This article has been updated to include examples related to the reporting of occurrence span code M1 and recommended remarks to include on the claim. Please take time to review the article to ensure proper billing.
News
Quality Payment Program: Preview Your Performance Information by December 12
HIV: Screening is Knowledge
Claims, Pricers, & Codes
Resubmit Telehealth Claims with Modifier CS
Federally Qualified Health Center Prospective Payment System: CY 2024 Pricer
Rural Health Clinic CY 2024 All-Inclusive Rate
MLN Matters® Articles
Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease
ESRD & Acute Kidney Injury Dialysis: CY 2024 Updates
Medicare Physician Fee Schedule Final Rule Summary: CY 2024
Information for Patients
Medicaid and CHIP Renewals: Patient-Centered Messaging for Clinical Offices and Health Care Settings
The following billing and coding articles have been revised:
The following article has been revised and will become effective January 14, 2024:
New:
Make sure your billing staff knows about changes and instructions effective January 1, 2024. Delay in Clinical Laboratory Fee Schedule (CLFS) data reporting period. Mapping for new test codes. Updates for costs subject to the reasonable charge payment.
New:
Make sure your billing staff knows about complexity add-on code G2211. Medicare pays separately starting January 1, 2024. We don’t pay when you report an associated O/O E/M visit with modifier 25.
News
CMS Roundup (Nov 17, 2023)
Provider Enrollment Application Fee: CY 2024
Clinical Laboratory Fee Schedule: CY 2024 Final Payment Determinations & Reporting Delay
Medicare Ground Ambulance Data Collection System: 5 Top Tips
Respiratory Virus Season: Protect Your Patients
Events
Inpatient Rehabilitation Facility Prospective Payment System: Coverage Requirements Webinar — November 29
Ambulance Open Door Forum — November 30
MLN Matters® Articles
Lymphedema Compression Treatment Items: Implementation
ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2024 Update —Revised
Publications
New Ownership Reporting Requirements for Providers Using the Form CMS-855A
Intravenous Immune Globulin Demonstration — Revised
Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model — Revised
New:
Make sure your billing staff knows CMS removed NCD 220.6.20 NCD Manual, effective October 13, 2023. Your MACs will make coverage determinations for Positron Emission Tomography (PET beta amyloid imaging for dementia and neurodegenerative disease.
News
Unprecedented Efforts to Increase Transparency of Nursing Home Ownership
Hospital Price Transparency: Use Required CMS Template Layout to Encode Hospital Standard Charge Information
Quality Payment Program: Preview Your Performance Information by December 12
Medicare Participation for CY 2024
Hospice: New Requirement for Physicians Who Certify Patient Eligibility
Medicare Ground Ambulance Data Collection System: CY 2024 Final Policies, Printable Instrument, & FAQs
CMS Health Information Handler Helps You Submit Medical Review Documentation Electronically
National Rural Health Day: Address Unique Health Care Needs
Lung Cancer: Help Your Patients Reduce Their Risk
Compliance
Skilled Nursing Facility: Appropriate Use of Place-Of-Service Codes
Claims, Pricers, & Codes
Vagus Nerve Stimulators: Transitional Pass-through Status for HCPCS Code C1827 — Updated
MLN Matters® Articles
Home Health Prospective Payment System: CY 2024 Update
Provider Enrollment Changes to the Medicare Program Integrity Manual
Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Claims
Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order — Revised
Multimedia
Home Health Agency Perspectives on Innovation: Panel Materials
The following billing and coding articles have been revised:
The following billing and coding article has been revised:
Update has been made for end stage renal dialysis (ESRD) denying incorrectly with reason code 37187. The mass adjustments have been initiated as Type of Bill 72J on November 7, 2023. These adjustments should be near finalization.
The comment period is now closed for the proposed LCD listed below. Comments received will be reviewed by our contractor medical directors. The response to comments article will be posted to our website when the final LCD is posted for notice.
New:
Make sure your billing staff knows about these changes effective January 1, 2024, Medicare enrollment of MFTs and MHCs, and other provider enrollment policy updates like denial reasons and revocations.
News
CMS Roundup (Nov 3, 2023)
Marriage and Family Therapists & Mental Health Counselors: Enroll in Medicare Now
American Indians or Alaska Natives: Help Your Patients Achieve Optimal Health
Claims, Pricers, & Codes
Home Health Prospective Payment System Grouper: January Update
Events
CMS Hospice Forum — November 14
Optimizing Healthcare Delivery to Improve Patient Lives Conference — November 15
HCPCS Public Meeting — November 28–30
Inpatient Rehabilitation Facility Prospective Payment System: Coverage Requirements Webinar — November 29
MLN Matters® Articles
ICD-10 & Other Coding Revisions to National Coverage Determinations: April 2024 Update
Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening — Revised
Publications
Home Health & Hospice Resources
Independent Diagnostic Testing Facility — Revised
The parameters of who may serve as a Medicare Contractor Advisory Committee (CAC) member were expanded by Change Request 10901 and the companion MLN Matters article. Novitas Solutions invites you to volunteer as a CAC member or alternate to represent your organization during our CAC meetings as part of our LCD development process.
Revised:
CMS made no substantive changes to the Article other than to update the web address of the CR transmittal.
CMS added 2 new CPT codes effective January 1, 2024, based on CR 13279.
CMS made no substantive changes to the Article other than to update the web address of the CR transmittal.
CMS added clarifying information about the -KX modifier for screening colonoscopy claims in the context of a complete colorectal cancer screening.
Update has been made for Direct Data Entry (DDE) providers submitting ambulance mileage services incorrectly receiving reason code 32226. A correction has been developed and is tentatively scheduled for November 27,2023. Providers will be able to resubmit DDE claims that have incorrectly been returned when the correction has been installed.
Final Rules
News
CY 2024 Home Health Prospective Payment System Final Rule
CY 2024 End-Stage Renal Disease Prospective Payment System Final Rule
Behavioral Health: Medicare Pays for 3 Services
Lymphedema Compression: Medicare Pays for Treatment Items
Diabetes: Recommend Preventive Services
Flu Shots Can Take Flu from Wild to Mild
Claims, Pricers, & Codes
Vagus Nerve Stimulators: Transitional Pass-through Status for HCPCS Code C1827
Publications
Interns & Residents Duplicate FTEs Audit Reviews
Expanded Home Health Value-Based Purchasing Model: October Newsletter
Medicare Payment Systems — Revised
The following billing and coding articles have been revised:
The following LCD and related billing and coding article have been retired:
The following billing and coding article has been retired:
News
New:
Make sure your billing staffs knows about newly available codes, recent coding changes, and NCD coding information.
Make sure your billing staffs knows about Newly available codes, Recent coding changes, and NCD coding information.
Medicare providers – please review this notice concerning voluntary refunds for 2023.
News
Help CMS Improve Provider Resources — Respond by November 9
CMS Roundup (Oct 20, 2023)
Nursing Facility Evaluation and Management Visits: Comparative Billing Report in October
Claims, Pricers, & Codes
Conditional Payment Claims: Continue to Submit to Your Medicare Administrative Contractor
Home Health Consolidated Billing Enforcement: CY 2024 HCPCS Code
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
Events
Inpatient Rehabilitation Facility Prospective Payment System: Coverage Requirements Webinar — November 29
MLN Matters® Articles
Medicare Deductible, Coinsurance, & Premium Rates: CY 2024 Update
Processing Claims Affected by Retroactive Entitlement
Publications
Medicare Secondary Payer: Don’t Deny Services & Bill Correctly — Revised
Information for Patients
2024 Medicare & You Handbook
The following LCD posted for comment on June 1, 2023, has been posted for notice. The LCD and related billing and coding article will become effective December 10, 2023.
The following Response to comments article contains summaries of all comments received and Novitas’ responses:
As a reminder, the comment period for the following proposed LCD is currently open and will close on November 11, 2023. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit comments
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, 2023:
New:
Make sure your billing staff knows when certain claims are payable beyond the timely filing limit. Also, how to handle claims when you can’t submit a patient assessment.
News
2024 Medicare Parts A & B Premiums and Deductibles
Help CMS Improve Provider Resources — Respond by November 9
CMS Health Information Handler Helps You Submit Medical Review Documentation Electronically
Health Literacy: Help Your Patients Get Information & Services
Claims, Pricers, & Codes
Discarded Drugs & Biologicals: When to Use JW & JZ Modifiers
Events
Provider Compliance Focus Group Meeting — November 2
Expanded Home Health Value-Based Purchasing Model: Preparing for CYs 2024 & 2025 Webinar — November 9
MLN Matters® Articles
Update for Blood Clotting Factor Add-on Payments
Publications
Complying with Medical Record Documentation Requirements — Revised
Expanded Home Health Value-Based Purchasing Model Resource Index — Updated
From Our Federal Partners
Health Care Preparedness Resources
The following LCD has been revised:
News
CMS Roundup (Oct 6, 2023)
Protect Your Patients: Give Them a Flu Shot
Publications
Direct Data Entry: 10-Digit Screen Expansion
Medicare Preventive Services — Revised
Medicare Provider Compliance Tips — Revised
New:
Make sure your billing staff knows about additional diagnosis codes eligible for payment for blood clotting factors and adjustment of certain claims with the added codes.
The top denial claims, top rejection claims and top returned to provider claims have been updated. Please take time to review this information.
CMS has announced the dollar amount that must remain in controversy to sustain appeal rights beginning January 1, 2024. Please review the article for details.
On October 3, the FDA amended the emergency use authorization of the Novavax COVID-19 vaccine, Adjuvanted to include the 2023–2024 formula to address currently circulating variants to provide better protection against the serious consequences of COVID-19, including hospitalization and death.
In response, CMS updated the payment allowance effective October 3, 2023, for the Novavax vaccine for CPT code 91304. The federal government is not purchasing these products. Medicare Part B pays for the drug and its administration under the applicable Medicare Part B payment policy. Use CPT code 90480 to bill for the administration of the vaccine.
Additionally, codes 0041A, 0042A and 0044A are no longer payable as of October 3, 2023.
As a result of these changes, updates have been made to the following references:
News
The following local coverage articles have been revised:
A document note has been added to the following articles:
News
Administration Moves Forward with Medicare Drug Price Negotiations to Lower Prescription Drug Costs for People with Medicare
CMS Requests Public Input on Coverage of Over-the-Counter Preventive Services, Including Contraception, Tobacco Cessation, and Breastfeeding Supplies
Action Plan for Sickle Cell Disease Month
CMS Burden Reduction News & Insights Fall Newsletter
New COVID-19 Treatments Add-On Payment Ended September 30
Clinical Laboratory Fee Schedule: Submit Your Comments
DMEPOS: New Provider Enrollment Appeals & Rebuttals Contractor Starts October 9
Help Detect Breast Cancer Early
Claims, Pricers, & Codes
RARCs, CARCs, Medicare Remit Easy Print, & PC Print: October Update
Publications
Medicare Provider Compliance Newsletter
Multimedia
Post-Acute Care Quality Reporting Programs: Brief Interview for Mental Status Video
Update has been made for end stage renal dialysis (ESRD) where an error was discovered with the transmission of data from the Eligibility Database (EDB) to the Common Working File (CWF) that resulted in a change in the date of first dialysis. The error began May 1, 2022, and resulted in some beneficiary records reflecting the ESRD eligibility date in the date of first dialysis field rather than the initial date of first dialysis.
October 02, 2023, all beneficiary files have been corrected. Providers may submit adjustments to correct claim payments where the onset adjustment was not applied correctly. Please include remarks on your adjustment submission indicating “onset adjustment correction.”
Representatives from all four DME MAC jurisdictions and the A/B MACs to explain coverage criteria, medical records requirements, certifying physician and practitioner roles. We hope you’ll join the Medicare administrative contractors for this valuable education opportunity!
The webinar is Wednesday, October 17 at noon ET / 11 a.m. CT / 10 a.m. MT. The time is usually one hour. Please register for this educational opportunity.
Please note: The Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (L35041/A54117) will not become effective on 10/01/2023.
A new Proposed LCD will be published for comment and presented at an open meeting in the near future.
In the meantime, current coverage has not changed. The following LCD and article remain in effect.
Our Medical Policy team has evaluated all active local coverage articles for any impact in response to the 2024 annual ICD-10-CM code update. The following is a list of the impacted articles. The revised articles will be published to the MCD and on our website towards the end of October. Please continue to watch our website for updates.
Billing and coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59268)
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: Cardiac Rhythm Device Evaluation (A56602)
Billing and coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
Billing and coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
Billing and coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
Billing and coding: Electroretinography (ERG) (A56672)
Billing and coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
Billing and coding: Intraoperative Neurophysiological Testing (A56722)
Billing and coding: Magnetic Resonance Angiography (MRA) (A56085)
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: Pharmacogenomics Testing (A58801)
Billing and coding: Psychiatric Codes (A57130)
Billing and coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Billing and coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111)
Billing and coding: Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (A56631)
Billing and coding: Transesophageal Echocardiography (TEE) (A56505)
Billing and coding: Vestibular and Audiologic Function Studies (A57434)
News
CMS Statement on Current Status of Blood Tests for Organ Transplant Rejection
CMS Roundup (Sept 22, 2023)
Cardiovascular Disease: Talk with Your Patients about Screening
Claims, Pricers, & Codes
ICD-10 Coordination & Maintenance Committee: Meeting Materials & Deadlines
MLN Matters® Articles
ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update
Publications
Expanded Home Health Value-Based Purchasing Model: September Newsletter
Checking Medicare Eligibility — Revised
Online registration for the Friday, October 13 open meeting is now available and presenter registration will close at noon ET on Wednesday, October 11. IMPORTANT: Our open meeting will be held via webinar 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.
The following LCD and related billing and coding article, which were posted for notice on August 3, 2023, will not become effective at this time. Please refer to below NOTE:
Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (L35041)
Billing and Coding: Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (A54117)
NOTE: Please refer to the current LCD and related article located on our website:
The following proposed LCD has been posted for comment. The comment period will end on November 11, 2023; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for consideration.
The following billing and coding articles have been revised:
The following LCD and related billing and coding article have been retired:
On September 11, the FDA approved and authorized for emergency use updated Moderna and Pfizer-BioNTech COVID-19 vaccines.
In response, CMS identifies an effective date of September 11, for CPT code 90480 and codes 91318-91322. The federal government is not purchasing these products. Medicare Part B pays for the drug and its administration under the applicable Medicare Part B payment policy.
Additionally, codes 91312, 91313, 91314, 91315, 91316, 91317, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A, 0154A, 0164A, 0171A, 0172A, 0173A, 0174A are no longer payable as of September 12, 2023.
As a result of these changes, updates have been made to the following references:
News
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Georgia
Organ Transplantation Affinity Group: Strengthening Accountability, Equity, And Performance
Psychotherapy for Crisis: Medicare Pays for Services
Flu Shot: Encourage Preferred Vaccines for Patients 65+
Help Reduce Health Gaps for Hispanic or Latino Patients
MLN Matters® Articles
Limitation on Recoupment of Overpayments
Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2024 Changes
Information for Patients
HHS Takes the Most Significant Action in a Decade to Make Care for Older Adults & People with Disabilities More Affordable and Accessible
There will be Common Working File (CWF) Dark Days from Friday, Friday, September 29,2023, through Sunday, October 1, 2023, due to the October 2023 release updates. The interactive voice response (IVR) will have limited availability.
New:
Make sure your billing staff knows about these changes of newly available codes, recent coding changes, and how to find NCD coding information.
The comment period is now closed for the following proposed LCD. 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.
Update has been made for end stage renal dialysis (ESRD) denying incorrectly with reason code 37187. A correction has been installed on September 13, 2023. This will prevent claims from continuing to process incorrectly.
Impacted claims will be identified and mass adjusted automatically. We will post an update when the mass adjustments begin.
News
COVID-19: Updated mRNA Vaccines for Patients 6 Months & Older
News
Inflation Reduction Act Continues to Lower Out-of-Pocket Prescription Drug Costs for Drugs with Price Increases Above Inflation
CMS Roundup (Sept 8, 2023)
New Provider Types 2024: Marriage and Family Therapists & Mental Health Counselors
PECOS 2.0 Is Coming Soon
Medicare Secondary Payer: Are You Getting Diagnosis Codes?
Social Determinants of Health: Collect Data with ICD-10-CM Z Codes
ESRD: Submitting Dialysis Claims That Include Capital Related Assets Eligible for the TPNIES
Medicare Physician Fee Schedule Database: October Update
Prostate Cancer: Encourage Your Patients to Get Screened
Claims, Pricers, & Codes
National Correct Coding Initiative: October Update
Integrated Outpatient Code Editor: Version 24.3
MLN Matters® Articles
Ambulatory Surgical Center Payment System: October 2023 Update
DMEPOS Fee Schedule: October 2023 Quarterly Update
Hospital Outpatient Prospective Payment System: October 2023 Update
Publications & Multimedia
Expanded Home Health Value-Based Purchasing Model: Updated Resource & Event Materials
National Government Services (NGS), along with CGS Administrators, Noridian Healthcare Solutions, Novitas Solutions, First Coast Service Options, Palmetto GBA, and WPS Government Health Administrators (WPS), will host a multi-jurisdictional Contractor Advisory Committee (CAC) meeting via teleconference/webinar. Discussions will focus on botulinum toxins.
Date: Thursday, October 19, 2023
Time: 2:00 p.m. to 5:00 p.m. ET
The purpose of the meeting is to obtain advice from subject matter experts (SMEs) regarding the strength of published evidence on botulinum toxins. The SME panel will respond to a series of key questions. CAC panels do not make coverage determinations, but Medicare administrative contractors (MACs) benefit from their advice. The public is invited to attend as observers.
Registration is required. The registration link, agenda, discussion questions, and bibliography are available on the NGS Website.
New:
Make sure your staff knows about how Medicare recoups overpayments and appeals and reconsiderations affect these recoupments.
The comment period is now closed for the following Proposed LCD. 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.
When submitting a prior authorization request (PAR), be mindful of specific guidelines relating to proper submission to avoid potential non-affirmations. Please review this new article that identities common issues and related recommendations from the Novitas Prior Authorization team to assist with proper submission.
News
New Version of CMS.gov
HHS Proposes Minimum Staffing Standards to Enhance Safety and Quality in Nursing Homes
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Florida
Laboratory Tests for Blood Counts: Comparative Billing Report in September
Expanded Home Health Value-Based Purchasing Model: Submit Technical Expert Panel Nominations by September 27
Physicians & Non-Physician Practitioners: Revised Medicare Enrollment Application Required November 1
DMEPOS: New Benefit Category Determinations
Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports
Healthy Aging: Recommend Services for Your Patients
MLN Matters® Articles
Changes to the Laboratory National Coverage Determination Edit Software: January 2024 Update
Inpatient Psychiatric Facilities Prospective Payment System: FY 2024 Updates
Publications
Evaluation and Management Services Guide — Revised
Multimedia
Medicare Ground Ambulance Data Collection System Video
From Our Federal Partners
Severe Vibrio vulnificus Infections in U.S. Associated with Warming Coastal Waters
Increased Respiratory Syncytial Virus Activity in Parts of Southeastern U.S.: New Prevention Tools Available to Protect Patients
Information for Patients
CMS Hosts Patient-Focused Listening Sessions this Fall
As a reminder, the comment period for the following proposed LCD is currently open and will close on September 16, 2023. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit comments
The following article, which was posted for notice on July 20, 2023, became effective on September 3, 2023:
Effective 30 days from the posting of this updated article, the description of the service must be reported in the narrative section and must provide enough details for processing. If the description of the service is too large for the narrative field, records should be submitted with the initial claim submission. If we are unable to process the service based on remarks and no records are submitted to support the service billed, the service will be rejected (Part B) or the claim will be returned as unprocessable (Part A) and the claim must be resubmitted with the appropriate information.
Starting approximately around July 17, 2023, some ESRD claims are not receiving reimbursement with reason code 37187 or reimbursing very low amounts for dialysis services.
News
HHS Selects the First Drugs for Medicare Drug Price Negotiation
Medicare Shared Savings Program Saves Medicare More Than $1.8 Billion in 2022 and Continues to Deliver High-quality Care
CMS Issues Draft Guidance on New Program to Allow People with Medicare to Pay Out-of-Pocket Prescription Drug Costs in Monthly Payments
CMS Roundup (Aug. 25, 2023)
CMS.gov Website Refresh – Provide Feedback on Test Website by September 5
Claims, Pricers, & Codes
HCPCS Application Summaries & Coding Decisions: Non-Drug & Non-Biological Items and Services
Home Health Prospective Payment System Grouper: October Update
Updated ICD-10 Medicare Severity Diagnosis-Related Group Version 41
From Our Federal Partners
Locally Acquired Malaria Cases Identified in Florida, Texas, & Maryland — Important Updates
As a reminder, the comment period for the following proposed LCD is currently open and will close on September 9, 2023. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit Comments
The following billing and coding articles have been revised:
New:
Make sure your billing staff knows about FY 2024 market basket update, FY 2024 wage index update, and IPF Quality Reporting Program (IPFQR).
News
Seasonal Flu Vaccine Pricing for 2023–2024 Season
Expanded Home Health Value-Based Purchasing Model: July 2023 Interim Performance Reports, Post-Event Materials, & Comment on CY 2024 Proposals
Behavioral Health Integration Services: Are Your Patients Eligible?
Claims, Pricers, & Codes
HCPCS Application Summaries & Coding Decisions: Non-Drug & Non-Biological Items & Services
New Place of Service Code 27 – Outreach Site/Street
Events
ICD-10 Coordination & Maintenance Committee Meeting — September 12–13
Optimizing Healthcare Delivery to Improve Patient Lives Conference – November 15
MLN Matters® Articles
Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Activation of Validation Edits for Providers with Multiple Service Locations — Revised
Prior authorization (PA) for facet joint interventions was effective for dates of service on and after July 1, 2023. The A/B MAC Prior Authorization Collaboration Workgroup developed a new article on facet joint interventions. This new article has been added to the Prior authorization (PA) program for certain hospital outpatient department (OPD) services webpage. Please carefully review this information.
Please take time to review this article on Correctly bill Units for the Tablo home dialysis machine for hemodialysis that has been added to the ESRD specialty page.
New:
Make sure your billing staff knows about private payor data reporting. You must report data between January – March 2024, General specimen collection fee increase, and new and deleted HCPCS codes.
News
CMS.gov Website Refresh – Test Website Available for Feedback
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in Hawaii Due to Recent Wildfires
Clotting Factor: CY 2024 Furnishing Fee
Claims, Pricers, & Codes
COVID-19: CPT Codes for Vaccines No Longer Authorized
Inpatient Rehabilitation Facility Prospective Payment System: FY 2024 Pricer Update
Skilled Nursing Facility Prospective Payment System: FY 2024 Pricer Update
MLN Matters® Articles
Hospice Payments: FY 2024 Update
ICD-10 & Other Coding Revisions to National Coverage Determinations: January 2024 Update
National Coverage Determination 30.3.3 – Acupuncture for Chronic Low Back Pain
Power Seat Elevation Equipment on Power Wheelchairs
Publications
Medicare Provider Enrollment — Revised
The following LCD and related Billing and Coding Article have been retired:
On April 18, 2023, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent mRNA vaccines to simplify the vaccination schedule for most individuals.
In response, CMS added a termination date of April 18, 2023, to the following CPT codes: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A 91300, 91301, 91305, 91306, 91307, 91308, 91309, 91311.
In addition, CMS added a termination date of June 1, 2023, to the following Janssen CPT codes: 0031A, 0034A, and 91303.
As a result of the change, updates have been made to the following references:
News
Immunization: Protect Your Patients
Claims, Pricers, & Codes
Outpatient Rehabilitation Claims with Reason Code W7072: Do You Need to Resubmit Claims?
MLN Matters® Articles
HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: October 2023 Update
Publications
Expanded Home Health Value-Based Purchasing Model: New Resource & Updated FAQs
Multimedia
Skilled Nursing Facility: Minimum Data Set Resident Assessment Instrument Training Materials
New:
Make sure your billing staffs are aware of these changes - newly available codes, recent coding changes, and how to find NCD coding information.
Make sure your billing staff knows about updated frequency edits for acupuncture for chronic low back pain (cLBP), and relevant codes for acupuncture and dry needling services starting January 1, 2024.
New:
Make sure your billing staffs knows about updates to the lists of HCPCS codes that are subject to the CB provision of the SNF prospective payment system. Additions and deletions of certain chemotherapy, blood clotting factors, and therapies inclusion codes from the Medicare Part A SNF files.
Certain outpatient claims that returned in error with CPT codes 98980 and/or 98981 along with revenue codes 42x, 43x and 44x for type of bill 22X, 23X, and 85X, processed on or after January 1, 2023, through implementation of the July 2023 Integrated Outpatient Code Editor quarterly release were corrected on 7/3/2023.
Any claims that have returned in error with reason code W7072 should be resubmitted.
Medical policy
The following LCD which posted for comment on April 14, 2022, and on August 11, 2022, has been posted for notice. The LCD and related billing and coding article will become effective September 17, 2023.
The following Response to Comments Article contains summaries of all comments received and Novitas’ responses:
The following proposed LCD has been posted for comment. The comment period will end on September 16, 2023; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for consideration.
Submit comments
The following billing and coding articles have been revised:
Online registration for the Friday, August 18, open meeting is now available and will close at noon ET on Wednesday, August 16. Important: Our open meeting will be held via webinar only. Our 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.
Final FY 2024 Payment Rules
Information was updated for not otherwise classified (NOC) and added for end stage renal disease (ESRD) related to the proper use of the JW and JZ modifiers. Please review this article for more information. Additionally, CMS recently update the Medicare Program Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions article.
New:
Make sure your billings staff knows about changes, effective October 1, 2023, billing J0889 for daprodustat, and new ICD-10-CM codes for comorbidity payment adjustment, and acute kidney injury.
Prior authorization (PA) for facet joint interventions was effective for dates of service on and after July 1, 2023. The PA article Hospital outpatient department services frequently asked questions (FAQs) has been updated to include FAQs for facet joint interventions. Please take time to review the updated information. Additionally, a checklist for facet joint interventions has been linked the PA program for certain outpatient department services homepage and general documentation requirements article.
It has been found that not all beneficiary files have been corrected. Providers should wait for updated information before adjusting any claims.
Please continue to monitor our Listservs and our Claims issue page. We will notify you of the appropriate corrective action in the near future.
News
CMS Continues Work on Behavioral Health
Discarded Drugs and Biologicals: Updated FAQs on JW & JZ Modifiers
Expanded Home Health Value-Based Purchasing Model: July 2023 Interim Performance Reports
Subsequent Annual Wellness Visits: Comparative Billing Report in July
Medicare Ground Ambulance Data Collection System: Submit Comments by September 11
Clinical Laboratories: New Diagnostic Tests & Reporting Reminder
Viral Hepatitis: Talk with Your Patients about Shots & Screenings
Claims, Pricers, & Codes
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
From Our Federal Partners
Biosimilars: Free Continuing Education Courses, Videos, & Resources from FDA
Online registration for the Friday, August 11, open meeting is now available and will close at noon ET on Wednesday, August 9. Important: Our open meeting will be held via webinar only. Our 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.
The following proposed LCD has been posted for comment. The comment period will end on September 9, 2023; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for consideration.
The following draft billing and coding article is related to the above proposed LCD.
On August 1, 2023, CMS will deploy full production activation editing and MACs are instructed to permanently turn on editing for reason codes 34977, 34978, 34984, 34985, 34986, and 34987. These reason codes will be set up to return to provider (RTP) claims that do not match exactly. Validation will be exact matching based on the information on the CMS-855A form submitted by the provider and entered into PECOS. Please review our Hospital off-campus outpatient department reporting article and SE19007 - Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations for guidance.
The edit implementation schedule is as follows:
Implementation Date |
Reason Code(s) |
Region |
8/1/2023 |
34977 and 34978 |
WPS JH, WPS JL |
8/8/2023 |
34977 and 34978 |
Arkansas, Louisiana, Mississippi, and Delaware |
8/15/2023 |
34977 and 34978 |
Oklahoma, District of Columbia, New Jersey, Maryland, and Pennsylvania |
8/22/2023 |
34977 and 34978 |
Colorado, New Mexico, and Texas |
9/5/2023 |
34984 and 34985 |
All states in JH and JL |
9/12/2023 |
34986 and 34987 |
All states in JH and JL |
Visit our calendar of events for our upcoming webinar “Provider - Based Hospital Off-Campus Practice Location Address Requirements” on August 16, 2023.
Please take a moment to review this article on updated addendum D instructions.
The top denial claims, top rejection claims and top returned to provider claims have been updated. Please take time to review this information.
Please review our revised article Appropriate use of not otherwise classified codes when billing drugs and biologicals.
New:
Make sure your billing staffs know about how CMS handles payment for Medicare patients disenrolling from PACE and condition codes and value code we require to prevent claims denials.
Make sure your billing staff knows about edit updates for SNFs billing on type of bill (TOB) 21X, swing bed TOB18X, and hospitals billing during an interrupted stay.
The following billing and coding articles have been revised:
The following article has been revised to reflect the July 2023 CPT/HCPCS code quarterly updates and will become effective September 3, 2023:
News
Percutaneous Transluminal Angioplasty of Carotid Artery Concurrent with Stenting: Proposed National Coverage Determination
Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease: Proposed National Coverage Determination
CMS Posts Program Year 2022 Open Payments Data to CMS.gov
Value-Based Insurance Design Model: CY 2024
DMEPOS Suppliers: When & Where to Submit Electronic Funds Transfer Authorization Agreement Form
New Domestic N95 Respirator Payment Adjustments
Medicare Providers: Deadlines for Joining an Accountable Care Organization
Compliance
Inpatient Admission Before Part A Entitlement: Bill Correctly
MLN Matters® Articles
Activation of Validation Edits for Providers with Multiple Service Locations — Revised
Publications
Telehealth Services — Revised
Multimedia
Post-Acute Care: Brief Interview for Mental Status Video
Noridian Healthcare Solutions along with CGS Administrators, National Government Services (NGS), Palmetto GBA, WPS Government Health Administrators (WPS), First Coast Service Options, and Novitas Solutions will host a Multi-Jurisdictional Contractor Advisory Committee (CAC) Meeting via teleconference. Discussions will focus on cervical fusion.
Date: Wednesday, August 16
Time: 1:00 p.m. to 4:00 p.m. CT (2:00 p.m. to 5:00 p.m. ET)
The Centers for Medicare & Medicaid Services (CMS) assigned Medicare Administrative Contractors (MACs) the task of developing Local Coverage Determinations (LCDs). The purpose of the CAC meeting is to provide a formal mechanism for healthcare professionals to be informed of the evidence used in developing an LCD and promote communications between the MACs and the healthcare community. The CAC panel will discuss the clinical literature related to Cervical Fusion. Discussions will occur between CAC panelists and Contractor Medical Directors. 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. Registration deadline to participate by listen-only mode will close on Wednesday, August 16, at 11:00 a.m. CT/noon ET.
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 on the Noridian CAC Meeting web page or the Novitas Multi-Jurisdictional CAC Meeting web page.
Note: Complete details will be posted at a later date.
On August 1, 2023, CMS will deploy full production activation editing and MACs are instructed to permanently turn on editing for reason codes 34977, 34978, 34984, 34985, 34986, and 34987. These reason codes will be set up to return to provider (RTP) claims that do not match exactly. Validation will be exact matching based on the information on the CMS-855A form submitted by the provider and entered into PECOS. Please review our Hospital off-campus outpatient department reporting article and SE19007 - Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations for guidance.
The reason code implementation schedule is as follows:
Implementation Date |
Reason Code(s) |
Region |
8/1/2023 |
34977 and 34978 |
WPS JH, WPS JL |
8/8/2023 |
34977 and 34978 |
Arizona, Louisiana, Mississippi, and Delaware |
8/15/2023 |
34977 and 34978 |
Oklahoma, District of Columbia, New Jersey, Maryland, and Pennsylvania |
8/22/2023 |
34977 and 34978 |
Colorado, New Mexico, and Texas |
9/5/2023 |
34984 and 34985 |
All states in JH and JL |
9/12/2023 |
34986 and 34987 |
All states in JH and JL |
Visit our calendar of events for our upcoming webinar “Provider - Based Hospital Off-Campus Practice Location Address Requirements” on July 26, 2023.
It has been found that not all beneficiary files have been corrected. Providers should wait for updated information before adjusting any claims.
Please continue to monitor our Listservs and our Claims issue page. We will notify you of the appropriate corrective action in the near future.
Effective for dates of service on and after July 6, 2023, Medicare will pay for Leqembi (lecanemab-irmb) for monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease. To ensure proper billing please take time to review the article.
The comment period is now closed for the following Proposed LCD. 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.
Proposed Rules
The following LCD and related billing and coding article have been retired:
As a reminder, the comment period for the following proposed LCD is currently open and will close on July 15, 2023. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit Comments
News
Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022
National Coverage Determination: Pre-exposure Prophylaxis Using Antiretroviral Drugs to Prevent HIV Infection
Medicare Dental Services: Learn What’s Covered
Claims, Pricers, & Codes
Institutional Providers: Resubmit Audiology Claims Returned with Reason Code 34963
Inpatient Prospective Payment System-Excluded Hospitals: Correcting Issue with Excluded Units
ICD-10-CM Diagnosis Codes: FY 2024 Coding Guidelines & Conversion Table
Events
Expanded Home Health Value-Based Purchasing Model: Overview of the Interim Performance Report Webcast — July 27
MLN Matters® Articles
ICD-10 & Other Coding Revisions to Laboratory National Coverage Determinations: October 2023 Update
Ambulatory Surgical Center Payment System: July 2023 Update — Revised
New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI — Revised
Publications & Multimedia
Period of Enhanced Oversight for New Hospices in Arizona, California, Nevada, & Texas
Expanded Home Health Value-Based Purchasing Model: New Resources
From Our Federal Partners
Rural Emergency Hospitals: Requirements in CMS Emergency Preparedness Final Rule
Learn how to bill for Rebyota fecal microbiota, live-jslm (J1440) to avoid rejections.
Broader Medicare Coverage of Leqembi Available Following FDA Traditional Approval
Broader Medicare coverage is now available for Biogen and Eisai’s Leqembi (the brand name for lecanemab) following the Food and Drug Administration’s (FDA) move to grant traditional approval to the drug that treats individuals with Alzheimer’s disease. The Centers for Medicare & Medicaid Services had previously announced this would be the case and released more details on coverage.
News
CY 2024 Home Health Prospective Payment System Proposed Rule
HHS Announces Actions to Lower Health Care Costs and Allow Medicare to Negotiate Lower Drug Prices
CMS Roundup (June 30, 2023)
Skilled Nursing Facility: COVID-19 Enforcement Discretion for Pharmacy Billing Ended June 30
Medicare Providers: Deadlines for Joining an Accountable Care Organization
Help People with Disabilities Get the Care They Need
MLN Matters® Articles
Corrections to Home Health Claims Edits
Publications
Medicare & Mental Health Coverage — Revised
From Our Federal Partners
Wildfire Smoke Exposure Poses Threat to At-Risk Populations
The following LCD and related billing and coding article, which was posted for Notice on June 2, 2023, will not become effective on July 17, 2023, as previously communicated. A new Proposed LCD will be published for comment and presented at an open meeting in the near future. Please continue to watch our website for updates.
The following LCDs will remain in effect at this time:
The following billing and coding article has been revised:
As a reminder, the comment period for the following proposed LCD is currently open and will close on July 15, 2023. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
New:
Make sure your billing staffs are aware of these changes newly available codes, recent coding changes, and how to find NCD coding information.
New:
Make sure your billing staff knows about Changes in the VBID Model’s hospice benefit component for CY 2024 and business requirements in
CR 11754,
CR 12349,
CR 12688, and
CR 12964.
We have updated the implantable infusion pump, skin substitute codes and drug codes that will require an invoice effective July 1, 2023.
Are you providing outpatient therapy services on institutional claims and receiving reason code 34963 indicating the attending physician is invalid? Read this article for assistance to resolve your claim returns.
News
CY 2024 ESRD Prospective Payment System Proposed Rule
Transforming Medicare Coverage: A New Medicare Coverage Pathway for Emerging Technologies and Revamped Evidence Development Framework
New Details of Plan to Cover New Alzheimer's Drugs
Model Participants for the Enhancing Oncology Model
Hospital Price Transparency: Volunteer for Machine-Readable File Validator Testing
Claims, Pricers, and Codes
RARCs, CARCs, Medicare Remit Easy Print, & PC Print: July Update
Events
Hospital Price Transparency Machine-Readable File Sample Format Webinar -- July 26
MLN Matters® Articles
Ambulatory Surgical Center Payment System: July 2023 Update -- Revised
From Our Federal Partners
Locally-Acquired Malaria Cases Identified in U.S.
Measles Guidance for the Summer Travel Season
Information for Patients
States Are Restarting Medicaid & CHIP Eligibility Reviews: Tell Your Patients to Prepare Now
Please review our article for instructions on billing digitization of glass microscope slides, CPT codes 0751T-0763T, for claims received on or after August 5, 2023.
Effective July 3, 2023, hearing and speech impaired customers should start using the National 711 teletypewriter (TTY) relay service to connect with Novitas-Solutions. After dialing 711, users will provide the 711-relay representative with our JL toll-free number (1-877-235-8073).
To connect with a Novitas Solutions representative you will provide the relay representative with the line of business (Part A or Part B) and then indicate you are requesting a live agent. Requesting a live agent will quickly connect you with one of our knowledgeable representatives. Our representatives are available Monday through Friday from 8:00 to 4:00 PM EST. (Excluding Holiday and training closures.)
The following articles which were posted for notice on May 11, 2023, are now effective:
Information has been added to assist providers in resolving issues related to reason code 34963. If you do not have access to PECOS to validate the attending providers’ name, you can use the order and referring data set at data.cms.gov to verify the physician’s name and spelling as seen in PECOS. Please take time to review this article.
News
CMS Roundup (June 16, 2023)
Lower Endoscopy: Comparative Billing Report in June
Medicare Physician Fee Schedule Database: July Update
Behavioral Health Integration Services: Get Information about the Codes
Claims, Pricers, & Codes
ICD-10-CM Diagnosis Codes: FY 2024
Events
Expanded Home Health Value-Based Purchasing Model: Overview of the Interim Performance Report Webcast — July 27
MLN Matters® Articles
New Waived Tests
Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process — Revised
Flowcharts outlining the processes for requesting a new local coverage determination (LCD) and an LCD reconsideration have been added to our LCD Center. For step-by-step instructions, see the new LCD request process and/or the LCD reconsideration request process flowchart(s).
There will be Common Working File (CWF) 'Dark' days from Friday, June 30, 2023 through Sunday, July 2, 2023, due to the July 2023 release updates. The interactive voice response (IVR) will have limited availability.
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
Have questions and not sure where to turn? Check out our FAQs for answers to your questions.
News
Inflation Reduction Act Continues to Lower Out-of-Pocket Prescription Drug Costs for Drugs with Price Increases Above Inflation
CMS Announces Multi-State Initiative to Strengthen Primary Care
Critical Access Hospitals: Annual Average Patient Length of Stay Requirement
Skilled Nursing Facility Probe and Educate Review
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
ESRD Prospective Payment System: July Update
Medicare Learning Network Web Refresh
Men’s Health: Encourage Your Patients to Prioritize Their Health
Claims, Pricers, & Codes
ICD-10-PCS Procedure Codes: FY 2024
MLN Matters® Articles
DMEPOS Fee Schedule: July 2023 Quarterly Update
Hospital Outpatient Prospective Payment System: July 2023 Update
New JZ Claims Modifier for Certain Medicare Part B Drugs
Ambulatory Surgical Center Payment System: July 2023 Update — Revised
Publications
Expanded Home Health Value-Based Purchasing Model: Resource Index, FAQs, & Specifications
Information for Patients
New Tools to Lower Prescription Drug Costs for Low-Income Seniors and People with Disabilities
Currently, Novitas and First Coast are evaluating our priority list to decide which topic to tackle next. We would appreciate your help in gathering the latest clinical literature and determining the subject we concentrate on. Based on our claims data, appeals, and recent local coverage determination (LCD) reconsideration requests, the topics we are considering are:
Non-FDG Prostate Cancer PET Studies
Predictive, prognostic and/or algorithmic protein-based tests (without genetic testing subparts or components) used in oncology
If you have clinical literature or practice guidelines/standards you would like us to consider for any of topics above, kindly send them to MedicalAffairs@guidewellsource.com before July 7 with the topic clearly noted in the subject line. We also welcome information about specific concerns you would like us to address or be aware of when we begin one of the above topics. While a meeting is not guaranteed, one of our Research Analysts will reach out if our policy team wishes to discuss the topic further with you.
Novitas and First Coast appreciate your willingness to assist us with our policy development process.
The following billing and coding article has been revised:
The following LCD and related billing and coding article have been retired:
The following LCD, which was posted for notice on April 27, 2023, became effective on June 11, 2023. The related billing and coding article for this LCD is also now effective:
The following billing and coding article, which was revised and published on April 27, 2023, is now effective:
Billing information related to the proper use of the JW and JZ modifiers has been updated. Please review this article for more information.
News
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the Territory of Guam Due to Recent Typhoon
CMS Roundup (June 2, 2023)
Gender-Specific Services: Billing Correctly and Usage of the Condition Code/Modifier
Medicare Shared Savings Program: Apply for January 1 Start Date by June 15
Skilled Nursing Facility Value-Based Purchasing Program: June Feedback Report
Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports
Medicare Providers: Deadlines for Joining an Accountable Care Organization
Help Address Disparities in the LGBTQI+ Community
Claims, Pricers, & Codes
National Correct Coding Initiative: July Update
Integrated Outpatient Code Editor: Version 24.2
MLN Matters® Articles
Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order
The following billing and coding article has been revised:
The following billing and coding article has been revised and will become effective June 11, 2023:
The following LCD and related billing and coding article has been retired:
The following LCDs and related billing and coding articles are being retired effective for dates of service on and after June 11, 2023:
On April 18, 2023, the FDA amended the emergency use authorizations (EUAs) of the Moderna and Pfizer-BioNTech COVID-19 bivalent mRNA vaccines to simplify the vaccination schedule for most individuals.
In response, CMS added a termination date of April 17, 2023, to the following CPT codes: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A 91300, 91301, 91305, 91306, 91307, 91308, 91309, 91311.
In addition, CMS is adding the following CPT codes effective April 18, 2023: 0121A, 0141A, 0142A, 0151A, 0171A, 0172A. CMS added these changes to the COVID-19 vaccines and monoclonal antibodies webpage.
As a result of the change, updates have been made to the following references:
New:
Make sure your billing staffs knows about using JW modifier data to show discarded amounts of drugs in a single-dose container or single-use package and reporting requirements for new JZ modifier starting July 1, 2023.
Make sure your billing staff knows MACs will review a small sample of SNF claims. To respond to documentation requests promptly to avoid claim denials. How to submit claims under the Patient Driven Payment Model.
Make sure your billing staff knows about fee schedule adjustment relief for rural and non-contiguous areas and supplier education on power wheelchair repair.
Currently, Novitas and First Coast are evaluating our priority list to decide which topic to tackle next. We would appreciate your help in gathering the latest clinical literature and determining the subject we concentrate on. Based on our claims data, appeals, and recent local coverage determination (LCD) reconsideration requests, the topics we are considering are:
Non-FDG Prostate Cancer PET Studies
Predictive, prognostic and/or algorithmic protein-based tests (without genetic testing subparts or components) used in oncology
If you have clinical literature or practice guidelines/standards you would like us to consider for any of topics above, kindly send them to MedicalAffairs@guidewellsource.com before June 9th with the topic clearly noted in the subject line. We also welcome information about specific concerns you would like us to address or be aware of when we begin one of the above topics. While a meeting is not guaranteed, one of our Research Analysts will reach out if our policy team wishes to discuss the topic further with you.
Novitas and First Coast appreciate your willingness to assist us with our policy development process.
The following LCD posted for comment on June 9, 2022 has been posted for notice. The LCD and related Billing and Coding Article will become effective July 17, 2023.
The following Response to Comments Article contains summaries of all comments received and Novitas’ responses:
New:
Make sure your billing staffs knows one visit to an audiologist without a physician or NPP order is permitted, per patient, once every 12 months. An audiologist’s NPI is the rendering provider on the line of service, with the AB modifier.
News
CMS Announces Plan to Ensure Availability of New Alzheimer’s Drugs
COVID-19 Health Care Staff Vaccination Final Rule
Medicare Secondary Payer Accident-Related Diagnosis Codes: How to Get Paid
Hospitals: New Payment Adjustments for Domestic N95 Respirators
Expanded Home Health Value-Based Purchasing Model: May Newsletter
Improve Cognitive Health: Medicare Covers Services
MLN Matters® Articles
Ambulatory Surgical Center Payment System: July 2023 Update
HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing Enforcement: July 2023 Quarterly Update
Updating Medicare Manual with Policy Changes in the CY 2020 & CY 2021 Final Rules
Publications
Medicare Preventive Services — Revised
Medical Record Maintenance & Access Requirements — Revised
Multimedia
Hospice Quality Reporting Program Web-Based Training — Revised
The following proposed LCD has been posted for comment. The comment period will end on July 15, 2023; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for consideration.
Submit Comments
The following Draft Billing and Coding Article is related to the above Proposed LCD.
The following Billing and Coding Article has been revised:
Online registration for the Friday, June 16 open meeting is now available and will close at noon ET on Wednesday, June 14. Important: During this unprecedented time, our open meeting will be held via webinar 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.
Please review CR 12748 for information regarding the upload of Notice program reimbursement (NPR) letters, interim rate reviews, and tentative settlement documentation into the System for Tracking Audit and Reimbursement (STAR).
New:
Make sure your billing staff knows about payment system updates, including new drug, biological and procedure codes, an ASC Payment Indicator (PI) correction for CPT code 0698T, and additional skin substitute products.
Reason code 34963 is validating the physician to the NPI and if there is a mismatch on the last name, it hits this edit. Please review this updated article for more information. Additionally, information has been added to MM12889 explaining how the attending physician information on a claim is verified.
News
DMEPOS Competitive Bidding Program: Temporary Gap Period Starts January 1
CMS Roundup (May 19, 2023)
Medicare Providers: Deadlines for Joining an Accountable Care Organization
ESRD-Related Services: Comparative Billing Report in May
Claims, Pricers, & Codes
COVID-19 Pfizer-BioNTech & Moderna Vaccines: Product & Administration Code Updates
MLN Matters® Articles
Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers — Revised
Publications
Checking Medicare Claim Status
Multimedia
J0510–J0530 Pain Interview: Understanding How a Patient Communicates Pain Video
Information for Patients
States Are Restarting Medicaid & CHIP Eligibility Reviews: Tell Your Patients to Prepare Now
New:
Make sure your billing staff knows about payment system updates and new codes for COVID-19, drugs, biologicals and radiopharmaceuticals, devices, and other items and services.
Novitas and First Coast greatly appreciate the comments and evidence we received as a result of the multi-jurisdictional Contractor Advisory Committee (CAC) meeting that was held on February 28, 2023, regarding remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices. After careful consideration, Novitas Solutions and First Coast Service Options will not develop a LCD for RPM and RTM for non-implantable devices. All the information and feedback received, along with any new evidence that becomes available, will be carefully considered if we decide to develop an LCD in the future.
Please keep in mind that Novitas and First Coast do not have a policy to match every procedure code, diagnosis code, or service reportable to Medicare. In some instances, we may have an LCD that is not applicable to all providers or services. In the absence of an LCD, NCD, or CMS Manual instruction; reasonable and necessary guidelines still apply to any service reported to Medicare.
New:
Make sure your billing staff knows about Updates to the list of HCPCS codes subject to the CB provision of the SNF prospective payment system (PPS), and additions and deletions of certain chemotherapy and vaccines codes from the Medicare Part B SNF files.
The Issues, denials, rejections, return to provider (RTP) and claims submission errors webpage has been updated. New features include top denial claims, top rejection claims and revised top returned to provider claims. Please take time to review this information.
News
COVID-19: Public Health Emergency Ended May 11
End of COVID-19 Public Health Emergency FAQs
Advancing Health Equity Through The CMS Innovation Center: First Year Progress And What’s To Come
Power Seat Elevation Equipment on Power Wheelchairs: Coverage, Coding, & Payment
Medicare Shared Savings Program: Apply for January 1 Start Date by June 15
Inpatient Rehabilitation Facility Services: Review Choice Demonstration
Women’s Health: Talk with Your Patients About Making their Health a Priority
Claims, Pricers, & Codes
COVID-19: Reporting CR Modifier & DR Condition Code After Public Health Emergency — Reminder
Events
Skilled Nursing Facility: Minimum Data Set Resident Assessment Instrument Training
Publications
Screening Pap Tests & Pelvic Exams — Revised
From Our Federal Partners
Potential Risk for New Mpox Cases
New:
Make sure your billing staff is aware of the updated billing instructions for the nursing facility visits code family, hospital inpatient or observation care code family, and substantive portion of a split, or shared, visit.
With the end of the COVID-19 PHE on May 11, many waivers and flexibilities will expire, be extended or become permanent. For additional guidance, please review our End of COVID-19 public health emergences (PHE) information webpage.
News
CMS Roundup (May 5, 2023)
Medicare Ground Ambulance Data Collection System: Report Information
Compliance
Bill Correctly: Power Mobility Devices Repairs
MLN Matters® Articles
Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
Home Dialysis Payment Adjustment & Performance Payment Adjustment for ESRD Treatment Choices Model: Updated Process
Publications
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance — Revised
Expanded Home Health Value-Based Purchasing Model: Updated Measure Calculation Resources
Although not required, Novitas is providing a 45-day notice of the revisions to the following article before the changes become effective on June 25, 2023:
The following Article has been revised and will become effective June 25, 2023:
The following LCD and related Billing and Coding Article have been retired:
The appropriate drug billing article has been revised to add the correct reporting of units, information on the JW and JZ modifier and more. Please take time to review this article.
New:
Your billing staff should know about adjustments to claim lines on Type of Bill 072X with condition codes 74 or 76, and monthly capitation payment (MCP) claims on claim lines with CPT codes 90957, 90958, 90959, 90960, 90961, 90962, 90965 and 90966.
Make sure your billing staff knows about expiration of the COVID-19 Public Health Emergency (PHE), next CLFS data reporting period, general specimen collection fee increase, and new and discontinued HCPCS codes.
News
FAQs on CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency
Guidance for the Expiration of the COVID-19 Public Health Emergency
COVID-19 Over-the-Counter Tests
Medicare Diabetes Prevention Program: Public Health Emergency Flexibilities Continue through December 31
Transplant Eco-System: Role of Data in CMS Oversight of The Organ Procurement Organizations
Expanded Home Health Value-Based Purchasing Model: April Newsletter & Performance Reports
Religious Nonmedical Health Care Institution Benefit & COVID-19 Vaccines
Clinical Laboratory Fee Schedule 2024 Preliminary Gapfill Rates: Submit Comments by June 26
Mental Health: Recommend Medicare Preventive Services
Claims, Pricers, & Codes
COVID-19: Reporting CR Modifier & DR Condition Code After Public Health Emergency Update
Claim Status Category & Claim Status Codes
Events
Medicare Shared Savings Program: Navigating the Application Webinar — May 8
HCPCS Public Meeting — May 30 – June 1
MLN Matters® Articles
New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI — Revised
Publications
Electronic Cell-Signaling Treatment
Currently, Novitas and First Coast are evaluating our priority list to decide which topic to tackle next. We would appreciate your help in gathering the latest clinical literature and determining the subject we concentrate on. Based on our claims data, appeals, and recent local coverage determination (LCD) reconsideration requests, the topics we are considering are:
Non-FDG Prostate Cancer PET Studies
Genetic testing for protein-based cancers
If you have clinical literature or practice guidelines/standards you would like us to consider for any of topics above, kindly send them to MedicalAffairs@guidewellsource.com before June 9th with the topic clearly noted in the subject line. We also welcome information about specific concerns you would like us to address or be aware of when we begin one of the above topics. While a meeting is not guaranteed, one of our Research Analysts will reach out if our policy team wishes to discuss the topic further with you.
Novitas and First Coast appreciate your willingness to assist us with our policy development process.
The following Proposed LCD and related draft billing and coding article have been retired and will not be finalized. Please refer to the current LCD and related article located on our website:
We are pleased to announce the addition of Part A drugs and biologicals to the Provider Specialties/Service page of our website. This is the central location for drug and biological information, including links to related CMS resources and references. Drugs and biologicals are used in the diagnosis, mitigation, treatment, or prevention of a disease or relief of discomfort.
The JW modifier is required to be reported on all claims for drugs and biologicals separately payable under Medicare Part B with unused and discarded amounts from single-dose containers or single-use packages. Effective July 1, 2023, providers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers that are separately payable under Medicare Part B when there are no discarded amounts. For more information on the proper use of the JW and JZ modifier, please review this article.
Currently, the systematic validation edits for OPPS providers with multiple service locations including outpatient off-campus provider-based departments are not activated. It is important for providers to continue to prepare for implementation by ensuring their enrollment information is up to date, and any claim submissions reflect the practice locations exactly as it appears from the practice location address screen which is received from PECOS. Please review our Hospital off-campus outpatient department reporting article for guidance.
Join us on Wednesday May 10, at 10:00 a.m. for an informative webinar relating to the end of the COVID-19 PHE. To register visit our calendar of events.
News
Hospital Price Transparency Enforcement Updates
For the First Time, HHS Is Making Ownership Data for All Medicare-Certified Hospice and Home Health Agencies Publicly Available
Behavioral Health Integration Services: Find Out What Medicare Covers & Who’s Eligible
Claims, Pricers, & Codes
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
Events
2023 Quality Conference — May 1–3
MLN Matters® Articles
Home Health Claims: Telehealth Reporting
Skilled Nursing Facility Prospective Payment System: Updates to Current Claims Editing
Information for Patients
States Are Restarting Medicaid & CHIP Eligibility Reviews: Tell Your Patients to Prepare Now
The following LCD, which posted for comment on October 13, 2022, has been posted for notice. The LCD and related billing and coding article will become effective June 11, 2023.
The following response to comments article contains summaries of all comments received and Novitas’ responses:
The following billing and coding article has been revised to become effective June 11.
The following billing and coding article has been revised:
The following LCDs and related billing and coding articles have been retired:
The following billing and coding article has been retired:
Please visit this new webpage for resources in effect for services provided for dates of service or admission occurring after the COVID-19 PHE ends on May 11, 2023.
For resources in effect during the COVID-19 PHE for services provided for dates of service or admission before May 12, 2023, please refer to Coronavirus COVID-19 information.
The following billing and coding articles have been revised:
New:
Make sure your staff knows about improved editing of claims that have interrupted stays that span 2 months and modified editing for occurrence span code (OSC) edits allowing for proper claims decisions.
News
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
Medical Review & Compliance: Respond to Additional Documentation Requests
Hospice: Comparative Billing Report in April
Compliance
Home Health Rural Add-On Policy
Claims, Pricers, & Codes
Grandfathered Tribal Federally Qualified Health Centers: CY 2023 Rate
Events
Medicare Ground Ambulance Data Collection System: Office Hours Session — April 27
Medicare Shared Savings Program: Navigating the Application Webinar — May 8
Clinical Laboratory Fee Schedule: Present or Speak at Upcoming Meetings
Multimedia
Medicare Home Health Prospective Payment System CY 2023: Materials from March Webinar
We continue to see an increase of claims return with reason code 34963. Effective with claims received on or after April 1, a new consistency edit was implemented in FISS that validates the attending provider NPI. Organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met. Please review this new article in addition to MLN Matters Article MM12889 for guidance.
Effective March 21, 2023, the Comprehensive Error Rate Testing (CERT) contractor, formerly known as NCI Information Systems, Inc., underwent a name change. The new name is Empower AI, Inc.
The CERT Documentation Center Customer Service may be contacted via:
Phone: 1-888-779-7477
Email: CertProvider@empower.ai
News
COVID-19: End of Public Health Emergency
CMS Roundup (Apr. 07, 2023)
Medicare Shared Savings Program: Application Toolkit Materials
Inpatient Rehabilitation Facility Interdisciplinary Team Meetings After the COVID-19 Public Health Emergency
Hospital Outpatient Departments: Prior Authorization for Facet Joint Interventions Starts July 1
Opioid Treatment Program Webpage Updates
Claims, Pricers, & Codes
Home Health Original Claims: Don’t Include Cross-Reference Document Control Numbers
Outpatient Rehabilitation Claims with Reason Code W7072: You Might Need to Resubmit Claims
Events
IRIS: XML Format & Duplicate Interns and Residents Full-Time Equivalents Review — May 3
MLN Matters® Articles
New Waived Tests
Publications
Intravenous Immune Globulin Demonstration — Revised
Medicare Modernization of Payment Software — Revised
Multimedia
Expanded Home Health Value-Based Purchasing Model: Self-Assessment Tool Webinar Materials
The following billing and coding article has been revised:
The following LCD and related billing and coding article have been retired:
The following proposed LCD and related draft billing and coding article have been retired and will not be finalized. Please refer to the current LCD and related article located on our website:
Proposed Rule
When submitting a prior authorization request (PAR) for certain hospital outpatient department (HOPD) services via fax, please use the new fax number 833-200-9268. The standard and expedited PAR fax/mail coversheets for HOPD have been revised to add this new fax number.
News
Resources & Flexibilities to Assist with Public Health Emergency in Mississippi Due to Recent Storms
Program for Evaluating Payment Patterns Electronic Reports
Advance Beneficiary Notice of Noncoverage: Form Renewal
New Recovery Audit Contractor for Region 2 Starting Spring 2023
Comprehensive Error Rate Testing Review Contractor Company Changed Name
Help Improve the Health of Minority Populations
Claims, Pricers, & Codes
RARCs, CARCs, Medicare Remit Easy Print, & PC Print: April Update
Events
PCG Provider Compliance Focus Group: Provider Compliance Activities Post-PHE — May 9
MLN Matters® Articles
Hospital Outpatient Prospective Payment System: April 2023 Update — Revised
Effective with claims received on or after April 1, a new consistency edit was implemented in FISS that validates the attending provider NPI. Organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met. Please review MLN Matters Article MM12889 for guidance.
The following billing and coding articles have been revised:
The following LCDs and related billing and coding articles have been retired:
The following billing and coding article has been retired:
We have updated the implantable infusion pump, skin substitute codes and drug codes that will require an invoice.
Proposed Rules
News
COVID-19: Booster Dose for Children 6 months – 4 years
Identity & Access Management System: Easier for Surrogates
Medicare Advantage Value-Based Insurance Design Model Extended
Supplemental Security Income & Medicare Beneficiary Data: FY 2021
DMEPOS for Skilled Nursing Facility: Pre-Discharge Delivery for Fitting & Training
Claims, Pricers, & Codes
COVID-19: Reporting CR Modifier & DR Condition Code After Public Health Emergency
April 2023 Quarterly Pricing File Revisions
MLN Matters® Articles
Medicare Part B Coverage of Pneumococcal Vaccinations
Supervision Requirements for Diagnostic Tests: Manual Update
Publications & Multimedia
Post-Acute Care Quality Reporting Program: Videos & Patient Cue Cards
Expanded Home Health Value-Based Purchasing Model: March Newsletter, FAQs, & Recordings
Information for Patients
States Are Restarting Medicaid & CHIP Eligibility Reviews: Tell Your Patients to Prepare Now
On March 14, the FDA amended the emergency use authorization of the updated (bivalent) Pfizer-BioNTech COVID-19 vaccine to include a single booster dose of the vaccine in children 6 months – 4 years old at least 2 months after completion of primary vaccination with 3 doses of the monovalent (single strain) Pfizer-BioNTech COVID-19 vaccine.
CMS issued a new code effective March 14, the new Pfizer-BioNTech COVID-19 vaccine bivalent administration codes 0174A. CMS added the fee for the recently added code to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of the change, updates have been made to the following references:
Due to scheduled maintenance, the EDI Gateway will not be available for electronic claim submissions or report retrievals on April 1 from 7 a.m. to 4 p.m. ET. We apologize for any inconvenience.
There is an update to the impacted LTCH inpatient claims impacted claims that incorrectly received the reason codes 37022, 37023 or 37027. The impacted claims were being held in status location S MQ247.
The correction was installed on March 27, 2023. All claims that were held have been released for processing.
The following Local Coverage Article, which was posted for notice on February 9, 2023, is now effective:
WPS Government Health Administrators (GHA), along with CGS Administrators, National Government Services (NGS), Noridian Healthcare Solutions, Novitas Solutions, First Coast Service Options, and Palmetto, will host a Multi-Jurisdictional Contractor Advisory Committee (CAC) meeting via webinar. Discussions will focus on trigger point injections.
Date: Thursday, April 27
Time: 1:00 p.m. – 4:00 p.m. CT (2:00 PM – 5:00 PM ET)
The purpose of the meeting is to obtain advice from CAC members and subject matter experts (SMEs) regarding the strength of published evidence on trigger point injections and procedures. In addition to discussion, the CAC and SME panel will vote on a series of key questions. CAC panels do not make coverage determinations, but Medicare Administrative Contractors (MACs) benefit from their advice. The public is invited to attend as observers.
Registration is required. Please register here.
Join here on the date of the meeting.
Complete details, including background material, questions, and the agenda are available on the WPS Contractor Advisory Committee (CAC) Meetings Website
If you do not have access to the Internet, you can access the meeting via telephone:
Participant Number: 1 (415) 655-0001 US Toll
Access Code: 2458 983 0704
News
Additional Residency Positions: Apply by March 31
Laboratory Testing Urinalysis: Comparative Billing Report in March
Long-Term Care Hospital Provider Preview Reports: Review by April 14
Inpatient Rehabilitation Facility Provider Preview Reports: Review by April 14
Make Your Voice Heard Summary: Reducing Burden & Increasing Efficiencies
Promote Kidney Health During National Kidney Month
Compliance
Critical Access Hospitals: Bill Correctly
Claims, Pricers, & Codes
Integrated Outpatient Code Editor: Version 24.1
Events
Medicare Home Health Prospective Payment System CY 2023 Webinar — March 29
MLN Matters® Articles
Ambulatory Surgical Center Payment System: April 2023 Update
DMEPOS Fee Schedule: April 2023 Update
The following articles have been retired:
New:
Make sure your billing staff knows about these changes Expanded list of provider types authorized to supervise diagnostic tests, and updates to Medicare Benefit Policy Manual.
News
HHS Releases Initial Guidance for Historic Medicare Drug Price Negotiation Program for Price Applicability Year 2026
Quality Payment Program: 2021 Care Compare Performance Information
Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports
Skilled Nursing Facility Value-Based Purchasing Program: March Feedback Report
Audiologists Can Furnish Certain Diagnostic Tests Without a Physician Order
Colorectal Cancer: Screening Saves Lives
Claims, Pricers, & Codes
COVID-19: Don’t Report CR Modifier & DR Condition Code After Public Health Emergency
Split (or Shared) Critical Care Visits: Billing Correction
ICD-10 Coordination & Maintenance Committee: Meeting Materials & Deadlines
HCPCS Application Summaries & Coding Decisions: Non-Drug & Non-Biological Items & Services
Events
Home Health Value-Based Purchasing Model Webinar: Strategies for Success Self-Assessment Tool — March 30
Publications
Medicare Secondary Payer: Don’t Deny Services & Bill Correctly
Behavioral Health Integration Services — Revised
Medicare Preventive Services — Revised
New:
Make sure your billing staff knows about payment system updates and new codes for COVID-19, Drugs, biologicals, radiopharmaceuticals, devices, and other items and services.
An issue has been identified with part of the Fiscal Intermediary Shared System (FISS) internal processing program to calculate days. This is causing LTCH inpatient claims to incorrectly receive the reason codes 37022, 37023 or 37027. The impacted claims are being held in status location S MQ247. A correction has been developed by FISS and is scheduled to be installed on April 3, 2023. No provider action is needed. Claims will be released for processing when the correction is installed.
The February 2023 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
News
Effective for dates of service (DOS) beginning July 1, 2023, CMS has added a new service category to the Hospital Outpatient Department (OPD) Prior Authorization program. This additional hospital OPD service category will require prior authorization as a condition of payment for facet joint interventions. Please review our article for further information.
News
Nutrition-Related Health Conditions: Recommend Medicare Preventive Services
Compliance
Advance Care Planning: Bill Correctly for Services
Claims, Pricers, & Codes
Medicare Physician Fee Schedule Database: April Update
Home Health Prospective Payment System Grouper: April Update
Events
Ambulance Open Door Forum: Medicare Ground Ambulance Data Collection System — March 16
MLN Matters® Articles
Extension of Changes to the Low-Volume Hospital Payment Adjustment & the Medicare Dependent Hospital Program
National Coverage Determination: Cochlear Implantation
Patient Driven Payment Model: Claim Edit Enhancements — Revised
Publications
Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier — Revised
Information for Patients
New Inflation Reduction Act Resources
The following billing and coding article has been revised:
There is an update to the colorectal cancer (CRC) screening test claims, HCPCS G0104, G0105, G0106, G0120, G0121, G0327, G0328, 81528 and 82270, with dates of service on or after January 1, will be held until national editing related to age and frequency limitations is implemented per the updated policies finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule (87 FR 69404), published in the Federal Register on November 18, 2022. Claims containing these HCPCS will be held in status location S/MT099 until the April 2023 release.
The correction, CR13017, was installed on February 27, 2023. All claims held have been released for processing.
News
The Future of Medicare Enrollment: Save Time with PECOS's Consolidated Application
Voluntary Prior Authorization Process for Certain Power Mobility Device Accessory Items
Expanded Home Health Value-Based Purchasing Model: February Newsletter
Events
ICD-10 Coordination & Maintenance Committee Meeting — March 7–8
Medicare Home Health Prospective Payment System CY 2023 Webinar — March 29
Medicare Cost Report E-Filing System Webinar — March 30
Multimedia
Shared Savings Program & Community-Based Organization Collaboration Webinar Materials
From Our Federal Partners
Cannabidiol: Discuss Potential Harms with Your Patients
Increase in Extensively Drug-Resistant Shigellosis in the U.S.
New:
Make sure your staff knows about expanded coverage for cochlear implantation services performed as part of FDA-approved category B investigational device exemption clinical trials for patients not meeting the coverage criteria, and as a routine cost in certain clinical trials for patients not meeting the coverage criteria.
News
The issue with low-volume hospital payment adjustment and the Medicare Dependent Hospital (MDH) Program has been updated. CMS issued change request 13103, instructing Medicare contractors to update the Provider Specific File (PSF) for certain hospitals impacted by the low-volume hospital payment adjustment policy or the MDH program.
The updates to the impacted provider files will be completed by March 10, 2023. The claims will be identified and automatically reprocessed within 75 days. No provider action is necessary.
New:
Make sure you know about Criteria and payment adjustments for FY 2023, and extension of the MDH program.
News
News
Hospital Price Transparency: Progress & Commitment to Achieving Its Potential
Home Infusion Therapy Services Monitoring Report
Immunosuppressive Drugs: Comparative Billing Report in February
Expanded Home Health Value-Based Purchasing Model Resources: Submit Feedback through March 31
Claims, Pricers, & Codes
HCPCS Level II Coding: FAQs for Single Source Drugs & Biologicals
National Correct Coding Initiative: No April Update
Publications
DMEPOS Quality Standards — Revised
The following billing and coding articles have been revised:
Have questions and not sure where to turn? Check out our FAQs for answers to your questions.
News
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
Unprecedented Efforts to Increase Transparency of Nursing Home Ownership
CMS Proposes Benefit Expansion for Mobility Devices, Advancing Health Equity for People with Disabilities
CMS Addresses Inequities in Rural Health in Medicare
Medicare Shared Savings Program: Application Deadlines for January 1, 2024, Start Date
Events
Medicare Home Health Prospective Payment System CY 2023 Webinar — March 29
MLN Matters® Articles
HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing: April 2023 Update
ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update
Multimedia
Expanded Home Health Value-Based Purchasing Model: First Performance Year Quick Guide Materials
Information for Patients
Options When ESRD Coverage with Medicare Ends
This meeting will be held via webinar only.
On February 28, at 6:00 p.m. ET, MACs Novitas Solutions (Jurisdictions H and L) and First Coast Service Options (Jurisdiction N), along with Noridian Healthcare Solutions (Jurisdictions E and F), CGS Administrators (Jurisdiction 15), Palmetto GBA (Jurisdictions J and M), and WPS Government Health Administrators (Jurisdictions 5 and 8) will host a multi-jurisdictional Contractor Advisory Committee (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 remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices and any compelling clinical data to assist in defining meaningful and measurable patient outcomes (e.g., decreases in emergency room visit and hospitalizations) for our Medicare beneficiaries to assist in the determination of whether an LCD should be developed. In addition to discussion, CAC members and SMEs will opine on pre-distributed questions during the meeting. CAC panels do not make coverage determinations, but MACs benefit from their advice.
This meeting will be held via webinar only and will be open to the public; however, only CAC members, SMEs, and our RPM/RTM national work group CMDs will participate in the meeting discussion; all other attendees will be non-speaking observers. The meeting will be recorded and both the audio and written transcript will be made public.
Complete meeting details including meeting agenda, bibliography, discussion questions, and non-speaking observer registration is now available on our multi-jurisdictional CAC website.
News
News
DMEPOS: Get Benefit Category Determinations
Nurse Practitioners & Clinical Nurse Specialists: Update to List of National Certifying Bodies
Help Address Heart Health Disparities
Compliance
What’s the Comprehensive Error Rate Testing Program?
Claims, Pricers, & Codes
Home Health: Revised Editing of Telehealth Claims
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
MLN Matters® Articles
Clinical Laboratory Fee Schedule & Laboratory Services Subject to Reasonable Charge Payment: Quarterly Update
New Payment Adjustments for Domestic N95 Respirators
Removal of a National Coverage Determination & Expansion of Coverage of Colorectal Cancer Screening
Rural Health Clinic & Federally Qualified Health Center Medicare Benefit Policy Manual Update
The following article has been revised and will become effective March 27:
The following billing and coding article has been revised:
The following LCDs and related billing and coding articles have been retired:
New information has been added regarding changes beginning January 1, for coverage of colorectal cancer screenings.
New:
Make sure your billing staffs are aware of these changes, newly available codes, recent coding changes, and how to find NCD coding information.
The following LCD, which was posted for notice on December 22, 2022, became effective on February 5. The related billing and coding article for this LCD is also now effective:
New:
Make sure your billing staff knows about Removal of NCD 160.22 - Ambulatory Electroencephalographic (EEG) Monitoring, lowering the minimum age for colorectal cancer screening (CRC) from age 50 to 45 for certain tests, expanding the definition of CRC screening tests and new billing instructions for colonoscopies under certain scenarios, and Medicare manual updates.
Make sure your reimbursement staff knows about these cost reporting period changes and documentation requirements starting January 1, new payment adjustments for domestic National Institute for Occupational Safety and Health (NIOSH)-approved surgical N95 respirators, and biweekly interim lump-sum payments.
Make sure your billing staff knows about next CLFS data reporting period, general specimen collection fee increase, new and discontinued HCPCS codes.
News
Aligning Quality Measures across CMS — The Universal Foundation
Medicare Ground Ambulance Data Collection System: Portal to Report is Open
Skilled Nursing Facilities: Care Compare January Refresh
Expanded Home Health Value-Based Purchasing Model: January Newsletter & Performance Reports
Therapy Services: Per-Beneficiary CY 2023 Threshold Amounts
Claims, Pricers, & Codes
Federally Qualified Health Center Prospective Payment System: CY 2023 Pricer
Events
Shared Savings Program & Community-Based Organization Collaboration Webinar — February 14
Medicare Ground Ambulance Data Collection System: Q&A Session — February 23
MLN Matters® Articles
Provider Enrollment: Regulatory Changes
A NCD spreadsheet FAQ has been added concerning illustrating diagnosis listing. Not all diagnosis codes listed in the NCD spreadsheets are covered. A message will appear at the top of the diagnosis listing to indicate denial or coverage.
More information can be found in the FastTrack to Medicare Coverage Policies – View NCD
We seek your input on establishing pricing under the Medicare program for the 2023 Gapfill laboratory test codes. If you have not already done so, please complete our Molecular Diagnostic Pathology Survey by February 13. Please complete a separate survey for each test you perform.
New:
Make sure your billing staff knows about the 2022 and 2023 updates of the Medicare Benefit Policy Manual, Chapter 13, and all other revisions clarifying existing policy.
Revised:
A revision to change request 13031 updated tables 5 and 6 and added table 20 to update the pass-through status of 5 devices to extend pass-through status for a 1-year period starting on January 1.
News
Medicare Enrollment in PECOS: Faster & Easier Application Process — Coming Summer 2023
Medicare Enrollment: Maintain the Same Owners in All Enrollment Records
Hospitals: Revised Beneficiary Notices Required April 27
Chiropractic Manipulative Treatment of the Spine: Comparative Billing Report in January
Poverty: Help Reduce Disparities
MLN Matters® Articles
Home Health Changes for Disaster Claims and Certain Adjustments
This meeting will be held via webinar only.
On February 28, at 6:00 p.m. ET, MACs Novitas Solutions (Jurisdictions H and L) and First Coast Service Options (Jurisdiction N), along with Noridian Healthcare Solutions (Jurisdictions E and F), CGS Administrators (Jurisdiction 15), Palmetto GBA (Jurisdictions J and M), and WPS Government Health Administrators (Jurisdictions 5 and 8) will host a multi-jurisdictional Contractor Advisory Committee (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 remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices and any compelling clinical data to assist in defining meaningful and measurable patient outcomes (e.g., decreases in emergency room visit and hospitalizations) for our Medicare beneficiaries to assist in the determination of whether an LCD should be developed. In addition to discussion, CAC members and SMEs will opine on pre-distributed questions during the meeting. CAC panels do not make coverage determinations, but MACs benefit from their advice.
Additional information is available on becoming a SME for the February 28, meeting. This meeting will be held via webinar only and will be open to the public; however, only CAC members, SMEs, and our RPM/RTM national work group CMDs will participate in the meeting discussion; all other attendees will be non-speaking observers. The meeting will be recorded and both the audio and written transcript will be made public.
Complete meeting details such as agenda, questions, bibliography, non-speaking observer registration and webinar information will be available on our multi-jurisdictional CAC website by February 14.
There are two updates currently. The first is the open claims issue associated with electronic funds transfer (EFT) deposits with an issuance date of January 9, and January 10, with a delayed deposit date of January 11, and January 12, respectively has been closed.
The second is colorectal cancer (CRC) screening test claims, HCPCS G0104, G0105, G0106, G0120, G0121, G0327, G0328, 81528 and 82270, with dates of service on or after January 1, will be held until national editing related to age and frequency limitations is implemented per the updated policies finalized in the CY 2023 Physician Fee Schedule (PFS) Final Rule (87 FR 69404), published in the Federal Register on November 18, 2022. Claims containing these HCPCS will be held in status location S/MT099 until the April 2023 release.
The following articles have been revised to reflect the 2023 Annual CPT/HCPCS Code updates effective for dates of service on and after January 1:
The following LCD and related article have been retired effective for dates of service on and after January 1:
The December 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. A new question / answer has been added to the general information category and an update has been made to the return to provider category. Please take time to review these and other FAQs for answers to your questions.
New:
Make sure your staff know about recent enrollment changes, including SNF screening and fingerprinting requirements, screening of certain changes of ownership, and screening for “bump-ups”
Revised:
A revision to change request 13031 updated tables 5 and 6 and added table 20 to update the pass-through status of 5 devices to extend pass-through status for a 1-year period starting on January 1.
News
Additional Steps to Strengthen Nursing Home Safety and Transparency
Increase in 2023 in Organizations and Beneficiaries Benefiting from Coordinated Care in Accountable Care Relationship
DMEPOS: Updates to Face-to-Face Encounter & Written Order Prior to Delivery List
Skilled Nursing Facility Provider Preview Reports: Review by February 16
Value-Based Insurance Design Model: Learn about the Hospice Benefit Component
Medicare Ground Ambulance Data Collection System: 5 Top Tips for Reporting
Glaucoma Awareness Month: Act to Prevent Vision Loss
Compliance
Home Health Rural Add-On Policy
Claims, Pricers, & Codes
ICD-10 Code Files & MS-DRGs Version 40.1: April Update
Integrated Outpatient Code Editor: Version 24.R1
Publications
Post-Acute Care Quality Reporting Programs: COVID-19 Public Reporting
Effective for dates of service on and after August 7, 2019, Medicare will pay claims from approved providers for administration o autologous T-cells expressing at least one Chimeric Antigen Receptor (CAR) for the treatment for cancer. This article was updated to add details for Carvykti and Part B (outpatient) billing instructions and pricing information.
Novitas seeks your input on establishing pricing under the Medicare program for the 2023 Gapfill laboratory test codes. If you have not already done so, please complete our Molecular Diagnostic Pathology Survey by February 13, 2023. Please complete a separate survey for each test you perform.
News
Key Dates for First Year of Inflation Reduction Act’s Medicare Drug Price Negotiation Program
Cognitive Assessment: CY 2023 Updates
Care Compare: Telehealth Indicator for Doctors & Clinicians
Clinical Laboratory Fee Schedule: CY 2023 Payment File
Clinical Laboratories: PAMA Reporting & Payment Reductions Delayed
Medicare Wellness Visits: Get Your Patients Off to a Healthy Start
Claims, Pricers, & Codes
Drugs & Biologicals in Single-Use Containers: Using JW & JZ Modifiers
MLN Matters® Articles
Travel Allowance Fees for Specimen Collection: 2023 Updates
ESRD & Acute Kidney Injury Dialysis: CY 2023 Updates — Revised
Home Health Prospective Payment System: CY 2023 Update — Revised
National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy — Revised
News
Electronic funds transfer (EFT) deposits with an issuance date of January 9, and January 10, will have a delayed deposit date of January 11, and January 12, respectively. EFT deposits with an issuance date effective January 11, and forward will resume with normal deposit timeframes. We apologize for the inconvenience. No action needs to be taken by the you at this time.
CMS released updated fees for the COVID-19 vaccines and the mAbs on the CMS COVID-19 Vaccines and Monoclonal Antibodies webpage.
As a result of these changes, the following articles have been created and added to our COVID-19 vaccine and monoclonal antibodies specialty page with these new fees:
New:
Make sure your billing staffs knows about specimen collection fees and travel allowances for 2023, and other policy updates and reminders.
News
COVID-19: Updated Vaccines for Children Ages 6 Months – 5 Years
Advisory Panel on Hospital Outpatient Payment: Request for Nominations
Certificates of Medical Necessity & DME Information Forms Discontinued January 1
Cervical Health: Encourage Screening
Claims, Pricers, & Codes
Home Oxygen: 3 New Claims Modifiers
Home Health Prospective Payment System: CY 2023 Rural Add-on Policy
Skilled Nursing Facility Consolidated Billing: CY 2023 HCPCS Codes
MLN Matters® Articles
Ambulatory Surgical Center Payment System: January 2023 Update
Effective November 8, 2022, the FDA has granted EUA for the emergency use of Swedish Orphan Biovitrum AB's (SOBI) Kineret (anakinra) for the treatment of COVID-19 in certain hospitalized patients. Please review our article for guidance.
Revised:
CMS revised this article due to a revised change request (CR) 12804. The CR revision didn’t change the substance of the article. The CR release date, transmittal numbers, and web addresses of the transmittals have been revised. All other information is the same.
The Novitas Solutions’ Medical Policy team has evaluated all active Local Coverage Articles for any impact in response to the 2023 Annual HCPCS/CPT Code Update. The following is a list of the impacted Articles. The revised Articles will be published to the Medicare Coverage Database and on our Website in January. Please continue to watch our website for updates.
Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985)
Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)
Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240)
Billing and Coding: Autonomic Function Tests (A54954)
Billing and Coding: Bariatric Surgical Management of Morbid Obesity (A56422)
Billing and Coding: Biomarkers for Oncology (A52986)
Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
Billing and Coding: Complex Drug Administration Coding (A59073)
Billing and Coding: Endovenous Stenting (A56414)
Billing and Coding: eVox® System and Other Electroencephalograph Testing for Memory Loss (A56440)
Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
Billing and Coding: Frequency of Hemodialysis (A55723)
Billing and Coding: Frequency of Laboratory Tests (A56420)
Billing and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee (A55036)
Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58110)
Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Billing and Coding: Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases (A53121)
Billing and Coding: Molecular Pathology and Genetic Testing (A58917)
Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
Billing and Coding: Non-Vascular Extremity Ultrasound (A55037)
Billing and Coding: Outpatient Sleep Studies (A56923)
Billing and Coding: Pharmacogenomics Testing (A58801)
Billing and Coding: Prolonged Drug and Biological Infusions Started Incident to a Physician’s Service Using an External Pump (A55134)
Billing and Coding: Psychiatric Codes (A57130)
Billing and Coding: Respiratory Pathogen Panel Testing (A58575)
Billing and Coding: Therapy and Rehabilitation Services (PT, OT) (A57703)
Billing and Coding: Urodynamic Services - Non-invasive (A58541)
On December 8, the FDA amended the Pfizer-BioNTech COVID-19 emergency use authorizations (EUAs) to authorize bivalent formulations of the vaccines for use as a third primary series dose for ages 6 months through 4 years and Moderna COVID-19 EUAs as a booster for ages 6 months through 5 years. CMS issued four new codes effective December 8, the new Pfizer-BioNTech COVID-19 vaccine bivalent product code 91317 and the new Moderna COVID-19 vaccine bivalent product code 91316 and the two new affiliated administration codes 0173A and 0164A, respectively. CMS added the fees for these recently added codes to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
Editor's Note:
Happy holidays from the MLN Connects team. We’ll release the next regular edition on Thursday, January 5, 2023.
News
HHS Proposes to Standardize Electronic Health Care Attachments Transactions and Electronic Signature Processes to Improve the Care Experience for Patients and Providers
Long-Term Care Hospital Provider Preview Reports: Review by January 17
Inpatient Rehabilitation Facility Provider Preview Reports: Review by January 17
Hospital Ownership Data Release
Clotting Factor: CY 2023 Furnishing Fee
Medicare Diabetes Prevention Program: CY 2023 Payment Rates
CMS Burden Reduction News & Insights
Claims, Pricers, & Codes
Medicare Part B Drug Pricing Files & Revisions: January Update
Integrated Outpatient Code Editor: Version 24.0
DMEPOS: Revised 2023 Fee Schedule Public Use File
National Correct Coding Initiative: Annual Policy Manual Update & Information on Other Payers
MLN Matters® Articles
Clinical Laboratory Fee Schedule: CY 2023 Annual Update
Hospital Outpatient Prospective Payment System: January 2023 Update
Laboratory Edit Software Changes: April 2023
New Medicare Part B Immunosuppressant Drug Benefit
Extension of Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital Program — Revised
Publications
Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier
Rural Emergency Hospitals
Intravenous Immune Globulin Demonstration — Revised
Medicare Preventive Services — Revised
From Our Federal Partners
CDC Interim Guidance: Antiviral Treatment of Influenza
Important Updates from the CDC on COVID-19 Therapeutics for Treatment & Prevention
The following LCD posted for comment on August 11, 2022, has been posted for notice. The LCD and related billing and coding article will become effective February 5, 2023.
The following response to comments article contains summaries of all comments received and Novitas’ responses:
The following billing and coding article has been revised:
The November 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. A new question / answer has been added to the return to provider category. Please take time to review these and other FAQs for answers to your questions.
There will be Common Working File (CWF) 'Dark' days from December 30, 2022, through Sunday, January 1, 2023, due to the January 2023 release updates. The interactive voice response (IVR) will have limited availability. Additionally, the Customer Contact Center will be closed Monday, January 2, 2023.
Please review this notice concerning voluntary refunds for 2022.
New:
MM12804 - New Medicare Part B Immunosuppressant Drug Benefit
Make sure your billing staff knows that this new benefit is effective January 1, 2023:
Extension of Medicare coverage for immunosuppressant drugs beyond 36 months for certain patients with kidney transplants
Coverage of premiums and cost sharing for some of these patients
News
Opioid Treatment Programs: New Information for 2023
Part B Immunosuppressive Drug Benefit: Check Medicare Eligibility
Home Health Quality Reporting Program: Get Final OASIS-E Instrument
Compliance
Bill Correctly: Power Mobility Devices
Claims, Pricers, & Codes
Intravenous Immune Globulin Treatment in the Home: ICD-10 Code Update
MLN Matters® Articles
DMEPOS Fee Schedule: CY 2023 Update
HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: April 2023
Home or Residence Services: Billing Instructions
National Coverage Determination 200.3: Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
Publications
Post-Acute Care Quality Reporting Program: Patient Health Questionnaire Cue Card
New:
Make sure your billing staff knows about changes to the laboratory NCD edit module for April 2023.
Make sure your billing staff knows about payment system updates and new codes for COVID-19, Drugs, biologicals, radiopharmaceuticals, devices, and other items and services.
This article includes updates to the allowed and not allowed revenue codes for billing Medicare Part B for inpatient services on a 12x type of bill based on recently updated information in the CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, section 240.
Revised:
CMS revised this article due to a revised change request (CR) 12970. CMS is giving your MAC 60 days to reprocess claims affected by the CR. The CR release date, transmittal number, and the web address of the CR are also revised. All other information is the same.
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
New:
MM13023 - Clinical Laboratory Fee Schedule: CY 2023 Annual Update
Make sure your billing staff knows about:
Instructions for the CY 2023 Clinical Laboratory Fee Schedule (CLFS)
Mapping for new codes for clinical laboratory tests
Updates for laboratory costs subject to the reasonable charge payment
The following LCD, which was posted for notice on October 27, is now effective. The related billing and coding article for this LCD is also now effective:
The following billing and coding articles have been revised:
New:
Make sure your billing staff knows about coverage for:
FDA-approved monoclonal antibodies
CMS-approved studies
Make sure your billing staff knows about billing for the new E/M visit family:
Codes
Care settings
News
CMS Proposes Rule to Expand Access to Health Information and Improve the Prior Authorization Process
Rural Emergency Hospitals: New Institutional Provider Type Starting January 1
Certificates of Medical Necessity & DME Information Forms Discontinued January 1
Drugs & Biologics: Reporting Average Sales Price Data
Provider Enrollment Application Fee: CY 2023
Skilled Nursing Facility Value-Based Purchasing Program: December Feedback Report
Bronchodilator Nebulizer Medications: Comparative Billing Report in December
Short-term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports
Flu Shots: Help Address Disparities
Compliance
Bill Correctly: Power Mobility Device Repairs
Claims, Pricers, & Codes
Medicare National Correct Coding Initiative: Annual Policy Manual Update
National Correct Coding Initiative: January Update
Events
FY 2024 New Technology Town Hall Meeting — December 14
Medicare Ground Ambulance Data Collection System Webinar: Data Certifier Role — December 15
MLN Matters® Articles
Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2023 Changes
National Coverage Determination 110.24: Chimeric Antigen Receptor T-cell Therapy
Rural Health Clinic All-Inclusive Rate: CY 2023 Update
From Our Federal Partners
Biosimilars & Interchangeable Products: Free Continuing Education Courses from FDA
Revised:
CMS revised this article due to a revised CR12842. As a result, CMS deleted the bullet point for NCD 150.3 on page 2. Also, CMS changed the CR release date, transmittal number and the CR web address. All other information remains the same.
New:
Make sure your billing staff knows about this annual update:
Fee schedule amounts for new and existing codes
Payment policy changes
New:
Make sure your billing staff knows about FY 2023 IPPS updates, FY 2023 LTCH PPS updates, and update to certain hospitals that CMS excludes from the IPPS.
Make sure your billing staff knows about these changes for CAR T-cell Therapy (CAR-T) billing Include additional place of service (POS) codes for office and independent clinics, bill in 0.1-unit fractions, and use 3 modifiers, including new modifier -LU.
The open claims issues associated with reason code 38204 has been closed.
News
CMS Urges Timely Patient Access to COVID-19 Vaccines, Therapeutics
Quality Payment Program: Preview Your Performance Information by December 20
Clinical Laboratory Fee Schedule: CY 2023 Final Payment Determinations
HIV: Screening is Knowledge
Compliance
LAAC & ICD National Coverage Determinations: Submit Proper Documentation
MLN Matters® Articles
National Fee Schedule for Medicare Part B Vaccine Administration
New Waived Tests
New & Expanded Flexibilities for Rural Health Clinics & Federally Qualified Health Centers during the COVID-19 PHE — Revised
Home Health Claims: New Grouper Edits — Revised
Publications
Checking Medicare Eligibility — Revised
From Our Federal Partners
Biosimilars: Are They the Same Quality?
Information for Patients
Options When ESRD Coverage with Medicare Ends
New:
Make sure your billing staff knows about RHC per-visit payment limit for CY 2023, specified (grandfathered) provider-based RHC payment limits, and cost report data requirements.
The comment period is now closed for the following Proposed LCDs. 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.
News
Colorectal Cancer Screening Test: Reduced Coinsurance for Related Procedures Begins January 1
Ambulance Fee Schedule: CY 2023 Inflation Factor & Productivity Adjustment
Medicare Ground Ambulance Data Collection System: Information to Help You Report
Health Professional Shortage Area: CY 2023 Bonus Payments
Rural Health: Help Address Disparities
MLN Matters® Articles
ESRD & Acute Kidney Injury Dialysis: CY 2023 Updates
Home Health Prospective Payment System: CY 2023 Update
Medicare Physician Fee Schedule Final Rule Summary: CY 2023
Publications
Federally Qualified Health Center — Revised
From Our Federal Partners
Managing Monkeypox in Patients Receiving Therapeutics: CDC Update
New:
Make sure your billing staff knows about:
Updated payment amount for preventive vaccine administration
HCPCS codes to which these adjustments apply
COVID-19 vaccine administration codes
As a reminder, the comment period for the following proposed LCDs is currently open and will close on November 26. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit Comments
New:
Make sure your billing staff knows about the following CY 2023 MPFS updates:
Telehealth originating site facility fee payment amount.
Expansion of coverage for colorectal cancer screening.
Coverage of audiology services.
Other covered services.
News
Hospital Price Transparency: Download Machine-Readable File Sample Formats & Data Dictionaries
Medical Review After the COVID-19 Public Health Emergency: New FAQ
Flu Shots & COVID-19 Vaccines: Each Visit is an Opportunity
Claims, Pricers, & Codes
DMEPOS: Corrected 2022 Fee Schedule Amounts
Hospital Part B Inpatient Services Billing
Outpatient Prospective Payment System Payment Rate for HCPCS Code Q5124
Events
HCPCS Public Meeting: November 29 – December 1
MLN Matters® Articles
Provider Enrollment Instructions: Seventh General Update
ICD-10 & Other Coding Revisions to National Coverage Determinations (NCDs): April 2023 Update
Publications
Home Health & Hospice: Medicare Provider Resources
Independent Diagnostic Testing Facility (IDTF) — Revised
Multimedia
Quality in Focus Videos to Increase Quality of Care
The following billing and coding articles have been revised.
The following LCD and related billing and coding article have been retired:
To reduce provider burden, certain contractor priced HCPCs codes no longer require a paper invoice. Effective November 12 claims not containing information about the invoice or cost associated with the code(s) will reject as unprocessable.
The parameters of who may serve as a Medicare Contractor Advisory Committee (CAC) member were expanded by Change Request 10901 and the companion MLN Matters article. We invite you to volunteer as a CAC member or alternate to represent your organization during our CAC meetings as part of our LCD development process.
The following articles which were posted for notice on September 29, became effective November 14.
Effective with the implementation of MLN MM12765 Significant updates to internet only manual (IOM) publication (Pub.) 100-05 Medicare secondary payer (MSP) Manual, Chapter 5 on October 13, CMS now refers to the entity that used to be known as the BCRC as the MSP Contractor. As a result, Novitas articles on the MSP specialty page referencing the BCRC have been updated to reflect the name change. Please take time to review these articles.
New:
Make sure your staff knows about these changes newly available codes, separate NCD coding revisions, and coding feedback.
Make sure your billing staff knows about these changes CY 2023 rate updates and policies for the ESRD Prospective Payment System (PPS). Updates to payment for renal dialysis services provided to patients with AKI in ESRD facilities.
Revised:
CMS revised this article due to revised CR 12888. The CR revision didn’t affect the substance of the article. CMS did revise the CR release date, transmittal number, and the web address of the CR. All other information is the same.
MLN Connects Newsletter: Nov 10, 2022
News
Teaching Hospitals: Phase 2 Section 131 Reviews — Submission Deadline November 18
Medicare Participation for CY 2023
CMS Innovation Center’s Strategy to Support Person-centered, Value-based Specialty Care
DMEPOS: Appeals & Rebuttals Contractor Clarification
Lung Cancer: Help Your Patients Reduce Their Risk
Compliance
What’s the Comprehensive Error Rate Testing Program?
Claims, Pricers, & Codes
Home Health Prospective Payment System Grouper: January Update
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
HCPCS Application Summary for Continuous Glucose Monitoring: Updated
MLN Matters® Articles
Telehealth Home Health Services: New G-Codes
From Our Federal Partners
Increased Respiratory Virus Activity, Especially Among Children
Ebola Virus Disease Outbreak in Central Uganda: Update
The September 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these and other FAQs for answers to your questions.
This meeting will be held via webinar only.
On February 28, 2023, Medicare administrative contractors (MACs) Novitas Solutions (Jurisdictions H and L) and First Coast Service Options (Jurisdiction N), along with Noridian Healthcare Solutions (Jurisdictions E and F), CGS Administrators (Jurisdiction 15), Palmetto GBA (Jurisdictions J and M), and WPS Government Health Administrators (Jurisdictions 5 and 8) will host a multi-jurisdictional Contractor Advisory Committee (CAC) meeting.
The purpose of the meeting is to obtain advice from a select panel regarding the strength of published evidence on remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for non-implantable devices and any compelling clinical data to assist in defining meaningful and measurable patient outcomes (e.g., decreases in emergency room visit and hospitalizations) for our Medicare beneficiaries. In addition to discussion, the panelists will opine on pre-distributed questions during the meeting. CAC panels do not make coverage determinations, but MACs benefit from their advice.
All panelists who have completed Conflict of Interest and Consent to Publish Comments Disclosure forms on file will be given the opportunity to submit responses to the 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, questions, agenda, and registration will be available on our multi-jurisdictional CAC website by February 14, 2023.
New:
Make sure your billing staff knows about updated provider enrollment instructions for:
Ownership disclosures
Electronic funds transfers (EFTs)
Special payment addresses
MLN Connects Newsletter: Nov 3, 2022
News
COVID-19 Vaccine: Novavax Booster Authorized
Medicare Part B Immunosuppressive Drug: Get Information on New Benefit
Part B Immunosuppressive Drug Benefit: Check Medicare Eligibility
Skilled Nursing Facilities: October Care Compare Release
Clinical Diagnostic Laboratories: Report Private Payor Rate Data Beginning January 1
Diabetes: Recommend Preventive Services
Claims, Pricers, & Codes
Home Health Consolidated Billing Enforcement: CY 2023 HCPCS Codes
Publications
Medicare Provider Compliance Tips — Revised
Multimedia
Hospice Quality Reporting Program: September Forum Materials
On October 19, the FDA amended the Novavax COVID-19 vaccine, Adjuvanted emergency use authorization (EUA) to authorize the use of a first booster dose for patients 18 years and older. CMS issued the CPT code 0044A effective October 19, for the administration of the Novavax COVID-19 vaccine booster dose. CMS added the fee for this code to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
This article has been updated and new FAQs have been added. Please take time to review the updated information.
MLN Connects Newsletter: OPPS/ASC & PFS Final Payment Rules
Final Rules
This newsletter is current as of the issue date. View the complete disclaimer.
MLN Connects Newsletter: Final Rules
Final Rules
This newsletter is current as of the issue date. View the complete disclaimer.
Reason code 32804 is editing incorrectly on incoming prior hospitalization interim bills. A correction has been developed and is tentatively scheduled to be installed on November 28. We will post an update confirming when the correction is successfully installed. Providers will be able to resubmit claims after that date.
MLN Connects Newsletter: Oct 27, 2022
News
COVID-19 Updated Booster Vaccines Covered Without Cost-Sharing for Eligible Children Ages 5–11
Oversight of Nation’s Poorest-Performing Nursing Homes
Initial Nursing Facility Evaluation & Management Visits: Comparative Billing Report in October
Help Promote Efficiency, Reduce Burden, & Advance Equity: Submit Comments by November 4
MLN Matters® Articles
Extension of Changes to the Low-Volume Hospital Payment Adjustment and the Medicare Dependent Hospital Program
Patient Driven Payment Model: Claim Edit Enhancements
The following LCD posted for comment on June 9, has been posted for notice. The LCD and related billing and coding article will become effective December 11.
The following response to comments article contains summaries of all comments received and Novitas’ responses:
New:
Make sure your billing staff knows about corrections to edits of SNF Type of Bill (TOB) 21X claims and changes to certain hospital overlap edits.
On October 12, the FDA amended the Pfizer-BioNTech and Moderna COVID-19 emergency use authorizations (EUAs) to authorize bivalent formulations of the vaccines for use as a singer booster does in younger age groups. CMS issued four new codes effective October 12, the new Pfizer-BioNTech COVID-19 vaccine bivalent product code 91315 and the new Moderna COVID-19 vaccine bivalent product code 91314 and the two new affiliated administration codes 0154A and 0144A, respectively. CMS added the fees for these recently added codes to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
New:
Make sure you’re aware of the extension to the low-volume hospital payment adjustments and MDH program.
On September 28, the United States District Court for the District of Columbia vacated the differential payment rates for 340B-acquired drugs in the calendar year (CY) 2022 outpatient prospective payment system (OPPS) final rule.
The Court vacated the average sales price (ASP) minus 22.5% drug payment rate in the Medicare OPPS system for 340B-acquired drugs with respect to its prospective application and explained that the reimbursement rate will revert to the default payment rate (generally ASP plus 6%) under the Medicare statute.
Update 10/21/2022: Providers may submit adjustments on any claim submitted for date of service in 2022 paid before September 28.
We will not perform mass adjustments on impacted claims with a 2022 date of service paid before September 28. Claims paid on or after September 28, will be automatically adjusted.
MLN Connects Newsletter: Oct 20, 2022
News
Skilled Nursing Facility Provider Preview Reports: Review by November 14
Help Your Patients Make Informed Health Care Decisions
Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment
Compliance
Implanted Spinal Neurostimulators: Document Medical Records
Claims, Pricers, & Codes
DMEPOS: Corrected 2022 E2102 Fee Schedule Amounts
MLN Matters® Articles
Medicare Deductible, Coinsurance, & Premium Rates: CY 2023 Update
Information for Patients
Medicare Open Enrollment: October 15 – December 7
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:
The following billing and coding article has been revised effective for dates of service on and after October 1:
The following LCD has been retired effective October 1:
To reduce provider burden, certain contractor priced HCPCs codes no longer require a paper invoice. Effective November 12 claims not containing information about the invoice or cost associated with the code(s) will reject as unprocessable. Please review this article for additional information. HCPCS code listing.
The following LCD, which was posted for notice on September 1, became effective on October 16. The related billing and coding article for this LCD is also effective:
CMS has released the 2023 Medicare rates, Part A and B deductible and coinsurance rates, and Part A and B premium amounts. Please review our article Deductibles/co-insurances/therapy thresholds for the updated amounts. This information can also be found directly via the link on the home page of our website.
New:
Make sure your billing staff knows about these CY 2023 rate changes. Medicare Part A and Medicare Part B deductible and coinsurance rates. Part A and Part B premium amounts.
MLN Connects Newsletter: Oct 13, 2022
News
Protect Your Patients in October: Give Them a Flu Shot & COVID-19 Vaccine
Vacating Differential Payment Rate for 340B-Acquired Drugs in 2022 Outpatient Prospective Payment System Final Rule with Comment Period
Clinical Laboratory Fee Schedule: Final Gapfill Recommendations
Claims, Pricers, & Codes
Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update Fiscal Year (FY) 2023
MLN Matters® Articles
Home Health Claims: New Grouper Edits
New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI
Publications
Medicare Preventive Services — Revised
National Expansion of the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model — Revised
From Our Federal Partners
Outbreak of Ebola Virus Disease in Central Uganda
The following proposed LCDs have been posted for comment. The comment period will end on November 26; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for our contractor medical directors to consider.
Submit comments
The following draft billing and coding articles are related to the above proposed LCDs.
The following billing and coding article has been revised.
Online registration for the October 28 open meeting is now available and will close at noon ET on Wednesday, October 26. Important: During this unprecedented time, our open meeting will be held via webinar only. The Novitas Solutions proposed 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.
To reduce provider burden, certain contractor priced HCPCS codes no longer require a paper invoice. The invoice amount should still be reported in item 19 of the CMS-1500 paper claim form or the electronic equivalent
Please review this article for additional information.
The Centers for Medicare & Medicaid Services has announced the dollar amount that must remain in controversy to sustain appeal rights beginning January 1, 2023. Please read this article for details.
Update 10/11/22: The correction was successfully installed. The services listed in CR12711 can be submitted.
New:
Make sure your billing staff knows a new consistency edit that validates the attending provider NPI. Organizational NPIs can’t be used in place of individual NPIs, unless exception conditions are met.
MLN Connects Newsletter: Oct 6, 2022
News
Resources & Flexibilities to Assist with Public Health Emergency in South Carolina
Implementation of Inflation Reduction Act Provision Addressing Medicare Payments for Biosimilars
CMS Asks for Public Input on Establishing First, National Directory of Health Care Providers and Services
Inflation Reduction Act Lowers Health Care Costs for Millions of Americans
Help Promote Efficiency, Reduce Burden, & Advance Equity: Submit Comments by November 4
Inpatient Rehabilitation Facilities: IRF-PAI & September Care Compare Release
Long-Term Care Hospitals: September Care Compare Release
Help Detect Breast Cancer Early
Claims, Pricers, & Codes
October 2022 Integrated Outpatient Code Editor (I/OCE) Specifications Version 23.3
MLN Matters® Articles
Ambulatory Surgical Center Payment System: October 2022 Update
DMEPOS Fee Schedule: October 2022 Quarterly Update
Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data
Information for Patients
2023 Medicare & You Handbook
The use of moderate or deep sedation, general anesthesia or monitored anesthesia care is usually unnecessary or rarely indicated for epidural steroid injections. General anesthesia is considered not medically reasonable and necessary for facet joint interventions. Please review this article for additional information.
The following billing and coding articles have been revised:
Revised:
CMS revised this article to reflect a revised change request (CR) 12656 that added new business requirements to add the other amount indicator “B2” for co-insurance reduction amount to the claim, modify edits that affect the co-insurance reduction amount, and report the applied coinsurance amount in the co-insurance field. The changes did not affect the contents of this article. CMS changed the CR release date, transmittal number and the CR web address. All other information remains the same.
New:
Make sure your billing staff knows that the data for: IPPS hospitals in the Ninth Circuit’s jurisdiction is updated based on Supreme Court decision in Azar v. Empire Health Foundation and all other hospitals is unchanged.
Make sure your billing staff knows about The October 2022 quarterly update for the DMEPOS fee schedule and fee schedule amounts for new and existing codes.
MLN Connects Newsletter: Sept 29, 2022
News
Resources & Flexibilities to Assist with Public Health Emergency in Puerto Rico
Resources & Flexibilities to Assist with Public Health Emergency in Florida
2023 Medicare Parts A & B Premiums and Deductibles
Clinical Laboratory Fee Schedule Payment Determinations & Voting Results: Submit Comments by October 24
DMEPOS: Change to Enrollment Contractor After November 6
Hispanic or Latino Patients: Help Address Disparities
Claims, Pricers, & Codes
ICD-10 Coordination & Maintenance Committee: Meeting Materials & Deadlines
HCPCS Application Summary for Non-Drug & Non-Biological Items and Services
The following Billing and Coding Article has been added to become effective November 14:
The following Article has been revised and will become effective November 14:
The following Billing and Coding Article has been revised:
Our Medical Policy team has evaluated all active local coverage articles for any impact in response to the 2023 Annual ICD-10 Code Update. The following is a list of the impacted articles. The revised articles will be published to the Medicare Coverage Database and on our website in the middle of October. Please continue to watch our website for updates.
Billing and Coding: Ambulance Services (Ground Ambulance) (A54574)
Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)
Billing and Coding: Cardiac Event Detection Monitoring (A56600)
Billing and Coding: Cardiac Rhythm Device Evaluation (A56602)
Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
Billing and Coding: Flow Cytometry (A56676)
Billing and Coding: Frequency of Hemodialysis (A55723)
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
Billing and Coding: Intraoperative Neurophysiological Testing (A56722)
Billing and Coding: Intravenous Immune Globulin (IVIG) (A56786)
Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A56776)
Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)
Billing and Coding: Monitored Anesthesia Care (A57361)
Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)
Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
Billing and Coding: Oximetry Services (A57205)
Billing and Coding: Pharmacogenomics Testing (A58801)
Billing and Coding: Psychiatric Codes (A57130)
Billing and Coding: Pulmonary Function Testing (A57320)
Billing and Coding: Real-Time, Outpatient Cardiac Telemetry (A52995)
Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111)
Billing and Coding: Thoracic Aortography and Carotid, Vertebral, and Subclavian Angiography (A56631)
Billing and Coding: Transesophageal Echocardiography (TEE) (A56505)
All claims that were incorrectly posted to CWF have been reviewed and any corrections that were needed have been completed. If you have claims that were impacted by a claim that was incorrectly posted to CWF, please adjust or resubmit your claim as appropriate.
There will be Common Working File (CWF) "Dark" days from Friday, September 30, through Monday, October 2, due to the October 2022 release upgrades. The interactive voice response will have limited availability.
The comment period is now closed for the following Proposed LCDs. 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.
The payment penalty phase will not begin January 1, 2023, even if the public health emergency (PHE) for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin. Please review this article for the guidelines.
Encourage Preferred Flu Vaccines for Patients 65+
MLN Connects newsletter for Thursday, September 22, 2022
News
Flu Shot: Encourage Preferred Vaccines for Patients 65+
Cataract Surgery: Comparative Billing Report
Do You Only Order or Certify Services? Use Revised Enrollment Form CMS-855O by January 1
Cardiovascular Disease: Talk with Your Patients about Screening
Claims, Pricers, & Codes
October 2022 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
MLN Matters® Articles
October 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)
Publications
Hospice Quality Reporting Program: New Resources
Due to the public health crisis this meeting will be held via webinar only.
Online registration for the Thursday, October 6, CAC Meeting is now available and will close at 3:30 p.m. ET on Wednesday, October 5. The purpose of the meeting is to obtain advice from CAC members regarding the strength of published evidence for Molecular Testing in Infectious Disease.
The CAC provides a formal mechanism for healthcare professionals to be informed of the evidence used in developing the LCD and promotes communications between the MAC and the healthcare community. CAC members will serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of the LCD. The final decision on all issues rests with the contractor medical directors (CMDs). More information regarding CAC meetings is available on our website.
Revised:
CMS revised this article due to a revised Change request (CR)12870. The CR revision corrected an acronym. CMS also changed the CR release date, the transmittal number, and the web address of the CR. All other information is the same.
The following local coverage article, which was posted for notice on August 4, is now effective:
The August 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these and other FAQs for answers to your questions.
As a reminder, the comment period for the following proposed LCDs is currently open and will close on September 24. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit Comments
Make Your Voice Heard
MLN Connects newsletter for Thursday, September 15, 2022
News
Make Your Voice Heard Request for Information Seeks Public Comment to Promote Efficiency, Reduce Burden, & Advance Equity within CMS Programs
Enhancing Oncology Model to Improve Cancer Care: Apply by September 30
Revision to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) to Align to 1834(a)(5)(E) of the Social Security Act
Claims, Pricers, & Codes
Billing for Hospital Part B Inpatient Services
National Correct Coding Initiative: October Quarterly Update
MLN Matters® Articles
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2023
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment — Revised
On August 31, the FDA amended the Pfizer-BioNTech emergency use authorization (EUA) to authorize bivalent booster doses (updated COVID-19 vaccines) for patients 12 years and older and amended the Moderna EUA to authorize bivalent booster doses (updated COVID-19 vaccines) for patients 18 years and older. CMS issued four new codes effective August 31, the new Pfizer-BioNTech COVID-19 vaccine, bivalent product code 91312 and the new Moderna COVID-19 vaccine, bivalent product code 91313 and the two new affiliated administration codes 0124A and 0134A, respectively. CMS added the fees for recently added codes to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
New:
Make sure your billing staff knows about New COVID-19 CPT vaccine and administration codes, Redosing update for EVUSHELD, New procedure to assess coronary disease severity using computed tomography angiography.
News
Updated COVID-19 Vaccines Providing Protection Against Omicron Variant Available at No Cost
Prostate Cancer: Talk to Your Patients about Screening
MLN Connects newsletter for Thursday, September 8, 2022
News
Short-Term Acute Care Hospitals: Program for Evaluating Payment Patterns Electronic Reports
Prostate Cancer: Talk to Your Patients about Screening
MLN Matters® Articles
Exceptions to Average Sales Price (ASP) Payment Methodology – Claims Processing Manual Changes
The comment period is now closed for the following Proposed LCD. 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.
New:
Make sure your billing staff knows about changes to the Laboratory NCD Edit Module for January 2023 and how to access the NCD spreadsheet that lists relevant changes.
Payment Allowances for Influenza Vaccine
MLN Connects newsletter for Thursday, September 1, 2022
News
CORRECTION: Monkeypox & Smallpox Vaccines: Include Product Code on Claims
COVID-19: Novavax Vaccine Authorized for Patients 12–17 Years Old
Medicare Shared Savings Program Saves Medicare More Than $1.6 Billion in 2021 & Continues to Deliver High-quality Care
Increased Use of Telehealth for Opioid Use Disorder Services During COVID-19 Pandemic Associated with Reduced Risk of Overdose
Sickle Cell Disease: What You Need to Know Video
Healthy Aging: Recommend Services for Your Patients
Compliance
DMEPOS Standard Written Order Requirements
Claims, Pricers, & Codes
Influenza Vaccine Payment Allowances - Annual Update for 2022–2023 Season
Quarterly Update to Home Health (HH) Grouper
Multimedia
Introduction to Language Access Plans Web-Based Training
Combating Medicare Parts C and D Fraud, Waste, & Abuse Web-Based Training — Revised
Information for Patients
How to Report a Medicare Complaint
New:
Make sure your billing staff knows about the updates to
chapter 17 of the Medicare Claims Processing Manual, and the exceptions to ASP payment methods.
Revised:
CMS revised this Article due to a revised CR 12822. The CR revision didn’t affect the substance of the article. CMS revised the CR release date, transmittal number, and the CR web address. All other information is the same.
The following LCD posted for comment on April 14has been posted for notice. The LCD and related Billing and Coding Article will become effective October 16.
The following Response to Comments Article contains summaries of all comments received and Novitas’ responses:
The following LCD has been revised:
The following LCD posted for comment on April 14 was reposted for comment on August 11, 2022. The comment period will end on September 24.
The following Draft Billing and Coding Article is related to the above Proposed LCD.
Submit Comments
When submitting prior authorization requests, be aware of response timeframes and documentation guidelines. Please take time to review this article for details.
As a reminder, the comment period for the following proposed LCD is currently open and will close on September 6. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit Comments
Medicare Secondary Payer: Manual Updates
MLN Connects newsletter for Thursday, August 25, 2022
News
Interns and Residents Information System XML Format: Updated Vendor List
Claims, Pricers, & Codes
Integrated Outpatient Code Editor: Java Beta File Release
MLN Matters® Articles
Significant Updates to Internet Only Manual (IOM) Publication (Pub.) 100-05 Medicare Secondary Payer (MSP) Manual, Chapter 5
Information for Patients
Coverage to Care: Updated Resources
A correction was performed by the shared systems involving cancel claims for dates of service in 2022. This correction removed the incorrectly posted cancel claim information from CWF.
We are in the process of reviewing the results of the correction and adjusting or re-entering impacted claims as needed. We will post notification when the corrections are complete.
The July 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these and other FAQs for answers to your questions.
The Comprehensive Error Rate Testing (CERT) report year is quickly coming to an end. Please review this article for details on upcoming deadlines.
Creating a Roadmap for the End of the COVID-19 Public Health Emergency
News
Health Care System Resiliency
Preparing the Health Care System for Operation After the Public Health Emergency: Secretary of Health and Human Services (HHS) Xavier Becerra extended the existing COVID-19 public health emergency (PHE) through October 15, 2022 – and has committed to providing states, health care providers, and other stakeholders a 60-day notice before ending the PHE.
Discontinuing Use of Certificates of Medical Necessity & Durable Medical Equipment Information Forms
MLN Connects newsletter for Thursday, August 18, 2022
News
CMS Discontinuing the Use of Certificates of Medical Necessity and Durable Medical Equipment Information Forms to Increase Efficiency and Reduce Burden for Clinicians, DME Suppliers, and Beneficiaries
Quality Payment Program: Comment on Proposed Changes by September 6
Skilled Nursing Facilities: Participate in Interoperability Survey
Home Health: Revised Guide to Help Desks
Claims, Pricers, & Codes
Claim Status Category and Claim Status Codes Update
Events
Home Health OASIS-E Virtual Workshops — September 13 & 14
MLN Matters® Articles
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) — January 2023 Update
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) — January 2023 Update – 2 of 2
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and Hospice Pricer for FY 2023
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update — Revised
On July 26, new codes were established for smallpox and monkeypox vaccines. When the government provides vaccines at no cost, only bill for the vaccine administration.
New:
Make sure your billing staff knows about Updates to Chapter 5 of the
Medicare secondary payer manual, and sending claims to primary payers before billing Medicare.
Make sure your billing staff knows about these changes -updates to advanced diagnostic laboratory tests, next CLFS data reporting period, and new codes added to the National HCPCS file.
New:
Make sure your staff knows about newly available codes, separate NCD coding revisions, and coding feedback.
Previous NCD coding changes are available. Also, see the
NCD spreadsheets for CR 12822. CMS isn’t including any policy changes in this ICD-10 quarterly update. We cover NCD policy changes using the current, longstanding NCD process.
Make sure your staff knows about newly available codes, separate NCD coding revisions, and coding feedback.
Previous NCD coding changes are available. Also, see the
NCD spreadsheets for CR 12842. CMS isn’t including any policy changes in this ICD-10 quarterly update. We cover NCD policy changes using the current, longstanding NCD process.
Information has been added to the COVID-19 vaccine and monoclonal antibodies billing for Part A article relating to commercially purchased payment allowance for the COVID-19 monoclonal antibody therapy Bebtelovimab (Q0222). Please review the article.
This new form is available on our Forms Catalog and is required by CMS when submitting a CAAP dispute.
Monkeypox & Smallpox Vaccines: New Product Codes
MLN Connects newsletter for Thursday, August 11, 2022
News
Monkeypox & Smallpox Vaccines: New Product Codes
Payment Allowance Update for COVID-19 Monoclonal Antibody Therapy Q0222 Injection, Bebtelovimab, 175 mg
CMS Announces Resources & Flexibilities to Assist Kentucky Due to Recent Storms
Hospice Quality Reporting Program: Measure Change
Compliance
What’s the Comprehensive Error Rate Testing Program?
Claims, Pricers, & Codes
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2022
Integrated Outpatient Code Editor: Java Beta File Release
MLN Matters® Articles
Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2023
Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2023
New Waived Tests
Implementation of the Capital Related Assets (CRA) Adjustment for the Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) Under the End-Stage Renal Disease Prospective Payment System (ESRD PPS) — Revised
Publications
Skilled Nursing Facility Billing Reference — Revised
Multimedia
Hospice Quality Reporting Program Videos
The following proposed LCDs have been posted for comment. The comment period will end on September 24; however, you are encouraged to submit your comments as soon as possible. When submitting your comments, we encourage you to submit literature/evidence supporting your recommendations for our medical directors to consider.
Submit comments
The following draft billing and coding articles are related to the above proposed LCDs.
The following billing and coding articles have been revised:
Online registration for the August 26 open meeting is now available and will close at noon ET on Wednesday, August 24. Important: During this unprecedented time, our open meeting will be held via webinar only. Our proposed 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.
New:
Make sure your billing staff knows about updates to:
FY 2023 Wage Index
FY 2023 Pricer
IPF Quality Reporting Program
Make sure your billing staff knows about these changes:
Fiscal year (FY) 2023 payment rates
Wage index cap
Revised:
CMS revised the article due to an updated CR that clarified language to present the policy as described in the regulation and to update the sequence of events in the example calculation. This correction clarifies that the offset adjustment is subtracted from the per treatment amount before the application of the 65% adjustment. The changes are in dark red font on pages 1 and 2. CMS also changed the CR transmittal date, transmittal number and the link to the transmittal. All other information is the same.
ICD-10-CM Code Files: Fiscal Year 2023
MLN Connects newsletter for Thursday, August 4, 2022
News
Hospices: Volunteer to Test Hospice Outcomes & Patient Evaluation Instrument
Immunization: Protect Your Patients
Claims, Pricers, & Codes
ICD-10-CM Code Files: Fiscal Year 2023
ICD-10 Medicare Severity Diagnosis-Related Group Version 40
Events
ICD-10 Coordination & Maintenance Committee Meeting — September 13–14
Publications
Items & Services Not Covered Under Medicare — Revised
The following Billing and Coding articles have been revised to reflect the July 2022 CPT/HCPCS Code Quarterly updates and/or in response to inquiries:
The following Article has been revised effective for dates of service on and after September 19.
New CMS Rule Increases Payments for Acute Care Hospitals & Advances Health Equity, Maternal Health
On August 1, CMS issued a final rule for inpatient and long-term care hospitals that builds on the Biden-Harris Administration’s key priorities to advance health equity and improve maternal health outcomes. As required by statute, the fiscal year (FY) 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) rule updates Medicare payments and policies for hospitals, drives high-quality, person-centered care, and promotes fiscal stewardship of the Medicare program. In addition, the rule finalizes new measures to encourage hospitals to build health equity into their core functions. These actions will improve care for people and communities who are disadvantaged or underserved by the health care system.
The rule includes three health equity-focused measures in hospital quality programs and establishes a “Birthing-Friendly” hospital designation. CMS will award this new designation to hospitals that participate in a statewide or national perinatal quality improvement collaborative program and have implemented the recommended quality interventions.
For acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record users, the final rule will result in an increase in operating payment rates of 4.3%. This reflects a FY 2023 projected hospital market basket update of 4.1%, reduced by a statutorily required productivity adjustment of a 0.3 percentage point and plus a 0.5 percentage point adjustment required by statute. This is the highest market basket update in the last 25 years and is primarily due to higher expected growth in compensation prices for hospital workers. Under the LTCH PPS, CMS expects payments in FY 2023 to increase by approximately 2.4% or $71 million.
“CMS is taking action to support hospitals, including updating payments to hospitals by a significantly higher rate than in the proposed IPPS rule. This final rule aligns hospital payments with CMS’ vision of ensuring access to health care for all people with Medicare and maintaining incentives for our hospital partners to operate efficiently,” said CMS Administrator Chiquita Brooks-LaSure. “It also takes important steps to advance health equity by encouraging hospitals to implement practices that reduce maternal morbidity and mortality.”
Advancing Health Equity:
Consistent with the agency’s definition of health equity, CMS is working to advance health equity by designing, implementing, and operationalizing policies and programs that support health for all the people served by our programs, eliminating avoidable differences in health outcomes experienced by people who are disadvantaged or underserved, and providing the care and support that our enrollees need to thrive.
To address health care disparities in hospital inpatient care and beyond, CMS is adopting three health equity-focused measures in the IQR Program. The first measure assesses a hospital’s commitment to establishing a culture of equity and delivering more equitable health care by capturing concrete activities across five key domains, including strategic planning, data collection, data analysis, quality improvement, and leadership engagement. The second and third measures capture screening and identification of patient-level, health-related social needs — such as food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. By screening for and identifying such unmet needs, hospitals will be in a better position to serve patients holistically by addressing and monitoring what are often key contributors to poor physical and mental health outcomes.
In the near future, CMS is also interested in using measures focused on connecting patients with identified social needs to community resources or services. CMS sought comment on the proposed rule. In the final rule, CMS acknowledges the robust comments received on key considerations that inform our approach to improving data collection, to better measure and analyze disparities across programs and policies, and approaches for updating the Hospital Readmissions Reduction Program (HRRP) that encourage providers to improve performance for socially at-risk populations.
CMS is also discontinuing the use of proxy data for uncompensated care costs in determining uncompensated care payments for Indian Health Service and Tribal hospitals, and hospitals in Puerto Rico, and we are establishing a new supplemental payment to prevent undue long-term financial disruption for these hospitals and to promote long-term payment stability. CMS is also finalizing new flexibilities for graduate medical education for rural hospitals participating in rural track programs, which will help promote workforce development in rural areas.
Improving Maternal Health Outcomes:
CMS is creating a new hospital designation to identify “Birthing-Friendly” hospitals and additional quality measure reporting to drive improvements in maternal health outcomes. CMS is finalizing this designation following the release of the comprehensive CMS Maternity Care Action Plan.
The Biden-Harris Administration has championed policies to improve maternal health and equity since taking office. Earlier this year, Vice President Harris convened a first-ever White House meeting with Cabinet Secretaries and agency leaders, including Secretary Becerra and CMS Administrator Chiquita Brooks-LaSure, to discuss the Administration’s whole-of-government approach to reducing maternal mortality and morbidity. In December 2021, Vice President Harris announced a historic call to action to improve health outcomes for parents and their young children in the United States. Implementing this new hospital designation is part of the Biden-Harris Administration’s continued response to that call to action, as noted in the CMS Maternity Care Action Plan.
The “Birthing-Friendly” hospital designation will provide important information to consumers about hospitals with a demonstrated commitment to reducing maternal morbidity and mortality by implementing best practices that advance health care quality and safety for pregnant and postpartum patients.
Conditions of Participation Pandemic Reporting for Hospital and Critical Access Hospitals (CAH):
CMS proposed to continue the current COVID-19 reporting requirements for hospitals and CAHs as well as establish new reporting requirements for future public health emergencies (PHE). Based on public feedback, CMS is finalizing the proposed requirements for continued COVID-19-related reporting for hospitals and CAHs with a reduced number of data categories as an off ramp to the current PHE. CMS is not finalizing the proposed reporting requirements for future PHEs.
Continued Public Reporting of Patient Safety Metrics:
CMS uses quality measures to ensure safety and quality within the health care system and to pay providers through value-based programs. For the FY 2023 Hospital-Acquired Condition (HAC) Reduction Program, CMS proposed to pause — meaning not calculate and subsequently not publicly report — the data for the PSI-90 measure, which is a composite measure that covers multiple patient safety indicators, such as pressure sores, falls, and sepsis. CMS’ proposal reflected concerns about the impact COVID-19 would have on the ability to interpret data and was also sensitive to the risks of financially penalizing hospitals for factors potentially out of their control. CMS recognizes the importance of this measure for patients and providers and is finalizing the calculation and public reporting of the CMS PSI-90 measure results. CMS will include the measure in Star Ratings in alignment with the feedback we received. Although this measure will be publicly reported, it will not be used in payment calculations in the HAC to avoid unintentional penalties related to the uneven impacts of COVID-19 across the country.
More Information:
Skilled Nursing Facilities: Final FY 2023 Payment Rule
Skilled Nursing Facilities: Learn What’s New for Fiscal Year 2023
CMS Seeks Public Feedback to Improve Medicare Advantage
Skilled Nursing Facilities: Learn What’s New for Fiscal Year 2023
CMS issued the Fiscal Year (FY) 2023 Skilled Nursing Facility (SNF) Prospective Payment System final rule to update payment policies and rates. See a summary of key provisions effective October 1, 2022:
2.7% net payment rate increase for skilled nursing facilities
Patient Driven Payment Model parity adjustment recalibration (use the FY 2023 proposed rule
calculator to learn more) and changes in ICD-10 code mappings
Permanent 5% cap on annual wage index decreases
SNF Quality Reporting Program: compliance date revisions for certain requirements, new influenza vaccination coverage for health care personnel measure, and regulation text revisions
SNF Value Based Purchasing: not apply the SNF 30-Day All Cause Readmission Measure for the FY 2023 program year and add 3 new measures for FY 2026 & 2027 program expansion years
CMS Seeks Public Feedback to Improve Medicare Advantage
The Centers for Medicare & Medicaid Services (CMS) released a Request for Information seeking public comment on the Medicare Advantage program. CMS is asking for input on ways to achieve the agency’s vision so that all parts of Medicare are working towards a future where people with Medicare receive more equitable, high quality, and person-centered care that is affordable and sustainable.
CMS encourages the public to submit comments to the Request for Information. Feedback from plans, providers, beneficiary advocates, states, employers and unions, and other partners to this Request for Information will help inform the Medicare Advantage policy development and implementation process.
More Information:
Enhanced Nursing Home Rating System
MLN Connects newsletter for Thursday, July 28, 2022
News
CMS Enhances Nursing Home Rating System with Staffing & Turnover Data
Clinical Laboratory Improvement Amendments Proposed Rule: Submit Comments by August 25
Hospices: Submit Technical Expert Panel Nominations by August 12
Viral Hepatitis: Talk to Your Patients about Screening
Claims, Pricers, & Codes
Integrated Outpatient Code Editor: Java Beta File Release
Events
Medicare Ground Ambulance Data Collection System Webinar: Using Facilities & Vehicles Templates — August 4
As indicated on July 25, the comment period for Genetic Testing for Oncology has been extended until September 6, due to changes that are being made to the final billing and coding article. Detailed information regarding the changes to the article is now visible on the document notes at the top of the proposed LCD and draft article.
Please refer to the related local coverage documents section at the bottom of the Proposed LCD for changes made to the draft article (DA59125, Billing and Coding: Genetic Testing for Oncology).
Submit comments
3 Final FY 2023 Payment Rules: Hospices, Inpatient Psychiatric Facilities, & Inpatient Rehabilitation Facilities
Hospices: Learn What’s New for Fiscal Year 2023
Inpatient Psychiatric Facilities: Learn What’s New for Fiscal Year 2023
Hospices: Learn What’s New for Fiscal Year 2023
CMS issued a Fiscal Year (FY) 2023 Hospice Payment Rate Update final rule to update Medicare hospice payments, wage index, quality reporting programs, and policies. See a summary of key provisions effective October 1, 2022:
Routine annual rate setting changes resulting in a 3.8% increase in payments for FY 2023
Permanent 5% cap on negative wage index changes
Hospice Quality Reporting Program (HQRP) updates, including the new Hospice Outcomes and Patient Evaluation Tool, the Consumer Assessment of Healthcare Providers and Systems hospice survey, quality measures for FY 2023, and a summary of public comments from the request for information to inform future efforts related to HQRP health equity
Inpatient Psychiatric Facilities: Learn What’s New for Fiscal Year 2023
CMS issued the Fiscal Year 2023 Inpatient Psychiatric Facilities (IPF) Prospective Payment System final rule to update IPF payments, wage index, and policies. See a summary of key provisions effective October 1, 2022:
Updated payment rates by 3.8% with estimated payments to increase by 2.5% after productivity adjustment
Applied a permanent 5% cap on wage index decreases
Inpatient Rehabilitation Facilities: Learn What’s New for Fiscal Year 2023
CMS issued the Fiscal Year 2023 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule to update Medicare payment policies and rates. See a summary of key provisions effective October 1, 2022:
Updated IRF PPS payment rates by 3.9% with estimated overall payments to increase by 3.2% after productivity and outlier adjustments
Applied a permanent 5% cap on annual wage index decreases
Expanded quality data reporting on all IRF patients, regardless of payer
The comment period for the following proposed LCD has been extended until September 6, due to changes that will be made to the final related billing and coding article. The change in the comment end date along with detailed information regarding the changes to the article will be visible on the Medicare Coverage Database (MCD) and our website on July 28. The information will be located on the document note at the top of the proposed LCD and on the document note at the top of the draft article. Please check our website on July 28, for this information.
Please do not resubmit comments already submitted, but we welcome additional comments related to the changes.
The comment period is now closed for the following proposed LCD. 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.
988 Suicide & Crisis Lifeline Available Nationwide
MLN Connects newsletter for Thursday, July 21, 2022
News
988 Suicide & Crisis Lifeline Available Nationwide
COVID-19: Novavax Vaccine, Adjuvanted — New Codes
Allergy & Immunology: Comparative Billing Report in July
Inpatient Rehabilitation Facilities: Care Compare July Refresh
Long-Term Care Hospitals: Care Compare July Refresh
Hospices & Home Health Agencies: Submit Technical Expert Panel Nominations by August 12
Skilled Nursing Facility Provider Preview Reports: Review by August 15
Opioid Treatment Programs: Comment by September 6
Compliance
Implanted Spinal Neurostimulators: Document Medical Records
Information for Patients
Medicare Savings Programs Help Pay Premiums
On July 13, the FDA amended the Novavax COVID-19 vaccine emergency use authorization. CMS issued new codes effective July 13, for the vaccine (91304) and administration codes (0041A and 0042A). CMS added the fees for recently added codes to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
The June 2022 Part A top inquiries FAQs, received by our Provider Contact Center, have been reviewed. A new question / answer has been added to the general information category. Please take time to review these and other FAQs for answers to your questions.
CMS Proposes Rule to Advance Health Equity, Improve Access to Care, & Promote Competition and Transparency
CMS is proposing actions to advance health equity and improve access to care in rural communities by establishing policies for Rural Emergency Hospitals (REH) and providing for payment for certain behavioral health services furnished via communications technology. Additionally, in line with President Biden’s Executive Order on Promoting Competition in the American Economy, the calendar year 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System proposed rule includes proposed enhanced payments under the OPPS and the Inpatient Prospective Payment System for the additional costs of purchasing domestically made NIOSH-approved surgical N95 respirators and a comment solicitation on competition and transparency in our nation’s health care system.
More Information:
Please review our new article regarding claims in MSP status/location RB75XX or PB75XX.
COVID-19: FDA Authorizes Pharmacists to Prescribe PAXLOVID with Certain Limits
MLN Connects newsletter for Thursday, July 14, 2022
News
COVID-19: FDA Authorizes Pharmacists to Prescribe PAXLOVID with Certain Limits
COVID-19: Moderna Vaccines for Children as Young as 6 Months — New Codes
Establishing the Framework for Health Equity at CMS
Post-Acute Care Report to Congress: Prototype Unified Payment for Medicare
Long Term Care Facilities: Nursing Home Five Star Rating Changes
Program for Evaluating Payment Patterns Electronic Reports for Home Health Agencies & Partial Hospitalization Programs
Home Health Quality Reporting Program: Final OASIS Data Specifications
Compliance
Collaborative Patient Care is a Provider Partnership
Claims, Pricers, & Codes
Claims Processing Instructions for the New Hepatitis B Vaccine Code 90759
HCPCS Application Summaries & Coding Decisions: Drugs & Biologicals
New Edit for Prospective Payment System (PPS) Outpatient and Inpatient Bill Types Receiving an Outlier Payment When a Device Credit is Reported
Events
Medicare Ground Ambulance Data Collection System Webinar: Allocating Expenses & Revenue — July 21
Information for Patients
Affordable Connectivity Program Lowers Cost of Broadband Services for Eligible Households
On June 17, the FDA amended the Moderna emergency use authorization to authorize the use for all patients 6 months - 5 years old and patients aged 6 years – 11 years. The vaccine is supplied in multiple dose vials. CMS issued an effective date of June 17, for the new vaccine product code (91311) and the new administration codes (0111A, 0112A, 0113A) for the first, second, and third dose with a blue cap with a magenta border and (0091A, 0092A and 0093A) for the first, second, and third dose with a blue cap with a purple border respectively. CMS added the fees for these recently added codes to the CMS COVID-19 vaccines and monoclonal antibodies webpage.
As a result of these changes, updates have been made to the following references:
On June 29, the FDA authorized revisions to EVUSHELD (tixagevimab co-packaged with cilgavimab) dosing to recommend repeat dosing six months with a dose of 300 mg of tixagevimab and 300 mg cilgavimab if patients need ongoing protection. For more information about dosage, dosing interval, and administration, review the Fact Sheet for Health Care Providers: EUA for EVUSHELD (tixagevimab co-packaged with cilgavimab) (ZIP).
Reason code W7120 was incorrectly returning claims to providers when the PT modifier was reported with surgical ranges 10000-69999 or 0000T-9999T. The Integrated Outpatient Code Editor was updated successfully.
As a reminder, the comment period for the following proposed LCDs is currently open and will close on July 23, 2022. Please consider including literature/evidence in support of your request with your comments. We encourage you to submit your comments as soon as possible.
Submit comments
Have questions and not sure where to turn? Check out our FAQs for answers to your questions.
CMS Proposes Physician Payment Rule to Expand Access to High-Quality Care
On July 7, CMS issued the Calendar Year 2023 Physician Fee Schedule (PFS) proposed rule, which would significantly expand access to behavioral health services, Accountable Care Organizations (ACOs), cancer screening, and dental care — particularly in rural and underserved areas. These proposed changes play a key role in the Biden-Harris Administration’s Unity Agenda — especially its priorities to tackle our nation’s mental health crisis, beat the overdose and opioid epidemic, and end cancer as we know it through the Cancer Moonshot — and ensure CMS continues to deliver on its goals of advancing health equity, driving high-quality, whole-person care, and ensuring the sustainability of the Medicare program for future generations.
“At CMS, we are constantly striving to expand access to high quality, comprehensive health care for people served by the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposals expand access to vital medical services like behavioral health care, dental care, and cancer treatment options, all while promoting access, innovation, and cost savings in the Medicare program.”
“Integrated coordinated, whole-person care — which addresses physical health, behavioral health, and social determinants of health — is crucial for people with Medicare, especially those with complex needs,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “If finalized, the proposals in this rule will advance equity, lead to better care, support healthier populations, and drive smarter spending of the Medicare dollar.
The proposed CY 2023 PFS conversion factor is $33.08, a decrease of $1.53 to the CY 2022 PFS conversion factor of $34.61. This conversion factor accounts for the statutorily required update to the conversion factor for CY 2023 of 0%, the expiration of the 3% increase in PFS payments for CY 2022 as required by the Protecting Medicare and American Farmers From Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in Relative Value Units.
Modernizing Coverage for Behavioral Health Services
In the 2022 CMS Behavioral Health Strategy, CMS set goals to remove barriers to care and improve access to, and the quality of, mental health and substance use care. To help address the acute shortage of behavioral health practitioners, the agency is proposing to allow licensed professional counselors, marriage and family therapists, and other types of behavioral health practitioners to provide behavioral health services under general (rather than direct) supervision. Additionally, CMS is proposing to pay for clinical psychologists and licensed clinical social workers to provide integrated behavioral health services as part of a patient’s primary care team.
CMS is also proposing to bundle certain chronic pain management and treatment services into new monthly payments, improving patient access to team-based comprehensive chronic pain treatment. Lastly, CMS is proposing to cover opioid treatment and recovery services from mobile units, such as vans, to increase access for people who are homeless or live in rural areas.
Expanding Access to Accountable Care Organizations
ACOs are groups of health care providers who come together to give coordinated, high-quality care to their Medicare patients. The Medicare Shared Savings Program covers more than 11 million people with Medicare and includes more than 500,000 providers.
CMS is proposing changes to the Medicare Shared Savings Program that, if finalized, represent some of the most significant reforms since the final rule that established the program was finalized in November 2011 and ACOs began participating in 2012. Building on the CMS Innovation Center’s successful ACO Investment Model, CMS is proposing to incorporate advance shared savings payments to certain new Medicare Shared Savings Program ACOs that could be used to address Medicare beneficiaries’ social needs. This is one of the first times Traditional Medicare payments would be permitted for such uses and is expected to be an opportunity for providers in rural and other underserved areas to make the investments needed to become an ACO and succeed in the program. CMS is also proposing that smaller ACOs have more time to transition to downside risk, further helping to grow participation in rural and underserved communities. CMS is also proposing a health equity adjustment to an ACO’s quality performance category score to reward excellent care delivered to underserved populations. Finally, CMS is proposing benchmark adjustments to encourage more ACOs to participate and succeed, which would help achieve the goal of having all people with Traditional Medicare in an accountable care relationship with a healthcare provider by 2030.
Improving Access to Colon Cancer Screening
Colon and rectal cancer were the second-leading cause of cancer deaths in the United States in 2020, with higher colorectal cancer death rates for Black Americans, American Indians, and Alaska Natives. To reduce barriers to getting a colonoscopy, CMS is proposing that a follow-up colonoscopy to an at-home test be considered a preventive service, which means that cost sharing would be waived for people with Medicare. Additionally, Medicare is proposing to cover the service for individuals 45 years of age and above, in line with the newly lowered age recommendation (down from 50) from the United States Preventive Services Task Force.
Proposing Payment for Dental Services that are Integral to Covered Medical Services
Medicare Part B currently pays for dental services when that service is integral to medically necessary services required to treat a beneficiary's primary medical condition. Some examples include reconstruction of the jaw following accidental injury or tooth extractions done in preparation for radiation treatment for jaw cancer. CMS is proposing to pay for dental services, such as dental examination and treatment preceding an organ transplant. In addition, CMS is seeking comment on other medical conditions where Medicare should pay for dental services, such as for cancer treatment or joint replacement surgeries, as well as on a process to get public input when additional dental services may be integral to the clinical success of other medical services.
More Information:
Expanding Access to Emergency Care Services in Rural Communities
MLN Connects newsletter for Thursday, July 7, 2022
News
Taking Action to Expand Access to Emergency Care Services in Rural Communities
People with Disabilities: Help Address Disparities
Compliance
DMEPOS Standard Written Order Requirements
Claims, Pricers, & Codes
Long COVID: Use ICD-10 Code U09.9
MLN Matters® Articles
July 2022 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised
Publications
Teaching Physicians, Interns, & Residents Guidelines — Revised
The Part A quarterly claim submission errors and resolutions are now available. Please take time to review these errors and avoid them on future claims.
Since CMS has mandated prior authorization for certain hospital OPD services as a condition of payment, when a prior authorization request (PAR) is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.
Visit the prior authorization for certain hospital OPD services webpage and the frequently asked questions for more information.
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