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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.
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.
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
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.
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.
CMS created these HCPCS codes to bill for prolonged services which exceed the maximum time for the highest-level E/M visit by at least 15 minutes.
To learn more, please visit:
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:
Please review this new article for guidance on coding.
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.
To assist provider with the proper billing and coding of nursing facility care visits, two new articles Nursing facility E/M services and Prolonged physician services: Nursing facility E/M visits have been added to the E/M center. Please take time to review the articles.
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 B 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.
The quarterly top claim denials have been updated. Please take time to review the information.
A new article has been added to assist providers with the proper billing relating to ASC facility claims.
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 April 2023 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
Please review the guidance issued for correctly billing genetic testing using large pharmacogenomics panels.
The following billing and coding articles have been revised:
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
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
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:
New:
Make sure your billing staff knows about clinical laboratory improvement amendments (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests.
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.
New information has been added regarding the pricing of Ambulatory Surgical Center Facility claims. Impacted claims be will adjusted.
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
ASC 2023 fee schedules have been revised and posted to our website.
Want to learn more about global surgery? You've come to the right place.
Event dates: April 4, 2023 – April 5, 2023
Fundamentals of Global Surgery (Part B)
In our first session, we’ll discuss the basics of global surgery and explore the E/M modifiers 24, 25, 57 and FT while demonstrating scenarios to appropriately apply these modifiers.
Fundamentals of Global Surgery – Surgical Modifiers (Part B)
In our second session, modifiers 54, 55, 58, 78, 79, 50, and LT/RT will be discussed and we 'll guide you through billing scenarios for surgical situations.
Check our webinar series by visiting our Event Calendar.
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:
The February 2023 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
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:
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
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:
A new issue has been added regarding PET scans and Tracer codes denying in error for dates of service 7/1/22– 2/14/23. All impacted claims will be adjusted.
Have questions and not sure where to turn? Check out our FAQs for answers to your questions.
New billing information has been added for repeat services to help avoid duplicate claim denials and appeals.
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
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. Reference the article for the HCPCS code listing.
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
New information has been added regarding changes beginning January 1, for coverage of colorectal cancer screenings.
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 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 new issue has been added regarding the processing of colorectal cancer (CRC) screening test claims.
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.
An issue has been added regarding claims that incorrectly denied for 99221-99223 and 99231-99233 with place of service 22.
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.
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:
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”
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.
ASC 2023 fee schedules have been revised and posted to our website.
Please review this article concerning the 2023 travel allowance for collection of specimens.
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
The December 2022 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
News
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
New:
Make sure your billing staff knows about new HCPCS C-codes on the ASC covered procedures list, new HCPCS codes for drugs and biologics, and skin substitute product assignments to high and low-cost groups.
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 2023 ASC Fee schedule is now available on our website.
The November 2022 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
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.
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
Make sure your billing staff knows about these changes:
New HCPCS codes
Discontinued HCPCS codes
Required CLIA certificates
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 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.
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 CLIA requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests.
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.
The October 2022 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
New:
Make sure your staff knows about these changes newly available codes, separate NCD coding revisions, and coding feedback.
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
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.
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:
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:
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:
Once CMS has released the CY 2023 physician fee schedule, it will be posted to our website.
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.
Please review the guidance issued for correctly billing infectious disease panels.
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.
CMS is proposing to adopt most of the changes in coding and documentation for Other E/M visits similar to the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, effective January 1, 2023.
Currently there are approximately 75 Other E/M CPT codes, and in 2023 there will be approximately 50 Other E/M CPT codes. Although these changes are proposed and not yet final, be prepared for what is on the horizon for 2023.
The Fact Sheet: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule | CMS contains a summary of the proposed changes.
A complete list of the changes can be found in the Federal Register at https://public-inspection.federalregister.gov/2022-14562.pdf beginning on page 297.
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 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)
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.
Please take time to review this article on cardiac and pulmonary rehabilitation programs that has been added to the Cardiology specialty page and to the coding and billing articles.
New:
Make sure your billing staff knows about Updates to the ASC payment system in October, new outpatient prospective payment system (OPPS) device pass-through code, newly established HCPCS codes for drugs and biologicals, and new skin substitute products low-cost group or high-cost group assignment.
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.
Goniotomy procedures performed in conjunction with insertion of a glaucoma drainage device is considered not reasonable and necessary.
We have detected an upward trend in the inappropriate billing of code combination 65820 reported with either 66989, 66991 or 0671T. This article is intended to provide guidance on how to properly bill for MIGS and remind providers of the instruction provided in LCD L38233, Micro-Invasive Glaucoma Surgery (MIGS) and billing and coding article A56633.
Codes defined:
65820 - Goniotomy defined as trabecular meshwork is incised and/or excised with a blade or other surgical instrument for at least several clock hours to create an opening into Schlemm canal from the anterior chamber, via an internal approach through the anterior chamber.
66989 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.
66991 - Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more.
As of January 1, the group 3 code below is considered not reasonable and necessary and is non-covered.
0671T is defined as insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant contract removal, one or more.
Per the LCD: Goniotomy procedure performed in conjunction with the insertion of a glaucoma drainage device is considered not medically reasonable and necessary. Routine performance of goniotomy with insertion of a glaucoma drainage device may be subject to focused medical review.
The following local coverage article, which was posted for notice on August 4, is now effective:
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:
The August 2022 Part B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
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
Our article has been updated. Please take time to review the updated 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.
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
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 antibody billing for Part B 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.
The DME Specialty page has been updated to include a Documentation Requirements tutorial.
The Comprehensive Error Rate Testing (CERT) program has noted a high error rate for glucose monitor claims. Please review our article for information to assist in reducing these types of errors.
New:
Make sure your billing staff knows about these changes:
CLIA requirements
New CLIA waived tests approved by the FDA
Use of modifier QW for CLIA-waived tests
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.
Please review this new article for proper billing.
New issues have been added regarding monitored anesthesia codes paid incorrectly, and denials that occurred for Q2049 and Q2050. Please review the information.
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 B top inquiries FAQs, received by our Provider Contact Center, have been reviewed. Please take time to review these FAQs for answers to your questions.
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:
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).
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
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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