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JM HHH Medicare AdvisoryLatest Medicare News for HHH

palmettogba.com/hhh

July 2020Volume 2020, Issue 07

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 .......................................................................................................3Special Edition Articles ..........................................................................................4New COVID-19 FAQs on Medicare Fee-for-Service Billing ..................................4COVID-19: Using the CR Modifier and DR Condition Code .................................4Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients ...............................................................................................................5

Coronavirus (COVID-19) Information .......................................................................5Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) ..............................................................................5

Home Health and Hospice Information ....................................................................16Quarterly Update to Home Health (HH) Grouper ..................................................16Therapy Codes Update ...........................................................................................17Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component .................................................................................................19July 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.2 ............................................................................................................22July 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) ....................................................................................................................26eTicket Enables Providers to Save Time with Every Call ......................................55Never Share Your eServices User ID and Password ..............................................56ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider Contact Center .......................................56Get Your Medicare News Electronically ................................................................57Medicare Learning Network® (MLN) ...................................................................58

Appeals Information ...................................................................................................59Part A East (PAE) Appeals Demo with the Qualified Independent Contractor (QIC) C2C Solutions ............................................................................59New eServices Feature ...........................................................................................59

Audit and Reimbursement Information ...................................................................60Unsolicited Voluntary Refunds ...............................................................................60 Cost Report Due Dates ...........................................................................................60

2 07/2020

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.

Electronic Data Interchange (EDI) Information ......................................................61Claim Status Category Codes and Claim Status Codes Update .............................61Implement 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 .......................................................................62Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update ....................64

eServices Information .................................................................................................65New eServices Appeals Feature .............................................................................65eServices Profile Verification Timeframes .............................................................66Do You Have a Question Regarding eServices? We Can Help! .............................66How Can We Be Of “eServices “ To You! .............................................................66eServices and Google Authenticator ......................................................................67

Fee Schedule Information ..........................................................................................69July Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule ................................................69Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules ..............72

Learning and Education Information .......................................................................802020 Jurisdiction M (JM) Home Health Medicare Workshop Series - Hitting the Target with Medicare ............................................................................802020 Jurisdiction M (JM) Hospice Medicare Workshop Series - Hitting the Target with Medicare ............................................................................82Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA .........................................................................................................84

Provider Enrollment Information .............................................................................85You Can Track Your Enrollment Application .........................................................85

Tools That You Can Use ..............................................................................................87Medicare Secondary Payer (MSP) Coding Module ...............................................87

Helpful Information ....................................................................................................89Contact Information for Palmetto GBA Home Health and Hospice ......................89

Upcoming Home Health and Hospice Educational Events

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 successful with Medicare billing, coverage and documentation requirements.

2020 Jurisdiction M (JM) Hospice Medicare Workshop Series - Hitting the Target with MedicarePalmetto 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.

For more information and registration instructions to attend these education sessions, please go to Page 80 of this issue.


3 07/2020

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

June 18, 2020https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-06-18-mlnc



May 28, 2020https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-28-mlnc

4 07/2020


Special Edition Articles

Friday, May 29, 2020: COVID-19: New FAQs on Medicare FFS Billing

New COVID-19 FAQs on Medicare Fee-for-Service Billing

CMS released additional Frequently Asked Questions (FAQs) (PDF) (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf) on our recent COVID-19-related waivers to help providers, including physicians, hospitals, and rural health clinics. Find more answers to questions on:

• Outpatient therapy

• Telehealth and appropriate coding

• Federally qualified health centers

Bookmark this document and check back for additional updates.

For More Information:

• Coronavirus.gov (https://www.cdc.gov/coronavirus/2019-ncov/index.html)

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

Monday, June 1, 2020: COVID-19: Using the CR Modifier and DR Condition Code

COVID-19: Using the CR Modifier and DR Condition Code

CMS revised MLN Matters Special Edition Article SE20011 on Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF) (https://www.cms.gov/files/document/se20011.pdf) to clarify when you must use modifier CR (catastrophe/disaster related) and/or condition code DR (disaster related) when submitting claims to Medicare. The update includes a chart of blanket waivers and flexibilities that require the modifier or condition code.


5 07/2020

Friday, June 19, 2020: Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients

Today, the Centers for Medicare & Medicaid Services (CMS) has instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html) that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID like in an outbreak. Original Medicare and Medicare Advantage plans will cover COVID-19 lab tests consistent with CDC guidance.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

Read the Medicare Learning Network article: https://www.cms.gov/files/document/se20011.pdf .

Read the memo to Medicare Advantage plans: https://cms.gov/files/document/hpms-memo-diagnostic-testing-nursing-home-residents-and-patients-coronavirus-disease-2019.pdf.

More information about Medicare coverage of COVID-19 tests is available at: https://www.medicare.gov/coverage/coronavirus-disease-2019-covid-19-tests.

CORONAVIRUS (COVID-19) INFORMATION

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

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

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

6 07/2020


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

Provider Information Available The Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020. The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued. More Information:

• Coronavirus Waivers and Flexibilities webpage

• Instructions to request an individual waiver if there is no blanket waiver

Background

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

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

2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-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.

Clarification for Using the “CR” Modifier and “DR” Condition Code When a PHE is declared and section 1135 authority is invoked, CMS has the authority to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Act, to approve blanket waivers of certain Social Security Act requirements. These waivers help prevent gaps in access to care for beneficiaries impacted by the emergency. In previous emergencies, CMS issued a limited number of waivers for the Medicare Fee-for-Service program. In order to allow CMS to assess the impact of prior emergencies, CMS has required the use of modifier “CR” and condition code “DR” for all services provided in a facility operating pursuant to CMS waivers that typically were in place, for limited geographical locations and durations of time.

For the COVID-19 PHE, CMS has issued many additional blanket waivers, flexibilities and modifications to existing deadlines and timetables that apply to the whole country. The full list of waivers and flexibilities can be found here (https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf). Due to the large volume and scope of these new blanket waivers and flexibilities, CMS is clarifying which require the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare.


7 07/2020

The chart below identifies those blanket waivers and flexibilities for which CMS requires the use of the modifier or condition code. Submission of the modifier or condition code is not required for any waivers or flexibilities not included in this chart.

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

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

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

X

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

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

X

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

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

X

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

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

X

8 07/2020


Care for Patients in Extended Neoplastic Disease Care Hospital

Allows extended neoplastic disease care hospitals to exclude inpatient stays where the hospital admits or discharges patients in order to meet the demands of the emergency from the greater than 20-day average length of stay requirement, which allows these facilities to be excluded from the hospital inpatient prospective payment system and paid an adjusted payment for Medicare inpatient operating and capital-related costs under the reasonable cost-based reimbursement rules.

X

Skilled Nursing Facilities (SNFs)

Using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

X

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

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

X

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

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

X


9 07/2020

Critical Access Hospitals

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

X

Replacement 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.

X

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

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

X

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

X

Waivers of certain hospital and Community Mental Health Center (CMHC) Conditions of Participation and provider-based rules

Allows a hospital or Community Mental Health Center (CMHC) to consider temporary expansion locations, including the patient’s home, to be a provider-based department of the hospital or extension of the CMHC, which allows institutional billing for certain outpatient services furnished in such temporary expansion locations. If the entire claim falls under the waiver, the provider would only use the DR condition code. If some claim lines fall under this waiver and others do not, then the provider would only append the CR modifier to the particular line(s) that falls under the waiver.

X X

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

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

X X

10 07/2020


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

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

X

Face-to-face and In-person Requirements for national and local coverage determinations

In the interim final rule with comment period (CMS-1744-IFC) CMS states that to the extent a national or local coverage determination would otherwise require a face-to-face or in-person encounter for evaluations, assessments, certifications or other implied face-to-face services, those requirements would not apply during the COVID-19 public health emergency.

X

Requirement for DMEPOS Prior Authorization

The requirement to submit a prior authorization request for certain DMEPOS items and services was paused. Suppliers were given the option to voluntary continue submitting prior authorization requests or to skip prior authorization and have the claim reviewed through post payment review at a later date. Claims that would normally require prior authorization, but were submitted without going through the process should be submitted with a CR modifier.

X

Signature requirements for proof of delivery

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

X

Part B Prescription Drug Refills

MACs may exercise flexibilities regarding the payment of Medicare Part B claims for drug quantities that exceed usual supply limits, and to permit payment for larger quantities of drugs, if necessary. MACs may require the use of the CR modifier in these cases.

X

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

• COVID-19 FAQs (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf)

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


11 07/2020

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

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

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency

CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

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

When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE, bill with:

• Place of Service (POS) equal to what it would have been had the service been furnished in-person

• Modifier 95, indicating that the service rendered was actually performed via telehealth

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

• Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier

• Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

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

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

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

12 07/2020


Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services

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

Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the PHE; that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes:

• Office and other outpatient services

• Hospital observation services

• Emergency department services

• Nursing facility services

• Domiciliary, rest home, or custodial care services

• Home services

• Online digital evaluation and management services

Cost-sharing does not apply to the above medical visit services for which payment is made to:

• Hospital Outpatient Departments paid under the Outpatient Prospective Payment System

• Physicians and other professionals under the Physician Fee Schedule

• Critical Access Hospitals (CAHs)

• Rural Health Clinics (RHCs)

• Federally Qualified Health Centers (FQHCs)

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


13 07/2020

COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers

During the COVID-19 PHE, Medicare will cover a medically necessary emergency and non-emergency ground ambulance transportation from any point of origin to a destination that is equipped to treat the condition of the patient consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished. On an interim basis, we are expanding the list of destinations that may include but are not limited to:

• Any location that is an alternative site determined to be part of a hospital, Critical Access Hospital (CAH), or Skilled Nursing Facility (SNF)

• Community mental health centers

• Federally Qualified Health Centers (FQHCs)

• Rural health clinics (RHCs)

• Physicians’ offices

• Urgent care facilities

• Ambulatory Surgery Centers (ASCs)

• Any location furnishing dialysis services outside of an End-Stage Renal Disease (ESRD) facility when an ESRD facility is not available

• Beneficiary’s home

CMS expanded the descriptions for these origin and destination claim modifiers to account for the new covered locations:

• Modifier D - Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility

• Modifier E – Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the beneficiary’s home

• Modifier H - Alternative care site for hospital, including CAH, provider-based ASC, or freestanding emergency center

• Modifier N - Alternative care site for SNF

• Modifier P - Physician’s office

• Modifier R - Beneficiary’s home

14 07/2020


For the complete list of ambulance origin and destination claim modifiers see Medicare Claims Processing Manual Chapter 15 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdf), Section 30 A.

New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing

To identify and reimburse specimen collection for COVID-19 testing, CMS established two Level II HCPCS codes, effective with line item date of service on or after March 1, 2020:

• G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source

• G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source

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

These codes are billable by clinical diagnostic laboratories.

Beneficiary Notice Delivery Guidance in Light of COVID-19 If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care:

• Important Message from Medicare (IM)_CMS-10065

• Detailed Notices of Discharge (DND)_CMS-10066

• Notice of Medicare Non-Coverage (NOMNC)_CMS-10123

• Detailed Explanation of Non-Coverage (DENC)_CMS-10124

• Medicare Outpatient Observation Notice (MOON)_CMS-10611

• Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131

• Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055

• Hospital Issued Notices of Non-Coverage (HINN)


15 07/2020

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include:

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

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

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

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

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

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

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

Document History

Date of Change Description June 1, 2020 We revised the article to add a section on Clarification for Using the “CR”

Modifier and “DR” Condition Code. All other information remains the same.

16 07/2020


April 10, 2020 Note: We revised this article to:

• Link to all the blanket waivers related to COVID-19 • Provide place of service coding guidance for telehealth claims • Link to the Telehealth Video for COVID-19 • Add information on the waiver of coinsurance and deductibles for certain

testing and related services • Add information on the expanded use of ambulance origin/destination

modifiers • Provide new specimen collection codes for clinical diagnostic laboratories

billing

• Add guidance regarding delivering notices to beneficiaries.

All other information is the same. March 20, 2020 We revised the article to add a note in the Telehealth section to cover the use

of modifiers on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same.

March 19, 2020 We corrected a typo in the article. One of the e-visit codes was incorrectly stated as 99431 and we corrected it to show 99421.

March 18, 2020 We revised this article to include information about the Telehealth waiver. All other information remains the same.

March 16, 2020 Initial article released.

HOME HEALTH AND HOSPICE INFORMATION

Quarterly Update to Home Health (HH) Grouper

MLN Matters Number: MM11839 Related CR Release Date: June 12, 2020 Related CR Transmittal Number: R10176CP Related Change Request (CR) Number: 11839 Effective Date: For From dates on or after October 1, 2020 Implementation Date: October 5, 2020

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

Provider Action Needed CR 11839 announces the October update to the HH Grouper software to reflect annual diagnosis code changes. Make sure your billing staffs are aware of these changes.


17 07/2020

Background The HH Grouper assigns each claim into an HH Resource Group (HHRG) based on the reported claim and beneficiary assessment information, including diagnosis codes. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code set is updated annually, effective October 1. Each year, 3M Health Information Systems (3M-HIS) (the Grouper Contractor) develops a new HH Grouper software package to reflect these updates.

The HH Grouper and related documentation for each update is located on the Centers for Medicare & Medicaid Services (CMS) website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/CaseMixGrouperSoftware. Current instructions regarding the HH Grouper are in Chapter 10, Section 80 of the Medicare Claims Processing Manual.

Version 02.0.20 of the HH Grouper is effective for claims with “From” dates on or after October 1, 2020.

Additional Information The official instruction, CR 11839, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10176cp.pdf.


Document History

Date of Change Description June 12, 2020 Initial article released.

Therapy Codes Update

MLN Matters Number: MM11791 Revised Related CR Release Date: May 26, 2020 Related CR Transmittal Number: R10161OTN Related Change Request (CR) Number: 11791 Effective Date: March 1, 2020 Implementation Date: MACs June 16, 2020 FISS - July 6, 2020

Note: We revised this article to reflect a revised CR11791. The CR revision changed the implementation date for the MACs and we revised that date in the article. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information is 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.

18 07/2020


Provider Action Needed This article informs you of updates to the list of codes that sometimes or always describe therapy services. The additions to the therapy code list reflect those made in the Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE). Please make sure your billing staffs are aware of these changes.

Background Section 1834(k)(5) of the Social Security Act (the Act) requires all claims for outpatient rehabilitation therapy services and all Comprehensive Outpatient Rehabilitation Facility (CORF) services be reported using a uniform coding system. The CY 2020 Current Procedural Terminology (CPT) and Level II HCPCS are the coding systems used for reporting these services. The therapy code listing is on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html.

CR 11791 implements policies reflective of those related to the interim final rule with comment (IFC) entitled Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 PHE (CMS-1744-IFC); and the IFC-entitled Medicare and Medicaid Programs Additional Policy and Regulatory Revisions in Response to the COVID-19 PHE (CMS-5531-IFC); and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). CR 11791 updates the therapy code list and associated policies effective March 1, 2020, for the duration of the COVID-19 PHE.

CMS is designating the below listed codes we’ve collectively termed as Communications Technology-Based Services (CTBS) as “sometimes therapy,” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to provide these services outside a therapy plan of care when appropriate. When provided by psychologists, licensed clinical social workers, or other practitioners, these CTBS codes are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier. When provided by therapists in private practice or therapists in institutional providers of therapy services, the CTBS codes are always provided under a physical therapy, occupational therapy, or speech-language pathology plan of care and must be reported with the associated GP, GO, or GN therapy modifier.

These three CPT codes, with their short descriptors, are added for telephone assessment and management services:

• CPT code 98966 (Hc pro phone call 5-10 min)



These five HCPCS codes, with their short descriptors, are added for remote evaluation of patient images/video, virtual check-ins, and online assessments (e-visits):

• HCPCS code G2010 (Remot image submit by pt)

• HCPCS code G2012 (Brief check in by MD/QHP)

• HCPCS code G2061 (Qual nonMD est pt 5-10 min)


19 07/2020

• HCPCS code G2062 (Qual nonMD est pt 11-20 min)

• HCPCS code G2063 (Qual nonMD est pt 21 min)

Additional Information The official instruction, CR 11791, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10161OTN.pdf.


Document History

Date of Change Description May 26, 2020 We revised this article to reflect a revised CR11791. The CR revision changed

the implementation date for the MACs and we revised that date in the article. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information is the same.

May 15, 2020 Initial article released.

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

MLN Matters Number: MM11754 Revised Related CR Release Date: June 9, 2020 Related CR Transmittal Number: R10170DEMO Related Change Request (CR) Number: 11754 Effective Date: January 1, 2021 - When the Hospice Election Start Date is on or after January 1, 2021 and prior to January 1, 2025 Implementation Date: October 5, 2020

Note: We revised this article on June 10, 2020, to reflect a revised CR 11754 issued on June 9. We revised the article to add a note to the effective date. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

Provider Type Affected This MLN Matters Article is for hospice care and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries who have elected hospice and are enrolled in Medicare Advantage (MA) plans participating in the voluntary Value-Based Insurance Design (VBID) Model’s hospice benefit component.

Provider Action Needed

20 07/2020


This article informs you of the implementation of the hospice benefit component associated with the VBID Model, being tested by the Centers for Medicare & Medicaid Services (CMS) Innovation Center and starting in Calendar Year (CY) 2021. The hospice benefit component of the Model will be tested through CY 2024. Thus, the Model test will apply when the Hospice Election Start Date is on or after January 1, 2021 and prior to January 1, 2025.

Please make sure your billing staffs are aware of this update as providers MUST still submit claims for these services to Medicare. Non-contracting providers must also submit the same billing forms used to bill original Medicare to plans participating in the VBID Model’s hospice benefit component for payment.

Background CMS announced in January 2019 that beginning in CY 2021, through the voluntary VBID Model, participating MA organizations could include the Medicare hospice benefit in their benefits package.

Currently, enrollees may enroll into MA and have access to all original Medicare benefits plus additional supplemental benefits beyond what original Medicare covers. When a MA enrollee elects hospice, Fee-For-Service (FFS) Medicare becomes responsible for coverage of most services while the MA organization retains responsibility for certain services (e.g. supplemental benefits). This hospice “carve-out” from MA results in an additional set of coverage rules for MA enrollees who elect hospice and fragments accountability for care and financial responsibility across the care continuum.

Under the hospice benefit component of the VBID Model, a beneficiary enrolled in an MA plan participating in the VBID Model’s hospice benefit component has elected hospice, all of his or her Medicare benefits continue to be covered by the plan; they do not revert to FFS. The Medicare hospice benefit, through the participating MA organization, will cover all hospice care from the effective date of election (on or after January 1, 2021) to the date of discharge or revocation. During the hospice election, the participating plan also covers attending physician services and all care unrelated to the terminal illness. Upon discharge or revocation, the participating plan continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.

CMS believes the policies being tested through this Model represent an opportunity for Medicare beneficiaries who choose MA and elect hospice, as well as their families and caregivers, to experience a more seamless transition to hospice care, with improved coordination of care.

Billing and Coverage: For services provided to a beneficiary enrolled in a plan participating in the VBID Model’s hospice benefit component, Medicare will deny payment for all claims with dates of service during a hospice election (with a hospice election start date on or after January 1, 2021 through December 31, 2024) and upon discharge or revocation, through the end of the month. Providers MUST still submit claims for these services to Medicare and can expect the following messaging:

• Claim Adjustment Reason Code (CARC) 96: Non-covered charge(s)


21 07/2020

• Remittance Advice Remark Code (RARC) MA73: Information remittance associated with a Medicare demonstration. No payment issued under Fee-For-Service Medicare as patient has elected managed care

• Group Code CO

Plans participating in the VBID Model’s hospice benefit component will be responsible for coverage of the above services. The list of MA Organizations participating in the Hospice Benefit Component of the VBID Model in CY 2021 will be made public on the VBID Model website in the Fall of 2020, which is available at https://innovation.cms.gov/innovation-models/vbid.

Note for Non-Contracting Providers of a Plan Participating in the VBID Model’s HospiceBenefit Component: Plans participating in the VBID Model’s hospice benefit component are required to reimburse non-contracting providers at least the original Medicare rate for Medicare covered services. In situations when plans must pay the Medicare amount, plans must accept from providers the same billing forms used to bill original Medicare.

Since MA Organizations must use certified Medicare providers of services – 1852(a)(1)(A) of the Act and 42 CFR 422.204(b)(3) – when a provider of services is under an Original Medicare sanction such as DPNA (denial of payment for new admissions), the MA Organizations will need to make other arrangements for admissions of MA plan enrollees until that Original Medicare sanction is lifted.

Additional Information The official instruction, CR 11754, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10170demo.pdf.

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

If you have questions regarding the VBID Model, please contact [email protected].

Document History

Date of Change Description June 10, 2020 We revised the article to reflect a revised CR 11754 issued on June 9. We

revised the article to add a note to the effective date. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

May 29, 2020 Initial article released.

22 07/2020


July 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.2

MLN Matters Number: MM11792 Related CR Release Date: June 5, 2020 Related CR Transmittal Number: R10165CP Related Change Request (CR) Number: 11792 Effective Date: July 1, 2020 Implementation Date: July 6, 2020

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 (HH&H) MACs, for services provided to Medicare beneficiaries.

Provider Action Needed This article provides the I/OCE instructions and specifications for the I/OCE employed under the Outpatient Prospective Payment System (OPPS) and non-OPPS. The specifications are for:

• Hospital outpatient departments

• Community mental health centers

• All non-OPPS hospital providers

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

Payment System (PPS) or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted at http://www.cms.gov/OutpatientCodeEdit/.

Make sure your billing staffs are aware of these changes.

Background The Centers for Medicare & Medicaid Services (CMS) informs you that the I/OCE update occurs July 1, 2020. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE.


23 07/2020

The summary of changes is in the following table. Readers should also review the entire document and note the highlighted sections, which also indicate changes from the prior release of the software. Some I/OCE modifications in the update are retroactive to prior releases. If so, the retroactive date appears in the ‘Effective Date’ column.

Effective Date Edits Affected Modification 10/01/2013 (See Section

6.2 of I/OCE Specifications for edit explanations.)

Add new payment method flag V (Contractor bypass applied to Federally Qualified Health Center (FQHC) PPS service and coinsurance is n/a (COVID-19)) and W (Contractor bypass applied to off-campus clinic visit for payment reduction) to be returned on output if supplied on input to the CB Payment Method Flag field. 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 (Section 3.2 of I/OCE Specifications) for more information.

10/01/2013 1, 2, 3, 5, 6, 8, 20, 22, 40, 41, 106, 108

Implement and program the following new bill types for Non-OPPS Hospital bill type processing and editing (OPPS flag = 2, Non-OPPS); 78x (Licensed Freestanding Emergency Medical Facility) 83x (Ambulatory Surgery Center) 84x (Freestanding Birthing Center) 89x (Special Facility – Other) See OCE edits Applied by Non-OPPS Hospital Bill Type Table. (Section 6.4 of I/OCE Specifications)

03/18/2020 For OPPS claims (bill type 13x w/o Condition Code (CC) 41), apply the Payment Adjustment Flag (PAF) of 9 (Deductible/co-insurance not applicable) for a visit line(s) that have modifier CS reported and the final Status Indicator (SI) for the line(s) is V or J2. Critical Care visit code 99291 and HOPD specimen collection code C9803 reported with modifier CS and SI= S, are also applicable for a PAF assignment of 9. See Medical Visit Processing and COVID-19 Testing-Related Services (Section 5.1) and Observation Processing under C-APCs (Section 5.6.4) for more information.

03/18/2020 Add new payment method flag value C (Payment made by FQHC PPS and coinsurance is n/a COVID-19) to be returned on FQHC claims (Bill type 77x) when HCPCS line items are reported with modifier CS. See FQHC PPS – COVID-19 Services (Section 5.19) for more information.

01/27/2020 Add new HCPCS code G2025 to the FQHC telehealth logic to receive appropriate FQHC payment values. Note: G2025 is added to the FQHC telehealth logic based on the component quarter start date of 01/01/2020, but the code should not be reported prior to its effective date of 01/27/2020. See FQHC PPS – Telehealth Services (Section 5.19) processing logic for more information.

07/01/2020 Add new payment method flag value B (Payer only testing). Not to be used other than for CMS testing purposes.

24 07/2020


10/01/2013 48, 50, 61, 62, 67, 68, 69, 72, 88, 89, 90, 91, 110

Add the following edits to list of applicable edits that may be used for the Contractor Bypass; 48, 50, 61,62, 67, 68, 69, 72, 88, 89, 90, 91, 110

10/01/2013 27, 35, 47 Update edit 35 logic to allow for the edit to be returned if an incidental education and training service(s) is the only service(s) reported on the claim (Bill Type 12x, 13x w/o CC 41). Note: Edit 47 is returned in addition to edit 35 in this circumstance described, as both edit conditions apply and there is no conflict in edit disposition. Edit 27 is now suppressed from being returned if this condition for edit 35 is present. See Daily Mental Health Processing section (Section 5.5.3) for more information.

04/01/2019 41, 48 Add revenue code 892 (Special Processed Drugs – FDA Approved Gene Therapy) to the list of valid revenue codes, effective 04/01/2019.

07/01/2020 68 Apply mid-quarter edit 68 (Service provided prior to date of National Coverage Determination (NCD) approval) to the following HCPCS; U0003 - 04/14/2020 U0004 - 04/14/2020 86328 - 04/10/2020 86769 - 04/10/2020 98966 - 03/01/2020 98967 - 03/01/2020 98968 - 03/01/2020 G2010 - 03/01/2020 G2012 - 03/01/2020 G2023 - 03/01/2020 G2024 - 03/01/2020 G2025 - 01/27/2020 C9803 – 03/01/2020

07/01/2020 110 Apply mid-quarter edit 110 (Service provided prior to initial marketing date) to the following HCPCS; Q5113 - 03/16/2020 Q5116 - 02/23/2020 C9058 – 11/15/2019 Q5119 – 02/03/2020 Q5120 – 11/15/2019

01/01/2020 Modify the Description of Modifier CS to “Covid-19 testing related svc”.


25 07/2020

07/01/2020 Make all HCPCS/Ambulatory Payment Classification (APC)/SI changes as specified by CMS. Updates were made to the following lists: MAP_ADDON_TYPEI • Addon Type I procedures (edit 106) DATA_CAPC • Comprehensive APC list (updated list and rank) OFFSET_HCPCS • Terminated Device Procedures for offset APC

OFFSET_CODEPAIRS • Device Offset Code Pairs (code pair updates for pass through

device offset logic) MAP_COMPOSITE

• Composite APC HCPCS list DATA_HCPCS • Device-Dependent Procedure list (edit 92) • Device Procedure Edit 92 Bypass list (edit 92) • Terminated Device Procedure list • Device list • FQHC non-covered list • FQHC flu-PPV list • High and Low-Cost Skin Substitute list (edit 87) • Edit 99 Exclusions list (edit 99)• Non-covered services lists (SI = E1, edits 9)• Non-reportable for OPPS list (SI = B, edit 62) • Services not billable to MAC list (SI = M, edit 72) • Separate payment by Medicare not provided (SI = E2, edit 13) • Procedure and Sex Conflict (edit 8) (Male and Female px list) • Comprehensive APC exclusion list • Inherent Bilateral list • X-ray procedure list applicable for modifiers FX/FY – CAA

Section 502b MAP_CONFLICT_RHC • RHC CG modifier non-payable conflict

DATA_MODIFIER

• Valid Modifier list (Description update only)DATA_EDIT_BYPASS

• Contractor Bypass Edits list

26 07/2020


07/01/2020 The following Data Table Report(s) is updated to include new fields: DATA_HCPCS

• Unused (New Column implemented for CMS testing only purposes) Please review the File Layout document for the descriptions of all Data Table Reports and associated fields and field values.

07/01/2020 20, 40 Implement version 26.2 of the NCCI (as modified for applicable outpatient institutional providers).

Additional Information The official instruction, CR 11792, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/r10165cp.pdf.


Document History


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


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

Provider Action Needed This article informs you about the changes to and billing instructions for various payment policies implemented in the July 2020 Outpatient Prospective Payment System (OPPS) update. The July 2020 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 11814. The July 2020 revisions to I/OCE data files, instructions, and specifications are provided in CR 11792. The article related to that CR, MM11792, is available at https://www.cms.gov/files/document/mm11792.pdf. Make sure that your billing staffs are aware of these changes.


27 07/2020

Background

Here is a summary of the main topics covered by CR 11814:

1. COVID-19 Laboratory Tests and Services and Other Laboratory Tests Coding Update Since February 2020, the Centers for Medicare and Medicaid Services (CMS) has recognized several COVID-19 laboratory tests and related services. The codes are listed in Table 1 along with their OPPS status indicators (SI). The codes, along with their short descriptors and status indicators are also listed in the July 2020 OPPS Addendum B (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates) that is posted on the CMS website. For information on the OPPS status indicator definitions, refer to OPPS Addendum D1 of the Calendar Year (CY) 2020 OPPS/Ambulatory Surgical Center (ASC) final rule.

Table 1. ─ COVID-19 Laboratory Tests and Services and Other Laboratory Tests Codes

HCPCS Code

Long Descriptor Add Date OPPS SI OPPS APC

U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel

02/04/2020 A N/A

U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

02/04/2020 A N/A

C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source

03/01/2020 Q1 5731

G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source

03/01/2020 B N/A

G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source

03/01/2020 B N/A

28 07/2020


87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

03/13/2020 A N/A

86328 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

04/10/2020 A N/A

86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

04/10/2020 A N/A

U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R

04/14/2020 A N/A

U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R

04/14/2020 A N/A

0014M Liver disease, analysis of 3 biomarkers (hyaluronic acid [ha], procollagen iii amino terminal peptide [piiinp], tissue inhibitor of metalloproteinase 1 [timp-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years

04/01/2020 Q4 N/A


29 07/2020

2. Status Indicator Changes for Certain Virtual Services In accordance with interim final rule changes adopted in light of the COVID-19 Public Health Emergency, CMS is recognizing payment for several additional virtual services including those related to telephone assessment and management services, remote evaluation of a prerecorded video or image and a virtual check-in.

Specifically, CMS is changing the following HCPCS codes to status indicator “A” retroactive to March 1, 2020, in the July I/OCE update since they are payable as therapy services under the Physician Fee schedule.

• Current Procedural Terminology (CPT) codes 98966 through 98968, which describe telephone assessment and management service provided by a qualified nonphysician health care professional

• HCPCS codes G2010 and G2012 describe a remote evaluation of a prerecorded video or image and a virtual check-in, respectively

The following HCPCS codes have been changed to status indicator “B” in the April re-release of the I/OCE retroactive to March 1, 2020, to be in line with the waivers so Critical Access Hospitals (CAHs) that chose Method II can bill the waiver services.

• CPT codes 99421-99423, which describe online digital evaluation and management service, for an established patient

• CPT codes 99441-99443, which describe telephone assessment and management services furnished by a physician or other qualified health care professional who may report evaluation and management services

• CPT code 99457, which describes remote physiologic monitoring treatment management services, by clinical staff/physician/other qualified health care professional

• CPT code 99474, which describes self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient.

The following rehabilitation HCPCS codes have been assigned to status indicator “A” in the April re-release of the I/OCE retroactive to March 1, 2020, since they are payable under the Physician Fee schedule.

• HCPCS codes G2061-G2063 which describe qualified nonphysician healthcare professional online assessment, for an established patient.

30 07/2020


The codes, along with their long descriptors, are listed in Table 2.

Table 2. ─ Status Indicator Changes for Certain Virtual Services that are Effective March 1, 2020

HCPCS Long Descriptor Status Indicator

98966 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

A


A


A

99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

B

99422 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

B

99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

B

99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

B


31 07/2020


B


B

99457 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes

B

99474 Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

B

G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment

A

G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

A

G2061 Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes

A

G2062 Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes

A

32 07/2020


G2063 Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes

A

3. a. New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only Effective January 27, 2020, CMS established new HCPCS code G2025 which is recognized for payment for a telehealth distant site service furnished by a RHC or FQHC only. See Table 3. This code is assigned to status indicator “A” retroactive to January 27, 2020, in the July OPPS Addendum B.

Table 3. ─ New Telehealth Code for a Telehealth Distant Site Service Furnished by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) Only

HCPCS Code

Long Descriptor Short Descriptor Add Date OPPS SI

G2025 Payment for a telehealth distant site service furnished by a rural health clinic (RHC) or federally qualified health center (FQHC) only

Dis site tele svcs RHC/FQHC

01/27/2020 A

b. Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE CMS added other codes for RHCs and FQHCs that are currently included in the I/OCE and the OPPS Addendum B for RHCs and FQHCs that are assigned to status indicator “A” with various effective dates in Table 4.

Table 4. ─ Other Telehealth Distant Site Codes for RHCs and FQHCs in the OPPS Addendum B and I/OCE

HCPCS Code

Long Descriptor Short Descriptor

Effective Date OPPS SI

G0071 Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only

Comm svcs by rhc/fqhc 5 min

01/01/2019 A


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G0466 Federally qualified health center (fqhc) visit, new patient; a medically-necessary, face-to-face encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a fqhc visit

Fqhc visit new patient

10/01/2014 A

G0467 Federally qualified health center (fqhc) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a fqhc visit

Fqhc visit, estab pt

10/01/2014 A

G0468 Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

Fqhc visit, ippe or awv

10/01/2014 A

G0469 Federally qualified health center (fqhc) visit, mental health, new patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a mental health visit

Fqhc visit, mh new pt

10/01/2014 A

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G0470 Federally qualified health center (fqhc) visit, mental health, established patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between an established patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a mental health visit

Fqhc visit, mh estab pt

10/01/2014 A

G0511 Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month

Ccm/bhi by rhc/fqhc 20min mo

01/01/2018 A

G0512 Rural health clinic or federally qualified health center (rhc/fqhc) only, psychiatric collaborative care model (psychiatric cocm), 60 minutes or more of clinical staff time for psychiatric cocm services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month

Cocm by rhc/fqhc 60 min mo

01/01/2018 A

4. New CPT Category III Codes Effective July 1, 2020 The American Medical Association (AMA) releases CPT Category III codes twice per year: in January, for implementation beginning the following July, and in July, for implementation beginning the following January.

For the July 2020 update, CMS is implementing 25 CPT Category III codes that the AMA released in January 2020 for implementation on July 1, 2020. The status indicators and APC assignments for these codes are shown in Table 5. CPT codes 0594T through 0619T have been added to the July 2020 I/OCE with an effective date of July 1, 2020. These codes, along with their short descriptors, status indicators, and payment rates (where applicable) are also listed in the July 2020 OPPS Addendum B that is posted on the CMS website. For information on the OPPS status indicators, refer to OPPS Addendum D1 of the CY 2020 OPPS/ASC final rule for the latest definitions.


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Table 5. ─ CPT Category III Codes Effective July 1, 2020

CPT Code

Long Descriptor OPPS SI

OPPS APC

0594T Osteotomy, humerus, with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments, computations of adjustment schedules, and management of the intramedullary lengthening device

J1 5114

0596T Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement

T 5372

0597T Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement

T 5372

0598T Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (eg, lower extremity)

T 5722

0599T Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; each additional anatomic site (eg, upper extremity) (List separately in addition to code for primary procedure)

N N/A

0600T Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous

J1 5361

0601T Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open

J1 5361

0602T Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent

Q4 N/A

0603T Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours

Q4 N/A

0604T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; initial device provision, set-up and patient education on use of equipment

V 5012

0605T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days

Q1 5741

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0606T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days

M N/A

0607T Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment

V 5012

0608T Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional

S 5741

0609T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs

E1 N/A

0610T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis

E1 N/A

0611T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs

E1 N/A

0604T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; initial device provision, set-up and patient education on use of equipment

V 5012

0605T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days

Q1 5741

0606T Optical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days

M N/A


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0607T Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment

V 5012

0608T Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional

S 5741

0609T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs

E1 N/A

0610T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis

E1 N/A

0611T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs

E1 N/A

0612T Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report

E1 N/A

0613T Percutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance by the proceduralist, when performed

E1 N/A

0614T Removal and replacement of substernal implantable defibrillator pulse generator

J1 5231

0615T Eye-movement analysis without spatial calibration, with interpretation and report

Q1 5734

0616T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens

J1 5491

0617T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens

J1 5492

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0618T Insertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange

J1 5492

0619T Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed

J1 5375

5. CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective July 1, 2020 The AMA CPT Editorial Panel deleted five PLA codes, specifically, CPT codes 0124U through 0128U, and established 30 new PLA codes, specifically, CPT codes 0172U through 0201U, effective July 1, 2020. Table 6 lists the long descriptors and status indicators for the newly created codes as well as the deleted codes.

CPT codes 0172U through 0201U have been added to the July 2020 I/OCE with an effective date of July 1, 2020. These codes, along with their short descriptors, status indicators, and payment rates (where applicable) are also listed in the July 2020 OPPS Addendum B that is posted on the CMS website. As noted in Table 6, several of the new codes are assigned to either status indicator “Q4” to indicate that the laboratory tests are conditionally packaged or status indicator “A” to indicate that the laboratory tests are paid under a different Medicare payment system other than the OPPS. For a complete list of the OPPS status indicators, refer to OPPS Addendum D1 of the CY 2020 OPPS/ASC final rule for the latest definitions.

Table 6. ─ PLA Coding Changes Effective July 1, 2020

CPT Code


OPPS APC

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

D 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

D N/A

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

D 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

D N/A


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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

D N/A

0172U Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score

A N/A

0173U Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes

A N/A

0174U Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or uncertain benefit of 39 chemotherapy and targeted therapeutic oncology agents

Q4 N/A

0175U Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes

A N/A

0176U Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA)

Q4 N/A

0177U Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status

A N/A

0178U Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction

Q4 N/A

0179U Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s)

A N/A

0180U Red cell antigen (ABO blood group) genotyping (ABO), gene analysis Sanger/chain termination/conventional sequencing, ABO (ABO, alpha 1-3-N-acetylgalactosaminyltransferase and alpha 1-3-galactosyltransferase) gene, including subtyping, 7 exons

A N/A

0181U Red cell antigen (Colton blood group) genotyping (CO), gene analysis, AQP1 (aquaporin 1 [Colton blood group]) exon 1

A N/A

0182U Red cell antigen (Cromer blood group) genotyping (CROM), gene analysis, CD55 (CD55 molecule [Cromer blood group]) exons 1-10

A N/A

0183U Red cell antigen (Diego blood group) genotyping (DI), gene analysis, SLC4A1 (solute carrier family 4 member 1 [Diego blood group]) exon 19

A N/A

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0184U Red cell antigen (Dombrock blood group) genotyping (DO), gene analysis, ART4 (ADP-ribosyltransferase 4 [Dombrock blood group]) exon 2

A N/A

0185U Red cell antigen (H blood group) genotyping (FUT1), gene analysis, FUT1 (fucosyltransferase 1 [H blood group]) exon 4

A N/A

0186U Red cell antigen (H blood group) genotyping (FUT2), gene analysis, FUT2 (fucosyltransferase 2) exon 2

A N/A

0187U Red cell antigen (Duffy blood group) genotyping (FY), gene analysis, ACKR1 (atypical chemokine receptor 1 [Duffy blood group]) exons 1-2

A N/A

0188U Red cell antigen (Gerbich blood group) genotyping (GE), gene analysis, GYPC (glycophorin C [Gerbich blood group]) exons 1-4

A N/A

0189U Red cell antigen (MNS blood group) genotyping (GYPA), gene analysis, GYPA (glycophorin A [MNS blood group]) introns 1, 5, exon 2

A N/A

0190U Red cell antigen (MNS blood group) genotyping (GYPB), gene analysis, GYPB (glycophorin B [MNS blood group]) introns 1, 5, pseudoexon 3

A N/A

0191U Red cell antigen (Indian blood group) genotyping (IN), gene analysis, CD44 (CD44 molecule [Indian blood group]) exons 2, 3, 6

A N/A

0192U Red cell antigen (Kidd blood group) genotyping (JK), gene analysis, SLC14A1 (solute carrier family 14 member 1 [Kidd blood group]) gene promoter, exon 9

A N/A

0193U Red cell antigen (JR blood group) genotyping (JR), gene analysis, ABCG2 (ATP binding cassette subfamily G member 2 [Junior blood group]) exons 2-26

A N/A

0194U Red cell antigen (Kell blood group) genotyping (KEL), gene analysis, KEL (Kell metallo-endopeptidase [Kell blood group]) exon 8

A N/A

0195U KLF1 (Kruppel-like factor 1), targeted sequencing (ie, exon 13) A N/A 0196U Red cell antigen (Lutheran blood group) genotyping (LU), gene

analysis, BCAM (basal cell adhesion molecule [Lutheran blood group]) exon 3

A N/A

0197U Red cell antigen (Landsteiner-Wiener blood group) genotyping (LW), gene analysis, ICAM4 (intercellular adhesion molecule 4 [Landsteiner-Wiener blood group]) exon 1

A N/A

0198U Red cell antigen (RH blood group) genotyping (RHD and RHCE), gene analysis Sanger/chain termination/conventional sequencing, RHD (Rh blood group D antigen) exons 1-10 and RHCE (Rh blood group CcEe antigens) exon 5

A N/A

0199U Red cell antigen (Scianna blood group) genotyping (SC), gene analysis, ERMAP (erythroblast membrane associated protein [Scianna blood group]) exons 4, 12

A N/A


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0200U Red cell antigen (Kx blood group) genotyping (XK), gene analysis, XK (X-linked Kx blood group) exons 1-3

A N/A

0201U Red cell antigen (Yt blood group) genotyping (YT), gene analysis, ACHE (acetylcholinesterase [Cartwright blood group]) exon 2

A N/A

6. Hemodialysis Arteriovenous Fistula (AVF) Procedures: Replacement Codes for HCPCS Codes C9754 and C9755 For CY 2019, based on two separate new technology applications received for hemodialysis arteriovenous fistula creation, CMS established two new HCPCS codes to describe the procedures. Specifically, CMS established HCPCS code C9754 for the Ellipsys System and C9755 for the WavelinQ System effective January 1, 2019. These codes were listed in the OPPS Addendum B that was released with the CY 2019 OPPS/ASC Final Rule. In addition, we listed the codes in the January 2019 OPPS quarterly update (Transmittal 4186, CR 11099) that was published on December 21, 2018.

For the July 2020 update, we are deleting HCPCS codes C9754 and C9755 since they will be replaced with HCPCS codes G2170 and G2171, respectively, effective July 1, 2020. We note that the replacement G-codes have been assigned to the same APC and status indicator as the predecessor HCPCS C-codes. Table 7 lists the HCPCS codes and long descriptors.

The codes, along with their short descriptors, APC assignment, status indicators, and payment rates are also listed in the July 2020 OPPS Addendum B that is posted on the CMS website. For information on the OPPS status indicator definitions, refer to OPPS Addendum D1 of the CY 2020 OPPS/ASC final rule.

Table 7. ─ Replacement Codes for HCPCS Codes C9754 and C9755

HCPCS Code

Long Descriptor Add Date Term Date Replacement Code

C9754 Creation of arteriovenous fistula, percutaneous; direct, any site, including all imaging and radiologic supervision and interpretation, when performed and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization, when performed)

1/1/2019 6/30/2020 G2170

G2170 Percutaneous arteriovenous fistula creation (AVF), direct, any site, by tissue approximation using thermal resistance energy, and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization) when performed, and includes all imaging and radiologic guidance, supervision and interpretation, when performed

7/1/2020 N/A N/A

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C9755 Creation of arteriovenous fistula, percutaneous using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, venography, and/or ultrasound, with radiologic supervision and interpretation, when performed

1/1/2019 6/30/2020 G2171

G2171 Percutaneous arteriovenous fistula creation (AVF), direct, any site, using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, enography, and/or ultrasound, with radiologic supervision and interpretation, when performed

7/1/2020 N/A N/A

7. 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.

We are establishing one new device pass-through category as of July 1, 2020. Table 8 provides a listing of new coding and payment information concerning the new device categories for transitional pass-through payment.

Table 8. – New Device Pass-Through Code Effective July 1, 2020

HCPCSCode

SI APC Short Descriptor Long Descriptor

C1748 H 2029 Endoscope, single, UGI Endoscope, single-use (i.e. disposable), upper gi, imaging/illumination device (insertable)

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 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.

i. We have determined the device offset amounts, or the portion of the APC payment amounts for APC 5303 (Level 3 Upper GI Procedures) and APC 5331 (Complex GI Procedures) that are associated with the costs of the device category described by HCPCS code C1748.


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The device in the category described by HCPCS code C1748 should always be billed with one of the CPT codes listed in Table 9. The table also includes the device offset associated with each code.

Table 9. – CPT Codes Reportable With HCPCS Code C1748 Effective July 1, 2020

CPT Code

Short Descriptor CY 2020

OPPS SI

CY 2020 OPPS APC

Device Offset Amount

43260 Ercp w/specimen collection J1 5303 $376.68 43261 Endo

cholangiopancreatograph J1 5303 $320.30

43262 Endo cholangiopancreatograph

J1 5303 $382.68

43263 Ercp sphincter pressure meas J1 5303 $128.36 43264 Ercp remove duct calculi J1 5303 $376.38 43265 Ercp lithotripsy calculi J1 5331 $816.09 43274 Ercp duct stent placement J1 5331 $1,287.96 43275 Ercp remove forgn body

duct J1 5303 $323.30

43276 Ercp stent exchange w/dilate J1 5331 $1,392.66 43277 Ercp ea duct/ampulla dilate J1 5303 $483.45 43278 Ercp lesion ablate w/dilate J1 5303 $452.56

ii. Application of Offset to C1734: On January 1, 2020, we determined that an offset would apply to C1734 because APC 5115 (Level 5 Musculoskeletal Procedures) and APC 5116 (Level 6 Musculoskeletal Procedures) already contain costs associated with the device described by C1734. C1734 should always be billed with CPT codes 27870, 28715, 28725 (which are assigned to APC 5115 for CY 2020) and 28705 (which is assigned to APC 5116 for CY 2020). The device offset is a deduction from pass-through payments for C1734. After further review, we have determined that the costs associated with C1734 are not already reflected in APCs 5115 or 5116. Therefore, we are not applying an offset to C1734. This determination to not apply the device offset from payment will be retroactive to January 1, 2020. See 68 FR 63438-9 for further discussion about the device offset policy.

Also, 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 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. 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. We refer readers to Addendum P of the CY 2020 final rule with comment period for the most current OPPS HCPCS Offset file. Addendum P is available on the CMS website.

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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 Devices 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 substantial clinical improvement criterion for the purposes of determining device pass-through payment status. The devices would still need to meet the other criteria for pass-through status. This applies to devices that receive pass-through payment status effective on or after January 1, 2020.

8. Changes to Certain Device Offsets for 2020 For CY 2020, in the absence of claims data, we applied a default device offset percentage of 31 percent for CPT codes 0548T and 0549T. Under existing policy, the associated claims data used for purposes of determining whether or not to apply the default device offset are the associated claims data for either the new HCPCS code or any predecessor code, as described by CPT coding guidance, for the new HCPCS code. Additionally, in limited instances where a new HCPCS code does not have a predecessor code as defined by CPT, but describes a procedure that was previously described by an existing code, we use clinical discretion to identify HCPCS codes that are clinically related or similar to the new HCPCS code, but are not officially recognized as a predecessor code by CPT, and to use the claims data of the clinically related or similar code(s) for purposes of determining whether or not to apply the default device offset to the new HCPCS code.

After further review, we have determined that the device offset percentage for C9746, the predecessor code to CPT code 0548T which was deleted June 30, 2019, would be a more appropriate, and clinically similar, device offset percentage for CPT codes 0548T and 0549T. For CY 2020, the device offset percentage of C9746 based on CY 2018 claims data was 63.56 percent. For CPT codes 0548T and 0549T, a device offset percentage of 63.56 percent results in device offset amounts of $5,127.98 for CPT code 0548T and $2,689.62 for CPT code 0549T for CY 2020. The device offset percentage of 63.56 percent and device offset amounts are now displayed in Addendum P to the CY 2020 OPPS/ASC final rule. This determination to apply the device offset percentage for C9746 to CPT codes 0548T and 0549T is retroactive to January 1, 2020.

9. Drugs, Biologicals, and Radiopharmaceuticals a. New CY 2020 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status Eleven new HCPCS codes have been created for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available starting on July 1, 2020. These drugs and biologicals will receive drug pass-through status starting July 1, 2020. These new codes are listed in Table 10.

Table 10. ─ New CY 2020 HCPCS Codes Effective July 1, 2020, for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status

CY 2020 HCPCS

Code

CY 2020 Long Descriptor CY 2020

SI

CY 2020 APC

C9059 Injection, meloxicam, 1 mg G 9371 J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg G 9353


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J7204 Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu

G 9354

J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg G 9364 J0742 Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg G 9362 Q5119 Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg G 9367 C9061 Injection, teprotumumab-trbw, 10 mg G 9355 J1429 Injection, golodirsen, 10 mg G 9356 C9063 Injection, eptinezumab-jjmr, 1 mg G 9357 C9122 Mometasone furoate sinus implant, 10 micrograms (sinuva) G 9346 J0896 Injection, luspatercept-aamt, 0.25 mg G 9347

b. Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals That Will Start To Receive Pass-Through Status There are two existing HCPCS codes for certain drugs, biologicals, and radiopharmaceuticals in the outpatient setting that will start to receive pass-through status beginning on July 1, 2020.These new codes are listed in Table 11.

Table 11. ─ Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals Receiving Pass-Through Status Effective July 1, 2020

CY 2020 HCPCS

Code

CY 2020 Long Descriptor April 2020 SI

July 2020

SI

CY 2020 APC

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

E2 G 9350

Q5118 Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg

K G 9348

c. Currently Existing HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals With Pass-Through Status Ending on June 30, 2020 There are two HCPCS codes for certain drugs, biologicals, and radiopharmaceuticals in the outpatient setting that will have their pass-through status end on June 30, 2020. These codes are listed in Table 12.

Table 12. ─ HCPCS Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals with Pass-Through Status Ending Effective June 30, 2020

CY 2020 HCPCS

Code

CY 2020 Long Descriptor April 2020 SI

July 2020

SI

CY 2020 APC

J0565 Injection, bezlotoxumab, 10 mg G K 9490 J2326 Injection, nusinersen, 0.1 mg G K 9489

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d. Drugs and Biologicals that Will Change from Non-Payable Status (Status Indicator = “E2”) to Separately Payable Status (Status Indicator = “K”) for the Period of February 23, 2020, through June 30, 2020 The status indicator for HCPCS code Q5116 (Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg) for the period of February 23, 2020, through June 30, 2020, will be changed retroactively from status indicator = “E2” to status indicator = “K.” This drug or biological is reported in Table 13.

Table 13. ─ CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals Retroactive for the Period of February 23, 2020, through June 30, 2020

HCPCS Code

Long Descriptor Old SI New SI APC Effective Date

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

E2 K 9350 02/23/2020

e. Drugs and Biologicals that Will Change from Non-Payable Status (Status Indicator = “E2”) to Separately Payable Status (Status Indicator = “K”) Retroactive for the Period of March 16, 2020, through June 30, 2020 The status indicator for HCPCS code Q5113 (Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg) will be changed from status indicator = “E2” to status indicator = “K” retroactively for the period of March 16, 2020, through June 30, 2020. This drug or biological is reported in Table 14.

Table 14. ─ CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals Retroactive for the Period of March 16, 2020, through June 30, 2020

HCPCS Code

Long Descriptor Old SI New SI APC Effective Date

Q5113 Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg

E2 K 9349 03/16/2020

f. Drugs and Biologicals that Will Be Separately Payable (Status Indicator = “K”) Retroactively for the Period of February 3, 2020, through June 30, 2020 HCPCS code Q5119 (Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg) will have its effective date changed to February 3, 2020. Furthermore, HCPCS code Q5119 will be retroactively separately payable with a status indicator of “K” for the period of February 3, 2020, through June 30, 2020. This drug or biological is reported in Table 15.


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Table 15. ─ CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals Retroactive for the Period of February 3, 2020, through June 30, 2020

HCPCS Code Long Descriptor SI APC Effective DateQ5119 Injection, rituximab-pvvr,

biosimilar, (ruxience), 10 mg K 9367 02/03/2020

g. Drugs and Biologicals that Will Be Separately Payable (Status Indicator = “K”) Retroactively for the Period of November 15, 2019, through March 31, 2020 We are changing the effective date of HCPCS code C9058 (Injection, pegfilgrastim-bmez, biosimilar, (Ziextenzo) 0.5 mg) to November 15, 2019. Furthermore, HCPCS code C9058 will be retroactively separately payable with a status indicator of “K” for the period of November 15, 2019, through March 31, 2020. This drug or biological is reported in Table 16.

Table 16. ─ CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals that Are Separately Payable Retroactive for the Period of November 15, 2019,

through March 31, 2020

HCPCS Code

Long Descriptor SI APC Effective Date

End Date

C9058 Injection, pegfilgrastim-bmez, biosimilar, (Ziextenzo) 0.5 mg

K 9345 11/15/2019 03/31/2020

h. HCPCS Codes for Drugs and Biologicals that Are Not Recognized in the OPPS (Status Indicator = “B”) Retroactively for the Period of November 15, 2019 through June 30, 2020 We are changing the effective date of HCPCS code Q5120 (Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg) to November 15, 2019. However, this drug is already described by HCPCS code C9058 which is a separately payable code for the period of November 15, 2019, until June 30, 2020. Therefore, HCPCS code Q5120 will be assigned to status indicator = “B” (Code Not Recognized by the OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x)) retroactively for the period of November 15, 2019, through June 30, 2020. Starting on July 1, 2020, HCPCS code Q5120 will be assigned to status indicator = “G” until June 30, 2023. This drug or biological is reported in Table 17.

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Table 17. ─ CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals that Are Not Recognized in the OPPS Retroactive for the Period of November

15, 2019, through June 30, 2020

HCPCS Code

Long Descriptor SI APC Effective Date

End Date

Q5120 Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg

B N/A 11/15/2019 06/30/2020

Q5120 Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg

G 9345 07/01/2020 06/30/2023

i. Existing HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals with a Change from Non-Payable Status (Status Indicator = “E1”) to Vaccine Not Payable in the OPPS (Status Indicator = “L”)

The status indicator for CPT code 90694 (Influenza virus vaccine, quadrivalent (aiiv4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use) changes from SI = “E1” to SI = “L” on July 1, 2020, as the vaccine described by CPT code 90694 may be covered by Medicare, but is payable outside of the OPPS. See Table 18.

Table 18. ─ Existing HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals with a Change from SI=E1 to SI=L, Effective July 1, 2020

HCPCS Code

Long Descriptor Old SI

New SI APC Effective Date

90694 Influenza virus vaccine, quadrivalent (aiiv4), inactivated, adjuvanted, preservative free, 0.5 ml dosage, for intramuscular use

E1 L N/A 07/01/2020

j. Newly Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of July 1, 2020 42 new drug, biological, and radiopharmaceutical HCPCS codes will be established on July 1, 2020. The new codes are listed in Table 19.

Table 19. ─ Other CY 2020 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals Effective July 1, 2020

New HCPCS

Code

Old HCPCS

Code

Long Descriptor SI APC

J7169 C9041 Injection, coagulation factor xa (recombinant), inactivated-zhzo (andexxa), 10 mg

G 9198

J0791 C9053 Injection, crizanlizumab-tmca, 5 mg G 9359


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J0691 C9054 Injection, lefamulin, 1 mg G 9332

J0223 C9056 Injection, givosiran, 0.5 mg G 9343

J1201 C9057 Injection, cetirizine hydrochloride, 0.5 mg G 9361

Q5120 C9058 Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg

G 9345

J7204 Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu

G 9354

C9059 Injection, meloxicam, 1 mg G 9371C9061 Injection, teprotumumab-trbw, 10 mg G 9355C9063 Injection, eptinezumab-jjmr, 1 mg G 9357C9122 Mometasone furoate sinus implant, 10 micrograms

(sinuva) G 9346

J0591 Injection, deoxycholic acid, 1 mg E1 N/AJ0742 Injection, imipenem 4 mg, cilastatin 4 mg and

relebactam 2 mg G 9362

J0896 Injection, luspatercept-aamt, 0.25 mg G 9347J1429 Injection, golodirsen, 10 mg G 9356J1558 Injection, immune globulin (xembify), 100 mg K 9372J3399 Injection, onasemnogene abeparvovec-xioi, per

treatment, up to 5x10^15 vector genomes K 9373

J7333 Hyaluronan or derivative, visco-3, for intraarticular injection, per dose

N N/A

J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg G 9364J9198 Injection, Gemcitabine hydrochloride, (Infugem),

100 mg N N/A

J9246 Injection, melphalan (evomela), 1 mg K 9375J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg G 9353Q4227 Amniocore, per square centimeter N N/AQ4228 Bionextpatch, per square centimeter N N/AQ4229 Cogenex amniotic membrane, per square

centimeter N N/A

Q4230 Cogenex flowable amnion, per 0.5 cc N N/AQ4231 Corplex p, per cc N N/AQ4232 Corplex, per square centimeter N N/AQ4233 Surfactor or nudyn, per 0.5 cc N N/AQ4234 Xcellerate, per square centimeter N N/AQ4235 Amniorepair or altiply, per square centimeter N N/AQ4236 Carepatch, per square centimeter N N/AQ4237 Cryo-cord, per square centimeter N N/A

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Q4238 Derm-maxx, per square centimeter N N/AQ4239 Amnio-maxx or amnio-maxx lite, per square

centimeter N N/A

Q4240 Corecyte, for topical use only, per 0.5 cc N N/AQ4241 Polycyte, for topical use only, per 0.5 cc N N/AQ4242 Amniocyte plus, per 0.5 cc N N/AQ4244 Procenta, per 200 mg N N/AQ4245 Amniotext, per cc N N/AQ4246 Coretext or protext, per cc N N/AQ4247 Amniotext patch, per square centimeter N N/AQ4248 Dermacyte amniotic membrane allograft, per

square centimeter N N/A

Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

E2 N/A

k. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) For CY 2020, payment for the majority of 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 + 6 percent of the reference product for biosimilars). Payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals that were acquired under the 340B program is made at the single rate of ASP - 22.5 percent (or ASP - 22.5 percent of the biosimilar’s ASP if a biosimilar is 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 2020, 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 (or ASP + 6 percent of the reference product for biosimilars). Payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available. Effective July 1, 2020, payment rates for many drugs and biologicals have changed from the values published in the CY 2020 OPPS/ASC final rule with comment period as a result of the new ASP calculations based on sales price submissions from the fourth quarter of CY 2019. In cases where adjustments to payment rates are necessary, changes to the payment rates will be incorporated in the July 2020 FISS release. CMS is not publishing the updated payment rates in CR 11814 implementing the July 2020 update of the OPPS. However, the updated payment rates effective July 1, 2020, are in the July 2020 update of the OPPS Addendum A and Addendum B on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS.

l. 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 payment 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.


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10. Skin Substitutes – New Products The payment for skin substitute products that do not qualify for pass-through status will be packaged into the payment for the associated skin substitute application procedure. The skin substitute products are divided into two groups: 1) high cost skin substitute products and 2) low cost skin substitute products for packaging purposes.

There are 13 new skin substitute HCPCS codes that will be active as of July 1, 2020. New skin substitute HCPCS codes are assigned into the low-cost skin substitute group unless CMS has pricing data that demonstrates that the cost of the product is above either the mean unit cost (MUC) of $48 or per day cost (PDC) of $790 for CY 2020. These codes are listed in Table 20.

Table 20. ─ New Skin Substitute Products Low Cost Group/High Cost Group Assignment Effective July 1, 2020

CY 2020 HCPCS

Code

CY 2020 Short Descriptor CY 2020

SI

Low/High Cost Skin Substitute

C1849 Skin substitute, synthetic N HighQ4227 Amniocore per sq cm N LowQ4228 Bionextpatch, per sq cm N LowQ4229 Cogenex amnio memb per sq cm N LowQ4232 Corplex, per sq cm N LowQ4234 Xcellerate, per sq cm N LowQ4235 Amniorepair or altiply sq cm N LowQ4236 Carepatch per sq cm N LowQ4237 cryo-cord, per sq cm N LowQ4238 Derm-maxx, per sq cm N LowQ4239 Amnio-maxx or lite per sq cm N LowQ4247 Amniotext patch, per sq cm N LowQ4248 Dermacyte Amn mem allo sq cm N Low

11. New Separately Payable Procedure Codes – Surgical Procedures Effective July 1, 2020, two new HCPCS codes have been created as described in Table 21.

Table 21. – New Surgical Procedure Effective July 1, 2020

HCPCS Code

Short Descriptor

Long Descriptor APC SI

C9759 Transcath intraop microinf

Transcatheter intraoperative blood vessel microinfusion(s) (e.g., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when performed

N/A N

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C9760 Non-blind interatrial shunt

Non-randomized, non-blinded procedure for NYHA Class II, III, IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right and left heart catheterization, transeptal puncture, 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

1591 T

12. New HCPCS Codes Describing Strain-Encoded Cardiac Magnetic Resonance Imaging (MRI) For the July 2020 Update, CMS is establishing two new codes to describe the technology associated with strain-encoded cardiac magnetic resonance imaging. Specifically, CMS is establishing HCPCS codes C9762 and C9763 to describe the strain imaging and stress imaging associated with strain-encoded cardiac MRI. Table 22 lists the long descriptors, status indicator, and APC assignment for both codes. For more information on OPPS status indicator “Q3”, refer to OPPS Addendum D1 of the Calendar Year 2020 OPPS/ASC final rule for the latest definition. These codes, along with their short descriptors, status indicator, and payment rates are also listed in the July 1, 2020, OPPS Addendum B.

Table 22.—New Strain-Encoded Cardiac MRI HCPCS Codes Effective July 1, 2020

HCPCS Code

Long Descriptor OPPS SI OPPS APC

C9762 Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging

Q3 5524

C9763 Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging

Q3 5524

13. New HCPCS Codes Describing Peripheral Intravascular Lithotripsy For the July 2020 Update, CMS is establishing four new codes to describe the technology associated with peripheral intravascular lithotripsy. CMS is establishing HCPCS codes C9764, C9765, C9766, and C9767 to describe procedures utilizing peripheral intravascular lithotripsy catheter. Table 23 lists the long descriptors, status indicators, and APC assignment for all four codes. For more information on OPPS status indicator “J1”, refer to OPPS Addendum D1 of the CY 2020 OPPS/ASC final rule for the latest definition. These codes, along with their short descriptors, status indicator, and payment rates are also listed in the July 1, 2020, OPPS Addendum B.


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Table 23. New Peripheral Intravascular Lithotripsy HCPCS Codes Effective July 1, 2020

HCPCS Code


OPPS APC

C9764 Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed

J1 5192

C9765 Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed

J1 5193

C9766 Revascularization, endovascular, open or percutaneous, any vessel (s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed

J1 5193

C9767 Revascularization, endovascular, open or percutaneous, any vessel (s); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel (s), when performed

J1 5194

14. Supervision of Outpatient Therapeutic Services On March 13, 2020, the President of the United States declared the COVID-19 outbreak a national emergency, and the Secretary declared the existence of a public health emergency (PHE). Subsequently, CMS implemented an interim final rule with comment period on April 6, 2020, to provide physician and hospital providers flexibilities in the administration of care retroactive to March 1, 2020. The goal of the interim final rule was to reduce burden on providers, suppliers, and practitioners during this public health emergency including avoiding exposure risks to COVID-19, and to expand the facilities where medical care may be provided and the available personnel who can provide that care. These policies are only in effect for the duration of the COVID-19 PHE.

In the CY 2020 OPPS/ASC final rule with comment period (84 FR 61359 through 61363), we changed the generally applicable minimum required level of supervision for most hospital outpatient therapeutic services from direct supervision to general supervision for hospitals and CAHs. Given the circumstances of the PHE for the COVID-19 pandemic, we believed it was critical that hospitals have the most flexibility possible to provide the services Medicare beneficiaries need during this challenging time. One of the policies in the April 6, 2020, interim final rule with comment period related to hospital outpatient hospital care was changing the minimum default level of physician supervision for non-surgical extended duration therapeutic services (NSEDTS) to general supervision for the entire service including the initiation portion of the service that had previously required direct supervision. Changing the minimum default level of supervision to general supervision for NSEDTS during the initiation of the service gives providers additional flexibility they will need to handle the burdens created by the PHE for the COVID-19 pandemic.

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Therefore, we assigned, on an interim basis, all outpatient hospital therapeutic services that fall under §410.27(a)(1)(iv)(E) (that is, NSEDTS), a minimum level of general supervision to be consistent with the minimum default level of general supervision that applies for most outpatient hospital therapeutic services. General supervision, as defined in our regulation at §410.32(b)(3)(i) means 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.

In addition, we adopted, on an interim final basis, a change to the direct supervision requirement for outpatient hospital therapeutic services for pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services. During the duration of the PHE, the direct supervision requirement may be satisfied by the virtual presence of the physician through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider. We revised §410.27(a)(1)(iv)(D), to reflect this change to allow the direct supervision requirement to be met by virtual presence.

15. OPPS Pricer Logic and Data Changes for the July 2020 Update There are no OPPS PRICER logic or data changes for the July 2020 update; therefore, there is no OPPS PRICER release for July 2020.

16. Changes to the Wage Index As noted in the January 2020 OPPS CR, in the CY 2020 OPPS we finalized changes to the CY 2020 OPPS wage index to remove urban to rural reclassifications from the calculation of the rural floor, increase the wage index values for hospitals with a wage index value below the 25th percentile wage index value of 0.8457 across all hospitals, and apply a 5 percent cap for CY 2020 on any wage index values that decreased relative to CY 2019.

While we developed a table of 2019 wages for the payment systems to automatically calculate whether the 5 percent cap on decreases applied, some providers, such as those that are new in 2020, were not included on the list.

17. 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. 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.

Additional Information The official instruction, CR 11814, issued to your MAC regarding this change is available athttps://www.cms.gov/files/document/r10166cp.pdf.



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Document History


eTicket Enables Providers to Save Time with Every Call

Palmetto GBA continues to develop tools to improve service and efficiency, and our new eTicket is no exception.eTicket, like the recently introduced ePass, will save you time when contacting the Provider Contact Center (PCC) about a particular issue on multiple occasions. While ePass provides you with a code to bypass authentication on subsequent calls to the PCC during a single day, eTicket enables our representatives to serve you quickly and with greater effectiveness.

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

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

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Never Share Your eServices User ID and Password

Palmetto GBA puts a priority on stability and security as far as our eServices portal is concerned, and your participation in keeping eServices secure is important.

Each eServices user should have his or her separate user ID and password. We prohibit sharing of user IDs and passwords in order to maintain the integrity of the system. Palmetto GBA will delete, without notice, any user names we find that are generic and any accounts that have a shared user ID.

If you are currently not using eServices, (https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do) our user-friendly internet portal, we encourage you to register today. It’s easy and it’s free.

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


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

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

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

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

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

Other resources:

• MLN Publications List: contains the electronic versions of the downloadable publications. These products are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.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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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]. APPEALS INFORMATION

Part A East (PAE) Appeals Demo with the Qualified Independent Contractor (QIC) C2C Solutions

We are pleased to announce that we have partnered with C2C Solutions for the PAE Appeals Demo. If select-ed for the demo, you will have the opportunity to speak directly with someone from C2C Solutions regard-ing your level 2 appeals reconsiderations. The unique aspect of this demo is that you may also volunteer to participate.

Please select the link below to view and listen to our on-demand webcast to learn more about the PAE Ap-peals Demo.

https://tinyurl.com/u7ekxmy

New eServices Feature

We are LIVE!!!

We are excited to announce that we have a new appeals feature in eServices! This new feature is available to all Part A and HHH providers that are actively using eServices and has claim inquiry permission. If you do not have claim inquiry permission your eServices administrator must grant you the claim inquiry permission to use this feature.

Please select the link below to view and listen to our on-demand webcast to learn more about the new fea-ture.

https://event.on24.com/wcc/r/2217457/CFBDBA6C9DAB56A83555A9FFC481B732

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AUDIT AND REIMBURSEMENT INFORMATION

Unsolicited Voluntary Refunds

The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

Cost Report Due Dates

CMS has delayed the cost report filing deadlines for all provider types, including hospitals, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Hospices, End Stage Renal Disease Facilities (ESRDs), Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), Community Mental Health Centers (CMHCs), Organ Procurement Organizations (OPOs), histocompatibility labs and home office cost statements, with a fiscal year ending between October 31, 2019 through December 31, 2019.The extended due dates are as follows:

Cost Reporting Period Ending

Initial Due Date Extended Due Date

10/31/2019 03/31/2020 06/30/202011/30/2019 04/30/2020 06/30/202012/31/2019 05/31/2020 07/31/2020

This is a blanket extension and providers do not need to request an extension.

We continue to encourage you to file your cost report early so that any issues can be resolved, and payment suspension can be avoided.

We also encourage you to submit your cost report via the Medicare Cost Report E-filing system (MCRef). This system is the fastest and most efficient way to submit your cost report to Palmetto GBA. The URL to obtain instructions on how to sign up for MCRef is https://mcref.cms.gov. One of the best benefits of using MCRef is you get immediate confirmation your cost report has been received. The system also offers electronic signature capability. For more information about MCRef, please see the following article.

Medicare Cost Report e-Filing - MLN Matters Article 10611


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ELECTRONIC DATA INTERCHANGE (EDI) INFORMATION

Claim Status Category Codes and Claim Status Codes Update

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


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

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

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

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

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

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Claim Status Codes when sending ASC X12 277 Health Care Claim Status Responses. They must also use valid Claim Status Category Codes and Claim Status Codes when sending ASC X12 277 Healthcare Claim Acknowledgments.

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



Document History

Date of Change Description May 22, 2020 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 Types Affected This MLN Matters Article is for physicians, hospitals, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed This article informs you of updates that the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, and CAGC rule publications. These system updates are based on the CORE Code Combination List to be published on or about June 1, 2020. Make sure that your billing staffs are aware of these updates.


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Background The Department of Health and Human Services (DHHS) adopted the Phase III CAQH CORE, EFT and ERA Operating Rule Set that was implemented on January 1, 2014, under the Affordable Care Act of 2010.

The Health Insurance Portability and Accountability Act (HIPAA) amended the Social Security Act (the Act) by adding Part C—Administrative Simplification—to Title XI of the Act, requiring the Secretary of DHHS (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. The Affordable Care Act defines operating rules and specifies the role of operating rules in relation to the standards.

CR 11709 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 June 1, 2020. This update is based on the CARC and RARC updates as posted at the Washington Publishing Company (WPC) website on or about March 1, 2020. This will also include updates based on a market-based review that CAQH CORE conducts once every 2 years to accommodate code combinations that are currently being used by health plans including Medicare, as the industry needs them.

You can refer to https://nex12.org/index.php/codes 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: The Affordable Care Act mandates that 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.

Additional Information The official instruction, CR 11709, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/r10150cp.pdf.


Document History


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Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update



Provider Action Needed CR 11708 updates the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs the Viable Information Processing System (ViPS) Medicare System (VMS) and the Fiscal Intermediary Shared System (FISS) to update Medicare Remit Easy Print (MREP) and PC Print. Make sure your billing staffs are aware of these updates. If they use the MREP or PC Print software, they will need to get the updates of that software.

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

The Centers for Medicare & Medicaid Services (CMS) instructs contractors to conduct updates based on the code update schedule that results in publication three times per year; around March 1, July 1, and November 1.

CR 11708 is a code update notification that indicates when updates to the CARC and RARC lists are made available at the official Accredited Standards Committee (ASC) X12 website. Shared System Maintainers (SSMs) are responsible for implementing code deactivations, making sure that any deactivated code is not used in original business messages, and allowing the deactivated code in derivative messages. SSMs must make sure that Medicare does not report any deactivated code on or after the effective date for deactivation as posted on the WPC website. If any new or modified codes have an effective date later than the implementation date specified in this CR, MACs must implement on the date specified at https://nex12.org/index.php/codes.


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Discrepancies between dates may arise, since the WPC website is only updated three times per year and those dates might not match the CMS release schedule. For CR 11708, MACs and SSMs must get the complete list of both CARCs and RARCs from the WPC website to obtain the comprehensive lists for both code sets to determine the changes that are included on the code list since the last code update CR (CR 11638 – you can view the associated MLN Matters Article on the CMS website at https://www.cms.gov/files/document/mm11638.pdf.



Document History


ESERVICES INFORMATION

New eServices Appeals Feature

We are live!

Palmetto GBA is pleased to announce that eServices has been enhanced with the addition of new appeals features. Part A and Home Health and Hospice providers that are actively using eServices and have access to the Claims Inquiry tab can get up-to-date appeals status, view and download decision letters, and more. Please contact your eServices administrator for access to the Claims Inquiry tab if you do not already have access.

Do you want to learn about all of the new appeals enhancements? View our on-demand webcast to learn more!

https://event.on24.com/wcc/r/2217457/CFBDBA6C9DAB56A83555A9FFC481B732

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eServices Profile Verification Timeframes

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

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

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

Email Notifications will be sent on day 240 and 250, instead of day 80 and 90

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 855–567–7271 (Monday – Friday, 8 a.m. to 6 p.m. ET).

To connect with an eServices representative:

• Press/say 1 or EDI

• Press/say 1 or eServices

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

How Can We Be Of “eServices “ To You!

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

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

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


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eServices and Google Authenticator

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

You now have three options to receive an MFA code:

• Email

• Text

• Google Authenticator

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

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

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

After selecting the Authenticator Setup button, you’ll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android:

• iPhone users must access iTunes

• Android users must access Google Play

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

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

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

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

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

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

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

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

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

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

After selecting the Authenticator Setup button, you’ll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android:

• iPhone users must access iTunes

• Android users must access Google Play

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

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

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

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

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


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FEE SCHEDULE INFORMATION

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


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

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

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

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

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

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Due to a delay in announcement of the next round of the CBP, contracts are not in effect in Round 1, Round 2, or the National Mail Order CBAs beginning January 1, 2019, resulting in a temporary gap period in the CBP. Additional program instructions for payment of items furnished in former CBAs is available in CR 11233, dated April 5, 2019. A related article is at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11233.pdf. The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. The DMEPOS Rural ZIP code file contains the ZIP codes designated as rural areas. ZIP codes for non-continental Metropolitan Statistical Areas (MSA) are not included in the DMEPOS Rural ZIP code file. The DMEPOS Rural ZIP code file is updated on a quarterly basis as necessary. Regulations at 42 CFR 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code is estimated to be outside any MSA. A rural area also includes any ZIP Code within an MSA that is excluded from a CBA established for that MSA. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes and will be updated on a quarterly basis as necessary.

CR 11810 provides update instructions for the following:

1. DMEPOS fee schedule file

2. PEN fee schedule file

3. DMEPOS Rural ZIP code file containing the Quarter 3, 2020 updates

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

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

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


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

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

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

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

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

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

Other Payment Changes Effective January 1, 2020, the parenteral nutrition solution code B4185 Parenteral nutrition solution, per 10 grams lipids was divided into two HCPCS codes: B4187 Omegaven, 10 grams lipids and B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids. Before this change, all claims for lipids

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furnished as part of parenteral nutrition fell under code B4185. Payment regulations at 42 CFR 414.110 specify that when there is a single code that describes two or more distinct complete items and separate codes are subsequently established for each item, the fee schedule amounts that applied to the single code continue to apply to each of the items described by the new codes. As required by this regulation, the fee schedule amounts for code B4185 apply to new code B4187 and revised code B4185 effective for items and services furnished on or after July 1, 2020.

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


Document History


Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules

MLN Matters Number: MM11805 Related CR Release Date: May 22, 2020 Related CR Transmittal Number: R10160OTN Related Change Request (CR) Number:11805 Effective Date: June 12, 2020 Implementation Date: June 12, 2020

Provider Types Affected This MLN Matters Article is for physicians and providers, including home health and hospice providers, who bill Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed This article provides a summary of policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rule With Comment (IFC) entitled, “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC) and Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program (CMS-5531-IFC).”

Please make sure your billing staffs are aware of these changes.


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Background In the event of a declared PHE, the Secretary of the Department of Health & Human Services (HHS) (the Secretary) has the authority to temporarily waive or modify application of certain Medicare requirements during the emergency period. The Secretary declared a PHE on January 31, 2020, for the 2019 Novel Coronavirus (COVID-19). In addition, the President declared a national emergency concerning COVID-19 on March 13, 2020.

CR 11805’s purpose is to provide a summary of the recent policy changes to the MPFS during the PHE. The Centers for Medicare & Medicaid Services (CMS) recently issued two Interim Final Rules with Comment (IFC) that revised payment policies and Medicare payment rates for services provided by physicians and nonphysician practitioners (NPPs) who are paid under the MPFS during the PHE.These IFCs are:

• Regulation number CMS-1744-IFC, titled, “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” and posted on the CMS website on March 31, 2020.

• Regulation number CMS-5531-IFC, titled, “Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program,” and was posted on the CMS website on April 30, 2020.

These changes are applicable to services provided during the PHE.

Medicare Telehealth Services

Payment for Medicare Telehealth Services Under Section 1834(m) of the Social Security Act (the Act) Pursuant to the waiver authority added under Section 1135(b)(8) of the Act by the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, to ease the use of telecommunications technology as a safe substitute for in-person services, CMS has added, on an interim basis, many services to the list of eligible Medicare telehealth services.

This list of added services includes:

• Initial inpatient and nursing facility visits

• Emergency department visits

• Initial and subsequent observation services

• Inpatient nursing facility and observation discharge day management home visits

• A number of physical therapy, occupational therapy, and speech language pathology services.

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On an interim basis, CMS eliminated several requirements associated with particular services provided via telehealth. CMS clarified several payment rules that apply to other services that are provided using telecommunications technologies that can reduce exposure risks. Specifically, CMS eliminated frequency limitations for subsequent inpatient and nursing facility visits and critical care consults, and instructed practitioners to identify the place of service normally used had the service occurred in person, and to append the 95 modifier to the claim to identify it as Medicare telehealth. This is to assure that the payment rate would be equal to that which ordinarily would have been paid under the MPFS were the services furnished in-person.

NOTE: Critical Access Hospitals (CAH) method II should continue to report Distant Site services with modifier GT.

Frequency Limitations on Subsequent Care Services in Inpatient and Nursing Facility Settings, and Critical Care Consultations and Required “Hands-on” Visits for End Stage Renal Disease (ESRD) Monthly Capitation Payments For ESRD Monthly Capitation Payments, CMS exercised enforcement discretion regarding the statutory requirement that for ESRD services furnished via telehealth there be a monthly “hands on,” evaluation of the vascular access site for the first 3 months of home dialysis and once every 3 months thereafter. Instead, CMS is permitting the required clinical examination to be furnished as a Medicare telehealth service during the PHE for the COVID-19 pandemic.

Telehealth Modalities Physician community feedback convinced CMS to clarify that for the COVID-19 pandemic PHE, interactive telecommunications system means multimedia communications equipment. The multimedia communications equipment includes (at a minimum) audio and video equipment permitting two-way, real-time, interactive communication between the patient and distant site physician or practitioner. CMS informed practitioners that they will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations during the COVID-19 pandemic PHE.

Communication Technology-Based Services (CTBS) For Communication Technology Based Services (CTBS) for the duration of the PHE for the COVID-19 pandemic, CMS established that these services, which may only be reported if they do not result in a visit, including a telehealth visit, can be furnished to both new and established patients. This allows such services to be available to as many Medicare beneficiaries are possible, given the need for an in-person visit could represent an exposure risk for vulnerable patients during the COVID-19 pandemic.

CMS also finalized that during the COVID-19 pandemic PHE, while consent to receive these services must be obtained annually, it may be obtained at the same time that a service is provided.

CMS expanded the range of practitioners eligible to bill for certain online assessment and management services to include practitioners who could not ordinarily bill for Evaluation and Management (E/M) services so that, for example, licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists may bill for these services when applicable.


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On an interim basis, during the PHE for the COVID-19 pandemic, CMS broadened the availability of HCPCS codes G2010 and G2012 that describe remote evaluation of patient images/video and virtual check-ins to recognize that in the context of the PHE for the COVID-19 pandemic, practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists might also use virtual check-ins and remote evaluations instead of other, in-person services within the relevant Medicare benefit to facilitate the best available appropriate care while mitigating exposure risks.

Direct Supervision by Interactive Telecommunications Technology For the duration of the COVID-19 pandemic PHE, CMS revised the definition of direct supervision to allow direct supervision to be provided using real-time interactive audio and video technology. CMS recognizes that given the risks of exposure, in some cases, technology would allow appropriate supervision without the physical presence of a physician.

CMS notes that in specifying that direct supervision includes virtual presence through audio/video real-time communications technology, and can include instances in which the physician enters into a contractual arrangement for auxiliary personnel as defined in the Federal regulations at 42 CFR 410.26(a)(1), to leverage additional staff and technology necessary to provide care that would ordinarily be provided incident to a physicians’ service (including services that are allowed to be performed via telehealth). CMS also notes that this change is limited to only the manner in which the supervision requirement can be met and does not change the underlying payment or coverage policies related to the scope of Medicare benefits, including Part B drugs.

Telephone E/M Services (CPT codes 99441-3 and 98966-8) For the duration of the COVID-19 pandemic PHE, CMS finalized separate payment for CPT codes 99441 through 99443 and 98966 through 98968; which describe E/M and assessment and management services provided via telephone. While the code descriptors for these services refer to an “established patient,” during the COVID-19 PHE, CMS is exercising enforcement discretion to relax enforcement of this aspect of the code descriptors.

As these audio-only services are being provided primarily as a replacement for care that would otherwise be reported as an in-person or telehealth visit using the office/outpatient E/M codes, CMS is cross-walking the values for CPT codes 99441, 99442, and 99443 to 99212, 99213, and 99214, respectively.

Also, given the understanding that these audio-only services are being provided as substitutes for office/outpatient E/M services, CMS recognizes that they should be considered as telehealth services, and is adding them to the list of Medicare telehealth services for the duration of the PHE.

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Level Selection for Office/Outpatient E/M Visits When Furnished Via Medicare Telehealth

CMS revised its policy to specify that the following changes, which are scheduled to become effective on January 1, 2021, under policies finalized in the CY 2020 MPFS Final Rule; will be effective throughout the COVID-19 pandemic PHE:

• The office/outpatient E/M level selection for office/outpatient E/M services when provided via telehealth can be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter.

• CMS finalized on an interim basis for the duration of the PHE for the COVID-19 pandemic, that the typical times for purposes of level selection for an office/outpatient E/M are the times listed in the CPT code descriptor.

Updating the Medicare Telehealth List CMS finalized that for the duration of the COVID-19 PHE, updates to the Medicare Telehealth List would be done on an ongoing, sub-regulatory basis.

Remote Physiologic Monitoring (RPM) Services (CPT codes 99453, 99454, 99457, 99458) CMS made several changes to RPM policies in response to the COVID-19 PHE, including:

1. Removed the requirement that there be an established patient-practitioner relationship. Both new and established patients can receive RPM services.

2. Modified the requirement that consent must be obtained prior to providing the RPM service. Instead, consent can be obtained at the time services are provided and by individuals providing RPM services under contract to the ordering physician or qualified healthcare professional.

3. Clarified that RPM services can be used for physiologic monitoring of patients with acute and/or chronic conditions.

4. Confirmed that RPM services can be furnished under general supervision.

5. For CPT codes 99453 and 99454, modified the number of days that data must be collected from the required 16 days to fewer than 16 days in a 30-day period as long as the other code requirements are met.

Supervision of Diagnostic Tests by Certain Nonphysician Practitioners Throughout the COVID-19 PHE, CMS finalized changes to regulations governing diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests. These changes allow nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives to provide the appropriate level of supervision required for the performance of diagnostic tests paid under the MPFS. Furthermore, these interim changes will continue to ensure that these nonphysician practitioners may order, provide directly, and now supervise the performance of diagnostic tests, subject to applicable State law, during the COVID-19 PHE.


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Application of Teaching Physician Regulations Under current rules, Medicare payment is made for services furnished by a teaching physician involving residents only if the physician is physically present for the key portion of the service or procedure or the entire procedure, where applicable. During the COVID-19 PHE, CMS finalized on an interim basis that teaching physicians may use audio/video, real-time communications technology to interact with the resident through virtual means, which would meet the requirement that they be present for the key portion of the service, including when the teaching physician involves the resident in providing Medicare telehealth services.

Teaching physicians involving residents in providing care at primary care centers can provide the necessary direction, management and review for the resident’s services using audio/video, real-time communications technology. Residents furnishing services at primary care centers may provide an expanded set of services to beneficiaries, including levels 4-5 of an office/outpatient E/M visit, telephone E/M, care management, and CTBS.

These flexibilities do not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, and anesthesia services. This allows teaching hospitals to maximize their workforce to safely take care of patients.

Resident Moonlighting Under current rules, Medicare considers the services of residents that are not related to their approved graduate medical education (GME) programs and performed in the outpatient department or the emergency department of a hospital as separately billable physicians’ services. During the COVID-19 PHE, CMS finalized that Medicare also considers the services of residents that are not related to their approved GME programs and provided to inpatients of a hospital in which they have their training program as separately billable physicians’ services.

Outpatient Physical and Occupational Therapy Services: Expanded Use of Therapy Assistants Allowed for Maintenance Therapy Services Current CMS policy for outpatient Part B physical therapy and occupational therapy services requires the physical therapist (PT) or occupational therapist (OT) to personally carry out the services of a maintenance program (more commonly known as maintenance therapy) when these services are needed to maintain, prevent, or slow the deterioration of a patient’s functional status as part of the maintenance program’s plan.

For the duration of the COVID-19 PHE, CMS finalized on an interim basis, that PTs and OTs are permitted to delegate to therapy assistants, when clinically appropriate, the responsibilities to furnish maintenance therapy services. CMS believes this is consistent with feedback from therapists and therapy providers on scope of practice issues and better aligns with maintenance therapy services furnished in the Part A-paid skilled nursing facility and home health settings. This flexibility will free-up PTs and OTs to furnish other services requiring their assessment skills to COVID-19 related services including CTBS that were made available for PTs, OTs, and speech-language pathologists during the PHE.

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Therapy Services-Student Documentation In the CY 2020 PFS final rule, CMS simplified medical record documentation requirements and finalized a general principle to allow the physician, physician assistant, or the advanced practice registered nurses (who furnish and bill for their professional services) to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.

For the duration of the COVID-19 PHE, CMS finalized on an interim basis, that any individual who has a separately enumerated benefit under Medicare law that authorizes them to furnish and bill for their professional services, whether or not they are acting in a teaching role, may review and verify (sign and date), rather than re-document, notes in the medical record made by physicians, residents, nurses, and students (including students in therapy or other clinical disciplines), or other members of the medical team.

Opioid Treatment Programs (OTPs) In light the COVID-19 pandemic PHE, in CMS-1744-IFC, CMS revised regulations at 42 CFR 410.67(b)(3) and (4) to allow therapy and counseling portions of weekly bundles of services provided by OTPs, as well as the add-on code for additional counseling or therapy, to be provided using audio-only telephone calls rather than via two-way interactive audio-video communication technology during this PHE if beneficiaries do not have access to two-way audio/video communications technology, provided all other applicable requirements are met.

In addition to the flexibilities described above, in CMS-5531-IFC, CMS revised regulations at 42 CFR 410.67(b)(7) on an interim final basis to allow periodic assessments to be furnished during the PHE for the COVID-19 pandemic via two-way interactive audio-video communication technology. Also, in cases where beneficiaries do not have access to two-way audio-video communications technology, the periodic assessments may be furnished using audio-only telephone calls rather than via two-way interactive audio-video communication technology, provided all other applicable requirements are met. This change is necessary to ensure that beneficiaries with opioid use disorders are able to continue to receive these important services during the PHE for the COVID-19 pandemic.

Ordering COVID-19 Diagnostic Laboratory Tests Having recognized the critical importance of expanding COVID-19 testing during the COVID-19 pandemic PHE, CMS has removed the requirement that certain diagnostic tests are covered only under the order of a treating physician or NPP. This will allow any healthcare professional, authorized to do so under State law, to order COVID-19 diagnostic laboratory tests (including serological and antibody tests). Because the symptoms for coronavirus, influenza, and respiratory syncytial virus (RSV) are often the same, such that concurrent testing for all three viruses is warranted, this provision will also apply to influenza and RSV tests only when they are furnished in conjunction with a medically necessary COVID-19 diagnostic laboratory test to establish or rule out a COVID-19 diagnosis or identify an adaptive immune response to SARS-COV-2.


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CMS has made conforming changes to the documentation and record-keeping requirements for lab tests that would not be relevant in the absence of a treating physician’s or NPP’s order. When an order is written for the test, CMS expects the ordering or referring National Provider Identifier information on the claim form under current requirements.

When provided without a physician’s or NPP’s order, the laboratory conducting the test(s) is required to directly notify the patient of the results and meet other applicable test result-reporting requirements.

CMS has finalized new specimen collection fees for COVID-19 testing under the MPFS. Physicians and NPPs must use CPT code 99211 to bill for a COVID-19 symptom and exposure assessment and specimen collection provided by clinical staff (such as pharmacists) incident to the physician’s or NPP’s services. This applies to all patients, not just established patients. The direct supervision requirement may be met through virtual presence of the supervising physician or practitioner using interactive audio and video technology. Cost sharing will not apply.

Pharmacists Providing Services Incident to Physician/NPP Services CMS clarified explicitly the existing policy that pharmacists may provide services incident to, and under the appropriate level of supervision of, the billing physician or NPP, if payment for the services is not made under Medicare Part D. This includes providing the services in accordance with the pharmacist’s state scope of practice and applicable state law.

Additional Information The official instruction, CR 11805, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10160otn.pdf.


Document History


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LEARNING AND EDUCATION INFORMATION

2020 Jurisdiction M (JM) Home Health Medicare Workshop Series - Hitting the Target with Medicare

Palmetto 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 successful with Medicare billing, coverage and documentation requirements.

These workshops will provide insight for home health agency staff at all levels. However, we do suggest that providers who are new to Medicare, or have new staff, attend our online learning courses for beginners at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analyses and some hints and tips as to why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers that know how to accurately and skillfully apply the information they learn to their documentation and billing practices.

Topics Covered During the Workshop

Part I

1. Questionable Encounters

a. State-Specific Data

b. Physician Query

2. Top Denials

a. Medical Review Denials

b. CERT Errors

3. Nursing Process/Care Planning

4. Case Scenarios

Part II5. What You Need to Know for 2020

a. 2020 Home Health Final Rule

b. Targeted Probe and Educate (TPE)

c. Patient-Driven Groupings Model (PDGM)


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6. Data-Driven Topics

a. Top Home Health Reason Codes

7. eServices Online Portal

8. Reminders

a. CERT Program

b. Provider Enrollment Revalidation

9. Provider Resources/Self Service Tools

a. Palmetto GBA Resources

b. CMS Resources

c. Top Links

d. Social Media

e. Education/Events

Home Health Workshop Sessions

Workshop Date

City and State Association Website Registration LinkWorkshop Time

09/09/2020 Monroe, LA The HomeCare Association of Louisianahttps://tinyurl.com/y9jyd8e

8:00 am - 12:00 pm CT

09/10/2020 Baton Rouge, LA The HomeCare Association of Louisianahttps://tinyurl.com/ya9mu9gt

8:00 am - 12:00 pm CT

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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.

These workshops will provide insight for hospice agency staff at all levels. However, we do suggest that providers who are new to Medicare, or have new staff, attend online learning courses for beginners offered at www.PalmettoGBA.com/hhh. Basic billing and other online educational resources can be found in the Self-Paced Learning section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analyses and some hints and tips as to why these errors occur. Palmetto GBA’s ultimate goal is to have educated and astute providers that know how to accurately and skillfully apply the information they learn to their documentation and billing practices.

The following topics will be covered during the workshop:Part I

1. Utilization

a. Length of Stay

b. Medicare Spending

c. Revenue Code Breakdown

d. Utilization by Discipline

2. Top Denials

a. Medical Review Denials

b. CERT Errors

3. Hospice Patient in a Facility

4. An Effective Interdisciplinary Team

Part II

1. What You Need to Know for 2020

a. 2020 Final Rule

b. Targeted Probe and Educate (TPE)

c. Physician Billing


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2. Data-Driven Topics

a. Top Hospice Reason Codes

3. eServices Online Portal

4. Reminders

a. CERT Program

b. Provider Enrollment Revalidation

5. Provider Resources/Self Service Tools

a. Palmetto GBA Resources

b. CMS Resources

c. Top Links

d. Social Media

e. Education/Events

Hospice Workshop Schedule

Workshop Date City and State Association Website Registration Link Workshop Time

9/9/2020 Monroe, LA

The HomeCare Association of Louisiana (HCLA)https://tinyurl.com/y9jyd8et 8:00 am - 12:00 pm CT

9/10/2020 Baton Rouge, LA

The HomeCare Association of Louisiana (HCLA)https://tinyurl.com/ya9mu9gt 8:00 am - 12:00 pm CT

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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-Home-Health-and-Hospice~AH2JQU8321

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.


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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.

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

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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/hhh.

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/hhh).


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TOOLS THAT YOU CAN USE

Appeals and Clerical Error Reopenings Module

This updated module provides education on correcting incomplete and/or invalid submissions, correcting claims with medically denied lines, clerical error reopening, and redetermination requests. There is also a further explanation on the submission of documentation for a clerical error reopening (bilateral procedure) and on adding late charges during the appeal process. A new section, Correcting Inpatient Discharge Status, was added to the module.

To access this module and other online training courses, please go to the Self-Paced Learning Section (https://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Home%20Health%20and%20Hospice~Learning%20Education~Self-Paced%20Learning) of the JM Home Health and Hospice (HHH) website.

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NOTES


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HELPFUL INFORMATION

Contact Information for Palmetto GBA Home Health and Hospice

Provider Contact Center: 855-696-0705

Email HHH: https://www.palmettogba.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=08

To contact a specific JM HHH department, please select the link below:

https://www.palmettogba.com/palmetto/providers.nsf/cudocs/JM%20Home%20Health%20and%20Hospice?open&Expand=1

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