NOTE: Should you have landed here as a result of a search ......Feedback for Your MAC: 2020 MAC...

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JM HHH Medicare AdvisoryLatest Medicare News for HHH

palmettogba.com/hhh

March 2020Volume 2020, Issue 03

The JM HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction M HHH. 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 HHH 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 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the Ameri-can 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 ..............................................................................................................3

Weekly Articles .......................................................................................................3MAC Satisfaction Indicator (MSI) Survery Information .........................................4

Feedback for Your MAC: 2020 MAC Satisfaction Indicator (MSI) Survey Will Be Coming Soon! .............................................................................................4

Home Health and Hospice Information ......................................................................5Claims Payment Issues Log .....................................................................................5Update to the Home Health Grouper for New Diagnosis Code for Vaping Related Disorder ....................................................................................................................62020 Annual Update to the Therapy Code List ........................................................7What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight ........................................................9January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 ............................................................................................................12 Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System ...........................................................17 eTicket Enables Providers to Save Time with Every Call ......................................27Never Share Your eServices User ID and Password ..............................................27ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider Contact Center .......................................28Get Your Medicare News Electronically ................................................................29Medicare Learning Network® (MLN) ...................................................................30

Medicare Beneficiary Identifier (MBI) Information ................................................31New Medicare Beneficiary Identifier (MBI) Get It, Use It ....................................31Medicare Beneficiary Identifier (MBI) Look-up Tool ............................................36

eServices Information .................................................................................................38Do You Have a Question Regarding eServices? We Can Help! .............................38How Can We Be of “eService” to You? .................................................................39eServices MBI: The Wait is Over ...........................................................................40

Fee Schedule Information ..........................................................................................41Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update ............................................................................41

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CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data con-tained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Influenza and Pneumococcal Pneumonia Vaccine Information .............................44Quarterly Influenza Virus Vaccine Code Update - July 2020 .................................44Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS ................................................46

Home Health Patient Driven Grouping Model (PDGM) Information...................47The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM) ..................................................................................................................47

Home Health Review Choice Demonstration (RCD) Information .........................51Need to stay abreast of the newest information regarding the Home Health Review Choice Demonstration (RCD)? .....................................51Quarterly Review Choice Demonstration (RCD) Medical Review Teleconference Schedule .................................................................................................................51

Learning and Education Information .......................................................................522020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule ........................................................................................522020 Jurisdiction M (JM) Hospice Medicare Workshop Series - Hitting the Target with Medicare ............................................................................522020 Jurisdiction M (JM) Home Health Medicare Workshop Series - Hitting the Target with Medicare ............................................................................54Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA ................................................................................................57

Provider Enrollment Information .............................................................................58Provider Enrollment Appeals Procedure ................................................................58You Can Track Your Enrollment Application .........................................................61

Tools That You Can Use ..............................................................................................63Medicare Secondary Payer (MSP) Coding Module ...............................................63

Helpful Information ....................................................................................................65Contact Information for Palmetto GBA Home Health and Hospice ......................65


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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

February 20, 2020https://www.cms.gov/files/document/2020-02-20.pdf

February 13, 2020https://www.cms.gov/files/document/2020-02-13-enews.pdf

Upcoming Home Health and Hospice Educational Events

2020 Jurisdiction M (JM) Hospice Medicare Workshop Series - Hitting the Target with Medicare Palmetto GBA is pleased to announce our 2020 Hospice Workshop Series “Hitting the Target with Medicare.” These workshops are designed to equip hospice providers and their staff with the tools they need to be successful with Medicare billing, coverage and documentation requirements.

2020 Jurisdiction M (JM) Home Health Medicare Workshop Series - Hitting the Target with MedicarePalmetto GBA is pleased to announce our 2020 Home Health Workshop Series “Hitting the Target with Medicare.” These workshops are designed to equip home health providers and their staff with the tools they need to be success-ful with Medicare billing, coverage and documentation requirements. 2020 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference SchedulePalmetto GBA will host a series of Medical Review Hot Topic Targeted Probe and Educate (TPE) Teleconferences in 2020. These calls are open to all providers. Please mark your calendars to join our Medical Review Subject Mat-ter Experts as they discuss and answer your questions concerning current TPE process.

Quarterly Review Choice Demonstration (RCD) Medical Review Teleconference Schedule If you are a home health provider in Illinois, North Carolina, Ohio, Florida or Texas, please join us for the quarterly Medical Review Choice Demonstration (RCD) teleconferences. These teleconferences will give you a chance to ask any questions you may have about RCD medical review topics. Each teleconference session will be held from 12 p.m. to 1 p.m. ET.

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

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February 6, 2020https://www.cms.gov/files/document/2020-02-06-enews.pdf

January 30, 2020https://www.cms.gov/files/document/2020-01-30-enews.pdf

January 23, 2020https://www.cms.gov/files/document/2020-01-23-enews.pdf

MAC SATISFACTION INDICATOR (MSI) SURVEY INFORMATION

Feedback for Your MAC: 2020 MAC Satisfaction Indicator (MSI) Survey Will Be Coming Soon!

Palmetto GBA wants to give you a chance to make your voice heard by providing feedback about your interaction with us over the past year.

The 2020 MAC Satisfaction Indicator (MSI), an annual survey administered by the Centers for Medicare & Medicaid Services (CMS), will be released soon.

The MSI provides you the opportunity to offer detailed feedback on Provider Enrolment, EDI and Claims, our Provider Contact Center, the eServices online portal and Palmetto GBA’s Provider Outreach and Education.


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Palmetto GBA has made numerous service improvements based on your feedback, and has more planned in the near future. See our “You Do Make a Difference” page for all the enhancements implemented.

Jurisdiction HHH: https://tinyurl.com/Feedback-HHH

HOME HEALTH AND HOSPICE INFORMATION

Claims Payment Issues Log

Palmetto GBA wants to keep you in the know, and one way we do this is by publishing a Claims Payment Issues Log. This log lets you know about any current system-related payment and processing issues. Many of these issues are reported to the Centers for Medicare & Medicaid Services (CMS), as well as the Multi-Carrier System (MCS) or Fiscal Intermediary Shared System (FISS) maintainers. If this log has an issue that impacts your claims and you’ve read about it on our site, sign up for an email to let you know if the article has been updated and/or the problem has been resolved. To do this, enter your information into the “Article Update Notification” box at the bottom of the individual log, and you’ll receive an email notice every time the log is changed.

To access these logs, please use the following links:

JJ Part A: https://www.palmettogba.com/palmetto/providers.nsf/DocsR/JJ-Part-A~AU2STG2520

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

JM Part A: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/JM-Part-A~8X7LPG4107

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JM Part B: https://www.palmettogba.com/palmetto/providers.nsf/docsCat/Providers~JM%20Part%20B~Browse%20by%20Topic~Claims%20Processing%20Issues%20Log

JM HHH: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/JM-Home-Health-and-Hospice~8XMNAE5202

Railroad Medicare (RRB SMAC): https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Railroad-Medicare~9AERC83708

Update to the Home Health Grouper for New Diagnosis Code for Vaping Related Disorder

MLN Matters Number: MM11656 Related CR Release Date: February 7, 2020 Related CR Transmittal Number: R2433OTN Related Change Request (CR) Number: 11656 Effective Date: April 1, 2020 Implementation Date: July 6, 2020

Provider Types Affected This MLN Matters Article is for Home Health Agencies (HHAs) billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11656 updates the version of the Home Health Grouper software used in Original Medicare claims processing. The new version includes the diagnosis code (U07.0) recently created for vaping related disorder. Make sure your billing staffs are aware of the update.

Background In response to recent occurrences of vaping related disorders, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing a new diagnosis code into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for reporting vaping-related disorder effective April 1, 2020. The Grouper Contractor, 3M Health Information Systems (3M-HIS), developed the new HH Grouper, Version 01.1.20, software package to accommodate this new code, effective for claim From dates on or after April 1, 2020. The HH Grouper assigns each claim into a Home Health Resource Group (HHRG) based on the reported claim and patient assessment information.

The revised HH Grouper and related documentation will be available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/CaseMixGrouperSoftware.


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There is no policy change. Current instructions regarding the HH Grouper are available in the Medicare Claims Processing Manual Publication, Chapter 10, Section 80 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf).

Additional Information

The official instruction, CR11656, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r2433otn.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 February 7, 2020 Initial article released.

2020 Annual Update to the Therapy Code List

MLN Matters Number: MM11501 Revised Related CR Release Date: January 28, 2020 Related CR Transmittal Number: R4501CP Related Change Request (CR) Number: 11501 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on January 29, 2020, to reflect an updated CR 11501. The update removed the sentence (When furnished to hospital outpatients, these two new biofeedback services will continue to be paid under the OPPS. ) from the CR policy section (1. below) about how the two new biofeedback codes are paid when furnished to hospital outpatients. Note that the two new biofeedback codes will be paid under the Medicare Physician Fee Schedule. The CR release date, transmittal number and link to the CR also changed. All other information is unchanged.

Provider Types Affected This MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries. Provider Action Needed CR 11501 updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2020 Current Procedural Terminology (CPT) and Level II HCPCS. Make sure your billing staffs are aware of these updates.

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Background Section 1834(k)(5) of the Social Security Act requires all claims for outpatient rehabilitation therapy services and all comprehensive outpatient rehabilitation facility services be reported using a uniform coding system. The CY 2020 CPT and Level II HCPCS is the coding system used for reporting these services. The therapy code listing is available at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html.

CR 11501 implements policies discussed in CY 2020 Medicare Physician Fee Schedule (MPFS) rulemaking. The CR updates the therapy code list and associated policies for CY 2020, as follows:

1. The CPT Editorial Panel created two new biofeedback codes to replace CPT code 90911. The Centers for Medicare & Medicaid Services (CMS) designated these new codes as “sometimes therapy” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physician assistants, and certified nurse specialists to furnish these services outside a therapy plan of care when appropriate. The two new “sometimes therapy” codes with their CPT long descriptors, are as follows:

• CPT code 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient

• CPT code 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

2. The CPT Editorial Panel also created, for CY 2020; CPT codes 97129 and 97130 to replace CPT code 97127, which CMS did not recognize. These new codes will effectively replace HCPCS code G0515, which will be deleted, effective January 1, 2020. These codes are designated “sometimes therapy” to permit physicians, NPPs, and psychologists to furnish these services outside a therapy plan of care when appropriate. The CPT long descriptors for the two new “sometimes therapy” codes are:

• CPT code 97129 - Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes

• CPT code 97130 - Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)

3. The CPT Editorial Panel also deleted the following codes for manual muscle testing for CY 2020: CPT codes 95831, 95832, 95833, and 95834.

4. The following 42 HCPCS Level II G-codes are deleted for dates of service after December 31, 2019:

• HCPCS codes G8978 through G8999; G9158 through G9176; and G9186


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These codes were used for Functional Reporting of therapy services for CY 2013 through 2018 but were retained for CY 2019 as discussed in the CY 2019 MPFS final rule at 83 FR 59661.

Note: CPT codes 0019T and 64550 are being removed from prior years, 2017 and 2019, respectively.

Additional Information The official instruction, CR 11501, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r4501cp.pdf.


Document History

Date of Change Description January 29, 2020 We revised the article to reflect an updated CR 11501. The update removed the

sentence (When furnished to hospital outpatients, these two new biofeedback services will continue to be paid under the OPPS.) from the CR policy section (1. above) about how the two new biofeedback codes are paid when furnished to hospital outpatients. Note that the two new biofeedback codes will be paid under the Medicare Physician Fee Schedule. The CR release date, transmittal number and link to the CR also changed. All other information is unchanged.

November 12, 2019 Initial article released. What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight

MLN Matters Number: SE19005 Revised Article Release Date: February 12, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We revised this article on February 12, 2020, to provide information on the impact of the final rule with comment CMS-1711-FC and to include a link to that final rule.

Provider Types Affected This MLN Matters® Special Edition Article is intended for new Home Health Agencies (HHAs) in the Medicare program.

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What You Need To Know SE 19005 provides important information about the Centers for Medicare & Medicaid Services’ (CMS) placement of new HHAs into a provisional period of enhanced oversight. You and your staff should be aware of these procedures.

Background The Affordable Care Act (ACA) included new statutory authority for a provisional period of enhanced oversight for new providers and suppliers to the Medicare program. See § 6401(a)(3) of the ACA and § 1866(j)(3) of the Social Security Act. The provisional period of enhanced oversight authority can help CMS address fraud, waste, and abuse concerns regarding particular providers and suppliers. Additionally, the provisional period of enhanced oversight will help CMS closely monitor provider or supplier types that historically have engaged in high levels of fraud, waste, and abuse.

What types of providers and/or suppliers will be affected by the initial use of the provisional period of enhanced oversight authority? CMS will focus on new HHAs in all states and territories during the provisional period of enhanced oversight authority for new HHAs that involves a suppression of Requests for Anticipated Payment (RAPs). See below for more information. In general, “new” providers, in the context of a provisional period of enhanced oversight, include providers that newly-enroll in the program, providers that submit changes of ownership (CHOWs) that fall under 42 C.F.R §489.18, and providers that submit changes of information reporting a100% ownership change. However, please note that as a result of CMS-1711-FC (https://www.federalregister.gov/documents/2019/11/08/2019-24026/medicare-and-medicaid-programs-cy-2020-home-health-prospective-payment-system-rate-update-home , published November 8, 2019, this particular provisional period of enhanced oversight involving a suppression of RAP payments will no longer apply to newly-enrolled HHAs (those certified to participate in Medicare on or after January 1, 2019) beginning January 1, 2020. HHAs that were certified to participate in Medicare on or after January 1, 2019 will not receive RAPs in calendar year 2020 and beyond based, instead, on the authority at 42 C.F.R. § 484.205(g)(2)(ii). This excludes all initial enrollments from this particular provisional period of enhanced oversight. However, the provisional period of enhanced oversight involving a suppression of RAP payments for new HHAs will continue to apply in CHOWs and changes of information that reflect a 100% change in ownership to the extent that these HHAs were certified to participate in Medicare prior to January 1, 2019.

What type of enhanced oversight? The provisional period will include a suppression of all RAP payments for 30 days to 1 year. RAPs are upfront payments HHAs receive before the beginning of a 60 day episode of home health services. All new HHAs will not receive RAPs as part of their billing process during the period of time they are in the provisional period of enhanced oversight. Each new HHA will receive individual notice of how long it will be in the provisional period of enhanced oversight with RAP suppression - the time period can vary from 30 days to 1 year.

When a new HHA submits a RAP while it is in the provisional period of enhanced oversight, the RAP will receive no payment. However, a new HHA must still submit a RAP for each home health episode in order for the final claim to be processed. New HHAs that are subject to RAP suppression will receive the appropriate, total payments for their services for each particular home health episode after the submission of a final claim.


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When will CMS start to place new HHAs into a provisional period of enhanced oversight? CMS began placing new HHAs into a provisional period of enhanced oversight with RAP suppression immediately following the issuance of MLN article SE19005.

How long will new HHAs be in a provisional period of enhanced oversight? New HHAs will be in a provisional period of enhanced oversight—and during that time subject to RAP suppression—for at least 30 days and not more than 1 year as per statutory authority.

How will new HHAs be notified that they are in a provisional period of enhanced oversight? CMS or one of its contractors will mail correspondence to new HHAs that are being placed in a provisional period of enhanced oversight. The correspondence will be mailed to the correspondence address that is on file for the HHA. The correspondence will include:

• The date on which the provisional period of enhanced oversight will be effective for the HHA and when it will end.

• Notice that while the HHA is in the provisional period of enhanced oversight all RAP payments will be suppressed.

• Notice that the HHA still needs to submit a RAP for each home health episode in order for the final claim to be processed.

Is this related to the Medicare final rule published November 13, 2018 (CMS-1689-FC) that eliminated RAP payments for newly-enrolled HHAs beginning January 1, 2020? No. The provisional period of enhanced oversight authority is a separate authority in the ACA and is unrelated to a recently published Medicare final rule with comment known as

CMS-1689-FC.1 As a result of this rule, newly-enrolled HHAs (those certified to participate in Medicare on or after January 1, 2019) will not receive RAP payments beginning January 1, 2020. If you would like more information about CMS-1689-FC and what it might mean for you, please submit an email inquiry to: [email protected].

References

• Section 6401(a)(3) of the Affordable Care Act is available at https://www.hhs.gov/sites/default/files/ppacacon.pdf beginning on page 687.

• Section 1866(j)(3) of the Social Security Act is available at https://www.ssa.gov/OP_Home/ssact/title18/1866.htm.

• Final rule with comment CMS-1711-FC is available at https://www.federalregister.gov/documents/2019/11/08/2019-24026/medicare-and-medicaid-programs-cy-2020-home-health-prospective-payment-system-rate-update-home.

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1 The full name of CMS-1689-FC is “Medicare and Medicaid Programs; CY2019 Home Health Prospective Payment System Rate Update and CY2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations”

Date of Change Description February 12, 2020 We revised the article to provide information on the impact of the final rule

with comment CMS-1711-FC and to include a link to that final rule.

October 25, 2019 We revised this article to clarify the answer to “What types of providers and/or suppliers will be affected by the initial use of the provisional period of enhanced oversight authority?” It also clarified when CMS started to place new HHAs into a provisional period of enhanced oversight. The article release date was updated.

February 15, 2019 Initial article released.

January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0

MLN Matters Number: MM11564 Revised Related CR Release Date: February 13, 2020 Related CR Transmittal Number: R4528CP Related Change Request (CR) Number: 11564 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on February 13, 2020, due to a revised Change Request (CR) that added two new attachments due to legislation. The CR release date, transmittal number and link to the transmittal also changed. All other information remains the same.

Provider Types Affected This MLN Matters Article is for hospitals, other providers and suppliers billing Medicare Administrative Contractors (MACs), including the Home Health and Hospice (HHH) MACs, for services provided to Medicare beneficiaries. What You Need To Know This article, based on CR 11564, informs MACs, including HHH MACs, and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2020. The I/OCE routes all institutional outpatient claims (which includes non-Outpatient Prospective Payment System (OPPS) hospital claims) through a single integrated OCE.


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CR 11564 provides the Integrated OCE instructions and specifications for the Medicare Integrated OCE version 21.0 that will be used as follows:

• Under the OPPS

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

• For limited services when provided in a home health agency not under the Home Health Prospective Payment System

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

Make sure your billing staffs are aware of these changes. Background The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/. The changes are summarized in the following table. Readers should also read through the entire document and note the highlighted sections, which also indicate changes from the prior release of the software. Some IOCE modifications in the update may be retroactively added to prior releases. If so, the retroactive date appears in the ‘Effective Date’ column.

Type Effective Date Edits Affected

Modification

Logic 01/01/2017 Add new payment method flag of Y (Contractor bypass applied to Section 603 service with reduction applied in OPPS Pricer) to be returned on output to identify a line(s) that have had a Contractor bypass applied and in addition the lines(s) need a reduction applied by Pricer. Note: The Contractor Bypass function is a CMS/Contractor related function and is not meant to be used by other end users or providers. See Contractor (MAC) Actions Impacting IOCE Processing for more information.

Logic 11/11/2019 110 Apply mid-quarter edit 110 (Service provided prior to initial marketing date) to HCPCS Q5115, if reported before 11/11/2019

Logic 01/01/2020 112 Implement new edit 112 (Information only service(s)) to line item reject HCPCS that are identified as being non-covered and meant for informational reporting purposes only. HCPCS applicable to the “information only service” list are available in the data file, Data_HCPCS.

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Logic 04/01/2018 106 Update Add-on code logic to separately edit drug administration add-on procedure codes, if the primary drug administration procedure is not present on the same claim. See Add-on Code Editing section for more information.

Logic 01/01/2020 22 Add the following new modifiers to the valid modifier list: • MA- Emer med cond susp/confirm • MB- Auc hardship, insuf internet • MC- Auc hardship, vendor issues • MD- Auc hardship, extreme circ • ME- Order adheres to auc • MF- Order does not adhere to auc • MG- Auc not applicable to order • MH- Auc consult not provided

Remove the following modifier from the valid modifier list: • GD- Unit of service > mue value • Reactivating the following modifier to the valid

modifier list: • CB- Esrd bene part a snf-sep pay

Documentation 01/01/2019 Update documentation for New Technology procedures being excluded from packaging with a Comprehensive APC J1 or J2 service. See Comprehensive APC processing section for more information.

Documentation 01/01/2020 Updated FQHC processing logic section for consistency purposes only. There are no logic changes being applied

Documentation 01/01/2020 Update specifications references to quarterly data files based on the new structure and file naming convention. Please note: Effective with v21.0 of the IOCE, quarterly data files are updated with a new structure, file-naming convention, and new tables. The file layout document should be used to aid users in identifying the new tables, layout, file-naming conventions, descriptions, and all applicable values where necessary.


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Content 01/01/2020 Make all HCPCS/APC/SI changes as specified by CMS. Updates were made to the following lists (please review the Quarterly Data Table Reports for additional detail). Due to the new table and file structure for Jan 2020, the tables that are updated which reference a list are specified below. MAP_ADDON_TYPE I • Addon Type I procedures (edit 106)

MAP_ADDON_DRUG_ADMIN • Drug administration add on procedures (edit 106)

(new list)

DATA_CAPC • Comprehensive APC list (updated list and rank)

MAP_CAPC • CAPC Complexity Adjusted Code Pairs

OFFSET_HCPCS • Terminated Device Procedures for offset APC

OFFSET_APC • Pass-through radiopharmaceutical for offset APC

(edit 99) • Pass-through skin substitute product for offset

APC (edit 99) • Pass-through contrast for offset APC (edit 99) • Pass-through stress agent for offset APC (edit 99)

OFFSET_CODEPAIRS Device Offset Code Pairs (code pair updates for pass-through device offset logic)

DATA_HCPCS • C-APC Exclusions list • Questionable Service list (edit 12) • Information Only Service list (edit 112) (new

list) • Low and High Cost Skin Substitute list (edit 87)

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• FQHC Non-Covered list • Daily Mental Health services list • Mental Health Not billable under PHP (edit 80) • Conditional bilateral list • Inherent bilateral list • Device and Device Intensive Procedures (edit 92) • Non-Standard Ct Scan HCPCS subject to NEMA • X-ray procedure list applicable for modifiers FX/

FY- CAA Section 502b • Non-covered services lists (SI = E1, for edits 9,

28, 50,) • Non-reportable for OPPS list (SI = B, edit 62) • Services not billable to MAC list (SI = M, edit

72) • Separate payment not provided list (SI = E2, edit

13) • Drug Administration Addon Code (edit 106)

(new list) • Procedure and Sex Conflict lists (edit 8) • Deductible Coinsurance Not Applicable list

MAP CONFLICT RHC • RHC CG modifier non-payable conflict

DATA_MODIFIER Valid Modifier list

Data Table Reports

01/01/2020 The following Data Table Report(s) is updated to include new fields: DATA_HCPCS • Addon_Drug_Admin • Information_Only

The following Data Table Report(s) is added:

MAP_ADDON_DRUG_ADMIN

Please review the File Layout document for the descriptions of all Data Table Reports and associated fields and field values

01/01/2020 20, 40 Implement version 26.0 of the NCCI (as modified for applicable outpatient institutional providers).

Additional Information The official instruction, CR11564, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/R4528cp.pdf.


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Document History

Date of Change Description February 13, 2020 Note: We revised this article due to a revised CR that added two new

attachments due to legislation. The CR release date, transmittal number and link to the transmittal also changed. All other information remains the same.

January 7, 2020 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: February 3, 2020 per CR11141 Implementation Date: July 1, 2019

Note: We revised this article on January 16, 2020, to link to CR11141 at https://www.cms.gov/files/document/r2419OTN.pdf, which shows the effective date is now February 3, 2020. 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 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).

Make sure your billing staffs are aware of these changes.

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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)

• Unified Program Integrity Contractor (UPIC)


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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 NPPESProvider 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)

Illustration of the main page

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

Illustration of the edit icon showing a pencil icon.Pencil icon is circled.


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

Shows checks for profile and address and on health information exchange section.

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

Optional endpoint is shown. Endpoint provides a simple secure scalable and standards-based way for participants to send authenticated encrypted health information directly to known trusted recipients over the internet. Endpoint information will be made available on the NPI registry API and data dissemination files for users to receive and consume

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]

Illustration of Search for Affiliation

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)

Illustration Screen to Enter the Affiliation


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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)

Endpoint Location Address Screen

Click Save.

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

Optional Endpoint Exchanging Healthcare Information Screen

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) existing endpoint screen

Existing Endpoint Screen


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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.

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.

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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. Also, see CR11141 at https://www.cms.gov/files/document/r2419OTN.pdf, which shows the effective date is now February 3, 2020.

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 Document History Date of Change Description January 16, 2020 We revised the article to link to CR11141 at https://www.cms.gov/files/

document/r2419OTN.pdf, which shows the effective date is now February 3, 2020. All other information remains the same.

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.

January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN Matters Number: MM11605 Revised Related CR Release Date: February 4, 2020 Related Transmittal Number: R4513CP & R267BP Related Change Request (CR) Number: 11605 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on February 4, 2020, due to an updated CR 11605. To reflect the updated CR in the article, we added Section 12.d. (Radiopharmaceuticals with Pass-Through Status as a Result of Division N, Title I, Subtitle A, Section 107(a) of the Further Consolidated Appropriations Act of 2020 (Public Law 116-94)) and Section 19 Extravascular Implantable Cardioverter Defibrillator (EV ICD). We renumbered existing Sections 12.d through 12.e. and changed Section 19 (Coverage Determinations) to Section 20. We also added Table 11 (Radiopharmaceuticals Receiving Pass-Through Status in Accordance with Public Law 116-94) and Table 14 (Extravascular Implantable Cardioverter Defibrillator (EV ICD) Effective January 1, 2020). We renumbered existing tables 11 through 13. The CR release date, transmittal numbers and link to the transmittals were also changed. All other information remains the same.

Provider Type Affected This MLN Matters article is for institutional providers billing Medicare Administrative Contractors (MACs) for hospital outpatient services provided to Medicare beneficiaries.

Provider Action Needed CR 11605 describes changes to and billing instructions for various payment policies that Medicare is implementing in the January 2020 Outpatient Prospective Payment System (OPPS) update. Make sure your billing staffs are aware of these changes.

Background The January 2020 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), Status Indicator (SI), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 11605. The CR identifies areas of key changes to billing instructions for various payment policies implemented in the January 2020 OPPS update. Those changes are as follows:

1.a. New Device Pass-Through Categories Section 1833(t)(6)(B) of the Social Security Act (the Act) requires that, under the OPPS, categories of devices be eligible for transitional pass-through payments for at least 2, but not more than 3 years. Section 1833(t)(6)(B)(ii)(IV) of the Act requires that we create additional categories for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices. The Centers for Medicare & Medicaid Services (CMS) is establishing five new device pass-through categories as of January 1, 2020. The following table provides a listing of new coding and payment information concerning the new device categories for transitional pass-through payment.

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

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Table 1 – New Device Pass-Through Codes Effective January 1, 2020

HCPCS Effective Date

SI APC Short Descriptor

Long Descriptor Device Offset from Payment

C1734 1/01/2020 H 2026 Orth/devic/drug bn/bn, tis/bn

Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)

CPT 27870 - $5,805.17

CPT 28705 - $8,354.15

CPT 28715 – $6,096.73

CPT 28725 – $5,291.06

C1824 01/01/2020 H 2024 Generator, CCM, implant

Generator, cardiac contractility modulation (implantable)

$13,019.03

C1839 01/01/2020 H 2028 Iris prosthesis Iris prosthesis $149.82 C1982 01/01/2020 H 2025 Cath, pressure, Catheter, pressure-generating, $2124.38

valve-occlu one-way valve, intermittently occlusive

C2596 01/01/2020 H 2027 Probe, robotic, water-jet

Probe, image-guided, robotic, waterjet ablation

$0.00

b. Device Offset from Payment: Section 1833(t)(6)(D)(ii) of the Act requires that we deduct from pass-through payments for devices an amount that reflects the device portion of the APC payment amount. This deduction is known as the device offset, or the portion(s) of the APC amount that is associated with the cost of the pass-through device. The device offset from payment represents a deduction from pass-through payments for the applicable pass-through device. CMS has determined:

• The device offset amounts for APC 5115 (Level 5 Musculoskeletal Procedures) and APC5116 (Level 6 Musculoskeletal Procedures) that are associated with the costs of the device category described by HCPCS code C1734 (Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)). The device in the category described by HCPCS code C1734 should always be billed with one of the following Current Procedural Terminology (CPT) codes:

o CPT code 27870 (Arthrodesis, ankle, open) which is assigned to APC 5115 for Calendar Year (CY) 2020;

o CPT code 28705 (Arthrodesis; pantalar) which is assigned to APC 5116 for Calendar Year (CY) 2020;

o CPT code 28715 (Arthrodesis; triple) which is assigned to APC 5115 for Calendar Year (CY) 2020 or;

o CPT code 28725 (Arthrodesis; subtalar) which is assigned to APC 5115 for Calendar Year (CY) 2020.


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• The device offset amount for APC 5231 (Level 1 Implantable Cardioverter-Defibrillator (ICD) and Similar Procedures) that is associated with the cost of the device category described by HCPCS code C1824 (Generator, cardiac contractility modulation (implantable)). The device in the category de-scribed by HCPCS code C1824 should always be billed with CPT code 0408T (Insertion or replace-ment of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transve-nous electrodes) which is assigned to APC 5231 for Calendar Year (CY) 2020.

• The device offset amount for APC 5491 (Level 1Intraocular Procedures) that is associated with the cost of the device category described by HCPCS code C1839 (Iris prosthesis). The device in the category described by HCPCS code C1839 should always be billed with CPT code 66999 (Unlisted procedure, anterior segment of eye), which is assigned to APC 5491 for Calendar Year (CY) 2020.

• The device offset amount for APC 5193 (Level 3 Endovascular Procedures) that is associated with the cost of the device category described by HCPCS code C1982(Catheter, pressure-generating, one-way valve, intermittently occlusive). The device in the category described by HCPCS code C1982 should always be billed with CPT Code 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction), which is assigned to APC 5193 for Calendar Year (CY) 2020.

• The device offset amount for APC 5376 (Level 6 Urology and Related Services) that is associated with the cost of the device category described by HCPCS code C2596(Probe, image-guided, robot-ic, waterjet ablation). The device in the category described by HCPCS code C2596 should always be billed with CPT code 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cysto-urethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when per-formed)), which is assigned to APC 5376 for Calendar Year (CY) 2020.

Refer to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ passthrough_payment.html for the most current device pass-through information.

c. Transitional Pass-Through Payments for Designated Devices Certain designated new devices are assigned to APCs and identified by the I/OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for device(s) used in the procedure. The I/OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible. All related payment calculations will be returned on the same APC line and identified as a designated new device. Refer to Addendum P of the CY2020 final rule with comment period for the most current OPPS HCPCS Offset file. Addendum P is available via the Internet on the CMS website.

d. Alternative Pathway for Devices That Have a Food and Drug Administration (FDA)Breakthrough Designation For devices that have received FDA marketing authorization and a Breakthrough Device designation from the FDA, CMS provided an alternative pathway to qualify for device pass-through payment status, under which devices would not be evaluated in terms of the current substantial clinical improvement criterion for the purposes of determining device pass-through payment status. The devices would still need to meet


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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS

the other criteria for pass-through status. This applies to devices that receive pass-through payment status effective on or after January 1,2020.

2.New Separately Payable Procedure Codes a. Medical Procedures Effective January 1, 2020, new HCPCS codes C9757 and C9758 have been created a sdescribed in the following table:

Table 2 – New Separately Payable Procedure Codes for Medical Procedures Effective January 1, 2020

HCPCS Code

Short Descriptor Long Descriptor APC SI

C9757 Spine/lumbar disk surgery

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

5115 J1

C9758 Interatrial shunt ide Blinded procedure for nyha class iii/iv heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study

1589 T

b. Blood Products Effective January 1, 2020, new HCPCS code P9099 has been created as described in the following table:

Table 3 – New Procedure Codes for Blood Products Effective January 1, 2020

HCPCS Code Short Descriptor Long Descriptor APC SI P9099 Blood component/

product noc Blood component or product not otherwise classified

N/A E2

3. Billing for Devices Under the OPPS Effective for dates of service beginning on or after January 1, 2019, providers may bypass the claims processing edit that requires a device HCPCS for the procedure. For certain device-intensive procedures that describe situations in which a device may not be required, providers may bypass the claims processing edits that require a device by reporting modifier “CG”. In light of this policy change, we are modifying section 61.2 of chapter 4 of the Medical Claims Processing Manual, publicatioin100-04. The modified manual section is part of CR11605.


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4.Comprehensive APCs (C-APCs) a. Two New Comprehensive APCs (C-APCs) Effective January 1, 2020 Comprehensive APCs provide a single payment for a primary service, and payment for all adjunctive services reported on the same claim is packaged into payment for the primary service. With a few exceptions, all other services reported on a hospital outpatient claim in combination with the primary service are considered to be related to the delivery of the primary service and packaged into the single payment for the primary service.

Each year, in accordance with section 1833(t)(9)(A) of the Act, we review and revise the services within each APC group and the APC assignments under the OPPS. As stated in the CY 2020 OPPS/ASC final rule with comment period, as a result of our annual review of the services and the APC assignments under the OPPS, we finalized the addition of two new C-APCs under the existing C-APC payment policy effective January 1, 2020. The new C-APCs that are effective January 1, 2020, include:

• C-APC 5182 (Level 2 Vascular Procedures) and • C-APC 5461 (Level 1 Neurostimulator and Related Procedures).

The following table lists these new C-APCs:

Table 4 — New Comprehensive APCs for CY 2020

CY 2020 APC CY 2020 APC Descriptor 5182 Level 2 Vascular Procedures 5461 Level 1 Neurostimulator and Related Procedures

The addition of these new C-APCs increases the total number of C-APCs to 67 for CY 2020. We note that Addendum J to the CY 2020 OPPS/ASC final rule with comment period contains all the data related to the C–APC payment policy methodology, including the list of complexity adjustments and other information for CY 2019. In addition, we note that HCPCS codes assigned to comprehensive APCs are designated with status indicator “J1” in the latest OPPS Addendum B, which is available at https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html.

b. Exclusion of Procedures Assigned to New Technology APCs from the C-APC Policy For CY 2020, we finalized a policy to continue to exclude payment for any procedure that isassigned to a New Technology APC from being packaged when included on a claim with a “J1” service assigned to a C-APC. We also finalized a policy to exclude payment for any procedures that are assigned to a New Technology APC from being packaged into the payment for comprehensive observation services (C-APC 8011) assigned to status indicator “J2” when the New Technology procedures are included on a claim with “J2” procedures. We note that HCPCS codes assigned to comprehensive APCs are designated with status indicator “J1” or “J2” in the latest OPPS Addendum B, which are available at https://www.cms.gov/ Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html. Further information on C-APC 8011 (Comprehensive Observation Services) is in the CY 2020 OPPS/ASC final rule with comment period.


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http:https://www.cms.govhttps://www.cms.gov/Medicare

5. Changes to the Inpatient – Only list (IPO) for CY 2020 The Medicare IPO list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. For CY 2020, CMS is removing 11 procedures from the IPO list. The changes to the IPO list for CY 2020 are in Table 5.

Table 5 — Changes to the IPO list for CY 2020

CY 2020 CPT Code

CY 2020 Long Descriptor Final Action CY 2020 OPPS APC Assignment

CY 2020 OPPS Status Indicator

27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft

Remove from the IPO

5115 J1

22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/ or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar;

Remove from the IPO

5115 J1

22634 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (list separately in addition to code for primary procedure)

Remove for the IPO

N/A N

63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical

Remove from the IPO

5114 J1

63266 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic

Remove from the IPO

5114 J1

63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Remove from the IPO

5114 J1

63268 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral

Remove from the IPO

5114 J1

00802 Anesthesia for procedures on lower anterior abdominal wall; panniculectomy

Remove from the IPO

N/A N


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CY 2020 CPT Code

CY 2020 Long Descriptor Final Action CY 2020 OPPS APC Assignment

CY 2020 OPPS Status Indicator

00865 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic)

Remove from the IPO

N/A N

00944 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy

Remove from the IPO

N/A N

01214 Anesthesia for open procedures involving hip joint; total hip arthroplasty

Remove from the IPO

N/A N

6. Changes to Medical Review for Certain Inpatient Hospital Admissions under Medicare Part A For CY 2020 and subsequent years, we finalized a policy to exempt procedures that have been removed from the IPO list from certain medical review activities related to compliance with the 2-midnight rule, which states that generally services are considered appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).

Specifically, procedures that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2-midnight rule within the 2-calendar years following their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) in determining whether a provider exhibits persistent noncompliance with the 2-midnight rule for purposes of referral to the RAC nor will these procedures be reviewed by RACs for “patient status” within the 2-calendar years following their removal from the IPO list. During this 2-year period, BFCC-QIOs will have the opportunity to review claims for procedures that have been recently removed from the IPO list in order to provide education for practitioners and providers regarding compliance with the 2-midnight rule, but claims identified as noncompliant with the 2-midnight rule will not be denied with respect to the site-of-service under Medicare Part A.

7.Supervision of Outpatient Therapeutic Services The generally applicable minimum required level of supervision for hospital out patient therapeutic services will change on January 1, 2020, from direct supervision to general supervision for services furnished by all hospitals and Critical Access Hospitals (CAHs). General supervision is defined in regulation at 42 Code of Federal (CFR) 410.32(b)(3)(i) to mean that the procedure is furnished under the physician’s overall direction and control, but that the physician’s presence is not required during the performance of the procedure. All the policy safeguards that have been in place to ensure the safety, health, and quality standards of the outpatient therapeutic services that beneficiaries receive will continue to be in place under our new policy. These safeguards include allowing providers and physicians the discretion to require a higher level of supervision to ensure a therapeutic outpatient procedure is performed without risking a beneficiary’s safety or their quality of the care, as well as the presence of outpatient hospital and CAH Conditions of Participation (CoPs), and other state and federal laws and regulations.

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