please visit:

https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/8-9-natural-disaster-SEP.pdf
https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Past-Emergencies/Hurricanes-and-tropical-storms.html

Disaster Preparedness Toolkit for State Medicaid Agencies: CMS developed an inventory of Medicaid and CHIP flexibilities and authorities available to states in the event of a disaster. For more information and to access the toolkit, visit: https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/index.html.

Dialysis Care: CMS is helping patients obtain access to critical life-saving services. The Kidney Community Emergency Response (KCER) program has been activated and is working with the End Stage Renal Disease (ESRD) Network, Network 13 – Louisiana, and Network 14 - Texas, to assess the status of dialysis facilities in the potentially impacted areas related to generators, alternate water supplies, education and materials for patients and more.

The KCER is also assisting patients who evacuated ahead of the storm to receive dialysis services in the location to which they evacuated. Patients have been educated to have an emergency supply kit on hand including important personal, medical, and insurance information; contact information for their facility, the ESRD Network hotline number, and contact information of those with whom they may stay or for out-of-state contacts in a waterproof bag. They have also been instructed to have supplies on hand to follow a three-day emergency diet. The ESRD Network 8 – Mississippi hotline is 1-800-638-8299, Network 13 – Louisiana hotline is 800-472-7139, the ESRD Network 14 - Texas hotline is 877-886-4435, and the KCER hotline is 866-901-3773. Additional information is available on the KCER website https://www.kcercoalition.com/.

During the 2017 and 2018 hurricane seasons, CMS approved special purpose renal dialysis facilities in several states to furnish dialysis on a short-term basis at designated locations to serve ESRD patients under emergency circumstances in which there were limited dialysis resources or access-to-care problems due to the emergency circumstances. 

Medical equipment and supplies replacements: Under the COVD-19 waivers, CMS suspended certain requirements necessary for Medicare beneficiaries who have lost or realized damage to their durable medical equipment, prosthetics, orthotics, and supplies as a result of the PHE. This will help to make sure that beneficiaries can continue to access the needed medical equipment and supplies they rely on each day. Medicare beneficiaries can contact 1-800-MEDICARE (1-800-633-4227) for assistance. 

Ensuring Access to Care in Medicare Advantage and Part D: During a public health emergency, Medicare Advantage Organizations and Part D Plan sponsors must take steps to maintain access to covered benefits for beneficiaries in affected areas. These steps include allowing Part A/B and supplemental Part C plan benefits to be furnished at specified non-contracted facilities and waiving, in full, requirements for gatekeeper referrals where applicable.

Emergency Preparedness Requirements: Providers and suppliers are expected to have emergency preparedness programs based on an all-hazards approach. To assist in the understanding of the emergency preparedness requirements, CMS Central Office and the Regional Offices hosted two webinars in 2018 regarding Emergency Preparedness requirements and provider expectations. One was an all provider training on June 19, 2018 with more than 3,000 provider participants and the other an all-surveyor training on August 8, 2018. Both presentations covered the emergency preparedness final rule which included emergency power supply; 1135 waiver process; best practices and lessons learned from past disasters; and helpful resources and more. Both webinars are available at https://qsep.cms.gov/welcome.aspx.

CMS also compiled a list of Frequently Asked Questions (FAQs) and useful national emergency preparedness resources to assist state Survey Agencies (SAs), their state, tribal, regional, local emergency management partners and health care providers to develop effective and robust emergency plans and tool kits to assure compliance with the emergency preparedness rules.  The tools can be located at:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Templates-Checklists.html

CMS Regional Offices have provided specific emergency preparedness information to Medicare providers and suppliers through meetings, dialogue, and presentations. The regional offices also provide regular technical assistance in emergency preparedness to state agencies and staff, who, since November 2017, have been regularly surveying providers and suppliers for compliance with emergency preparedness regulations. 

Additional information on the emergency preparedness requirements can be found here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf

CMS will continue to work with all geographic areas impacted by Hurricane Laura. We encourage beneficiaries and providers of healthcare services that have been impacted to seek help by visiting CMS’ emergency webpage (www.cms.gov/emergency).

For more information about the HHS PHE, please visit:

https://www.hhs.gov/about/news/2020/08/26/hhs-secretary-azar-declares-public-health-emergencies-in-louisiana-and-texas-due-to-hurricane-laura.html.


Updated Financial & overpayment / Refund forms

Novitas has updated Financial & overpayment / Refund forms to help stream line the process. Please review the new forms as well as instructions provided.

Return of Monies to Medicare form (8322) (Part B)
Extended Repayment Plan (ERP) Form - Not a Sole Proprietor
Extended Repayment Plan (ERP) Form - Sole Proprietor

If you have any questions on the overpayment processes please visit our web page Medicare Overpayments.


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 the article to add information about the HCPCS codes for outpatient prospective payment system, rural health clinic, federally qualified health center, and critical access hospital billers in the Families First Coronavirus Response Act waives coinsurance and deductibles for additional COVID-19 related services section. All other information remains the same.

August 27, 2020

CMS Provider Education Message:

COVID-19: Training to Strengthen Nursing Home Infection Control Practices

MLN Connects® for Thursday, August 27, 2020

View this edition as a PDF

News

Trump Administration Launches National Training Program to Strengthen Nursing Home Infection Control Practices
SNF Provider Preview Reports: Review Your Data by August 30
COVID: Nursing Home Toolkit
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

COVID-19: Waive Cost Sharing for These HCPCS Codes

MLN Matters® Articles

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021 — Revised
October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files — Revised

Publications

Creating an Effective Hospice Plan of Care

Multimedia

Physician Fee Schedule Listening Session: Audio Recording and Transcript

The following Proposed Local Coverage Determination (LCD) has been posted for comments. The comment period will end on October 10, 2020, however you are encouraged to submit your comments as soon as possible.

Colon Capsule Endoscopy (CCE) (DL38807)
Submit Comments

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

Billing and Coding: Colon Capsule Endoscopy (CCE) (DA58414)

The following Local Coverage Determination (LCD) posted for comment on April 30, 2020 has been posted for notice. The LCD and related Billing and Coding Article will become effective October 11, 2020:

Implantable Continuous Glucose Monitors (I-CGM) (L38617)
Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58110)

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

Response to Comments: Implantable Continuous Glucose Monitors (I-CGM) (A58415)

The following Future Billing and Coding Article, which will replace the current Billing and Coding Article: Chiropractic Services (A52987), has been published and will become effective October 01, 2020:

Billing and Coding: Chiropractic Services (A58345)

The following LCDs and related Billing and Coding Articles have been retired:

Hyperbaric Oxygen (HBO) Therapy (L35021)
Billing and Coding: Hyperbaric Oxygen (HBO) Therapy (A56714)
Reflectance Confocal Microscopy (L37375)
Billing and Coding: Reflectance Confocal Microscopy (A56969)

Online Registration Available for September 11, 2020, Open Meeting and Proposed LCD Now Posted

Online registration for the September 11, 2020, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, September 9, 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.


August 26, 2020

Practitioners! Are you ordering oxygen for your patients?

This is your opportunity to hear directly from the Medicare administrative contractors (MACs). This session will focus on:

Practitioner role in documenting clinical need for oxygen
Testing requirements
Effects from COVID-19 public health emergency

Representatives from the four durable medical equipment (DME) MACs will join your regular A/B education staff to bring you this webinar with the objective of increasing practitioner understanding for required clinical documentation. It is our hope that this information will ease practitioner burden and assist in making it a smoother process for your patients to obtain the oxygen that is prescribed.

Register here


August 25, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11937 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
CMS revised this article on August 24, 2020, to reflect an updated change request (CR) 11937 that includes additional COVID-19 codes 86408, 86409, 0225U, 0226U, effective August 10, 2020. CR 11937 also added codes 0015M and 0016M, effective October 1, 2020. The CR release date, transmittal number and link to the transmittal also changed. All other information remains the same.

August 21, 2020

July 2020 top claim submission errors

The July 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.


August 20, 2020

CMS Provider Education Message:

Routine Provider Inspections Resume

MLN Connects® for Thursday, August 20, 2020

View this edition as a PDF

News

CMS Announces Resumption of Routine Inspections of All Provider and Suppliers, Issues Updated Enforcement Guidance to States, and Posts Toolkit to Assist Nursing Homes
Reduce Provider Burden: Electronic Medical Documentation Interoperability Pilot Program

Events

CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Homes: New Format

MLN Matters® Articles

New COVID-19 Policies for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act— Revised

Publications

Enhancing RN Supervision of Hospice Aide Services

Multimedia

Medicare Secondary Payer (MSP) Provision (June 2020)

OTP claim submission errors

The Opioid treatment program claim submission errors have been updated.  Please take time to review these errors to ensure claims are billed and paid correctly. 


August 19, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11854 – October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
The Centers for Medicare & Medicaid Services (CMS) revised this article to reflect a revised change request (CR) 11854 issued on August 14, 2020. The revised CR did not change the substance of the article. CMS revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

August 18, 2020

Reminder: Roster billing for Part B providers

The new standard roster billing forms for the flu vaccine and pneumococcal vaccine services are available on our website along with an example of the CMS-1500 claim form. Claims will be returned as unprocessable when the standard roster billing forms are not submitted with the CMS-1500 (02/12) claim form or if the roster billing forms/CMS-1500 claim forms.


August 17, 2020

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

The July 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions..


August 14, 2020

POE A/B MAC Medicare Secondary Payer (MSP) series question and answer document

Novitas, in collaboration with the A/B Medicare administrative contractor (MAC) Provider Outreach & Education (POE) Collaboration Team, developed a question and answer document based on questions received during the MSP series event. 


August 13, 2020

CMS Provider Education Message:

COVID-19: CMS/CDC Nursing Home Training Series Webcast – August 13

MLN Connects® for Thursday, August 13, 2020

View this edition as a PDF

News

Trump Administration Announces Initiative to Transform Rural Health
Physician Compare Preview Period Open through August 20
Management of Acute and Chronic Pain – Stakeholder Engagement Opportunity: Reply by August 21
SNF Provider Preview Reports: Review Your Data by August 30
PEPPERs for HHAs and PHPs
Hospitals: Three Year Geographic Reclassification Data for FY 2022 MGCRB Applications
Opioids: Co-Prescribing Naloxone

Events

National CMS/CDC Nursing Home COVID-19 Training Series Webcast — August 13
Dr. Todd Graham Pain Management Study Listening Session — August 27

MLN Matters® Articles

Billing for Home Infusion Therapy Services On or After January 1, 2021
Correction to Editing Update for Vaccine Services
International Classification of Diseases, 10th Revision (ICD10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2021 Update
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update
Update to Osteoporosis Drug Codes Billable on Home Health Claims
Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season — Revised

Multimedia

HQRP Training Resources Web-Based Training Course

The following Billing and Coding Article has been revised, consistent with CPT guidelines, to clarify that non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes should not be reported with skin replacement surgery application codes. Claims received on and after August 13, 2020 reporting non-graft wound dressings with a surgery application code will be rejected.

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

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

Cardiac Rhythm Device Evaluation (L34833)
Speech-Language Pathology (SLP) Services: Communication Disorders (L35070)

The following Billing and Coding Articles have been revised:

Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (A56642)
Non-Invasive Peripheral Venous Studies (A52993)

The following LCDs and their related Billing and Coding Articles have been retired:

Molecular Diagnostics: Genitourinary Infectious Disease Testing (L35015)
Billing and Coding: Molecular Diagnostics: Genitourinary Infectious Disease Testing (A56791)
Sacral Nerve Stimulation (L35449)
Billing and Coding: Sacral Nerve Stimulation (A57617)

August 11, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11880 – Billing for Home Infusion Therapy Services On or After January 1, 2021
This article provides guidance to providers and suppliers about claims processing systems changes necessary to implement Section 5012(d) of the 21st Century Cures Act. These changes are effective on and after January 1, 2021. Make sure that your billing staff is aware of these changes.
MM11937 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
This article informs laboratories of changes resulting from the quarterly update to the clinical laboratory fee schedule. Please be sure your billing staff is aware of these updates.

August 10, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11939 – Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2020 Update
This article informs you about the issuance of updated payment files in the October update of the 2020 MPFS. Make sure your billing staffs are aware of these updates.

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.

Endovenous Stenting (DL37893)
Transurethral Waterjet Ablation of the Prostate (DL38712)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (DL34924)

August 6, 2020

CMS Provider Education Message:

Physician Fee Schedule Proposed Rule Listening Session: Register Now

MLN Connects® for Thursday, August 6, 2020

View this edition as a PDF

News

Electronic Prescribing of Controlled Substances in Medicare Part D: Request for Information
Release of the IRF Web Pricer
Subsequent Nursing Facility E/M Services: Comparative Billing Report
Nursing Home Compare Refresh
Medicare Ground Ambulance Data Collection System: Updated Documents
MACs Resume Medical Review on a Post-Payment Basis
Renewed ABN: Deadline Extended to January 1
COVID-19: Telemedicine, Clinical Experiences, Resources for Hospitals and Urgent Care Centers
Protect Your Patients Against Vaccine-Preventable Diseases

Events

National CMS/CDC Nursing Home COVID-19 Training Series Webcast — August 6
COVID-19: Lessons from the Front Lines Call — August 7
Physician Fee Schedule Proposed Rule: Understanding 4 Key Topics Listening Session — August 13
Dr. Todd Graham Pain Management Study Listening Session — August 27

MLN Matters® Articles

New Waived Tests
Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation

August 5, 2020

Special Edition – Tuesday, August 04, 2020

Provider Education Message:

PFS, OPPS, and IRF: FY 2021 Payment Rules

Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas
Trump Administration Proposes Policies to Provide Seniors with More Choices and Lower Costs for Surgeries
CMS Updates Medicare Payment Policies for IRFs

Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas

CMS is proposing changes to expand telehealth permanently, consistent with the Executive Order on Improving Rural and Telehealth Access that President Trump signed. The Executive Order and proposed rule advance our efforts to improve access and convenience of care for Medicare beneficiaries, particularly those living in rural areas. Additionally, the proposed rule implements a multi-year effort to reduce clinician burden under our Patients Over Paperwork initiative and to ensure appropriate reimbursement for time spent with patients. This proposed rule also takes steps to implement President Trump’s Executive Order on Protecting and Improving Medicare for our Nation’s Seniors and continues our commitment to ensure that the Medicare program is sustainable for future generations.

Expanding Beneficiary Access to Care through Telehealth:

Over the last three years, as part of the Fostering Innovation and Rethinking Rural Health strategic initiatives, CMS has been working to modernize Medicare by unleashing private sector innovations and improve beneficiary access to services furnished via telecommunications technology. Starting in 2019, Medicare began paying for virtual check-ins, meaning patients across the country can briefly connect with doctors by phone or video chat to see whether they need to come in for a visit. In response to the COVID-19 pandemic, CMS moved swiftly to significantly expand payment for telehealth services and implement other flexibilities so that Medicare beneficiaries living in all areas of the country can get convenient and high-quality care from the comfort of their home while avoiding unnecessary exposure to the virus. Before the Public Health Emergency (PHE), only 14,000 beneficiaries received a Medicare telehealth service in a week, while over 10.1 million beneficiaries have received a Medicare telehealth service during the PHE from mid-March through early-July. For more information on Medicare’s unprecedented increases in telemedicine and its impact on the health care delivery system, visit the CMS Health Affairs blog.

As directed by President Trump’s Executive Order on Improving Rural and Telehealth Access, through this rule, CMS is taking steps to extend the availability of certain telemedicine services after the PHE ends, giving Medicare beneficiaries more convenient ways to access health care particularly in rural areas where access to health care providers may otherwise be limited.

“Telemedicine can never fully replace in-person care, but it can complement and enhance in-person care by furnishing one more powerful clinical tool to increase access and choices for Americas seniors,” said CMS Administrator Seema Verma. “The Trump Administration’s unprecedented expansion of telemedicine during the pandemic represents a revolution in health care delivery, one to which the health care system has adapted quickly and effectively. Never one merely to tinker around the edges when it comes to patient-centered care, President Trump will not let this opportunity slip through our fingers.”

During the PHE, CMS added 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services that could be paid when delivered by telehealth. CMS is proposing to permanently allow some of those services to be done by telehealth, including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home) and certain types of visits for patients with cognitive impairments. CMS is seeking public input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services, such as emergency department visits for a specific time period, through the calendar year in which the PHE ends. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.

Prioritizing Investment in Preventive Care and Chronic Disease Management:

Under our Patients Over Paperwork initiative, the Trump Administration has taken steps to eliminate burdensome billing and coding requirements for Evaluation and Management (E/M) (for office/outpatient visits) that make up 20 percent of the spending under the Physician Fee Schedule. These billing and documentation requirements for E/M codes were established 20 years ago and have been subject to longstanding criticism from clinicians that they do not reflect current care practices and needs. After extensive stakeholder collaboration with the American Medical Association and others, simplified coding and billing requirements for E/M visits will go into effect January 1, 2021, saving clinicians 2.3 million hours per year in burden reduction. As a result of this change, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients.

Additionally, last year, the Trump Administration finalized historic changes to increase payment rates for office/outpatient E/M visits beginning in 2021. The higher payment for E/M visits takes into account the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of their Medicare patients, of which two-thirds have multiple chronic conditions. The prevalence of certain chronic conditions in the Medicare population is growing. For example, as of 2018, 68.9% of beneficiaries have 2 or more chronic conditions. In addition, between 2014 and 2018, the percent of beneficiaries with 6 or more chronic conditions has grown from 14.3% to 17.7%.

In this rule, CMS is proposing to similarly increase the value of many services that are comparable to or include office/outpatient E/M visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services, and others. The proposed adjustments, which implement recommendations from the American Medical Association, help to ensure that CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients, like primary care and complex or chronic disease management.

Bolstering the Health Care Workforce/Patients Over Paperwork:

CMS is also taking steps to ensure that health care professionals can practice at the top of their professional training. During the COVID-19 public health emergency, CMS announced several temporary changes to expand workforce capacity and reduce clinician burden so that staffing levels remain high in response to the pandemic. As part of its Patients over Paperwork initiative to reduce regulatory burden for providers, CMS is proposing to make some of these temporary changes permanent following the PHE. Such proposed changes include:

Nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law
Clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare
Allowing physical and occupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings
Allowing physical or occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient’s medical record

For More Information:

CY 2021 Physician Fee Schedule and Quality Payment Program Proposed Rule: Public comments are due by October 5, 2020.
CY 2021 Physician Fee Schedule Proposed Rule Fact Sheet
CY 2021 Quality Payment Program Proposed Rule Fact Sheet
Medicare Diabetes Prevention Program Fact Sheet

Trump Administration Proposes Policies to Provide Seniors with More Choices and Lower Costs for Surgeries

Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule advances CMS’ commitment to increasing competition

As directed by President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, CMS is proposing several policies that would give Medicare beneficiaries more choices in where they seek care and lower their out-of-pocket costs for surgeries. The proposed rule takes steps that would allow hospitals and ambulatory surgical centers to operate with better flexibility and patients to have what they need to make informed decisions on where they receive care.

“President Trump’s mandate is to put patients and doctors back in charge of health care,” said CMS Administrator Seema Verma. “Following through on that mandate entails loosening the stranglehold of government control that has accumulated over decades. Surgeries can be expensive. Patients should have as many options as possible for lowering their costs while getting quality care. These proposed changes, if finalized, would do exactly that, help put patients and doctors back in the driver’s seat and in a position to make decisions about their own care."

For patients having surgery, hospital outpatient departments are subject to the same quality and safety standards as inpatient settings under Medicare rules. With this in mind, for 2021, CMS proposes to expand the number of procedures that Medicare would pay for in the hospital outpatient setting by eliminating the “Inpatient Only list,” which includes procedures for which Medicare will only make payment when performed in the hospital inpatient setting. This proposed change would remove regulatory barriers to give beneficiaries the choice to receive these services in a lower cost setting and convenience to go home as early as the same day after a procedure, when their clinician decides such a setting is appropriate. CMS would phase-in this proposal over three years and would gradually allow over 1,700 additional services to be paid when furnished in the hospital outpatient setting. In 2021, approximately 300 musculoskeletal services (such as certain joint replacement procedures) would be newly payable in the hospital outpatient setting. The proposed change would be the largest one-time reduction to the Inpatient Only list by far; from 2017 through 2020, approximately 30 services total were removed from the Inpatient Only list.

Medicare pays for most services furnished in ASCs at a lower rate than hospital outpatient departments. As a result, when receiving care in an ASC rather than a hospital outpatient department, patients can potentially lower their out-of-pocket costs for certain services. For example, for one of the most common cataract surgeries, currently, on average, a Medicare beneficiary pays $101 if the procedure is done in a hospital outpatient department compared to $51 if done in a surgery center.

CMS proposes to expand the number of procedures that Medicare would pay for when performed in an ASC, which would give patients more choices in where they receive care and ensure CMS does not favor one type of care setting over another. For CY 2021, we propose to add eleven procedures that Medicare would pay for when provided in an ASC, including total hip arthroplasty. Since 2018, CMS has added 28 procedures to the list of surgical services that can be paid under Medicare when performed in ASCs.

Additionally, we propose two alternatives that would further expand our goals of increasing access to care at a lower cost. Under the first alternative, CMS would establish a process where the public could nominate additional services that could be performed in ASCs based on certain quality and safety parameters. Under the other proposed alternative, we would revise the criteria used to determine the procedures that Medicare would pay for in an ASC, potentially adding approximately 270 procedures that are already payable when performed in the hospital outpatient setting to the ASC list. Under this alternative, we solicit comment on whether the ASC conditions for coverage (the baseline health and safety requirements for Medicare-participating ASCs) should be revised given the potential for a significant expansion in the nature of services that would be added under this alternative proposal.

As part of the Trump Administration’s commitment to lowering drug prices, CMS is proposing a change that would lower beneficiaries’ out-of-pocket drug costs for certain hospital outpatient drugs. In 2018 and 2019, CMS implemented a payment policy to help beneficiaries save on coinsurance for drugs that were administered at hospital outpatient departments and acquired through the 340B program, which allows certain hospitals to buy outpatient drugs at lower costs. Due to CMS’ policy change, which was recently upheld by the United States Court of Appeals for the D.C Circuit, Medicare beneficiaries now benefit from the steep discounts that 340B-enrolled hospitals receive when they purchase drugs through the 340B program.

For 2021, CMS would provide even larger discounts for beneficiaries by proposing to further reduce the payment rate for drugs purchased through the 340B Program based on hospital survey data on drug acquisition costs. CMS is proposing to pay for 340B acquired drugs at average sales price minus 28.7 percent. With this proposed change, CMS estimates that, in 2021, Medicare beneficiaries would save an additional $85 million on out-of-pocket payments for these drugs and that OPPS payments for 340B drugs would be reduced by approximately $427 million. The savings from this change would be reallocated on an equal percentage basis to all hospitals paid under the OPPS. We propose that children’s hospitals, certain cancer hospitals, and rural sole community hospitals would continue be excepted from these drug payment reductions. In the alternative, and in light of the court’s recent decision, we propose to continue our current policy of paying ASP minus 22.5% for 340B drugs.

In continuing the agency’s Patients Over Paperwork Initiative to reduce burden for health care providers, CMS is proposing to establish, update, and simplify the methodology to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with CY 2021. The Overall Star Rating summarizes a variety of quality measures published on the Medicare.gov Hospital Compare tool for common conditions that hospitals treat, such as heart attacks or pneumonia. Along with publicly reported data on Hospital Compare, the Overall Star Rating helps patients make better informed health care decisions.

Responding to stakeholder feedback about the current methodology used to calculate the Overall Star Rating, CMS is proposing revisions on how to calculate the ratings and grouping hospitals in the Readmission measure group by the hospital’s percentage of patients who are dually enrolled in Medicare and Medicaid, which would help provide better insight on health disparities. These and other proposed changes are intended to reduce provider burden, improve the predictability of the star ratings, and make it easier to compare ratings between similar hospitals.

As part of the agency’s Rethinking Rural Health Initiative, in the FY 2020 Inpatient Prospective Payment System (IPPS) final rule, CMS increased the wage index for certain low wage index hospitals for at least four years, beginning in FY 2020. In the CY 2020 OPPS/ASC Payment System final rule, CMS adopted changes to the wage index for outpatient hospitals as were finalized in the FY 2020 IPPS final rule, including the increase in wage index for certain low wage index hospitals. The OPPS wage index adjusts hospital outpatient payment rates to account for local differences in wages that hospitals face in their respective labor markets. For 2021, under the OPPS, CMS proposes to continue to adopt the IPPS post-reclassified wage index, including the wage index increase for certain low wage index hospitals. The increase would address a common concern that the current wage index system contributes to disparities between high and low wage index hospitals. Overall, CMS estimates that payment for outpatient services in rural hospitals across the country would increase by 3 percent, which is 0.5 percent higher than the national average increase of 2.5 percent.

For More Information:

Proposed Rule
Fact Sheet

CMS Updates Medicare Payment Policies for IRFs

On August 4, CMS finalized a Medicare payment rule that further advances our efforts to strengthen the Medicare program by better aligning payments for Inpatient Rehabilitation Facilities (IRFs). The final rule updates Medicare payment policies and rates for facilities under the IRF Prospective Payment System (PPS) for FY 2021. This final rule also includes making permanent the regulatory change to eliminate the requirement for physicians to conduct a post admission visit since much of the information is included in the pre-admission visit. This flexibility was offered during the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE), and the rule would make this flexibility permanent beyond the expiration of the PHE. In recognition of the interdisciplinary role that non-physician practitioners are currently performing with patients in the IRF, CMS is also finalizing that a non-physician practitioner may perform one of the three required visits in lieu of the physician in the second and later weeks of a patient’s care when consistent with the non-physician practitioner’s state scope of practice. Additionally, for FY 2021, CMS is updating the IRF PPS payment rates by 2.4 percent.  

For More Information:

Final Rule
Fact Sheet

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11905 – International Classification of Diseases, 10th Revision (ICD10) and Other Coding Revisions to National Coverage Determination (NCDs)--January 2021 Update
This article 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.

Revised:

MM11882 – Influenza Vaccine Payment Allowances – Annual Update for 2020-2021 Season
The Centers for Medicare & Medicaid Services revised this article on July 31, 2020, to reflect an updated change request 11882 that extended the implementation date. All other information remains the same.

August 4, 2020

June 2020 top claim submission errors

The June 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.


August 3, 2020

Provider Education Message:

FY 2021 Medicare Payment Policies for IPFs, SNFs, and Hospices

CMS Updates Medicare Payment Policies for IPFs, SNFs, and Hospices
COVID-19: Coverage of Physician Telehealth Services Provided to SNF Residents

CMS Updates Medicare Payment Policies for IPFs, SNFs, and Hospices

On July 31, CMS finalized three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for Inpatient Psychiatric Facilities (IPFs), Skilled Nursing Facilities (SNFs), and hospices.

Inpatient Psychiatric Facilities:

The final rule updates Medicare payment policies and rates for the IPF Prospective Payment System (PPS) for FY 2021. In this final rule, CMS is finalizing a 2.2 percent payment rate update and finalizing its proposal to adopt revised Office of Management and Budget (OMB) statistical area delineations resulting in wage index values being more representative of the actual costs of labor in a given area. CMS is finalizing updates to allow advanced practice providers, including physician assistants, nurse practitioners, psychologists, and clinical nurse specialists to operate within the scope of practice allowed by state law by documenting progress notes in the medical record of patients for whom they are responsible, receiving services in psychiatric hospitals.

Skilled Nursing Facilities:

The final rule updates the Medicare payment rates and the quality programs for SNFs. These updates include routine technical rate-setting updates to the SNF PPS payment rates, as well as finalizes adoption of the most recent OMB statistical area delineations and applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021. CMS is also finalizing changes to the ICD-10 code mappings that would be effective beginning in FY 2021 in response to stakeholder feedback. CMS projects aggregate payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021, compared to FY 2020.

Hospices:

For FY 2021, hospice payment rates are updated by the market basket percentage increase of 2.4 percent ($540 million). Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual market basket percentage increase for the year. The hospice payment system includes a statutory aggregate cap. The aggregate cap limits the overall payments made to a hospice annually. The final hospice cap amount for the FY 2021 cap year is $30,683.93, which is equal to the FY 2020 cap amount ($29,964.78) updated by the final FY 2021 hospice payment update percentage of 2.4 percent.

For More Information:

PF Final Rule and Fact Sheet
SNF Final Rule and Fact Sheet
Hospice Final Rule and Fact Sheet

COVID-19: Coverage of Physician Telehealth Services Provided to SNF Residents

The current COVID-19 Public Health Emergency (PHE) does not waive any requirements related to Skilled Nursing Facility (SNF) Consolidated Billing (CB); however, CMS added CPT codes 99441, 99442, and 99443, to the list of telehealth codes coverable under the waiver during the COVID-19 PHE. These codes designate three different time increments of telephone evaluation and management service provided by a physician. You can bill for these physician services separately under Part B when furnished to a SNF’s Part A resident.

Medicare Administrative Contractors (MACs) will reprocess claims for CPT codes 99441, 99442, and 99443 with dates of service on or after March 1, 2020, that were denied due to SNF CB edits. You do not have to do anything. If you already received payment from the SNF for these physician services, return that payment to the SNF once the MAC reprocesses your claim.


July 31, 2020

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 the article on July 30, 2020, to add the section “Counseling and COVID-19 Testing." All other information remains the same.

July 30, 2020

Special Edition – Thursday, July 30, 2020

Provider Education Message:

Payment for COVID-19 Counseling, Reporting Hospital Therapeutics, Out-of-Pocket Drug Costs

CMS and CDC Announce Provider Reimbursement Available for Counseling Patients to Self-Isolate at Time of COVID-19 Testing
CMS Announces New Hospital Procedure Codes for Therapeutics in Response to the COVID-19 Public Health Emergency
Trump Administration Continues to Keep Out-of-Pocket Drug Costs Low for Seniors

CMS and CDC Announce Provider Reimbursement Available for Counseling Patients to Self-Isolate at Time of COVID-19 Testing

On July 30, CMS and the Centers for Disease Control and Prevention (CDC) are announcing that payment is available to physicians and health care providers to counsel patients, at the time of Coronavirus Disease 2019 (COVID-19) testing, about the importance of self-isolation after they are tested and prior to the onset of symptoms. 

The transmission of COVID-19 occurs from both symptomatic, pre-symptomatic, and asymptomatic individuals emphasizing the importance of education on self-isolation as the spread of the virus can be reduced significantly by having patients isolated earlier, while waiting for test results or symptom onset. The CDC models show that when individuals who are tested for the virus are separated from others and placed in quarantine, there can be up to an 86 percent reduction in the transmission of the virus compared to a 40 percent decrease in viral transmission if the person isolates after symptoms arise.

Provider counseling to patients, at the time of their COVID-19 testing, will include the discussion of immediate need for isolation, even before results are available, the importance to inform their immediate household that they too should be tested for COVID-19, and the review of signs and symptoms and services available to them to aid in isolating at home. In addition, they will be counseled that if they test positive, to wear a mask at all times, and they will be contacted by public health authorities and asked to provide information for contact tracing and to tell their immediate household and recent contacts in case it is appropriate for these individuals to be tested for the virus and to self-isolate as well. 

CMS will use existing evaluation and management payment codes to reimburse providers who are eligible to bill CMS for counseling services no matter where a test is administered, including doctor’s offices, urgent care clinics, hospitals, and community drive-thru or pharmacy testing sites.

For More Information:

Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) MLN Matters Special Edition Article SE20011 
Counseling Check List, including resource links

CMS Announces New Hospital Procedure Codes for Therapeutics in Response to the COVID-19 Public Health Emergency

With the emergence of Coronavirus Disease 2019 (COVID-19) and the new treatments that have followed, it is critical to be able to track the use of these treatments and their effectiveness in real-time. CMS responded to this need, and in record time is implementing new procedure codes to allow Medicare and other insurers to identify the use of the therapeutics remdesivir and convalescent plasma for treating hospital in-patients with COVID-19. These new codes, which go into effect August 1, will enable CMS to conduct real-time surveillance and obtain real-world evidence in how these drugs are working and provide critical information on their effectiveness and how they can protect patients. These codes can be reported to Medicare and other insurers may also use the codes to identify the use of COVID-19 therapies and help facilitate monitoring and data collection on their use.

These new codes are being implemented into the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). ICD-10-PCS is the Health Insurance Portability and Accountability Act (HIPAA) designated code set for reporting hospital inpatient procedures, which is developed and maintained by CMS and can be used by other health insurers.

The implementation of these new procedure codes is part of the Trump Administration’s ongoing efforts to protect the health and safety of COVID-19 patients across the country during the public health emergency.    

For more information, see ICD-10 MS-DRGs Version 37.2 Effective August 1.


Trump Administration Continues to Keep Out-of-Pocket Drug Costs Low for Seniors

On July 29, CMS announced the average basic premium for Medicare Part D prescription drug plans, which cover prescription drugs that beneficiaries pick up at a pharmacy. Under the leadership of President Trump, for the first time seniors that use insulin will be able to choose a prescription drug plan in their area that offers a broad set of insulins for no more than $35 per month per prescription.

The average basic Part D premium will be $30.50 in 2021. The 2021 and 2020 average basic premiums are the second lowest and lowest, respectively, average basic premiums in Part D since 2013. This trend of lower Part D premiums, which have decreased by 12 percent since 2017, means that beneficiaries have saved nearly $1.9 billion in premium costs over that time. Further, Part D continues to be an extremely popular program, with enrollment increasing by 16.7 percent since 2017.

“At every turn, the Trump Administration has prioritized policies that introduce choice and competition in Part D,” said CMS Administrator Seema Verma. “The result is lower prices for life-saving drugs like insulin, which will be available to Medicare beneficiaries at this fall’s Open Enrollment for no more than $35 a month. In short, Part D premiums continue to stay at their lowest levels in years even as beneficiaries enjoy a more robust set of options from which to choose a plan that meets their needs.”

In addition to the $1.9 billion in premium savings for beneficiaries since 2017, the Trump Administration has produced substantial Part D program savings for taxpayers. With about 200 additional standalone prescription drug plans and 1,500 additional Medicare Advantage plans with prescription drug coverage joining the program between 2017 and 2020, and that trend expected to continue in 2021, increased market competition has led to lower costs and lower Medicare premium subsidies, which has saved taxpayers approximately $8.5 billion over the past four years.

Earlier this year, CMS launched the Part D Senior Savings Model, which will allow Medicare beneficiaries to choose a plan that provides access to a broad set of insulins at a maximum $35 copay for a month’s supply. Starting January 1, 2021, beneficiaries who select these plans will save, on average, $446 per year, or 66 percent, on their out-of-pocket costs for insulin. Beneficiaries will be able to choose from more than 1,600 participating standalone Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage, all across the country this open enrollment period, which runs from October 15 through December 7. And because the majority of participating Medicare Advantage plans with prescription drug coverage do not charge a Part D premium, beneficiaries who enroll in those plans will save on insulin and not pay any extra premiums.

In January 2020, CMS, through the Part D Payment Modernization Model, offered an innovative new opportunity for Part D plan sponsors to lower costs for beneficiaries, while improving care quality. Under this model, Part D sponsors can better manage prescription drug costs through all phases of the Part D benefit, including the catastrophic phase. Through the use of better tools and program flexibilities, sponsors are better able to negotiate on high cost drugs and design plans that increase access and lower out-of-pocket costs for beneficiaries. For CY 2021, there will be nine plan options in Utah, New Mexico, Idaho and Pennsylvania that participate in this model.

In Medicare Part D, beneficiaries choose the prescription drug plan that best meets their needs, and plans have to improve quality and lower costs to attract beneficiaries. This competitive dynamic sets up clear incentives that drive towards value. CMS has taken steps to modernize the Part D program by providing beneficiaries the opportunity to choose among plans with greater negotiating tools that have been developed in the private market and by providing patients with more transparency on drug prices. Improvements to the Medicare Part D program that CMS has made to date include:

Beginning in 2021, providing more information on out-of-pocket costs for prescription drugs to beneficiaries by requiring Part D plans to provide a real time benefit tool to clinicians with information that they can discuss with patients on out-of-pocket drug costs at the time a prescription is written
Implementing Part D legislation signed by President Trump to prohibit “gag clauses,” which keep pharmacists from telling patients about lower-cost ways to obtain prescription drugs
Beginning in 2021, requiring the Explanation of Benefits document that Part D beneficiaries receive each month to include information on drug price increases and lower-cost therapeutic alternatives
Providing beneficiaries with more drug choices and empowering beneficiaries to select a plan that meets their needs by allowing plans to cover different prescription drugs for different indications, an approach used in the private sector
Reducing the maximum amount that low-income beneficiaries pay for certain innovative medicines known as “biosimilars,” which will lower the out-of-pocket cost of these innovative medicines for these beneficiaries
Empowering Medicare Advantage to negotiate lower costs for physician-administered prescription drugs for seniors for the first time, as well allowing Part D plans to substitute certain generic drugs on plan formularies more quickly during the year, so beneficiaries immediately have access to the generic, which typically has lower cost sharing than the brand
Increasing competition among plans by removing the requirement that certain Part D plans have to “meaningfully differ” from each other, making more plan options available for beneficiaries

For More Information:

Part D Senior Savings Model webpage
Ratebooks & Supporting Data webpage: View the 2021 Part D base beneficiary premium, the Part D national average monthly bid amount, the Part D regional low-income premium subsidy amounts, the de minimis amount, the Medicare Advantage employer group waiver plan regional payment rates, and the Medicare Advantage regional PPO benchmarks

CMS Provider Education Message:

COVID-19 Impacts on Medicare Beneficiaries – Updated Data

MLN Connects® for Thursday, July 30, 2020

View this edition as a PDF

News

CMS Updates Data on COVID-19 Impacts on Medicare Beneficiaries
Short-Term Acute Care Hospitals: Submit Occupational Mix Surveys by September 3
PEPPERs for SNFs, Hospices, IRFs, IPFs, CAHs, and LTCHs
Hospice Quality Reporting Program: HART v1.6.0
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

COVID-19: Laboratory Claims Requiring the NPI of the Ordering/Referring Professional — Update
Medicare Diabetes Prevention Program: Valid Claims

Events

National CMS/CDC Nursing Home COVID-19 Training Series Webcast — July 30

MLN Matters® Articles

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87426
Overview of the Repetitive, Scheduled Non-Emergent Ambulance Prior Authorization Model — Revised
Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan — Revised

Publications

Medicare Quarterly Provider Compliance Newsletter, Volume 10, Issue 4
Home Health, IRF, LTCH, and SNF Quality Reporting Programs: COVID-19 PHE

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

Billing and Coding: Allergy Testing (A56558)
Billing and Coding: Hemophilia Factor Products (A56433)
Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee (A55036)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)

As a reminder, the comment period for the following Proposed Local Coverage Determinations (LCDs) is currently open and will close on August 8, 2020. We encourage you to submit your comments as soon as possible to allow ample time for us to review them thoroughly.

Endovenous Stenting (DL37893)
Transurethral Waterjet Ablation of the Prostate (DL38712)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (DL34924)
Submit Comments

July 29, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11916 – New Waived Tests
This article informs you 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 its contractors of the new tests so that they can accurately process claims. There are 5 newly added waived complexity tests. Make sure your billing staffs are aware of these CLIA-related changes.

July 27, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11927 – Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 87426
This article informs you about the addition of the QW modifier to HCPCS code 87426 [(Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]]. Please make sure your billing staffs are aware of this modifier addition to code 87426.

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 the article on July 24, 2020, to add clarifying language to the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section to show it applies to lab tests regardless of the HCPCS codes used to report those tests. All other information remains the same.

July 23, 2020

Special Edition – Thursday, July 23, 2020

Provider Education Message:

Trump Administration Announces New Resources to Protect Nursing Home Residents Against COVID-19 

As part of the unprecedented efforts taken by the Trump Administration, President Trump announced several new CMS initiatives designed to protect nursing home residents from Coronavirus Disease 2019 (COVID-19).

“From the moment the threat of this virus materialized, the Trump Administration has placed a priority on protecting nursing home residents,” said CMS Administrator Seema Verma. “Today’s multi-pronged intervention represents the latest efforts in fulfilling that unwavering commitment. As caseloads continue to increase in areas around the country, it has never been more important that nursing homes have what they need to maintain a sturdy defense against the virus. These measures will help them do exactly that.” 

New Funding:

HHS will devote $5 billion of the Provider Relief Fund authorized by the Coronavirus Aid, Relief, and Economic Security (CARES) Act to Medicare-certified long term care facilities and state veterans’ homes (“nursing homes”), to build nursing home skills and enhance nursing homes’ response to COVID-19, including enhanced infection control. This funding could be used to address critical needs in nursing homes including hiring additional staff, implementing infection control “mentorship” programs with subject matter experts, increasing testing, and providing additional services, such as technology so residents can connect with their families if they are not able to visit. Nursing homes must participate in the Nursing Home COVID-19 Training (described below) to be qualified to receive this funding. This new funding is in addition to the $4.9 billion previously announced to offset revenue losses and assist nursing homes with additional costs related to responding to the COVID-19 public health emergency and the shipments of personal protective equipment provided to nursing homes by the Federal Emergency Management Agency.

Enhanced Testing:

Building on the initiative HHS announced last week, in which rapid point-of-care diagnostic testing devices will be distributed to nursing homes, and the new funding from the Provider Relief Fund, CMS will begin requiring, rather than recommending, that all nursing homes in states with a 5% positivity rate or greater test all nursing home staff each week. This new staff testing requirement will enhance efforts to keep the virus from entering and spreading through nursing homes by identifying asymptomatic carriers.

More than 15,000 testing devices will be deployed over the next few months to help support this mandate, with over 600 devices shipping this week. Funds from the Provider Relief Fund can also be used to pay for additional testing of visitors.

Additional Technical Assistance & Support:

The Trump administration recently deployed federal Task Force Strike Teams to provide onsite technical assistance and education to nursing homes experiencing outbreaks in an effort to help reduce transmission and the risk of COVID-19 spread among residents. The first deployments took place in 18 nursing homes in Illinois, Florida, Louisiana, Ohio, Pennsylvania and Texas between July 18 and July 20.  The Task Force Strike Teams are composed of clinicians and public health service officials from CMS, the Centers for Disease Control & Prevention (CDC), and the Office of the Assistant Secretary for Health. 

The Task Force Strike Teams went into nursing homes based on data they reported to the CDC that indicated an increase in COVID-19 cases. The teams focused on the four key areas of support, including keeping COVID-19 out of facilities, detecting COVID-19 cases quickly, preventing virus transmission, and managing staff. The goal was to determine what immediate actions nursing homes needed to take to help reduce the spread and risk of COVID-19 among residents, and to better understand what federal, state, and local resources nursing homes need to ensure the health and safety of their residents. CMS and its partners plan to use what is learned on the ground to determine remote education and other critical needs to support nursing homes and mitigate future outbreaks.

In addition, CMS, in partnership with the CDC, is rolling out an online, self-paced, on-demand Nursing Home COVID-19 Training focused on infection control and best practices. The training being offered has 23 educational modules and a scenario-based learning modules that include materials on cohorting strategies and using telehealth in nursing homes to assist facilities as they continue to work to mitigate the virus spread in their facilities. This program supplements training already underway to better equip nursing homes to contain and stop the spread of COVID-19. The training is a requirement for nursing homes to receive the additional funding from the Provider Relief Fund Program.

The training will be available to all 15,400 nursing homes nationwide along with specialized technical assistance to nursing homes who have been found to have infection prevention deficiencies in their most recent CMS inspection and had recent COVID-19 cases based upon their data submissions to CDC. A certificate of completion is offered and recognition badges can be downloaded for nursing homes to display on their website.

Weekly Data on High Risk Nursing Homes:

Early on during this pandemic, CMS required nursing homes to inform residents, their families and representatives of COVID-19 cases in their nursing homes. Starting in May, CMS and CDC began collecting weekly data on each nursing home including their number of COVID-19 cases. Now that this data collection process has matured, the White House and CMS will release a list of nursing homes with an increase in cases that will be sent to states each week as part of the weekly Governor’s report to ensure states have the information needed to target their support to the highest risk nursing homes.

This announcement builds on the unprecedented and aggressive actions CMS has taken to address the impact of COVID-19 in nursing homes. 

See the full text of this excerpted CMS Press Release (issued July 22), including a list of actions CMS took to address the impact of COVID-19 in nursing homes.


CMS Provider Education Message:

Telemedicine Hack: 10-Week Learning Community for Ambulatory Providers

MLN Connects® for Thursday, July 23, 2020

View this edition as a PDF

News

Peripheral Vascular Intervention for Claudication: Comparative Billing Report
Physician Compare Preview Period Open through August 20

Claims, Pricers & Codes

SNF Patient Driven Payment Model Interrupted Stay Issue

Events

Telemedicine Hack: A 10-Week Learning Community to Accelerate Telemedicine Implementation for Ambulatory Providers: July 22–September 23
National CMS/CDC Nursing Home COVID-19 Training Series Webcast — July 23

MLN Matters® Articles

Change to the Payment of Allogeneic Stem Cell Acquisition Services
July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

Multimedia

Part A Cost Report Call: Audio Recording and Transcript

The following Local Coverage Determination (LCD) and its related Billing and Coding Article has been revised:             

Trigger Point Injections (L35010)
Billing and Coding: Trigger Point Injections (A57751)

The following LCD has been revised:

Wound Care (L35125)

The following Billing and Coding Article has been revised:

Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240)

The following LCDs and related Billing and Coding Articles have been retired:

Nusinersen (Spinraza) (L37682)
Billing and Coding: Nusinersen (Spinraza) (A56860)
Strapping (L36423)
Billing and Coding: Strapping (A56804)

July 22, 2020

Frequently Asked Questions (FAQs)

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


July 20, 2020

CMS Provider Education Message:

Provider Education Message:

COVID-19: Nursing Home Testing, SNF Benefit Period Waiver

MLN Matters Special Edition Article SE20011 Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) is updated. Learn about:

Updated Centers for Disease Control and Prevention guidelines for testing nursing home residents and patients
Update on applying the Skilled Nursing Facility (SNF) benefit period waiver

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 (CMS) revised the article to add a row at the end of the waiver/flexibility table (page seven) to address services provided by the hospital in the patient’s home as a provider-based outpatient department when the patient is registered as a hospital outpatient. CMS also added the section on Teaching physicians and residents: Expansion of current procedure terminology codes that may be billed with the GE modifier. All other information remains the same.

July 16, 2020

CMS Provider Education Message:

Nursing Homes & COVID: Five Things to Know, Additional Resources, Training

MLN Connects® for Thursday, July 16, 2020

View this edition as a PDF

News

CMS Directs Additional Resources to Nursing Homes in COVID-19 Hotspot Areas
Five Things About Nursing Homes During COVID-19
PEPPER for Short-term Acute Care Hospitals
Lower Extremity Joint Replacement: Comparative Billing Report

Events

Nursing Home Training Series Webcasts: New Topic for July 16
COVID-19: Lessons from the Front Lines Call — July 17

MLN Matters® Articles

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020
Influenza Vaccine Payment Allowances - Annual Update for 2020-2021 Season
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2021
October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2020 Update
July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised
July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised
Claim Status Category Codes and Claim Status Codes Update — Rescinded

Prior authorization request (PAR) cover sheet instructions

Instructions on how to complete the PAR cover sheet have been added to our PA for certain hospital outpatient department (OPD) webpage. Failure to complete the PAR cover sheet in its entirety could result in delays in processing your PAR request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.


As a reminder, the comment period for the following proposed local coverage determinations is currently open and will close on August 8, 2020. We encourage you to submit your comments as soon as possible to allow ample time for us to review them thoroughly.

Endovenous Stenting (DL37893)
Transurethral Waterjet Ablation of the Prostate (DL38712)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (DL34924)
Submit Comments

July 15, 2020

Roster billing for Part B providers

We created standard roster billing forms for both flu and pneumococcal vaccine services along with an example of the modified CMS-1500 claim form. For additional information, please take a moment to read the full article.


July 14, 2020

Part B claims issues log update

A new issue has been added to the Part B claims issues log regarding optical claim recognition claims and zip codes. 


The following Local Coverage Determinations (LCDs) which were posted for notice on May 28, 2020 are now effective. The related Billing and Coding articles for these LCDs are also now effective:

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)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11882 – Influenza Vaccine Payment Allowances - Annual Update for 2020-2021 Season
This article informs you of the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 of each year. Please make sure your billing staffs are aware of these updates.

July 13, 2020

Part B Medicare Report June 2020

The June 2020 Part B Medicare Report is now available. Please take a moment to review.


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11889 – Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2020
This article announces the changes that will be included in the October 2020 quarterly release of the edit module for clinical diagnostic laboratory services. Please be sure your billing staffs are aware of these updates.

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

The June 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


July 10, 2020

Modifiers used during the COVID-19 Public Health Emergency (PHE)

Novitas in collaboration with the the A/B Medicare Administrative Contractor (MAC) Provider Outreach & Education (POE) Collaboration Team created a chart detailing the modifiers to be used during the COVID-19 PHE.


Medicare Learning Network® MLN Matters® Articles from CMS

Rescinded:

MM11699 – Claim Status Category Codes and Claim Status Codes Update
This article was rescinded on July 9, 2020, as the related change request (CR) 11699, transmittal R10148CP, dated May 22, 2020, was rescinded and will not be replaced.

Revised:

MM11815 – 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 to add information on COVID-19 codes 87426, 0223U and 0224U. CMS also revised the CR release date, transmittal number and the web address of the CR. All other information remains the same.

July 9, 2020

CMS Provider Education Message:

ICD-10-CM Diagnosis Codes: FY 2021

MLN Connects® for Thursday, July 9, 2020

View this edition as a PDF

News

Open Payments: Program Year 2019 Data
LTCH Provider Preview Reports: Review Your Data by July 18
IRF Provider Preview Reports: Review Your Data by July 21
Reduce Provider Burden: Participate in Medical Documentation Interoperability Pilot
COVID-19: Alternate Care Site Toolkit, Third Edition

Claims, Pricers & Codes

ICD-10-CM Diagnosis Codes: FY 2021
Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifier

Events

Nursing Home Training Series Webcasts — July 9 and 16

MLN Matters® Articles

Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)
Revising Chapters 3 and 5 of Publication (Pub.) 100-08, to Reflect the Recent Final Rule CMS-1713-F
New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site — Revised

Publications

Hospice Quality Reporting Program: COVID-19 PHE

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 the article to add a row at the end of the waiver/flexibility table (page seven) to address services provided by the hospital in the patient’s home as a provider-based outpatient department when the patient is registered as a hospital outpatient. Also, we added the section on Teaching physicians and residents: Expansion of current procedure terminology codes that may be billed with the GE modifier. All other information remains the same.

July 7, 2020

MLN Connects Special Edition for Monday, July 6, 2020

Provider Education Message:

ESRD PPS CY 2021 Proposed Rule; COVID-19: New and Expanded Flexibilities for RHCs & FQHCs

ESRD PPS CY 2021 Proposed Rule
COVID-19: New and Expanded Flexibilities for RHCs & FQHCs during the Public Health Emergency

ESRD PPS CY 2021 Proposed Rule

On July 6, 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, 2021. 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 and proposes changes to the ESRD Quality Incentive Program (QIP).

In addition to the annual technical updates for the ESRD PPS, the proposed rule proposes the following:

An addition to the ESRD PPS base rate to include calcimimetics in the ESRD PPS bundled payment
Changes to the eligibility criteria and determination process for the Transitional add-on Payment adjustment for New and Innovative Equipment and Supplies (TPNIES)
Expansion of the TPNIES to include new and innovative capital-related assets that are home dialysis machines
A change to the low-volume adjustment eligibility criteria and attestation requirement to account for the COVID-19 public health emergency
An update to the ESRD PPS wage index to adopt the new Office of Management and Budget delineations with a transition period
Information received from two manufacturers whose products, a dialyzer and a cartridge for a home dialysis machine, are being considered for TPNIES in CY 2021

Additionally, the proposed rule proposes the following updates to the ESRD QIP:

Scoring methodology changes to the ultrafiltration rate reporting measure
Updates to the National Healthcare Safety Network validation study

The proposed CY 2021 ESRD PPS base rate is $255.59, an increase of $16.26 to the current base rate of $239.33. This proposed amount reflects the application of the proposed wage index budget-neutrality adjustment factor (.998652), the proposed addition to the base rate of $12.06 to include calcimimetics, and a proposed productivity-adjusted market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (1.8 percent), equaling $255.59 (($239.33 x .998652) + $12.06) x 1.018 = $255.59).

The proposed rule also includes:

Annual update to the wage index
Update to the outlier policy
Low-volume eligibility criteria and attestation requirement
Impact analysis

For More Information:

Proposed Rule
Press Release

See the full text of this excerpted CMS Fact Sheet (issued July 6).

COVID-19: New and Expanded Flexibilities for RHCs & FQHCs during the Public Health Emergency

On July 6, CMS updated MLN Matters Article SE20016 to clarify how Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can apply the Cost Sharing (CS) modifier to preventive services furnished via telehealth. This update includes:

Additional claim examples
New section on the RHC Productivity Standard

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11769 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2020 Update
Change request 11769 updates the HCPCS code set for codes related to drugs and biologicals. Please alert your billing staffs of these updates.
MM11854 – October 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
This article updates the quarterly ASP Medicare Part B pricing files and informs providers of revisions to prior quarterly pricing files. Please make sure your billing staffs are aware of these updates and revisions.

Revised:

MM11842 – July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
The Centers for Medicare & Medicaid Services revised this article on July 2, 2020, to correct the last sentence in Section 6.e, on page 10. It should have stated, “C9058 is replaced by Q5120 effective July 1, 2020.” All other information is unchanged.

July 2, 2020

CMS Provider Education Message:

Attend Nursing Home Training Series Webcasts

MLN Connects® for Thursday, July 2, 2020

View this edition as a PDF

News

CMS Proposes to Expand Coverage Policy for Transcatheter Edge-to-Edge Repair for Patients with Mitral Valve Regurgitation
Physician Compare Preview Period Open through August 20
ABN Form Renewal
Medicare Enrollment Application Fee Refunds through EFT

Claims, Pricers & Codes

SNF Benefit Waiver Period: Billing Update

Events

Nursing Home Training Series Webcasts — July 2, 9, and 16
Medicare Part A Cost Report: New Online Status Tracking Feature Call — July 9

MLN Matters® Articles

July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.3, Effective October 1, 2020
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – July 2020 Update — Revised
National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS) — Revised
Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer — Revised

The following LCDs and related Billing and Coding Articles have been revised:

Allergy Testing (L36241)
Billing and Coding: Allergy Testing (A56558)
Assays for Vitamins and Metabolic Function (L34914)
Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)
Biomarkers for Oncology (L35396)
Billing and Coding: Biomarkers for Oncology (A52986)
Biomarkers Overview (L35062)
Billing and Coding: Biomarkers Overview (A56541)
Magnetic Resonance Angiography (MRA) (L34865)
Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)
Pulmonary Function Testing (L35360)
Billing and Coding: Pulmonary Function Testing (A57320)

The following LCDs have been revised:

Epidural Injections for Pain Management (L36920)
Psychiatric Codes (L35101)

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)

The following LCDs and the related Billing and Coding Articles have been retired effective for dates of service on and after July 1, 2020:

In Vitro Chemosensitivity & Chemoresistance Assays (L36634)
Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56710)
Microvascular Therapy (L36434)
Billing and Coding: Microvascular Therapy (A54343)
Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (L36419)
Billing and Coding: Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure (A56856)
Services That Are Not Reasonable and Necessary (L35094)
Billing and Coding: Services That Are Not Reasonable and Necessary (A56967)
Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy (L34891)
Billing and Coding: Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy (A57656)

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 the billing instructions on page 12 of this article. Changes include instructions to readmit the beneficiary on day 101 to start the skilled nursing facility benefit period waiver. All other information remains the same.

June 29, 2020

Advance Beneficiary Notice (ABN) Form Renewal

Providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) issue the ABN Form CMS-R-131 to beneficiaries in situations where Medicare payment is expected to be denied

The ABN form and instructions have been approved by the Office of Management and Budget (OMB) has been renewed.

The new ABN form is effective for current use with an expiration date of June 30, 2023.

Please update any old forms, use of the old ABN form (version 03/2020) will be considered invalid after August 31, 2020.

ABN form and instructions:

Advance Beneficiary Notice of non-coverage
ABN Form Instructions
ABN Forms
Medicare Claims Processing Manual, 100-4, Chapter 30

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)
On June 26, 2020, the Centers for Medicare & Medicaid Services revised the article to add the section, “Skilled Nursing Facility (SNF) Benefit Period Waiver - Provider Information” and related billing instructions. All other information remains the same.

June 26, 2020

Provider Education Message:

Special Edition – Friday, June 26, 2020

COVID-19: SNF Benefit Period Waiver, HHAs Proposed Rule, Ending Nursing Home Blanket Waiver

COVID-19: SNF Benefit Period Waiver
HHAs: Proposed Payment and Policy Changes and Home Infusion Therapy Benefit for CY 2021
CMS Announces Plans to End the Blanket Waiver Requiring Nursing Homes to Submit Staffing Data

COVID-19: SNF Benefit Period Waiver

Disruptions during a Public Health Emergency can affect the Skilled Nursing Facility (SNF) benefit:

Prevent a beneficiary from having the Qualifying Hospital Stay (QHS)
Disrupt the process of ending the beneficiary’s current benefit period and renewing their benefits

Emergency waivers of QHS and benefit period requirements under §1812(f) of the Social Security Act help restore SNF coverage that beneficiaries affected by the emergency would be entitled to under normal circumstances.

Learn more about the waiver and how to bill in MLN Matters Article SE20011.

HHAs: Proposed Payment and Policy Changes and Home Infusion Therapy Benefit for CY 2021

On June 25, CMS issued a proposed rule [CMS-1730-P] for FY 2021 that updates the Medicare payment rates for Home Health Agencies (HHAs). This proposed rule also includes a proposal to make permanent the regulatory changes related to telecommunications technologies in providing care under the Medicare home health benefit beyond the expiration of the Public Health Emergency for the COVID-19 pandemic.

For More Information:                                                         

Fact Sheet
Proposed Rule

CMS Announces Plans to End the Blanket Waiver Requiring Nursing Homes to Submit Staffing Data

On June 25, CMS announced plans to end the emergency blanket waiver requiring all nursing homes to resume submitting staffing data through the Payroll-Based Journal (PBJ) system by August 14, 2020. The PBJ system allows CMS to collect nursing home staffing information which impacts the quality of care residents receive. The blanket waiver was intended to temporarily allow the agency to concentrate efforts on combating COVID-19 and reduce administrative burden on nursing homes so they could focus on patient health and safety during this Public Health Emergency.

The memorandum also provides updates related to staffing and quality measures used on the Nursing Home Compare website and the Five Star Rating System.

To view the memorandum to states and nursing home stakeholders, visit: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/changes-staffing-information-and-quality-measures-posted-nursing-home-compare-website-and-five-star.


Hospital outpatient department (HOPD) services prior authorization (PA) calculator

Novitas has developed a HOPD PA calculator to help you determine the time you have remaining to perform the approved procedure before the PA expires. The service listed on the prior authorization request (PAR) must be performed within 120 days of the date of the decision letter. The 120 days begins with the date on the decision letter. By entering the date of the decision in the tool, it will tell you the last date your authorization will be valid. For more information on the HOPD PA program refer to Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services.


June 25, 2020

CMS Provider Education Message:

COVID-19: New Data Details Impacts on Medicare Beneficiaries

MLN Connects® for Thursday, June 25, 2020

View this edition as a PDF

News

Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries
Hospital Outpatient Departments: Prior Authorization Begins July 1
IRF Provider Preview Reports: Review Your Data by July 18
LTCH Provider Preview Reports: Review Your Data by July 18
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Claims, Pricers & Codes

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

Events

Personal Protective Equipment Strategies for COVID Care Webcast — June 25
Medicare Part A Cost Report: New Online Status Tracking Feature Call — July 9

Publications

Clinical Laboratory Fee Schedule Annual Payment Determination Process

The following Proposed Local Coverage Determinations (LCDs) have been posted for comments. The comment period will end on August 8, 2020, however you are encouraged to submit your comments as soon as possible to allow ample time for us to review them thoroughly.

Endovenous Stenting (DL37893)
Transuretheral Waterjet Ablation of the Prostate (DL38712)
Treatment of Chronic Venous Insufficiency of the Lower Extremities (DL34924)
Submit Comments

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

Billing and Coding: Treatment of Chronic Insufficiency of the Lower Extremities (DA55229)
Billing and Coding: Transurethral Waterjet Ablation of the Prostate (DA58243)

The following Billing and Coding Article has been revised:

Billing and Coding: Endovenous Stenting (A56414)

The following LCD and related Billing and Coding Article have been retired:

Lacrimal Punctum Plugs (L35095)
Billing and Coding: Lacrimal Punctum Plugs (A56780)

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11842 – July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System
This article describes changes to and billing instructions for various payment policies implemented in the July 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.

Revised:

MM11461 – National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)
The Centers for Medicare & Medicaid Services (CMS) revised this article to reflect the revised change request (CR)11461, issued on June 23, 2020. The CR revision clarified instructions for the Medicare administrative contractors and changed the implementation date to July 22, 2020. In the article, CMS changed the implementation date, the CR release date, transmittal number, and the web address. All other information remains the same.

Online Registration Available for July 10, 2020, Open Meeting and Proposed LCDs Now Posted

Online registration for the July 10, 2020, Open Meeting is now available and will close at 12:00 PM (Noon) Eastern Time (ET) on Wednesday, July 8, 2020. IMPORTANT: During this unprecedented time, our Open Meeting will be held via teleconference only. The Novitas Solutions Proposed Local Coverage Determinations (LCDs) are 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.


June 24, 2020

A/B MAC and DME MAC collaborative webinar on therapeutic shoes for persons with diabetes

Do you order therapeutic shoes for your patients that are enrolled in Medicare? Do you wonder why you are asked for specific documentation? These questions and many more will be addressed during the “Therapeutic shoes for persons with diabetes” webinar on June 30, 2020. Register today!


Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11840 – Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.3, Effective October 1, 2020
Change request 11840 provides the quarterly update to the NCCI PTP edits. Please be sure your billing staffs are aware of the updates.

June 23, 2020

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

There will be Common Working File (CWF) "Dark" days from Friday, July 3, 2020 through Sunday, July 5, 2020 due to the July 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.


Ambulatory Surgical Center (ASC) fee schedule update

The July 1, 2020 ASC fee schedule is available and can now be downloaded using the links provided on our ASC fee schedule updates page.


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)
On June 19, 2020, the Centers for Medicare & Medicaid Services revised the article to add the section, “Medicare coverage of COVID-19 testing for nursing home residents and patients.” All other information remains the same.
MM11655 – International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) -- July 2020 Update
The Centers for Medicare & Medicaid Services revised this article to reflect a revised change request (CR) 11655. The CR was revised to remove Current Procedural Technology (CPT) code 0048U from the business requirement for national coverage determinations (NCD) 90.2 Next generation sequencing (NGS) and corresponding removals of CPT 0048U and its associated diagnosis codes from the NCD 90.2 NGS spreadsheet. This revision is necessary because the CPT code does not meet the policy criteria in NCD 90.2 for NGS. In this article, we revised the CR release date, transmittal number, and the web address. All other information remains the same.

June 22, 2020

Provider Education Message:

Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

Today, the Centers for Medicare & Medicaid Services (CMS) has instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID like in an outbreak. Original Medicare and Medicare Advantage plans will cover COVID-19 lab tests consistent with CDC guidance.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

Read the Medicare Learning Network article: https://www.cms.gov/files/document/se20011.pdf.

Read the memo to Medicare Advantage plans: https://cms.gov/files/document/hpms-memo-diagnostic-testing-nursing-home-residents-and-patients-coronavirus-disease-2019.pdf

More information about Medicare coverage of COVID-19 tests is available at: https://www.medicare.gov/coverage/coronavirus-disease-2019-covid-19-tests


June 18, 2020

CMS Provider Education Message:

COVID-19 Diagnostic Laboratory Tests: Billing for Clinician Services

MLN Connects® for Thursday, June 18, 2020

View this edition as a PDF

News

Hospitals: Submit Medicare GME Affiliation Agreements by October 1 During the COVID-19 PHE

Claims, Pricers & Codes

COVID-19 Diagnostic Laboratory Tests: Billing for Clinician Services

Events

COVID-19: Lessons from the Front Lines Call — June 19
Medicare Part A Cost Report: New Online Status Tracking Feature Call — July 9

MLN Matters® Articles

New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site
July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
Quarterly Update to Home Health (HH) Grouper
NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) — Revised
Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component — Revised

Publications

CLIA Program and Medicare Laboratory Services — Revised
Medicare Preventive Services — Revised

June 16, 2020

Prior authorization request (PAR) hospital outpatient procedures Medicare Part A fax/mail cover sheet

The PAR fax/mail cover sheet is now available. The hospital outpatient department (OPD), or provider on behalf of the hospital OPD, must submit the PAR to us before the service is provided to the beneficiary and before the claim is submitted for processing. For more information on PAR submission, review the guidelines for submitting the PAR. The expedited PAR cover sheet is available when the normal timeframe for a decision notification could jeopardize the life or health of the beneficiary.

Refer to Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services webpage for more details on the PA program. Questions can be directed to the PA customer service at 855-340-5975.


June 15, 2020

The comment period is now closed for the following Proposed Local Coverage Determination. Comments received will be reviewed by our Contractor Medical Directors. The Response to Comments Article and finalized Billing and Coding Article will be related to the final LCD when it is posted for notice.

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

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11815 – Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
This article informs laboratories of changes in the quarterly update to the clinical laboratory fee schedule. Please be sure your billing staff is aware of these updates.

Revised:

MM11660 – NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR)
The Centers for Medicare & Medicaid Services revised this article to reflect a revised change request (CR) 11660 issued on June 10, 2020. The CR revisions were for formatting purposes only and did not alter the substance of the article. In the article, CMS revised the CR release date, transmittal numbers, and web addresses. All other information remains the same.

June 12, 2020

May 2020 Part B Newsletter

The May 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.


Prior authorization (PA): Hospital outpatient department services (OPD) frequently asked questions (FAQs)

The PA hospital OPD FAQ document has been developed to include questions and answers posed during our webinars on the PA program for certain hospital OPD services.


June 11, 2020

CMS Provider Education Message:

COVID-19: Reopening Health Care Facilities

MLN Connects® for Thursday, June 11, 2020

View this edition as a PDF

News

Nursing Home COVID-19 Data and Inspections Results Available on Nursing Home Compare
Trump Administration Encourages Reopening of Health Care Facilities
HHS Announces New Laboratory Data Reporting Guidance for COVID-19 Testing
Prior Authorization Process and Requirements for Certain Hospital OPD Services: Payment for Related Services

Events

Medicare Documentation Requirement Lookup Service Special Open Door Forum — June 25

MLN Matters® Articles

July 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.2
July Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)
Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - October 2020

Medicare Learning Network® MLN Matters® Articles from CMS

Revised:

MM11754 – Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component
The Centers for Medicare & Medicaid Services (CMS) revised this article on June 10, 2020, to reflect a revised change request (CR) 11754 issued on June 9. CMS revised the article to add a note to the effective date, the CR release date, transmittal number, and the web address. All other information remains the same.

June 9, 2020

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

The May 2020 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.


May 2020 top claim submission errors

The May 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.


June 8, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11810 – July Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
This article informs durable medical equipment Medicare administrative contractors about the changes to the DMEPOS fees schedules that are updated on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Make sure your billing staffs are aware of these changes.

June 5, 2020

CMS-1500 (02-12) claim form instructions when Medicare is secondary

New updates have been made to the existing article.  Please ensure that you prevent claim rejections by following the guidance outlined in the article. 


June 4, 2020

CMS Provider Education Message:

ICD-10-PCS Procedure Codes: FY 2021

MLN Connects® for Thursday, June 4, 2020

View this edition as a PDF

News

Trump Administration Unveils Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results
Hospice Provider Preview Reports: Review Your Data by June 29

Claims, Pricers & Codes

ICD-10-PCS Procedure Codes: FY 2021

Events

COVID-19: Lessons from the Front Lines Call — June 5

MLN Matters® Articles

Claim Status Category Codes 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
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules
Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component
Supplier Education on Use of Upgrades for Multi-Function Ventilators — Revised
Therapy Codes Update — Revised
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2020 Update — Rescinded

Publications

Medicare Secondary Payer — Revised

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

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 Billing and Coding Article has been added:

Billing and Coding: Screening for Cervical Cancer with Human Papillomavirus (HPV)( A58216)

The following Billing and Coding Article has been revised:

 Billing and Coding: Epidural Injections for Pain Management (A56681)

Duplicate editing for COVID-19 laboratory services

A new article has been added relating to duplicative testing for COVID-19.  Please take time to review the information. 


June 3, 2020

Medicare Learning Network® MLN Matters® Articles from CMS

New:

MM11461 – National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS)
Change request 11461 notifies Medicare administrative contractors that effective for claims with dates of service on or after February 15, 2019, the Centers for Medicare & Medicaid Services will cover Food and Drug Administration approved VNS devices for treatment resistant depression through coverage with evidence development for patients that meet specific conditions of coverage and criteria. Please make sure your billing staffs are aware of this change.

Revised:

SE20011 – Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
On June 1, 2020, the Centers for Medicare & Medicaid Services revised the article to add a section on clarification for using the “CR” modifier and “DR” condition code. All other information remains the same.

June 1, 2020

Special Edition – Monday, June 1, 2020

Provider Education Message:

COVID-19: Using the CR Modifier and DR Condition Code

CMS revised MLN Matters Special Edition Article SE20011 on Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) to clarify when you must use modifier CR (catastrophe/disaster related) and/or condition code DR (disaster related) when submitting claims to Medicare. The update includes a chart of blanket waivers and flexibilities that require the modifier or condition code.


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.