JULY 2020 • Medicare Bulletin › parta › pubs › bulletin › ... · Physicians and NPPs must use CPT code 99211 to bill for a COVID-19 symptom and exposure assessment and specimen

MedicareBulletin

JURISDICTION 15KENTUCKY & OHIO PART A

JULY 2020 • WWW.CGSMEDICARE.COM

GR 2020-07ORIGINATED JUNE 29, 2020

© 2020 Copyright, CGS Administrators, LLC.

Reaching Out to the Medicare Community

http://www.cgsmedicare.com

Medicare BulletinJurisdiction 15

Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyright 2020 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN GR 2020-07 JULY 2020 2

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TABLE OF CONTENTSAdministrationContact Information for CGS Medicare Part A 3

Medicare Credit Balance Quarterly Reminder 3

MLN Connects Weekly News 4

MM11669: Claim Status Category Codes and Claim Status Codes Update 5

MM11708: Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update 6

MM11709: 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 7

MM11778: Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section 9

Provider Contact Center (PCC) Training 9

Quarterly Provider Update 10

SE20019: Medicare Continues to Modernize Payment Software 10

Stay Informed and Join the CGS ListServ Notification Service 13

Upcoming Educational Events 13

CodingMM11750: New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services 13

CoverageMM11650: National Coverage Determination (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM) 14

MM11755: National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP) 16

Prior Authorization Process and Requirements for Certain Hospital OPD Services: Payment for Related Services 19

COVID-19Home Health Plans of Care: NPs, CNSs, and PAs Allowed to Certify 19

SE20018: COVID-19 Blanket Swing Bed Waiver for Addressing Barriers to Nursing Home Placement for Hospitalized Individuals 20

EnrollmentSE20017: Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing 25

Fee ScheduleMM11661 (Revised): Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update 28

MM11788: Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2020 Update 32

MM11805: Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules 35

HospitalMM11559 (Revised): Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current Policy 41

MM11580: Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan 42

Skilled Nursing Facility (SNF)MM11727: Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process 44

TherapyMM11791 (Revised): Therapy Codes Update 45

https://www.onlineproviderservices.com/cgs_ops/initLogin.do

myCGS is a secure Internet-based application where you can view beneficiary eligibility, claims status, online remittances, financial information, and much more!

my

go.cms.gov/mln



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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters issued after February 1997 are available at no cost from our website at http://www.cgsmedicare.com. © 2020 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN GR 2020-07 JULY 2020

RETURN TO TABLE OF CONTENTS

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A D M I N I S T R AT I O N

Contact Information for CGS Medicare Part A

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center at 1.866.590.6703. Listen carefully and choose the option most appropriate for the reason you are calling.

y 1 – Claimsy 2 – Electronic Data Interchange (EDI y 3 – Provider Enrollment

y 4 - Overpayment Recoveryy 9 – General Inquiries

For additional contact information, please access the Kentucky & Ohio Part A “Contact Information” web page at https://www.cgsmedicare.com/parta/cs/index.html for information about the myCGS web portal, the Interactive Voice Response (IVR) system, as well as telephone numbers, fax numbers, and mailing addresses for other CGS departments.

BEFORE YOU CALLAccess the “How Do I…?” icon (https://www.cgsmedicare.com/parta/cs/howdoi.html) and the “Education & Events” icon (https://www.cgsmedicare.com/parta/education/index.html) to access resources that may be able to answer your question.


Medicare Credit Balance Quarterly Reminder

This article is a reminder to submit the Quarterly Medicare Credit Balance Report. The next report is due in our office postmarked by July 30, 2020, for the quarter ending June 30, 2020. A Medicare credit balance is an amount determined to be refundable to the Medicare program for an improper or excess payment made to a provider because of patient billing or claims processing errors.

Each provider must submit a quarterly Medicare Credit Balance Report (CMS-838) and certification for each individual PTAN, which is available at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS838.pdf.

NOTE: Please do not submit duplicate Credit Balance Reports. To ensure CGS has received your report, consider using the website portal myCGS to submit your report. myCGS provides instant confirmation of receipt and allows you to check the status. Submitting your CBR using certified mail, or other methods that require a signature upon delivery is also an option.

The report must be postmarked by the date indicated above. If the report is received with a postmark date later than the date indicated above, we are required to withhold 100 percent of all payments being sent to your facility. This withholding will remain in effect until the reporting requirements are met. If no credit balance exists for your facility during a quarter, a signed Medicare Credit Balance Report certification is still required. Please include your Medicare provider number on the certification form.

THE MEDICARE LEARNING NETWORK®

A Valuable Educational Resource! The Medicare Learning Network® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more.

Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.


https://www.cgsmedicare.com/parta/cs/index.html

https://www.cgsmedicare.com/parta/cs/howdoi.html

https://www.cgsmedicare.com/parta/education/index.html

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS838.pdf

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS838.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

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Refer to the Medicare Credit Balance Report (CMS-838) form for complete instructions.

To ensure timely receipt and processing, send the CMS-838/Certification within 30 days of the quarter end date using one of the options below:

myCGS, secure Web Portal: Refer to the myCGS User Guide, “Chapter 7: Forms Tab” at http://www.cgsmedicare.com/pdf/mycgs/chapter7.pdf for details.

Reports may be faxed to: 1.803.462.2584 MCBR Receipts Attn: Credit Balance Reporting

Regular and Certified Mail: CGS Attn: Credit Balance Reporting PO Box 20023 Nashville, TN 37202

Fed Ex/UPS/Overnight Courier: CGS J15 Credit Balance Reporting 2 Vantage Way Nashville, TN 37228

Please note that if you have or will be submitting an adjustment, please send the UB-04 along with the CMS-838 form.

y If you are issuing a refund check for a credit balance:

Send the CMS-838 and a copy of the refund check using one of the options listed above.

Send the refund check with a copy of the CMS-838 or documentation that indicates the check is for a credit balance, the quarter end date, and provider number associated with the check to the appropriate address below:

CGS - J15 Part A Kentucky CGS – J15 Part A Ohio PO Box 957582 PO Box 957635 St. Louis, MO 63195-7582 St. Louis, MO 63195-7635

If you have general questions related to the Credit Balance report, call the Provider Contact Center at 1.866.590.6703 (Option 4).


MLN Connects Weekly News

The MLN Connects is the official news from the Medicare Learning Network and contains a weeks worth of Medicare-related messages. These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

y May 15, 2020 Special Edition - https://www.cms.gov/files/document/2020-05-15-mlnc-se.pdf

y May 19, 2020 Special Edition - https://www.cms.gov/files/document/2020-05-19-mlnc-se.pdf

y May 21, 2020 - https://www.cms.gov/files/document/2020-05-21-mlnc.pdf

y May 28, 2020 - https://www.cms.gov/files/document/2020-05-28-mlnc.pdf

y May 29, 2020 - https://www.cms.gov/files/document/2020-05-29-mlnc-se.pdf

y June 4, 2020 - https://www.cms.gov/files/document/2020-06-04-mlnc.pdf

y June 11, 2020 - https://www.cms.gov/files/document/2020-06-11-mlnc.pdf


http://www.cgsmedicare.com/pdf/mycgs/chapter7.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/files/document/2020-05-15-mlnc-se.pdf


https://www.cms.gov/files/document/2020-05-21-mlnc.pdf





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MM11669: Claim Status Category Codes and Claim Status Codes UpdateThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

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

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 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.

BACKGROUNDThe 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 http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ and http://www.wpc-edi.com/reference/codelists/healthcare/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 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.


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/

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ADDITIONAL INFORMATIONThe official instruction, CR 11699, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10148cp.pdf.

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

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center at 1.866.590.6703 and choose Option 1.

DOCUMENT HISTORY

Date of Change DescriptionMay 22, 2020 Initial article released.


MM11708: Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print UpdateThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index



PROVIDER ACTION NEEDEDCR 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.

BACKGROUNDThe 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.


https://www.cms.gov/files/document/r10148cp.pdf

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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.

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.

ADDITIONAL INFORMATIONThe official instruction, CR 11708, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10149cp.pdf.



DOCUMENT HISTORY



MM11709: 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) COREThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index



https://nex12.org/index.php/codes

https://nex12.org/index.php/codes

https://www.cms.gov/files/document/mm11638.pdf





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PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, hospitals, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDThis 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.

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

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




http://www.wpc-edi.com/Reference

http://www.caqh.org/sites/default/files/core/phase-iii/code-combinations/CORE-required_CodeCombos.xlsx?token=_29xvBua

http://www.caqh.org/sites/default/files/core/phase-iii/code-combinations/CORE-required_CodeCombos.xlsx?token=_29xvBua



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DOCUMENT HISTORY



MM11778: Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico SectionThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11778 Related Change Request (CR) Number: 11778 Related CR Release Date: May 15, 2020 Effective Date: June 16, 2020 Related CR Transmittal Number: R10135CP Implementation Date: June 16, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors for services to Medicare beneficiaries.

WHAT YOU NEED TO KNOWThis article informs you that Medicare will remove Section 20 (and all of its subsections) of the Medicare Claims Processing Manual (Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico). The key impact is that modifier CS is no longer to be used to denote services related to the 2010 oil spill.

ADDITIONAL INFORMATIONThe official instruction, CR 11778, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10135CP.pdf.



DOCUMENT HISTORY



Provider Contact Center (PCC) Training

Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs). The list below indicates when the CGS Part A PCC (1.866.590.6703) will be closed for CSR training and staff development.




https://www.cms.gov/files/document/r10135CP.pdf


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Date PCC Training/ClosuresFriday, July 3, 2020 Office closed for July 4th HolidayThursday, July 9, 2020 9:00 a.m. – 11:00 a.m. Eastern TimeThursday, July 23, 2020 9:00 a.m. – 11:00 a.m. Eastern Time

The Interactive Voice Response (IVR) (1.866.289.6501) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at https://www.cgsmedicare.com/parta/cs/cgs_j15_parta_ivr_user_guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For additional information, go to https://www.cgsmedicare.com/parta/index.html and click the “myCGS” button on the left side of the Web page.

For your reference, access the “Kentucky/Ohio Part A 2020 Holiday/Training Closure Schedule” at https://www.cgsmedicare.com/parta/cs/2020_holiday_schedule.pdf for a complete list of PCC closures.


Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all nonregulatory changes to Medicare including transmittals, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to:

y Inform providers about new developments in the Medicare program;

y Assist providers in understanding CMS programs and complying with Medicare regulations and instructions;

y Ensure that providers have time to react and prepare for new requirements;

y Announce new or changing Medicare requirements on a predictable schedule; and

y Communicate the specific days that CMS business will be published in the Federal Register.

To receive notification when regulations and program instructions are added throughout the quarter, refer to the CMS.gov Email Updates Web page at https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/EmailUpdates.html to subscribe. Refer to the CMS Quarterly Provider Update at https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html for additional information.


SE20019: Medicare Continues to Modernize Payment SoftwareThe Centers for Medicare & Medicaid Services (CMS) issued the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: SE20019 Related Change Request (CR) Number: N/A Article Release Date: May 19, 2020 Effective Date: N/A Related CR Transmittal Number: N/A Implementation Date: N/A


https://www.cgsmedicare.com/parta/cs/cgs_j15_parta_ivr_user_guide.pdf

https://www.cgsmedicare.com/parta/cs/cgs_j15_parta_ivr_user_guide.pdf

https://www.cgsmedicare.com/parta/index.html

https://www.cgsmedicare.com/parta/cs/2020_holiday_schedule.pdf

http://CMS.gov

https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/EmailUpdates.html

https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/EmailUpdates.html

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html



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PROVIDER TYPES AFFECTEDThis MLN Matters Article is for Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. For providers using software vendors, it is important that your vendor be aware of this modernization.

PROVIDER ACTION NEEDEDThis article informs providers about efforts by the Centers for Medicare & Medicaid Services (CMS) to modernize payment grouping and code editing software. A previous article, SE19013, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19013.pdf provided initial information on this modernization. SE20019 informs providers that in October 2020, CMS will expand this modernization effort to include these additional software products:

y The IRF Case-Mix Group (CMG) Grouper

y The IRF Pricer and PC Pricer

NOTE: A similar conversion for the SNF Patient Driven Payment Model (PDPM) Grouper is planned for October 2021.

BACKGROUNDIn July 2019, CMS issued SE19013, titled, Medicare Plans to Modernize Payment Grouping and Code Editor Software. The article described Medicare’s plans to convert the Medicare Code Editor (MCE), the Inpatient Group (MS-DRG), and the Integrated Outpatient Code Editor (I/OCE) from legacy programming languages into Java.

IRF CMG GrouperThe current IRF CMG Grouper software is distributed as a Dynamic Linked Library (DLL) download package. This program is run in the Internet Quality Improvement and Evaluation System (iQIES) and the iQIES User Tool to calculate Health Insurance Prospective Payment System (HIPPS) codes from IRF Patient Assessment Instrument (IRF-PAI) assessments, which CMS reports back to the IRF on their IRF-PAI validation reports. It is also available to provider billing software vendors to incorporate into their products. CMS will convert this program to Java for Fiscal Year (FY) 2021. Vendors should prepare to use the Java version of the IRF CMG Grouper for IRF-PAI assessments with discharge dates on and after October 1, 2020.

A Beta test version of the IRF CMG Grouper will be available in late June 2020 via the current download page located at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/CMG. The production version of the IRF CMG Grouper will be available on the same site in late August 2020.

IRF PricerCMS annually produces 10 Pricer programs to assist providers and other payers in estimating what Original Medicare would have paid institutional providers under various payment systems. Currently, CMS posts these programs on its website as both COBOL source code and in a COBOL-based PC Pricer format. Over the next 2 years, CMS will convert these COBOL-based products to Java versions.

The first of these conversions will be the IRF Pricer and its corresponding PC Pricer. CMS will convert this program to Java for FY 2021. Stakeholders should prepare to use the Java version of these Pricers for IRF claims with discharge dates on and after October 1, 2020. The remaining Pricer and PC Pricers will be converted to Java versions for FY or CY 2022. All Pricer software is available at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/index.


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19013.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19013.pdf

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/CMG

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/CMG

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/index

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/index

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SNF PDPM GrouperThe current SNF PDPM Grouper software is distributed as a DLL download package. This program is run in the QIES/ Assessment and Submission and Processing (ASAP) system to calculate HIPPS codes from Minimum Data Set (MDS) assessments, which are reported to the SNF on their MDS validation reports. It is also available to provider billing software vendors to incorporate into their products. CMS will convert this program to Java for FY 2022. Vendors should prepare to use the Java version of the SNF PDPM Grouper for MDS assessments with Assessment Reference Dates (ARDs) on and after October 1, 2021.

A Beta test version of the SNF PDPM Grouper is currently planned for late June 2021, via the current download page at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation. The production version of the SNF PDPM Grouper is planned for posting on the same site in late August 2021.

Table 1 presents the CMS timeline for the Java conversion schedule.

Table 1 – Java Conversion Schedule SummaryProgram Last non-Java Release Java-only ReleaseHH Grouper N/A v.1, January 2020 CompletedIRF CMG Grouper v.4.01, March 2020 v.5.0.0, October 2020IRF Pricer October 2019 October 2020SNF PDPM Grouper v.2.0.0, October 2020 v.3.0.0, October 2021Inpatient Prospective Payment System (IPPS) Pricer October 2020 October 2021Long Term Care Hospital (LTCH) Pricer October 2020 October 2021SNF Pricer October 2020 October 2021Hospice Pricer October 2020 October 2021Inpatient Psychiatric Hospital (IP)F Pricer October 2020 October 2021Federally Qualified Health Center (FQHC) Pricer January 2021 January 2022Outpatient PPS (OPPS) Pricer January 2021 January 2022End Stage Renal Disease (ESRD) Pricer January 2021 January 2022Home Health (HH) Pricer January 2021 January 2022Medicare Code Editor (MCE) v.39, October 2021 v.40, October 2022MS-DRG Grouper v.39, October 2021 v.40, October 2022Integrated Outpatient Code Editor (I/OCE) v.24, January 2023 v.24.1, April 2023

NOTE: The dates shown in the middle column reflect CMS’ current expectations. However, they may be subject to change.

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


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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation

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Stay Informed and Join the CGS ListServ Notification Service

The CGS Listserv Notification Service is the primary means used by CGS to communicate with Kentucky and Ohio Medicare Part A providers. The Listserv is a free email notification service that provides you with prompt notification of Medicare news including policy, benefits, claims submission, claims processing and educational events. Subscribing for this service means that you will receive information as soon as it is available, and plays a critical role in ensuring you are up-to-date on all Medicare information.

Consider the following benefits to joining the CGS ListServ Notification Service:

y It’s free! There is no cost to subscribe or to receive information.

y You only need a valid e-mail address to subscribe.

y Multiple people/e-mail addresses from your facility can subscribe. We recommend that all staff (clinical, billing, and administrative) who interacts with Medicare topics register individually. This will help to facilitate the internal distribution of critical information and eliminates delay in getting the necessary information to the proper staff members.

To subscribe to the CGS ListServ Notification Service, go to http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp and complete the required information.


Upcoming Educational Events

The CGS Provider Outreach and Education (POE) department offers educational events through webinars and teleconferences throughout the year. Registration for these events is required. For upcoming events, please refer to the Part A Calendar of Events Web page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/parta_report/parta_report.aspx. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.

If you have a topic that you would like the CGS POE department to present, send us your suggestion to [email protected].

C O D I N G

MM11750: New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy ServicesThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11750 Related CR Release Date: May 8, 2020 Related Change Request (CR) Number: 11750 Effective Date: October 1, 2020 Related CR Transmittal Numbers: R10124CP and R10124FM Implementation Date: October 5, 2020


http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/parta_report/parta_report.aspx

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/parta_report/parta_report.aspx

mailto:[email protected]



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PROVIDER TYPE AFFECTEDThis MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

PROVIDER ACTION NEEDEDThis article informs you of new physician specialty codes for Micrographic Dermatologic Surgery (MDS) (D7), and Adult Congenital Heart Disease (ACHD) (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6). Make sure that your billing staffs are aware of these changes.

BACKGROUNDPhysicians and certain other suppliers self-designate their Medicare specialty on the Medicare enrollment application (CMS-855I, CMS-855O, or CMS-855B) or Internet-based Provider Enrollment, Chain and Ownership System (PECOS) when they enroll in the Medicare program. Medicare specialty codes describe the specific/unique types of medicine that physicians (and certain other suppliers) practice. The Centers for Medicare & Medicaid Services (CMS) uses specialty codes for programmatic and claims processing purposes.

ADDITIONAL INFORMATIONThe official instruction, CR 11750, issued to your MAC regarding this change is in two transmittals. The first updates the Medicare Claims Processing Manual and it is available at https://www.cms.gov/files/document/r10124cp.pdf. The second updates the Medicare Financial Management Manual and it is at https://www.cms.gov/files/document/r10124fm.pdf.



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MM11650: National Coverage Determination (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11650 Effective Date: July 2, 2019 Related Change Request (CR) Number: 11650 Implementation Date: June 16, 2020 – local MAC Related CR Transmittal Numbers: edits; October 5, 2020 – Medicare systems R10073CP and R10073NCD Related CR Release Date: May 1, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, hospitals, and other providers billing Medicare Administrative Contractors (MACs) for Ambulatory Blood Pressure Monitoring (ABPM) services provided to Medicare beneficiaries.



https://www.cms.gov/files/document/r10124fm.pdf




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WHAT YOU NEED TO KNOWThis article informs you that, for dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid Services (CMS) will cover ABPM for the diagnosis of hypertension in Medicare beneficiaries under updated criteria.

For dates of service on and after July 2, 2019, CMS will cover ABPM for the diagnosis of hypertension in Medicare beneficiaries under the following circumstances:

1. For beneficiaries with suspected White Coat Hypertension (WCH), which is defined as average office systolic Blood Pressure (BP) greater than 130 mm Hg but less than 160 mm Hg or diastolic BP greater than 80 mm Hg but less than 100 mm Hg on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two BP measurements taken outside the office which are less than 130/80 mm Hg.

2. For beneficiaries with suspected masked hypertension, which is defined as average office BP between 120 mm Hg and 129 mm Hg for systolic BP or between 75 mm Hg and 79 mm Hg for diastolic BP on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two BP measurements taken outside the office which are greater than or equal to 130/80 mm Hg.

ABPM devices must be:

y Capable of producing standardized plots of BP measurements for 24 hours with daytime and night-time windows and normal BP bands demarcated

y Provided to patients with oral and written instructions, and a test run in the physician’s office must be performed

y Interpreted by the treating physician or treating non-physician practitioner

Coverage of other indications for ABPM is at the discretion of the MACs.

NOTE: Effective for dates of service on or after July 2, 2019, for eligible patients, ABPM is covered once per year.

When denying claims for subsequent ABPM on or after October 5, 2020, (HCPCS 93784) because a previous claim with HCPCS 93784 is paid in claims history within the past 12 months, MACs will use the following messages:

y Claim Adjustment Reason Code (CARC) 119: Benefit maximum for this time period or occurrence has been reached.

y Remittance Advice Remarks Code (RARC) N130: Consult plan benefit documents/guidelines for information about restrictions for this service.

NOTE: Previous ABPM procedure codes 93786, 93788, and 93790 will be end-dated for claims with dates of service on and after July 2, 2019.

BACKGROUNDABPM is a diagnostic test that allows for the identification of various types of high BP. The Medicare National Coverage Determinations (NCD) Manual, Section 20.19, establishes conditions of coverage for ABPM. CMS has covered ABPM since 2001 only for those patients with documented suspected WCH. On January 16, 2003, a technical correction for this NCD was issued to clarify that a physician is required to perform the interpretation of the data obtained through ABPM, but there are no requirements regarding the setting in which the interpretation is performed.

NOTE: The ABPM claims processing instructions provided in previous CRs 2726 and 9751 should be consulted for additional information. Articles related to those CRs are available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM2726.pdf and https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9751.pdf, respectively.


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM2726.pdf




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ADDITIONAL INFORMATIONThe official instruction, CR 11650, consists of two transmittals. The first amends the Medicare Claims Processing Manual and it is available at https://www.cms.gov/files/document/r10073cp.pdf. The second transmittal amends the NCD Manual and it is at https://www.cms.gov/files/document/r10073ncd.pdf.



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MM11755: National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11755 Effective Date: January 21, 2020 Related CR Release Date: May 8, 2020 Implementation Date: June 24, 2020 – A/B MACs, Related CR Transmittal Numbers: October 5, 2020 – Medicare Shared Systems, R10128NCD and R10128CP January 4, 2021, CWF BR 13 only Related Change Request (CR) Number: 11755

PROVIDER TYPES AFFECTEDThis MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDThis article informs you that the Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic Low Back Pain (cLBP) effective for claims with dates of service (DOS) on and after January 21, 2020. Note that CMS still determines that acupuncture for treatment of fibromyalgia or osteoarthritis is still not considered reasonable and necessary and remain non-covered by Medicare. Make sure your billing staffs are aware of these changes.

BACKGROUNDAcupuncture is the selection and manipulation of specific acupuncture points through the insertion of needles or “needling,” or other “non-needling” techniques focused on these points.

The National Coverage Determination (NCD) for Acupuncture (30.3), issued in May 1980, states that Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic, or for other therapeutic purposes, may not be made. Accordingly, acupuncture was not considered reasonable and necessary within the meaning of section 1862(a)(1) of the Social Security Act (the Act). In 2004, CMS considered the use of acupuncture for fibromyalgia and determined that there was no convincing evidence for the use of acupuncture for pain relief in patients with fibromyalgia (NCD 30.3.1). Similarly, in that same year, CMS concluded that




https://www.cms.gov/files/document/r10073ncd.pdf





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there was no convincing evidence for the use of acupuncture for pain relief in patients with osteoarthritis (NCD 30.3.2).

In the most recent national coverage analysis for acupuncture specifically targeted for cLBP, CMS determined it will cover acupuncture for cLBP under section 1862(a)(1)(A) of the Act effective for claims with DOS on and after January 21, 2020. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

For the purpose of this decision, cLBP is defined as:

y Lasting 12 weeks or longer

y Nonspecific, in that it has no identifiable systemic cause (for example: not associated with metastatic, inflammatory, infectious, etc. disease)

y Not associated with surgery

y Not associated with pregnancy

An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

Example: If the 20th service is performed on March 21, 2020, the next service cannot be performed until March 1, 2021, beginning a new year. This means 11 full months must pass from the date of the last service before eligibility begins again.

Treatment must be discontinued if the patient is not improving or is regressing.

Physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and auxiliary personnel may furnish acupuncture if they meet the criteria in NCD 30.3.3 (https://www.cms.gov/files/document/r10128ncd.pdf). (Once at this link, see pages 7-8.)

All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.

Claims Processing General Informationy Effective for claims with DOS on or after January 21, 2020, MACs will recognize and pay for acupuncture for cLBP services reported with CPT codes 97810, 97811, 97813, 97814, 20560, and 20561 as covered services under NCD 30.3.3.

y The applicable ICD-10 diagnosis codes are in the attachment to CR 11755 and one of the above CPT codes must be reported for acupuncture for cLBP services.

y MACs will accept claims with the -KX modifier for an additional 8 services (over and above the initial 12 in 90 days) for up to 20 visits in 12 months. By applying the -KX modifier to the claim, the therapy provider is confirming that the additional services are medically necessary as justified by appropriate documentation in the medical record.

Institutional Claims Bill Type and Revenue Coding Informationy Effective for claims with DOS on or after January 21, 2020, MACs will recognize acupuncture for cLBP services reported on institutional claims on types of bill (TOBs) 012X, 013X, 71X, 77X, and 085X (and revenue codes not equal to 096X, 097X, and 098X for Method 1 Critical Access Hospitals (CAHs)).

y Effective for claims with DOS on or after January 21, 2020, MACs will recognize acupuncture for cLBP services reported with Revenue Code 0940 on institutional claims.

y Effective for claims with DOS on or after January 21, 2020, MACs will recognize acupuncture for cLBP services reported on institutional claims on TOB 085X CAH Method II with revenue codes 096X, 097X, and 098X.

y MACS will return to provider or return as unprocessable acupuncture for cLBP claims that do not contain the required CPT and ICD-10 diagnosis codes using the following messages:



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� Claim Adjustment Reason Code (CARC) 16 - Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s) or other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

� Remittance Advice Remarks Code (RARC) M76 - Missing/incomplete/invalid diagnosis or condition.

� Group Code CO – Contractual Obligation

y MACs will return to provider/return as unprocessable claims for acupuncture for cLBP for more than 12 services per annum without the -KX modifier and use these messages:

� CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

� RARC N657 - This should be billed with the appropriate code for these services.

� Group Code CO

y MACs will reject/deny more than 20 acupuncture for cLBP claims per annum using the following messages:

� CARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

� RARC N640 - Exceeds number/frequency approved/allowed within time period.

� Group Code CO

MACs will not search for acupuncture for cLBP claims with DOS on or after January 21, 2020, but will adjust claims that are brought to their attention.

ADDITIONAL INFORMATIONCMS issued the official instruction, CR 11755, via two transmittals. The first updates the Medicare NCD Manual and it is available at https://www.cms.gov/files/document/r10128ncd.pdf. The second transmittal updates the Medicare Claims Processing Manual and it is available at https://www.cms.gov/files/document/r10128cp.pdf.



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C OV E R AG E

Prior Authorization Process and Requirements for Certain Hospital OPD Services: Payment for Related Services

This article was originally published in the June 11, 2020 MLN Connects at https://www.cms.gov/files/document/2020-06-11-mlnc.pdf

Beginning July 1, certain hospital Outpatient Department (OPD) services require prior authorization as a condition of payment. While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to or associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the OPD setting are affected.

Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a post-payment basis.

For More Information:

y Final rule - https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf

y Prior Authorization for Certain Hospital OPD Services webpage - https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services

y Send questions to [email protected]

C OV I D -19

Home Health Plans of Care: NPs, CNSs, and PAs Allowed to Certify

This article was originally published in the May 7, 2020 MLN Connects at https://www.cms.gov/files/document/2020-05-07-mlnc.pdf

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act to allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This is a permanent change that will continue after the Public Health Emergency.

Effective for claims with dates of service on or after March 1, 2020, these non-physician practitioners may bill the following codes:

y G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care

y G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care

y G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and




https://www.govinfo.gov/content/pkg/FR-2019-11-12/pdf/2019-24138.pdf

https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services







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multidisciplinary care modalities involving regular physician development and/or revision of care plans

The descriptors of the three codes will be revised at a later date to include the non-physician practitioner specialties.

C OV I D -19

SE20018: COVID-19 Blanket Swing Bed Waiver for Addressing Barriers to Nursing Home Placement for Hospitalized IndividualsThe Centers for Medicare & Medicaid Services (CMS) issued the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


PROVIDER TYPES AFFECTEDThis MLN Matters Article is for hospitals requesting Medicare approve swing beds as a hospital service to provide skilled nursing level care for hospitalized patients who don’t need acute level care but can’t find nursing home placement during the COVID-19 Public Health Emergency (PHE).

WHAT YOU NEED TO KNOWUnder the COVID-19 PHE blanket waiver entitled, “Expanded ability for hospitals to offer long-term care services (“swing-beds”) for patients that do not require acute care but do meet the Skilled Nursing Facility (SNF) level of care criteria as set forth at 42 CFR 409.31,” all Medicare enrolled hospitals (except psychiatric and long term care hospitals) that need to provide post-hospital SNF level swing-bed services for non-acute care patients in hospitals can apply for swing bed approval to provide these services, so long as the waiver is not inconsistent with the state’s emergency preparedness or pandemic plan.

Under Section 1135(b)(1) of the Social Security Act (the Act), the Centers for Medicare & Medicaid Services (CMS) has waived the requirements at 42 CFR 482.58, “Special Requirements for hospital providers of long-term care services (“swing-beds”)” subsections (a)(1)-(4) “Eligibility,” to allow hospitals to establish SNF swing beds payable under the SNF Prospective Payment System (PPS) to provide additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF. NOTE: All other hospital conditions of participation and those SNF provisions at 42 CFR 482.58(b), to the extent not waived, continue to apply. See swing bed waiver for additional requirements.

This MLN Matters Special Edition article provides answers to the key questions hospitals may have as they pursue this option for treating their patients.

SWING BEDS AND HOSPITALS

What is a swing bed and how is it relevant to hospitals?“Swing-bed” is a term that means the care and reimbursement for the care of a patient in a hospital bed that “swings” from acute care to post hospital SNF care. A swing-bed hospital means a hospital or Critical Access Hospital (CAH) participating in Medicare that has an approval from CMS to provide post hospital SNF care and meets the requirements specified in 42 CFR 482.58 for a hospital or 42 CFR 485.645 for a CAH.




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Can any hospital have swing beds?Hospitals, defined in Section 1861(e) of the Act, can be approved to provide swing bed services allowing them to use their beds for acute care or post-hospital SNF care after meeting the eligibility criteria at 42 CFR 482.58(a)(1)-(4) and by meeting the requirements at 42 CFR 482.58(b). Similarly, CAHs are also eligible to provide swing bed services by meeting the requirements at 42 CFR 485.645, if approved.

Under Section 1135(b)(1) of the Act, CMS waived the eligibility requirements at 42 CFR 482.58(a)(1)-(4) during the COVID-19 PHE to allow hospitals, except for psychiatric and long term care hospitals, to apply for swing bed services that need to provide SNF level care for non-acute care patients, so long as the waiver is not inconsistent with the state’s emergency preparedness or pandemic plan.

How do hospitals request approval for swing beds?Under normal circumstances, hospitals and CAHs submit a Form CMS-855A to their Medicare Administrative Contractor (MAC) to request swing bed approval.

During the COVID-19 PHE, hospitals and CAHs call the Medicare provider enrollment hotline to request swing bed approval. See additional details below under MLN section “Swing Bed Waiver During the PHE”.

Do hospitals have to designate a special unit in the hospital for swing beds?A hospital or CAH does not have to locate their swing beds in a special section of the facility unless the hospital or CAH requires it. Approved swing bed hospitals or CAHs may use any acute care inpatient bed within the hospital or CAH to provide swing bed services.

Documentation of the acute care discharge and admission to swing bed status must be in the beneficiary’s medical record. The medical record must include:

y acute care discharge orders including a discharge summary;

y admission orders to swing bed status (whether the beneficiary stays in the same hospital or CAH or transfers to an approved swing bed hospital or CAH); and,

y appropriate progress notes.

Under the current PHE, can a hospital make other arrangements besides applying for swing bed approval for a SNF to admit the hospital’s SNF-level patients and care for them in the hospital’s beds?Yes. A hospital can enter into an agreement for services furnished to a SNF under arrangement to be a “facility without walls,” in other words, a temporary expansion site. Specifically, the SNF may temporarily transfer its resident to the hospital for SNF care in the hospital beds where the SNF bills CMS for the care and pays the hospital under the arrangement, as long as this is not inconsistent with a state’s emergency preparedness or pandemic plan, or as directed by the local or state health department. Making arrangements with another facility or provider for the provision of care during an emergency is a longstanding practice that SNFs have commonly followed during previous natural disasters and other emergency situations. Such practices are supported by the SNF participation requirements at 42 CFR 483.73, which require each SNF to have emergency preparedness policies and procedures in place, and at 42 CFR 483.70(j), which require every Medicare-participating SNF to have in effect with at least one hospital a transfer agreement to facilitate the exchange of patients and information between the two institutions.

When the hospital enters into a contractual arrangement with a SNF for the use of general inpatient routine beds, the hospital will need to enter the amount received under contract from the SNF on Form CMS-2552-10, Worksheet A-8, as a revenue offset. The amount received must be used to offset general inpatient routine care costs on Worksheet A, line 30, and the applicable days must be reported on Worksheet S-3, Part I, subscripted line 24.20.


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My hospital has patients ready for discharge to a SNF. We have been unable to find a SNF to accept some of our patients for post-acute care. We have not yet pursued a swing bed approval nor have we located a SNF to facilitate an arrangement. Can we receive outlier or other special payments under IPPS or OPPS for keeping the patient additional days?When a hospital inpatient’s care needs drop from acute- to SNF-level but no SNF bed is available, the regulations at §424.13(c) permit a physician to certify that the beneficiary’s continued inpatient stay in the hospital is, in fact, medically necessary under this particular set of circumstances. If the services are reasonable and necessary, a hospital that is paid under the Inpatient Prospective Payment System (IPPS) continues to be paid under the IPPS, including any applicable outlier payments. Similarly, a hospital paid under the Outpatient Prospective Payment System (OPPS) continues to be paid under the OPPS for registered hospital outpatients, including any applicable outlier payments.

While a hospital would have ordinarily discharged an acute level of care inpatient to a SNF after a hospital inpatient stay, we note that under the blanket waivers issued during the PHE, the hospital is able to pursue swing bed approval if it believes it will encounter difficulty in placing a patient who requires a SNF level of care following a hospital stay.

SWING BED WAIVER DURING THE PHE

Who does the swing bed waiver apply to?This waiver applies to all Medicare-certified enrolled hospitals, except psychiatric and long-term care hospitals, that undertake to provide post-hospital SNF level swing-bed services for non-acute care patients in hospitals, so long as the waiver is not inconsistent with the state’s emergency preparedness or pandemic plan. The hospital shall not bill for SNF PPS payment using swing beds when patients require acute level care or continued acute care at any time while this waiver is in effect. This waiver is permissible for swing bed admissions during the COVID-19 PHE with an understanding that the hospital must have a plan to discharge swing bed patients as soon as practicable, either when a bed becomes available in a SNF, or when the PHE ends, whichever is earlier.

The patient’s medical record must demonstrate the plan to discharge the SNF patients according to a discharge planning process that meets the requirements of section1861(ee) of the Act and implementing regulations at 42 CFR 482.43, “Discharge Planning”. The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences.

NOTE: All other hospital conditions of participation and those SNF swing bed special requirements at 42 CFR 482.58(b) also apply, to the extent they are not also waived.

How do hospitals request approval for swing beds?Under the swing bed waiver during the PHE, hospitals must call the Medicare provider enrollment hotline to add swing bed services. Contact information for the Medicare provider enrollment hotlines is available at https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf.

When calling the provider enrollment hotline, the hospital must attest to CMS that:

y they have made a good faith effort to exhaust all other options;

y there are no SNFs within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 PHE;

y the hospital meets all waiver eligibility requirements; and,


https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

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y they have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.

How can rural or urban hospitals qualify for the waiver?In order to qualify for this waiver, hospitals must:

y not use SNF swing beds for acute level care;

y comply with all other hospital conditions of participation and those SNF provisions set out at 42 CFR 482.58(b) to the extent not waived; and

y be consistent with the state’s emergency preparedness or pandemic plan.

My hospital is currently allowed to have swing beds under Medicare policy. Can my hospital increase the number of swing beds under this waiver? If so, how?Under normal circumstances, hospitals and CAHs submit a Form CMS-855A to their MAC to request authority to offer swing bed services or to request an increase in the number of swing beds. For the duration of the PHE related to COVID-19, CMS has waived the requirements that CAHs limit the total number of beds to 25 (regardless whether they are acute care or swing beds) at 42 CFR 485.620. Under the CMS swing bed waiver during the PHE, hospitals and CAHs must call the CMS provider enrollment hotline to request swing bed approval or to request an increase to the number of swing beds.

When calling the provider enrollment hotline, the hospital must attest to CMS that:

y they have made a good faith effort to exhaust all other options;

y there are no skilled nursing facilities within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 PHE;

y the hospital meets all waiver eligibility requirements; and,

y they have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.

SWINGS BEDS AND THE REQUIRED MDS

Do hospitals exercising the SNF swing bed waiver need to complete an MDS Swing Bed Assessment to be paid under the SNF PPS?Hospitals must complete comprehensive assessments of a swing bed patient’s needs, strengths, goals, life history and preferences, using the MDS Resident Assessment Instrument (RAI) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/MDSApplicability) specified by CMS for patients receiving a SNF level of care. As stated in CFR §413.343(a) and (b), providers reimbursed under the SNF PPS are required to submit the resident assessment data described at §483.20 and therefore hospitals must complete the MDS Swing Bed Assessment for each patient to be paid under the SNF PPS.

NOTE: CAHs are not required to use the RAI (42 CFR 485.645(d)(6)); CMS exempts CAH swing bed services from the SNF PPS and pays them based on 101 percent of the reasonable cost of the services (see 42 CFR 413.114(a)(2)).

Is there a tool to help hospitals access the MDS Swing Bed Assessment?Yes. The Resident Assessment Validation and Entry System (jRAVEN) was developed by CMS and is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. For questions related to jRAVEN or technical support please contact the QTSO Help Desk by calling 800-339-9313 or by email to [email protected].


https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/MDSApplicability

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/MDSApplicability


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What resources are available to hospitals for questions about completing the MDS?Hospital providers may use the MDS RAI manual at https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf . Providers may also request assistance from their MAC or from their state RAI coordinator. To find their RAI coordinator, providers should consult the list in Appendix B of the MDS RAI manual, which is available at https://www.cms.gov/files/document/appendix-b-03262020.pdf.

BILLING AND PAYMENT FOR SWING BED SERVICES

How do hospitals bill for patients located in a swing bed receiving a SNF Level of Care?Medicare pays hospitals offering swing bed SNF-level services (excluding CAHs) under the SNF PPS. The SNF PPS covers all SNF services provided to beneficiaries in a Medicare Part A covered SNF stay (ancillary, routine, and capital), except certain specified services, which are separately billable to Part B. Instructions for swing bed billing are in Section 60.B of Chapter 3 of the Medicare Claims Processing Manual, which is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf. Questions on Medicare billing should be directed to your MAC.

How is the SNF PPS payment rate determined?Information from the MDS RAI, including a variety of patient characteristics, such as the patient’s primary diagnosis and comorbidities, is used in determining the case-mix group for SNF patients in a Medicare Part A covered stay under the SNF PPS Patient Driven Payment Model (PDPM) classification system. This case-mix group is recorded on the claim to determine the SNF PPS payment rate.

Where can hospitals find information on the SNF PPS PDPM?Information on PDPM is at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.

ADDITIONAL INFORMATION

What are the SNF provisions set out at 42 CFR 482.58(b)?The Medicare hospital conditions of participation at 42 CFR 482.58(b) skilled nursing facility services, requires that the hospital seeking approval for swing beds must be substantially in compliance with the following skilled nursing facility (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=dcf21655a45f57cffeb132be058cb703&term_occur=999&term_src=Title:42:Chapter:IV:Subchapter:G:Part:482:Subpart:D:482.58) requirements contained in subpart B of 42 CFR part 483 (https://www.law.cornell.edu/cfr/text/42/part-483):

1. Resident (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=a747821bda156b5fed8947a4b7538024&term_occur=999&term_src=Title:42:Chapter:IV:Subchapter:G:Part:482:Subpart:D:482.58) rights (§ 483.10(b)(7) (https://www.law.cornell.edu/cfr/text/42/483.10#b_7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (h), (g)(8) and (17), and (g)(18) introductory text of this chapter).

2. Admission, transfer (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=98f2d9c1e461596dd61babfb6c4ca4bf&term_occur=999&term_src=Title:42:Chapter:IV:Subchapter:G:Part:482:Subpart:D:482.58), and discharge rights (§ 483.5 (https://www.law.cornell.edu/cfr/text/42/483.5) definition of transfer (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=98f2d9c1e461596dd61babfb6c4ca4bf&term_occur=999&term_src=Title:42:Chapter:IV:Subchapter:G:Part:482:Subpart:D:482.58) and discharge, § 483.15(c)(1) (https://www.law.cornell.edu/cfr/text/42/483.15#c_1), (c)(2)(i), (c)(2)(ii), (c)(3), (c)(4), (c)(5), and (c)(7)).


https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf

https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf

https://www.cms.gov/files/document/appendix-b-03262020.pdf

https://www.cms.gov/files/document/appendix-b-03262020.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf

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

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

https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=dcf21655a45f57cffeb132be058cb703&term_occur=999&term_src=Title



https://www.law.cornell.edu/cfr/text/42/part-483

https://www.law.cornell.edu/cfr/text/42/part-483

https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=a747821bda156b5fed8947a4b7538024&term_occur=999&term_src=Title



https://www.law.cornell.edu/cfr/text/42/483.10#b_7

https://www.law.cornell.edu/cfr/text/42/483.10#b_7

https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=98f2d9c1e461596dd61babfb6c4ca4bf&term_occur=999&term_src=Title



https://www.law.cornell.edu/cfr/text/42/483.5




https://www.law.cornell.edu/cfr/text/42/483.15#c_1

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3. Freedom from abuse, neglect, and exploitation (§ 483.12(a)(1) (https://www.law.cornell.edu/cfr/text/42/483.12#a_1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)).

4. Social services (§ 483.40(d)) (https://www.law.cornell.edu/cfr/text/42/483.40#d).

5. Discharge summary (§ 483.20(l)) (https://www.law.cornell.edu/cfr/text/42/483.20#l). (NOTE: The regulations at §483.20(l) setting forth the requirements for a nursing home resident discharge summary was revised and re-designated as §483.21(c)(2) in 2016 (81 FR 68858, Oct. 4, 2016)).

6. Specialized rehabilitative services (§ 483.65) (https://www.law.cornell.edu/cfr/text/42/483.65).

7. Dental services (§ 483.55(a)(2) (https://www.law.cornell.edu/cfr/text/42/483.55#a_2), (3), (4), and (5) and (b)).

Please see SOM Appendix A for guidance on the 42 CFR 482.58(b) hospital requirements at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf.

Please also see SOM Appendix PP for the corresponding guidance for SNF requirements at 42 CFR 483 at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf.



DOCUMENT HISTORY


E N R O L L M E N T

SE20017: Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 TestingThe Centers for Medicare & Medicaid Services (CMS) issued the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


PROVIDER TYPES AFFECTEDThis MLN Matters Article is for Medicare-enrolled pharmacies and other Medicare-enrolled suppliers, or pharmacies and suppliers seeking to enroll temporarily as independent clinical diagnostic laboratories to help address the urgent need for COVID-19 testing.

WHAT YOU NEED TO KNOWPharmacies and other suppliers currently enrolled in Medicare may also enroll temporarily as independent clinical diagnostic laboratories during the COVID-19 public health emergency via


https://www.law.cornell.edu/cfr/text/42/483.12#a_1


https://www.law.cornell.edu/cfr/text/42/483.40#d

https://www.law.cornell.edu/cfr/text/42/483.20#l




https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf




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the provider enrollment hotline. This will provide additional laboratory resources to meet the urgent need to increase COVID-19 testing capability.

Pharmacies and other suppliers who are not currently enrolled in Medicare and want to enroll as an Independent Clinical Diagnostic Laboratory, must submit a CMS-855B (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf) enrollment application to the Medicare Administrative Contractor (MAC) serving your geographic area. To locate your designated MAC, see https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/MACs-by-State-June-2019.pdf.

ENROLLMENT GUIDANCEMedicare-enrolled pharmacies and other Medicare-enrolled suppliers can initiate temporary Medicare independent clinical diagnostic laboratory billing privileges via the provider enrollment hotline (see hotline information below). To start the process, you will need to provide limited information, including:

y Legal Business Name

y National Provider Identifier (NPI)

y Tax Identification Number (TIN)

y State license

y CLIA certificate number (see below)

y Address information

y Contact information (telephone number).

Your MAC will collect this information from you over the phone, however, temporary Medicare billing privileges will not be established during the phone conversation. The MAC will notify the pharmacy or other supplier of their temporary Medicare billing privileges and effective date via email within 2 business days.

To maintain billing privileges as an Independent Clinical Diagnostic Laboratory, the pharmacy or other supplier must submit a CMS-855B (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf) enrollment application within 30 days after the public health emergency ends to the MAC serving your geographic area.

Provider Enrollment Hotline InformationMedicare-enrolled pharmacies and other Medicare-enrolled suppliers seeking to initiate temporary Medicare independent clinical diagnostic laboratory billing privileges should only contact the hotline for the MAC serving your geographic area. To locate your designated MAC see https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/MACs-by-State-June-2019.pdf.

The hotlines are operational Monday – Friday and at the specified times below.

CGS Administrators, LLC (CGS)

y The toll-free Hotline Telephone Number: 1.855.769.9920

y Hours of Operation: 7:00 a.m. – 4:00 p.m. CT

First Coast Service Options Inc. (FCSO)


y Hours of Operation: 8:30 a.m. – 4:00 p.m. EST

National Government Services (NGS)




https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf


https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/MACs-by-State-June-2019.pdf






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National Supplier Clearinghouse (NSC)


y Hours of Operation: 9:00 a.m. – 5:00 p.m. ET

Novitas Solutions, Inc.


y Hours of Operation: 8:30 a.m. – 4:00 p.m. EST

Noridian Healthcare Solutions



Palmetto GBA


y Hours of Operation: 8:30 a.m. – 5:00 p.m. ET

Wisconsin Physician Services (WPS)



Important Clinical Laboratory Improvement Amendments (CLIA) Certificate Number InformationNote that the CLIA program does not allow the Centers for Medicare & Medicaid Services (CMS) to approve section 1135 waiver requests with respect to waivers of CLIA program requirements for public health emergencies. The section 1135 waiver authority is only applicable to specified programs (or penalties) authorized by the Social Security Act (SSA). The CLIA program does not fall into this category of programs. CMS does not have the authority to grant waivers or exceptions that are not established in statute or regulation.

If you would like to apply for a CLIA certificate, please submit your application form (CMS-116, CLIA Application Form) (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS116.pdf) to the state (SA Contacts) (https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf) where the laboratory is located.

CMS wants to ensure that laboratories located in the United States applying for a CLIA certificate are able to begin testing for COVID-19 as quickly as possible. Once the laboratory has identified a qualified laboratory director and has provided all required information on the CMS-116 application, a CLIA number will be assigned. Once the CLIA number has been assigned, the laboratory can begin testing as long as applicable CLIA requirements have been met (for example, establishing performance specifications).

Note that different CLIA program certificates correspond to the complexity of tests performed by a given laboratory. For example, laboratories with a Certificate of Waiver can only conduct tests designated as waived by the Food and Drug Administration (FDA). More information is available at https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/HowObtainCLIACertificate.pdf

Information specific to obtaining a CLIA Certificate of Waiver is available at https://www.cms.gov/Regulations-and-Guidance/legislation/CLIA/downloads/howobtaincertificateofwaiver.pdf.

ADDITIONAL INFORMATIONFrequently Asked Questions (FAQs) about CLIA guidance during the COVID-19 emergency are available at https://www.cms.gov/files/document/clia-laboratory-covid-19-emergency-frequently-asked-questions.pdf.


https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS116.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS116.pdf

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/HowObtainCLIACertificate.pdf

https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/HowObtainCLIACertificate.pdf

https://www.cms.gov/Regulations-and-Guidance/legislation/CLIA/downloads/howobtaincertificateofwaiver.pdf

https://www.cms.gov/Regulations-and-Guidance/legislation/CLIA/downloads/howobtaincertificateofwaiver.pdf

https://www.cms.gov/files/document/clia-laboratory-covid-19-emergency-frequently-asked-questions.pdf

https://www.cms.gov/files/document/clia-laboratory-covid-19-emergency-frequently-asked-questions.pdf

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CLIA laboratory guidance to state agencies during the COVID-19 Public Health Emergency are available at https://www.cms.gov/files/document/qso-20-21-clia.pdf-0.



DOCUMENT HISTORY


F E E S C H E D U L E

MM11661 (Revised): Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 UpdateThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11661 Revised Related Change Request (CR) Number: 11661 Related CR Release Date: May 1, 2020 Effective Date: January 1, 2020 Related CR Transmittal Number: R10098CP Implementation Date: April 6, 2020

NOTE: We revised this article on May 4, 2020, to reflect the revised CR 11661, issued on May 1, 2020, to revise the relative value units for codes 99441, 99442, and 99443, and add information for codes G2025 and G0071, listed in the CR attachment. The statement at the end of page 4 was updated. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries and reimbursed using the Medicare Physician Fee Schedule (MPFS).

PROVIDER ACTION NEEDEDThis article informs you that the Centers for Medicare & Medicaid Services (CMS) issued payment files to the MACs based upon the 2020 MPFS Final Rule, published in the Federal register on November 15, 2019. CR 11661 amends those payment files. Make sure your billing staffs are aware of these changes.

BACKGROUNDSection 1848(c)(4) of the Social Security Act authorizes the Secretary of the Department of Health and Human Services (HHS) to establish ancillary policies necessary to implement relative values for physicians’ services. The updated payment files are effective for services you furnish between January 1, 2020 and December 31, 2020.

Summary of Changes for April 2020Below is a summary of the changes for the April update to the 2020 MPFS. Unless otherwise stated, these changes are effective for dates of service on and after January 1, 2020.


https://www.cms.gov/files/document/qso-20-21-clia.pdf-0




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1. The G codes listed in Table 1 are new codes, effective January 1, 2020.

Table 1: New Codes effective January 1, 2020Code ActionG2168 Status indicator = E; there are no RVUs, payment policy indicators do not apply.G2169 Status indicator = E; there are no RVUs, payment policy indicators do not apply.

NOTE: For new codes, please refer to the following link for more information: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.

2. The HCPCS codes listed in Table 2 have revisions to Relative Value Units, effective for dates of service on and after January 1, 2020.

Table 2: HCPCS Codes with Revisions to Relative Value UnitsCode Modifier ActionG0105 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.20G0121 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.2144388 53 Non-Facility PE RVU change = 2.79, MP RVU change = 0.2045378 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.21G2001 MP RVU change = 0.05G2002 MP RVU change = 0.08G2003 MP RVU change = 0.13G2004 MP RVU change = 0.22G2005 MP RVU change = 0.28G2006 MP RVU change = 0.05G2007 MP RVU change = 0.09G2008 MP RVU change = 0.13G2009 MP RVU change = 0.22G2013 MP RVU change = 0.28

3. The HCPCS codes listed in Table 3 have been revised, effective for dates of service on and after January 21, 2020. Please see the following link for more information regarding these codes: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295.

Table 3: Revised HCPCS codesCode Action20560 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator =

0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

20561 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

97810 Status Code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

97811 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical component indicator = 0



The Relative Value Units (RVU) for these codes are listed below.


https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295

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Code Work RVU Non Facility PE RVU Facility PE RVU MP RVU20560 0.32 0.39 0.12 0.0320561 0.48 0.57 0.18 0.0597810 0.60 0.40 0.23 0.0597811 0.50 0.25 0.19 0.0597813 0.65 0.47 0.25 0.0597814 0.55 0.36 0.21 0.05

4. The G code listed in Table 4 is no longer valid on the MPFS effective for dates of service on and after April 01, 2020.

Table 4: G Code No Longer ValidCode ActionG1000 Status Change to I

5. The G codes listed in Table 5 are new codes, effective April 01, 2020. CR 11550 implemented these codes.

Table 5: New G CodesCode ActionG1012 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1013 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1014 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1015 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1016 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1017 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1018 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1019 Status indicator = X, there are no RVUs, payment policy indicators do not apply

Please see https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update for more information on the above new codes.

As part of the public health emergency for the 2019 Novel Coronavirus (COVID-19) pandemic, the following codes have been revised per guidance provided in: the interim final rule with comment (IFC) entitled, Medicare Program and Medicaid Program; Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC); the IFC entitled, Medicare and Medicaid Programs; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-5531-IFC); and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

CODE ACTION98966 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator =









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CODE ACTION99443 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator =


The RVUs for these codes are listed below.

Code Work RVU Non Facility PE RVU Facility PE RVU MP RVU98966 0.25 0.13 0.10 0.0298967 0.50 0.23 0.19 0.0598968 0.75 0.33 0.29 0.0699441 0.48 0.75 0.20 0.0599442 0.97 1.06 0.40 0.0899443 1.50 1.45 0.62 0.11

The following new codes are effective March 1, 2020, and after. Please see CR 11681 for more information. A related MLN Matters article (MM11681) is available at https://www.cms.gov/files/document/mm11681.pdf.

y G2023 - Status indicator = X, there are no RVUs, payment policy indicators do not apply

y G2024 - Status indicator = X, there are no RVUs, payment policy indicators do not apply

The following new code is effective March 13, 2020, and after. Please see CR 11681 for more information.

y 87635 - Status indicator = X, there are no RVUs, payment policy indicators do not apply

The following new code is for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Please see Special Edition Medicare Learning Network Matters (MLN) article SE20016 for more information. MLN SE20016 is available at https://www.cms.gov/files/document/se20016.pdf.

Code ActionG2025 Dis site tele svcs RHC/FQHC

NOTE: MLN article SE20016 also displays a revised RHC/FQHC payment for G0071 effective March 1, 2020. Codes G0071 and G2025 will appear on the MPFSDB with Status indicator X, but have no physician fee schedule payment, and the payment policy indicators will not apply.

ADDITIONAL INFORMATIONThe official instruction, CR11661, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/r10098CP.pdf.



DOCUMENT HISTORY

Date of Change DescriptionMay 4, 2020 We revised this article to reflect the revised CR 11661, issued on May 1, 2020, to revise

the relative value units for codes 99441, 99442, and 99443, and add information for codes G2025 and G0071, listed in the CR attachment. The statement at the end of page 4 was updated. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.




https://www.cms.gov/files/document/se20016.pdf

https://www.cms.gov/files/document/se20016.pdf



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Date of Change DescriptionApril 14, 2020 We revised this article to reflect the revised CR 11661, issued on April 6, to make MPFSDB

file revisions for COVID-19. In the article, we added updates for codes G2023, G2024, 87635, 98966, 98967, 98968, 99441, 99442, and 99443 to the April 2020 MPFSDB update file. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

February 27, 2020 We revised this article to reflect the revised CR11661 issued on that date. In the article, we changed the MP RVU for code G2013 in Table 2 to 0.28. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

February 18, 2020 Initial article released.


MM11788: Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2020 UpdateThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11788 Related Change Request (CR) Number: 11788 Related CR Release Date: May 8, 2020 Effective Date: January 1, 2020 Related CR Transmittal Number: R10120OTN Implementation Date: July 6, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries and reimbursed using the Medicare Physician Fee Schedule (MPFS).

PROVIDER ACTION NEEDEDThis article informs you that the Centers for Medicare & Medicaid Services (CMS) issued payment files to the MACs based upon the 2020 MPFS Final Rule. CR 11788 amends those payment files. Make sure your billing staffs are aware of these changes.

BACKGROUNDPayment files were issued to the MACs based upon the CY 2020 MPFS Final Rule, published in the Federal Register on November 15, 2019. The updated payment files are effective for services furnished between January 1, 2020, and December 31, 2020. Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services.

Summary of Changes for July 20201. The HCPCS code listed in Table 1 has a revision to the Bilateral Surgery indicator,

effective for dates of service on or after January 1, 2020.

Table 1CODE ACTION30930 Bilateral Surgery Indicator Change = 2

2. The HCPCS codes listed in Table 2 have revisions to the Outpatient Prospective Payment System (OPPS) Relative Value Unit (RVU) display amounts, effective for dates of service on and after January 1, 2020. These are contractor priced codes and no




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payment changes are being made. However, the “Non-Facility Practice Expense (PE) for OPPS” and “Facility PE for OPPS” fields are being revised to correct a display issue.

Table 2HCPCS CODE MODIFIER ACTION78429 Non-Facility PE Used for OPPS Payment RVU change = 40.52, Facility PE

Used for OPPS Payment RVU change = 40.5278429 TC Non-Facility PE Used for OPPS Payment RVU change = 39.97, Facility PE

Used for OPPS Payment RVU change = 39.9778430 Non-Facility PE Used for OPPS Payment RVU change = 40.49, Facility PE

Used for OPPS Payment RVU change = 40.4978430 TC Non-Facility PE Used for OPPS Payment RVU change = 39.97, Facility PE

Used for OPPS Payment RVU change = 39.97

3. The HCPCS codes listed in Table 3 are new codes effective for dates of service on and after April 10, 2020.

Table 3HCPCS CODE ACTION86328 Status indicator = X, there are no RVUs, payment policy indicators do not apply.86769 Status indicator = X, there are no RVUs, payment policy indicators do not apply.

NOTE: For new codes, please refer to the following link for more information: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

4. The HCPCS code listed in Table 4 has been revised, effective July 1, 2020.

Table 4CODE ACTION90694 Status Code Indicator Change = X

5. The G codes listed in Table 5 are new codes, effective July 1, 2020.

Table 5CODE ACTIONG2170 Status indicator = C, there are no RVUs, Multiple Procedure indicator = 2, Bilateral Surgery

indicator = 0, Assistant at Surgery indicator = 2, Co-Surgeons indicator = 1, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

G2171 Status indicator = C, there are no RVUs, Multiple Procedure indicator = 2, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 2, Co-Surgeons indicator = 1, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

Please see the link below for more information on the above new codes: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

6. The MPFSDB file will reflect the changes and addition of new codes below effective for dates of service July 1, 2020, and after. The implementation of these “J” and “Q” code changes shown in Table 6 are being communicated via other instructions. The descriptors and more information are available: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

Table 6CODE ACTIONJ0223 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J0591 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J0691 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J0742 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J0791 Status indicator = E, there are no RVUs, payment policy indicators do not apply.








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Table 6CODE ACTIONJ0896 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J1201 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J1429 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J1558 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J3399 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J7169 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J7204 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J7321 Short descriptor = Hyalgan or supartz inj doseJ7333 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J9177 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J9198 Status indicator = E, there are no RVUs, payment policy indicators do not apply.J9199 Status indicator = IJ9245 Short descriptor = Inj melpha hydroch nos 50 mgJ9246 Status indicator = E, there are no RVUs, payment policy indicators do not applyJ9358 Status indicator = E, there are no RVUs, payment policy indicators do not applyQ4176 Short descriptor = Neopatch or therion, 1 sq cmQ4227 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4228 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4229 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4230 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4231 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4232 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4233 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4234 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4235 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4236 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4237 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4238 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4239 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4240 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4241 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4242 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4244 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4245 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4246 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4247 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q4248 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q5119 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q5120 Status indicator = E, there are no RVUs, payment policy indicators do not apply.Q5121 Status indicator = E, there are no RVUs, payment policy indicators do not apply.

7. The new CPT codes listed in Table 7 (0594T and 0596T-0619T) are effective for dates of service July 1, 2020, and after. On the MPFSDB file, all of these codes are Procedure Status C and have no RVUs. The Global Days are YYY. For all these codes, the indicators are: Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 0, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0


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Table 7CODE ACTION CODE ACTION0594T Osteot hum xtrnl lngth dev 0608T Rem mntr pulm flu mntr alys0596T Temp fml iu vlv-pmp 1st insj 0609T Mrs disc pain acquisj data0597T Temp fml iu valve-pmp rplcmt 0610T Mrs disc pain transmis data0598T Ncntc r-t fluor wnd img 1st 0611T Mrs disc pain alg alys data0599T Ncntc r-t fluor wnd img ea 0612T Mrs discogenic pain i&r0600T Ire abltj 1+tum organ perq 0613T Perq tcat intratrl septl sht0601T Ire abltj 1+tumors open 0614T Rmvl&rplcmt ss impl dfb pg0602T Transdermal gfr measurements 0615T Eye mvmt alys w/o calbrj i&r0603T Transdermal gfr monitoring 0616T Insertion of iris prosthesis0604T Rem oct rta dev setup&educaj 0617T Insj iris prosth w/rmvl&insj0605T Rem oct rta techl sprt min 8 0618T Insj iris prosth sec io lens0606T Rem oct rta phys/qhp ea 30d 0619T Cysto w/prst8 commissurotomy0607T Rem mntr pulm flu mntr setup

ADDITIONAL INFORMATIONThe official instruction, CR 11788, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/r10120OTN.pdf,



DOCUMENT HISTORY



MM11805: Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final RulesThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

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

PROVIDER TYPES AFFECTEDThis 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.


https://www.cms.gov/files/document/r10120OTN.pdf




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PROVIDER ACTION NEEDEDThis 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.

BACKGROUNDIn 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:

y 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.

y 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 ServicesPayment 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:

y Initial inpatient and nursing facility visits

y Emergency department visits

y Initial and subsequent observation services

y Inpatient nursing facility and observation discharge day management home visits

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

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


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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 ModalitiesPhysician 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.

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.


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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.

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:

y 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.

y 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.


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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.

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.

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.


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



DOCUMENT HISTORY


H O S P I TA L

MM11559 (Revised): Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent with Current PolicyThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11559 Revised Related Change Request (CR) Number: 11559 Related CR Release Date: April 30, 2020 Effective Date: July 1, 2020 Related CR Transmittal Number: R10095OTN Implementation Date: July 6, 2020

NOTE: We revised this article to reflect a revised CR 11559, issued on April 30, 2020. The CR changes had no impact on the substance of the article. In the article, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

PROVIDER TYPE AFFECTEDThis MLN Matters® Article is for physicians, hospitals, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

WHAT YOU NEED TO KNOWCR 11559 informs MACs about changes to Medicare Common Working File (CWF) edits to ensure the original 1-Day and 3-Day Payment Window edits’ set and bypass conditions are consistent with current policy.

There are no policy changes. Current policy is in the Medicare Claims Processing Manual, Chapter 4, Section 10.12, “Payment Window for Outpatient Services Treated as Inpatient Services” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf) and Chapter 3, Section 40.3, “Outpatient Services Treated as Inpatient Services” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c03.pdf).


https://www.cms.gov/files/document/r10160otn.pdf




https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf




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ADDITIONAL INFORMATIONThe official instruction, CR11559, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10095otn.pdf.

NOTE: The business requirements of CR11559 are effective for all dates of service processed on or after January 6, 2020.



DOCUMENT HISTORY

Date of Change DescriptionApril 30, 2020 We revised this article to reflect a revised CR 11559, issued on April 30, 2020. The CR

changes had no impact on the substance of the article. In the article, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

February 7, 2020 Initial article released.

H O S P I TA L

MM11580: Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) PlanThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11580 Related Change Request (CR) Number: 11580 Related CR Release Date: May 1, 2020 Effective Date: Claims received on or after Related CR Transmittal Number: R10071CP October 1, 2020 Implementation Date: October 5, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters article is for providers, especially hospitals, submitting claims to Medicare Administrative Contractors (MACs) for Part A services provided to Medicare beneficiaries when a beneficiary’s Medicare Advantage (MA) plan becomes effective during the inpatient admission.

WHAT YOU NEED TO KNOWCR 11580 modifies Medicare system edits on inpatient claims when a beneficiary’s MA plan becomes effective during the inpatient admission. Also, the Centers for Medicare & Medicaid Services (CMS) is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under Section 422.109(a)(2) of title 42 of the Code of Federal Regulations (CFR). Original Fee-For-Service (FFS) Medicare will pay for services obtained by beneficiaries enrolled in MA plans in this circumstance.

BACKGROUNDWhen a Medicare beneficiary enrolls in an MA plan, the MA benefits replace traditional FFS claims payment. For inpatient claims (hospital claims paid under a prospective payment






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system), Medicare policy states that the payer at the time of admission will continue to be responsible for any inpatient stay when a beneficiary enrolls or dis-enrolls from an MA plan after the admission date and prior to the hospital discharge. When a beneficiary is admitted as an inpatient and does not have Part A hospital benefits remaining or benefits exhaust during the stay, Medicare allows the provider to submit a claim for ancillary services that are payable under Part B on Type of Bill (TOB) 012X. The beneficiary is still classified as an inpatient even though no Medicare Part A benefits are payable, as stated in 42 CFR 422.318.b.1.

CMS is aware of an issue where its Common Working File (CWF) is incorrectly rejecting TOB 012X when the beneficiary enrollment in an MA plan was effective after the admission date on the claim. This issue also affects providers who submit claims for flu vaccines provided to inpatient beneficiaries during a Medicare Part A covered stay.

Effective October 1, 2016, Medicare reimburses a Skilled Nursing Facility (SNF) or hospital facility for a flu vaccine provided during an inpatient stay. Medicare requires the facility to submit the vaccine on an ancillary claim using the discharge date as the statement covers from and through date.

In addition, CMS is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under 42 Code of Federal Regulations (CFR) Section 422.109(a)(2). Original fee-for-service Medicare will pay for services obtained by beneficiaries enrolled in MA plans in this circumstance.

Consistent with Section1862(t)(2) of the Social Security Act (the Act), MACs will pay for identified significant cost services for Medicare beneficiaries enrolled in MA plans. With CR 11580, CMS will update its systems to handle these situations.

Your MAC will allow Condition Code (CC) 78 on inpatient and outpatient claims for MA beneficiaries when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under 42 CFR Section 422.109(a)(2). An update will occur to any current editing that does not allow this scenario.

NOTE: Condition Code 78 = newly covered Medicare service for which a Health Maintenance Organization (HMO) does not pay.

ADDITIONAL INFORMATIONThe official instruction, CR 11580, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10071CP.pdf.



DOCUMENT HISTORY





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S K I L L E D N U R S I N G FAC I L I T Y (S N F )

MM11727: Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment ProcessThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11727 Related Change Request (CR) Number: 11727 Related CR Release Date: May 8, 2020 Effective Date: October 1, 2019 Related CR Transmittal Number: R10109OTN Implementation Date: October 5, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for Skilled Nursing Facilities (SNFs) and hospital swing bed facilities billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 11727 contains updates to Medicare’s claims processing systems to make corrections to processing of adjustments and other billing issues for SNF Patient Driven Payment Model (PDPM) claims. Make sure your billing staffs are aware of these updates.

BACKGROUNDCR 11727 will implement changes to the SNF Prospective Payment System (PPS), specifically implementing requirements for PDPM. SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X (subject to SNF PPS), will be subject to these requirements.

A prior CR (CR 11152) (see the related MLN Matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11152.pdf) omitted requirements for adjustment claims and the need to enforce sequential billing in order for the variable per diem to pay correctly. CR 11727 will implement requirements for those types of transactions.

As part of these corrections, your MAC will calculate the prior days value to pass into the SNF PRICER for claims subject to SNF PPS after October 1, 2019, as follows:

y Add the cost report days for claims with the same date of admission with dates of service prior to the from date of the currently being priced claim. This count will exclude cancel claims, MA claims with condition code 04 and claims (with the same admission date) with dates of service after the from date of this claim.

Note that your MAC will adjust any Medicare Advantage (MA) claims brought to their attention, that processed prior to October 1, 2020, so that the prior days count is corrected to exclude the MA days.

There is no new policy CR 11727.

ADDITIONAL INFORMATIONThe official instruction, CR 11727, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10109otn.pdf.










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DOCUMENT HISTORY


T H E R A PY

MM11791 (Revised): Therapy Codes UpdateThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

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

BACKGROUNDSection 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




http://www.cms.gov/Medicare/Billing/TherapyServices/index.html

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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:

y 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):

y HCPCS code G2010 (Remot image submit by pt)

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

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

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

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

ADDITIONAL INFORMATIONThe 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 DescriptionMay 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.

TEST YOUR KNOWLEDGE AND EARN CREDIT!https://www.surveymonkey.com/r/XW23SLD

Do you need to earn education credit? Launch the “Test your Knowledge” exercise! Correctly answer eight of ten questions based on this month’s Medicare Bulletin to earn a certificate that may be used to obtain education credit through coding and/or specialty societies. Good luck!


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Documents

JULY 2020 • Medicare Bulletin › parta › pubs › bulletin › ... · Physicians and NPPs must use CPT code 99211 to bill for a COVID-19 symptom and exposure assessment and specimen