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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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JJ PART B MEDICARE ADVISORYLatest Medicare News for JJ Part B What’s Inside...

AdministrationMSI Live Announcement: Evaluate Our Services .................................................................3 How Can We Be Of “eServices” To You!

ePass is Now Available to Ease the Burden of Repeated Authentication When Calling

................................................................................4 Claims Payment Issues Log .....................................................................................................4 Get Your Medicare News Electronically .................................................................................5

Palmetto GBA’s Provider Contact Center ............................................................................7 eTicket Enables Providers to Save Time with Every Call .......................................................8 Reassignment of Medicare Benefits: Revised CMS-855R Required May 1 ...........................9 CMS Quarterly Provider Update ...........................................................................................10 eServices Profile Verification Timeframes .............................................................................10 Medicare Beneficiary Identifier (MBI) Look-up Tool ...........................................................12 Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the

Coronavirus (COVID-19)...................................................................................................14 Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare .......20 Proper Use of Modifier 59 .....................................................................................................21 Accepting Payment from Patients with a Medicare Set-Aside Arrangement ........................28

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

(DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements ......................................................................................................................31

EducationEducational Events Where You Can Ask Questions .............................................................36

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

Medicare Remit Easy Print (MREP) and PC Print Update ................................................37

palmettogba.com/jjb

The JJ 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 JJ 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/JJB.

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.

April 2020 Volume 2020, Issue 4

https://www.PalmettoGBA.com/JJB

Fee Schedules and Reimbursement Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update .....................39

Medicine International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage

Determinations (NCDs) – July 2020 Update ............................................................................................................43 Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type ................................45

Ambulatory Surgical Center (ASC) April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System .........................................................47

Cardiology NCD 20.4 Implantable Cardiac Defibrillators (ICDs) ..................................................................................................52

Laboratory Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory

Improvement Amendment (CLIA) Edits ...................................................................................................................55 Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge

Payment .....................................................................................................................................................................61

Radiology Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for

Institutional Claims ...................................................................................................................................................66

Etcetera Medical Director’s Desk ...............................................................................................................................................83 MLN ConnectsTM ..........................................................................................................................................................88

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 4/2020

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

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

The survey for Jurisdiction J Part B providers is now available (https://www.surveygizmo.com/s3/5439699/?MAC_BRNC=17&MAC=JJ-Palmetto).

The survey for Jurisdiction M Part B providers is now available (https://www.surveygizmo.com/s3/5439699/?MAC_BRNC=11&MAC=JM-Palmetto).


3 4/2020

https://www.surveygizmo.com/s3/5439699/?MAC_BRNC=17&MAC=JJ-Palmettohttps://www.surveygizmo.com/s3/5439699/?MAC_BRNC=11&MAC=JM-Palmetto

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.

Claims Payment Issues Log Palmetto GBA wants to keep you in the know, and one way we do this is by publishing a Claims Payment Issues Log. This log lets you know about any current system-related payment and processing issues. Many of these issues are reported to the Centers for Medicare & Medicaid Services (CMS), as well as the Multi-Carrier System (MCS) or Fiscal Intermediary Shared System (FISS) maintainers.

If this log has an issue that impacts your claims and you’ve read about it on our site, sign up for an email to let you know if the article has been updated and/or the problem has been resolved. To do this, enter your information into the “Article Update Notification” box at the bottom of the individual log, and you’ll receive an email notice every time the log is changed.

To access these logs, please use the following link:

JJ Part B: https://www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-B~AVGL3B4132


4 4/2020

https://www.palmettogba.com/eServicesuserguidehttps://www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-B~AVGL3B4132

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.


5 4/2020

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].


6 4/2020

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-Publicationshttps://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.


7 4/2020

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.


8 4/2020

http://www.PalmettoGBA.com

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

Physicians and non-physician practitioners: Use the revised CMS-855R (Reassignment of Benefits) application posted on the CMS Forms List (http://go.usa.gov/cuujB). Medicare Administrative Contractors will accept current and revised versions of the form through April 30, 2020. Starting May 1, 2020 you must use the revised form. Form updates: • Can select Change of Reassignment Information as submission reason • Option to identify a secondary practice address

Visit the Medicare Provider-Supplier Enrollment webpage (http://go.usa.gov/cuujB) for more information about Medicare enrollment.


9 4/2020

http://go.usa.gov/cuujBhttp://go.usa.gov/cuujB

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 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


10 4/2020

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

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 877–567–7271 (Monday – Friday, 8 a.m. to 6 p.m. ET).

To connect with an eServices representative: • Press/say 1 or EDI • Press/say 1 or eServices

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


11 4/2020

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yeshttps://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yeshttps://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_Flowchart.pdf/$File/IVR_Flowchart.pdf

Medicare Beneficiary Identifier (MBI) Look-up Tool The Medicare Beneficiary Identifier (MBI) Look-up tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. The MBI Look-up tool will only return an MBI if the new Medicare card has been mailed to avoid potential confusion if the MBI is used before the beneficiary receives their new Medicare card.

As background, the New Medicare Card Project, was established in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which mandates the removal of the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) from Medicare cards by April 2019. CMS began mailing new Medicare cards with the MBI on April 2, 2018. The Railroad Retirement Board mailed new Medicare cards with the MBI to all Railroad Medicare beneficiaries in June 2018.

From April 1, 2018 to December 31, 2019, CMS will offer a transition period during which the system will accept both HICNs and MBIs on Medicare transactions (including eligibility requests and claims) for beneficiaries in the Medicare program prior to April 1, 2018 (i.e., those who received a HICN on their Medicare card). Note: Providers should not submit both numbers on the same transaction.

Beginning in January 2020, physicians may only use MBIs, with limited exceptions.

When the new Medicare card is mailed to people with Medicare, you will be able to use the eServices MBI Look-Up Tool to obtain a patient’s MBI. To submit an inquiry you must do the following: • Once logged into eServices, click on the MBI LOOKUP tab located in the header of the portal • Complete the required* fields:

• Beneficiary’s Last Name • First Name • Date of birth and • Social security number. NOTE: The social security number must be in the XXX-XX-XXXX format

• To meet our CAPTCHA requirements, you must select the I’M NOT A ROBOT checkbox • Click SUBMIT INQUIRY

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.

12 4/2020

Figure 1: MBI Lookup Tab

Look-Up Tool Status Results If the inquiry successfully returns an MBI, the screen will refresh with the data at the bottom.

Figure 2: MBI Lookup Successful Response Screenshot

In the event that your MBI lookup request does not result in a successful response, eServices will display error messages to assist you. If any required fields are left blank or are not in a proper format, a message will appear advising you which fields to correct.

Figure 3: MBI Lookup Unsuccessful Response Screenshot

Ch eck the CMS New Medicare Card Project Outreach & Education webpage at https://www.cms.gov/Medicare/New-Medicare-Card/Outreach-and-Education/Outreach-and-education and the Medicare Beneficiary Identifier (MBI) Look-up Tool Clarification article at https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdf for additional information.


13 4/2020

https://www.cms.gov/Medicare/New-Medicare-Card/Outreach-and-Education/Outreach-and-educationhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdf

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

MLN Matters Number: SE20011 Revised Article Release Date: March 18, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We revised this article on March 18, 2020, to include information about the Telehealth waiver. 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: • Current Emergencies (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-

Emergencies/Current-Emergencies-page) webpage • Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-

an-1135-Waiver-Updated-11-16-2016.pdf) 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-institutional,

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

Medicare FFS Questions & Answers (Q&As) available on the Waivers and Flexibilities webpage apply to items and services for Medicare beneficiaries in the current emergency. These Q&As are displayed in two files:


14 4/2020

https://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-pagehttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf

• Q&As 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.

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

Blanket Waivers Issued by CMS You do not need to apply for the following approved blanket waivers:

Skilled Nursing Facilities (SNFs) • Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF stay

provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

• 42 CFR 483.20: This waiver provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission (Blanket waiver for all impacted facilities).

Home Health Agencies • 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related

to OASIS Transmission (Blanket waiver for all impacted agencies). • To ensure the correct processing of home health emergency related claims, Medicare Administrative

Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

Critical Access Hospitals This action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours. (Blanket waiver for all impacted hospitals)

Housing Acute Care Patients in Excluded Distinct Part Units CMS has determined it is appropriate to issue a blanket waiver to inpatient prospective payment system (IPPS) hospitals that, as a result of the emergency, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the emergency. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients.)

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital CMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and


15 4/2020

https://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.pdf

environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital CMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility (IRF) prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.

IRFs may exclude patients from the hospital’s or unit’s 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 and the patient’s medical record properly identifies the patient as such. 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.

Care for Patients in Long-Term Care Acute Hospitals (LTCH)s CMS has determined it is appropriate to issue a blanket waiver to long-term care hospitals (LTCHs) to exclude patient stays 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 which allows these facilities to be paid as LTCHs.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by the Emergency CMS has determined it is appropriate to issue a blanket waiver where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable, contractors 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.

For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Medicare Advantage Plan or other Medicare Health Plan Beneficiaries CMS reminds suppliers that Medicare beneficiaries enrolled in a Medicare Advantage or other Medicare Health Plans should contact their plan directly to find out how it replaces DMEPOS damaged, lost, or unavailable in an emergency. Beneficiaries who do not have their plan’s contact information can contact 1-800-MEDICARE (1-800-633-4227) for assistance.


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Replacement Prescription Fills Medicare payment may be permitted for replacement prescription 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 or unavailable due to the emergency.

Telehealth Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. Arange of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Prior to this waiver Medicare could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.

There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries: • Medicare telehealth visits • Virtual check-ins • e-visits

For more information, review the Medicare Telemedicine Health Care Provider Fact Sheet at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet and Medicare Telehealth Frequently Asked Questions at: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf.


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Summary of Medicare Telemedicine Services Type of Services

MEDICARE TELEHEALTH VISITS

What is the servie?

A visit with a provider that uses telecommunication systems between a provider and a patient.

HCPCS/CPT Code

Common telehealth services include:

• 99201-99215 (Office or other outpatient visits)

• G0425-G0427 (Tele-health consultations, emergency department or initial inpatient)

• G0406-G0408 (Fol-low-up inpatient tele-health consultations fur-nished to beneficiaries in hospitals or SNFs).

For a complete list: https://www. cms.gov/Medicare/Medicare-general-information/telehealth/ telehealth-codes

Patient Relationship with Provider For new* or established patients. *To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

VIRTUAL A brief (5-10 minutes) HCPCS code G2012 For established patients CHECK-IN check in with your

practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient.

HCPCS code G2010

E-VISITS A communication between a patient and their provider through an online patient portal

• 99431 • 99422 • 99423 • G2061 • G2062 • G2063

For established patients

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


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

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.html.

Document History Date of Change Description March 18, 2020 We revised this article to include information about the Telehealth waiver. All

other information remains the same. March 16, 2020 Initial article released.


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Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare

MLN Matters Number: SE20009 Article Release Date: March 3, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Provider Types Affected This MLN Matters Article is for physicians, non-physician practitioners, other providers, and suppliers who may bill Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries who are enrolled in Health Maintenance Organization (HMO) Medicare Non-Risk plans.

What You Need To Know This MLN Matters article reinforces existing Medicare policy that allows non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.

Background The Centers for Medicare & Medicaid Services’ (CMS) has received reports from Medicare cost plans (under Sections 1876 and 1833 of the Social Security Act) that non-network providers sometimes will not treat cost plan members because the providers do not realize that the payer may be either the cost plan or original Medicare.

For example, when a Medicare cost plan enrollee visits a non-network physician, the physician’s office typically queries CMS’HIPAAEligibility Transaction System (HETS) to determine the eligibility of the patient. Currently, HETS specifies that cost plan enrollees are an “HM,” where HM refers to a “Health Maintenance Organization (HMO) Medicare Non-Risk” enrollee. As a result, some non-network physicians may not understand that the system is referring to an enrollee in a Medicare cost plan under Section 1876 or Section 1833 of the Social Security Act and therefore the provider will be paid by original Medicare.

CMS is reminding all providers that Medicare cost plan enrollees have coverage both through the Medicare cost plan and through original Medicare. Non-network physicians may bill the CMS MAC and these claims will be processed in the same manner as claims submitted on behalf of original Medicare enrollees.

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

Document History Description Date of Change

March 3, 2020 Initial article released.


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Proper Use of Modifier 59 MLN Matters® Number: SE1418 Revised Related Change Request (CR) #: N/A Article Release Date: March 2, 2020 Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A

Note: We revised this article on March 2, 2020, to include modifiers -X{EPSU}. All other information is unchanged.

Provider Types Affected This MLN Matters® Special Edition Article is for physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services they provide to Medicare beneficiaries.

Provider Action Needed This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to clarify the proper use of Modifiers 59 and –X{EPSU}. The article only clarifies existing policy. Make sure that your billing staffs are aware of the proper use of Modifiers 59 and –X{EPSU}.

Background The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations.

For NCCI PTP-associated edits that have a Correct Coding Modifier Indicator (CCMI) of “0,” the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

For NCCI PTP-associated edits that have a CCMI of “1,” the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI PTP-associated modifiers. (Refer to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, for general information about the NCCI program, NCCI PTP-associated edits, CCMIs, and NCCI PTP-associated modifiers. This manual is available in the download section at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html)

One function of NCCI PTP-associated edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI PTP-associated modifier that is often used incorrectly.


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The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

Modifiers 59, -X{EPSU} and other NCCI PTP-associated modifiers should NOT be used to bypass a NCCI PTP-associated edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier that is used. Modifiers XE, XS, XP, and XU are effective January 1, 2015 (See MLN Matters article MM8853 (https:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/ MM8853.pdf)). These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be used in lieu of modifier 59 whenever possible. (Modifier 59 should only be used if no other more specific modifier is appropriate.)

CMS allows the Modifiers 59 or –X{ESPU} on Column One or Column Two codes (See the related transmittal at CR11168 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2259OTN.pdf)). The modifiers are defined as follows: • XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This

modifier should only be used to describe separate encounters on the same date of service. • XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure” • XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner” • XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap

usual components of the main service”

1. Modifiers 59 or –XS are used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

Modifiers 59 or –XS are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI PTP-associated modifiers –that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI. (See examples 1, 2, and 3.) From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. Modifiers 59 or –XS should only


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be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not generally constitute treatment of different anatomic sites. For example:

• Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying thedistal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site.(See example 4.)

• Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site.(See example 5.)

• Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of asingle anatomic site. (See example 6.)

2. Modifiers 59 or –XE are used appropriately when the procedures are performed in different en-counters on the same day.Another common use of modifiers 59 or –XE is for surgical procedures, non-surgical therapeuticprocedures, or diagnostic procedures that are performed during different patient encounters on the sameday and that cannot be described by one of the more specific NCCI PTP-associated modifiers – i.e.,24, 25, 27, 57, 58, 78, 79, or 91. (See example 7) Modifiers 59 or -XE should only be used if no othermodifier more appropriately describes the relationship of the two procedure codes.

3. Modifiers 59 or –XU are used inappropriately if the basis for its use is that the narrative descrip-tion of the two codes is different.One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59allowing its use to describe a “different procedure or surgery.” The code descriptors of the two codes ofa code pair edit usually represent different procedures, even though they may be overlapping. The editindicates that the two procedures should not be reported together if performed at the same anatomicsite and same patient encounter as those procedures would not be considered to be “separate anddistinct.” The provider should not use modifiers 59 or –XU for such an edit based on the two codesbeing “different procedures.” (See example 8.) However, if the two procedures are performed at separateanatomic sites or at separate patient encounters on the same date of service, modifiers 59 or –X{ES}may be appended to indicate that they are different procedures on that date of service. Additionally, theremay be limited circumstances sometimes identified in the National Correct Coding Initiative PolicyManual for Medicare Services (available in the downloads section at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html) when the two codes of an edit pair may be reportedtogether with modifiers 59 or –X{ES} when performed at the same patient encounter or at the sameanatomic site.

4. Other specific appropriate uses of modifiers 59 or -XEThere are three other limited situations in which two services may be reported as separate and distinctbecause they are separated in time and describe non-overlapping services even though they may occurduring the same encounter, i.e.:A. Modifiers 59 or –XE are used appropriately for two services described by timed codes provided

during the same encounter only when they are performed sequentially. There is an appropriateuse for modifier 59 that is applicable only to codes for which the unit of service is a measure of time(e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separateand distinct and not interspersed with each other (i.e., one service is completed before the subsequentservice begins), modifiers 59 or –XE may be used to identify the services. (See example 9.)

B. Modifiers 59 or –XU are used appropriately for a diagnostic procedure which precedes a ther-apeutic procedure only when the diagnostic procedure is the basis for performing the thera-


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peutic procedure. When a diagnostic procedure precedes a surgical procedure or non-surgical ther-apeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the thera-peutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 10.) If the diagnostic procedure is an in-herent component of the surgical procedure, it should not be reported separately.

C. Modifiers 59 or –XU are used appropriately for a diagnostic procedure which occurs sub-sequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic pro-cedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of Modifiers 59 or –X{EPSU} do not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers 59 or –X{EPSU}. The HCPCS/ CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Examples of Modifier 59 Usage Following are some examples developed to help guide physicians and providers on the proper use of Modifiers 59 or –X{EPSU} (Please remember that Medicare policy is that Modifiers 59 or –X{EPSU} are used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or diff erent anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. Append Modifier 59, XE, XS, XP, or XU to Column 1 or Column 2 codes when applicable).

Example 1: Column 1 Code / Column 2 Code - 17000/11102 • CPT Code 17000 – Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical

curettement), premalignant lesions (eg, actinic keratoses); first lesion • CPT Code - 11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion

Modifiers 59 or -XS may be reported with code 11102 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifiers 59 or -XS.


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Modifiers 59 or -XS are used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

Example 2: Column 1 Code/Column 2 Code 47370/76942 • CPT Code 47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency • CPT Code 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization

device), imaging supervision and interpretation

CPT code 76942 should not be reported and Modifiers 59 or –X{EPSU} should not be used if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure. Code 76942 may be reported with modifiers 59 or –X{EPSU} if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Example 3: Column 1 Code/Column 2 Code 93453/76000 • CPT Code 93453 – Combined right and left heart catheterization including intraprocedural injections(s)

for left ventriculography, imaging supervision and interpretation, when performed • CPT Code 76000 – Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or

71034 (eg, cardiac fluoroscopy)

CPT code 76000 should not be reported and Modifiers 59 or –X{EPSU} should not be used for fluoroscopy that is used in conjunction with a cardiac catheterization procedure. Modifier 59 or –XU may be reported with code 76000 if the fluoroscopy is performed for a procedure unrelated to the cardiac catheterization procedure.

Example 4: Column 1 Code / Column 2 Code - 11055/11720 • CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion • CPT Code 11720 – Debridement of nail(s) by any method(s); one to five

CPT codes 11720 and 11055 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifiers 59 or –X{EPSU} should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifiers 59 or –XS may be reported with code 11720 if one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

Example 5: Column 1 Code / Column 2 code - 67210/67220 • CPT Code 67210 – Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions;

photocoagulation • CPT Code 67220 – Destruction of localized lesion of choroid (eg, choroidal neovascularization);

photocoagulation (eg, laser), 1 or more sessions


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CPT code 67220 should not be reported and Modifier 59 or –X{EPSU} should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ.

Example 6: Column 1 Code / Column 2 Code - 29827/29820 • CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair • CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

CPT code 29820 should not be reported and Modifiers 59 or –X{EPSU} should not be used if both procedures are performed on the same shoulder during the same operative session. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not Modifiers 59 or –X{EPSU}.

Example 7: Column 1 Code / Column 2 Code - 93015/93040 • CPT Code 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise,

continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report

• CPT Code 93040 – Rhythm ECG, one to three leads; with interpretation and report

Modifiers 59 or –XE may be reported if the rhythm ECG is performed at a different encounter than the cardiovascular stress test. If a rhythm ECG is performed during the cardiovascular stress test encounter, CPT code 93040 should not be reported and Modifier 59 should not be used. Modifiers 59 or –XE are used appropriately when the procedures are performed in different encounters on the same day.

Example 8: Column 1 Code/Column 2 code - 34833/34820 • CPT code 34833 - Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis

or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

• CPT code 34820 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

CPT code 34833 is followed by a CPT Manual instruction that states: “(Do not report 34833 in conjunction with 33364, 33953, 33954, 33959, 33962, 33969, 33984, 34820 when performed on the same side).” Although the CPT code descriptors for 34833 and 34820 describe different procedures, they should not be reported together for the same side. Modifiers 59 or –X{EPSU} should not be appended to either code to report the two procedures for the same side of the body. If the two procedures were performed on different sides of the body, they may be reported with modifiers LT and RT as appropriate. However, modifiers 59 or –X{EPSU} are used inappropriately if the basis for their use is that the narrative description of the two codes is different.

Example 9: Column 1 Code / Column 2 Code - 97140/97530 • CPT Code 97140 – Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage,

manual traction), one or more regions, each 15 minutes • CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of

dynamic activities to improve functional performance), each 15 minutes


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Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block. Modifier 59 used appropriately when two timed procedures are performed in different blocks of time on the same day.

Example 10: Column 1 Code / Column 2 Code - 37220/75710 • CPT Code 37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial

vessel; with transluminal angioplasty • CPT Code 75710 – Angiography, extremity, unilateral, radiological supervision and interpretation.

Modifiers 59 or –XU may be reported with CPT code 75710 if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery. Modifiers 59 or –XU are used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

Additional Information The CMS webpage on the National Correct Coding Initiative Edits is available at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

Document History Date of Change March 2, 2020

May 17, 2019

January 3, 2018

May 27, 2015

June 2, 2014

Description We revised the article to include modifiers -X{EPSU}. All other information is unchanged. We revised this article to reflect that CPT Code 11100 was deleted on January 1, 2019. In Example 1, CPT Code 11100 is replaced with CPT Code 11102. We updated the article to conform with latest Modifier 59 article on the NCCI website with the latest Modifier 59 article. The key update was the addition of information regarding the XE, XS, XP, and XU modifiers. This article was revised to provide a reference to MLN Matters Article SE1503 (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1503.pdf) that advises physicians, providers and suppliers submitting bills to Medicare that additional guidance and education on the appropriate use of the new X modifiers will be introduced in a gradual, controlled fashion by CMS and that providers may continue to use Modifier -59 after January 1, 2015, in any instance in which it was correctly used before January 1, 2015. All other information is unchanged. Initial article released.


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Accepting Payment from Patients with a Medicare Set-Aside Arrangement

MLN Matters Number: SE17019 Revised Article Release Date: February 19, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We revised this article on February 19, 2020, to add information about submitting electronic attestations via the WCMSAP. This is in the Additional Information Section of the article. We added a note on page 2, regarding WCMSA funds. We also updated the link to an updated version of the WCMSA Reference Guide. All other information remains the same.

Provider Type Affected This MLN Matters Article is for providers, physicians, and other suppliers who are told by patients that they must pay the bill themselves because they have a Medicare Set-Aside Arrangement (MSA).

What You Need To Know This article is based on information received from Medicare beneficiaries, their legal counsel, and other entities that assist these individuals, indicating that physicians, providers, and other suppliers are often reluctant to accept payment directly from Medicare beneficiaries who state they have a MSA and must pay for their services themselves. This article explains what an MSA is and explains why it is appropriate to accept payment from a patient that has a funded MSA. Please review your billing practices to be sure they are in line with the information provided.

Background Medicare is always a secondary payer to liability insurance (including self-insurance), no-fault insurance, and workers’ compensation benefits. The law precludes Medicare payment for services to the extent that payment has been made or can reasonably be expected to be made promptly. When future medical care is claimed, or a settlement, judgment, award, or other payment releases (or has the effect of releasing) claims for future medical care, it can reasonably be expected that the monies from the settlement, judgment, award, or other payment are available to pay for future medical items and services which are otherwise covered and reimbursable by Medicare.

Medicare should not be billed for future medical services until those funds are exhausted by payments to providers for services that would otherwise be covered and reimbursable by Medicare.

Medicare should not be billed for future medical services until those funds are exhausted by payments to providers for services that would otherwise be covered and reimbursable by Medicare.

An MSA is a financial arrangement that allocates a portion of a settlement, judgment, award, or other payment to pay for future medical services. The law mandates protection of the Medicare trust funds but does not


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mandate an MSA as the vehicle used for that purpose. MSAs are the most frequently used formal method of preserving those funds for the Medicare beneficiary to pay for future items or services which are otherwise covered and reimbursable by Medicare and which are related to what was claimed or the settlement, judgment, award, or other payment had the effect of releasing. These funds must be exhausted before Medicare will pay for treatment related to the claimed injury, illness, or disease.

Medicare beneficiaries are advised that before receiving treatment for services to be paid by their MSA, they should advise their health care provider about the existence of the MSA. They are also notified that their health care providers should bill them directly, and that they should pay those charges out of the MSA if: • The treatment or prescription is related to what was claimed or the settlement, judgment, award, or other

payment had the effect of releasing AND • The treatment or prescription is something Medicare would cover.

The obligation to protect the Medicare trust funds exists regardless of whether or not there is a formal CMS approved MSA amount. A Medicare beneficiary may or may not have documentation they can provide the physician, provider, or supplier from Medicare approving a Medicare Set-Aside amount.

Provider Action Needed Where a patient who is a Medicare beneficiary states that he/she is required to use funds from the settlement, judgment, award, or other payment to pay for the items or services related to what was claimed or which the settlement, judgment, award, or other payment, it is appropriate for you to document your records with that information and accept payment directly from the patient for such services.

Note: Providers should also accept payment from professional administrators holding Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) funds. Providers should not bill Medicare where a third party holds and administers one of these WCMSA funds.

Note: Providers should also accept payment from professional administrators holding Workers’Compensation Medicare Set-Aside Arrangement (WCMSA) funds. Providers should not bill Medicare where a third party holds and administers one of these WCMSA funds.

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

You can review a related document (Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/Downloads/WCMSA-Reference-Guide-Version-3_0. pdf)) published in 2019. Beneficiaries may submit a WCMSA attestation electronically through the WCMSA Portal (WCMSAP), or send by mail, either as paper documents or CD. Using the WCMSAP for a WCMSA submission or attestation is the recommended approach as it is more efficient than mailing this information. For information about how to use the WCMSAP (https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSAP/WCMSA-Portal, please see the WCMSAP page.

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