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JM Part A Medicare AdvisoryLatest Medicare News for JM Part A

palmettogba.com/jma

October 2019 Volume 2019, Issue 10

The JM Part A Medicare Advisory contains coverage, billing and other information for Jurisdiction M 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 JM 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 .......................................................................................................4Hurricane Dorian Information ....................................................................................4

Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims ........................................................................................................4Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims .......................................................................................................................4

Multiple Provider Information ..................................................................................12 Part A East Qualified Indepenent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration .........................................................................12ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider Contact Center .......................................12Medicare Diabetes Prevention Program Booklet ...................................................152020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments ................................................................................................................15Annual Clotting Factor Furnishing Fee Update 2020 ............................................17October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files ........................18Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations – Update .............................................................20October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3 ............................................................................................................23Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update ........................................26Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System ...........................................................32Get Your Medicare News Electronically ................................................................41Medicare Learning Network® (MLN) ...................................................................42

Medicare Beneficiary Identifier (MBI) Information ................................................43New Medicare Card: Transition Period Ends in Less Than 4 Months ...................43Medicare Beneficiary Identifier (MBI) Look-up Tool ............................................44

2 10/2019

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.

Comparative Billing Report (CBR) Information .....................................................46Heart Failure and Shock Diagnostic Related Grouping (DRG codes 291-293) .....46

Electronic Data Interchange (EDI) Information ......................................................49Claim Status Category and Claim Status Codes Update ........................................49Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE .....................................................................................................................50Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update ......................................................................................................52

eServices Information .................................................................................................53Do You Have a Question Regarding eServices? We Can Help! .............................53How Can We Be of “eService” to You? .................................................................54

Fee Schedule Information ..........................................................................................55October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule .................................................55Ambulance Fee Schedule and Medicare Transports Booklet .................................58

Hospital Information ..................................................................................................58Billing for Hospital Part B Inpatient Services ........................................................58October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) ....................................................................................................................60Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004 .........................................................................71Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004 (Entire Change Request) ................................74

Influenza Vaccine Information...................................................................................80It’s Flu season again - Use Medicare Beneficiary Identifiers to Bill Medicare ......80Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season .812019-2020 Influenza (Flu) Resources for Health Care Professionals ....................82

Inpatient Rehabilitation Facility (IRF) Information ...............................................87Inpatient Rehabilitation Facility Prospective Payment System Booklet – Revised ...................................................................................................................87Inpatient Rehabilitation Facilities (IRFs): Improving Documentation Positively Impacts CERT Web-Based Training Course – Revised .........................................88

Learning and Education Information .......................................................................89MACtoberfest Registration Ending Soon! .............................................................89End Stage Renal Disease (ESRD) Webcast: October 23, 2019 ..............................902019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule ........................................................................................90Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA ................................................................................................91

Medical Policy Information ......................................................................................92International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) - January 2020 Update ..............................................................................................92Part A Local Coverage Determinations (LCDs) Updates .......................................94Part A Article Updates ............................................................................................98Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) Updates ..........................................................................102Part A/B Article Updates ......................................................................................104Response to Comments: Cervical Disc Replacement .........................................112


3 10/2019

Upcoming Part A Educational Events

A/B MACtoberfest 2019The JJ/JM Part and Part B MACtoberfest® Conference will be held October 8-9, 2019, in Asheville, North Carolina. End Stage Renal Disease (ESRD) Webcast: October 23, 2019Join Palmetto GBA on Wednesday, October 23, 2019, at 11 a. m. ET for a Medicare Part A End Stage Renal Disease (ESRD) webcast. We will review renal dialysis facility (RDF) requirements, consolidated billing, coverage, documentation and more! 2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) TeleconferencePalmetto GBA will host its last Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconference for the year at 2 p.m. ET on Monday, December 2, 2019 in 2019. These calls are open to all providers.

For more information and registration instructions to attend these education sessions, please go to Page 89 of this issue.

Medical Policy Information (continued)Response to Comments: Corneal Hysteresis ........................................................113MolDX Local Coverage Determinations (LCDs) Updates ..................................113MolDX Article Updates ........................................................................................120

Provider Enrollment Information ...........................................................................150You Can Track Your Enrollment Application .......................................................150

Skilled Nursing Facility Information ......................................................................1512020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update ..................................................................................................................151

Tools You Can Use .....................................................................................................153Federally Qualified Health Centers (FQHCs) - A to Z Module ...........................153Hyperbaric Oxygen Therapy Module ...................................................................154Medicare Secondary Payer (MSP) Process Tool ..................................................155We’re using Medicare Beneficiary Identifiers (MBIs) .........................................156

Helpful Information ..................................................................................................157Contact Information for Palmetto GBA Part A ....................................................157

4 10/2019


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

September 19, 2019https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-09-19-eNews.pdf



August 29, 2019https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-08-29-eNews.pdf

HURRICANE DORIAN INFORMATION

Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims

MLN Matters Number: SE19019 Article Release Date: September 4, 2019 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A


5 10/2019

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

Provider Information Available The Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the States of Georgia and South Carolina on September 2, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 29, 2019, for Georgia, and retroactive to August 31, 2019, for South Carolina. The PHE is in effect for 90 days. The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued. More Information:

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

• Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf) to request an individual waiver if there is no blanket waiver

Background Section 1135 and Section 1812(f) Waivers As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.

The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format. .

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

• Q&As that apply without any Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.

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

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

6 10/2019


Skilled Nursing Facilities (SNFs)

• Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

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

Home Health Agencies

• 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Blanket waiver for all impacted agencies).

• To ensure the correct processing of home health disaster related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

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

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

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


7 10/2019

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

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or DisasterCMS has determined it is appropriate to issue a blanket waiver where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the disaster or emergency.

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

Extension for Medicare Geographic Classification Review Board (MGCRB) ApplicationsCMS has granted an extension to the deadline of application re-classification requirements located at 42 CFR § 412.256 for the affected areas due to the disaster or emergency. Applications for reclassifications from hospitals in these areas must be received by the MGCRB not later than October 1, 2019.

Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions Allows Hospital Wage Index Development Time Table for hospitals in a disaster or emergency area to request revisions to and provide documentation for their Worksheet S-3 wage data and occupational mix data as included in the preliminary Public Use Files (PUFs), respectively. CMS has granted an extension for hospitals in the affected area. MACs must receive the revision requests and supporting documentation by October 1, 2019. If hospitals encounter difficulty meeting this extended deadline, hospitals should communicate their concerns to CMS via their MAC, and CMS may consider an additional extension if CMS determines it is warranted.

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

8 10/2019


Replacement Prescription FillsMedicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.

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

The Centers for Disease Control and Prevention released ICD-10-CM coding advice to report healthcare encounters.

Providers may also want to review the CMS Emergency and Preparedness webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.html.

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

Document History

Date of Change Description September 4, 2019 Initial article released.

Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims


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

Provider Information Available The Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the State of North Carolina on September 4, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to September 1, 2019, and are in effect for 90 days.


9 10/2019

The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.

More Information:

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

• Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf) to request an individual waiver if there is no blanket waiver

Background

Section 1135 and Section 1812(f) Waivers As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.

2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.

Medicare FFS Questions & Answers (Q&As) available on the Waivers and Flexibilities (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities.html) webpage apply to items and services for Medicare beneficiaries in the current disaster or emergency. These Q&As are displayed in two files:

o Q&As that apply without any Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.

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

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

10 10/2019


Skilled Nursing Facilities (SNFs)

• Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

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

Home Health Agencies

• 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Blanket waiver for all impacted agencies).

• To ensure the correct processing of home health disaster related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

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

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

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


11 10/2019

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

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or DisasterCMS has determined it is appropriate to issue a blanket waiver where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the disaster or emergency.

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

Extension for Medicare Geographic Classification Review Board (MGCRB) Applications CMS has granted an extension to the deadline of application re-classification requirements located at 42 CFR § 412.256 for the affected areas due to the disaster or emergency. Applications for reclassifications from hospitals in these areas must be received by the MGCRB not later than October 1, 2019.

Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions Allows Hospital Wage Index Development Time Table for hospitals in a disaster or emergency area to request revisions to and provide documentation for their Worksheet S-3 wage data and occupational mix data as included in the preliminary Public Use Files (PUFs), respectively.

CMS has granted an extension for hospitals in the affected area. MACs must receive the revision requests and supporting documentation by October 1, 2019. If hospitals encounter difficulty meeting this extended deadline, hospitals should communicate their concerns to CMS via their MAC, and CMS may consider an additional extension if CMS determines it is warranted.

12 10/2019


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

Replacement Prescription Fills Medicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.


The Centers for Disease Control and Prevention released ICD-10-CM coding advice to report healthcare encounters.

Providers may also want to review the CMS Emergency and Preparedness webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.html.

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

Document History


MULTIPLE PROVIDER INFORMATION

Part A East Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration

C2C Innovative Solutions, Inc. (C2C), the Part A East QIC, is currently offering providers telephone discussions and reopenings under this Medicare Appeals Demonstration. This demonstration allows providers the valuable opportunity to engage in a telephone discussion with the QIC’s medical reviewer prior to their decision being rendered; or, it allows the provider its last opportunity to submit documentation for appeals that are pending a hearing at the Office of Medicare Hearings and Appeals (OMHA). The additional documentation may allow the QIC to render a fully favorable reopening decision and eliminate the need for the OMHA hearing.


13 10/2019

Watch your mail and respond.If you receive a request for documentation or a scheduling notice for a discussion from C2C, please respond promptly to take advantage of this unique opportunity. This additional exchange of information may result in appeal outcomes favorable to the provider.

For more information, please visit C2C Innovative Solutions website (https://www.c2cinc.com/Appeals-Demonstration) external link and select Part A East Appeals Demonstration.

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.

14 10/2019


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


15 10/2019

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

2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

MLN Matters Number: MM11437 Revised Related CR Release Date: August 23, 2019 Related CR Transmittal Number: R4379CP Related Change Request (CR) Number: 11437 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on September 4, 2019, to add: “MACs will continue to accept the AQ modifier on claims for services furnished in a geographic HPSA that is not on the list of ZIP codes for automated payments” (page 2). All other information is unchanged.

16 10/2019


Provider Types Affected This MLN Matters article is for physicians and providers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed CR 11437 provides files for the automated payments of Health Professional Shortage Area (HPSA) bonuses for dates of service January 1, 2020, through December 31, 2020. Please make sure your billing staffs are aware of these updates.

Background Section 413(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment file. The Centers for Medicare & Medicaid Services (CMS) creates the automated HPSA ZIP code file using the latest designations as close as possible to November 1 of each year. CMS makes the HPSA ZIP code file available to the MACs in early December of each year. MACs implement the HPSA ZIP code file and use it for claims with dates of service January 1 to December 31 of the following year. The MACs must make automatic HPSA bonus payments to physicians providing eligible services in a ZIP code contained on the file. Note that:

• MACs will continue to accept the AQ modifier for partially designated HPSA claims

• MACs will continue to review samples of paid claims submitted with the AQ modifier

• MACs will continue to accept the AQ modifier on claims for services furnished in a geographic HPSA that is not on the list of ZIP codes for automated payments

You should review the Physician Bonuses webpage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html each year to determine whether you need to add modifier AQ to your claim in order to receive the bonus payment, or to see if the ZIP code in which you rendered services will automatically receive the HPSA bonus payment.

Additional Information The official instruction, CR 11437, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4379CP.pdf.

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


17 10/2019

Document History

Date of Change Description September 4, 2019 We revised this article to add: “MACs will continue to accept the AQ

modifier on claims for services furnished in a geographic HPSA that is not on the list of ZIP codes for automated payments” (page 2).

August 23, 2019 Initial article released.

Annual Clotting Factor Furnishing Fee Update 2020

MLN Matters Number: MM11435 Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4384CP Related Change Request (CR) Number: 11435 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

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

What You Need To Know CR 11435 announces that the clotting factor furnishing fee for 2020 is $0.226 per unit. Make sure your billing staffs are aware of the update to the annual clotting factor furnishing fee for 2020.

Background The Medicare Modernization Act, section 303(e)(1), added section 1842(o)(5)(C) of the Social Security Act, which requires a furnishing fee be paid for items and services associated with clotting factor. The Centers for Medicare & Medicaid Services (CMS) includes the clotting factor furnishing fee in the published national payment limits for clotting factor billing codes. When the national payment limit for a clotting factor is not included on the Average Sales Price (ASP), Medicare Part B Drug Pricing File, or the Not Otherwise Classified (NOC) Pricing File, the MACs must pay for the clotting factor as well as the furnishing fee.

For dates of service from January 1, 2020, through December 31, 2020, the clotting factor furnishing fee of $0.226 per unit is included in the published payment limit for clotting factors and will be added to the payment for a clotting factor when no payment limit for the clotting factor is published either on the ASP or NOC drug pricing files.

Additional Information The official instruction, CR11435, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4384CP.pdf.

18 10/2019



Document History


October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

MLN Matters Number: MM11343 Revised Related CR Release Date: September 13, 2019 Related CR Transmittal Number: R4395CP Related Change Request (CR) Number: 11343 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Note: We revised this article on September 16, 2019, to reflect the revised CR11343 issued on September 13. The CR revision had no impact on the substance of the article. We did update 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, providers, and suppliers billing Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries. Provider Action Needed CR11343 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after September 13, 2019. CMS gives MACs the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions available in Chapter 4, Section 50 of the Medicare Claims Processing Manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Make sure that your billing staffs are aware of these changes

Background The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CR11343 instructs MACs to download and implement the October 2019 and, if released, the revised July 2019, April 2019, January 2019, and October 2018 ASP drug pricing files for Medicare Part B drugs


19 10/2019

CR11343 addresses the following pricing files:

• File: October 2019 ASP and ASP NOC -- Effective Dates of Service: October 1, 2019, through December 31, 2019

• File: July 2019 ASP and ASP NOC -- Effective Dates of Service: July 1, 2019, through September 30, 2019

• File: April 2019 ASP and ASP NOC -- Effective Dates of Service: April 1, 2019, through June 30, 2019

• File: January 2019 ASP and ASP NOC -- Effective Dates of Service: January 1, 2019, through March 31, 2019

• File: October 2018 ASP and ASP NOC -- Effective Dates of Service: October 1, 2018, through December 31, 2018

For any drug or biological not listed in the ASP or NOC drug pricing files, your MACs will determine the payment allowance limits in accordance with the policy in the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. For any drug or biological not listed in the ASP or NOC drug pricing files that you bill with the KD modifier, MACs will determine the payment allowance limits in accordance with instructions for pricing and payment changes for infusion drugs furnished through an item of Durable Medical Equipment (DME) on or after January 1, 2017, associated with the passage of the 21st Century Cures Act which is available at https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf. Note: MACs will not search and adjust claims that have already been processed unless you bring such claims to their attention. Additional Information The official instruction, CR11343, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4395CP.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 September 16, 2019 We revised this article on September 16, 2019, to reflect the revised

CR11343 issued on September 13. The CR revision had no impact on the substance of the article. We did update the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

July 9, 2019 Initial article released.

20 10/2019


Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations – Update

MLN Matters Number: SE19007 Revised Related Change Request (CR) Number: 9613; 9907 Article Release Date: September 5, 2019 Effective Date: N/A Related CR Transmittal Numbers: R1704OTN and R1783OTNImplementation Date: N/A

Note: We revised this article on September 5, 2019, to announce a delay of full implementation until April 2020.

Provider Types Affected This MLN Matters® Special Edition Article is for Outpatient Prospective Payment System (OPPS) providers that have multiple service locations submitting claims to Medicare A/B Medicare Administrative Contractors (MACs).

What You Need To Know This article conveys the activation of systematic validation edits to enforce the requirements in the Medicare Claims Processing Manual, Chapter 1, Section 170, which describes Payment Bases for Institutional Claims. These requirements are not new requirements. The Centers for Medicare & Medicaid Services (CMS) discussed these requirements in CRs 9613 and 9907, both of which were effective on January 1, 2017. MLN Matters articles for CRs 9613 and 9907 are available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9613.pdf and https://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9907.pdf, respectively. Make sure your billing staff is aware of these instructions.

Background Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare Physician Fee Schedule (MPFS) and OPPS payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.

Claim Level Information: Medicare outpatient service providers report the service facility location for an off-campus, outpatient, provider-based department of a hospital in the 2310E loop of the 837 institutional claim transaction. Direct Data Entry (DDE) submitters also must report the service facility location for an off-campus, outpatient, provider-based department of a hospital. Paper submitters report the service facility address information in Form Locator (FL) “01” on the paper claim form. For MPFS services, Medicare systems use this service facility information to determine the applicable payment method or locality whenever it is present.


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Additionally, Medicare systems will validate service facility location to ensure services are provided in a Medicare enrolled location. The validation will be exact matching based on the information on the Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS). Providers need to ensure that the claims data matches their provider enrollment information.

When all the services rendered on the claim are from the billing provider address, providers are:

• To report the billing provider address only in the billing provider loop 2010AA and not to report any service facility location in loop 2310E (or in DDE MAP 171F screen for DDE submitters).

When all the services rendered on the claim are from one campus of a multi-campus provider that reports a billing provider address, providers are:

• To report the campus address where the services were rendered in the service facility location in loop 2310E if the service facility address is different from the billing provider address loop 2010AA (or in DDE MAP 171F screen for DDE submitters).

When all the services rendered on the claim are from the same off-campus, outpatient, provider-based department of a hospital, providers are:

• To report the off-campus, outpatient, provider-based department service facility address in the service facility provider loop 2310E (or in DDE MAP 171F screen for DDE submitters).

When there are services rendered on the claim from multiple locations:

• If any services on the claim were rendered at the billing provider address, providers should report the billing provider address only in the billing provider loop 2010AA and do not report the service facility location in loop 2310E (or in DDE MAP 171F screen for DDE submitters).

• If any services on the claim were rendered at more than one of the campus locations of a multi-campus provider that is not the main billing provider address, providers should report the service facility address in loop 2310E if all of the service facility addresses are different from the billing provider address in loop 2010AA (or in DDE MAP 171F screen for DDE submitters)

• If any services on the claim were rendered at one of the campus locations of a multi-campus provider that is not the main billing provider address and services were also rendered at other off-campus department practice locations, providers should report the campus address where the services were rendered in the service facility location in loop 2310E if the service facility address is different from the billing provider address in loop 2010AA (or in DDE MAP 171F screen for DDE submitters).

• If no services on the claim were rendered at the billing provider address or any campus location of a multi-campus provider, providers should report the service facility address in loop 2310E (or in DDE MAP 171F screen for DDE submitters) from the first registered department practice location encounter of the “From” date on the claim.

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National Testing

Round 1 Testing During the week of July 23, 2018, through July 30, 2018, CMS performed a national trial activation of the FISS Edits 34977 and 34978 in production environments. Reason Codes 34977 (claim service facility address doesn’t match provider practice file address) and 34978 (Off-campus provider claim line that contains a HCPCS must have a PN or PO) were activated. The testing was transparent to providers as most claims impacted by the test were suspended for one (1) billing cycle and then editing was turned off so the claim could continue processing as normal.

This national test brought to light that many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments.

Most discrepancies had to do with spelling variations. For example, in PECOS, the word entered was “Road” as part of their address, but the provider entered “Rd” or “Rd.” as part of their address on the claim submission. Another example, in PECOS the word entered was “STE” as part of their address, but the provider entered “Suite” as part of their address on the claim submission.

Round 2 Testing Providers should also ensure that all practice locations are present in PECOS and if any locations are not in PECOS to submit the 855A to add the location(s). Providers can review their practice locations in PECOS and/or the confirmation letter from PECOS when they last enrolled that was received from their A/B MAC to ensure that their service facility address for their off-campus provider department locations provided on claims is an exact match.

CMS conducted a second round of national testing in November 2018. Providers should have used the time before this national testing to correct the off-campus provider department location addresses within their billing systems to match exactly PECOS for their off-campus provider departments.

Round 3 Testing Prior to conducting round 3 testing, CMS issued instructions to the FISS maintainer to make the practice location address screen available to providers in DDE at the April 2019 system quarterly release. Starting in April 2019, the practice location screen will be available in DDE. CMS has postponed full production implementation for three additional months to allow time for providers to adjust to the new practice location screen. CMS will continue with additional round(s) of testing to ensure that we have a smooth implementation of the edits. CMS plans to conduct a June 2019 national testing to ensure providers have used the new practice location screen tool and made necessary claims submission updates to their systems.

Round 3 Testing Update & Full Production Delayed Another Quarter CMS has completed round 3 testing. We are in the process of analyzing the data, but at this point, we have discovered no major issues during round 3 testing. Based on stake-holder comments and to allow additional time to review the round 3 testing, however, CMS has decided to postpone full production implementation for three additional months until April 2020. Once the April 2020 Quarterly release is implemented, CMS will direct A/B MACs to permanently turn on the edits and set them up to Return-to-Provider (RTP) claims that do not exactly match.


23 10/2019

Providers can make corrections to their service facility address for a claim submitted in the DDE MAP 171F screen for DDE submitters. Providers who need to add a new or correct an existing practice location address will still need to submit a new 855A enrollment application in PECOS.

CMS expects that the 3 year time frame that the edits have not been active have provided ample time for providers to validate their claims submission system and the PECOS information for their off-campus provider departments are exact matches.


Document History

Date of Change Description September 5, 2019 We revised the article to announce a delay of full implementation until April 2020. June 28, 2019 We revised this article to provide an update on Round 3 testing and to announce a

delay of full implementation until October 2019. March 26, 2019 Initial article released.

October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3

MLN Matters Number: MM11412 Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4383CP Related Change Request (CR) Number: 11412 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Provider Types Affected This MLN Matters Article is for institutional providers and suppliers billing Medicare Administrative Contractors (MACs), including the Home Health and Hospice MACs, for services provided to Medicare beneficiaries.

Provider Action Needed CR 11412 provides the Integrated Outpatient Code Editor (I/OCE) instructions and specifications for the Medicare Integrated OCE version 20.3 used as follows:

• Under the Outpatient Prospective Payment System (OPPS)

• For Non-OPPS hospital outpatient departments, community mental health centers and all non-OPPS providers

• For limited services when provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System

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• For a hospice patient for the treatment of a non-terminal illness

Make sure your billing staffs are aware of these changes.

Background CR11412 informs the MACs and the Fiscal Intermediary Shared System (FISS) maintainer that the Centers for Medicare & Medicaid Services (CMS) is updating the I/OCE for October 1, 2019. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE.

The following table summarizes the modifications of the I/OCE for the October 2019 V20.3 release. Readers should review the entire CR 11412 document and note the highlighted sections, which also indicate changes from the prior release of the software. CMS has added some I/OCE modifications in the update retroactively to prior releases. If so, the retroactive date appears in the ‘Effective Date’ column of the below table. CMS will post the I/OCE specifications at http://www.cms.gov/OutpatientCodeEdit/.

Effective Date Edits Affected Modification10/1/2019 Update the Claim Return Buffer Table to add new field “Return

Code”10/1/2019 1, 3, 5 Update diagnosis code editing for validity, gender, and external

cause of morbidity, based on the FY 2020 ICD-10-CM code revisions to the Medicare Code Editor (MCE).

10/1/2019 2 Update the age range for Maternity diagnoses to a low age of 9 and a high age of 64. If outside this range an age conflict exists and edit 2 is returned. This change is based on the FY 2020 ICD-10-CM code revisions to the MCE.

10/1/2019 109 Update the Code first list for mental health diagnosis reporting, based on the FY 2020 ICD-10-CM code revisions.

1/01/2019 92 Implement logic to bypass edit 92 when a device procedure is reported with modifier CG. The edit is bypassed only if the device procedure reported with modifier CG is on the “Edit 92 Modifier Bypass” list. See Device Dependent Procedure Editing and Processing in the I/OCE specification document attached to CR 11412 for more information.

7/01/2019 Update logic to Return Payer Value Code QW and the applicable Value Code amount on an adjusted Partial Hospitalization Program (PHP) interim claim, if Condition Code MW is supplied on input. See Partial Hospitalization and CMHC Processing logic in the I/OCE specifications for more information.

7/01/2019 110 Apply mid-quarter edit 110 (Service provided prior to initial marketing date) to HCPCS Q5107, if reported before 07/18/2019.

7/01/2019 22 Remove modifier CB from the list of Valid Modifiers retroactive to July 1, 2019


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4/01/2019 13 Add edit 13 to the list of edits that can be bypassed when using the Contractor Bypass logic.

1/01/2016 93 Update edit 93 to return a line item denial or rejection flag of 1, retroactive to its effective date (1/1/2016).

10/1/2019 Revised documentation on the processing action of HCPCS 94762 when it is reported without critical care. See Critical Care Processing for documentation update.

10/1/2019 Make all HCPCS/Ambulatory Payment Classification (APC)/Status Indicator (SI) changes as specified by CMS (quarterly data files)

• Comprehensive APC Exclusion list

• Device Procedure lists (edit 92)

• Terminated Device Procedure for offset APC

• Edit 99 Exclusions list

• FQHC Non-Covered list

• Non-Covered Service list (edit 9)

• Service not billable to the MAC (edit 72)

• Edit 92 Modifier bypass list

• Low cost skin substitute list (edit 87) 10/1/2019 20, 40 Implement version 25.3 of the NCCI (as modified for applicable

outpatient institutional providers).

Additional Information The official instruction, CR 11412, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4383CP.pdf.


Document History


26 10/2019


Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update MLN Matters Number: MM11422 Revised Related CR Release Date: September 17, 2019 Related CR Transmittal Number: R4396CP Related Change Request (CR) Number: 11422 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Note: We revised this article on September 18, 2019, to reflect the revised CR11422 issued on September 17. The revised CR did not impact the content of the article. 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 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


27 10/2019

4) J0291 a. Short Descriptor: Inj., plazomicin, 5 mg b. Long Descriptor: Injection, plazomicin, 5 mg c. TOS: 1

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

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

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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

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. a. Short Descriptor: Inj. Calaspargase pegol-mknl b. b. Long Descriptor: Injection, calaspargase pegol-mknl, 10 units c. 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

22) J9269 a. Short Descriptor: Inj. tagraxofusp-erzs 10 mcg b. Long Descriptor: Injection, tagraxofusp-erzs, 10 micrograms c. TOS: 1


29 10/2019

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

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

30 10/2019


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

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

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


31 10/2019

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.

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

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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/R4396CP.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 September 18 2019 We revised the article to reflect the revised CR11422 issued on September

17. The revised CR had no impact on the content of the article. 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 16 2019 Initial article released.

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

MLN Matters Number: MM11003 Revised Related CR Release Date: April 16, 2019 Related CR Transmittal Number: R2281OTN Related Change Request (CR) Number: 11003 Effective Date: July 1, 2019 Implementation Date: July 1, 2019

Note: We revised this article on August 26, 2019, to reflect changes made to the eMDR registration screens within NPPES. The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs. In particular, the steps and screens relating to “Create new Endpoint Information in NPPES” and “Delete an existing Endpoint Information in NPPES” have been revised or added. A section discussing “Who should Register the endpoint information in NPPES” was also added. The NPPES updates result in no changes to the CR. All other information is unchanged.

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 11003 introduced the enrollment process for the providers who intend to get their Additional Documentation Request (ADR) letters electronically (as eMDR) through their registered Health Information Handler (https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html).


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Make sure your billing staffs are aware of these changes.

Background In response to a number of requests from Medicare providers, the Centers for Medicare & Medicaid Services (CMS) is adding the functionality to send ADR letters electronically. CMS conducted a pilot supporting the electronic version of the ADR letter known as Electronic Medical Documentation Request (eMDR) via the esMD system. Since the eMDRs may contain Protected Health Information (PHI) data being sent to the prospective provider, CMS will require a valid consent from the authorized individual representing the provider along with the destination details including any delegation to their associated or representing organizations such as Health Information Handlers (HIHs).

The article published as a part of CR 11003 (which follows) will educate providers on the steps to be performed in order to receive the ADR letter electronically as an eMDR.

MLN Article Information Attached to CR 11003 Terminology

• NPPES: National Plan and Provider Enumeration System

• eMDR: Electronic Medical Documentation Request. (Electronic form of ADR)

• esMD: Electronic Submission of Medical Documentation

• HIH: Health Information Handler

• RC: Review Contractor

• ADR: Additional Documentation Request

Timeline

• July 2019 - Providers can register to give their consent that an HIH of their choice can receive transactions on their behalf.

• January 2020 - Providers can receive eMDR (Pre or Post Pay) through their HIH and process the data systematically.

• April 2020 - Providers can receive the list of ‘Requested Documents for an ADR’ along with eMDR through their HIH.

CMS requires its review contractors to support sending ADR letters electronically as eMDRs. The following contractors are exempted from participation in the eMDR process:

• Payment Error Rate Measurement (PERM) contractors

• The Comprehensive Error Rate Testing (CERT) contractors (can opt to participate in the eMDR process)

• Quality Improvement Organizations (QIO) (can opt to participate in the eMDR process)

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• Unified Program Integrity Contractor (UPIC)

CMS is implementing systematic changes to esMD, for the providers to receive ADR letters (Pre/Post) electronically as eMDR. Advantages for the provider to receive eMDRs include:

• ADR letter data in an electronic format (eMDR) provides structured data that can be used for system processing

• Electronic ADR letter (as eMDR) reaches the provider faster and brings traceability to the exchange

• ADRs received electronically makes for efficient management of ADR requests and responses

Registration To receive the ADRs electronically as an eMDR via the esMD system:

• Provider must ensure that they have a Business Associate Agreement (BAA) in place with an HIH of their choice

• Provider must update the NPPES system to authorize their HIH to receive electronic transactions on their behalf (details mentioned below)

• HIH must complete additional processing steps after which the provider will receive eMDR

Points to Note for Registered Providers

1. eMDR (ADR letters sent via esMD) may have PHI data and requires:

• Consent from authorized individual to receive electronically

• Endpoint information where the eMDR has to be sent

• Active agreements between Provider and HIH, covering security and privacy requirements to handle PHI data

2. eMDR enrollment must use NPPES system to gather provider consent and endpoint information (only provider’s authorized individual has access to NPPES).

3. A provider (by NPI) must have an active agreement with one HIH at a time to send/receive data via esMD for all supported Lines of Businesses (LOBs).

4. A provider (by NPI) enrolling and registering for eMDR will receive ADR letters electronically via esMD from all RCs sending out ADR letters. CMS exempts PERM, CERT, UPIC, and QIO contractors from sending eMDRs.

5. A provider (by NPI) enrolling for eMDR is applicable to all its PTANs.

6. HIH shall complete additional processing steps after which provider receives eMDR (after January 2020).


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7. The eMDR registration process (new, HIH change or removal) is not effective until all process steps are completed without any discrepancies.

8. Provider is responsible to update NPPES with the latest HIH details.

9. A provider registering for the first time to receive eMDR will receive both electronically and by mail for the first three ADRs as a transition step.

10. A provider enrollment for MAC portals and DDE (Part A) are separate from eMDR enrollment and registration.

Create new ‘Endpoint Information’ in NPPES Provider Profile in NPPES (to be updated by the provider’s authorized person)

Step 1: Navigate to the main page after logging in. (https://nppes.cms.hhs.gov)

Step 2: Scroll down and click on the edit icon under the ‘Action’ column.

Step 3: Proceed to the ‘HEALTH INFORMATION EXCHANGE’ section.

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Step 4: Scroll down to ‘Endpoint for Exchanging Healthcare Information (optional)’ section and fill out the details as mentioned below the screen shot.

Provider shall enter the following information in NPPES:

• Endpoint Type: ‘Connect URL’

• Endpoint: [Website URL of the HIH] (to be provided by HIH)

• Endpoint Description: [HIH OID] (to be provided by HIH)

• Endpoint Use: ‘Other’

• Other Endpoint Use: ‘CMS esMD eMDR’


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Is this Endpoint affiliated to another Organization? (Here provider shall choose ‘Yes’ and enter all the details of the HIH) (If the provider themselves are HIHs then choose their own name and address)

• Affiliation: [Click on ‘Choose Affiliation’ and try to search the HIH name using ‘Organization name’ parameter]

If there are no results, enter the HIH organization name (to be provided by HIH) in the ‘Affiliated Organization Legal Business Name’ and Click Save. (Shown as below)

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• Endpoint location: [ If the HIH address is not part of the dropdown, Click on ‘Add New Endpoint Location’ and enter the HIH address] (to be provided by HIH)

Click Save.

Step 5: After all the details are entered on this screen, please check the terms and conditions check box and click ‘Save’.


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Delete an existing ‘Endpoint’ information in NPPES Step 1: After logging in to NPPES, Navigate to the “Health Information Exchange section” you will find all existing Endpoints listed in a grid (see screen shot below)

Step 2: To delete an Endpoint, click on the “Delete” icon in the “Action” column, the system will prompt the user, click “yes” to delete the Endpoint and add another one. Note : Users can only delete Endpoints. They cannot modify any end point. Use cases

1. A new enrollment and registration request.

• Provider - Provider shall enter an agreement with an HIH to accept eMDR on their behalf. An authorized user of the provider shall update the NPPES system with the HIH details.

• HIH - HIHs after getting a confirmation of the NPPES update shall send an eMDR enrollment request to esMD.

2. Removal of an eMDR registered provider (does not want ADRs electronically any more).

• Provider - An authorized user of the provider shall remove the HIH details from the NPPES system.

• HIH - HIHs after getting a confirmation of the NPPES deletion, shall send an eMDR remove request to esMD.

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3. Change from one HIH to the other (HIH1 to HIH2)

1. Provider - An authorized user of the provider shall remove HIH1 and add HIH2 details in the NPPES system.

2. HIH1 - HIH1 after getting a confirmation of the NPPES deletion, shall send an eMDR remove request to esMD.

3. HIH2 - HIH2 after getting a confirmation of the NPPES update shall send an eMDR enrollment request to esMD.

4. Who should Register the end point information in NPPES?

All Provider(s) or Provider Organizations who intends to receive the Additional Documentation Request (ADRs) electronically, via esMD, as a pre-requisite need to register in NPPES.

• Use Case A (Individual Providers)

In the current process a physical ADR letter is delivered to the provider ‘A’ with NPI 123X.

If the provider is willing to receive the ADRs electronically, then the provider must register in NPPES with the details of their End-Point who will receive the electronic ADRs on their behalf.

• Use Case B (Group Practices / Hospitals)

When a claim is submitted by a hospital or a group practice (for a provider), our assumption is, a physical ADR is being sent to the group practice or Hospital address and further gets dispersed to the intended Provider via internal communication mechanism.

If the group practice / Hospital is interested to receive ADRs electronically (on behalf of their provider(s), then the group practice / Hospital specific NPI shall be registered in NPPES.

Additional Information The official instruction, CR11003, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2281OTN.pdf. A detailed provider education document is attached to CR11003.

CMS will notify providers via MLN Matters articles If there are any changes to the process of registration.


For more information on esMD, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html.


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Document History

Date of Change Description August 26, 2019 We revised this article to reflect changes made to the eMDR registration

screens within NPPES. The article includes illustrations of the new screens that providers will have to complete in order to register to receive the eMDRs. In particular, the steps and screens relating to “Create new Endpoint Information in NPPES” and “Delete an existing Endpoint Information in NPPES” have been revised or added. A section discussing “Who should Register the endpoint information in NPPES” was also added. The NPPES updates result in no changes to the CR

April 17, 2019 We reissued this article to reflect an updated Change Request (CR) that added an MLN article attachment. The article is reissued to include the CR attachment (MLN article) in its entirety. The CR release date, transmittal number and link to the transmittal was also changed.

February 1, 2019 Initial article released.

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 4 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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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

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


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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.

COMPARATIVE BILLING REPORT (CBR) INFORMATION

Heart Failure and Shock Diagnostic Related Grouping (DRG codes 291-293)

This Comparative Billing Report (CBR) focuses on providers who submit claims for Heart Failure and Shock Diagnostic Related Grouping (DRG codes 291–293). CBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

Palmetto GBA has partnered with MCG, to proactively inform the provider community in regards to the implementation of care guidelines alongside data analysis to increase efficiency and lessen the need for readmission for same/similar diagnosis.

MCG’s Inpatient & Surgical Care guidelines provide evidence-based criteria and other tools for efficient review of utilization and documentation of medical necessity, making it a valuable resource for proactive care management and assessment of patients facing hospitalization or surgery. The guidelines are designed to be used in conjunction with a provider’s clinical judgment. Please visit MCG’s website for additional information at http://www.mcg.com.


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For your personalized Heart Failure and Shock DRG results log on to eServices at https://www.palmettogba.com/eServices.

Heart Failure and Shock Diagnostic Related Grouping (DRG’s 291–293) Defined

DRG Code

Description Category Subcategory

291 Heart Failure and Shock with Major Complication/ Comorbidity

Cardiovascular Non-Surgical

292 Heart Failure and Shock with Complication/ Comorbidity


293 Heart Failure and Shock without Complication / Comorbidity or /Major Complications/ Comorbidity


MethodsThe metrics reviewed in this CBR are the utilization for each DRG category and readmission rates in comparison to peer groups in the state and the jurisdiction. This report is an analysis of Medicare Part A claims extracted from the Palmetto GBA data warehouse.

A provider is considered to have a re-admission when a beneficiary has been admitted to a hospital under any diagnoses within 30-days after discharge from heart failure diagnoses under his care. The re-admission rate is calculated as number of re-admission over number of all admissions during the past six months. For the purpose of this CBR, “peer group” is defined as other providers in Jurisdiction M (JM) that have billed the grouping of DRG codes. The analysis shows the portions of your Heart Failure and Shock DRG claims at each level compared to your peers in JM.

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Example of eCBR Results from eServices


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ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION

Claim Status Category and Claim Status Codes Update


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 11393 updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Make sure your billing staffs are aware of these updates.

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee (NCMC) in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards. These standards were adopted under HIPAA for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s). Proprietary codes may not be used in the ASC X12 276/277 transactions to report claim status.

The NCMC meets at the beginning of each ASC X12 trimester meeting (January/February; June; and September/October) and makes decisions about additions, modifications, and retirement of existing codes. The NCMC allows the industry 6 months for implementation of newly added or changed codes.

The code sets are available at http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ and http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes . Specific details, including the date when a code was added, changed, or deleted, are included in the code lists. All code changes approved during the September/October 2019 NCMC meeting will be posted to above linked websites on or about November 1, 2019.

The Centers for Medicare & Medicaid Services (CMS) will issue notifications regarding the need for future updates to these codes. When instructed, MACs must update their claims systems to ensure that the current version of these codes is used in their claim status responses. The MACs and Medicare’s shared systems maintainers will make changes as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.

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These code changes are used in editing of all ASC X12 276 transactions processed on or after the implementation date and should be reflected in the ASC X12 277 transactions issued on an after CR 11393’s implementation date.

Note: References in CR 11393 to “277 responses,” and “Claim Status Responses,” encompass both the ASC X12 277 Health Care Claim Status Response and the ASC X12 277 Healthcare Claim Acknowledgement transactions.


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

Document History

Date of Change Description August 23, 2019 Initial article released.

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


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

Provider Action Needed CR 11394 instructs MACs and Medicare’s Shared System Maintainers (SSMs) to update systems based on the CORE 360 Uniform use of CARC, RARC and CAGC rule publication. These system updates are based on the CORE Code Combination List to be published on or about October 1, 2019. Make sure that your billing staffs are aware of these changes.


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Background The Secretary of Health and Human Services (HHS) adopted the Phase III CAQH CORE, EFT and ERA Operating Rule Set that was implemented on January 1, 2014 under the Affordable Care Act. The Health Insurance Portability and Accountability Act (HIPAA) amended the Social Security Act by adding Part C—Administrative Simplification—to Title XI of the Social Security Act, requiring the Secretary to adopt standards for certain transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information. Through the Affordable Care Act, Congress sought to promote implementation of electronic transactions and achieve cost reduction and efficiency improvements by creating more uniformity in the implementation of standard transactions. This was done by mandating the adoption of a set of operating rules for each of the HIPAA transactions.

CR 11394 deals with the regular update in CAQH CORE defined code combinations per Operating Rule 360 - Uniform Use of CARC and RARC (835) Rule.

CAQH CORE will publish the next version of the Code Combination List on or about October 1, 2019. This update is based on the CARC and RARC updates as posted at the Washington Publishing Company (WPC) website on or about July 1, 2019. This will also include updates based on market based review that CAQH CORE conducts once a year to accommodate code combinations that are currently being used by health plans including Medicare, as the industry needs them.

Visit http://www.wpc-edi.com/Reference for CARC and RARC updates and http://www.caqh.org/sites/default/files/core/phase-iii/code-combinations/CORE-required_CodeCombos.xlsx?token=_29xvBua for CAQH CORE defined code combination updates.

NOTE: All health plans including Medicare must comply with CORE 360 Uniform Use of CARCs and RARCs (835) rule or CORE developed maximum set of CARC/RARC and CAGC combinations for a minimum set of four (4) business scenarios. Medicare can use any code combination if the business scenario is not one of the four (4) CORE defined business scenarios. With the four (4) CORE defined business scenarios, Medicare must use the code combinations from the lists published by CAQH CORE.



Document History


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Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update

MLN Matters Number: MM11418 Related CR Release Date: August 23, 2019 Related CR Transmittal Number: R4371CP Related Change Request (CR) Number: 11418 Effective Date: January 1, 2020 Implementation Date: January 6, 2020 – MACs with capability to do so should implement effective October 1, 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 11418 advises the MACs to obtain the most recent Healthcare Provider Taxonomy Codes (HPTCs) code set and use it to update their internal HPTC tables and, or reference files. Please make sure your billing staffs are aware of these changes.

Background The National Uniform Claim Committee (NUCC) maintains the HPTC codes set for standardized classification of health care providers. The NUCC updates the code set twice per year with changes effective April 1 and October 1. The HPTC list is available for review or download from the NUCC website at www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40.

The changes to the code set include the addition of a new code and addition of definitions to existing codes. When reviewing the HPTC code set online, revisions made since the last release are identifiable by the following color code:

• New items are green

• Modified items are orange

• Inactive items are red

Note: When reviewing the HPTC code set online, revisions made since the last release are identified. The Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to comply with requirements in the electronic transaction format implementation guides adopted as national standards. The institutional and professional claim electronic standard implementation guides (X12 837-I and 837-P) each require use of valid codes contained in the HPTC set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.


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Please Note:

• Valid HPTCs are those codes approved by the NUCC for current use

• Terminated codes are not approved for use after a specific date and newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears

• Specialty and/or provider type codes issued by any entity other than the NUCC are not valid

• Medicare would be guilty of non-compliance with HIPAA if MACs accepted claims that contain invalid HPTCs

Although the NUCC generally posts their updates on the Washington Publishing Company (WPC) web page three months prior to the effective date, changes are not effective until April 1 or October 1 as indicated in each update.



Document History


ESERVICES INFORMATION

Do You Have a Question Regarding eServices? We Can Help!

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

To connect with an eServices representative:

• Press/say 1 or EDI

• Press/say 2 for all other calls

• Press/say 1 or eServices

https://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_Flowchart.pdf/$File/IVR_Flowchart.pdf

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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

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!


55 10/2019

FEE SCHEDULE INFORMATION

October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

MLN Matters Number: MM11433 Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4386CP Related Change Request (CR) Number: 11433 Effective Date: September 1, 2019 for implementation of fees for code E0766; October 1, 2019 for all other changes Implementation: October 7, 2019

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

What You Need To Know CR 11433 informs DME MACs about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. Make sure your billing staff are aware of these changes.

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

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

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The methods for adjusting DMEPOS fee schedule amounts under this authority are at 42 CFR Section 414.210(g). Additional information on adjustments to the fee schedule amounts based on information from CBPs is available in:

1. Transmittal 3551, Change Request (CR) 9642, June 23, 2016: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9642.pdf

2. Transmittal 3416, CR 9431, November 23, 2015: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9431.pdf

3. Transmittal 4209, CR 11064, January 18, 2019: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11064.pdf. Also, CR 11064 provides information on the adjusted fee payment basis for items and services furnished from January 1, 2019,through December 31, 2020, in the following three areas:

• Rural and noncontiguous non-Competitive Bidding Areas (CBAs)

• Non-rural and contiguous non-CBAs

• Former CBAs during a temporary gap in the DMEPOS CBP

Because of a delay in the announcement of the next round of the CBP, contracts will not be in effect in Round 1, Round 2, or the National Mail Order CBAs beginning January 1, 2019, resulting in a temporary gap period in the CBP. Additional program instructions for payment of items furnished in former CBAs is available in Transmittal 4275, CR 11233, and dated April 5, 2019. See the related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11233.pdf.

Fee Schedule and ZIP Code Files CR 11433 provides instructions for the October 2019 DMEPOS Rural ZIP code file containing the Quarter 4 2019 Rural ZIP code changes. Also, in the update is the Former CBA ZIP code file containing the Quarter 4, 2019, Round 1 2017, and Round 2 Re-compete CBA ZIP codes.

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

The ZIP code associated with the permanent address of the beneficiary determines the applicability of the adjusted fee schedule amounts in former CBAs. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes for Round 1 2017 and Round 2 Re-compete CBAs and will be updated on a quarterly basis as necessary.


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The following DMEPOS fee schedule and ZIP code Public Use Files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the data files on the CMS Website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/index.html

1. DMEPOS FeeschedulePUF

2. DME PEN FeeschedulePUF

3. DME RuralcodePUF

4. Former CBA FeeschedulePUF

5. Former CBA National Mail Order Diabetic Testing Supply (DTS) FeeschedulePUF

6. Former CBA ZIPcodePUF

Specific Coding and Pricing Issues As part of this update, the fee schedule amounts for the HCPCS code E0766 (electrical stimulation device used for cancer treatment, includes all accessories, any type) is included in the DMEPOS fee schedule file effective September 1, 2019. Suppliers should add the Class III ‘KF’ modifier when billing HCPCS code E0766.



Document History


58 10/2019


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.

HOSPITAL INFORMATION

Billing for Hospital Part B Inpatient Services

MLN Matters Number: MM11413 Related CR Release Date: September 13, 2019 Related CR Transmittal Number: R4394CP Related Change Request (CR) Number: 11413 Effective Date: October 1, 2013 Implementation Date: October 15, 2019


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Provider Types Affected This MLN Matters Article is for hospital providers billing Medicare Administrative Contractors (MACs) for Part B inpatient services provided to Medicare beneficiaries.

What You Need To Know CR 11413 reminds MACs of the policy regarding billing instructions for hospital Part B inpatient service claims, including the allowance of Revenue Code 0240 on 012x Type of Bills (TOB). No policy is being updated. Be sure your billing staffs are aware of this billing instruction.

Background Medicare pays for hospital (including Critical Access Hospitals (CAH)) inpatient Part B services in the circumstances provided in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 6, Section 10 (“Medical and Other Health Services Furnished to Inpatients of Participating Hospitals”) (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c06.pdf). Hospitals must bill Part B inpatient services on a 12x Type of Bill. A/B MACs (Part A) should be aware of the policy regarding billing for hospital Part B inpatient service claims, including the allowance of Revenue Code 0240 on 012x Type of Bills (TOB). This Part B inpatient claim is subject to the statutory time limit for filing Part B claims described in the Medicare Claims Processing Manual, Chapter 1, Section 70 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). No policy is being updated.

Also, note that the revised manual section that is part of CR 11413 points out that Revenue Code 0942 is used by rural hospitals for kidney disease education (KDE) services. The actual geographic location, core based statistical area (CBSA) is used to identify facilities located in rural areas. Also, Medicare covers KDE services on claims from section 401 hospitals. Additionally, models may allow this Revenue Code.

Additional Information The official instruction, CR 11413, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2019Downloads/R4394CP.pdf.


Document History


60 10/2019


October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN Matters Number: MM11451 Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4387CP Related Change Request (CR) Number: 11451 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Provider Types Affected This MLN Matters article is for hospital outpatient facilities, physicians, providers, including home health and hospice providers, and suppliers billing Medicare Administrative Contractors (MACs) for hospital outpatient services provided to Medicare beneficiaries.

Provider Action Needed CR 11451 describes changes to and billing instructions for various payment policies that Medicare is implementing in the October 2019 Outpatient Prospective Payment System (OPPS) update. Make sure your billing staffs are aware of these changes.

Background The October 2019 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 11451.

The October 2019 revisions to I/OCE data files, instructions, and specifications are provided in the October 2019 I/OCE CR, which will be available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4383CP.pdf.

1. CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective Oct 1, 2019 The American Medical Association (AMA) CPT Editorial Panel deleted one PLA code (0104U) and established 34 new PLA codes (CPT codes 0105U-0138U), effective October 1, 2019. Table 1 lists the long descriptors and status indicators for the codes.

For more information on OPPS status indicators “A,” “D,” “E1,” “N,” and “Q4,” refer to OPPSAddendum D1 of the Calendar Year (CY) 2019 OPPS/ASC final rule for the latest definitions. CPT codes 0105U-0138U are in the October 2019 I/OCE with an effective date of October 1, 2019.

CPT Code Long Descriptor OPPS SI OPPS APC

0104U Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only])

D N/A


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0105U 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)

Q4 N/A

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

Q4 N/A

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

Q4 N/A

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

Q4 N/A

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

A N/A

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

Q4 N/A

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

A N/A

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

A N/A

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

A N/A

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

A N/A

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

A N/A

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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

Q4 N/A

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

Q4 N/A

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

A N/A

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

Q4 N/A

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

A N/A

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

Q4 N/A

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

Q4 N/A

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

Q4 N/A

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

E1 N/A

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

Q4 N/A


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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

Q4 N/A

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

Q4 N/A

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

Q4 N/A

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

A N/A

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) (List separately in addition to code for primary procedure)

N N/A

0131U Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure)

N N/A

0132U Hereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure)

N N/A

0133U Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)

N N/A

0134U Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure)

N N/A

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0135U Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure)

N N/A

0136U ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

0137U PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

2. New CPT Category II Codes Effective October 1, 2019 For the October 2019 update, the Centers for Medicare & Medicaid Services (CMS) is implementing five new CPT Category II codes that the AMA released on July 8, 2019, for implementation on October 1, 2019. New CPT codes 2023F, 2025F, 2033F, 3051F, and 3052F are in the October 2019 I/OCE with an effective date of October 1, 2019.

Also, the AMA is revising the code descriptors for CPT codes 2022F, 2024F, 2026F, and deleting 3045F on September 30, 2019. The status indicators and APC assignments for the codes are shown in Table 2 These codes, along with their short descriptors, status indicators, and payment rates are listed in the October 2019 OPPS Addendum B that is posted at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html. For information on the OPPS status indicator “M”, refer to OPPS Addendum D1 of the CY 2019 OPPS/ASC final rule for the latest definition.

Table 2: New, Revised, and Deleted CPT Category II Codes

CPT Code Status Long Descriptor OPPSSI

OPPSAPC

2022F REVISE Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)2

M N/A

2023F NEW Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)2

M N/A

2024F REVISE 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)2

M N/A


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2025F NEW 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)2

M N/A

2026F REVISE Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (DM)2

M N/A

2033F NEW Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy (DM)2

M N/A

3045F DELETE Most recent hemoglobin A1c (HbA1c) level 7.0–9.0% (DM)

D N/A

3051F NEW Most recent hemoblobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% (DM)

M N/A

3052F NEW Most recent hemoblobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% (DM)2

M N/A

3. Advanced Diagnostic Laboratory Tests (ADLT) Under the Clinical Lab Fee Schedule (CLFS) On May 17, 2019, CMS announced the approval of three laboratory tests as ADLTs under paragraph (1) of the definition of an ADLT in 42 CFR Section 414.502. CMS notes that under the OPPS, tests that receive ADLT status under Section 1834A(d)(5)(A) of the Social Security Act (the Act) are assigned to status indicator “A.” These laboratory tests are listed in Table 3.

Based on the ADLT designation, CMS revised the OPPS status indicator for HCPCS codes 0080U and 81599 to “A” (Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS) effective July 1, 2019. However, because the ADLT designation was made in May 2019, it was too late to include this change in the July 2019 I/OCE Release and the July 2019 OPPS update; therefore, we are including this change in the October 2019 I/OCE Release with an effective date of July 1, 2019.

Note that the DecisionDx-UM test, as described by HCPCS code 0081U, was also approved for ADLT status on May 17, 2019, however it was already assigned OPPS SI “A” based on being a molecular pathology test.

The latest list of ADLTs under the CLFS is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/List-of-Approved-ADLTs.pdf. For more information on the OPPS status indicator “A”, refer to OPPS Addendum D1 of the CY 2019 OPPS/ASC final rule for the latest definitions.

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Table 3: ADLT Codes and Long Descriptors

Lab Name Test Name CPT Code CPT Code Long DescriptorBiodesix BDX-XL2 0080U Oncology (lung), mass spectrometric analysis of

galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy

Castle BioSciences, Inc.

DecisionDX-Melanoma

81599* Unlisted multianalyte assay with algorithmic analysis

Castle BioSciences Inc.

DecisionDx-UM

0081U Oncology (uveal melanoma), mRNA, gene‐expression profiling by real‐time RT‐PCR of 15 genes (12 content and 3 housekeeping genes), utilizing fine needle aspirate or formalin‐fixed paraffin‐embedded tissue, algorithm reported as risk of metastasis.

4. Drugs, Biologicals, and Radiopharmaceuticals

a. HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals with Pass-through Status For October 2019, two HCPCS codes have received pass-through status for reporting drugs and biologicals in the hospital outpatient setting. These new codes are in Table 4.

Table 4: Codes Receiving Pass-Through Status

HCPCS Code

Long Descriptor SI APC

J3111 Injection, romosozumab-aqqg, 1 mg G 9327J9356 Injection, trastuzumab, 10 mg and

Hyaluronidase-oysk G 9314

b. Separately Payable Drugs and Biologicals that Will Receive Pass-Through Status (Status Indicator = “G”) for the Period of April 1, 2019, Through June 30, 2019 The status indicator for HCPCS code C9042 (Injection, bendamustine hcl (belrapzo), 1 mg) for the period of April 1, 2019, through June 30, 2019, will be changed retroactively from status indicator = “E2” to status indicator = “G.” This drug is in Table 5.


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Table 5: C9042 Updated Status Indicator

HCPCS Code

Long Descriptor OldSI

New SI

APC

C9042 Injection, bendamustine hcl (belrapzo), 1 mg

E2 G 9313

c. Drugs and Biologicals that Will Change from Non-Payable Status (Status Indicator = “E2”) to Separately Payable Status (Status Indicator = “K”) for the Period of July 18, 2019, through September 30, 2019 The status indicator for HCPCS code Q5107 (Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg) for the period of July 18, 2019, through September 30, 2019, will be changed retroactively from status indicator = “E2” to status indicator = “K”. This drug is in Table 6.

Table 6: Q5107 Updated Status Indicator

HCPCS Code

Long Descriptor OldSI

New SI

APC

Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

E2 K 9329

d. New Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of October 1, 2019 There are 45 new drug, biological, and radiopharmaceutical HCPCS codes that will be established on October 1, 2019. The new codes are in Table 7.

Table 7: New Drug, Biological, and Radiopharmaceutical Codes to be Established on October 1, 2019

New HCPCS

Code

Old HCPCS

Code

Long Descriptor SI APC

J1943 C9035 Injection, aripiprazole lauroxil (aristada initio), 1 mg G 9179J0222 C9036 Injection, Patisiran, 0.1 mg G 9180J2798 C9037 Injection, risperidone, (perseris), 0.5 mg G 9181J9204 C9038 Injection, mogamulizumab-kpkc, 1 mg G 9182J0291 C9039 Injection, plazomicin, 5 mg G 9183J3031 C9040 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)

G 9197

J0641 C9043 Injection, levoleucovorin, 0.5 mg G 9323

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J9119 C9044 Injection, cemiplimab-rwlc, 1 mg G 9304J9313 C9045 Injection, moxetumomab pasudotox-tdfk, 0.01 mg G 9305J1096 C9048 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg G 9308J9269 C9049 Injection, tagraxofusp-erzs, 10 micrograms G 9309J9210 C9050 Injection, emapalumab-lzsg, 1 mg G 9310J0121 C9051 Injection, omadacycline, 1 mg G 9311J1303 C9052 Injection, ravulizumab-cwvz, 10 mg G 9312J1097 C9447 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/

ml ophthalmic irrigation solution, 1 ml G 9324

J0122 Injection, eravacycline, 1 mg K 9325J0593 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)

K 9326

J1944 J1942 Injection, aripiprazole lauroxil, (aristada), 1 mg K 9470J7314 Injection, fluocinolone acetonide, intravitreal implant

(Yutiq), 0.01 mgK 9470

J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg

E2 N/A

J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg

E2 N/A

J9118 Injection, calaspargase pegol-mknl, 10 units E2 N/AQ4205 Membrane graft or membrane wrap, per square

centimeter N N/A

Q4206 Fluid flow or fluid GF, 1 cc N N/AQ4208 Novafix, per square centimeter N N/AQ4209 Surgraft, per square centimeter N N/AQ4210 Axolotl graft or axolotl dualgraft, per square

centimeter N N/A

Q4211 Amnion bio or Axobiomembrane, per square centimeter

N N/A

Q4212 Allogen, per cc N N/AQ4213 Ascent, 0.5 mg N N/AQ4214 Cellesta cord, per square centimeter N N/AQ4215 Axolotl ambient or axolotl cryo, 0.1 mg N N/AQ4216 Artacent cord, per square centimeter N N/AQ4217 Woundfix, BioWound, Woundfix Plus, BioWound

Plus, Woundfix Xplus or BioWound Xplus, per square centimeter

N N/A

Q4218 Surgicord, per square centimeter N N/AQ4219 Surgigraft-dual, per square centimeter N N/A


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Q4220 BellaCell HD or Surederm, per square centimeter N N/AQ4221 Amniowrap2, per square centimeter N N/AQ4222 Progenamatrix, per square centimeter N N/AQ4226 MyOwn skin, includes harvesting and preparation

procedures, per square centimeter N N/A

Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

K 9329

Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg

E2 N/A

Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg

K 9330

Q5118 Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mg

E2 N/A

J7401 S1090 Mometasone furoate sinus implant, 10 micrograms N N/A

e. Ambulatory Payment Classification (APC) Assignment Change for HCPCS code J9030, BCG live intravesical instillation, 1 mg, Effective July 1, 2019, in the October 2019 I/OCE Release

See Table 8 for the APC assignment change for HCPCS code, J9030, effective July 1, 2019, in the October 2019 I/OCE Release.

Table 8: J9030 – APC Assignment Change

HCPCS Code Long Descriptor Old APC Assignment

New APC Assignment

Effective Date

J9030 BCG live intravesical instillation, 1 mg

0809 9322 07/01/19

f. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) For CY 2019, payment for nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that were not acquired through the 340B Program is made at a single rate of ASP + 6 percent (or ASP - 22.5 percent if acquired under the 340B Program), which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug, biological, or therapeutic radiopharmaceutical. In CY 2019, a single payment of ASP + 6 percent for pass-through drugs, biologicals, and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items.

Payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later-quarter ASP submissions become available. Effective October 1, 2019, payment rates for some drugs and biologicals have changed from the values published in the July 2019 update of the OPPS Addendum A and Addendum B. CMS is not publishing the updated payment rates in this CR implementing the October 2019 update of the OPPS. However, the updated payment rates effective October 1, 2019, can be found in the October 2019 update of the OPPS Addendum A and Addendum B on the CMS website at http://www.cms.gov/HospitalOutpatientPPS/.

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g. Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates Some drugs and biologicals based on ASP methodology will have payment rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected payments rates will be accessible on the CMS website on the first date of the quarter at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates.html. Providers may resubmit claims that were impacted by adjustments to previous quarter’s payment files.

5. Clarification on the Guidance for Intraocular or Periocular Injections of Combinations of Anti- Inflammatory Drugs and Antibiotics On September 15, 2015, CMS issued CR 9298 (Transmittal R3352CP), which provided guidance for “dropless cataract surgery.” (See related MLN Matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9298.pdf. CR 11451 is a clarification to CR 9298 on “dropless cataract surgery.” Intraocular or periocular injections of combinations of anti-inflammatory drugs and antibiotics are being used with increased frequency in ocular surgery (primarily cataract surgery). One example of combined or compounded drugs includes, triamcinolone and moxifloxacin with or without vancomycin. Such combinations may be administered as separate injections or as a single combined injection. Because such injections may obviate the need for post-operative anti-inflammatory and antibiotic eye drops, some have referred to cataract surgery with such injections as “dropless cataract surgery.” However, nothing in this CR is intended to preclude physicians or other professionals from discussing the potential benefits and drawbacks of dropless therapy with their patients and prescribing it if the patient so elects.

6. OPPS Pricer logic and data changes for October There are no OPPS PRICER logic or data changes for October; therefore, there is no OPPS PRICER release for October.

7. Coverage Determinations As a reminder, the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.




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Document History


Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004

MLN Matters Number: MM10484 Related CR Release Date: September 6, 2019 Related CR Transmittal Number: R2357OTN Related Change Request (CR) Number: 10484 Effective Date: December 9, 2019 Implementation Date: December 9, 2019

Provider Types Affected This MLN Matters Article is for hospitals participating in the Disproportionate Share Hospital (DSH) program and bill Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 10484 directs MACs to inform hospitals of the additional instructions for making an election for a particular fiscal period covered by the Centers for Medicare & Medicaid Services’ (CMS) Ruling 1498-R (as modified by CMS Ruling 1498-R2). Please make sure your cost report staffs are aware of these instructions.

Background On April 28, 2010, the Administrator of CMS issued CMS Ruling 1498-R, which addressed administrative appeals on three different issues related to Medicare DSH payment, which included the following:

1. The Medicare-Supplementary Security Income (SSI) fraction data-matching process issue, and the method for recalculating the hospital’s Medicare-SSI fraction by matching Medicare and SSI entitlement data

2. The exclusion from the Medicare fraction and the numerator of the Medicaid fraction of non-covered inpatient hospital days for patients entitled to Medicare Part A, including days for which the patient’s Part A inpatient hospital benefits were exhausted

3. The exclusion from the DSH calculation of labor/delivery room (LDR) inpatient days. On April 22, 2015, the Administrator of CMS issued CMS Ruling 1498-R2, which effectively amended CMS Ruling 1498-R.

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The modification and amendment of CMS Ruling 1498-R affects a change only with respect to the relief that is available for revised Medicare-SSI fractions, and the interaction between Medicare-SSI fractions suitably revised to address the data-matching process issue and the issue of Medicare Part A non-covered or exhausted benefit days (“dual-eligible non-covered days”) for cost-reporting periods involving patient discharges before October 1, 2004.

Section 9105 of the Consolidated Omnibus Budget Reconciliation Act of 1985 provides that for discharges occurring on or after May 1, 1986, an additional payment must be made to Inpatient Prospective Payment System (IPPS) hospitals serving a disproportionate share of low-income patients. The additional payment is determined by multiplying the Federal portion of the Diagnosis-Related Group (DRG) payment by the DSH adjustment factor. (See 42 CFR 412.106, at https://www.gpo.gov/fdsys/pkg/CFR-2013-title42-vol2/pdf/CFR-2013-title42-vol2-sec412-106.pdf.)

Prior to the implementation of the fiscal year (FY) 2005 IPPS final rule, inpatient days were included in the numerator of the Medicare-SSI fraction only if the inpatient hospital days were “covered” under Medicare Part A and the patient was entitled to SSI benefits. Part A coverage of inpatient days alone was required for inclusion in the denominator of the Medicare-SSI fraction.

The FY 2005 IPPS final rule amended the DSH regulations by eliminating the requirement that Part A inpatient hospital days must be covered for such days to be included in the Medicare-SSI fraction and made clear that patient days were to be included in that fraction if the patient was entitled to Medicare Part A. See the FY 2005 IPPS final rule (69 FR 49246) (revising 42 CFR 412.106(b)(2)(i)).

Under this revised policy, the inpatient days of a person who was entitled to Medicare Part A are included in the numerator of the hospital’s Medicare-SSI fraction (provided that the patient was also entitled to SSI at that time) and in the Medicare-SSI fraction denominator, regardless of whether the individual’s inpatient hospital stay was covered under Part A or whether the patient’s Part A hospital benefits were exhausted. The FY 2005 IPPS final rule revision to the DSH regulations was effective for patient discharges occurring on or after October 1, 2004 (69 FR 49099).

CMS issued Ruling 1498-R2 on April 22, 2015, and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/CMS-Rulings-Items/CMS1498-R2.html .CMS Ruling 1498-R2 provided notice of CMS’ determination that CMS Ruling 1498-R shall be amended regarding its remedy for recalculation of certain Medicare DSH payment adjustments.

CMS Ruling 1498-R required the Provider Reimbursement Review Board (PRRB) and other Medicare administrative appeals tribunals to remand each qualifying appeal to the appropriate Medicare contractor.

CMS Ruling 1498-R further explained how CMS and Medicare contractors were to recalculate the provider’s DSH adjustment resolving any of the three different DSH issues. CMS and the Medicare contractor also were to apply the provisions of CMS Ruling 1498-R on all three DSH issues, to each qualifying hospital cost reporting period where the contractor had not yet final settled the provider’s Medicare cost report. CMS Ruling 1498-R2 is a modification and amendment of CMS Ruling 1498-R, but only in so far as CMS Ruling 1498-R2 requires an election with respect to the Medicare-SSI component of


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the DSH payment adjustment for cost reports that involve SSI ratios for Federal FY 2004 and earlier, or SSI ratios for hospital cost-reporting periods, but only for those patient discharges occurring before October 1, 2004.

CMS issued CR 9896 on December 16, 2016, which provided instructions to hospitals on exercising an election for cost-reporting periods subject to CMS Ruling 1498-R and the amendment in CMS Ruling 1498-R2.

Specifically, CR 9896 stated that a provider may elect whether to receive a suitably revised Medicare-SSI fraction based on “covered days,” or “total days,” for hospital cost-reporting periods that involve SSI ratios for Federal FY 2004 and earlier, or SSI ratios for hospital cost-reporting periods, but only for those patient discharges occurring before October 1, 2004. This election is available for hospital cost-reporting periods where the Medicare contractor has not yet final settled the provider’s Medicare cost report, as well as appeals remanded to the contractor pursuant to CMS Ruling 1498-R. The election is also available for hospital cost-reporting periods previously reopened specifically on the Medicare-SSI fraction issue – neither CMS Ruling 1498-R nor the amendment in CMS Ruling 1498-R2 required reopening.

However, 42 CFR 412.106(b)(3) allows hospitals the opportunity to request to have its Medicare-SSI fraction realigned based on its cost-reporting period (as opposed to the Federal FY). Therefore, in lieu of an election, many hospitals requested that the Notice of Amount Program Reimbursement (NPR)/revised NPR based on its Federal FY for cost-reporting periods subject to this CR be delayed until they:

1. Review the patient-level detail supporting CMS’ calculation of the revised ratios for the Federal FYs encompassing the hospitals’ cost-reporting period(s), or

2. Request that the revised Medicare-SSI fraction be calculated for the discharge occurring in the hospitals’ own cost-reporting period(s).

If a hospital wishes to review its patient-level data to determine if it wants to elect a realigned Medicare-SSI fraction, the hospital shall notify the Medicare contractor in writing within 30 days from the date of this CR so that issuance of an NPR/revised NPR with a revised Medicare-SSI fraction calculated based on the Federal FY is placed on hold. The hospital should notify the Medicare contractor within 180 calendar days of its request to place the cost report on hold as to whether it wants to:

• Submit a request for a realigned Medicare-SSI fraction, or

• Settle the cost report with a revised Medicare-SSI fraction based on the Federal FY.

If a hospital fails to meet this deadline, the Medicare contractor shall issue an NPR/revised NPR based on the higher (total or covered) of the Federal FY ratios for that hospital using the FY ratios from the CMS website for the relevant FYs. The provider may subsequently request alignment using normal timelines and procedures.

Also, if a hospital previously received an initial NPR/revised NPR with a revised Medicare-SSI fraction calculated based on the Federal FY, the hospital may request realignment, based on the revised Medicare-SSI fraction, within the normal timeframes.

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Additional Information The official instruction, CR10484, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2357OTN.pdf.


Document History

Date of Change Description September 9, 2019 Initial article released

Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004 (Entire Change Request)

To view CR 10484/Transmittal 2357 in its entirety, please go to the next page.


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INFLUENZA VACCINE INFORMATION

It’s Flu season again - Use Medicare Beneficiary Identifiers to Bill Medicare

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (https://www.congress.gov/bill/114th-congress/house-bill/2/text) requires The Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards. CMS mailed new cards to all people with Medicare which have randomly generated Medicare Beneficiary Identifiers (MBIs) (https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf) instead of SSN-based Health Insurance Claim Numbers (HICNs).

Use MBIs to check eligibility and bill for influenza vaccinations to protect Medicare beneficiaries’ personal identities. Get the MBI:

• Ask your patients for their cards. If they did not 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)

• 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.

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 https://www.mymedicare.gov/ to get the MBI.

If the lookup 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.

• Check the remittance advice. CMS included the new MBI on the remittance advice for each claim you submitted with a valid and active HICN since October, 2018, and will continue to return MBIs through December 31, 2019. Get the MBI from the remittance advice, save it in your systems, and use it to bill for this year’s flu vaccinations.

Tips for using MBIs:

• Don’t use hyphens or spaces to avoid rejection of your claim

• MBIs use 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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Starting January 1, 2020, you must use the MBI:

• We will reject claims you submit with HICNs with a few exceptions (https://www.cms.gov/Medicare/New-Medicare-Card/index.html)

• We will reject all eligibility transactions you submit with HICNs

For more information, please review CMS’ New Medicare Beneficiary Identifier (MBI), Get It, Use It article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf).

Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season

MLN Matters Number: MM11428 Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4382CP Related Change Request (CR) Number: 11428 Effective Date: August 1, 2019 Implementation Date: No later than October 1, 2019

Provider Types Affected This MLN Matters Article is for physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for influenza vaccines provided to Medicare Beneficiaries.

Provider Action Needed CR 11428 informs MACs about payment allowances for influenza virus vaccines, which are updated on August 1 of each year. The Centers for Medicare & Medicaid Services (CMS) will post the payment allowances for influenza vaccines that are approved after the release of CR 11428 at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html. Make sure your billing staffs are aware of the payment allowances for the 2019-2020 season.

Background Medicare bases seasonal influenza vaccines payment on 95 percent of the Average Wholesale Price (AWP). The Medicare Part B payment allowances apply for the dates indicated as effective dates on the website mentioned above. CMS will provide payment allowances for codes for which products have not yet been approved when the products have been approved and pricing information becomes available to CMS.

Also, CMS bases the payment allowances for pneumococcal vaccines on 95 percent of the AWP and CMS updates these allowances on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug Pricing Files.

The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the AWP, as reflected in the published compendia, except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). Where the

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vaccine is furnished in the hospital outpatient department, RHC, or FQHC, payment for the vaccine is based on reasonable cost. Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.

Note that effective for dates of service 8/1/2019 - 7/31/2020, unless otherwise specified, MACs will determine the Medicare Part B payment allowance for HCPCS Q2039.

Note that MACs will reprocess any previously processed and paid claims for the current flu season that were paid using influenza vaccine payment allowances other than the allowances published in the influenza vaccine pricing website for the 2019/2020 season, which began on August 1, 2019. This reprocessing should occur by November 1, 2019.



Document History


2019-2020 Influenza (Flu) Resources for Health Care Professionals


Provider Types Affected All health care professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries and submit bills for these services to Medicare Administrative Contractors (MACs).

Provider Action Needed Special Edition (SE) MLN Matters article SE19022 provides information about influenza (flu) resources for health care professionals and providers relevant to the 2019-2020 flu season. Health care professionals should:

• Keep this article and refer to it throughout the 2019-2020 flu season.


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• Take advantage of each office visit as an opportunity to encourage patients to protectthemselves from the flu and serious complications by getting a flu shot.

• Continue to provide the flu shot if you have vaccine available, even after the new year.

• Remember to immunize yourself and your staff.

Background The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare Part B reimburses health care providers for flu vaccines and their administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies).

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious complications by using every office visit as an opportunity to recommend they take advantage of Medicare’s coverage of the annual flu shot. As a reminder, please help prevent the spread of the flu by immunizing yourself and your staff! Know What to Do About the Flu!

Payment Rates for 2019-2020 Each year, CMS updates the Medicare Healthcare Common Procedure Coding System (HCPCS) and Current Procedure Terminology (CPT) codes and payment rates for personal flu and pneumococcal vaccines. Payment allowance limits for such vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). In these cases, the payment for the vaccine is based on reasonable cost.

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.

The following table contains the applicable Medicare Part B payment allowances for HCPCS and CPT codes:

Code Labeler Name Drug Names Payment Allowance

Effective Dates

90653 Seqirus Inc Fluad (2019/2020) $59.530 08/01/2019 – 07/31/2020

90662 Sanofi Pasteur Fluzone High-Dose (2019/2020)

$56.006 08/01/2019 – 07/31/2020

90672 MedImmune FluMist Quadrivalent (2019/2020

$26.876 08/01/2019 – 07/31/2020

90674 Seqirus Inc Flucelvax Quadrivalent (2019/2020) (Pres Free)

$28.130 08/01/2019 – 07/31/2020

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90682 Sanofi Pasteur Flublok Quadrivalent (2019/2020)

$56.006 08/01/2019 – 07/31/2020

90685 Sanofi Pasteur Seqirus

Fluzone Quadrivalent 0.25ml (2019/2020) (Pres Free) Afluria Quadrivalent 0.25ml (2019/2020) (Pres Free)

$20.343 08/01/2019 – 07/31/2020

90686 GlaxoSmithKline Seqirus Inc Sanofi Pasteur

Fluarix Quadrivalent (2019/2020) (Pres Free), Flulaval Quadrivalent (2019/2020) (Pres Free), Fluzone Quadrivalent (2019/2020) (Pres Free) Afluria Quadrivalent (2019/2020) (Pres Free)

$19.032 08/01/2019 – 07/31/2020

90687 Sanofi Pasteur Seqirus

Fluzone Quadrivalent 0.25ml (2019/2020) Afluria Quadrivalent 0.25ml (2019/2020)

$9.403 08/01/2019 – 07/31/2020

90688 GlaxoSmithKline, Seqirus Inc, Sanofi Pasteur

Flulaval Quadrivalent (2019/2020), Fluzone Quadrivalent (2019/2020), Afluria Quadrivalent (2019/2020)

$17.835 08/01/2019 – 07/31/2020

90756 Seqirus Flucelvax Quadrivalent (2019/2020)

$26.657 08/01/2019

If the Food and Drug Administration approves any new vaccine after publication of this article, CMS will post the payment limits and effective dates for those vaccines at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html.

Background on influenza vaccine payment allowances for 2019/2020 is in MM11428, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11428.pdf. Note: MACs will reprocess any previously processed and paid claims for the current flu season that were paid using influenza vaccine payment allowances other than the allowanced published in the influenza vaccine pricing website for the 2019/2020 season that began on August 1, 2019. This reprocessing should occur by November 1, 2019.



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Educational Products for Health Care Professionals

The Medicare Learning Network® (MLN) has developed a variety of educational resources to help you understand Medicare guidelines for seasonal flu vaccines and their administration.

1. MLN Influenza Related Products for Health Care Professionals

• Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B educational tool - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf

• Medicare Preventive Services educational tool - https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

• Mass Immunizers and Roster Billing for Influenza Virus and Pneumococcal Vaccinations booklet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf

2. Other CMS Resources

• Provider Resources webpage - https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources.html

• Prevention Services webpage - http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html

• Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

• Medicare Claims Processing Manual - Chapter 18, Preventive and Screening Services http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

3. Other ResourcesThe following non-CMS resources are useful information and tools for the 2019 – 2020 flu season:

• Advisory Committee on Immunization Practices - http://www.cdc.gov/vaccines/acip/index.html

• Centers for Disease Control and Prevention - http://www.cdc.gov/flu

• Flu.gov - http://www.flu.gov

• Food and Drug Administration - http://www.fda.gov

• Immunization Action Coalition - http://www.immunize.org

• Indian Health Services - http://www.ihs.gov

• National Alliance for Hispanic Health - http://www.hispanichealth.org

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• National Foundation For Infectious Diseases - http://www.nfid.org/influenza

• National Library of Medicine Medline Plus - http://www.nlm.nih.gov/medlineplus/immunization.html

• HHS.gov Vaccines and Immunization - http://www.hhs.gov/nvpo

• Office of Disease Prevention and Health Promotion - http://healthfinder.gov/FindServices/Organizations/Organization/HR2013/office-of-disease-prevention-and-health-promotion-us-department-of-health-and-human-services

• World Health Organization - http://www.who.int/en

Document History



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INPATIENT REHABILITATION FACILITY (IRF) INFORMATION

Inpatient Rehabilitation Facility Prospective Payment System Booklet – Revised

A revised Inpatient Rehabilitation Facility Prospective Payment System Booklet is available. Learn about:

• How payments are determined

• Fiscal year updates

• Quality Reporting Program

The revised booklet is available on the CMS website: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/InpatRehabPaymtfctsht09-508.pdf

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Inpatient Rehabilitation Facilities (IRFs): Improving Documentation Positively Impacts CERT Web-Based Training Course – Revised

The Inpatient Rehabilitation Facilities (IRFs): Improving Documentation Positively Impacts CERT revised web-based training (WBT) course is available through the Medicare Learning Network Learning Management System at https://learner.mlnlms.com. Learn about:

• IRF Services

• Documentation requirements

• Comprehensive Error Rate Testing (CERT) program


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LEARNING AND EDUCATION INFORMATION

MACtoberfest Registration Ending Soon!

Palmetto GBA is hosting its annual two-day Medicare Part A and B MACtoberfest® for Jurisdiction J (JJ) and Jurisdiction M (JM) providers on October 8–9, 2019, in Asheville, North Carolina.

This can’t-miss conference is Palmetto GBA’s largest education event of the year! Our goal is to keep providers apprised of Medicare guidelines and regulations. Topics include Medicare Secondary Payer (MSP), Top Appeals Errors, Targeted Probe & Education, Voluntary Refunds, Local Coverage Determinations (LCDs), Navigating the Provider Enrollment Process and Billing and Coverage Guidelines for Ambulance, Federally Qualified Health Centers (FQHCs) and Skilled Nursing Facility (SNF) providers, and Patient Driven Payment Model (PDPM), to name a few. The recommended participants are administrators, billers, nurses and other healthcare professionals that submit claims to Medicare.

Register for the 2019 MACtoberfest® (https://www.palmettogba.com/palmetto/mactoberfest2019.nsf/home?openform) external link.

Act now before it’s too late!

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End Stage Renal Disease (ESRD) Webcast: October 23, 2019

Join Palmetto GBA on Wednesday, October 23, 2019, at 11 a. m. ET for a Medicare Part A End Stage Renal Disease (ESRD) webcast. We will review renal dialysis facility (RDF) requirements, consolidated billing, coverage, documentation and more!

Register now.https://event.on24.com/eventRegistration/EventLobbyServlet?target=reg20.d=2041608&sessionid=1&key=1686D89D79226EFAB37714761B6EBF23&regTag=&sourcepage=register

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

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 December 2, 2019Time 2:00 p.m. - 3:00 p.m. ETParticipation Number

(877) 789-3907

Confirmation ID Number

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


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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/DocsCat/JM-Part-A~AH2JQQ2870

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 1-855-696-0705.

92 10/2019


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 Revised Related CR Release Date: September 19, 2019 Related CR Transmittal Number: R2362OTN 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

Note: We revised this article on September 23, 2019, due the release of an updated Change Request (CR).The update added to the CR: (1) a revised spreadsheet for NCD110.23, requirement 3, (2) FISS responsibility and new verbiage to NCD150.3, requirement 4 and associated spreadsheet, and, (3) revised verbiage to NCD110.21, requirement 11. All other information remains the same.

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 CR 11392, go to https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR11392.zip. Relevant NCD coding changes in CR 11392 include:

• NCD20.7 Percutaneous Transluminal Angioplasty

• NCD110.18 Aprepitant


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• NCD110.23 Stem Cell Transplantation

• NCD150.3 Bone Mineral Density Studies

• NCD220.4 Mammography

• 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 11392 that you bring to their attention.

Additional InformationThe official instruction, CR 11392, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2362OTN.pdf.


Document History

Date of Change Description September 23, 2019 We revised this article due the release of an updated CR. The update

added to the CR: (1) a revised spreadsheet for NCD110.23, requirement 3, (2) FISS responsibility and new verbiage to NCD150.3, requirement 4 and associated spreadsheet and (3) revised verbiage to NCD110.21, requirement 11.

August 12, 2019 Initial article released.

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Part A Local Coverage Determinations (LCDs) Updates

Revised LCDsThe table below provides a summary of recent Part A LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/jja/lcd. Select “Active LCDS under the LCDs, NCDs, Coverage Articles page of the Medical Policies” section. Make sure “Active LCDs” is selected under the “Select LCD Types(s)” section. Then select the “Submit” button. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCD ID NumberRevision Number

Changes/Additions/Deletions Effective Date

Outpatient Occupational TherapyLCD Number: L34427Revision Number: 20

Under CMS National Coverage Policy added 42 CFR §410.3(b) (3) Describes levels of supervision. Under Coverage Indications, Limitations and/or Medical Necessity removed quoted IOM text from the third and fourth paragraphs and added verbiage “supervision are those given in 42 CFR §410.3(b) (3).” Removed quoted IOM text from the seventh paragraph. Under NOTE removed quoted IOM text and added verbiage “some services must be provided by a licensed therapist and may not be performed by an Occupational Therapy Assistant.

Such services include:

• Making clinical judgments or decisions

• Developing, managing, or furnishing skilled maintenance programs

• Supervising other clinicians or taking responsibility for the service rendered

• Acting outside of the direction and supervision of a treating occupational therapist in accordance with state laws.”

09/05/2019


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Outpatient Occupational TherapyLCD Number: L34427Revision Number: 20continued

Under Maintenance Therapy quoted IOM text was removed and replaced with a maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, § 220 and §220.2 and must meet this. A maintenance program must meet the criteria of IOM 100-02 Chapter 15 § 220.2 to be considered reasonable and necessary. Under General Occupational Therapy Guidelines Removed quoted IOM text from #4. Under SPECIFIC PROCEDURE AND MODALITY GUIDELINES removed all coding verbiage and codes. Under MAINTENANCE PROGRAMS removed IOM text and replaced with a maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary’s need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient’s unique circumstance. The provision of therapy services by skilled therapy personnel does not itself make the service one that requires skilled care. Under Associated Information Documentation Requirements Removed quoted IOM text from #1 and replaced with “and support that the services billed were covered and performed”. Removed verbiage addressing functional reporting. All coding located in the Coding Information section has been moved into the related Billing and Coding: Outpatient Occupational Therapy A53064 article and removed from the LCD.

09/05/2019

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Outpatient Physical TherapyLCD Number: L34428Revision Number: 18

All coding located in the Coding Information section has been moved into the related Billing and Coding: Outpatient Physical Therapy A53065 article and removed from the LCD.

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: Outpatient Physical Therapy A53065 article.

Under CMS National Coverage Policy added 42 CFR §410.3 (b) (3).

Under Coverage Indications, Limitations and/or Medical Necessity removed quoted Internet Only Manual (IOM) text in the fourth paragraph and changed verbiage to read “For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.3(b)(3).” Removed quoted Internet Only Manual (IOM) text in the tenth and eleventh paragraphs and changed verbiage to read “Some services must be provided by a licensed therapist and may not be performed by a physical therapy assistant such services include: Making clinical judgements or decisions; Developing, managing or furnishing skilled maintenance programs; Supervising other clinicians or taking responsibility for the service rendered: Acting outside of the directions and supervision of a treating physical therapist in accordance with state laws.” Under subheading Maintenance Therapy Necessity removed quoted Internet Only Manual (IOM) text in the fourth paragraph and changed verbiage to read “A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual Pub.100-02, Medicare Benefit Policy Manual, Chapter 15, §220. A maintenance program must meet these criteria to be considered reasonable and necessary.” Under GENERAL PHYSICAL THERAPY GUIDELINES removed quoted Internet Only Manual (IOM) text from #5. Under subheading Maintenance Programs verbiage was changed to read ”A maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary’s need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively.

08/22/2019


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Outpatient Physical TherapyLCD Number: L34428Revision Number: 18continued

Provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient’s unique circumstance. The provision of therapy services by skilled personnel does not in itself make the service one that requires skilled care.” Under Associated Information subheading Documentation Requirements under #1 changed verbiage to read “Documentation supporting medical necessity should be legible and support that the services billed were covered and performed.” Removed verbiage addressing Functional Reporting in the second paragraph. Under Bibliography changes were made to citations to reflect AMA citation guidelines and retired sources were removed. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/22/2019

Outpatient Speech Language Pathology LCD Number: L34429Revision Number: 15

All coding located in the Coding Information section has been moved into the related Billing and Coding: Outpatient Speech Language Pathology A56868 article and removed from the LCD.

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: Outpatient Speech Language Pathology A56868 article.

Under Coverage Indications, Limitations and/or Medical Necessity removed first paragraph regarding quoted Internet Only Manual (IOM) text. Removed quoted IOM text in the third paragraph and changed verbiage to read “skilled services as described by the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.3”. Removed quoted IOM text in the fifth paragraph and changed verbiage to read “The SLP assesses a patient and develops a plan for treatment as described by Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3”. Under subheading Restorative/Rehabilitative therapy removed quoted National rulings text and changed verbiage to read “Restorative / Rehabilitative therapy is intended for patients for whom the goal of therapy is to reverse some loss of function as described in Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Transmittal 179, dated January 14, 2014, Change Request 8458”. Under subheading Maintenance therapy removed quoted National rulings text and changed verbiage to read

08/22/2019

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Outpatient Speech Language Pathology LCD Number: L34429Revision Number: 15continued

“Maintenance therapy is intended for patients for whom the goal of treatment is to slow or prevent deterioration in function as described in Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Transmittal 179, dated January 14, 2014, Change Request 8458”. Under subheading Evaluation/Re-evaluation: 20. Motion fluoroscopic evaluation of swallowing function by cine or video recording removed quoted IOM text and changed verbiage to read “Guidance for the appropriate supervision of this study is given in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3”.Under 21. Flexible endoscopic evaluation of swallowing by cine or video recording removed quoted IOM text and changed verbiage to read “The skills and competencies required of clinicians providing this service are described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3”. 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 and defined where appropriate throughout the LCD.

Part A Article Updates

Revised Article UpdatesThe table below provides a summary of recent Part A article revision/updates. To view these revised articles, go to www.PalmettoGBA.com/jja/lcd. Select Coverage Articles under the LCDs, NCDs, Coverage Articles page of the Medical Policies section. 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.

TitleArticle ID NumberRevision Number


Billing and Coding: Cardiac Event Detection Article Number: A56606Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes ICD-10 codes I48.1 and I48.2 were deleted and ICD-10 codes I48.11, I48.19, I48.20, and I48.21 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

Billing and Coding: Homocysteine Level, Serum Article Number: A56675Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes the description changed for ICD-10 codes I70.238 and I70.248. ICD-10 codes I82.451, I82.452, I82.453, I82.459, I82.461, I82.462, I82.463, I82.469, I82.551, I82.552, I82.553, I82.559, I82.561, I82.562, I82.563, and I82.569 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019


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Billing and Coding: Magnetic Resonance Angiography Article Number: A56775 Revision Number: 2

Under Covered ICD-10 Codes Group 1, 2, 3, 4 and 5: Codes added ICD-10 Codes I26.93 and I26.94. Under Covered ICD-10 Codes Group 2: Codes added ICD-10 Codes I80.241, I80.242, I80.243, I80.249, I80.251, I80.252, I80.253 and I80.259. Under Covered ICD-10 Codes Group 3 and 5: Codes added ICD-10 Code N99.85. Under Covered ICD-10 Codes Group 1: Codes the code descriptions were revised for ICD-10 Codes G43.A0 and G43.A1. Under Covered ICD-10 Codes Group 2, 3 and 5: Codes the code descriptions were revised for ICD-10 Codes I70.238 and I70.248. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face and/or Neck Article Number: A56729Rev #2

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 Codes S02.831A, S02.831B, S02.831D, S02.831G, S02.831K, S02.831S, S02.832A, S02.832B, S02.832D, S02.832G, S02.832K, S02.832S, S02.839A, S02.839B, S02.839D, S02.839G, S02.839K, S02.839S, S02.841A, S02.841B, S02.841D, S02.841G, S02.841K, S02.841S, S02.842A, S02.842B, S02.842D, S02.842G, S02.842K, S02.842S, S02.849A, S02.849B, S02.849D, S02.849G, S02.849K, S02.849S, S02.85XA, S02.85XB, S02.85XD, S02.85XG, S02.85XK, and S02.85XS. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Outpatient Occupational TherapyArticle Number: A53064Revision Number: 12

Under Article Title changed title to Billing and Coding: Outpatient Occupational Therapy. All coding located in the SPECIFIC PROCEDURE AND MODALITY GUIDELINES and Coding Information sections has been removed from the related Outpatient Occupational Therapy L34427 LCD and added to this article.

09/05/2019


Under Covered ICD-10 Codes Group 1: Codes code descriptions for I70.238, I70.248, J44.0 and M66.88 were revised. ICD-10 codes L89.006, L89.016, L89.026, L89.106, L89.116, L89.126, L89.136, L89.146, L89.156, L89.206, L89.216, L89.226, L89.306, L89.316, L89.326, L89.46, L89.506, L89.516, L89.526, L89.606, L89.616, L89.626, Q66.01, Q66.02, Q66.11, Q66.12, Q66.211, Q66.212, Q66.221, Q66.222, Q66.31, Q66.32, Q66.41, Q66.42, Q66.71, Q66.72, Q66.91, Q66.92, S02.121A, S02.121B, S02.121D, S02.121G, S02.121K, S02.121S, S02.122A, S02.122B, S02.122D, S02.122G, S02.122K, S02.122S, S02.831A, S02.831B, S02.831D, S02.831G, S02.831K, S02.831S, S02.832A, S02.832B, S02.832D, S02.832G, S02.832K, S02.832S, S02.841A, S02.841B, S02.841D, S02.841G, S02.841K, S02.841S, S02.842A, S02.842B, S02.842D, S02.842G, S02.842K and S02.842S were added. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019


Under Revenue Codes code 0434 was added. It was inadvertently left off during a previous revision.This revision becomes effective on 10/1/2019.

10/01/2019

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Billing and Coding: Outpatient Physical TherapyArticle Number: A53065Revision Number: 13

Under Covered ICD-10 Codes Group 1: Codes ICD-10 codes M84.633S, M84.634S, M84.641S, M84.642S, M84.650D and M84.650S were added due to an article revision request. Under Covered ICD-10 Codes Group 1: Codes code descriptions for I70.238, I70.248, J44.0, M66.88, M77.51 and M77.52 were revised. ICD-10 codes L89.006, L89.016, L89.026, L89.106, L89.116, L89.126, L89.136, L89.146, L89.156, L89.206, L89.216, L89.226, L89.306, L89.316, L89.326, L89.46, L89.506, L89.516, L89.526, L89.606, L89.616, L89.626, L89.816, L89.896, L89.96, Q66.01, Q66.02, Q66.11, Q66.12, Q66.211, Q66.212, Q66.221, Q66.222, Q66.31, Q66.32, Q66.41, Q66.42, Q66.71, Q66.72, Q66.91, Q66.92, S02.121A, S02.121B, S02.121D, S02.121G, S02.121K, S02.121S, S02.122A, S02.122B, S02.122D, S02.122G, S02.122K, S02.122S, S02.831A, S02.831B, S02.831D, S02.831G, S02.831K, S02.831S, S02.832A, S02.832B, S02.832D, S02.832G, S02.832K, S02.832S, S02.841A, S02.841B, S02.841D, S02.841G, S02.841K, S02.841S, S02.842A, S02.842B, S02.842D, S02.842G, S02.842K and S02.842S were added. These additions are due to the Annual ICD-10 Updates.

This revision becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Outpatient Speech Language Pathology Article Number: A56868NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Speech Language Pathology L34429.

Evaluation/Re-evaluation

Note: Current Procedural Terminology (CPT®) does not define a re-evaluation code for Speech Language Pathology: use the evaluation code.

1. Treatment of speech, language, voice, communication, and/or auditory processing disorder (CPT® code 92507); individual

• Regarding speech-generating devices (SGDs), use CPT® code 92607 and 92608 for selection and prescription; use CPT® code 92609 for programming and modification.

2. Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals (CPT® code 92508)

• Note: Regardless of the therapy being performed, if the patient is not receiving direct 1 on 1 contact but is being supervised by the therapist, the group therapy code should be used.

08/15/2019

Billing and Coding: Outpatient Speech Language Pathology Article Number: A56868Revision Number: 1

All coding located in the Coding Information section has been removed from the related Outpatient Speech Language Pathology L34429 LCD and added to this article.

08/15/2019


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All coding located in the Coding Information section has been removed from the related Outpatient Physical Therapy L34428 LCD and added to this article.

Under Article Title changed the title from “Outpatient Physical Therapy Supplemental Instruction Article” to “Billing and Coding: Outpatient Physical Therapy”. Under Article Text added the following verbiage Hot/Cold Packs (CPT® code 97010) The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. Ice massage should be reported using CPT® code 97010. Direct One-on-One Contact Regardless of the procedure or modality being performed, if the patient is not receiving direct one-on-one contact but is being supervised by the therapist, the group therapy code should be used. Orthotic Management and Training and Prosthetic Training (CPT® code 97760) For entities subject to this policy, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPT® code 97760, unless the entities are certain that duplicate payments will not be made to DMEPOS suppliers using the “L” code. Community/Work Reintegration (CPT® code 97537) Should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community. Removed codes 97014 and G0282 from non-covered codes.

08/22/2019


Under Covered ICD-10 Codes Group 1: Codes code descriptions for I70.238, I70.248, J44.0, M66.88, M77.51 and M77.52 were revised. ICD-10 codes L89.006, L89.016, L89.026, L89.106, L89.116, L89.126, L89.136, L89.146, L89.156, L89.206, L89.216, L89.226, L89.306, L89.316, L89.326, L89.46, L89.506, L89.516, L89.526, L89.606, L89.616, L89.626, L89.816, L89.896, L89.96, Q66.01, Q66.02, Q66.11, Q66.12, Q66.211, Q66.212, Q66.221, Q66.222, Q66.31, Q66.32, Q66.41, Q66.42, Q66.71, Q66.72, Q66.91, Q66.92, S02.121A, S02.121B, S02.121D, S02.121G, S02.121K, S02.121S, S02.122A, S02.122B, S02.122D, S02.122G, S02.122K, S02.122S, S02.831A, S02.831B, S02.831D, S02.831G, S02.831K, S02.831S, S02.832A, S02.832B, S02.832D, S02.832G, S02.832K, S02.832S, S02.841A, S02.841B, S02.841D, S02.841G, S02.841K, S02.841S, S02.842A, S02.842B, S02.842D, S02.842G, S02.842K and S02.842S were added. This revision is due to the Annual ICD-10 Updates and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Respiratory Therapy (Respiratory Care) Article Number: A56717Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes the description changed for ICD-10 code J44.0 and ICD-10 codes I26.93 and I26.94 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

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

Revised LCDsThe table below provides a summary of recent Part A/B MAC LCD revisions/updates. To view these revised LCDs, go to www.PalmettoGBA.com/jja/lcd. Select Active LCDS under the LCDs, NCDs, Coverage Articles page of the Medical Policies section. Make sure “Active LCDs” is selected under the “Select LCD Types(s)” section. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCD ID NumberRevision Number


Laparoscopic Sleeve Gastrectomy for Severe ObesityLCD Number: L34576Revision Number: 17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity A56852 article and removed from the LCD.

08/15/2019

Micro-Invasive Glaucoma Surgery (MIGS) LCD Number: L37531Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) A56866 article and removed from the LCD.

Under CMS National Coverage Policy removed verbiage, “CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.” Formatting, punctuation, and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/15/2019

Ophthalmology: Extended Ophthalmoscopy and Fundus PhotographyLCD Number: L33467Revision Number: 13

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added ICD-10 code Q87.19 and deleted ICD-10 code Q87.1. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Ophthalmology: Extended Ophthalmoscopy and Fundus PhotographyLCD Number: L33467Revision Number: 14

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity has been removed and is included in the related Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography A53060 article.

Under CMS National Coverage Policy deleted the sentences that read “Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the policy. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:”

10/01/2019


103 10/2019

PolysomnographyLCD Number: L36593Revision 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: Polysomnography A56995 article.

Under Coverage Indications, Limitations and/or Medical Necessity removed quoted Internet Only Manual (IOM) text. Under the subheading Medical Conditions for Which Testing is Covered replaced the first paragraph containing IOM text with the verbiage “Diagnostic testing will only be covered if the patient demonstrates clinical evidence of one or more of the following conditions:”. Under the subheading Limitations of Coverage: removed italics from text.

09/12/2019

Rituximab LCD Number: L35026Revision Number: 25

Under LCD Title changed title to Rituximab. The drug name “Rituxan®” was removed throughout the LCD.

This revision is due to the Q3 2019 CPT®/HCPCS Code Update and is effective for dates of service on or after 7/1/2019

07/01/2019

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)LCD Number: L34431Revision Number: 17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56825 article and removed from the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/08/2019

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)LCD Number: L34431Revision Number: 18

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: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) A56825 article. Under Coding Information: Bill Type Codes removed code 021x as it was inadvertently added with Revision 17.

09/05/2019

Spinal Cord Stimulators for Chronic PainLCD Number: L37632Revision Number: 4

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity and Associated Information sections and all coding located in the Coding Information section has been moved into the related Billing and Coding: Spinal Cord Stimulators for Chronic Pain A56876 article and removed from the LCD. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation were corrected throughout the LCD.

08/22/2019

Voretigene Neparvovec-rzyl (Luxturna™) LCD Number: L37863Revision Number: 3

Under Contract Number removed contract 11004 as it was inadvertently added with Revision 1. Under Coding Information: Bill Type Codes removed code 022x as it was inadvertently added with Revision 1.

09/05/2019

YAG CapsulotomyLCD Number: L37644Revision: 3

All coding located in the Coding Information section has been moved into the related Billing and Coding: YAG Capsulotomy A56792 article and removed from the LCD.

Punctuation and typographical errors were corrected throughout the LCD.

08/08/2019

104 10/2019


Part A/B Article Updates

The table below provides a summary of recent Part A/B MAC article revision/updates. To view these revised articles, go to www.PalmettoGBA.com/jja/lcd. Select Coverage Articles under the LCDs, NCDs, Coverage Articles page of the Medical Policies section. Under the Articles for Contractor Browser section, make sure the Active Articles category is selected and the click on the Submit button. The articles are listed in alphabetical order.

TitleArticle ID NumberRevision Number


Billing and Coding: Cardiac Computed Tomography & Angiography Article Number: A56691Revision Number: 3

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 Codes I26.93, I26.94, I48.11, I48.19, I48.20 and I48.21. Under Covered ICD-10 Codes Group 1: Codes deleted ICD-10 Codes I48.1 and I48.2. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Cardiac Radionuclide Imaging Article Number: A56476Revision Number: 3


10/01/2019

Billing and Coding: Cervical Disc ReplacementArticle Number: A57021NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cervical Disc Replacement L38033.

10/28/2019


105 10/2019

Billing and Coding: Chemotherapy Article Number: A56141Revision Number: 5

Under Article Title revised the title to remove the word “for”. Under Article Text revised the verbiage to support the purpose of this article. All CPT/HCPCS groups and ICD-10 code groups were re-grouped to correspond with one another. Under CPT/HCPCS Codes Group 10: Codes added HCPCS code J9036. Under CPT/HCPCS Codes Group 20: Paragraph revised the indications for Lutathera® (Lutetium Lu 177 Dotatate). Under Covered ICD-10 Codes Group 28: Codes added ICD-10 code C25.1. Added CPT/HCPCS Codes Group 29: Paragraph and Codes as well as Covered ICD-10 Codes Group 29: Paragraph and Codes for Secondary for Onivyde® (Irinotecan liposome). Added CPT/HCPCS Codes Group 30: Paragraph and Codes to include multiple drugs where no ICD-10 codes have been identified under the Covered ICD-10 Codes section of the article. Indications were revised under CPT/HCPCS Codes Group 30: Paragraph for #5 Keytruda® (Pembrolizumab) J9271 and #11 Tecentriq® (Atezolizumab) J9022. Indications were added under CPT/HCPCS Codes Group 30: Paragraph for #8 Herceptin Hylecta (trastuzumab and hyaluronidase) J9355. Under CPT/HCPCS Codes Group 30: Codes added Q5112, Q5113 and Q5114 for #7 HERCEPTIN® (Trastuzumab) J9355, Q5112, Q5113, Q5114 and J9355 for #8 Herceptin Hylecta (trastuzumab and hyaluronidase) J9355.

This revision becomes effective on 8/22/2019; however, HCPCS codes J9036, J9355, Q5112, Q5113 and Q5114 are effective for dates of service on or after 7/1/19 and were added due to the Q3 CPT/HCPCS Update.

08/22/2019

Billing and Coding: Colonoscopy/Sigmoidoscopy/ProctosigmoidoscopyArticle Number: A56632Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 codes Z86.003 and Z86.004. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

Billing and Coding: Computerized Axial Tomography (CT), Thorax Article Number: A56580Revision Number: 3

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 Codes I26.93, I26.94 N63.15 and N63.25. Under Covered ICD-10 Codes Group 1: Codes the code description was revised for ICD-10 Code J44.0. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: CT of the Abdomen and Pelvis Article Number: A56421Revision Number: 4

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 Codes N99.85 and R11.15. Under Covered ICD-10 Codes Group 1: Codes the code description was revised for ICD-10 Code N35.814. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

106 10/2019


Billing and Coding: CT of the Head Article Number; A56612Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 codes S02.831S, S02.832A, S02.832B, S02.832D, S02.832G, S02.832K, S02.832S, S02.839A, S02.839B, S02.839D, S02.839G, S02.839K, S02.839S, S02.841A, S02.841B, S02.841D, S02.841G, S02.841K, S02.841S, S02.842A, S02.842B, S02.842D, S02.842G, S02.842K, S02.842S, S02.849A, S02.849B, S02.849D, S02.849G, S02.849K, S02.849S, S02.85XA, S02.85XB, S02.85XD, S02.85XG, S02.85XK, S02.85XS, T50.911A, T50.911D, T50.911S, T50.912A, T50.912D, T50.912S, T50.913A, T50.913D, T50.913S, T50.914A, T50.914D, T50.914S, T50.915A, T50.915D, T50.915S, T50.916A, T50.916D, T50.916S, T67.01XA, T67.01XD, T67.01XS, T67.02XA, T67.02XD, T67.02XS, T67.09XA, T67.09XD, T67.09XS, Z86.002, Z86.003, Z86.004, Z86.005, Z86.006 and Z86.007. Under Covered ICD-10 Codes Group 1: Codes deleted ICD-10 codes H81.41, H81.42, H81.43, T67.0XXA, T67.0XXD and T67.0XXS. Under Covered ICD-10 Codes Group 1: Codes the code descriptions were revised for ICD-10 codes G43.A0, G43.A1, T44.1X6A, T44.1X6D and T44.1X6S. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Echocardiography LCD Article Number:A56625Revision Number: 2

Under Covered ICD-10 Codes Group 2, 3, 4, and 5: Codes ICD-10 codes I48.1 and I48.2 were deleted. Under Covered ICD-10 Codes Group 2: Codes added ICD-10 codes I26.93, I26.94, I48.11, I48.19, I48.20, I48.21, T50.915A, T50.915D, T50.915S, T50.916A, T50.916D, and T50.916S. Under Covered ICD-10 Codes Group 3: Codes added ICD-10 codes I26.93, I26.94, I48.11, I48.19, I48.20, and I48.21. Under Covered ICD-10 Codes Group 4: Codes added ICD-10 codes T50.915A, T50.915D, T50.915S, T50.916A, T50.916D, T50.916S, I48.11, I48.19, I48.20, and I48.21. Under Covered ICD-10 Codes Group 5: Codes added ICD-10 codes I26.93, I26.94, I48.11, I48.19, I48.20, and I48.21. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

Billing and Coding: Implantable Automatic DefibrillatorsArticle Number: A56343Revision Number: 2

Under Article Title changed title from Implantable Automatic DEFIBRILLATORS - Coding and Billing to Billing and Coding: Automatic Implantable Defibrillators. Under Article Text “D. Other “ added ICD-10-PCS codes 0JH60FZ, 0JH63FZ, 0JPT0FZ and 0JPT3FZ. These revisions are due to the Annual ICD-10 Updates and become effective on 10/1/2019.

10/01/2019

Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity Article Number: A56852 NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Laparoscopic Sleeve Gastrectomy for Severe Obesity L34576.

08/15/2019

Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity Article Number: A56852 Revision Number: 1

All coding located in the Coding Information section has been removed from the related Laparoscopic Sleeve Gastrectomy for Severe Obesity L34586 LCD and added to this article.

08/15/2019


107 10/2019

Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity Article Number: A56852 Revision Number: 2

Under Covered ICD-10 Codes Group 2: Codes the code description was revised for ICD-10 code Z68.43. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) Article Number: A56866NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS) L37531.

08/15/2019

Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) Article Number: A56866Revision Number: 1

All coding located in the Coding Information section has been removed from the related Micro-Invasive Glaucoma Surgery (MIGS) L37531 LCD and added to this article.

08/15/2019

Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography Article Number: A53060Revision Number: 9

All coding located in the Coding Information section has been removed from the related Ophthalmology: Extended Ophthalmoscopy and Fundus Photography L33467 LCD and added to this article.

Under Article Title changed the title from Coding Article for Ophthalmology: Extended Ophthalmoscopy and Fundus Photography to Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography.

Under Article Text added the verbiage “The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for the Ophthalmology: Extended Ophthalmoscopy and Fundus Photography L33467.” at the beginning of the section, and added the verbiage “CPT® code 92227 (remote imaging for detection of retinal disease, e.g. retinopathy in a patient with diabetes, with analysis and report under physician supervision, unilateral or bilateral) is not for routine screening, but is covered for evaluation of asymptomatic patients at risk with known disease (e.g. diabetes mellitus) that is likely to cause retinal disease when the test is ordered by the treating physician. CPT® code 92228 (remote imaging for monitoring and management of active retinal disease, e.g. diabetic retinopathy, with physician review, interpretation and report, unilateral or bilateral) is a covered service when ordered by the treating physician.” at the end of the section.

10/10/2019

Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography Article Number: A53060Revision Number: 10

Under Covered ICD-10 Codes Group 3: Code added ICD-10 code Q87.11. This revision is due the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

108 10/2019


Billing and Coding: PolysomnographyArticle Number: A56995NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Polysomnography L36593.

HCPCS codes G0398, G0399, and G0400 and CPT codes 95800, 95801 and 95806 (unattended sleep study) by definition involve the absence of a technologist. Unattended sleep studies must meet the narrative definition of the codes. G0400, Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels, must measure respiratory movement, airflow, and oxygen saturation. Effective for dates of service on or after 01/01/2011, CPT codes 95800 and 95801 have been added.

09/12/2019

Billing and Coding: PolysomnographyArticle Number: A56995Revision Number: 1

All coding located in the Coding Information section has been removed from the related Polysomnography L36593 LCD and added to this article.

09/12/2019

Billing and Coding: Removal of Benign and Malignant Skin LesionsArticle Number: A56346Revision Number: 4

Under Covered ICD-10 Codes Group 1: Codes added ICD-10 Codes Z86.006 and Z86.007. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Retroperitoneal UltrasoundArticle Number: A55336Revision Number: 7

Under CPT/HCPCS Codes Group 1: Paragraph added “This article does not address diagnosis coding for these 3 CPT® codes.” Under Group 1: Codes removed CPT® codes 76700, 76705 and 76706. Under Covered ICD-10 Codes Group 1: Codes added ICD-10 codes R10.13 and R10.9.

09/07/2019

Billing and Coding: Retroperitoneal UltrasoundArticle Number: A55336Revision Number: 8

Under Covered ICD-10 Codes Group 1: Codes the code description for R82.993 was revised. This revision is due to the Annual ICD-10 Updates and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: RituximabArticle Number: A56380Revision Number: 2

Under Article Title title was changed to Billing and Coding: Rituximab. Under CPT/HCPCS Codes Groups 1: Codes and Groups 2: Codes added the HCPCS code Q5115. The drug name “Rituxan®” was removed throughout the article. Added Q5115 under Covered ICD-10 Codes Group 1: Paragraph and ICD-10 Codes Group 2: Paragraph.This revision is due to the Q3 2019 CPT®/HCPCS Code Update and is effective for dates of service on or after 7/1/2019.

07/01/2019

Billing and Coding: RituximabArticle Number: A56380Revision Number: 3

Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph removed code J9311 and added code J9312.

09/19/2019

Billing and Coding: Routine Foot CareArticle Number: A56680Revision Number: 2

Under Covered ICD-10 Codes Group 3: Codes I80.241, I80.242, I80.243, I80.249, I80.251, I80.252, I80.253 and I80.259 were added. These revisions are due to the Annual ICD-10 Updates and become effective on 10/1/2019.

10/01/2019


109 10/2019

Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)Article Number: A56825NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) L34431.

08/08/2019

Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)Article Number: A56825Revision Number: 1

All coding located in the Coding Information section has been removed from the related Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) L34431 LCD and added to this article.

08/08/2019

Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)Article Number: A56825Revision Number: 2

Under Article Text added verbiage SCODI (92133, 92134) and fundus photography (92250) are mutually exclusive codes. However, there may be a limited number of clinical situations in which it is necessary to perform both techniques in order to evaluate and treat the patient. In these situations, both CPT codes may be reported appending modifier 59 to indicate a distinct procedural service. Documentation supportive of the need to perform both techniques should be clear in the medical record. Under Coding Information: CPT/HCPCS codes removed codes from Group 1 Paragraph and added codes to Group 1: Codes. These codes were inadvertently added to Group 1 Paragraph.

09/05/2019

Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker Article Number: A54831Revision Number: 8

Under Article Title changed the title from Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing to Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker. Under Covered ICD-10 Codes Group 2: Codes deleted I48.1 and added I48.11 and I48.19. This revision is due to the Annual ICD-10 Code Update and becomes effective on 10/1/2019.

10/01/2019

Billing and Coding: Somatosensory TestingArticle Number: A56769Revision Number: 2

Under Covered ICD-10 Codes Group 1: Codes the following ICD codes have been added: R20.0, R20.1, R20.2, R20.3, R20.8.

08/01/2019

110 10/2019


Billing and Coding: Spinal Cord Stimulators for Chronic PainArticle Number: A56876NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Spinal Cord Stimulators for Chronic Pain L37632.

Indications This A/B MAC will reimburse for placement of a maximum of two leads or sixteen contacts, and for two SCS trials per anatomic spinal region per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology).

If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal. Generally, electronic analysis services (CPT® codes 95970, 95971 and 95972) are not considered medically necessary when provided at a frequency more often than once every thirty days. More frequent analysis may be necessary in the first month after implantation.

Utilization Guidelines CPT® code 63650 - Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, outpatient hospital, or hospital.

CPT® code 63655 - One permanent spinal cord stimulator per patient per lifetime and must be performed in an ASC, outpatient hospital or hospital. CPT® codes 63661 and 63663 - Will not be reimbursed in the office setting since they are included in 63650.

The HCPCS/CPT® code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

08/22/2019

Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization Article Number A56389Revision Number: 3

Under Covered ICD-10 Codes Group 1: Codes ICD-10 code R11.15 was added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019


111 10/2019

Billing and Coding: Use of Laterality Modifiers Article Number: A56869NEW

In order to facilitate claims processing and avoid denials for duplicate claims, claims which contain CPT®/HCPCS codes describing services performed on anatomic structures that can be distinguished as left or right require laterality modifiers. This article is not a comprehensive listing of all such codes; however, all claims involving the CPT® codes included in this article will be rejected unless the appropriate laterality modifiers (-RT; -LT) for unilateral procedures are reported. Bilateral procedures should be indicated by the appropriate modifier for bilateral procedures. CPT® codes that are designated in their description as “unilateral or bilateral” do not require additional laterality modifiers.

Claim lines for CPT®/HCPCS codes requiring use of the RT and LT modifiers, submitted without the RT and/or LT modifiers or with the RT/LT on a single claim line will be rejected as incorrect coding.

09/09/2019

Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna™) Article Number: A56419Revision Number: 3

Under Contract Number removed contract 11004 as it was inadvertently added with Revision 1.

09/05/2019

Billing and Coding: YAG CapsulotomyArticle Number: A56792NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for YAG Capsulotomy L37644.

08/08/2019

Billing and Coding: YAG CapsulotomyArticle Number: A56792Revision Number: 1

All coding located in the Coding Information section has been removed from the related YAG Capsulotomy L37644 and added to this article.

08/08/2019

Billing and Coding for Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication Article Number: A56384Revision Number: 2

Under Revenue Codes: Codes the description changed for Revenue code 0964. This revision is due to the 2019 Annual NUBC Code Update and is effective for dates of service on or after 7/1/2019.

07/01/2019

Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy Article Number: A55069Revision Number: 5


10/01/2019

Spinal Cord Stimulators for Chronic PainArticle Number: A56876Revision Number: 1

All coding located in the Coding Information section has been removed from the Spinal Cord Stimulators for Chronic Pain L37632 LCD and added to this article.

08/29/2019

112 10/2019


Response to Comments: Cervical Disc Replacement

The comment period for the Cervical Disc Replacement L38033 Local Coverage Determination (LCD) began on 5/6/19 and ended on 6/20/19. The comments below were received from the provider community. The notice period for L38033 begins on 9/12/19 and will become effective on 10/28/19.

Comment 1:In response to the draft Local Coverage Determination (LCD) for Cervical Disc Replacement (DL38033), [We are] fully supportive of the proposed LCD Coverage Guidance Document in its entirety. The proposed policy affords patients and providers with an appropriate treatment option and no changes are requested.

Response 1:Thank you for your comment.

Comment 2:[We] support the finalization of this proposed/draft LCD. We greatly appreciate Palmetto affirming the ability of cervical disc replacement to “maintain anatomical disc space height, normal segmental lordosis, and physiological motion patters at the index and adjacent cervical level with reduced risk of adjacent level DD commonly seen above or below a fusion site”. This proposed LCD will appropriately allow licensed healthcare providers the ability to offer their patients an alternative treatment to spinal fusion that encourages spinal motion and maintains the normal biomechanics of the cervical spine. As stated in the proposed LCD, Palmetto will consider FDA-approved prosthetic cervical discs reasonable and necessary for the treatment of Medicare beneficiaries with symptomatic cervical degenerative disease of herniated disc when medical necessity criteria are met. We respectfully request that you incorporate a discussion on [our] Artificial Cervical Disc in the final LCD for Cervical Disc Replacement, DL38033. This inclusion will ensure that all FDA-approved cervical discs are discussed within the LCD.

Response 2:We respectfully disagree. The LCD process is intended to provide coverage guidance for services, including drugs and devices, for which there is sufficient peer-reviewed high quality evidence to support medical necessity in the Medicare population. FDA approval alone is not sufficient to warrant Medicare coverage. No supporting research was submitted with this comment. Due to the unavailability of U.S.-based, high-quality, peer-reviewed published clinical research of this device, we must conclude that it is still investigational and therefore unreasonable to consider for coverage at this time. Upon availability of this evidence, we can reconsider coverage upon request.

Comment 3:For Coverage Limitation #6, we believe the statement should be revised to state: “The Beneficiary is free from absolute contraindications to cervical disc replacement” For Investigational Coverage Limitation bullet #4, we disagree with this limitation. Patients that meet all other indications and are having surgery for adjacent level disease (a disc that has degenerated next to a prior fusion) are potentially good candidates for artificial disc replacement instead of another fusion. While we understand these were not the patients studied in large trials, the alternative treatment (another fusion) has a poor track record of success. For Investigational Coverage Limitation bullet #9. We believe this bullet should be qualified. We believe, in the studies this was listed as moderate and severe arthropathy.


113 10/2019

Response 3:Strict adherence to careful patient selection contributed significantly to demonstrating the net health benefit for CDR. These criteria are necessary to reasonably attribute intractable cervical radicular pain or myelopathy to a specific disc level. Moreover, CDR only replaces the disc therefore, the posterior elements, such as the facets and ligaments, are required to be free from anatomic malformation. However, we agree that it is reasonable to include patients with mild disease when the source of cervical radicular pain or myelopathy can be clearly attributed to the corresponding disc. Therefore, we will qualify this exclusion as suggested. We also agree to qualify the contraindications as absolute and more clearly indicate those clinical characteristics where CDR is not reasonable. Lastly, given the absence of literature to establish the safety and efficacy of CDR in patients with a previous fusion, it is by definition investigational. Therefore, this limitation will remain as is.

Response to Comments: Corneal Hysteresis

The comment period for the Corneal Hysteresis L38026 Local Coverage Determination (LCD) began on 5/6/19 and ended on 6/20/19. The comments below were received from the provider community. The notice period for L38026 begins on 9/5/19 and will become effective on 10/21/19.

Comment 1:

Palmetto GBA received one document that referenced corneal hysteresis.

Response 1:

This document was addressed to a different Medicare Administrative Contractor and referenced a proposed LCD that did not belong to Palmetto GBA. Therefore, this is not a valid comment.

114 10/2019


MolDX Local Coverage Determinations (LCDs) Updates

Revised LCD UpdatesThe table below provides a summary of recent Part A MolDX LCD revisions/updates. To view these revised LCDs, go to www.palmettogba.com/moldx. Select MolDX LCDs under the Topics section. Go to your jurisdiction and select Medical Policies. Scroll down to the LCDs, NCDs, Coverage Articles section click on Active LCDs and select Active LCDs. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCDID NumberRevision Number


GlycoMark Testing for Glycemic Control LCD Number: L36761Revision Number: 3

All coding located in the Coding Information section has been moved into the related Billing and Coding: GlycoMark Testing for Glycemic Control A56872 article and removed from the LCD.

08/15/2019

In Vitro Chemosensitivity & Chemoresistance Assays LCD Number: L34554Revision Number: 9

All coding located in the Coding Information section has been moved into the related Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays A56871 article and removed from the LCD.

08/15/2019

Lab: Bladder/Urothelial Tumor Markers LCD Number: L33420Revision Number: 14

All coding located in the Coding Information section has been moved into the related Billing and Coding: Lab: Bladder/Urothelial Tumor Markers A53095 article and removed from the LCD.

08/22/2019

Lab: Controlled Substance Monitoring and Drugs of Abuse Testing LCD Number: L35724Revision Number: 10

All coding located in the Coding Information section has been moved into the related Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse Testing A54799 article and removed from the LCD.

Under Coverage Indications, Limitations and/or Medical Necessity changed verbiage under Drug Test Methods from “CLIA levels of complexity (CLIA-waived, moderate complexity and high complexity) are addressed only as they relate to the HCPCS code description and the coding/billing guidance to be attached to this document” to “CLIA levels of complexity (CLIA waived, moderate complexity and high complexity) are addressed only as they correspond to the HCPCS code description found in the related billing and coding article.”

08/29/2019

Lab: Flow Cytometry LCD Number: L34513Revision Number: 13

All coding located in the Coding Information section has been moved into the related Billing and Coding: Lab: Flow Cytometry A55717 article and removed from the LCD.

08/22/2019

Lab: Special Histochemical Stains and Immunohistochemical StainsLCD Number: L35922Revision Number: 7

All coding located in the Coding Information section has been moved into the related Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains A56838 article and removed from the LCD. Formatting was corrected throughout the LCD.

08/08/2019


115 10/2019

MolDX: 4Kscore Assay LCD Number: L36763Revision Number: 5

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: 4Kscore Assay A56932 article and removed from the LCD.

08/22/2019

MolDX: AlloSure® Donor-Derived Cell-Free DNA Test LCD Number: L37266Revision Number: 5

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA Test A56965 article and removed from the LCD.

08/29/2019

MolDX: APC and MUTYH Gene Testing LCD Number: L36827 Revision Number: 6

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: APC and MUTYH Gene Testing A56824 article and removed from the LCD.

08/08/2019

MolDX: Biomarkers in Cardiovascular Risk Assessment LCD Number: L36129Revision Number: 14

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes the description changed for ICD-10 codes I70.238 and I70.248, ICD-10 code I48.2 was deleted, and ICD-10 codes I48.11, I48.19, I48.20, I48.21 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

MolDX: Biomarkers in Cardiovascular Risk Assessment LCD Number: L36129Revision Number: 15

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment A56943 article and removed from the LCD.

10/01/2019

MolDX: BDX-XL2 LCD Number: L37031Revision Number: 7

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: BDX-XL2 A56929 article and removed from the LCD.

08/22/2019

MolDX: BRCA1 and BRCA2 Genetic TestingLCD Number: L36082Revision Number: 17

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic Testing A56854 article and removed from the LCD.

Under Coverage Indications, Limitations and/or Medical Necessity removed italics from text and corrected formatting throughout the section.

08/15/2019

MolDX: Breast Cancer Assay: Prosigna LCD Number: L36125Revision Number: 10

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Breast Cancer Assay: Prosigna A56949 article and removed from the LCD.

08/29/2019

MolDX: Breast Cancer Index™ (BCI) Gene Expression Test LCD Number: L37794Revision Number: 2

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test A56875 article and removed from the LCD.

08/15/2019

MolDX: ConfirmMDx Epigenetic Molecular Assay LCD Number: L35632Revision Number: 11

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular Assay A56955 article and removed from the LCD.

08/29/2019

116 10/2019


MolDX: Circulating Tumor Cell Marker Assays LCD Number: L35071Revision Number: 6

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Circulating Tumor Cell Marker Assays A56873 article and removed from the LCD.

08/15/2019

MolDX: Corus® CAD AssayLCD Number: L37612Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Corus® CAD Assay A56930 article and removed from the LCD.

Under Bibliography the first source was removed as the website is no longer available. The sources were renumbered accordingly to reflect the first source being removed.

08/22/2019

MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing LCD Number: L35072Revision Number: 16

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: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing A56842 article.

08/08/2019

MolDX: Cystatin C Measurement LCD Number: L37581Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Cystatin C Measurement A56948 article and removed from the LCD.

08/29/2019

MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease LCD Number: L37785Revision Number: 2

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease A56921 article and removed from the LCD.

08/22/2019

MolDX: Decipher® Prostate Cancer Classifier Assay LCD Number: L35868Revision Number: 11

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Decipher® Prostate Cancer Classifier Assay A56958 article and removed from the LCD.

08/29/2019

MolDX: DecisionDx-Melanoma LCD Number: L37725Revision Number: 2

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: DecisionDx-Melanoma A56961 article and removed from the LCD.

08/29/2019

MolDX: DecisionDx-UM (Uveal Melanoma) LCD Number: L37033Revision Number: 6

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) A56906 article and removed from the LCD.

08/22/2019

MolDX: EndoPredict Breast Cancer Gene Expression Test LCD Number: L37264Revision Number: 5

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression Test A56963 article and removed from the LCD.

8/29/19

MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test LCD Number: L37857Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test A56898 article and removed from the LCD.

08/22/2019


117 10/2019

MolDX: Genesight® Assay for Refractory Depression LCD Number: L35633Revision Number: 12

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Genesight® Assay for Refractory Depression A56927 article and removed from the LCD.

08/22/2019

MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease LCD Number: L36044Revision Number: 19

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease A56959 article and removed from the LCD.

08/29/2019

MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) LCD Number: L36089Revision Number: 9

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) A56899 article and removed from the LCD.

08/22/2019

MolDX: Genetic Testing for Lynch Syndrome LCD Number: L35024Revision Number: 16

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Genetic Testing for Lynch Syndrome A54987 article and removed from the LCD.

08/15/2019

MolDX: Genomic Health™ Oncotype DX® Prostate Cancer AssayLCD Number: L36153Revision Number: 14

All coding located in the Coding Information section has been removed from the LCD and is included in the Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay A56285 article. Under Sources of Information sources were removed and placed under Bibliography. Formatting, punctuation and typographical errors were corrected throughout the LCD.

08/15/2019

MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) LCD Number: L37699Revision Number: 2

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Guardant360® Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) A56960 article and removed from the LCD.

08/29/2019

MolDX: HLA-B*15:02 Genetic Testing LCD Number: L36033Revision Number: 8

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing A56877 article and removed from the LCD.

08/15/2019

MolDX: HLA-DQB1*06:02 Testing for Narcolepsy LCD Number: L36464Revision Number: 7

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy A56857 article and removed from the LCD.

08/15/2019

MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer LCD Number: L37870Revision Number: #2

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer A56924 article and removed from the LCD.

08/22/2019

118 10/2019


MolDX: MDS FISH LCD Number: L37602Revision Number: 1

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Summary of Evidence section has been removed from the LCD and is included in the related Billing and Coding: MolDX: MDS FISH A56913 article.

08/22/2019

MolDX: MGMT Promoter Methylation Analysis LCD Number: L35974Revision Number: 8

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: MGMT Promoter Methylation Analysis A56941 article and removed from the LCD

08/29/2019

MolDX: Molecular Diagnostic Tests (MDT) LCD Number: L35025Revision: 25

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A56853 article and removed from the LCD.

Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/15/2019

MolDX: Molecular RBC Phenotyping LCD Number: L36074Revision Number: 9

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Molecular RBC Phenotyping A56922 article and removed from the LCD.

08/22/2019

MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels LCD Number: L37713Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels A56851 article and removed from the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD.

08/15/2019

MolDX: myPath Melanoma AssayLCD Number: L37859Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: myPath Melanoma Assay A56858 article and removed from the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD.

08/15/2019

MolDX: NRAS Genetic Testing LCD Number: L35073Revision Number: 16

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: NRAS Genetic Testing A56962 article and removed from the LCD.

08/29/2019

MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) LCD Number: L37701Revision Number: 1

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) A56964 article and removed from the LCD.

08/29/2019

MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) LCD Number: L36912Revision Number: 7

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) A56870 article and removed from the LCD.

08/15/2019


119 10/2019

MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate CancerLCD Number: L37262Revision Number: 11

All coding located in the Coding Information section has been removed from the LCD and is included in the Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay A56285 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

08/15/2019

MolDX: Percepta® Bronchial Genomic Classifier LCD Number: L36854Revision Number: 5

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier A56849 article and removed from the LCD.

Under LCD Title changed the title from “MolDX: Percepta© Bronchial Genomic Classifier” to “MolDX: Percepta® Bronchial Genomic Classifier”.

Formatting, punctuation, and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

08/15/2019

MolDX: Prolaris™ Prostate Cancer Genomic Assay LCD Number: L35869Revision Number: 10

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay A56918 article and removed from the LCD.

08/22/2019

MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease LCD Number: L37043Revision Number: 6

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease A56911 article and removed from the LCD.

08/22/2019

MolDX: ProMark Risk Score LCD Number: L36665Revision Number: 4

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: ProMark Risk Score A56957 article and removed from the LCD.

08/29/2019

MolDX: Prometheus IBD sgi Diagnostic PolicyLCD Number: L37260Revision Number: 5

All coding located in the Coding Information section has been moved into the related Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy A56933 article and removed from the LCD

08/22/2019

120 10/2019


MolDX Article Updates

Revised ICD-10 LCD Article UpdatesThe table below provides a summary of recent Part A MolDX ICD-10 LCD revisions/updates. To view these revised LCDs, go to www.palmettogba.com/moldx. Select MolDX LCDs under the Topics section. Go to your state and select Medical Policies. Scroll down to the LCDs, NCDs, Coverage Articles section click on Coverage Articles and select Active LCDs. Then select the Submit button. The LCDs are listed in alphabetical order.

TitleLCD Article ID NumberRevision Number


Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) Article Number: A56593Revision Number: 4

Under CPT/HCPCS Codes Group 1: Codes added CPT® code 0097U.

Under Covered ICD-10 Codes Group 1: Paragraph changed verbiage from “One of the following diagnosis codes must be on the claim to bill for 87505” to “One of the following diagnosis codes must be on the claim to bill for 87505, 87506, or 0097U.”

08/15/2019

Billing and Coding: GlycoMark Testing for Glycemic Control Article Number: A56872NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for GlycoMark Testing for Glycemic Control L36761.

To receive a GlycoMark test denial, please submit the following claim information:

• CPT® code 84378 or 84999• An Advance Beneficiary Notice (ABN) is not required for

statutorily excluded services o For a voluntary issued ABN, append with GX modifiero To indicate a statutorily excluded service, append with a

GY modifier

08/15/2019

Billing and Coding: GlycoMark Testing for Glycemic Control Article Number: A56872Revision Number: 1

All coding located in the Coding Information section has been removed from the related GlycoMark Testing for Glycemic Control L36761 LCD and added to this article.

08/15/2019

Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays Article Number: A56871Revision Number: 1

All coding located in the Coding Information section has been removed from the related In Vitro Chemosensitivity & Chemoresistance Assays L34554 LCD and added to this article.

08/15/2019


121 10/2019

Billing and Coding: Lab: Bladder/Urothelial Tumor Markers Article Number: A53095Revision Number: 8

Under Article Title changed the name from “MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines Update” to “Billing and Coding: Lab: Bladder/Urothelial Tumor Markers”.

Under Article Text added the verbiage “The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L33420).” at the beginning of the section. The verbiage “To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:

• Select the appropriate CPT code • Enter 1 unit of service (UOS) • Select the appropriate ICD-10-CM code” was added at the

end of the section.

08/22/2019

Billing and Coding: Lab: Bladder/Urothelial Tumor Markers Article Number: A53095Revision Number: 9

All coding located in the Coding Information section has been removed from the related Lab: Bladder/Urothelial Tumor Markers L33420 LCD and added to this article.

08/22/2019

Billing and Coding: Lab: Flow Cytometry Article Number: A55717Revision Number: 3

Under Article Title changed the name from “Flow Cytometry Coverage Clarification” to “Billing and Coding: Lab: Flow Cytometry”.

Under Article Text added the verbiage “The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Flow Cytometry (L34513).” at the beginning of the section. The verbiage “To report a Flow Cytometry service, please submit the following claim information:

• Select the appropriate CPT® code • Enter 1 unit of service (UOS) •Select the appropriate ICD-10-

CM code” was added at the end of the section.

08/22/2019

Billing and Coding: Lab: Flow Cytometry Article Number: A55717Revision Number: 4

All coding located in the Coding Information section has been removed from the related Lab: Flow Cytometry L34513 LCD and added to this article.

08/22/2019

Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical StainsArticle Number: A56838NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Special Histochemical Stains and Immunohistochemical Stains L35922.

To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:

•Select the appropriate CPT® code•Enter 1 unit of service (UOS)

08/08/2019

122 10/2019


Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical StainsArticle Number: A56838Revision Number: 1

All coding located in the Coding Information section has been removed from the related Lab: Special Histochemical Stains and Immunohistochemical Stains L35922 LCD and added to this article.

08/08/2019

Billing and Coding: MolDX: 4Kscore Assay Article Number: A56932NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: 4Kscore Assay L36763.

To report a 4Kscore service, please submit the following claim information:

• Select CPT® code 81539.• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the

CPT® code in the comment/narrative field for the following Part B claim field/types: o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim

• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types: o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form

08/22/2019

Billing and Coding: MolDX: 4Kscore Assay Article Number: A56932Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: 4Kscore Assay L36763 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA Test Article Number: A56965NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: AlloSure® Donor-Derived Cell-Free DNA Test L37266.

To report an AlloSure® service, please submit the following claim information:

• Select CPT® code 81479• Enter 1 unit of service (UOS)• •Enter the appropriate DEX Z-Code™ identifier adjacent

to the CPT® code in the comment/narrative field for the following Part B claim field/types: o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim

• •Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types: o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form

• •Select the appropriate ICD-10-CM code

08/29/2019


123 10/2019

Billing and Coding: MolDX: AlloSure® Donor-Derived Cell-Free DNA Test Article Number: A56965Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: AlloSure® Donor-Derived Cell-Free DNA Test L37266 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: APC and MUTYH Gene Testing Article Number: A56824NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: APC and MUTYH Gene Testing L36827.

To report an APC and MUTYH Gene Testing service, please submit the following claim information:

• Select appropriate CPT® code• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the



• Select the appropriate ICD-10-CM code

08/08/2019

Billing and Coding: MolDX: APC and MUTYH Gene Testing Article Number: A56824Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: APC and MUTYH Gene Testing L36827 LCD and added to this article.

08/08/2019

Billing and Coding: MolDX: BDX-XL2 Article Number: A56929NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: BDX-XL2 L37031.

To report a BDX-XL2 service, please submit the following claim information:

• Select PLA code 0080U• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the



• Select ICD-10-CM code R91.1

08/22/2019

124 10/2019


Billing and Coding: MolDX: BDX-XL2 Article Number: A56929Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: BDX-XL2 L37031 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment Article Number: A56943NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Biomarkers in Cardiovascular Risk Assessment L36129.

To report a Biomarker in Cardiovascular Risk Assessment service, please submit the following claim information:

• Select the appropriate CPT® code• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




10/01/2019

Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment Article Number: A56943Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Biomarkers in Cardiovascular Risk Assessment L36129 LCD and added to this article.

10/01/2019

Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic TestingArticle Number: A56854NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: BRCA1 and BRCA2 Genetic Testing (L36082).

To report a BRCA1/BRCA2 Genetic Testing service, please submit the following claim information:





08/15/2019


125 10/2019

Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic TestingArticle Number: A56854Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: BRCA1 and BRCA2 Genetic Testing (L36082) LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: BRCA1 and BRCA2 Genetic TestingArticle Number: A56854Revision Number: 2

Under CPT/HCPCS Codes Group 1: Code added HCPCS codes 0102U, 0103U and 0104U. This revision is due to the third quarter CPT®/HCPCS Code Update and has a retroactive effective date of 7/1/2019.

07/01/2019

Billing and Coding: MolDX: Breast Cancer Assay: Prosigna Article Number: A56949NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Breast Cancer Assay: Prosigna L36125.

To report a Prosigna service, please submit the following claim information:

• Select CPT® code 81520 • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/29/2019

Billing and Coding: MolDX: Breast Cancer Assay: Prosigna Article Number: A56949Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Breast Cancer Assay: Prosigna L36125 LCD and added to this article.

08/29/2019

126 10/2019


Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test Article Number: A56875NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Breast Cancer Index™ (BCI) Gene Expression Test L37794.

Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.

The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:

• Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; and

• Patient has early-stage disease (T1-3, pN0, M0); and• Patient is lymph node negative• Patient has no evidence of distant breast cancer metastasis

(i.e., non-relapsed); and• Test results will be used in determining treatment

management of the patient for chemotherapy and/or extension of endocrine therapy.

MolDX expects this test will be performed once per patient lifetime on FFPE tissue from the primary tumor specimen obtained prior to adjuvant treatment.

To bill a BCI service, please provide the following claim information:

• CPT code 81518• Enter “1” in the Days/Unit field• Select the appropriate ICD-10-CM diagnosis• Enter the assigned Z-code™ in the comment/narrative field

for the following claim field/types: o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim

• Enter DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form


08/15/2019

Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test Article Number: A56875Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Breast Cancer Index™ (BCI) Gene Expression Test L37794 LCD and added to this article.

08/15/2019


127 10/2019

Billing and Coding: MolDX: Circulating Tumor Cell Marker Assays Article Number: A56873NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Circulating Tumor Cell Marker Assays L35071.

To report a CTC service, please submit the following claim information:

o Select the appropriate CPT® code o Enter 1 unit of service (UOS)o Enter the appropriate DEX Z-Code™ identifier adjacent to the


o Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types: o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form

08/15/2019

Billing and Coding: MolDX: Circulating Tumor Cell Marker Assays Article Number: A56873Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Circulating Tumor Cell Marker Assays L35071 LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular Assay Article Number: A56955NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: ConfirmMDx Epigenetic Molecular Assay L35632.

To report a ConfirmMDx epigenetic assay service, please submit the following claim information:




• Select the appropriate ICD-10-CM code.

08/29/2019

Billing and Coding: MolDX: ConfirmMDx Epigenetic Molecular Assay Article Number: A56955Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: ConfirmMDx Epigenetic Molecular Assay L35632 LCD and added to this article.

08/29/2019

128 10/2019


Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse Testing Article Number: A54799Revision Number: 10

All coding located in the Coding Information section has been removed from the related Lab: Controlled Substance Monitoring and Drugs of Abuse Testing L35724 LCD and added to this article.

Under Article Title changed the title from “Controlled Substance Monitoring and Drugs of Abuse Coding and Billing Guidelines” to “Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse Testing”. Under Article Text added the sentence “The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Controlled Substance Monitoring and Drugs of Abuse Testing L35724” to the first paragraph and added the last paragraph. Formatting, punctuation and typographical errors were corrected throughout the article.

08/29/2019

Billing and Coding: MolDX: Corus® CAD Assay Article Number: A56930NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Corus® CAD Assay L37612.To receive a Corus® CAD denial, please submit the following claim information:

• CPT® code 81493• An Advance Beneficiary Notice (ABN) is not required for


GY modifier• Enter the appropriate DEX Z-Code™ identifier adjacent to the



08/22/2019

Billing and Coding: MolDX: Corus® CAD AssayArticle Number: A56930Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Corus® CAD Assay L37612 LCD and added to this article.

08/22/2019


129 10/2019

Billing and Coding: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic TestingArticle Number: A56842NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing L35072.

To report a CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing service, please submit the following claim information:



• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form


08/08/2019

Billing and Coding: MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic TestingArticle Number: A56842Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing L35072 LCD and added to this article.

08/08/2019

Billing and Coding: MolDX: Cystatin C Measurement Article Number: A56948NEW

The information in this article contains billing, coding, or, other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Cystatin C Measurement L37581.

To report a Cystatin C service, please submit the following claim information:

• Select CPT® code 82610• Enter 1 unit of service (UOS)• Select the appropriate ICD-10-CM code

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT®/HCPCS codes included in this article. Providers are reminded that not all CPT®/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT®/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.

08/29/2019

Billing and Coding: MolDX: Cystatin C Measurement Article Number: A56948Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Cystatin C Measurement L37581 LCD and added to this article.

08/29/2019

130 10/2019


Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease Article Number: A56921NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (L37785).

To report an Decipher® Prostate Cancer Classifier Assay service, please submit the following claim information:




• Select ICD-10-CM code C61

08/22/2019

Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease Article Number: A56921Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease L37785 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test Article Number: A56898NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test L37857.

To report an Envisia Genomic Classifier service, please submit the following claim information:

o Select CPT® code 81479o Enter 1 unit of service (UOS)o Enter the appropriate DEX Z-Code™ identifier adjacent to the



o Select the appropriate ICD-10-CM code

08/22/2019


131 10/2019

Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test Article Number: A56898Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test L37857 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) Article Number: A56906NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) MolDX: DecisionDx-UM (Uveal Melanoma) (L37033).To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information:

• Select PLA code 0081U • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the

CPT® code in the comment/narrative field for the following Part B claim field/types:

o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim

• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:

o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form


08/22/2019

Billing and Coding: MolDX: Decipher® Prostate Cancer Classifier Assay Article Number: A56958NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Decipher® Prostate Cancer Classifier Assay L35868.

To report a Decipher® Prostate Cancer Classifier Assay service, please submit the following claim information:

• Select CPT® code 81479. • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the



• Select ICD-10-CM code C61.

08/29/2019

Billing and Coding: MolDX: Decipher® Prostate Cancer Classifier Assay Article Number: A56958Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Decipher® Prostate Cancer Classifier Assay L35868 LCD and added to this article.

08/29/2019

132 10/2019


Billing and Coding: MolDX: DecisionDx-Melanoma Article Number: A56961NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: DecisionDx-Melanoma L37725.

To report a DecisionDx-Melanoma service, please submit the following claim information:





08/29/2019

Billing and Coding: MolDX: DecisionDx-Melanoma Article Number: A56961Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: DecisionDx-Melanoma L37725 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) Article Number: A56906Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: DecisionDx-UM (Uveal Melanoma) L37033 and added to this article.

08/22/2019

Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression Test Article Number: A56963NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: EndoPredict Breast Cancer Gene Expression Test L37264.

To report an EndoPredict service, please submit the following claim information:





08/29/2019


133 10/2019

Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression Test Article Number: A56963Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: EndoPredict Breast Cancer Gene Expression Test L37264 LCD and added to this article.

08/29/2019

Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) Article Number: A56593Revision Number: 5

Under Covered ICD-10 Codes Group 1: Codes ICD-10 code D81.3 was deleted and ICD-10 codes D81.30, D81.31, D81.32, and D81.39 were added. Under Covered ICD-10 Codes Group 2: Codes ICD-10 code D81.3 was deleted and ICD-10 codes D81.30, D81.31, D81.32, and D81.39 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

Billing and Coding: MolDX: Genesight® Assay for Refractory Depression Article Number: A56927NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: GeneSight® Assay for Refractory Depression (L35633).To report a GeneSight® Psychotropic assay service, please submit the following claim information:





08/22/2019

Billing and Coding: MolDX: Genesight® Assay for Refractory DepressionArticle Number: A56927Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Genesight® Assay for Refractory Depression L35633 LCD and added to this article.

08/22/2019

134 10/2019


Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease Article Number: A56959NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36044.

To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:

• Select appropriate CPT® code • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/29/2019

Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease Article Number: A56959Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36044 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) Article Number: A56899NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (L36089).

To report a Genetic Testing for Hypercoagulability / Thrombophilia service, please submit the following claim information: o Select appropriate CPT® codeo Enter 1 unit of service (UOS)o Enter the appropriate DEX Z-Code™ identifier adjacent to the



08/22/2019


135 10/2019

Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) Article Number: A56899Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) L36089 LCD and added to this article.

8/22/19

Billing and Coding: MolDX: Genetic Testing for Lynch Syndrome Article Number: A54987Revision Number: 8

Under CPT/HCPCS Codes Group 1: Codes added CPT® codes 88341 and 88342 as they were inadvertently removed in Revision 5.

08/15/2019

Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay Article Number: A56285Revision Number: 1

Under Article Title changed the title from “MolDX: Oncotype DX® Genomic Prostate Score Coding and Billing Article” to “Billing and Coding: MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay”. Under Article Text added the verbiage “The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genomic Health™ Oncotype DX® Prostate Cancer Assay L36153 and MolDX: Oncotype DX® Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer L37262”. Removed the word “Score” from the first and second paragraph and replaced it with the word “Assay”. Added a bullet and corresponding verbiage “Select ICD-10-CM code C61” to the third paragraph. CPT® was inserted throughout the article where applicable.

08/15/2019

Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing Article Number: A56877NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: HLA-B*15:02 Genetic Testing L36033.

To report an HLA-B*15:02 service, please submit the following claim information:

• Select 81381• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/15/2019

136 10/2019


Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing Article Number: A56877Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: HLA-B*15:02 Genetic Testing L36033 LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy Article Number: A56857NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464.

08/15/2019

Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy Article Number: A56857Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464 LCD and added to this article.

08/15/2019


137 10/2019

Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility Article Number: A56859NEW

Medicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.

Claims for CPT® codes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.

HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.

Services for organ transplants must be billed as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.

HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.

09/09/2019

138 10/2019


Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility Article Number: A56859NEWcontinued

Acquisition charges do not apply to autologous transplants.

HLA CPT® codes unrelated to transplant testing have coverage as outlined in the following Local Coverage Determinations (LCDs):

• CPT® 81381 – The MolDX: HLA-B*15:02 Genetic Testing L36033 LCD addresses limited coverage for HLA-B*15:02 genotype testing.

• CPT® 81383 – The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.

09/09/2019

Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing Article Number: A56877NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: HLA-B*15:02 Genetic Testing L36033.

To report an HLA-B*15:02 service, please submit the following claim information:

• Select 81381• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/15/2019

Billing and Coding: MolDX: HLA-B*15:02 Genetic Testing Article Number: A56877Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: HLA-B*15:02 Genetic Testing L36033 LCD and added to this article.

08/15/2019


139 10/2019

Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer Article Number: A56924NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37870.

To report an InvisionFirst™ – Lung service, please submit the following claim information:

• Select CPT® code 81479• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/22/2019

140 10/2019


Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer Article Number: A56924Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37870 and added to this article.

08/22/2019

Billing and Coding: MolDX: MDS FISHArticle Number: A56913NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: MDS FISH L37602.

Coding for FISH TestingThere are two sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, one distinguishes between the two sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPT® codes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders. When a pathologist performs ISH techniques as an adjunct to a surgical pathology or cytopathology case, CPT® codes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual). These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.

To report an MDS FISH service, please submit the following claim information:

• Select the appropriate CPT® code • Enter 1 unit of service (UOS)• Select the appropriate ICD-10-CM code

A DEX Z-Code™ identifier is not required for FISH testing. If submitting a DEX Z-Code™ identifier, please submit following the below instructions:

• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types: o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim


08/22/2019


141 10/2019

Billing and Coding: MolDX: MDS FISH Article Number: A56913Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: MDS FISH L37602 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: MGMT Promoter Methylation Analysis Article Number: A56941NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: MGMT Promoter Methylation Analysis L35974.

To report a MGMT Promoter Methylation Analysis service, please submit the following claim information:

• Select Bill Type Code 022x – Skilled Nursing – Inpatient (Medicare Part B only)





08/29/2019

Billing and Coding: MolDX: MGMT Promoter Methylation Analysis LCD Article Number: A56941Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: MGMT Promoter Methylation Analysis L35974 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) Article Number: A56853NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L35025.

To report a Molecular Diagnostic Test service, please submit the following claim information:




08/15/2019

142 10/2019


Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) Article Number: A56853Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Molecular Diagnostic Tests (MDT) L35025 LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) Article Number: A56853Revision Number: 2

Under CPT/HCPCS Codes Group 1: Codes added code range 0084U-0104U. This revision is due to the Q3 2019 CPT/HCPCS Code Update and is effective for dates of service on or after 7/1/2019.

07/01/2019

Billing and Coding: MolDX: Molecular RBC Phenotyping Article Number: A56922NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular RBC Phenotyping (L36074).

To report a Molecular RBC Phenotyping service, please submit the following claim information:• Select PLA Code 0001U • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/22/2019

Billing and Coding: MolDX: Molecular RBC Phenotyping Article Number: A56922Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Molecular RBC Phenotyping L36074 LCD and added to this article.

08/22/2019

Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels Article Number: A56851NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels L37713.

08/15/2019

Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels Article Number: A56851Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels L37713 LCD and added to this article.

08/15/2019


143 10/2019


Under Article Text added all verbiage and corresponding bullet points under the first paragraph. Under CPT/HCPCS Codes Group 1: Codes added codes 0098U, 0099U, and 0100U. Under Covered ICD-10 Codes Group 1: Paragraph added the verbiage “0098U, 0099U, and 0100U” to the first sentence. This revision is due to the Q3 2019 CPT/HCPCS Code Update and is effective for dates of service on or after 7/1/2019.

07/01/2019


Under Covered ICD-10 Codes Group 1: Codes ICD-10 code D81.3 was deleted and ICD-10 codes D81.30, D81.31, D81.32, and D81.39 were added. This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

10/01/2019

Billing and Coding: MolDX: myPath Melanoma AssayArticle Number: A56858NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: myPath Melanoma Assay L37859.

08/15/2019

Billing and Coding: MolDX: myPath Melanoma AssayArticle Number: A56858Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: myPath Melanoma Assay L37859 LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: myPath Melanoma AssayArticle Number: A56858Revision Number: 2

Under Article Text added all verbiage and corresponding bullet points under the first paragraph. Under CPT/HCPCS Codes Group 1: Codes added code 0090U. This revision is due to the Q3 2019 CPT/HCPCS Code Update and is effective for dates of service on or after 7/1/2019.

07/01/2019

Billing and Coding: MolDX: NRAS Genetic Testing Article Number: A56962NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: NRAS Genetic Testing L35073.

To report a NRAS Genetic Testing service, please submit the following claim information:





08/29/2019

144 10/2019


Billing and Coding: MolDX: NRAS Genetic Testing Article Number: A56962Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: NRAS Genetic Testing L35073 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) Article Number: A56870NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) L36912.

To report an Oncotype DX® Breast Cancer for DCIS service, please submit the following claim information:

• Select PLA code 0045U• Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the




08/15/2019

Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) Article Number: A56870Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) L36912 LCD and added to this article.

08/15/2019


145 10/2019

Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) Article Number: A56964NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) L37701.

To report an Oncotype DX AR-V7 Nucleus Detect service, please submit the following claim information:





08/29/2019

Billing and Coding: MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) Article Number: A56964Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) L37701 LCD and added to this article.

08/29/2019

Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier LCD Article Number: A56849NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Percepta® Bronchial Genomic Classifier L36854.

To report a Percepta® Bronchial Genomic Classifier service, please submit the following claim information:

• Select CPT® code 81479.• Enter 1 unit of service (UOS).• Enter the appropriate DEX Z-Code™ identifier adjacent to the



• Select the appropriate ICD-10-CM code.

08/15/2019

146 10/2019


Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier Article Number: A56849Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Percepta® Bronchial Genomic Classifier L36854 LCD and added to this article.

08/15/2019

Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay Article Number: A56918NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prolaris™ Prostate Cancer Genomic Assay L35869.To report a Prolaris™ assay service, please submit the following claim information:

• Select CPT® code 81541• Enter 1 unit of service (UOS)

• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types:

o Loop 2400 or SV101-7 for the 5010A1 837P

o Box 19 for paper claim

• Enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:

o Line SV202-7 for 837I electronic claim

o Block 80 for the UB04 claim form • Select ICD-10-CM code C61

8/22/19

Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay Article Number: A56918Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Prolaris™ Prostate Cancer Genomic Assay L35869 LCD and added to this article.

8/22/19


147 10/2019

Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease Article Number: A56911NEW

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease (L37043).To report a Prolaris ™ prostate cancer assay service, please submit the following claim information:





08/22/2019

Billing and Coding: MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease Article Number: A56911Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease L37043 and added to this article.

08/22/2019

Billing and Coding: MolDX: ProMark Risk Score Article Number: A56957NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: ProMark Risk Score L36665.To report a ProMark assay service, please submit the following claim information:





08/29/2019

Billing and Coding: MolDX: ProMark Risk Score Article Number: A56957Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: ProMark Risk Score L36665 LCD and added to this article.

08/29/2019

148 10/2019


Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic PolicyArticle Number: A56933NEW

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prometheus IBD sgi Diagnostic Policy L37260.

To receive a Prometheus IBD sgi Diagnostic denial, please submit the following claim information:

• Select the applicable CPT® code• Enter 1 unit of service (UOS)• An Advance Beneficiary Notice (ABN) is not required for


GY modifier• If submitting a DEX Z-Code™ identifier, enter the

appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types: o Loop 2400 or SV101-7 for the 5010A1 837Po Box 19 for paper claim

• If submitting a DEX Z-Code™ identifier, enter the appropriate DEX Z-Code™ identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types: o Line SV202-7 for 837I electronic claimo Block 80 for the UB04 claim form

08/22/2019

Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy Article Number: A56933Revision Number: 1

All coding located in the Coding Information section has been removed from the related MolDX: Prometheus IBD sgi Diagnostic Policy L37260 LCD and added to this article.

08/22/2019


149 10/2019

MolDX: Billing and Coding for Lynch Syndrome Testing Services Article Number: A54987Revision Number: 5

Under Article ID changed the article title to Billing and Coding: MolDX: Genetic Testing for Lynch Syndrome.

Under Article Text added the verbiage” The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for Lynch Syndrome (L35024).” at the beginning of the section. Under the Step 2 – Method 2 subsection, added CPT® codes 81293 and 81294 to Step 5A, 81296 and 81297 to Step 5B, 81299 and 81300 to Step 5C, and 81318 and 81319 to Step 5D. The following verbiage was added at the end of this section:

“To report a Lynch Syndrome service, please submit the following claim information:

• Select the appropriate CPT® code • Enter 1 unit of service (UOS)• Enter the appropriate DEX Z-Code™ identifier adjacent to the



• Select the appropriate ICD-10-CM code”

08/15/2019


All coding located in the Coding Information section has been removed from the related MolDX: Genetic Testing for Lynch Syndrome (L35024). LCD and added to this article.

08/15/2019


Under CPT/HCPCS Codes Group 1: Codes added HCPCS codes 0101U and 0104U. This revision is due to the third quarter CPT®/HCPCS Code Update and has a retroactive effective date of 7/1/2019.

07/01/2019

150 10/2019


PROVIDER ENROLLMENT INFORMATION

You Can Track Your Enrollment Application

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

Enrollment Application Status Lookup links: JJA: https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHR2975&url=yes HHH: https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHR3825&url=yes JMA: https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBBR3N28&url=yes


151 10/2019

SKILLED NURSING FACILITY (SNF) INFORMATION

2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update


Provider Types Affected This MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and Durable Medical Equipment (DME) MACs, for services provided to Medicare beneficiaries who are in a Part A covered Skilled Nursing Facility (SNF) stay.

Provider Action Needed CR 11441 makes changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that will be used to revise Medicare’s Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF Consolidated Billing (CB) in Chapter 6, Section 110.4.1 and Chapter 6, Section 20.6 in the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf). Make sure your billing staffs are aware of these changes.

Background CWF currently has edits in place for claims received for beneficiaries in a Part A covered SNF stay, as well as for beneficiaries in a non-covered stay. These edits allow only those services excluded from CB to be separately paid. Barring any delay in the MPFS, the Centers for Medicare & Medicaid Services (CMS) will provide the new code files to CWF by November 1, 2019.

As soon as possible after the final MPFS is released, CMS will post the new code files at http://www.cms.gov/SNFConsolidatedBilling/. It is important and necessary for the provider/MAC community to view the “General Explanation of the Major Categories” file located at the bottom of each year’s update in order to understand the Major Categories including additional exclusions not driven by HCPCS codes.



152 10/2019


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/jma .

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/jma).


153 10/2019

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/Docs/Providers~JM%20Part%20A~Learning%20Education~Self-Paced%20Learning) of the JM Part A website.

154 10/2019


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.



155 10/2019

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.


156 10/2019


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


157 10/2019

HELPFUL INFORMATION

Contact Information for Palmetto GBA Part A

Provider Contact Center: 855-696-0705

Email Part A: https://www.palmettogba.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=01

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

https://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/JM%20Part%20A

158 10/2019


NOTES


159 10/2019

NOTE: Should you have landed here as a result of a search ......Current Dental Terminology, fourth...

Documents

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