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JJ Part A Medicare AdvisoryLatest Medicare News for JJ Part A

palmettogba.com/jja

September 2019Volume 2019, Issue 09

The JJ Part A Medicare Advisory contains coverage, billing and other information for Jurisdiction J Part A. 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 A 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 http://www.PalmettoGBA.com/Medicare.

CPT only copyright 2018 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 schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, 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 © 2012 American Dental Association (ADA). All rights reserved.

What’s Inside...MLN Connects ..............................................................................................................4

Weekly Articles .......................................................................................................4Special Edition Articles ..........................................................................................5PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020 .....5Medicare OPPS and ASC Payment System CY 2020 Proposed Rule .....................6ESRD and DMEPOS CY 2020 Proposed Rule ........................................................8IPPS/LTCH: FY 2020 PPS Final Rule ...................................................................10IRF: FY 2020 Payment and Policy Changes ..........................................................11Hospice: FY 2020 Hospice Payment Rate Final Rule ............................................11Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12 .............................................................................................12OPPS and ASC Proposed Rule Listening Session — August 14 ...........................13

Multiple Provider Information ..................................................................................14ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider Contact Center .......................................14Medicare Diabetes Prevention Program Booklet ...................................................16Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual .....................................................................16Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment ............17Modification to the National Coordination of Benefits Agreement (COBA) Crossover Process ...................................................................................................18Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements ...20Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update ........................................25Medicare Beneficiary Identifier (MBI) Look-up Tool ............................................35Get Your Medicare News Electronically ................................................................37Medicare Learning Network® (MLN) ...................................................................38

Medicare Beneficiary Identifier (MBI) Information ................................................39New Medicare Card: Transition Period Ends in Less Than 5 Months ...................39New Medicare Beneficiary Identifier (MBI) Get It, Use It ....................................40

Cost Report Information ............................................................................................44New Documentation Requirements for Filing Medicare Cost Reports .................44

2 09/2019

CPT codes, descriptors and other data only are copyright 2018 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 con-tained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Electronic Data Interchange (EDI) Information ......................................................46Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices ................................................................46

End Stage Renal Disease (ESRD) Information ........................................................48Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services ............................................................................................48

eServices Information .................................................................................................50How Can We Be of “eService” to You? .................................................................50

Fee Schedule Information ..........................................................................................51Ambulance Fee Schedule and Medicare Transports Booklet .................................51Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update .......................................................................52Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment .................................................................55

Hospital Information ..................................................................................................61Display PARHM Claim Payment Amounts ...........................................................61Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2020 ............................................................62Medicare Coverable Services for Integrative and Non- pharmacological Chronic Pain Management .....................................................................................64Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020 .......................................................................................69

Learning and Education Information .......................................................................73Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast: August 28, 2019 ......................................................................................732019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule ........................................................................................74Part A Skilled Nursing Facility (SNF) Focus on Billing Webcast: September 12, 2019 ................................................................................................74September 18, 2019, Part A Ask the Contractor Teleconference (ACT) Specialty Clinical Topic: Diagnosis Related Group (DRG) 682 - Renal Failure ...74Part A Quarterly Updates Webcast: September 25, 2019 .......................................75JJ/JM Part A and Part B MACtoberfest Conference ..............................................76Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA ................................................................................................77

Medical Policy Information ......................................................................................78International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update ..............................................................................................78Part A Local Coverage Determinations (LCDs) Updates .......................................80Part A Local Coverage Determinations (LCDs) Article Updates ...........................80Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) Updates ............................................................................83Part A/B Local Coverage Determinations (LCDs) Article Updates .......................85MolDX Local Coverage Determinations (LCDs) Article Updates ........................94

Skilled Nursing Facility (SNF) Information ............................................................95October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement ........95Medicare Shared Savings Program (Shared Savings Program) Skilled Nursing Facility (SNF) Affiliates’ Requirement to Include Demonstration Code 77 on SNF 3- Day Rule Waiver Claims ......................................................................97


3 09/2019

Upcoming Part A Educational Events Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast: August 28, 2019 Please join Palmetto GBA on Wednesday, August 28, 2019, at 11 a.m. ET for the Part A Inpatient Psychiatric Fa-cility (IPF) Coverage and Documentation webcast. Palmetto GBA will provide an overview of coverage and med-ical necessity, including medical review findings and documentation tips for Diagnosis Related Group (DRG) 885 Psychoses. 2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) TeleconferencePalmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2019. These calls are open to all providers. Part A Skilled Nursing Facility (SNF) Focus on Billing Webcast: September 12, 2019 Please join Palmetto GBA on Thursday, September 12, 2019, at 11 a.m. ET for a Part A Skilled Nursing Facility (SNF) Focus on Billing webcast! We will review specific billing topics including sanction, qualifying stay, leave of absence, interrupted stay, CERT clinical spotlight and more!

September 18, 2019, Part A Ask the Contractor Teleconference (ACT) Specialty Clinical Topic: Diagnosis Related Group (DRG) 682 - Renal FailurePalmetto GBA will host the Part A Ask the Contractor Teleconference (ACT) on Wednesday, September 18, 2019, at 11 a.m. ET. The ACT call is designed to open the communication channels between Palmetto GBA and our Part A provider community. The ACT Specialty Clinical Topic is DRG 682 – Renal Failure with Major Complication or Comorbidity (MCC).

Part A Quarterly Updates Webcast: September 25, 2019Please join Palmetto GBA on Wednesday, September 25, 2019, at 11 a. m. ET for the Part A Quarterly Updates Webcast.

A/B MACtoberfest 2019The JJ/JM Part and Part B MACtoberfest® Conference will be held October 8-9, 2019, in Asheville, North Caroli-na.

For more information and registration instructions to attend these education sessions, please go to Page 73 of this issue.

Tools You Can Use .....................................................................................................100Federally Qualified Health Centers (FQHCs) - A to Z Module ...........................100Hyperbaric Oxygen Therapy Module ...................................................................101Medicare Secondary Payer (MSP) Process Tool ..................................................102We’re using Medicare Beneficiary Identifiers (MBIs) .........................................103

Helpful Information ..................................................................................................105Contact Information for Palmetto GBA Part A ....................................................105

4 09/2019


MLN CONNECTS

MLN Connects will contain Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recent issues, please copy and paste the following links into your Web browser:

Weekly Articles

August 22, 2019https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-08-22-eNews.pdf




July 25, 2019https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-07-25-eNews.pdf

July 18, 2019https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-07-18-eNews.pdf


5 09/2019

Special Edition Articles

Thursday, July 29, 2019

CMS Provider Education Message:

• PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020

• Medicare OPPS and ASC Payment System CY 2020 Proposed Rule

• ESRD and DMEPOS CY 2020 Proposed Rule

PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020

On July 29, CMS issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. This proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better accessibility, quality, affordability, empowerment, and innovation. It also includes proposals to streamline the Quality Payment Program with the goal of reducing clinician burden. This includes a new, simple way for clinicians to participate in our pay-for-performance program, the Merit-based Incentive Payment System (MIPS), called the MIPS Value Pathways.

The proposed rule also includes:

• CY 2020 PFS rate setting and conversion factor

• Medicare telehealth services

• Payment for evaluation and management services

• Physician supervision requirements for physician assistants

• Review and verification of medical record documentation

• Care management services

• Comment solicitation on opportunities for bundled payments

• Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs

• Bundled payments for substance use disorders

• Therapy services

• Ambulance services

• Ground ambulance data collection system

6 09/2019


• Open Payments Program

• Medicare Shared Savings Program

• Stark advisory opinion process

For More information:

• Proposed Rule (https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other): Public comments due by September 27

• Press Release (https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors )

• PFS Proposed Rule Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-2)

• Quality Payment Program Proposed Rule Fact Sheet https://qpp-cm-prod-content.s3.amazonaws.com/uploads/594/2020%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf

See the full text of this excerpted Fact Sheet (Issued July 29).(https://qpp-cm-prod-content.s3.amazonaws.com/uploads/594/2020%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf)

Medicare OPPS and ASC Payment System CY 2020 Proposed Rule

On July 29, CMS proposed policies that follow directives in President Trump’s Executive Order, entitled “Improving Price and Quality Transparency in American Health Care to Put Patients First,” that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The proposed changes also encourage site-neutral payment between certain Medicare sites of services. Finally, the proposed rule proposes updates and policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed polices in the CY 2020 OPPS/ASC Payment System proposed rule would further advance the agency’s commitment to increasing price transparency, (including proposals for requirements that would apply to each hospital operating in the United States), strengthening Medicare, rethinking rural health, unleashing innovation, reducing provider burden, and strengthening program integrity so that hospitals and ambulatory surgical centers can operate with better flexibility and patients have what they need to become active health care consumers.


7 09/2019

In accordance with Medicare law, CMS is proposing to update OPPS payment rates by 2.7 percent. This update is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for Multi-Factor Productivity (MFP).

In the CY 2019 OPPS/ASC final rule with comment period, we finalized our proposal to apply the hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). CMS is not proposing any changes to its policy to use the hospital market basket update for ASC payment rates for CY 2020-2023. Using the hospital market basket, CMS proposes to update ASC rates for CY 2020 by 2.7 percent for ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for MFP. This change will also help to promote site neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.


• Proposed definition of ‘hospital,’ ‘standard charges,’ and ‘items and services’

• Proposed requirements for making public all standard charges for all items and services

• Proposed requirements for making public consumer-friendly standard charges for a limited set of ‘shoppable services’

• Proposals for monitoring and enforcement

• Method to control for unnecessary increases in utilization of outpatient services

• Changes to the Inpatient Only list

• ASC covered procedures list

• High-cost/low-cost threshold for packaged skin substitutes

• Device pass-through applications

• Addressing wage index disparities

• Changes in the level of supervision of outpatient therapeutic services in hospitals and critical access hospitals

• Hospital Outpatient Quality Reporting Program

• Ambulatory Surgical Center Quality Reporting Program

• CY 2020 OPPS payment methodology for 340B purchased drugs

• Partial Hospitalization Program rate setting and update to per diem rates

• Revision to the organ procurement organization conditions for certification

8 09/2019


• Potential changes to the organ procurement organization and transplant center regulations: Request for Information

For More Information:

• Proposed Rule: Public comments due by September 27 (https://www.federalregister.gov/documents/2019/08/09/2019-16107/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical)

• Press Release (https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price)

See the full text of this excerpted CMS Fact Sheet (issued July 29) (https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center).

ESRD and DMEPOS CY 2020 Proposed Rule

On July 29, CMS issued a proposed rule that proposes to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2020. This rule also:

• Proposes updates to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI

• Proposes changes to the ESRD Quality Incentive Program

• Includes requests for information on data collection resulting from the ESRD PPS technical expert panel, on possible updates and improvements to the ESRD PPS wage index, and on new rules for the competitive bidding of diabetic testing strips.

In addition, this rule proposes a methodology for calculating fee schedule payment amounts for new Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items and services and making adjustments to the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts. This rule would also:

• Make amendments to revise existing policies related to the competitive bidding program for DMEPOS

• Streamline the requirements for ordering DMEPOS items, and create one Master List of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements

The proposed CY 2020 ESRD PPS base rate is $240.27, an increase of $5.00 to the current base rate of $235.27. This proposed amount reflects a reduced market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (1.7 percent) and application of the wage index budget-neutrality adjustment factor (1.004180).


9 09/2019


• Annual update to the wage index

• Update to the outlier policy

• Eligibility criteria for the Transitional Drug Add-on Payment Adjustment (TDAPA)

• Basis of Payment for the TDAPA for calcimimetics

• Average sales price conditional policy for the application of the TDAPA:

• New and innovative renal dialysis equipment and supplies

• Discontinuing the application of the erythropoiesis-stimulating agent monitoring policy

• Impact analysis:


• Proposed Rule: Public comments due by September 27 (https://www.federalregister.gov/documents/2019/08/06/2019-16369/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis)

• Press Release (https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney)

See the full text of this excerpted CMS Fact Sheet (issued July 29) (https://www.cms.gov/newsroom/fact-sheets/end-stage-renal-disease-esrd-and-durable-medical-equipment-prosthetics-orthotics-and-supplies-dmepos).

10 09/2019


Friday, August 2, 2019

• IPPS/LTCH: FY 2020 PPS Final Rule

• IRF: FY 2020 Payment and Policy Changes

• Hospice: FY 2020 Hospice Payment Rate Final Rule

IPPS/LTCH: FY 2020 PPS Final Rule

On August 2, CMS finalized policy changes to spur competition and innovation that will help deliver improved care and outcomes at a better value to patients. The final rule updates Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for FY 2020 and advances two key CMS priorities—“Rethinking Rural Health” and “Unleashing Innovation” by making historic changes to how Medicare pays hospitals. This final rule:

• Increases the wage index for certain low-wage index hospitals, including many rural hospitals

• Increases Medicare add-on payments for high cost eligible new technologies from 50-65%

• Clarifies policies on “substantial clinical improvement” to qualify for new technology add on payments

• Provides an alternative pathway where Breakthrough Devices are no longer required to demonstrate evidence of “substantial clinical improvement” to qualify for new technology add-on payments

• Provides an alternative pathway where Qualified Infectious Disease Products are no longer required to meet the “substantial clinical improvement” criteria for technology add-on payments, which are increased from 50 to 75%


• Final Rule https://www.federalregister.gov/documents/2019/08/16/2019-16762/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the)

• Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2020-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute-0)

Press release See the full text of this excerpted CMS Press Release (Issued August 2). (https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-policies-advance-rural-health-and-medical-innovation).


11 09/2019

IRF: FY 2020 Payment and Policy Changes

On July 31, CMS issued a final rule (https://www.federalregister.gov/documents/2019/08/08/2019-16603/medicare-programs-inpatient-rehabilitation-facility-irf-prospective-payment-system-for-federal) that updates Medicare payment policies and rates for facilities under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program for FY 2020. We are continuing our efforts towards the eventual transition to a unified post-acute care system through updates to the data used for IRF payments, including revising the Case-Mix Groups (CMGs), updating the CMG relative weights and average length of stay values, and using concurrent inpatient prospective payment system wage index data for the IRF PPS to align wage index data across settings of care.

For FY 2020, CMS is finalizing updates to the IRF PPS payment rates using the most recent data to reflect an estimated 2.5 percent increase factor (reflecting an IRF-specific market basket increase factor of 2.9 percent, reduced by a 0.4 percentage point multifactor productivity adjustment). CMS projects that IRF payments will increase by 2.5 percent (or $210 million) for FY 2020, relative to payments in FY 2019.

This Rule Finalizes:

• Rebase and revise the IRF market basket

• Clarification of “rehabilitation physician”

• Two new quality measures

See the full text of this excerpted CMS Fact Sheet (Issued July 31) (https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2020-payment-and-policy-changes-medicare-inpatient-rehabilitation-facilities-cms-1710-f).

Hospice: FY 2020 Hospice Payment Rate Final Rule

On July 31, CMS issued a final rule that demonstrates continued commitment to strengthening Medicare by better aligning the hospice payment rates with the costs of providing care and increasing transparency so patients can make more informed choices. For FY 2020, hospice payment rates are updated by 2.6 percent ($520 million increase in their payments). The final hospice cap amount for the FY 2020 cap year will be $29,964.78, which is equal to the FY 2019 cap amount ($29,205.44) updated by the final FY 2020 hospice payment update percentage of 2.6 percent. The aggregate cap limits the overall payments per patient made to a hospice annually.

12 09/2019


This Rule Finalizes:

• Rebasing to more accurately align Medicare payments with the costs of providing care

• Modifications to the election statement beginning in FY 2021, increasing coverage transparency for beneficiaries under a hospice election

• Hospice Quality Reporting Program updates, including developing a hospice assessment tool for real-time patient assessments


• Final Rule (https://www.federalregister.gov/documents/2019/08/06/2019-16583/medicare-program-fy-2020-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting)

• Hospice Center webpage (https://www.cms.gov/Center/Provider-Type/Hospice-Center.html)

• Hospice Quality Reporting webpage (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/index.html)

See the full text of this excerpted CMS Fact Sheet (Issued July 31) (https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2020-hospice-payment-rate-update-final-rule).

Wednesday, August 7, 2019

• Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12

• OPPS and ASC Proposed Rule Listening Session — August 14

Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics Listening Session — August 12

Monday, August 12 from 1-2:30 pm ET

Register (https://blh.ier.intercall.com/)for Medicare Learning Network events.

Proposed changes to the CY 2020 Physician Fee Schedule are aimed at reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care. During this listening session, CMS experts briefly cover three provisions from the proposed rule and address your clarifying questions to help you formulate your written comments for formal submission:

• Increasing value of Evaluation and Management (E/M) payments

• Continuing to improve the Quality Payment Program by streamlining the program’s requirement’s in order to reduce clinician burden


13 09/2019

• Creating the new Opioid Treatment Program benefit in response to the opioid epidemic

We encourage you to review the following materials prior to the call:

• Proposed rule (https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other )

• Press release (https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors)

• Physician Fee Schedule proposed rule fact sheet (https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-2)

• Quality Payment Program proposed rule fact sheet (https://qpp-cm-prod-content.s3.amazonaws.com/uploads/594/2020%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf )

Note: Feedback received during this listening session is not a substitute for your formal comments on the rule. See the proposed rule (https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other ) for information on submitting these comments by September 27.

Target Audience: Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent health care providers; and other stakeholders.

OPPS and ASC Proposed Rule Listening Session — August 14

Wednesday, August 14 from 2:30 to 4 pm ET

Register (https://blh.ier.intercall.com/) for Medicare Learning Network events.

CMS proposed updates and policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment systems, including price and quality transparency that lay the foundation for a patient-driven health care system. During this listening session, CMS experts briefly cover provisions from the proposed rule and address your clarifying questions to help you formulate your written comments for formal submission. Topics include:

• Price transparency: Requirements for all United States hospitals to make their standard charges public

• Increasing choices and encouraging site neutrality, including payments for clinic visits

14 09/2019


We encourage you to review the proposed rule (https://www.federalregister.gov/documents/2019/08/09/2019-16107/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical), press release (https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price), and fact sheet (https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price) prior to the call. Note: Feedback received during this listening session is not a substitute for your formal comments on the rule. See the proposed rule (https://www.federalregister.gov/documents/2019/08/09/2019-16107/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical) for information on submitting these comments by September 27.

Target Audience: All hospitals operating in the United States and other stakeholders.

MULTIPLE PROVIDER INFORMATION

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.


15 09/2019

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

16 09/2019


Medicare Diabetes Prevention Program Booklet

Medicare Diabetes Prevention Program booklet is available from the Centers for Medicare & Medicaid Services website at:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MDPP-MLN34893002.pdf

Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual

MLN Matters Number: MM11403 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4364CP Related Change Request (CR) Number: 11403 Effective Date: November 18, 2019 Implementation Date: November 18, 2019

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 11403 updates the language in sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual to add a link to the current influenza codes and payment rates. Make sure your billing staffs are


17 09/2019

aware of these updates. For the Medicare-covered codes for the influenza vaccines approved by Food and Drug Administration (FDA) for the current influenza vaccine season, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

Additional Information The official instruction, CR11403, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4364CP.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 August 16, 2019 Initial article released.

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment

MLN Matters Number: MM11273 Revised Related CR Release Date: July 25, 2019 Related CR Transmittal Number: R4339CP Related Change Request (CR) Number: 11273 Effective Date: January 1, 2019 Implementation Date: August 27, 2019

Note: We revised this article on July 25, 2019, to reflect the reissued CR11273 dated July 25. In the article, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

Provider Type Affected This MLN Matters article is for physicians and other providers billing Medicare Administrative Contractors (MACs) for home visit services provided to Medicare beneficiaries.

Provider Action Needed CR11273 removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit. Also, the Centers for Medicare & Medicaid Services (CMS) added a new section to chapter 12 of the Medicare Claims Processing Manual regarding Evaluation and Management (E/M) codes that you may bill with superficial radiation treatment. Make your billing staff aware of these changes.

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Background In CR11273, CMS removes the requirement that the medical record show a home visit was medically necessary instead of an office or outpatient visit from the Medicare Claims Processing Manual, Chapter 12, Section 30.6.14.1. Also, you may bill E/M codes (99211, 99212, and 99213) for levels I through III with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.

See Chapter 13, Section 70.2, of the Medicare Claims Processing Manual for information regarding services bundled into treatment management codes.



Document History

Date of Change Description July 25, 2019 We revised this article to reflect the reissued CR11273 dated July 25. In the article,

we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

May 29, 2019 Initial article released.

Modification to the National Coordination of Benefits Agreement (COBA) Crossover Process

MLN Matters Number: MM11307 Related CR Release Date: August 2, 2019 Related CR Transmittal Number: R2331OTN Related Change Request (CR) Number: 11307 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Provider Type Affected This MLN Matters Article is for providers, including hospices, submitting institutional claims to Medicare Administrative Contractors (MACs) requiring Coordination of Benefits (COB) for services provided to Medicare beneficiaries.


19 09/2019

Provider Action Needed CR 11307 explains actions the Centers for Medicare & Medicaid Services (CMS) is taking to ensure that the MACs handle certain Medicare Fee-For-Service inpatient claims submitted without a required diagnosis code or incorrect Claim Adjustment Group Code, as included on submissions for incoming Medicare Secondary Payer (MSP) claims, in a standard manner. Make sure your billing staffs are aware of this information.

Background Medicare must follow the specifications in both the National Uniform Billing Committee (NUBC) and National Uniform Claims Committee (NUCC) manuals, as well as the Technical Report Version 3 (TR-3) Implementation Guides with respect to 837 claims transactions. Medicare is also required to comply with the Council for Affordable Quality Health Care, Inc., Committee on Operating Rules for Informational Exchange (CAQH-CORE) requirements governing Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC) combinations and associated use of Claim Adjustment Group Codes.

CMS recently determined it was not consistently following the NUBC Manual guidance concerning the requirement of an admitting diagnosis code on Type of Bill (TOB) 18x (Hospital Swing Beds—Inpatient), 21x (Skilled Nursing Facility-Inpatient), and 41x (Religious Non-Medical Health Care Institutions--Inpatient) claims. CMS also determined that Medicare is currently accepting and adjudicating incoming electronic MSP claims that have an incorrect Group Code (OA, for example) included with CARC 45.

Per CAQH-CORE requirements, CARC 45 [defined as, “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.”] may only be used with Group Codes “PR” (patient responsible) and “CO” (contractual obligation), not with other Group Codes such as “OA” (other adjustment) or “PI” (payer-initiated).

Medicare is detecting these issues on incoming electronic and hard-copy (paper) claims and on claims submitted via Direct Data Entry (DDE). CMS will create new edits to address incoming electronic claims with these characteristics through a separate instruction. CMS will address Part B MAC requirements relating to a primary payer’s incorrect usage of Group Code OA and PI on incoming MSP claims through a future change request.

CMS is addressing Fiscal Intermediary Shared System (FISS) and MAC requirements relating to incoming hard-copy (paper) and DDE-submitted claims, as applicable, through CR11307.

FISS will create a new Return to Provider (RTP) edit to be used by associated MACs when an incoming TOB) 18x (Hospital Swing Beds—Inpatient), 21x (Skilled Nursing Facility-Inpatient), or 41x (Religious Non-Medical Health Care Institutions--Inpatient)TOB DDE-keyed claim or hard-copy UB04 21x TOB claim is submitted without an Admitting Diagnosis Code. Upon receipt of the newly created RTP edit, the Part A MAC will return the claim to the provider for correction. FISS will also create an RTP edit the MACs will use when an incoming MSP claim, submitted either via DDE or as a hard-copy UB04 claim with an accompanying Explanation of Benefits (EOB), contains a Group Code OA or PI with CARC 45.

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Upon receipt of the newly created RTP edit, the MACs, including the Home Health and Hospice (HH&H) MAC, must return the claim to the provider for corrections.

Additional Information The official instruction, CR 11307, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2331OTN.pdf.


Document History


Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements

MLN Matters Number: MM11268 Related CR Release Date: July 26, 2019 Related CR Transmittal Number: R2323OTN Related Change Request (CR) Number: 11268 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

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

What You Need To Know CR11268 informs MACs that, effective on January 1, 2020 (the start of the AUC program Educational and Operations Testing Period), they should accept the Appropriate Use Criteria (AUC) related HCPCS modifiers on claims. Please be sure your billing staff and vendors are aware of this update. Subsequent CRs will follow at a later date that will continue AUC program implementation.

Background The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services furnished to Medicare beneficiaries. Examples of advanced imaging services include:

• Computed tomography

• Positron emission tomography


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• Nuclear medicine

• Magnetic resonance imaging

Under this program, when an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). A CDSM is an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient’s specific clinical condition during the patient’s workup. The CDSM will provide the ordering professional with a determination of whether that order adheres to AUC, does not adhere to AUC, or if there is no AUC applicable (for example, no AUC is available to address the patient’s clinical condition) in the CDSM consulted.

When this program is fully implemented at a future date, a consultation must take place for any applicable imaging service ordered by an ordering professional that would be furnished in an applicable setting and paid under an applicable payment system and information related to the consultation must be appended to claims.

Note: The applicable setting is where the imaging service is furnished, not the setting where the imaging service is ordered.

Applicable settings include:

• Physician offices

• Hospital outpatient departments (including emergency departments)

• Ambulatory Surgical Centers (ASCs)

• Independent diagnostic testing facilities

Applicable payment systems include:

• Physician Fee Schedule (PFS)

• Hospital Outpatient Prospective Payment System

• ASCs

Voluntary participation was established for this program from July 1, 2018, through December 31, 2019. CR 10481 discusses the voluntary participation period. The related MLN article may be read at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10481.pdf. This CR contains information related to the Educational and Operations Testing Period which is expected to last for one year (January 1, 2020 – December 31, 2020). Full program implementation is expected January 1, 2021. At that time, information regarding the ordering professional’s consultation with CDSM, or exception to such consultation, must be appended to the furnishing professional’s claim in order for that claim to be paid.

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Exceptions to consulting CDSMs include:

• The ordering professional having a significant hardship

• Situations in which the patient has an emergency medical condition

• An applicable imaging service ordered for an inpatient and for which payment is made under Part A

Ultimately, PAMA requires that the program results in prior authorization for ordering professionals that are identified as having outlier-ordering patterns. Before the prior authorization component of this program begins, there will be notice and comment rulemaking to develop the outlier methodology.

AUC PolicyRegulatory language for this program is in 42 Code of Federal Regulations (CFR), Section 414.94 (https://www.govinfo.gov/content/pkg/CFR-2016-title42-vol3/pdf/CFR-2016-title42-vol3-sec414-94.pdf), titled, “Appropriate Use Criteria for Advanced Diagnostic Imaging Services.” In the Calendar Year (CY) 2018 Physician Fee Schedule final rule (https://www.govinfo.gov/content/pkg/FR-2017-11-15/pdf/2017-23953.pdf), CMS stated that this program will be implemented in 2020, with an Educational and Operations Testing Period.

During this phase of the program claims will not be denied for failing to include AUC-related information or for misreporting AUC information on non-imaging claims (for example, failure to include one of the below modifiers and/or one of the below G codes or reporting modifiers on the wrong claim line or for the wrong service), but inclusion is encouraged.

Also, the claims processing systems will be prepared by January 1, 2020, to accept claims that contain a Current Procedural Terminology (CPT) or HCPCS C code, for advanced diagnostic imaging along with a line item HCPCS modifier to describe either the level of adherence to AUC or an exception to the program and a separate line item G-code to identify the qualified CDSM consulted.

During CY 2020, CMS expects ordering professionals to begin consulting qualified CDSMs and providing information to the furnishing practitioners and providers for reporting on their claims. Situations in which furnishing practitioners and providers do not receive AUC-related information from the ordering professional can be reported by modifier MH. Even though claims will not be denied during this Educational and Operations Testing Period, inclusion is encouraged.

The following HCPCS modifiers have been established for this program for placement on the same line as the CPT code for the advanced diagnostic imaging service:

• MA - Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition

• MB - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access


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• MC - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues

• MD - Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

• ME - The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

• MF - The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional

• MG - The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

• MH - Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider

• QQ - Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional (effective date: 7/1/18)

Claims that report HCPCS modifier ME, MF, or MG on the Advanced Diagnostic Imaging Services claim line should additionally contain a G-code (on a separate claim line) to report which qualified CDSM was consulted (NOTE: Multiple G codes on a single claim is acceptable.):

• G1000 - Clinical Decision Support Mechanism Applied Pathways, as defined by the Medicare Appropriate Use Criteria Program

• G1001 - Clinical Decision Support Mechanism eviCore, as defined by the Medicare Appropriate Use Criteria Program

• G1002 - Clinical Decision Support Mechanism MedCurrent, as defined by the Medicare Appropriate Use Criteria Program

• G1003 - Clinical Decision Support Mechanism Medicalis, as defined by the Medicare Appropriate Use Criteria Program

• G1004 - Clinical Decision Support Mechanism National Decision Support Company, as defined by the Medicare Appropriate Use Criteria Program

• G1005 - Clinical Decision Support Mechanism National Imaging Associates, as defined by the Medicare Appropriate Use Criteria Program

• G1006 - Clinical Decision Support Mechanism Test Appropriate, as defined by the Medicare Appropriate Use Criteria Program

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• G1007 - Clinical Decision Support Mechanism AIM Specialty Health, as defined by the Medicare Appropriate Use Criteria Program

• G1008 - Clinical Decision Support Mechanism Cranberry Peak, as defined by the Medicare Appropriate Use Criteria Program

• G1009 - Clinical Decision Support Mechanism Sage Health Management Solutions, as defined by the Medicare Appropriate Use Criteria Program

• G1010 - Clinical Decision Support Mechanism Stanson, as defined by the Medicare Appropriate Use Criteria Program

• G1011 - Clinical Decision Support Mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria Program

Since G-codes do not have associated payment rates (e.g. they are not payable codes and are only used for reporting), it is expected that your MAC will appropriately adjudicate a no-pay G-code line-item and use the following message: • CARC 246 -This non-payable code is for required reporting only

• RARC N620 Alert - This procedure code is for quality reporting/informational purposes only

Note: Although these codes are not associated with a payment rate there may be circumstances when a nominal charge amount may be necessary for operational reasons related to claims processing. The beneficiary is not responsible for the denied charge.

Medicare Appropriate Use Criteria Program for Advanced Diagnostic Imaging – Code List

HCPCS Advanced Imaging Procedure Codes

Magnetic Resonance Imaging 70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498, 77046, 77047, 77058, 77059

Computerized Tomography 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497

Single-Photon Emission Computed Tomography 76390


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Nuclear Medicine 78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78270, 78271, 78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78710, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78811, 78812, 78813, 78814, 78815, 78816, 78999

C-codes C8900, C8901, C8902, C8903, C8905, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936

Additional Information The official instruction, CR11268, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2323OTN.pdf.

Institutional claim providers do not have the capability to report line level ordering physician information on the institutional claim at this point. CMS is working with industry partners and will provide additional instructions on reporting line level ordering physician information for institutional claims at a future date.

Additional information regarding the AUC program is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/index.html.


Document History

Date of Change Description July 26, 2019 Initial article released.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update

MLN Matters Number: MM11422 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4367CP Related Change Request (CR) Number: 11422 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

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

Provider Action Needed CR 11422 updates the HCPCS code set for codes related to drugs and biologicals. Make sure your billing staffs are aware of these updates.

Background The HCPCS code set is updated quarterly. CR 11422 informs MACs and providers of the latest updates to specific drug/biological HCPCS codes. The October 2019 quarterly HCPCS file includes forty-four (44) new HCPCS codes. Effective for claims with dates of service on or after October 1, 2019, you may use, as appropriate, the following HCPCS codes on claims for Medicare:

1) J0121

a. Short Descriptor: Inj., omadacycline, 1 mg

b. Long Descriptor: Injection, omadacycline, 1 mg

c. Type of Service (TOS): 1,P

2) J0122

a. Short Descriptor: Inj., eravacycline, 1 mg

b. Long Descriptor: Injection, eravacycline, 1 mg

c. TOS: 1,P

3) J0222

a. Short Descriptor: Inj., patisiran, 0.1 mg

b. Long Descriptor: Injection, Patisiran, 0.1 mg

c. TOS: 1

4) J0291

a. Short Descriptor: Inj., plazomicin, 5 mg

b. Long Descriptor: Injection, plazomicin, 5 mg

c. TOS: 1


27 09/2019

5) J0593

a. Short Descriptor: Inj., lanadelumab-flyo, 1 mg

b. Long Descriptor: Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)

c. TOS: 1

6) J1096

a. Short Descriptor: Dexametha opth insert 0.1 mg

b. Long Descriptor: Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

c. TOS: 1

7) J1097

a. Short Descriptor: Phenylep ketorolac opth soln

b. Long Descriptor: Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml

c. TOS: 1

8) J1303

a. Short Descriptor: Inj., ravulizumab-cwvz 10 mg

b. Long Descriptor: Injection, ravulizumab-cwvz, 10 mg

c. TOS: 1,P

9) J1943

a. Short Descriptor: Inj., aristada initio, 1 mg

b. Long Descriptor: Injection, aripiprazole lauroxil, (aristada initio), 1 mg

c. TOS: 1

28 09/2019


10) J1944

a. Short Descriptor: Inj., aripirazole lauroxil 1 mg

b. Long Descriptor: Injection, aripiprazole lauroxil, (aristada), 1 mg

c. TOS: 1

11) J2798

a. Short Descriptor: Inj., perseris, 0.5 mg

b. Long Descriptor: Injection, risperidone, (perseris), 0.5 mg

c. TOS: 1,P

12) J3031

a. Short Descriptor: Inj., fremanezumab-vfrm 1 mg

b. Long Descriptor: Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

c. TOS: 1, P

13) J3111

a. Short Descriptor: Inj. romosozumab-aqqg 1 mg

b. Long descriptor: Injection, romosozumab-aqqg, 1 mg

c. TOS: 1

14) J7314

a. Short Descriptor: Inj., yutiq, 0.01 mg

b. Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg

c. TOS: 1

15) J7331

a. Short Descriptor: Synojoynt, inj., 1 mg

b. Long Descriptor: Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg

c. TOS: 1


29 09/2019

16) J7332

a. Short Descriptor: Inj., triluron, 1 mg

b. Long Descriptor: Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg

c. TOS: 1

17) J7401

a. Short Descriptor: Mometasone furoate sinus imp

b. Long Descriptor: Mometasone furoate sinus implant, 10 micrograms

c. TOS: 1

18) J9118

a. Short Descriptor: Inj. Calaspargase pegol-mknl

b. Long Descriptor: Injection, calaspargase pegol-mknl, 10 units

c. TOS: 1,P

19) J9119

a. Short Descriptor: Inj., cemiplimab-rwlc, 1 mg

b. Long Descriptor: Injection, cemiplimab-rwlc, 1 mg

c. TOS: 1

20) J9204

a. Short Descriptor: Inj, mogamulizumab-kpkc, 1 mg

b. Long Descriptor: Injection, mogamulizumab-kpkc, 1 mg

c. TOS: 1,P

21) J9210

a. Short Descriptor: Inj., emapalumab-lzsg, 1 mg

b. Long Descriptor: Injection, emapalumab-lzsg, 1 mg

c. TOS: 1

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22) J9269

a. Short Descriptor: Inj. tagraxofusp-erzs 10 mcg

b. Long Descriptor: Injection, tagraxofusp-erzs, 10 micrograms

c. TOS: 1

23) J9313

a. Short Descriptor: Inj., lumoxiti, 0.01 mg

b. Long Descriptor: Injection, moxetumomab pasudotox-tdfk, 0.01 mg

c. TOS: 1,P

24) Q4205

a. Short Descriptor: Membrane graft or wrap sq cm

b. Long Descriptor: Membrane graft or membrane wrap, per square centimeter

c. TOS: 1

25) Q4206

a. Short Descriptor: Fluid flow or fluid gf 1 cc

b. Long Descriptor: Fluid flow or fluid GF, 1 cc

c. TOS: 1

26) Q4208

a. Short Descriptor: Novafix per sq cm

b. Long Descriptor: Novafix, per square centimeter

c. TOS: 1

27) Q4209

a. Short Descriptor: Surgraft per sq cm

b. Long Descriptor: Surgraft, per square centimeter

c. TOS: 1


31 09/2019

28) Q4210

a. Short Descriptor: Axolotl graf dualgraf sq cm

b. Long Descriptor: Axolotl graft or axolotl dualgraft, per square centimeter

c. TOS: 1

29) Q4211

a. Short Descriptor: Amnion bio or axobio sq cm

b. Long Descriptor: Amnion bio or Axobiomembrane, per square centimeter

c. TOS: 1

30) Q4212

a. Short Descriptor: Allogen, per cc

b. Long Descriptor: Allogen, per cc

c. TOS: 1

31) Q4213

a. Short Descriptor: Ascent, 0.5 mg

b. Long Descriptor: Ascent, 0.5 mg

c. TOS: 1

32) Q4214

a. Short Descriptor: Cellesta cord per sq cm

b. Long Descriptor: Cellesta cord, per square centimeter

c. TOS: 1

33) Q4215

a. Short Descriptor: Axolotl ambient, cryo 0.1 mg

b. Long Descriptor: Axolotl ambient or axolotl cryo, 0.1 mg

c. TOS: 1

32 09/2019


34) Q4216

a. Short Descriptor: Artacent cord per sq cm

b. Long Descriptor: Artacent cord, per square centimeter

c. TOS: 1

35) Q4217

a. Short Descriptor: Woundfix biowound plus xplus

b. Long Descriptor: Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter

c. TOS: 1

36) Q4218

a. Short Descriptor: Surgicord per sq cm

b. Long Descriptor: Surgicord, per square centimeter

c. TOS: 1

37) Q4219

a. Short Descriptor: Surgigraft dual per sq cm

b. Long Descriptor: Surgigraft-dual, per square centimeter

c. TOS: 1

38) Q4220

a. Short Descriptor: Bellacell HD, Surederm sq cm

b. Long Descriptor: BellaCell HD or Surederm, per square centimeter

c. TOS: 1

39) Q4221

a. Short Descriptor: Amniowrap2 per sq cm

b. Long Descriptor: Amniowrap2, per square centimeter

c. TOS: 1


33 09/2019

40) Q4222

a. Short Descriptor: Progenamatrix, per sq cm

b. Long Descriptor: Progenamatrix, per square centimeter

c. TOS: 1

41) Q4226

a. Short Descriptor: Myown harv prep proc sq cm

b. Long Descriptor: MyOwn skin, includes harvesting and preparation procedures, per square centimeter

c. TOS: 1

42) Q5116

a. Short Descriptor: Inj., trazimera, 10 mg

b. Long Descriptor: Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg

c. TOS: 1,P

43) Q5117

a. Short Descriptor: Inj., kanjinti, 10 mg

b. Long Descriptor: Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg

c. TOS: 1,P

44) Q5118

a. Short Descriptor: Inj., zirabev, 10 mg

b. Long Descriptor: Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg

c. TOS: 1,P

HCPCS codes J1942 (Aripiprazole lauroxil 1mg/Injection, aripiprazole lauroxil, 1 mg) and S1090 (Mometasone sinus implant/Mometasone furoate sinus implant, 370 micrograms) are being discontinued effective October 1, 2019; and may not be used in submitting claims to Medicare with dates of service on or after that date.

34 09/2019


Effective for claims with dates of service on or after October 1, 2019, the long and short descriptors for the following HCPCS codes will be modified. The TOS and all other indicators will remain the same.

1) J0641

a. New Short Descriptor: Inj., levoleucovorin, 0.5 mg

b. New Long Descriptor: Injection, levoleucovorin, 0.5 mg

2) J2794

a. New Short Descriptor: Inj., risperdal consta, 0.5 mg

b. New Long Descriptor: Injection, risperidone (risperdal consta), 0.5 mg

3) J7311

a. New Short Descriptor: Inj., retisert, 0.01 mg

b. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg

4) J7313

a. New Short Descriptor: Inj., iluvien, 0.01 mg

b. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg

5) Q4122

a. New Short Descriptor: Dermacell, awm, porous sq cm

b. New Long Descriptor: Dermacell, dermacell awm or dermacell awm porous, per square centimeter

6) Q4165

a. New Short Descriptor: Keramatrix, Kerasorb sq cm

b. New Long Descriptor: Keramatrix or kerasorb, per square centimeter

7) Q4184

a. New Short Descriptor: Cellesta or duo per sq cm

b. New Long Descriptor: Cellesta or cellesta duo, per square centimeter


35 09/2019

Additional Information The official instruction, CR 11422, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4367CP.pdf.


Document History


Medicare Beneficiary Identifier (MBI) Look-up Tool

The Medicare Beneficiary Identifier (MBI) Lookup tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. If you do not already have access, sign up (https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do) now for access to eServices to use the tool.

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.

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 an HICN on their Medicare card). The transition period ensures your Medicare patients continue to get care by allowing you to use either the HICN or the MBI for all Medicare transactions. Note: Providers should not submit both numbers on the same transaction.

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

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:

o Beneficiary’s Last Name

o First Name

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o Date of Birth

o 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

Figure 1: MBI Lookup Tab

Lookup Tool Status ResultsIf the inquiry successfully returns an MBI, the screen will refresh with the data at the bottom.


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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 an error message 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

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

Get Your Medicare News Electronically

The Palmetto GBA Medicare 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.

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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.html

• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media for-mat. 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 “For-mats 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 prod-ucts 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 prod-ucts are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Out-reach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. 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 ListTo 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.


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Note: This article was revised on August 8, 2017, to reflect an updated Change Request (CR) 9859. In the article, the CR release date, transmittal numbers, and the Web address of the CR are revised. Also, a clarification was made on page 3 to denote that HBV is not separately payable for ESRD TOB 72X unless reported with modifier AY. Another bullet point was added on page 3 to show that contractor pricing applies to G0499 with dates of service September 28, 2016 through December 31, 2017. All other information is unchanged. 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].

MEDICARE BENEFICIARY IDENTIFIER (MBI) INFORMATION

New Medicare Card: Transition Period Ends in Less Than 5 Months

Starting January 1, 2020, you must use the Medicare Beneficiary Identifier (MBI). We will reject claims you submit with the Health Insurance Claim Number (HICN), with a few exceptions (https://www.cms.gov/Medicare/New-Medicare-Card/index.html) and reject all eligibility transactions.

Many providers are using the MBI for Medicare transactions. For the week ending August 2, providers sub-mitted 77% of fee-for-service claims with the MBI. Protect your patients’ identities by using MBIs now for all Medicare transactions. Don’t have an MBI?

• Ask your patient for their card. If they did not get a new card, give them the Get Your New Medi-care Card flyer in English (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Net-work-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf) or Spanish (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf).

• Use your Medicare Administrative Contractor’s look up tool. Sign up (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf ) for the Portal to use the tool.

• Check the remittance advice. We return the MBI on the remittance advice for every claim with a valid and active HICN.

For more information, see the MLN Matters Article (https://www.cms.gov/Outreach-and-Education/Medi-care-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf).

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New Medicare Beneficiary Identifier (MBI) Get It, Use It

MLN Matters Number: SE18006 ReissuedArticle Release Date: August 19, 2019Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We reissued this article on August 19, 2019, to show that all new Medicare cards have been mailed, to encourage providers to use MBIs now to protect patients’ identities, to emphasize that providers must use MBIs beginning January 1, 2020, and to explain the rejection codes providers will get if they submit a HICN after January 1, 2020.

Provider Type Affected This Special Edition MLN Matters® Article is for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs) and Home Health and Hospice MACs, for services provided to Medicare beneficiaries.

Provider Action Needed Use MBIs now for all Medicare transactions. The Centers for Medicare & Medicaid Services (CMS) finished mailing new Medicare cards. The new cards without Social Security Numbers (SSNs) offer better identity protection. Help protect your patients’ personal identities by getting their MBIs and using them for Medicare business, including claims submission and eligibility transactions.

Starting January 1, 2020, even for services provided before this date, you must use MBIs. With a few exceptions, Medicare will reject claims you submit with Health Insurance Claim Numbers (HICNs.) Medicare will reject all eligibility transactions you submit with HICNs.

There are 3 ways you and your office staff can get MBIs:

1. Ask your Medicare patients Ask your Medicare patients for their new Medicare cards when they come for care. If they didn’t get a new card, give them the Get Your New Medicare Card flyer in English (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf) or Spanish (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf).

2. Use your MAC’s secure MBI look-up tool You can look up MBIs for your Medicare patients when they don’t or can’t give them. Sign up (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf) for the Portal to use the tool. You can use this tool even after the end of the transition period – the tool doesn’t end on December 31, 2019. Even if your patients are in a Medicare Advantage Plan, you can look up their MBIs to bill for things like indirect medical education.


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You must have your patient’s SSN for the search and it may differ from the HICN, which uses the SSN of the primary wage earner. If your Medicare patient doesn’t want to give the SSN, tell your patient to log into mymedicare.gov to get the MBI.

If the look-up tool returns a last name matching error and the beneficiary’s last name includes a suffix, such as Jr. Sr. or III, try searching without and with the suffix as part of the last name.

3. Check the remittance advice We’ll also return the MBI on every remittance advice when you submit claims with valid and active HICNs through December 31, 2019. Get the MBI from the remittance advice and save it in your systems to use with your next Medicare transaction.

Background The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required CMS to remove SSNs from all Medicare cards by April 2019. CMS replaced the SSN-based HICN with a new, randomly generated MBI. The new MBI is noticeably different than the HICN. Just like with the HICN, the MBI hyphens on the card are for illustration purposes: don’t include the hyphens or spaces on transactions. The MBI uses numbers 0-9 and all uppercase letters except for S, L, O, I, B, and Z. We exclude these letters to avoid confusion when differentiating some letters and numbers (for example, between “0” and “O”).

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The Railroad Retirement Board (RRB) also mailed new Medicare cards with MBIs. The RRB logo will be in the upper left corner and “Railroad Retirement Board” at the bottom, but you can’t tell from looking at the MBI if your patient is eligible for Medicare because they’re a railroad retiree. You’ll be able to identify them by the RRB logo on their card, and we’ll return a “Railroad Retirement Medicare Beneficiary” message on the Fee-For-Service (FFS) MBI eligibility transaction response.

Use the MBI the same way you used the HICN. Put the MBI in the same field where you’ve always put the HICN. This also applies to reporting informational only and no-pay claims. Don’t use hyphens or spaces with the MBI to avoid rejection of your claim. The MBI replaces the HICN on Medicare transactions including Billing, Eligibility Status, and Claim Status. The effective date of the MBI, like the old HICN, is the date each beneficiary was or is eligible for Medicare. After January 1, 2020, we will reject claims submitted with HICNs, with few exceptions. You will get:

• Electronic claims- Reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)

• Paper claims- paper notice; Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

The beneficiary or their authorized representative can request an MBI change. CMS can also change an MBI. An example is if the MBI is compromised. There are different scenarios for using the old or new MBIs:

FFS claims submissions with:

• Dates of service before the MBI change date – use old or newMBIs.

• Span-date claims with a “From Date” before the MBI change date – use old or newMBIs.

• Dates of service that are entirely on or after the effective date of the MBI change – use new MBIs.


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FFS eligibility transactions when the: • Inquiry uses new MBI – we’ll return all eligibility data.

• Inquiry uses the old MBI and request date or date range overlap the active period for the old MBI – we’ll return all eligibility data. We’ll also return the old MBI termination date.

• Inquiry uses the old MBI and request date or date range are entirely on or after the effective date of the new MBI – we’ll return an error code (AAA 72) of “invalid member ID.”

When the MBI changes, we ask the beneficiary to share the new MBI with you. You can also get the MBI from your MAC’s secure MBI lookup tool.

Exceptions There are a few exceptions when you can use either the HICN or MBI on or after January 1, 2020:

• Appeals – You can use either HICNs or MBIs for claim appeals and relatedforms.

• Claim status query – You can use the HICN or MBI to check the status of a claim (276 transactions) if the earliest date of service on the claim is before January 1, 2020. If you are checking the status of a claim with a date of service on or after January 1, 2020, you must use the MBI.

• Span-date claims – You can use HICNs or MBIs for 11X-Inpatient Hospital, 32X- Home Health (home health claims and Request for Anticipated Payments [RAPs]) and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (December 31, 2019). If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019. Since you submit home health claims for a 60-day payment episode, you can send in the episode’s RAP with either the HICN or the MBI, but after the transition period ends on December 31, 2019, you have to use the MBI when you send in the final claim that goes with it.

The MBI doesn’t change Medicare benefits. Protect the MBI as Personally Identifiable Information (PII); it is confidential like the HICN.

Medicare Advantage and Prescription Drug plans continue to assign and use their own identifiers on their health insurance cards. For patients in these plans, continue to ask for and use the plans’ health insurance cards.

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

To sign up for your MAC’s secure portal MBI look-up tool, visit https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf.

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The MBI format specifications, which provide more details on the construct of the MBI, are available at https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf.

A fact sheet discussing the transition to the MBI and the new cards is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf.

Date of Change Description August 19, 2019 We reissued this article to show that all new Medicare cards have been mailed, to

encourage providers to use MBIs now to protect patients’ identities, to emphasize that providers must use MBIs beginning January 1, 2020, and to explain the rejection codes providers will get if they submit a HICN after January 1, 2020.

March 6, 2019 We revised this article to add language that the MBI look-up tool can be used to obtain an MBI even for patients in a Medicare Advantage Plan. All other information remains the same.

December 10, 2018 The article was revised to update the language regarding when MACs can return an MBI through the MBI look up tool (page 1). All other information remains the same.

July 11, 2018 This article was revised to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

June 25, 2018 This article was revised to provide additional information regarding the ways your staff can get MBIs (page 1).

June 21, 2018 The article was revised to emphasize the need to submit the MBI without hyphens or spaces to avoid rejection of your claim.

May 25, 2018 Initial article released.

COST REPORT INFORMATION

New Documentation Requirements for Filing Medicare Cost Reports

MLN Matters Number: SE19015 Article Release Date: August 21, 2019 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Provider Type Affected This MLN Matters Special Edition (SE) article is for all providers who file Medicare cost reports.

What You Need To Know SE19015 reminds providers of the new documentation requirements for filing Medicare Cost Reports that were published in the Fiscal Year (FY) 2019 Inpatient Perspective Payment System (IPPS) Final Rule.


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Background Participating Medicare providers are required under 42 Code of Federal Regulations (CFR) Section 413.20(a) (https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-20.pdf) to maintain sufficient financial records and statistical data for proper determination of costs payable under the Medicare program. In accordance with Section 413.20(d), providers must furnish such information to Medicare contractors as necessary to assure proper payment.

The FY 2019 Medicare IPPS final rule (63 Federal Register (FR) 41144) (https://www.federalregister.gov/documents/2018/08/17/2018-16766/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the), published on August 17, 2018, changed the required supporting documentation that you must submit with the Medicare cost report. Meeting these requirements allows for an acceptable cost report submission for cost-reporting periods beginning on or after October 1, 2018.

Note: Cost-report submissions that do not include the required documentation will be rejected for lack of supporting documentation (per Section 413.24(f)(5)(i)).

Causes for cost report rejection can vary by organization or situation, such as:

1. Teaching Hospitals (Section 413.24(f)(5)(i)(A)) – A cost report will be rejected for lack of supporting documentation if it does not include the Intern and Resident Information System data.

2. Bad Debt (Section 413.24(f)(5)(i)(B)) – For providers claiming Medicare bad debt reimbursement, a cost report will be rejected for lack of supporting documentation if it does not include a detailed bad debt listing that corresponds to the amount of bad debt claimed in the provider’s cost report.

3. Disproportionate Share Hospital (DSH) Eligible Hospitals (Section 413.24(f)(5)(i)(C)) – For hospitals claiming a DSH payment adjustment, a cost report will be rejected for lack of supporting documentation if it does not include a detailed listing of the hospital’s Medicaid-eligible days that corresponds to the Medicaid-eligible days claimed in the hospital’s cost report. Also, if the hospital submits an amended cost report that changes its Medicaid-eligible days, the hospital must submit an amended listing or an addendum to the original listing of the hospital’s Medicare-eligible days that corresponds to the Medicaid-eligible days claimed in the hospital’s amended cost report.

4. Charity Care and Uninsured Discounts (Section 413.24(f)(5)(i)(D)) – For DSH-eligible hospitals reporting charity care and/or uninsured discounts, a cost report will be rejected for lack of supporting documentation if it does not include a detailed listing of charity care and/or uninsured discounts that corresponds to the amounts claimed in the DSH-eligible hospital’s cost report. Also, until a standard format is adopted, a hospital must submit a charity care and/or uninsured discount list with its cost report that supports the amounts reported in its cost report including information such as patient name, dates of service, insurer (if applicable), and the amount of the charity care and/or uninsured discount given to the patient.

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5. Home Office Cost Allocations (Section 413.24(f095)(i)(E) – For providers claiming costs on their cost reports that are allocated from a home office or chain organization with the same FY end, a cost report will be rejected for lack of supporting documentation if the home office or chain organization has not submitted a Home Office Cost Statement to the chain provider’s servicing contractor that corresponds to some portion of the amounts allocated from the home office or chain organization to the provider’s cost report. Conversely, for providers claiming costs on their cost report that are allocated from a home office or chain organization that has a different fiscal year end, a cost report will be rejected for lack of supporting documentation if the home office or chain organization has not submitted to the chain provider’s servicing contractor, a Home Office Cost Statement that corresponds to some portion of the amounts allocated from the home office or chain organization to the provider’s cost report.

As noted in the Final Rule, the Centers for Medicare & Medicaid Services (CMS) agrees that requiring this information to be submitted in standardized formats would ensure consistency of the documentation and facilitate the contractor’s review. CMS plans to include standard formats (templates) in a Paperwork Reduction Act notice to request public comment. Therefore, standardized formats will not be required for cost-report periods beginning on or after October 1, 2018, until further notice.

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


ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION

Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service Remittance Advices


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


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Provider Action Needed CR 11369 states, effective January 1, 2020, MACs will include a revised informational Remittance Advice Remark Code (RARC) Alert Code N817 on all RAs returned from processed claims containing a laboratory service. Make sure your billing staffs are aware of these changes.

Background Section 1834A of the Social Security Act, as established by Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). The CLFS final rule, “Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule” (CMS-1621-F) was published in the Federal Register on June 23, 2016.

Under the CLFS final rule, reporting entities must report to the Centers for Medicare & Medicaid Services (CMS) certain private payor rate information (applicable information) for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate Healthcare Common Procedure Coding System (HCPCS) code.

Laboratories, including an independent laboratory, a physician office laboratory, or a hospital outreach laboratory, that meet the definition of an applicable laboratory, must report information including laboratory test HCPCS codes, associated private payor rates, and volume data according to the below timeframes, generally every 3 years.

• January-June 2019: Collect data

• July-December 2019: Analyze data

• January-March 2020: Report data

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes. Medicare policy states that Claim Adjustment Reason Codes (CARCs) and RARCs, as appropriate, which provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment, are required in the remittance advice and coordination of benefits transactions.

To assist in reminding laboratories of their reporting obligations, the following new alert RARC code will appear on remittances:

• N817: ALERT-Applicable laboratories are required to collect and report private payordata and report that data to CMS between January 1, 2020 - March 31, 2020.

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Document History


END STAGE RENAL DISEASE (ESRD) INFORMATION

Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services

MLN Matters Number: MM11312 Related CR Release Date: August 9, 2019 Related CR Transmittal Number: R2338OTN Related Change Request (CR) Number: 11312 Effective Date: April 1, 2012 Implementation Date: January 6, 2020

Provider Types Affected This MLN Matters Article is for physicians, hospitals, and other providers billing Medicare Administrative Contractors (MACs) for kidney transplant services for Medicare beneficiaries.

Provider Action Needed CR11312 directs MACs to implement logic that ensures they bypass payment window edits (3-days and 1-day) when processing claims for donor post-kidney transplant complications services. MACs will hold certain claims, as noted below, until Medicare’s Common Working File (CWF) system edits these claims correctly. Please be sure your billing staffs are aware of these changes.

Background The Centers for Medicare & Medicaid Services (CMS) has learned that payment window edits, both the 1-day and 3-day edits, need to be bypassed in addition to other claims processing system bypasses implemented in April 2012 with CR7523.

MACs must hold any donor post-kidney transplant complication services claims that receive the following edits until the CWF system implements CR11312:


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3-Day Payment Window Edits:

• 7109: Outpatient Diagnostic Service against Inpatient in history

• 7113: Inpatient against Outpatient Diagnostic Service in history

• 7114: Outpatient Therapeutic Service against Inpatient in history

• 7115: Inpatient against Outpatient Therapeutic Service

1-Day Payment Window Edits:

• 7119: Outpatient Diagnostic Services against Inpatient in history

• 7120: Inpatient against Outpatient Diagnostic Services in history

• 7121: Outpatient Therapeutic Services against Inpatient in history

• 7122: Inpatient against Outpatient Therapeutic Services in history

Note: CR11312 makes no policy changes.

Additional Information You can review MM7523 at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7523.pdf.

The official instruction, CR11312, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2338OTN.pdf.


Document History


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ESERVICES INFORMATION

How Can We Be of “eService” to You?

You may have noticed that over the past year we have been busy upgrading our secure web portal, eServices. Designed specifically with you, the provider, in mind, we have added many new features to help you manage patient accounts and practice information in a more efficient manner.

How Does eServices Help You? Palmetto GBA’s eServices is a free internet-based, provider self-service secure application. Palmetto GBA’s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eServices application. Our innovative tool allows you to access a wide range of information — from looking up patient eligibility to retrieving a variety of detailed provider reports. The best part is…we are not finished yet! Keep an eye out for more improvements in the near future. Let’s revisit the many features the eServices application provides. Over the next few months we will delve deeper into several key features.

• Eligibility

• Claims Status

• eClaim Submissions — available for Part B and Railroad Medicare providers

• Clerical Error Claim Reopening Requests — available for Part B

• Remittances Online

• Financial Information — payment floor and last three checks paid

• Financial Forms — eOffset requests, eCheck payments and CMS-838 Credit Balance form (Part A and HHH only)

• Secure Forms — Appeals, Medical Review ADR Response Form, Prior Authorization Form (JM Part B and HHH), Wage Index Form (Part A only) and General Inquiry Form

• eDelivery

• eReview — eCBR, eUtilization and eAudit (JM, JJ Part A and RRB only)

• Additional Documentation Form — available for JJ Part B and JM Part B

• MBI (Medicare Beneficiary Identifier) Lookup


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You can participate in eServices if you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA and have payment amounts on file. This agreement with instructions to complete can be found at, www.PalmettoGBA.com under the EDI section for your line of business.

The eServices home page is: www.palmettogba.com/eServices. If you are not taking advantage of the many benefits of eServices, what are you waiting for? Get started today!

FEE SCHEDULE INFORMATION

Ambulance Fee Schedule and Medicare Transports Booklet

A new Ambulance Fee Schedule and Medicare Transports Booklet is available. Learn about coverage, billing, and payment for ground and air ambulance transport benefits. This resource is located on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf.

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Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update

MLN Matters Number: MM11402 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4362CP Related Change Request (CR) Number: 11402 Effective Date: January 1, 2019 Implementation Date: October 7, 2019

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 11402 informs providers that the Centers for Medicare & Medicaid Services (CMS) issued payment files to the MACs based on the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. CR 11402 amends those payment files. Please make sure your billing staffs are aware of these changes.

Background The updated payment files are effective for services you deliver from January 1, 2019, through December 31, 2019.

Section 1848(c)(4) of the Social Security Act authorizes the Secretary of the Department of Health and Human Services (HHS) to establish ancillary policies necessary to implement relative values for physicians’ services.

Summary of Changes for October 2019

1. Codes 96931 and 96934 (the global components) are changing their Relative Value Units (RVUs) as indicated in Table 1. The rationale behind this change is that the global codes (96931/96934) need to sum to the values of the professional and technical component codes (96932 and 96933 for 96931, respectively; and 96935 and 96936 for 96934, respectively). These changes apply to services as of January 1, 2019.

Table 1: Changes for the October Update to the 2019 MPFSDB

Code Action 96931 Malpractice RVU = 0.06 96934 Non-Facility and Facility PE RVU = 1.71; Malpractice RVU = 0.05


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2. The short descriptor for HCPCS Code Q5115 is being updated (as shown in Table 2) to coincide with the changes published in CR 11296, and is effective for claims with dates of service on and after July 1, 2019. You can review the article related to CR 11296 at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf.

Table 2: Updated Short Descriptor

Code Action Q5115 Short descriptor = Inj truxima 10 mg

The following “J” and “Q” code updates are effective for dates of service October 1, 2019, and after. See CR 11422 for additional information. (An MLN Matters article related to CR 11422 will be available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11422.pdf.) See Table 3 for a list of the code updates.

Table 3: Code Updates

Code Action J0121 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0122 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0222 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0291 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0593 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0641 Short Descriptor = Inj., levoleucovorin, 0.5 mg J1096 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1097 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1303 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1942 Procedure Status = I J1943 Procedure Status = E; there are no RVUs, payment policy indicators do not apply.J1944 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J2794 Short Descriptor = Inj risperdal consta, 0.5mg J2798 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J3031 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J3111 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7311 Short Descriptor = Inj., retisert, 0.01 mg J7313 Short Descriptor = Inj., iluvien, 0.01 mg J7314 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7331 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7332 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7401 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9118 Procedure Status = E; there are no RVUs, payment policy indicators do not apply.

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J9119 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9204 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9210 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9269 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9313 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4122 Short Descriptor = Dermacell, awm, porous sq cm Q4165 Short Descriptor = Keramatrix, Kerasorb sq cm Q4184 Short Descriptor = Cellesta or duo per sq cm Q4205 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4206 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4208 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4209 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4210 Procedure Status = E; there are no RVUs, payment policy indicators do not apply.Q4211 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4212 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4213 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4214 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4215 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4216 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4217 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4218 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4219 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4220 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4221 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4222 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q4226 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q5116 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q5117 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Q5118 Procedure Status = E; there are no RVUs, payment policy indicators do not apply.

Note: MACs will not search their files to retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims that you bring to their attention.

Additional Information The official instruction, CR 11402, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4362CP.pdf.




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


Provider Type 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 11406 provides instructions for the quarterly update to the Clinical Laboratory Fee Schedule (CLFS). Make sure your billing staffs are aware of these updates.

Background Effective January 1, 2018, CLFS rates are based on weighted median private payor rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. For more details, visit PAMA Regulations at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html.

Note: Part B deductible and coinsurance do not apply for services paid under the CLFS.

Access to Data File Under normal circumstances, CMS will make the updated CLFS data file available to MACs approximately six weeks prior to the beginning of each quarter. Internet access to the quarterly CLFS data file will be available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html. Other interested parties, such as the Medicaid State agencies, the Indian Health Service, the United Mine Workers, and the Railroad Retirement Board, should use the Internet to retrieve the quarterly CLFS. It will be available in multiple formats: Excel, text, and comma delimited.

Pricing Information The CLFS includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615). The fees are established in accordance with Section 1833(h)(4)(B) of the Social Security Act.

Advanced Diagnostic Laboratory Tests (ADLTs) Effective July 1, 2019 CMS approved three ADLTs. Please visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html#ADLT_tests for additional information regarding these tests.

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New Codes Effective October 1, 2019 These following table shows the new codes effective October 1, 2019. All the codes have a Type of Service (TOS) code of 5. These codes are contractor-priced until they appear on the January 1, 2020 CLFS as applicable. MACs will only price Proprietary Laboratory Analysis (PLAs) codes for laboratories within their jurisdiction. Note that a more complete table that includes the name of the laboratories is attached to CR11406.

CPT Code Long Descriptor Short Descriptor0105U Nephrology (chronic kidney disease),

multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD)

NEPH CKD MULT ECLIA TUM NEC

0106U Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13CO2 excretion

GSTR EMPTG 7 TIMED BRTH SPEC

0107U Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method

C DIFF TOX AG DETCJ IA STOOL

0108U Gastroenterology (Barrett’s esophagus), whole slide–digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX-2, CD45RO, HIF1a, HER-2, K20) and morphology, formalin-fixed paraffin- embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer

GI BARRETT ESOPH 9 PRTN BMRK

0109U Infectious disease (Aspergillus species), real-time PCR for detection of DNA from 4 species (A. fumigatus, A. terreus, A. niger, and A. flavus), blood, lavage fluid, or tissue, qualitative reporting of presence or absence of each species

ID ASPERGILLUS DNA 4 SPECIES


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0110U Prescription drug monitoring, one or more oral oncology drug(s) and substances, definitive tandem mass spectrometry with chromatography, serum or plasma from capillary blood or venous blood, quantitative report with steady-state range for the prescribed drug(s) when detected

RX MNTR 1+ORAL ONC RX&SBSTS

0111U Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue

ONC COLON CA KRAS&NRAS ALYS

0112U Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug- resistance gene

IADI 16S&18S RRNA GENES

0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence- based detection, algorithm reported as risk score

ONC PRST8 PCA3&TMPRSS2- ERG

0114U Gastroenterology (Barrett’s esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett’s esophagus

GI BARRETTS ESOPH VIM&CCNA1

0115U Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected

RESPIR IADNA 18 VIRAL&2 BACT

0116U Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with LC-MS/MS, oral fluid, algorithm results reported as a patient- compliance measurement with risk of drug to drug interactions for prescribed medications

RX MNTR NZM IA 35+ORAL FLU

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0117U Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5- hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3- hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC- MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain

PAIN MGMT 11 ENDOGENOUS ANAL

0118U Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor- derived cell-free DNA in the total cell-free DNA

TRNSPLJ DON-DRV CLL-FR DNA

0119U Cardiology, ceramides by liquid chromatography–tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events

CRD CERAMIDES LIQ CHROM PLSM

0120U Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter

ONC B CLL LYMPHM MRNA 58 GEN

0121U Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood

SC DIS VCAM-1 WHOLE BLOOD

0122U Sickle cell disease, microfluidic flow adhesion (P-Selectin), whole blood

SC DIS P-SELECTIN WHL BLOOD

0123U Mechanical fragility, RBC, shear stress and spectral analysis profiling

MCHNL FRAGILITY RBC PRFLG

0124U Fetal congenital abnormalities, biochemical assays of 3 analytes (free beta-hCG, PAPP-A, AFP), time-resolved fluorescence immunoassay, maternal dried-blood spot, algorithm reported as risk scores for fetal trisomies 13/18 and 21

FTL CGEN ABNOR 3 ANALYTES


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0125U Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, maternal serum, algorithm reported as risk scores for fetal trisomies 13/18, 21, and preeclampsia

FTL CGEN ABNOR PRNT COMP 5

0126U Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk scores for fetal trisomies 13/18, 21, and preeclampsia

FTL CGEN ABNOR PRNT COMP 5 Y

0127U Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia

OB PE 3 ANALYTES

0128U Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk score for preeclampsia

OB PE 3 ANALYTES Y CHRMSM

0129U Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53)

HERED BRST CA RLTD DO PANEL

0130U Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53)

HERED COLON CA DO MRNA PNL

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0131U Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes)

HERED BRST CA RLTD DO PNL 13

0132U Hereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes)

HERED OVA CA RLTD DO PNL 17

0133U Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes)

HERED PRST8 CA RLTD DO 11

0134U Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes)

HERED PAN CA MRNA PNL 18 GEN

0135U Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes)

HERED GYN CA MRNA PNL 12 GEN

0136U ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis

ATM MRNA SEQ ALYS

0137U PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis

PALB2 MRNA SEQ ALYS

0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis

BRCA1 BRCA2 MRNA SEQ ALYS

Deleted Codes Effective October 1, 2019 Existing code 0104U is being deleted.




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Document History


HOSPITAL INFORMATION

Display PARHM Claim Payment Amounts

MLN Matters Number: MM11355 Related CR Release Date: August 9, 2019 Related CR Transmittal Number: R228DEMO Related Change Request (CR) Number: 11355 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Provider Types Affected This MLN Matters Article is for hospitals participating in the Pennsylvania Rural Health Model (PARHM) and billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR11355 announces creation of a protected line level field to house the line level payment amount for the PARHM. This field will represent the actual amount Medicare paid for the line. Make sure your billing staffs are aware of these changes.

Background The Pennsylvania Rural Health Model changes Medicare reimbursement for hospital participants in the following way: rather than typical Fee-for-Service (FFS) claims reimbursement for certain services, Medicare makes every-other-week, lump sum payments to participating hospitals for those services. Each of these payments is equal to 1/26 of the Medicare global budget amount, which is set prospectively with the potential for adjustments during the year. The Centers for Medicare & Medicaid Services (CMS) is using the Periodic Interim Payment (PIP) process to make these biweekly payments. The participating hospitals continue to submit claims to CMS as usual, but CMS does not make FFS reimbursement on services that are included in the global budget. This means that claims that only include global budget services are treated as zero-pay; and claims that include both global budget services and non-global services are partially paid (for the non-global budget services).

CMS records the “net reimbursement amount” as the amount that would have been paid in the absence of the global budgets. For example, if a claim from a participating hospital only includes global budget services, the “net reimbursement amount” does not display $0 (the amount actually paid by CMS on that claim)—instead it records whatever amount Medicare would have reimbursed the hospital in the absence of the model. The biweekly Periodic Interim Payments (PIPs) also display reimbursement amounts.

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Additional Information The official instruction, CR11355, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R228DEMO.pdf.

You may find information about the PARHM at https://innovation.cms.gov/initiatives/pa-rural-health-model/.


Document History


Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2020

MLN Matters Number: MM11345 Revised Related CR Release Date: August 15, 2019 Related CR Transmittal Number: R4368CP Related Change Request (CR) Number: 11345 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Note: We revised this article on August 16, 2019, to reflect a revised CR11345 issued on August 15. CMS revised the CR to replace the Health Insurance Prospective Payment System (HIPPS) Case Mix Group (CMG) Codes spreadsheet with a corrected version. In this article, we revised the CR release date, transmittal number and the web address of the CR. All other information remains the same.

Provider Types Affected This MLN Matters Article is for Inpatient Rehabilitation Facilities (IRFs) billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11345 notifies MACs that a new IRF Pricer software package will be released prior to October 1, 2019, which will contain the updated rates that are effective for claims with discharges that fall within October 1, 2019, through September 30, 2020. MACs will install and pay IRF claims with the FY 2020 IRF PPS Pricer for discharges on or after October 1, 2019. Make sure your billing staffs are aware of these changes.


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Background On August 7, 2001, the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register a final rule that established the PPS for IRFs, as authorized under Section 1886(j) of the Social Security Act (the Act). In that final rule, CMS set forth per discharge Federal rates for Federal fiscal year (FY) 2002. These IRF PPS payment rates became effective for cost reporting periods beginning on or after January 1, 2002. Annual updates to the IRF PPS rates are required by Section 1886(j)(3)(C) of the Act.

The FY 2020 IRF PPS Final Rule sets forth the prospective payment rates applicable for IRFs for FY 2020. A new IRF PRICER software package will be released prior to October 1, 2019. The Pricer software package will also use the revised Case Mix Groups (CMGs) as discussed in the final rule. The IRF PPS pays for discharges occurring on or after October 1, 2019, using 95 CMGs and 5 special CMGs. MACs will install the new revised Pricer program timely to ensure accurate payments for the IRF PPS claims with discharges occurring on or after October 1, 2019 through September 30, 2020.

The PRICER updates for FY2020 are as follows:

PRICER Updates: For IRF PPS FY 2020 (October 1, 2019 – September 30, 2020)

• The standard Federal rate is $16,489

• The adjusted standard Federal rate is $16,167

• The fixed loss amount is $9,300

• The labor-related share is 0.727

• The non-labor related share is 0.273

• Urban national average CCR is 0.405

• Rural national average CCR is 0.500

• The Low-Income Patient (LIP) Adjustment is 0.3177

• The Teaching Adjustment is 1.0163

• The Rural Adjustment is 1.149

Section 1886(j)(7)(A)(i) of the Act requires application of a 2 percentage point reduction of the applicable market basket increase factor for IRFs that fail to comply with the quality data submission requirements. The mandated reduction will be applied in FY 2020 for IRFs that failed to comply with the data submission requirements during the data collection period January 1, 2018, through December 31, 2018. Thus, in compliance with Section 1886(j)(7)(A)(i) of the Act, CMS will apply a 2 percentage point reduction to the applicable FY 2020 market basket increase factor (2.5 percent) in calculating an adjusted FY 2020 standard payment conversion factor to apply to payments for only those IRFs that failed to comply with the data submission requirements.

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Application of the 2 percentage point reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year. Also, reporting-based reductions to the market basket increase factor will not be cumulative; they will only apply for the FY involved.

The adjusted FY 2020 standard payment conversion factor that will be used to compute IRF PPS payment rates for any IRF that failed to meet the quality reporting requirements for the period from January 1, 2018, through December 31, 2018 will be $16,167.

Additional Information The official instruction, CR11345, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4368CP.pdf.


Document History

Date of Change Description August 16, 2019 We revised the article to reflect a revised CR11345 issued on August 15. CMS

revised the CR to replace the Health Insurance Prospective Payment System (HIPPS) CMG Codes spreadsheet with a corrected version. In the article, we revised the CR release date, transmittal number and the web address of the CR. All other information remains the same.

August 2, 2019 Initial article released.

Medicare Coverable Services for Integrative and Non- pharmacological Chronic Pain Management

MLN Matters Number: SE19008 Article Release Date: August 19, 2019Related 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 (NPPs), hospitals, and other providers furnishing and billing Medicare Administrative Contractors (MACs) for chronic pain management services for Medicare beneficiaries.

What You Need To Know Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain. This article is informational only and does not convey any new or revised Medicare policies.


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Background The Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force Report states, “The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal costs. Although estimates vary depending on the methodology used to assess pain, it is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities.” In addition to opioids and other prescription medications, there are non-pharmacologic treatment options for pain. The Food and Drug Administration (FDA) approved several drug treatments that beneficiaries enrolled in Medicare Part D plans may use alone or as part of an integrative and comprehensive pain management plan. Medicare also covers certain non-pharmacologic options for pain management. Consider the following treatments and services to help treat patients who have chronic pain.

National Coverage Determinations National Coverage determinations (NCDs) are policies CMS issues that cover, noncover, or limit coverage of items, new technologies or services on a national basis. CMS develops NCDs through an evidence-based process. The evidence must show the services meaningfully improve health outcomes for Medicare beneficiaries. The process developing NCDs encourages public participation.Medicare has issued NCDs for the following chronic pain treatment services:

• Electrical nerve stimulation (NCD 160.7 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf)

• Induced lesions of nerve tracts (NCD 160.1 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf)

• Inpatient hospital pain rehabilitation (NCD 10.3 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)

• Outpatient hospital pain rehabilitation (NCD 10.4 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)

• Supervised exercise therapy for symptomatic peripheral artery disease (NCD 20.35 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)

• Screening for depression (NCD 210.9 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf)

Each of these nationally covered services has some coverage limitations based on beneficiary criteria. Some of the longer-standing NCDs have complementary LCDs, which clarify coverage. Find all NCDs at https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. You may search for NCDs using our Medicare Coverage Database at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

Local Coverage Determinations (LCDs) MACs develop LCDs through a process similar to NCDs, but with LCDs, MACs determine whether to cover a particular item or service within their geographic region (as opposed to a national basis). To find the MAC for your state, please see http://go.cms.gov/MAC-website-list.

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While local coverage may differ slightly from state to state, there are also many similarities around covered services. Here are some examples of local coverage of services to treat chronic pain that may be available in your geographic area:

• Lumbar epidural injections

• Nerve blockade for chronic pain and neuropathy

• Spinal cord stimulators

• Peripheral nerve stimulation

• Facet join injections

• Physical or occupational therapy

• Injections – tendons, ligaments

• Psychiatry and psychology services for pain disorders related to psychological factors

These are general examples. Each LCD has detailed information and may include a description of covered indications, related coding information and any coverage restrictions. See all LCDs at https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. You may search for LCDs using our Medicare Coverage Database at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

As with NCDs, each of these services has some limitations to coverage. Be sure to review LCDs completely. If you have questions about an LCD, your MAC can help.

Additional National Policies to Care for Medicare Beneficiaries with Chronic PainBeneficiaries with multiple (two or more) chronic conditions that you expect will last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline can get Chronic Care Management (CCM) services, or Complex CCM services. An MLN booklet is available at https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf. CCM services are extensive and include:

• Structured recording of patient health information, including recording the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology.

• Maintaining a comprehensive electronic care plan

• Managing transitions of care and other care management services

• Coordinating and sharing patient health information timely within and outside thepractice

Medicare also covers Behavioral Health Integration Services for treatment of behavioral health, or psychiatric conditions, including substance use disorders. These services use a care team approach to facilitate and coordinate behavioral health treatment regardless of if the diagnosis or diagnoses are pre-


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existing or newly diagnosed. These services may benefit some beneficiaries who have a co-occurring behavioral health condition(s). Please see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf for more information.

These and other care management services can give your patients the medical care and coordination services they need to help manage their pain, and other chronic conditions. You can bill these services for 30-day or one month periods and may include activities you or your clinical staff perform. You can get more information at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.html.

Preventive Services You can use Medicare’s Initial Preventive Physical Exam (IPPE) and subsequent Annual Wellness Visits (AWV) to help detect illnesses in the earliest stages to evaluate your patients’ pain severity, and to review the current treatment plan. If your patient is using prescription opioids, you can assess the benefit of other, non-opioid pain treatments and therapies that could be used in conjunction with, or in lieu of opioid medication, review with patients the benefits and risks of continuing opioid treatment, provide your interested and motivated patients with support to slowly taper opioid dosages, mitigate overdose risk for patients who take high-dose opioids, and offer or arrange for medication-assisted treatment when opioid use disorder is identified.

Reviewing opioid use is an important and routine part of your patient’s medical history, and it is helpful to diagnose and then treat patients with pain, patients with a substance use disorder including opioid use disorder, and those who may have both. You can refer your patients, as appropriate, under the IPPE and AWV based on information you discussed as part of the visit. While Medicare works toward implementing some additional services (such as from the SUPPORT for Patients and Communities Act), many are already available through the IPPE and AWV. Read more about coverage of these services at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf.

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

Review CMS’ list of opioid resources at https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers/Opioid-Resources-Page.html.

Also, consider the following:

Technical Assistance for providers

• CMS Quality Improvement Organization: https://qioprogram.org/locate-your-qio?map=qin

• CMS Hospital Innovation and Improvement Network: https://partnershipforpatients.cms.gov/wherepartnershipsareinaction/wherepartnershipsareinaction.html#HIINs

• Transforming Clinical Practice Initiative: https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices

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Other relevant MLN Matters Articles and Publications

• AWV MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf)

• IPPE MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf)

• Substance abuse MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1604.pdf)

• Transitional Care services fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

• Telehealth services fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf

• DME fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DME_Physicians_Other_Pract_Factsheet_ICN900926.pdf

• Eldercare locator - https://eldercare.acl.gov/Public/Index.aspx

Other Background References

1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention,Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. http://www.ncbi.nlm.nih.gov/books/NBK91497/. Accessed January 7, 2018.

2. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact ChronicPain Among Adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. doi:10.15585/mmwr.mm6736a2

3. National Academies. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington DC: National Academies of Sciences, Engineering, and Medicine; 2017.

4. Pain Management Best Practices Inter-Agency Task Force final report -https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf

5. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for ChronicPain: https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

Document History



69 09/2019

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020


Provider Types AffectedThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for inpatient psychiatric services provided to Medicare beneficiaries, which Medicare reimburses under the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS).

Provider Action Needed CR 11420 identifies changes that the Centers for Medicare & Medicaid Services (CMS) must make as part of the annual IPF PPS update established in the Medicare Program; FY 2020 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2019 (FY 2020) Final Rule. These changes are applicable to discharges occurring from October 1, 2019, through September 30, 2020 (FY 2020). Make sure your billing staffs are aware of these changes.

Background On November 15, 2004, CMS published in the Federal Register a final rule that established the IPF PPS under the Medicare program in accordance with provisions of Section 124 of Public Law 106-113, the Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999 (BBRA). Payments to IPFs under the IPF PPS are based on a federal per diem base rate which includes both inpatient operating and capital-related costs (including routine and ancillary services), but excludes certain pass-through costs (such as bad debts and graduate medical education). CMS must make annual updates to the IPF PPS. The FY 2020 changes which were implemented in the FY 2020 IPF PPS and Quality Reporting Updates final rule are:

Market Basket Update Since the IPF PPS inception, CMS’ Office of the Actuary periodically revises and rebases the IPF market basket to reflect more recent data on IPF cost structures. CMS last rebased and revised the market basket applicable to IPFs in the FY 2016 IPF PPS final rule, when CMS adopted a 2012-based IPF-specific market-basket. For FY 2020, CMS is using the 2016-based IPF-specific market basket to update the IPF PPS payments (that is, the Federal per diem base rate and Electroconvulsive Therapy (ECT) payment per treatment). The 2016-based IPF-specific market basket update for FY 2020 is 2.9 percent. However, this 2.9 percent is subject to two reductions required by the Social Security Act (the Act), as described below.

Section 1886(s)(2)(A)(ii) of the Act requires the application of an “other adjustment” that reduces any update to the IPF market basket update by percentages specified in Section 1886(s)(3) of the Act for Rate Year (RY) beginning in 2010 through the RY beginning in 2019. For the FY beginning in 2019 (that is, FY 2020), Section 1886(s)(3)(E) of the Act requires the reduction to be 0.75 percentage point.

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Also, Section 1886(s)(2)(A)(i) of the Act requires the application of the “productivity adjustment” described in Section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS for the RY beginning in 2012 (that is, an RY that coincides with an FY), and each subsequent RY. For the FY beginning in 2019 (that is, FY 2020), the reduction is 0.4 percentage point. CMS updated the IPF PPS base rate for FY 2020 by applying the adjusted market basket update of 1.75 percent (which includes the 2016-based IPF-specific market basket update of 2.9 percent, less the “other adjustment” of 0.75 percentage point, and less the productivity adjustment of 0.4 percentage point) and the wage index budget neutrality factor of 1.0026 to the FY 2019 Federal per diem base rate of $782.78, yielding an FY 2020 Federal per diem base rate of $798.55. Similarly, applying the adjusted market basket update of 1.75 percent and the wage index budget neutrality factor of 1.0026 to the FY 2019 ECT payment per treatment of $337.00 yields an ECT payment per treatment of $343.79 for FY 2020.

FY 2020 Wage Index Update CMS finalized a policy to remove the one-year lag of the wage index data by updating the IPF PPS wage index for FY 2020 with the concurrent wage data from the FY 2020 Inpatient Prospective Payment System (IPPS) wage index before reclassifications and other adjustments are taken into account, instead of using the FY 2019 IPPS wage index data. CMS is implementing changes to the wage index in a budget-neutral manner. Thus, there will not be an impact on aggregate Medicare payments to IPFs.

Also, on August 15, 2017, the Office of Management and Budget (OMB) announced in OMB Bulletin No. 17–01 that one Micropolitan Statistical Area now qualifies as a Metropolitan Statistical Area. The new urban Core-Based Statistical Area (CBSA) is Twin Falls, Idaho (CBSA 46300). This CBSA is comprised of the principal city of Twin Falls, Idaho in Jerome County, Idaho and Twin Falls County, Idaho. Prior to this re-designation, Jerome County and Twin Falls County, Idaho were classified as rural. Currently, there is a single IPF in new CBSA 46300 (provider 13S002), which will lose its 17 percent rural adjustment as a result of being re-designated as urban.

The FY 2020 final IPF PPS wage index is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientPsychFacilPPS/WageIndex.html.

IPF Quality Reporting Program (IPFQR) Section 1886(s)(4) of the Act requires the establishment of a quality data reporting program for the IPF PPS beginning in FY 2014. CMS finalized new requirements for quality reporting for IPFs in the “Hospital Inpatient Prospective Payment System for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates” Final Rule (August 31, 2012) (77 FR 53258, 53644 through 53360).


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Section 1886(s)(4)(A)(i) of the Act requires that, for FY 2014 and each subsequent fiscal year, the Secretary shall reduce any annual update to a standard Federal rate for discharges occurring during the FY by two percentage points for any IPF that does not comply with the quality data submission requirements with respect to an applicable year. Therefore, a two-percentage point reduction is applied when calculating the Federal per diem base rate and the ECT payment per treatment as follows:

• The adjusted market basket update of 1.75 percent (which includes the 2016-based IPF-specific market basket update of 2.9 percent, less the “other adjustment” of 0.75 percentage point reduction to the market basket update, and less a required productivity adjustment reduction of 0.4 percentage point) is reduced by 2.0 percentage points, for a negative update of -0.25 percent for IPFs that failed to meet quality reporting requirements.

• For IPFs that failed to submit quality reporting data under the IPFQR program for FY 2020, the -0.25 percent update and the wage index budget neutrality factor of 1.0026 are applied to the FY 2019 Federal per diem base rate of $782.78, yielding a Federal per diem base rate of $782.85.

• Similarly, for IPFs that failed to submit quality reporting data under the IPFQR program for FY 2020, the -0.25 percent update and the wage index budget neutrality factor of 1.0026 are applied to the FY 2019 ECT payment per treatment of $337.00, yielding a per treatment ECT payment of $337.03 for FY 2020.

PRICER Updates: IPF PPS Fiscal Year 2020 (October 1, 2019 – September 30, 2020):

• The Federal per diem base rate is $798.55 for IPFs that complied with quality data submission requirements.

• The Federal per diem base rate is $782.85, when applying the two-percentage point reduction, for IPFs that failed to comply with quality data submission requirements.

• The fixed dollar loss threshold amount is $14,960.

• The IPF PPS wage index is based on the FY 2020 pre-floor, pre-reclassified acute care hospital wage index.

• The labor-related share is 76.9 percent.

• The non-labor related share is 23.1 percent.

• The ECT payment per treatment is $343.79 for IPFs that complied with quality data submission requirements.

• The ECT payment per treatment is $337.03 when applying the two-percentage point reduction, for IPFs that failed to comply with quality data submission requirements.

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The National Urban and Rural Cost to Charge Ratios (CCRs) for the IPF PPS Fiscal Year 2020

CCRs Rural Urban National Median 0.5720 0.4370 National Ceiling 2.0239 1.7263

ICD-10 CM/PCS Updates For FY 2020, the IPF PPS adjustment factors are unchanged from those used in FY 2019. However, CMS updated the ICD-10-CM/PCS code set, effective October 1, 2019. These updates affect the ICD-10-CM/PCS codes that underlie the IPF PPS MS-DRGs and the IPF PPS comorbidity categories. The updated FY 2020 MS-DRG code lists are available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html, and the updated FY 2020 IPF PPS comorbidity categories are available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientPsychFacilPPS/tools.html. There were no changes from FY 2019 to FY 2020 to the IPF Code First list or the IPF ECT procedure code list.

COLA Adjustment The IPF PPS Cost of Living Adjustment (COLA) factors list for FY 2020 was unchanged from FY 2019. The following table shows adjustments for Alaska and Hawaii.

Cost of Living Adjustments (COLAs)

Area Cost of Living Adjustment Factor

Alaska City of Juneau and 80-kilometer (50-mile) radius by road

1.25

Rest of Alaska 1.25

Hawaii - City and County of Honolulu 1.25

Hawaii - County of Hawaii 1.21

Hawaii - County of Kauai 1.25

Hawaii - County of Maui and County of Kalawao 1.25

Alaska City of Juneau and 80-kilometer (50-mile) radius by road

1.25

Rest of Alaska 1.25Hawaii - City and County of Honolulu 1.25Hawaii - County of Hawaii 1.21Hawaii - County of Kauai 1.25Hawaii - County of Maui and County of Kalawao 1.25


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Rural Adjustment For FY 2020, IPFs designated as “rural” continue to receive a 17 percent rural adjustment.

Additional Information The official instruction, CR11420, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4357CP.pdf. An attachment to CR11420 contains other tables that show variable per diem adjustments, age adjustments, DRG adjustments, and comorbidity adjustments.


Document History


LEARNING AND EDUCATION INFORMATION

Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast: August 28, 2019

Please join Palmetto GBA on Wednesday, August 28, 2019, at 11 a.m. ET for the Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation webcast. Palmetto GBA will provide an overview of coverage and medical necessity, including medical review findings and documentation tips for Diagnosis Related Group (DRG) 885 Psychoses.

Registration for this webcast is available at https://tinyurl.com/y5oa5zgb.

Note: An NPI and PTAN are required to register. You should only enter ‘N/A’ if you do not have an NPI or PTAN.

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2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule

Palmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2019. These calls are open to all providers. Please mark your calendars to join our Medical Review Subject Matter Experts as they discuss and answer your questions concerning current TPE process.

Medical Review Hot Topic Targeted Probe and Educate TeleconferenceDate September 3, 2019 December 2, 2019Time 2:00 p.m. -

3:00 p.m. ET2:00 p.m. - 3:00 p.m. ET

Participation Number

(877) 789-3907 (877) 789-3907

Confirmation ID Number

5369828 6879568

This schedule is also available on the Palmetto GBA Event Registration Portal at https://www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304

Part A Skilled Nursing Facility (SNF) Focus on Billing Webcast: September 12, 2019

Please join Palmetto GBA on Thursday, September 12, 2019, at 11 a.m. ET for a Part A Skilled Nursing Facility (SNF) Focus on Billing webcast! We will review specific billing topics including sanction, qualifying stay, leave of absence, interrupted stay, CERT clinical spotlight and more!

Register Now (https://tinyurl.com/y45m59rh)

Note: For tracking purposes, an NPI and PTAN are required to register. You should only enter ‘N/A’ if you do not have an NPI or PTAN.

September 18, 2019, Part A Ask the Contractor Teleconference (ACT) Specialty Clinical Topic: Diagnosis Related Group (DRG) 682 - Renal Failure

Palmetto GBA will host the Part A Ask the Contractor Teleconference (ACT) on Wednesday, September 18, 2019, at 11 a.m. ET. The ACT call is designed to open the communication channels between Palmetto GBA and our Part A provider community.

The ACT Specialty Clinical Topic is DRG 682 – Renal Failure with Major Complication or Comorbidity (MCC). Join our Clinical Consultant, April Gause, as she provides information concerning recent medical review findings and how to improve your documentation.


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All provider questions will be responded to during the call regardless of whether they concern this topic or not.Conference Call Information

• Date: September 18, 2019

• Time: 11 a.m. – 12 p.m. ET; 10 a.m. – 11 a.m. CT

• Teleconference Number: 877–789–3907

• Confirmation Code: 2596299

Submit Your QuestionsWe encourage you to submit questions prior to the call. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form (https://palmettogba.com/palmetto/mforms.nsf/files/PO-JM-A-5008.pdf/$File/PO-JM-A-5008.pdf?Open& ). Once the form is completed, please fax it to (803) 462-2678, Attention: Part A Ask-the-Contractor Teleconference, at least five business days before the scheduled teleconference.

Part A Quarterly Updates Webcast: September 25, 2019

Please join Palmetto GBA on Wednesday, September 25, 2019, at 11 a. m. ET for the Part A Quarterly Updates Webcast.

This 60-minute Webcast is designed to provide pertinent updates, changes and reminders to assist the provider community in staying compliant with Medicare rules and regulations and will include:

• Any new billing regulations

• Hot topics that impact provider billing

Registration for this webcast is available on ON24 (https://event.on24.com/eventRegistration/EventLobbyServlet?target=reg20.882371&sessionid=1&key=CD299B46CEA9E5B3FB794D12DDFD5225&regTag=&sourcepage=register).

Note: This webcast is intended for JM and JJ Part A Providers. An NPI and PTAN are required to register. You should only enter ‘N/A’ if you do not have an NPI or PTAN.

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JJ/JM Part A and Part B MACtoberfest Conference

The JJ/JM Part and Part B MACtoberfest® Conference will be held October 8-9, 2019, in Asheville, North Carolina.

To register for this conference, please visit the MACtoberfest website (https://palmettogba.com/palmetto/mactoberfest2019.nsf/home?openform).

Hotel Reservations must be made by 12 a.m., Saturday, September 7, 2019, to receive the discounted rate. To make your room reservations, please select Crowne Plaza website (https://tinyurl.com/y67f55b8).


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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.

To access the following information, go to https://www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-A~AW8UM97436

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.

Preceding 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 Webcasts The Quarterly Update Webcasts are intended to provide ongoing, scheduled 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.

Event Registration Portal 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 1-877-567-7271.

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MEDICAL POLICY INFORMATION

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update

MLN Matters Number: MM11392 Related CR Release Date: August 9, 2019 Related CR Transmittal Number: R2348OTN Related Change Request (CR) Number: 11392 Effective Date: January 1, 2020 Implementation Date: January 6, 2020 -MAC local edits 45 days from date of this CR

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 11392 constitutes a maintenance update of International Classification of Diseases (ICD)-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Please make sure your billing staffs are aware of these updates.

Background Previous NCD coding changes appear in ICD-10 quarterly updates available at https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html, along with other CRs implementing new policy NCDs.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.

To review the NCD spreadsheets included with CR11392, go to https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2348OTN.zip.

Relevant NCD coding changes in CR 11392 include:

• NCD20.7 Percutaneous Transluminal Angioplasty

• NCD110.18 Aprepitant

• NCD110.23 Stem Cell Transplantation

• NCD150.3 Bone Mineral Density Studies

• NCD220.4 Mammography


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• NCD220.13 Percutaneous Image-Guided Breast Biopsy

• NCD270.3 Blood Derived-Products for Chronic, Non-Healing Wounds

When denying claims associated with the attached NCDs, except where otherwise indicated, MACs will use:

• Remittance Advice Remark Codes (RARC) N386 with Claim Adjustment Reason Code (CARC) 50, 96, and/or 119. See latest CAQH CORE update.

• Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32, or with occurrence code 32 and a GA modifier, indicating a signed Advance Beneficiary Notice (ABN) is on file).

• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).

• For modifier GZ, use CARC 50.

Note: MACs will adjust any claims processed in error associated with CR 11134 that you bring to their attention.



Document History


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Part A Local Coverage Determinations (LCDs) Updates

Revised ICD-10 LCDsThe table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/jja/lcd. Under the Medical Policies section, select Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCD NumberRevision Number

Changes/Additions/Deletions Effective Date

Magnetic Resonance AngiographyLCD Number: L34424Revision Number: 11

All coding located in the Coding Information section has been moved into the related Billing and Coding: Magnetic Resonance Angiography A56775 article and removed from the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/01/2019

Magnetic Resonance Imaging of the Orbit, Face, and/or Neck LCD Number: L34425Revision Number: 11

All coding located in the Coding Information section has been moved into the related Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck A56729 article and removed from the LCD.

07/25/2019

Outpatient Observation Bed/Room Services LCD Number: L34552 Revision Number: 10

All coding located in the Coding Information section has been moved into the related Billing and Coding: Outpatient Observation Bed/Room Services A56673 article and removed from the LCD.

07/11/2019

Respiratory Therapy (Respiratory Care) LCD Number: L34430Revision Number: 14

All coding located in the Coding Information section has been moved into the related Billing and Coding: Respiratory Therapy (Respiratory Care) A56717 article and removed from the LCD.

All verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Respiratory Therapy (Respiratory Care) A56717 article. Formatting was corrected throughout the LCD.

07/25/2019

Stretta Procedure LCD Number: L34553Revision Number: 7

All coding located in the Coding Information section has been moved into the related Billing and Coding: Stretta Procedure A56703 article and removed from the LCD.

07/18/2019


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Part A Local Coverage Determinations (LCDs) Article Updates

Revised ICD-10 LCD Article UpdatesThe table below provides a summary of a recent Part A MAC ICD-10 LCD article revision/updates. To view these revised LCD articles, go to www.PalmettoGBA.com/jja/lcd. In the Articles section select Coverage Articles. Under the Articles for Contractor Browser section, make sure the Active Articles category is selected and the click on the Submit button. The LCD articles are listed in alphabetical order.

TitleLCD Article ID NumberRevision Number


Billing and Coding: Magnetic Resonance AngiographyLCD Article Number: A56775NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnetic Resonance Angiography L34424.

08/01/2019

Billing and Coding: Magnetic Resonance AngiographyLCD Article Number: A56775Revision Number: 1

All coding located in the Coding Information section has been removed from the related Magnetic Resonance Angiography L34424 LCD and added to this article.

08/01/2019

Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck LCD Article Number: A56729NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Orbit, Face, and/or Neck L34425.

07/25/2019

Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or NeckLCD Article Number: A56729Revision Number: 1

All coding located in the Coding Information section has been removed from the related Magnetic Resonance Imaging of the Orbit, Face, and/or Neck L34425 LCD and added to this article.

07/25/2019

Billing and Coding: Outpatient Observation Bed/Room ServicesLCD Article Number: A56673NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Observation Bed/Room Services L34552.

07/11/2019

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Billing and Coding: Outpatient Observation Bed/Room ServicesLCD Article Number: A56673Revision Number: 1

All coding located in the Coding Information section has been removed from the related Outpatient Observation Bed/Room Services L34552 LCD and added to this article.

07/11/2019

Billing and Coding: Respiratory Therapy (Respiratory Care) LCD Article Number: A56717NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Respiratory Therapy (Respiratory Care) L34430.

Documentation Requirements

Therapeutic procedures whose principle aim is to treat a respiratory impairment should be identified using the G0237-G0239 series of HCPCS codes. CPT® codes 97000 to 97799 are not to be billed by professionals involved in treating respiratory conditions, unless these services are delivered by physical or occupational therapists and meet the other requirements for physical and occupational therapy services.

07/25/2019

Billing and Coding: Respiratory Therapy (Respiratory Care) LCD Article Number: A56717Revision Number: 1

All coding located in the Coding Information section has been removed from the related Respiratory Therapy (Respiratory Care) L34430 LCD and added to this article.

07/25/2019

Billing and Coding: Stretta ProcedureLCD Article Number: A56703NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Stretta Procedure L34553.

07/18/2019

Billing and Coding: Stretta ProcedureLCD Article Number: A56703Revision Number: 1

All coding located in the Coding Information section has been removed from the related Stretta Procedure L34553 LCD and added to this article.

07/18/2019


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Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) Updates

Revised ICD-10 LCDsThe table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/jja/lcd. Under the Medical Policies section, select Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCD NumberRevision Number


Cardiac Computed Tomography & Angiography (CCTA) LCD Number: L33423Revision Number: 12

All coding located in the Coding Information section has been removed and is included in the related Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) A56691 article.

07/11/2019

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy LCD Number: L36471Revision Number: 8

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy A56687 article.

07/11/2019

Intravenous Immunoglobulin (IVIG) LCD Number: L34580Revision Number: 17

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Intravenous Immunoglobulin (IVIG) A56718 article.

07/25/2019

Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential TremorLCD Number: L37761Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor A56690 article and removed from the LCD.

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

07/11/2019

Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®) LCD Number: L36109Revision Number: 12

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®) A56723 article.

07/25/2019

84 09/2019


Nerve Blocks and Electrostimulation for Peripheral Neuropathy LCD Number: L37642Revision Number: 3

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy A56731 article.

Under Bibliography changes were made to citations to reflect AMA citation guidelines.

07/25/2019

Ophthalmic Angiography (Fluorescein and Indocyanine Green) LCD Number: L34426Revision Number: 17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) A56774 article and removed from the LCD.

08/01/2019

Routine Foot CareLCD Number: L37643Revision Number: 4

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been moved into the related Billing and Coding: Routine Foot Care A56680 article and removed from the LCD.

Under CMS National Coverage Policy “Chapter 1” was added to “CMS Internet- Only Manual, Pub 100-03, Medicare National Coverage Determination Manual, §70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy).” Punctuation was corrected throughout the LCD.

07/25/2019

Somatosensory TestingLCD Number: L56769Revision Number: 11

Under CMS National Coverage Policy removed the verbiage “Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:” All coding located in the Coding Information section has been moved into the related Billing and Coding: Somatosensory Testing A56769 article and removed from the LCD.

08/01/2019

White Cell Colony Stimulating FactorsLCD Number: L37176Revision Number: 12

All coding located in the Coding Information section has been moved into the related Billing and Coding: White Cell Colony Stimulating Factors A56748 article and removed from the LCD.

08/01/2019

Wireless Capsule Endoscopy LCD Number: L36427Revision Number: 10

All coding located in the Coding Information section has been moved into the related Billing and Coding: Wireless Capsule Endoscopy A56727 article and removed from the LCD.

07/25/2019

Total Joint Arthroplasty LCD Number: L33456Revision Number: 17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Total Joint Arthroplasty A56777 article and removed from the LCD.

Formatting was corrected throughout the LCD and reference access dates were updated under the Bibliography section.

08/01/2019


85 09/2019

Part A/B Local Coverage Determinations (LCDs) Article Updates

Revised ICD-10 LCD Article UpdatesThe table below provides a summary of a recent Part A/B MAC ICD-10 LCD article revision/updates. To view these revised LCD articles, go to www.PalmettoGBA.com/jja/lcd. In the Articles section select Coverage Articles. Under the Articles for Contractor Browser section, make sure the Active Articles category is selected and the click on the Submit button. The LCD articles are listed in alphabetical order.



Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) LCD Article Number: A56691NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Computed Tomography & Angiography (CCTA) L33423.

07/11/2019

Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) LCD Article Number: A56691Revision Number: 1

All coding located in the Coding Information section has been removed from the related Cardiac Computed Tomography & Angiography (CCTA) L33423 LCD and added to this article.

07/11/2019

Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) LCD Article Number: A56691Revision Number: 2

All ICD-10 codes and verbiage listed in the Non-Covered ICD-10 Codes Group 1: Paragraph and Codes sections were moved to the Covered ICD-10 Group 2: Paragraph and Codes sections as it was inadvertently placed in the wrong section.

Under Non-Covered ICD-10 Codes Group 1: Paragraph added the verbiage “All ICD-10 codes not listed under “ICD-10 Codes that Support Medical Necessity” will be denied as not medically necessary.”

07/11/2019

Billing and Coding: Computerized Axial Tomography (CT), Thorax LCD Article Number: A56580Revision Number: 2

Under Article Text – Utilization Guidelines removed place of service (99).

08/01/2019

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Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy LCD Article Number: A56687NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy L36471.

This policy does not address sacral conditions, injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 code M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.87 or M53.88 are not subject to the requirements of this article.

07/11/2019

Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy LCD Article Number: A56687Revision Number: 1

All coding located in the Coding Information section has been removed from the related Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy L36471 LCD and added to this article.

07/11/2019

Billing and Coding: Intravenous Immunoglobulin (IVIG) LCD Article Number: A56718NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Intravenous Immunoglobulin L34580.

Note: With respect to HCPCS codes J2792 Injection, Rho D immune globulin (human), solvent detergent (WINRho) and J2791 Injection immune globulin (human), (Rhophylac), this article only addresses their use intravenously.

07/25/2019

Billing and Coding: Intravenous Immunoglobulin (IVIG) LCD Article Number: A56718Revision Number: 1

All coding located in the Coding Information section has been removed from the related Intravenous Immunoglobulin (IVIG) L34580 LCD and added to this article.

07/25/2019


87 09/2019

Billing and Coding: Intravesical Instillation of Bacillus Calmette-Guérin (BCG) LCD Article Number: A56754NEW

Due to the current shortage of Bacillus Calmette-Guérin (BCG) for intravesical instillation it may be necessary to maintain ongoing treatment for bladder cancer with this product at less than the Food and Drug Administration (FDA) label dose of 81 mg (1 vial) per instillation. In response to this situation, Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code by which to report BCG which will allow for reporting of doses less than 1 vial per instillation. HCPCS code J9030 BCG live intravesical instillation, 1 mg becomes effective 7/1/2019 and replaces HCPCS code J9031 BCG intravesical per instillation. HCPCS code J9031 BCG intravesical per instillation will no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be reported with the number of units corresponding to the units being equal to the number of milligrams actually instilled per treatment, as the unit equals 1 mg for the new code.

For updates on the current shortage of BCG live intravesical:

https://www.ashp.org/Drug-Shortages/Current-Shortages

07/01/2019

Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential TremorLCD Article Number: A56690NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor L37761.

07/11/2019

Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential TremorLCD Article Number: A56690Revision Number: 1

All coding located in the Coding Information section has been removed from the related Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor L37791 LCD and added to this article

07/11/2019

Billing and Coding: Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®)LCD Article Number: A56723NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®) L36109.

Utilization Guidelines Coverage is for an initial implant and up to five additional implants. Implants in excess of six (any CPT® code 52442 billed beyond the number of five) will deny individually but may be reconsidered on appeal when documentation is supplied to support the use of additional implants beyond a total of six.

07/25/2019

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Billing and Coding: Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®)LCD Article Number: A56723Revision Number: 1

All coding located in the Coding Information section has been removed from the related Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift®) L36109 LCD and added to this article.

07/25/2019

Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral NeuropathyLCD Article Number: A56731NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Nerve Blocks and Electrostimulation for Peripheral Neuropathy L37642.

Utilization Guidelines:Use of Physical Medicine and Rehabilitation CPT/HCPCS Codes (97032, 97139, G0282, G0283) for these treatments is inappropriate.

07/25/2019

Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral NeuropathyLCD Article Number: A56731Revision Number: 1

All coding located in the Coding Information section has been removed from the related the Nerve Blocks and Electrostimulation for Peripheral Neuropathy L37642 LCD and added to this article.

07/25/2019

Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) LCD Article Number: A56774NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Ophthalmic Angiography (Fluorescein and Indocyanine Green) L34426.

08/01/2019

Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) LCD Article Number: A56774Revision Number: 1

All coding located in the Coding Information section has been removed from the related Ophthalmic Angiography (Fluorescein and Indocyanine Green) L34426 LCD and added to this article.

08/01/2019

Billing and Coding: Removal of Benign and Malignant Skin Lesions LCD Article Number: A56346Revision Number: 3

The Article Title was changed to “Billing and Coding: Removal of Benign and Malignant Skin Lesions”. Under Covered ICD-10 Codes Group 1: Codes added ICD-10 code L72.11.

08/23/2019


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Billing and Coding: Routine Foot CareA56680NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care L37643.

Coding for Mycotic NailsAlthough CPT® coding does not exclusively apply CPT® codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT® codes usually used to code for services related to debriding mycotic nails.

Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded with ICD-10 code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2 as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.

The nail debridement procedure codes (11720-11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.

Coding for Systemic ConditionsFoot care services are covered in the presence of certain conditions described in the CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §290 identified by the following ICD-10 codes:

Diabetes mellitus*E08.00-E13.9

Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)

I70.201-I70.92 I73.00-I73.01 I73.9

07/25/2019

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Billing and Coding: Routine Foot CareA56680NEWContinued

Buerger’s disease (thromboangiitis obliterans)I73.1

Chronic thrombophlebitis*I80.00-I80.3

Peripheral neuropathies involving the feet:

o Associated with malnutrition and vitamin deficiency*E56.9 and G63

Malnutrition (general, pellagra)*E46, E52, or E64.0 and G63

Alcoholism*G62.1

Malabsorption (celiac disease, tropical sprue)*K90.0 or K90.1 and G63

Pernicious Anemia*D51.0 and G63

o Associated with carcinoma*G13.0

o Associated with diabetes mellitus*E08.40 E08.42 E09.40 E09.42 E10.40 E10.42 E11.40 E11.42 E13.40 E13.42

o Associated with drugs and toxins*G62.0 G62.2 G62.82

o Associated with multiple sclerosis*G35 and G63

o Associated with uremia (chronic renal disease)*N18.1-N18.9 and G63

07/25/2019


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o Associated with traumatic injuryS86.001A-S86.009S S86.091A-S86.109SS86.191A-S86.201S S86.209A-S86.209S S86.291A-S86.309S S86.391A-S86.809S S86.891A-S86.909S S86.991A-S86.999S S89.80XA-S89.92XS S96.001A-S96.009S S96.091A-S96.109S S96.191A-S96.209S S96.291A-S96.809S S96.891A-S96.909S S96.991A-S96.999S S99.811A-S99.929S and G63

o Associated with leprosy or neurosyphilisA30.0-A30.9 and G63A52.10-A52.3 and G63

o Associated with hereditary disordersG60.0-G60.9

Heredity sensory radicular neuropathyG60.0

Angiokeratoma corporis diffusum (Fabry’s)E75.21 and G63

Amyloid neuropathyE85.0-E85.9 and G63

When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and national provider identifier (NPI) of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.

07/25/2019

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A presumption of coverage will be applied when the physician rendering the routine foot care has identified:

• One (1) Class A finding using modifier Q7;

• Two (2) Class B findings using modifier Q8; or

• One (1) Class B and two (2) Class C findings using modifier Q9.

In addition to a valid billing indicator, these services must include a systemic condition diagnosis listed above. All claims for routine foot care based on the presence of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.

Claims without a systemic diagnosis listed will be denied as non-covered routine-type foot care services.

Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory non-covered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the national provider identifier (NPI) of the doctor of medicine or osteopathy.

07/25/2019

Billing and Coding: Routine Foot CareLCD Article Number; A56680Revision Number: 1

All coding located in the Coding Information section has been removed from the related Routine Foot Care L37643 LCD and added to this article.

07/25/2019

Billing and Coding: Somatosensory TestingLCD Article Number: A56769 NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Somatosensory Testing L34433.

08/01/2019

Billing and Coding: Somatosensory TestingLCD Article Number: A56769 Revision Number: 1

All coding located in the Coding Information section has been removed from the related Somatosensory Testing L34433 LCD and added to this article.

08/01/2019

Billing and Coding: Total Joint Arthroplasty LCD Article Number: A56777NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Total Joint Arthroplasty L33456.

08/01/2019

Billing and Coding: Total Joint Arthroplasty LCD Article Number: A56777Revision Number: 1

All coding located in the Coding Information section has been removed from the related Total Joint Arthroplasty L33456 and added to this article.

08/01/2019


93 09/2019

Billing and Coding: White Cell Colony Stimulating FactorsLCD Article Number: A56748NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for White Cell Colony Stimulating Factors L37176.

08/01/2019

Billing and Coding: White Cell Colony Stimulating FactorsLCD Article Number: A56748Revision Number: 1

All coding located in the Coding Information section has been removed from the related White Cell Colony Stimulating Factors L37176 LCD and added to this article.

08/01/2019

Billing and Coding: Wireless Capsule Endoscopy LCD Article Number: A56727 NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Wireless Capsule Endoscopy L36427.

07/25/2019

Billing and Coding: Wireless Capsule Endoscopy LCD Article Number: A56727 Revision Number: 1

All coding located in the Coding Information section has been removed from the related Wireless Capsule Endoscopy L36427 LCD and added to this article.

07/25/2019

94 09/2019


MolDX Local Coverage Determinations (LCDs) Article Updates

Revised ICD-10 LCD Article UpdatesThe table below provides a summary of recent Part A MolDX ICD-10 LCD article revisions/updates. To view these revised LCD articles, go to www.palmettogba.com/moldx. Select MolDX LCDs under the Topics section. Go to your state and select Active. Scroll down to the Final LCDs for Contractor Results section and make sure the Active LCDs category is selected. Scroll down to the Associated Documents section and access the link. Then select the Submit button. The LCDs are listed in alphabetical order.



Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)LCD Article Number: A56593Revision Number: 2

Updated the date of service for 0097U to 7/1/2019 from 4/1/2019. 07/01/2019

Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)LCD Article Number: A56593Revision Number: 3

Under ICD-10 Codes that are Covered Group 1 Paragraph deleted the statement “To bill for 87506, the claim must contain A04.71 or A04.72 plus at least one other code from the list.”

05/23/2019


95 09/2019

SKILLED NURSING FACILITY (SNF) INFORMATION

October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement


Provider Type Affected This MLN Matters article is an update to alert physicians, providers, and suppliers who bill Medicare Administrative Contractors (MACs) of CPT code adjustments for services provided to Medicare beneficiaries in a Skilled Nursing Facility (SNF).

Provider Action Needed CR 11381 provides updates to the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

CR11381 alerts providers of incorrectly categorized CPT codes 29580, 29581, and 29584. CR 11381 provides instructions to categorize these codes correctly on the SNF CB files.

Section 1888 of the Social Security Act codifies SNF PPS and Consolidated Billing (CB). The new coding identified in each update describes the same services that are subject to SNF PPS payment by law. No additional services are in place because of these routine updates; that is, the new updates occur because of changes to the coding system, not because of redefined services subject to SNF CB. There are no other regulatory changes beyond code list updates.

Make sure your billing staffs are aware of these changes.

Background The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes excluded from the CB provision of the SNF PPS. There are services excluded from SNF PPS and CB paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. If services not appearing on the exclusion list appear on claims to MACs, including Durable Medical Equipment MACs (DME MACs), Medicare will not pay to any providers other than a SNF. For non-therapy services, SNF CB applies only to the services furnished to a SNF resident during a covered Part A stay; however, SNF CB applies to physical and occupational therapies and speech-language pathology services whenever furnished to a SNF resident, regardless of whether Part A covers the stay. To assure proper payment in all settings, Medicare systems must edit for services provided to SNF beneficiaries both included and excluded from SNF CB.

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The updated lists for institutional and professional billing are available at https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html.

CR 11381 instructs Medicare’s Common Working File (CWF) maintainer to remove the following HCPCS from processing file #1 (Physician Services for SNF CB), effective October 1, 2019:

• 29580 - paste/unna boot

• 29581-29584 - application of multi compression systems

The CWF will add the following HCPCS to processing file #4 (Part B Stay Only – Therapy Services), effective October 1, 2019

• 29580 - paste/unna boot

• 29581 - Lower Extremity Application of Strapping-Any Age

• 29584 - Lower Extremity Application of Strapping-Any Age

MACs will not search their files for incorrectly paid claims. They will reopen and reprocess claims when you bring such claims to their attention.

Additional Information The official instruction, CR 11381, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4341CP.pdf.


Document History



97 09/2019

Medicare Shared Savings Program (Shared Savings Program) Skilled Nursing Facility (SNF) Affiliates’ Requirement to Include Demonstration Code 77 on SNF 3- Day Rule Waiver Claims


Provider Types Affected This MLN Matters Article is for Skilled Nursing Facilities (SNFs) and hospitals and Critical Access Hospitals (CAHs) operating under swing bed agreements who are eligible and approved as SNF affiliates of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (Shared Savings Program) and submitting claims to Medicare Administrative Contractors (MACs) for SNF services provided to Medicare beneficiaries under a SNF 3-day rule waiver.

Provider Action Needed CR 11290 requires SNF affiliates of ACOs participating in the Shared Savings Program to include demonstration code 77 in the treatment authorization field on claims when the SNF affiliate intends for the claim to be subject to the SNF 3-day rule waiver. Beginning with admissions on or after January 1, 2020, ACO SNF affiliates need to submit demonstration code 77 on claims in the treatment authorization field to serve as the SNF affiliate’s attestation that the eligibility requirements for using a SNF 3-Day Rule Waiver have been met. Should Medicare systems determine the beneficiary is deemed ineligible for services under the demonstration code 77, MACs will reject the claim with the following messages:

• Claim Adjustment Reason Code (CARC) 272: Coverage/program guidelines were not met.

• Remittance Advice Remark Code (RARC) N564: Patient did not meet the inclusion criteria for the demonstration project or pilot program.

This waiver is only available to ACOs that are eligible and approved to use the SNF 3-day rule waiver. Make sure your SNF billing staffs are aware of the requirement to include demonstration code 77 in the treatment authorization field.

Background The Medicare SNF benefit is for beneficiaries who are assignable or prospectively assigned to an eligible and approved ACO and require a short-term intensive say in a SNF and requires skilled nursing or rehabilitation care. Section 1861(i) of the Social Security Act (the Act) requires beneficiaries to have a prior inpatient hospital stay of no fewer than three consecutive days to be eligible for inpatient SNF care to be covered by Medicare. This requirement is the SNF 3-day rule.

CMS understands it could be medically appropriate for some patients to receive skilled nursing care or rehabilitation services provided at SNFs without prior hospitalization or with an inpatient hospital stay of fewer than 3 days.

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The Shared Savings Program payment incentives and care delivery rules are designed to enable its ACO participants to improve the quality of care while reducing the rate of growth in expenditures. CMS implemented a waiver for the SNF 3-day rule to enable certain eligible and approved Shared Savings Program ACOs to select the most appropriate care delivery site for a subset of SNF-eligible beneficiaries while reducing expenditures through care improvement. This waiver is only available to eligible and approved ACOs participating in the Shared Savings Program.

CMS proposed and finalized through rulemaking (80 Federal Register (FR) 32692) a waiver of the prior 3-day inpatient hospitalization requirement in order to provide Medicare SNF coverage when certain beneficiaries, assigned to Shared Savings Program ACOs that are eligible and approved to use the SNF 3-day rule waiver, are admitted to designated SNF affiliates either directly or after fewer than three inpatient hospital days. The waiver is available for eligible and approved Shared Savings Program ACOs that demonstrate the capacity and infrastructure to identify and manage beneficiaries who would be either directly admitted to a SNF or admitted to a SNF after an inpatient hospital stay of fewer than 3 days, for services otherwise covered under the Medicare SNF benefit. Beneficiaries with certain characteristics who are assigned to a Shared Savings Program ACO may be admitted to qualifying SNF affiliates, based upon the referral of a treating physician who is an ACO provider/supplier. All other requirements for the Medicare SNF benefit remain unchanged.

CR 11290 requires SNF affiliates (including hospitals and Critical Access Hospitals (CAHs) operating under swing bed agreements and partnering with ACOs as SNF affiliates) to include demonstration code 77 in the treatment authorization code field on claims when the SNF affiliate intends for CMS to waive the 3-day qualifying hospital stay requirement. Including demonstration code 77 in the treatment authorization code field provides an attestation on behalf of the SNF affiliate that the eligibility requirements for Medicare to make payment for services provided pursuant to the SNF 3-day rule waiver have been met.

Eligibility requirements include, but are not limited to, the beneficiary having been evaluated and approved for admission to the SNF within 3 days prior to the SNF admission by an ACO provider/supplier that is a physician, consistent with the ACO’s beneficiary evaluation and admission plan.

Information regarding the eligibility requirements is found in the “SNF Nursing Facility 3-Day Rule Waiver,” guidance document in the “Program Guidance & Specifications,” section of the Shared Savings Program webpage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html. A current list of eligible and approved ACOs and their SNF affiliates approved to use this waiver is available and updated annually at the Data.CMS.gov webpage at https://data.cms.gov/browse?category=Special+Programs%2FInitiatives+-+Medicare+Shared+Savings+Program+%28MSSP%29&page=1


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Document History


This advisory should be shared with all health care practitioners and managerial members of the provider/supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www.PalmettoGBA.com/jja.

Address Changes

Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to https://pecos.cms.hhs.gov on the CMS website. To obtain the hard copy form plus information on how to complete and submit it – visit the Palmetto GBA website (www.PalmettoGBA.com/jja).

100 09/2019


TOOLS THAT YOU CAN USE

Federally Qualified Health Centers (FQHCs) - A to Z Module

The Federally Qualified Health Centers (FQHCs) - A to Z Module provides an overview of the FQHC benefit and information on covered services in an FQHC and how to bill and receive payment for FQHC services.

To access this module and other online training courses, please go to the Self-Paced Learning Section (https://www.palmettogba.com/palmetto/providers.nsf/docsr/Providers~JJ%20Part%20A~Education~Self-Paced%20Learning) of the JJ Part A website.


101 09/2019

Hyperbaric Oxygen Therapy Module

The Hyperbaric Oxygen (HBO) Therapy Module explains HBO therapy, covered and non-covered conditions as indicated per NCD 20.29 for treatment, as well as documentation guidelines pertinent to establishing medical necessity when submitting claims to Medicare.


102 09/2019


Medicare Secondary Payer (MSP) Process Tool

Palmetto GBA education team has developed an Interactive Medicare Secondary Payer (MSP) Process Tool. This tool provides a description of the Medicare Secondary Payer (MSP) process with billing instructions for each type of MSP situation.

The self-paced learning module will assist providers in understanding the various MSP billing processes for Palmetto GBA, including the eight types of MSP situations: Working Aged, Disability, ESRD, Liability, No-Fault, Workers’ Compensation, Public Health Services (PHS) and the Federal Black Lung program.



103 09/2019

We’re using Medicare Beneficiary Identifiers (MBIs)

For more information about the new Medicare card, please go to the New Medicare card Web Page on the CMS Website.

To access this page, copy and paste the following link in your browser:

https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

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NOTES


105 09/2019

HELPFUL INFORMATION

Contact Information for Palmetto GBA Part A

Provider Contact Center: 877-567-7271

Email Part A: http://www.palmettogba.com/palmetto/feedback.nsf/Feedback?OpenAgent&SendTo=49

To contact a specific JJ Part A department, please select the link below:

https://www.palmettogba.com/palmetto/providers.nsf/cudocs/JJ%20Part%20A?open

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