NOTE: Should you have landed here as a result of a search ......as psychiatry, preventive services,...

NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

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JM PART B MEDICARE ADVISORY Latest Medicare News for JM Part B What’s Inside...

Administration Outpatient Department PA......................................................................................................3 eServices and Google Authenticator .......................................................................................4 How Can We Be Of “eServices” To You! ...............................................................................6 eServices Profile Verification Timeframes ..............................................................................6 Get Your Medicare News Electronically ................................................................................7 ePass is Now Available to Ease the Burden of Repeated Authentication When Calling

Palmetto GBA’s Provider Contact Center ...........................................................................9 eTicket Enables Providers to Save Time with Every Call ....................................................10 CMS Quarterly Provider Update ..........................................................................................11 Claim Status Category Codes and Claim Status Codes Update ...........................................13 Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the

Coronavirus (COVID-19)..................................................................................................15

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) July Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and

Supplies (DMEPOS) Fee Schedule ...................................................................................25

Education Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA29

Electronic Data Interchange (EDI) Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC),

Medicare Remit Easy Print (MREP) and PC Print Update ...............................................32 Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds

Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE ..........................................................34

Continued >>

palmettogba.com/jmb

The JM Part B Medicare Advisory contains coverage, billing and other information for Part B. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM Part B Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at https://www.PalmettoGBA.com/JMB.

CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee sched-ules, relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2019 American Dental Association (ADA). All rights reserved.

July 2020 Volume 2020, Issue 7

https://www.PalmettoGBA.com/JMB

Fee Schedules and Reimbursement Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health

Emergency (PHE) Interim Final Rules .....................................................................................................................36

Medicine National Coverage Determination (NCD) 160.18 Vagus Nerve Stimulation (VNS) ...................................................43 NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) ..................................................................................45

Hospice Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component ......................47

Laboratory Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge

Payment .....................................................................................................................................................................50

Therapy Therapy Codes Update ..................................................................................................................................................60

Etcetera Medical Director’s Desk ...............................................................................................................................................62 MLN ConnectsTM ..........................................................................................................................................................64

CMS Provider Minute Videos

The Medicare Learning Network has a series of CMS Provider Minute Videos (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting documentation. Check the site often as CMS adds new videos periodically to further help you navigate the Medicare program.

CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

2 7/2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimediahttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimediahttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia

Outpatient Department PA Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services and to ensure that medical necessity is met. Providers can submit a PA request as early as June 17, 2020, for date of service on or after July 1, 2020, for the following:

1. Blepharoplasty 2. Botulinum toxin injections 3. Panniculectomy 4. Rhinoplasty 5. Vein ablation

Please watch our website for upcoming education regarding OPD PA. You may go to the CMS website to view a full list of HCPCS codes that require a PA at https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services.


3 7/2020

https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-serviceshttps://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-serviceshttps://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services

eServices and Google Authenticator

To enhance the security of Medicare information, the Centers for Medicare & Medicaid Services (CMS) requires the use of multi-factor authentication (MFA) each time you log in to eServices. We're excited to announce a new option to protect your account - Google Authenticator.

You now have three options to receive an MFA code: • Email • Text • Google Authenticator

Are you new to eServices? Or maybe you already have an eServices account...no worries! In just a few quick steps, you can set up Google Authenticator. This two-step verification is available when initially registering for eServices or if you already have an existing eServices account.

Initial Registration Upon initial registration to eServices, you must complete the fields on the MFA Setup screen.

The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google Authenticator option.

After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android: • iPhone users must access iTunes • Android users must access Google Play

A successful installation prompts this screen showing your device is now linked. Select Submit to save the changes.

At your initial login to eServices, you are asked to choose your preferred method for receiving your MFA code.

Select the Use the app button to receive the MFA code via the Google Authenticator app.

Continued >> CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

4 7/2020

After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will renew every 30 seconds.

Enter the code in the available field and select the Submit button.

Existing Account At your next login to eServices, you are asked to choose your preferred method for receiving your MFA code.

You must choose from the text or email options since you haven’t set up the Google Authenticator option yet.

After verification, go to the My Account tab to change your account settings.

From the My Account tab, scroll down until you see the MFA Setup options.

The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google Authenticator option.

After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android: • iPhone users must access iTunes • Android users must access Google Play

A successful installation prompts this screen showing your device is now linked. Select Submit to save the changes.

At your next login to eServices, you are again asked to choose your preferred method for receiving your MFA code. But not you’ll notice you can also choose to receive your code with the Google Authenticator app.

Select the Use the app button to receive the MFA code via the Google Authenticator app.

After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will renew every 30 seconds.

Enter the code in the available field and select the Submit button.


5 7/2020

How Can We Be Of “eServices” To You! Do you want to use eServices, but feel you just have too many accounts to keep track of? Palmetto GBA’s portal offer all providers the option to link your provider facilities through our Account Linking feature! Account linking gives users the ability to link their previously assigned eServices user IDs under one default ID. Getting started is simple! Users should log into eServices with the user ID that they wish to designate as their default login ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged into eServices, they will select the My Account Tab and then access the Account Linking sub-tab. This will allow the provider to choose the accounts they wish to link.

Note: Providers are only able to link active eServices accounts.

Once your accounts are linked you will be able to log in, click a drop-down menu that lists all your linked NPI and PTAN combinations attached to your ID, and select the individual account you’d like to view. For complete step-by-step instructions, please view the eServices User Guide at https://www.palmettogba.com/eServicesuserguide.

eServices Profile Verification Timeframes eServices Profile Verification has been extended from 90 to 250 days, allowing more time for you to complete this process. During this time, please make sure that all eServices user ID profiles are up to date to avoid interruption or deactivation.

As a result of this change, several additional timeframe alerts have been adjusted.

Pop-ups Pop-ups will be displayed for days 240–249, instead of days 80–89 Redirected Accounts will be redirected for days 250–259, instead of days 90–99 Deactivated Accounts will be deactivated on day 260, instead of day 100 Email Notification Email Notifications will be sent on day 240 and 250, instead of day 80 and 90


6 7/2020

https://www.palmettogba.com/eServicesuserguide

Get Your Medicare News Electronically The Palmetto GBAMedicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: • Medicare incentive programs • Fee Schedule changes • New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv: Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

eServices Eligibility eServices, by Palmetto GBA, allows you to search for patient eligibility, which is a functionality of HETS. HETS requires you to enter beneficiary last name and Medicare ID Number, in addition to either the birth date or first name. See options below:

• Medicare ID Number, Last Name, First Name, Birth Date • Medicare ID Number, Last Name, Birth Date • Medicare ID Number, Last Name, First Name

For more information about eServices and the many services it offers, please visit our website at http://www.PalmettoGBA.com/eServices.


7 7/2020

http://tinyurl.com/PalmettoGBAListservhttp://www.PalmettoGBA.com/eServices

Medicare Learning Network® (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims

processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index • MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To

access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”

• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources: • MLN Publications List: contains the electronic versions of the downloadable publications. These products

are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service: 1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or

Unsubscribe’ link under the ‘Options’ tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].


8 7/2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/indexhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-lmailto:[email protected]

ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider

Contact Center Authentication is required before Palmetto GBA is authorized to discuss Medicare information with a provider. The ePass is an eight-digit code providers can elect to receive, per each NPI and PTAN combination, following their first-time authentication when they call the Provider Contact Center (PCC). This ePass can then be used for the remainder of the day in order to authenticate. This code will be delivered in one of two ways: • Through the IVR, follow the first-time authentication steps by selecting Option 5 for ePass and then Option

2 to receive ePass; or • Request your ePass verbally while speaking with a Customer Service Agent (CSA) following first-time

authentication

The goal of the ePass is to ease provider burden by eliminating the need to repeatedly authenticate each time you contact the PCC in a given day. The ePass can then be used for the remainder of that business day in order to authenticate. Simply select Option 5 for ePass and Option 1 to enter your 8-digit ePass number.

This enhancement is in direct response to provider feedback with the goal of improving your provider experience with Palmetto GBA.


9 7/2020

eTicket Enables Providers to Save Time with Every Call Palmetto GBAcontinues to develop tools to improve service and efficiency, and our new eTicket is no exception.

eTicket, like the recently introduced ePass, will save you time when contacting the Provider Contact Center (PCC) about a particular issue on multiple occasions. While ePass provides you with a code to bypass authentication on subsequent calls to the PCC during a single day, eTicket enables our representatives to serve you quickly and with greater effectiveness.

When you speak to a customer care representative by phone, a numeric inquiry number or eTicket is generated which provides a reference to the subject matter of your conversation with our PCC. When you call us with additional follow-up questions or for more information specific to a prior call, you can input your eTicket number into the IVR. Upon being transferred to a service representative, your topic of inquiry and data related to your previous call with Palmetto GBA will automatically be presented on the service representative’s screen, expediting their ability to serve you.

Palmetto GBA welcomes you to eTicket. Look for additional information at www.PalmettoGBA.com, in our Listserv newsletters and on Palmetto GBA’s social media channels.


10 7/2020

http://www.PalmettoGBA.com

CMS Quarterly Provider Update The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to: • Inform providers about new developments in the Medicare program • Assist providers in understanding CMS programs and complying with Medicare regulations and instructions • Ensure that providers have time to react and prepare for new requirements • Announce new or changing Medicare requirements on a predictable schedule • Communicate the specific days that CMS business will be published in the ‘Federal Register’

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.

We encourage you to bookmark the Quarterly Provider Update Web site at www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index and visit it often for this valuable information.

eServices Extends Administrator Unlock Feature Beyond 30 Days Palmetto GBA has implemented new “Disable User” functionality in eServices that will disable a user that has been inactive for 30 days instead of terminating the User ID. Administrators will now be able to enable the user up to 120 days after 30 days of inactivity. If the user ID is not enabled within this time, the account will be terminated. We will send notification to providers through a series of periodic emails (up to the 120-day limit) to remind the user of their status and provide instructions to re-enable eServices IDs.

In short, provider administrators can now simply unlock users as well as other administrators. This is a significant change from past guidelines. Previously: • Provider Administrators and users were required to login at least once every 30 days

• Accounts in which users did not login past 30 days were deactivated/terminated • If the provider admin did not login, all user accounts associated with the provider admin were also

deactivated/terminated • This created additional work for administrators as they were required to create new accounts for deactivated/

terminated users

The Provider Contact Center eServices Helpdesk is also able to assist if the provider administrator is unable to complete this task.


11 7/2020

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index

You Can Track Your Enrollment ApplicationPalmetto GBA makes it easy for you to track your enrollment application with our Application Status Lookup Tool. This tool provides tracking data for application types 855A, 855B, 855I, 855R and 855O, and Medicare Diabetes Prevention Program. Additionally, the tool will provide updates on submitted CMS 588 (EFT), CMS 460 (Participating Agreement), reconsideration requests, opt-out affidavits, license updates and voluntary terminations requests. • Jurisdiction J, Part B:

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yes • Jurisdiction M, Part B:

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yes


12 7/2020

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yeshttps://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yes

Claim Status Category Codes and Claim Status Codes Update

MLN Matters Number: MM11699 Related CR Release Date: May 22, 2020 Related CR Transmittal Number: R10148CP Related Change Request (CR) Number: 11699 Effective Date: October 1, 2020 Implementation Date: October 5, 2020

Provider Types Affected This MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11699 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. Make sure your billing staff is aware of this update.

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the NCMC. The codes are listed in the ASC X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transaction standards adopted under HIPAA for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s). Proprietary codes are unallowable in the ASC X12 276/277 transactions to report claim status.

The National Code Maintenance Committee (NCMC) meets at the beginning of each ASC X12 trimester meeting (January/February, June, and September/October) and makes decisions about additions, modifications, and retirement of existing codes. The Committee has decided to allow the industry six (6) months for implementation of newly added or changed codes.

The codes sets are available at https://nex12.org/index.php/codes (for Health Care Claim Status Category and Health Care Claim Status Codes). Included in the code lists are specific details, such as the date of an addition, change, or deletion of a code. All code changes approved during the June 2020 committee meeting will be listed on these sites on or about July 1, 2020. These code changes are to be used in editing of all ASC X12 276 transactions processed on or after the date of implementation and to be reflected in the ASC X12 277 transactions issued on and after the date of implementation of this CR 11699.

The MACs must comply with the requirements contained in the current standards adopted under HIPAA for electronically submitting certain health care transactions, among them the ASC X12 276/277 Health Care Claim Status Request and Response. The MACs will use valid Claim Status Category Codes and Claim Status Codes when sending ASC X12 277 Health Care Claim Status Responses. They must also use valid Claim Status Category Codes and Claim Status Codes when sending ASC X12 277 Healthcare Claim Acknowledgments.


13 7/2020

https://nex12.org/index.php/codes

References in CR 11699 to “277 responses” and “claim status responses” encompass both the ASC X12 277 Health Care Claim Status Response and the ASC X12 277 Healthcare Claim Acknowledgment transactions.

Additional Information The official instruction, CR 11699, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10148cp.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

Document History Date of Change Description May 22, 2020 Initial article released.


14 7/2020

https://www.cms.gov/fihttp://go.cms.gov/MAC-website-list

Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

MLN Matters Number: SE20011 Revised Article Release Date: June 1, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: On June 1, 2020, we revised the article to add a section on Clarification for Using the “CR” Modifier and “DR” Condition Code. All other information remains the same.

Provider Types Affected This MLN Matters® Special Edition Article is for providers and suppliers who bill Medicare Fee-For-Service (FFS).

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

Background Section 1135 and Section 1812(f) Waivers As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act: 1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC

X12 837 institutional claims format or paper Form CMS-1450. 2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institution-

al, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.

Clarification for Using the “CR” Modifier and “DR” Condition Code When a PHE is declared and section 1135 authority is invoked, CMS has the authority to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Act, to approve blanket waivers of certain Social Security Act requirements. These waivers help prevent gaps in access to care for beneficiaries impacted by the emergency. In previous emergencies, CMS issued a limited number of waivers for the Medicare Fee-for-Service program. In order to allow CMS to assess the impact


15 7/2020

of prior emergencies, CMS has required the use of modifier “CR” and condition code “DR” for all services provided in a facility operating pursuant to CMS waivers that typically were in place, for limited geographical locations and durations of time.

For the COVID-19 PHE, CMS has issued many additional blanket waivers, flexibilities and modifications to existing deadlines and timetables that apply to the whole country. The full list of waivers and flexibilities can be found here (https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf). Due to the large volume and scope of these new blanket waivers and flexibilities, CMS is clarifying which require the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare. The chart below identifies those blanket waivers and flexibilities for which CMS requires the use of the modifier or condition code. Submission of the modifier or condition code is not required for any waivers or flexibilities not included in this chart.

Please note that CMS will not deny claims due to the presence of the “CR” modifier or “DR” condition code for services/items related to a COVID-19 waiver that are not on this list, or for services/items that are not related to a COVID-19 waiver. There may be potential claims implications, such as claims denials, for claims that do not contain the modifier or condition code as required in the below chart. However, providers do not need to resubmit or adjust previously processed claims to conform to the requirements below, unless claims payment was affected.

Waiver/Flexibility Summary CR DR Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital

Allows acute care hospitals with excluded distinct part inpatient psychiatric units to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit as a result of a disaster or emergency.

X

Housing Acute Care Patients in the IRF or Inpatient Psychiatric Facility (IPF) Excluded Distinct Part Units

Allows acute care hospitals to house acute care inpatients in excluded distinct part units, such as excluded distinct part unit IRFs or IPFs, where the distinct part unit’s beds are appropriate for acute care inpatients.

X

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital

Allows acute care hospitals with excluded distinct part inpatient rehabilitation units to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit as a result of this PHE.

X


16 7/2020

https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

Supporting Care for Patients in Long Term Care Acute Hospitals (LTCHs)

CMS has determined it is appropriate to issue a blanket waiver to long-term care hospitals (LTCHs) where an LTCH admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement at § 412.23(e) (2), which allows these hospitals to participate in the LTCH PPS. In addition, during the applicable waiver time period, CMS has determined it is appropriate to issue a blanket waiver to hospitals not yet classified as LTCHs, but seeking classification as an LTCH, to exclude patient stays where the hospital admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement, which must be met in order for these hospitals to be eligible to participate in the LTCH PPS.

X

Care for Patients in Allows extended neoplastic disease care hospitals to exclude X Extended Neoplastic inpatient stays where the hospital admits or discharges patients in Disease Care Hospital order to meet the demands of the emergency from the greater than

20-day average length of stay requirement, which allows these facilities to be excluded from the hospital inpatient prospective payment system and paid an adjusted payment for Medicare inpatient operating and capital-related costs under the reasonable cost-based reimbursement rules.

Skilled Nursing Using the authority under Section 1812(f) of the Act, CMS is X Facilities (SNFs) waiving the requirement for a 3-day prior hospitalization for

coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).


17 7/2020

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, allow the DME Medicare Administrative Contractors (MACs) to have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency.

X

Modification of 60-Day Limit for Substitute Billing Arrangements (Locum Tenens)

Modifies the 60-day limit to allow a physician or physical therapist to use the same substitute for the entire time he or she is unavailable to provide services during the COVID-19 emergency, plus an additional period of no more than 60 continuous days after the public health emergency expires. On the 61st day after the public health emergency ends (or earlier if desired), the regular physician or physical therapist must use a different substitute or return to work in his or her practice for at least one day in order to reset the 60-day clock. Physicians and eligible physical therapists must continue to use the Q5 or Q6 modifier (as applicable) and do not need to begin including the CR modifier until the 61st continuous day.

X

Critical Access Hospitals

Waives the requirements that Critical Access Hospitals limit the number of inpatient beds to 25, and that the length of stay, on an average annual basis, be limited to 96 hours.

X

Replacement Medicare payment may be permitted for replacement prescription X Prescription Fills fills (for a quantity up to the amount originally dispensed) of

covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.

Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDHs)

For hospitals classified as MDHs prior to the PHE, waives the eligibility requirements that the hospital has 100 or fewer beds during the cost reporting period and that at least 60 percent of the hospital’s inpatient days or discharges were attributable to individuals entitled to Medicare Part A benefits during the specified hospital cost reporting periods.

X


18 7/2020

IRF 60 Percent Rule Allows an IRF to exclude patients from its inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF

X

Waivers of certain Allows a hospital or Community Mental Health Center (CMHC) X X hospital and to consider temporary expansion locations, including the Community Mental patient’s home, to be a provider-based department of the hospital Health Center or extension of the CMHC, which allows institutional billing for (CMHC) Conditions certain outpatient services furnished in such temporary expansion of Participation and locations. If the entire claim falls under the waiver, the provider provider-based rules would only use the DR condition code. If some claim lines fall

under this waiver and others do not, then the provider would only append the CR modifier to the particular line(s) that falls under the waiver.

Billing Procedures for ESRD services when the patient is in a SNF/NF

In an effort to keep patients in their SNF/NF and decrease their risk of being exposed to COVID-19, ESRD facilities may temporarily furnish renal dialysis services to ESRD beneficiaries in the SNF/NF instead of the offsite ESRD facility. The in-center dialysis center should bill Medicare using Condition Code 71 (Full care unit. Billing for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility). The in-center dialysis center should also apply condition code DR to claims if all the treatments billed on the claim meet this condition or modifier CR on the line level to identify individual treatments meeting this condition.

X X

Clinical Indications for Certain Respiratory, Home Anticoagulation Management, Infusion Pump and Therapeutic Continuous Glucose Monitor national and local coverage determinations

In the interim final rule with comment period (CMS-1744-IFC and CMS-5531-IFC) CMS states that clinical indications of certain national and local coverage determinations will not be enforced during the COVID-19 public health emergency. CMS will not enforce clinical indications for respiratory, oxygen, infusion pump and continuous glucose monitor national coverage determinations and local coverage determinations.

X


19 7/2020

Face-to-face and In- In the interim final rule with comment period (CMS-1744- X person Requirements IFC) CMS states that to the extent a national or local coverage for national and determination would otherwise require a face-to-face or in-local coverage person encounter for evaluations, assessments, certifications or determinations other implied face-to-face services, those requirements would not

apply during the COVID-19 public health emergency. Requirement for The requirement to submit a prior authorization request for X DMEPOS Prior certain DMEPOS items and services was paused. Suppliers Authorization were given the option to voluntary continue submitting prior

authorization requests or to skip prior authorization and have the claim reviewed through post payment review at a later date. Claims that would normally require prior authorization, but were submitted without going through the process should be submitted with a CR modifi er.

Signature requirements for proof of delivery

The signature requirement for Part B drugs and certain Durable Medical Equipment (DME) that require a proof of delivery and/ or a beneficiary signature was waived. Providers should use a CR modifier on the claim and document in the medical record the appropriate delivery date and that a signature could not be obtained because of COVID-19.

X

Part B Prescription MACs may exercise flexibilities regarding the payment of X Drug Refills Medicare Part B claims for drug quantities that exceed usual

supply limits, and to permit payment for larger quantities of drugs, if necessary. MACs may require the use of the CR modifier in these cases.

Medicare FFS Questions & Answers (FAQs) available on the Waivers and Flexibilities webpage (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities) apply to items and services for Medicare beneficiaries in the current emergency. These FAQs are displayed in these files: • COVID-19 FAQs (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf) • FAQs that apply without any Section 1135

(https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_ Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.

• FAQs apply only with a Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf) waiver or, when applicable, a Section 1812(f) waiver.

Blanket Waivers Issued by CMS View the complete list of COVID-19 blanket waivers.

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.


20 7/2020

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilitieshttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilitieshttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilitieshttps://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf

View a complete list (https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.

When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE, bill with: • Place of Service (POS) equal to what it would have been had the service been furnished in-person • Modifier 95, indicating that the service rendered was actually performed via telehealth

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims: • Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous

(store and forward) technology, use GQ modifier • Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

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

CMS released a video providing answers to common questions about the Medicare telehealth services benefit.

Video (https://www.youtube.com/watch?v=bdb9NKtybzo&feature=youtu.be)

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

Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the PHE; that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes: • Office and other outpatient services • Hospital observation services • Emergency department services • Nursing facility services • Domiciliary, rest home, or custodial care services • Home services • Online digital evaluation and management services


21 7/2020

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codeshttps://www.youtube.com/watch?v=bdb9NKtybzo&feature=youtu.be

Cost-sharing does not apply to the above medical visit services for which payment is made to: • Hospital Outpatient Departments paid under the Outpatient Prospective Payment System • Physicians and other professionals under the Physician Fee Schedule • Critical Access Hospitals (CAHs) • Rural Health Clinics (RHCs) • Federally Qualified Health Centers (FQHCs)

Previously, CMS made available the CS modifier for the gulf oil spill in 2010; however, CMS recently repurposed the CS modifier for COVID-19 purposes. Now, for services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.

COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers During the COVID-19 PHE, Medicare will cover a medically necessary emergency and non-emergency ground ambulance transportation from any point of origin to a destination that is equipped to treat the condition of the patient consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished. On an interim basis, we are expanding the list of destinations that may include but are not limited to: • Any location that is an alternative site determined to be part of a hospital, Critical Access Hospital (CAH),

or Skilled Nursing Facility (SNF) • Community mental health centers • Federally Qualified Health Centers (FQHCs) • Rural health clinics (RHCs) • Physicians’ offices • Urgent care facilities • Ambulatory Surgery Centers (ASCs) • Any location furnishing dialysis services outside of an End-Stage Renal Disease (ESRD) facility when an

ESRD facility is not available • Beneficiary’s home

CMS expanded the descriptions for these origin and destination claim modifiers to account for the new covered locations: • Modifier D - Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC

or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility • Modifier E – Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the

beneficiary’s home • Modifier H - Alternative care site for hospital, including CAH, provider-based ASC, or freestanding

emergency center • Modifier N - Alternative care site for SNF • Modifier P - Physician’s office • Modifier R - Beneficiary’s home

For the complete list of ambulance origin and destination claim modifiers see Medicare Claims Processing Manual Chapter 15


22 7/2020

(https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdf), Section 30 A.

New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing To identify and reimburse specimen collection for COVID-19 testing, CMS established two Level II HCPCS codes, effective with line item date of service on or after March 1, 2020: • G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]), any specimen source • G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source

Note that G2024 is applicable to patients in a non-covered stay in a SNF and not to those residents in Medicare-covered stays (whose bundled lab tests would be covered instead under Part A’s SNF benefit at Section 1861(h) of the Act).

These codes are billable by clinical diagnostic laboratories.

Beneficiary Notice Delivery Guidance in Light of COVID-19 If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care: • Important Message from Medicare (IM)_CMS-10065 • Detailed Notices of Discharge (DND)_CMS-10066 • Notice of Medicare Non-Coverage (NOMNC)_CMS-10123 • Detailed Explanation of Non-Coverage (DENC)_CMS-10124 • Medicare Outpatient Observation Notice (MOON)_CMS-10611 • Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131 • Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055 • Hospital Issued Notices of Non-Coverage (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include: • Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room

safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off , notices to beneficiaries may also be delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.

• Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

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


23 7/2020

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdfhttps://www.cms.gov/media/137111

Additional Information The complete list of COVID-19 blanket waivers is available at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.

Review information on the current emergencies webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.


Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index

Document History Date of Change June 1, 2020

April 10, 2020

March 20, 2020

March 19, 2020

March 18, 2020

March 16, 2020

Description We revised the article to add a section on Clarification for Using the “CR” Modifier and “DR” Condition Code. All other information remains the same. Note: We revised this article to: • Link to all the blanket waivers related to COVID-19 • Provide place of service coding guidance for telehealth claims • Link to the Telehealth Video for COVID-19 • Add information on the waiver of coinsurance and deductibles for certain testing

and related services • Add information on the expanded use of ambulance origin/destination modifiers • Provide new specimen collection codes for clinical diagnostic laboratories billing • Add guidance regarding delivering notices to beneficiaries. All other information is the same. We revised the article to add a note in the Telehealth section to cover the use of modifiers on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same. We corrected a typo in the article. One of the e-visit codes was incorrectly stated as 99431 and we corrected it to show 99421. We revised this article to include information about the Telehealth waiver. All other information remains the same. Initial article released.


24 7/2020

https://www.cms.gov/fihttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-pagehttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-pagehttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certifi

July Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee

Schedule MLN Matters Number: MM11810 Related CR Release Date: June 5, 2020 Related CR Transmittal Number: R10168CP Related Change Request (CR) Number: 11810 Effective Date: July 1, 2020 Implementation Date: July 5, 2020

Provider Types Affected This MLN Matters® Article is for providers and suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services that Medicare reimburses under the DMEPOS fee schedule.

Provider Action Needed This article informs DME MACs about the changes to the DMEPOS fees schedules that are updated on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Make sure your billing staffs are aware of these changes.

Background Medicare pays for DME, prosthetic devices, orthotics, prosthetics and surgical dressings on a fee schedule basis per Sections 1834(a), (h), and (i) of the Social Security Act (the Act). Additionally, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulations (CFR) Section 414.102 for Parenteral and Enteral Nutrition (PEN), splints, casts and Intraocular Lenses (IOLs) inserted in a physician’s office. The DMEPOS and PEN fee schedule files contain HCPCS codes that are subject to the adjusted fee schedule amounts under 1834(a)(1)(F) of the Act, as well as codes that are not subject to the fee schedule Competitive Bidding Program (CBP) adjustments.

Section 1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain items furnished on or after January 1, 2016, in areas that are not Competitive Bid Areas (CBAs), based on information from CBPs for DME. Section 1842(s)(3)(B) of the Act provides authority for making adjustments to the fee schedule amount for enteral nutrients, equipment and supplies (enteral nutrition) based on information from CBPs.

The methods for adjusting DMEPOS fee schedule amounts under this authority are established at 42 CFR 414.210(g). More information on adjustments to the fee schedule amounts based on information from CBPs is available in CR 11570, dated January 3, 2020. (See the related article at https://www.cms.gov/files/document/MM11570.pdf.) Also, with the exception of the changes made by Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), CR 11570 provides information on the adjusted fee payment basis for items and services furnished from January 1, 2019, through December 31, 2020, in the following three areas: rural and noncontiguous non-CBAs, non-rural and contiguous non-CBAs and in former CBAs during a temporary gap in the DMEPOS CBP.


25 7/2020

https://www.cms.gov/fi

Due to a delay in announcement of the next round of the CBP, contracts are not in effect in Round 1, Round 2, or the National Mail Order CBAs beginning January 1, 2019, resulting in a temporary gap period in the CBP. Additional program instructions for payment of items furnished in former CBAs is available in CR 11233, dated April 5, 2019. A related article is at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ downloads/MM11233.pdf.

The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. The DMEPOS Rural ZIP code file contains the ZIP codes designated as rural areas. ZIP codes for non-continental Metropolitan Statistical Areas (MSA) are not included in the DMEPOS Rural ZIP code file. The DMEPOS Rural ZIP code file is updated on a quarterly basis as necessary. Regulations at 42 CFR 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code is estimated to be outside any MSA. A rural area also includes any ZIP Code within an MSA that is excluded from a CBA established for that MSA. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes and will be updated on a quarterly basis as necessary.

CR 11810 provides update instructions for the following: 1. DMEPOS fee schedule file 2. PEN fee schedule file 3. DMEPOS Rural ZIP code file containing the Quarter 3, 2020 updates

These files will also be available as Public Use Files (PUFs) for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the data files on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.

Interim Final Rule with Comment Period (CMS-5531-IFC) The interim final rule with comment period (CMS-5531-IFC) entitled “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program” was published in the Federal Register on Friday, May 8, 2020. The IFC implements Section 3712 of the CARES Act, which was signed into law on March 27, 2020. Sections 3712(a) and (b) of the CARES Act, respectively, require the following: a) For items and services subject to the fee schedule adjustments furnished in rural or non-contiguous

areas, the fee schedule amounts will continue to be based on a blend of 50 percent of the adjusted fee schedule amounts and 50 percent of the unadjusted fee schedule amounts (that is, no change from the current fee schedule amounts) through December 31, 2020, or the duration of the COVID-19 Public Health Emergency (PHE), whichever is later.

b) For items and services subject to the fee schedule adjustments furnished in non-rural contiguous non-CBAs, the fee schedule amounts will be based on a blend of 75 percent of the adjusted fee schedule amounts and 25 percent of the unadjusted fee schedule amounts (that is, an increase in the fee schedule amounts) for claims with dates of service beginning March 6, 2020, and continuing until the end of the COVID-19 PHE.


26 7/2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedulehttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule

DMEPOS and PEN fee schedule files containing the revised non-rural 75/25 blended fees were transmitted in late April to the DME MACs for implementation.

Since the PHE has not ceased, the July 2020 DMEPOS and PEN fee files continue to include the non-rural contiguous non-CBA 75/25 blended fees required by Section 3712(b) of the CARES Act.

Additional information on Section 3712 of the CARES Act is available in CR 11784, dated May 8, 2020. A related article is available at https://www.cms.gov/files/document/MM11784.pdf.

As the revised fee schedule amounts are based in part on unadjusted fee schedule amounts, the DMEPOS fee schedule files will also temporarily incorporate fee schedule amounts for certain codes billed in conjunction with modifier KE for all areas. Background information on the KE modifier was issued in CR 6270, dated November 7, 2008. (A related article is at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/MM6270.pdf. In cases where accessories included in the Initial Round One CBP in 2008 are furnished for use with base equipment that was not included in the 2008 CBP (for example, manual wheelchairs where the KU modifier does not apply, canes, and aspirators), for beneficiaries residing in non-rural areas, suppliers should append the KE modifier to the HCPCS code for the accessory.

Further Consolidated Appropriations Act, 2020 The Further Consolidated Appropriations Act, 2020 (Pub. L. 116-94) was signed into law on December 20, 2019. Section 106 of the Act mandates that, during the period beginning on January 1, 2020, and ending June 30, 2021, the adjustments to the Medicare fee schedule amounts for certain DME based on information from CBPs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with complex rehabilitative manual wheelchairs (HCPCS codes E1161, E1231, E1232, E1233, E1234, and K0005) and certain manual wheelchairs currently described by HCPCS codes E1235, E1236, E1237, E1238, and K0008. As a result, KU modifier fees for wheelchair accessory and seat and back cushion HCPCS codes impacted by this change have been added to the DMEPOS fee schedule file as part of this update and are effective for dates of service through June 30, 2021. The fees for items denoted with the HCPCS modifier KU represent the unadjusted fee schedule amounts (that is, the Calendar Year (CY) 2015 fee schedule amount updated to the present calendar year by the DMEPOS covered item updates). Additional instructions, as well as the applicable complex rehabilitative and certain manual wheelchair accessory codes associated with this provision are listed in Transmittal 10019, CR 11635, dated May 7, 2020.

Other Payment Changes Effective January 1, 2020, the parenteral nutrition solution code B4185 Parenteral nutrition solution, per 10 grams lipids was divided into two HCPCS codes: B4187 Omegaven, 10 grams lipids and B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids. Before this change, all claims for lipids furnished as part of parenteral nutrition fell under code B4185. Payment regulations at 42 CFR 414.110 specify that when there is a single code that describes two or more distinct complete items and separate codes are subsequently established for each item, the fee schedule amounts that applied to the single code continue to apply to each of the items described by the new codes. As required by this regulation, the fee schedule amounts for code B4185 apply to new code B4187 and revised code B4185 effective for items and services furnished on or after July 1, 2020.


27 7/2020

https://www.cms.gov/fihttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/

Additional Information The official instruction, CR 11810, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10168CP.pdf.


Document History Date of Change Description June 5, 2020 Initial article released.

Do You Have a Question Regarding eServices? We Can Help! Palmetto GBA has dedicated representatives available to provide technical assistance and answer questions about our secure online portal — eServices. Our Provider Contact Center (PCC) representatives can be reached at 855–696–0705 (Monday – Friday, 8 a.m. to 4:30 p.m. ET).

To connect with an eServices representative: • Press/say 1 or EDI • Press/say 2 for all other calls • Press/say 1 or eServices

IVR Call Flow Chart: https://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_Flowchart.pdf/$File/IVR_Flowchart.pdf


28 7/2020

https://www.cms.gov/fihttp://go.cms.gov/MAC-website-listhttps://www.palmettogba.com/Palmetto/Providers.Nsf/fi

Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA

Don’t Miss this Wonderful Opportunity! If you are in search of an opportunity to interact with and get answers to your Medicare billing, coverage and documentation questions from Palmetto GBA’s Provider Outreach and Education

(POE) department, please see these educational offerings which have a question and answer session:

Event Date/Time Address, Phone number of link if Webcast Top Five Claim July 1, https://event.on24.com/wcc/r/2325224/E3A4E3AE31D29A2E925902DFF4C31BE6 Denial and 2020, Rejection Reason and/or Remark Codes Webcast Series: Part 3: Claim Adjustment Reason Code 109

11 a.m. ET

Top Jurisdiction July 14, https://event.on24.com/wcc/r/2447446/71965069D2B38598793747B3503B9A46 M Medicare Part 2020, B Review Denials with a Focus on CPT 66984 Extracapsular Cataract Extraction Removal with Insertion of Intraocular Lens Prosthesis

11 a.m. ET

JJ/JM Part B July 21, https://event.on24.com/wcc/r/2441174/7CAF4D8B3A34AA94D332FE7BC3C7DF06 Lunch and Learn: 2020, On The Dotted Line - Medicare Signature Requirements

12 p.m. ET

Top Five Claim July 22, https://event.on24.com/wcc/r/2325237/B430D45E00022943F73F0A015B69A404 Denial and 2020, Rejection Reason and/or Remark Codes Webcast Series: Part 4: Claim Adjustment Reason Code 18

11 a.m. ET


29 7/2020

https://event.on24.com/wcc/r/2325224/E3A4E3AE31D29A2E925902DFF4C31BE6https://event.on24.com/wcc/r/2447446/71965069D2B38598793747B3503B9A46https://event.on24.com/wcc/r/2441174/7CAF4D8B3A34AA94D332FE7BC3C7DF06https://event.on24.com/wcc/r/2325237/B430D45E00022943F73F0A015B69A404

Event Date/Time Address, Phone number of link if Webcast Jurisdiction M Focus Service Surgical Debridement CPT 11042-11047

July 28, 2020, 11 a.m. ET

https://event.on24.com/wcc/r/2447484/3C6DA6419ABCEE003BC834E2218EE69E

Top Five Claim Denial and Rejection Reason and/or Remark Codes Webcast Series: Part 5: Claim Adjustment Reason Code 16

July 30, 2020, 11 a.m. ET

https://event.on24.com/wcc/r/2325242/07D90DDF09D2FD93516B3082E64C26C5

Jurisdiction J and M Part B Ask the Contractor Teleconference

August 11, 2020, 11 a.m. ET

Call-in Number: 866–745–0425, Pass Code: 6728988

Check out these resources Type of Education Description Quarterly Ask the Contractor Teleconferences (ACTs)

ACTs are intended to open the communication channels between providers and Palmetto GBA, which allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference.

Proceding the presentation, providers are given an opportunity to ask questions both on the topics discussed as well as any other question they may have. While we encourage providers to submit questions prior to the call, this is not required. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form. Once the form is completed, please fax it to (803) 935-0140, Attention: Ask-the-Contractor Teleconference

Quarterly Updates The Quarterly Update Webcasts are intended to provide ongoing, scheduled Webcasts opportunities for providers to stay up to date on Medicare requirements.

Providers are able to type a question and have it responded to by the POE department throughout the webcast. At the end of the presentation the moderator will also read and respond to questions submitted by attendees in order to share the responses with the group at large.


30 7/2020

https://event.on24.com/wcc/r/2447484/3C6DA6419ABCEE003BC834E2218EE69Ehttps://event.on24.com/wcc/r/2325242/07D90DDF09D2FD93516B3082E64C26C5

Type of Education Event Registration Portal

Description Visit our Event Registration Portal to find information on upcoming educational events and seminars.

This is a complete listing of both our face-to-face outreach opportunities as well as our teleconference and webcast listings. Providers are able to dialogue with POE and get answers to their questions at all of these educational events.

If you have a question that you need an answer to today or a claims specific question which requires the disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at 1-855-696-0705 for Jurisdiction M or 877-567-7271 for Jurisdiction J.

CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dent

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