MARCH 2020 • Medicare BulletinyyNPPES: National Plan and Provider Enumeration System yyeMDR: Electronic Medical Documentation Request. (Electronic form of ADR) yyesMD: Electronic

MedicareBulletin

JURISDICTION 15KENTUCKY & OHIO PART B

MARCH 2020 • WWW.CGSMEDICARE.COM

GR 2020-03ORIGINATED FEBRUARY 3, 2020

© 2020 Copyright, CGS Administrators, LLC.

Reaching Out to the Medicare Community

ARTICLES CONTAINED IN THIS EDITION ARE CURRENT AS OF JANUARY 30, 2020.

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 2020-03 MARCH 2020 2

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KENTUCKY & OHIOAdministrationContact Information for CGS Medicare Part B Providers 3Provider Contact Center (PCC) Training 4Upcoming Educational Events 4MM11003 Revised: Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System 5Ambulatory Surgery CenterMM11607: January 2020 Update of the Ambulatory Surgical Center (ASC) Payment System 31CodingMM11628: Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to- Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020 37DMEPOSMM11570 Revised: CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 12MM11596: 2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List 20IDTFIndependent Diagnostic Testing Facility (IDTF) Web Page Update 3

LaboratoryMM11598 Revised: Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment 21MM11641: Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens 38SE19006 Revised: Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System 43Medicare Beneficiary Identifier (MBI)SE18006 Reissued: New Medicare Beneficiary Identifier (MBI) Get It, Use It 39PreventiveMM11335 Revised: Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS 11Sleep StudyProvider Compliance Tips for Polysomnography (Sleep Studies) 3

New Medicare Beneficiary Identifier (MBI)USE IT NOW!

#NewCardNewNumber Learn more by visting: https://www.cms.gov/Medicare/ New-Medicare-Card/index.html

go.cms.gov/mlnhttps://www.cms.gov/Medicare/New-Medicare-Card/index.htmlhttps://www.cms.gov/Medicare/New-Medicare-Card/index.html

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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 2020-03 MARCH 2020

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K E N T U C K Y & O H I O

Independent Diagnostic Testing Facility (IDTF) Web Page Update

CGS Administrators, LLC (CGS) has recently updated the Independent Diagnostic Testing Facility (IDTF) Performance Standards (V10) (https://www.cgsmedicare.com/partb/enrollment/idtf.html) Web page. Specifically, two codes were added, 76393 and G2066.

Please share this information with your appropriate staff.


Provider Compliance Tips for Polysomnography (Sleep Studies)

In response to an Office of Inspector General (OIG) Report, the Centers for Medicare & Medicaid Services (CMS) revised the national fact sheet titled “Provider Compliance Tips for Polysomnography (Sleep Studies)” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforPolysomnography-MLN4013531.pdf). The revised fact sheet provides common claim submission errors, tips on how to prevent denials, coverage criteria and Medicare resources. Providers should also be aware of the following CMS resources.

yy Medicare Claims Processing Manual, Chapter 15, Section 70 - https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

yy Questionable Billing for Polysomnography Services OIG Report - https://oig.hhs.gov/oei/reports/oei-05-12-00340.pdf

yy Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements OIG Report - https://oig.hhs.gov/oas/reports/region4/41707069.pdf

Please share this with your appropriate staff.


Contact Information for CGS Medicare Part B Providers

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center at 1.866.276.9558 and choose Option 1. Access the Kentucky & Ohio Part B “Contact Information” Web page at https://www.cgsmedicare.com/partb/cs/index.html for information about the Interactive Voice Response (IVR) system, as well as telephone numbers, fax numbers, and

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.

http://www.cgsmedicare.comhttps://www.cgsmedicare.com/partb/enrollment/idtf.htmlhttps://www.cgsmedicare.com/partb/enrollment/idtf.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforPolysomnography-MLN4013531.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforPolysomnography-MLN4013531.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforPolysomnography-MLN4013531.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdfhttps://oig.hhs.gov/oei/reports/oei-05-12-00340.pdfhttps://oig.hhs.gov/oei/reports/oei-05-12-00340.pdfhttps://oig.hhs.gov/oas/reports/region4/41707069.pdfhttps://oig.hhs.gov/oas/reports/region4/41707069.pdfhttps://www.cgsmedicare.com/partb/cs/index.htmlhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.htmlhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

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mailing addresses for other CGS departments.

BEFORE YOU CALLAccess the “How Do I…?” icon (https://www.cgsmedicare.com/partb/cs/howdoi.html) from the Jurisdiction 15 Part B Contact Information page at https://www.cgsmedicare.com/partb/cs/index.html. In addition, refer to the “Education & Events” icon to access resources that may be able to answer your question.


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 B PCC (1.866.276.9558) will be closed for CSR training and staff development.

Date PCC Training/ClosuresThursday, March 12, 2020 PCC Closed, 9:00 a.m.– 11:00 a.m. Eastern TimeThursday, March 26, 2020 PCC Closed, 9:00 a.m.– 11:00 a.m. Eastern Time

The Interactive Voice Response (IVR) (1.866.290.9481) 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/partb/cs/partb_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://cgsmedicare.com/partb/index.html and click the “myCGS” button on the left side of the Web page.

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


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 B Calendar of Events Home page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/partb_report/partb_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].

http://www.cgsmedicare.comhttps://www.cgsmedicare.com/partb/cs/howdoi.htmlhttps://www.cgsmedicare.com/partb/cs/index.htmlhttps://www.cgsmedicare.com/partb/cs/index.htmlhttps://www.cgsmedicare.com/partb/cs/partb_ivr_user_guide.pdfhttps://www.cgsmedicare.com/partb/cs/partb_ivr_user_guide.pdfhttps://cgsmedicare.com/partb/index.htmlhttps://www.cgsmedicare.com/partb/cs/2020_holiday_schedule.pdfhttps://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/partb_report/partb_report.aspxhttps://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/partb_report/partb_report.aspxmailto:[email protected]

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MM11003 Revised: Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System

MLN Matters Number: MM11003 Revised Related CR Release Date: April 16, 2019 Related Change Request (CR) Number: 11003 Effective Date: February 3, 2020 per CR11141 Related CR Transmittal Number: R2281OTN Implementation Date: July 1, 2019

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

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

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

Make sure your billing staffs are aware of these changes.

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

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

MLN ARTICLE INFORMATION ATTACHED TO CR 11003

Terminologyyy NPPES: National Plan and Provider Enumeration System

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

yy esMD: Electronic Submission of Medical Documentation

yy HIH: Health Information Handler

yy RC: Review Contractor

yy ADR: Additional Documentation Request

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

http://www.cgsmedicare.comhttps://www.cms.gov/files/document/r2419OTN.pdfhttps://www.cms.gov/files/document/r2419OTN.pdf

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

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

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

yy Payment Error Rate Measurement (PERM) contractors

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

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

yy Unified Program Integrity Contractor (UPIC)

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

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

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

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

RegistrationTo receive the ADRs electronically as an eMDR via the esMD system:

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

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

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

Points to Note for Registered Providers

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

- Consent from authorized individual to receive electronically

- Endpoint information where the eMDR has to be sent

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

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

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

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

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

6. HIH shall complete additional processing steps after which the Providers can receive eMDRs (after January 2020).

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


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

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

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

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

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

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

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

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

Provider shall enter the following information in NPPES:

yy Endpoint Type: ‘Connect URL’

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

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

yy Endpoint Use: ‘Other’

yy Other Endpoint Use: ‘CMS esMD eMDR’


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

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

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

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

Click Save.


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

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

Step 2: To delete an Endpoint, click on the “Delete” icon in the “Action” column, the system will prompt the user, click “yes” to delete the Endpoint and add another one.

Note: Users can only delete Endpoints. They cannot modify any end point.

Use cases

1. A new enrollment and registration request.

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

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

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


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

- HIH - HIHs after getting the confirmation from the providers regarding the deletion in NPPES, shall send an eMDR remove request to esMD.

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

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

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

3. HIH2 - HIH2 after getting the confirmation of the addition in NPPES shall send an eMDR registration request to esMD.

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

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

- Use Case A (Individual Providers)

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

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

- Use Case B (Group Practices/Hospitals)

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

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

ADDITIONAL INFORMATIONThe official instruction, CR11003, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2281OTN.pdf. A detailed provider education document is attached to CR11003. Also, see CR11141 at https://www.cms.gov/files/document/r2419OTN.pdf, which shows the effective date is now February 3, 2020.

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

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

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

DOCUMENT HISTORY

Date of Change DescriptionJanuary 16, 2020 We revised the article to link to CR11141 at https://www.cms.gov/files/document/r2419OTN.pdf,

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

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Date of Change DescriptionAugust 26, 2019 We revised this article to reflect changes made to the eMDR registration screens within NPPES.

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

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

February 1, 2019 Initial article released.


MM11335 Revised: Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS

MLN Matters Number: MM11335 Revised Related CR Release Date: January 22, 2020 Related CR Transmittal Number: R2422OTN Related Change Request (CR) Number: 11335 Effective Date: April 1, 2020 Implementation Date: April 6, 2020

Note: We revised this article on January 23, 2020, due to an updated CR 11335 that deleted references to certain inquiry screens. In the article, we changed the CR release date, transmittal number and link to the transmittal. All other information remains the same.

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

WHAT YOU NEED TO KNOWCR 11335 instructs Medicare’s Common Working File (CWF) to send the Date of Service (DOS) for both PPV HCPCS codes (90670 and 90732) to the Medicare Beneficiary Database (MBD).

This will allow other systems to know whether the DOS was for the initial vaccine or the second vaccine. Once the CR is implemented, providers will receive more detail in reply to eligibility transactions on whether their beneficiaries have received one or both PPV vaccines.

BACKGROUNDCurrently, the CWF groups these two HCPCS codes under the PPV HCPCS group code and sends a single next eligible date from the CWF to the MBD. There is no logic included on the MBD to differentiate between the initial vaccine (code 90670) and the second vaccine (code 90732).

For eligibility transactions, CWF processes the two codes as if they were the same code and stores the next eligible date in the one field that exists in the CWF Beneficiary Master File for PPV. This means that the date stored in this field may represent the date of the Initial dose or the second dose.

Eligibility transactions have a need to return the PPV DOS as well as the related National Provider Identifier (NPI) for both of these PPV HCPCS codes (90670 and 90732) for a


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beneficiary, so that a provider may determine if a beneficiary is eligible for either service, or if the beneficiary has already received both vaccines.

With CR 11335, eligibility transactions will be able to send providers more PPV details for a beneficiary. This includes up to 10 occurrences of historical PPV HCPCS codes, NPI, and DOS for each beneficiary.

ADDITIONAL INFORMATIONThe official instruction, CR11335, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r2422otn.pdf.


DOCUMENT HISTORY

Date of Change DescriptionJanuary 23, 2020 We revised the article due to an updated CR 11335 that deleted references to certain inquiry

screens. In the article, we changed the CR release date, transmittal number and link to the transmittal. All other information remains the same.

December 13, 2019 We revised this article due to an updated CR that added business requirement 11335.9 in the CR for contractor integration testing. We also changed the CR release date, transmittal number and link to the transmittal.

October 11, 2019 Initial article released.


MM11570 Revised: CY 2020 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

MLN Matters Number: MM11570 Revised Related CR Release Date: January 3, 2020 Related CR Transmittal Number: R4487CP Related Change Request (CR) Number: 11570 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on January 3, 2020, to reflect an updated Change request (CR) that corrected the CY 2020 maintenance and servicing fee for certain oxygen equipment to $73.02 in the CR’ s business requirement 11570.9. The transmittal number, CR release date and link to the transmittal also changed. All other information remains the same.

PROVIDER TYPE AFFECTEDThis MLN Matters Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items or services paid under the DMEPOS fee schedule provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDChange Request (CR) 11570 provides the Calendar Year (CY) 2020 annual update for the Medicare DMEPOS fee schedule. The instructions include information on the data files, update factors, and other information related to the update of the fee schedule. Make sure your billing staffs are aware of these updates.

BACKGOUNDThe Centers for Medicare & Medicaid Services (CMS) updates the DMEPOS fee schedule on an annual basis in accordance with statute and regulations. Payment on a fee schedule basis is required for certain Durable Medical Equipment (DME), prosthetic devices, orthotics,

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prosthetics, and surgical dressings by Section1834 (a), (h), and (i) of the Social Security Act (the Act). Additionally, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulations (CFR) Section 414.102 for Parenteral and Enteral Nutrition (PEN), splints, casts, and Intraocular Lenses (IOLs) inserted in a physician’s office. The DMEPOS and PEN fee schedule files contain HCPCS codes that are subject to fee schedule adjustments using information on the payment determined for these items under the DMEPOS Competitive Bidding Program (CBP), as well as codes that are not subject to the CBP or fee schedule adjustments.

Fee Schedule Adjustment MethodologiesSection 1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for DME items included in the CBP for payment of the items in areas that are not competitive bidding areas (CBAs). Section 1842(s)(3)(B) of the Act provides authority for making adjustments to the fee schedule amounts for enteral nutrients, equipment, and supplies (enteral nutrition) based on information from the CBP.

The methodologies for adjusting DMEPOS fee schedule amounts using information from the CBP are in regulations at 42 CFR Section 414.210(g). The DMEPOS and PEN fee schedule files contain HCPCS codes that are subject to the adjusted fee schedule amounts, as well as codes that are not subject to the fee schedule CBP adjustments. Recent program instructions on these fee schedule adjustments are available in Transmittal 4209, CR 11064, January 18, 2019 at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11064.pdf

For CY 2020, the following applicable Fee Schedule Adjustment Methodologies and fee schedule amounts reflect the area in which the items and services are furnished.

1. Fee Schedule Amounts for Areas within the Contiguous United StatesFor claims with dates of service from January 1, 2019, through December 31, 2020, the adjusted fee schedule amounts for items furnished in non-competitively bid rural areas are a blend of 50 percent of the adjusted fee schedule amount and 50 percent of the unadjusted fee schedule amount for the item, which is updated by the covered item updates specified in Sections 1834(a)(14) and 1842(s)(B) of the Act, for DME and enteral nutrition respectively. For claims with dates of service from January 1, 2019, through December 31, 2020, the adjusted fee schedule amounts for items furnished in other non-competitively bid areas are based on 100 percent of the adjusted fee schedule amounts.

To determine the adjusted fee schedule amounts, the average of the Single Payment Amounts (SPAs) from CBAs located in eight different regions of the contiguous United States are used to adjust the fee schedule amounts for the states located in each of the eight regions. These Regional SPAs or RSPAs are also subject to a national ceiling (110 percent of the average of the RSPAs for all contiguous states plus the District of Columbia) and a national floor (90 percent of the average of the RSPAs for all contiguous states plus the District of Columbia).

This methodology applies to enteral nutrition and most competitively bid DME items furnished in the contiguous United States, that is, those included in more than 10 CBAs. Fees schedule amounts for competitively bid DME items included in 10 or fewer CBAs adjust so that they are equal to 110 percent of the average of the SPAs for the 10 or fewer CBAs.

Additionally, the fee schedule amounts for areas within the contiguous United States designated as rural areas adjust to equal the national ceiling amounts described above. Regulations at Section 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code estimated to be outside any Metropolitan Statistical Area (MSA). A rural area also includes any ZIP Code within an MSA excluded from a CBA established for that MSA.

The CBP and SPAs generated from the CBP that are used to adjust the fee schedule amounts expired on January 1, 2019. Pursuant to 42 CFR Section 414.210(g)(4), the adjusted fee schedule amounts are increased by 1.6 percent on January 1, 2020, based on

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the percentage change in the CPI for all Urban Consumers (CPI-U) for the 12-month period ending June 30, 2019.

2. Fee Schedule Amounts for Areas outside the Contiguous United StatesFee schedule amounts for items furnished in areas outside the contiguous United States (that is, noncontiguous areas such as Alaska, Guam, Hawaii) are based on a blend of 50 percent of the adjusted fee schedule amount and 50 percent of the unadjusted fee schedule amounts updated by the covered item updates specified in Sections 1834(a)(14) and 1842(s)(B) of the Act. Areas outside the contiguous United States receive adjusted fee schedule amounts so they are equal to the higher of the average of SPAs for CBAs in areas outside the contiguous United States (currently only applicable to Honolulu, Hawaii) or the national ceiling amounts described above and calculated based on SPAs for areas within the contiguous United States.

For the CY January 1, 2020 fee schedule update, the adjusted fee schedule amounts in non-bid areas will receive a CPI-U update per Section 414.210(g) of 1.6 percent due to the adjustments being based on SPAs from competitive bidding programs that are no longer in effect.

KE Modifier

Because the rural and non-contiguous fee schedule amounts are based partially on unadjusted fee schedule amounts, fees for certain items included in the 2008 Original Round One CBP, denoted with the KE modifier, appear on the fee schedule file only for items furnished in rural and non-contiguous areas. Instructions and a list of the applicable KE HCPCS codes are available in Transmittal 1630, CR 6270, from November 7, 2008 (see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6270.pdf). From June 1, 2018, through December 31, 2020, the rural and non-contiguous KE fee schedule amounts will be based on a blend of 50 percent of the adjusted fee schedule amount and 50 percent of the unadjusted KE fee schedule amount updated by the covered item updates specified in Sections 1834(a)(14) and 1842(s)(B) of the Act. The non-rural fees for these KE codes contain zeros on the fee schedule file since KE is not a valid option for areas without blended fees.

For certain accessories used with base equipment included in the CBP in 2008 (for example, power wheelchairs, walkers, and negative pressure wound therapy pumps), the unadjusted fee schedule amounts include a 9.5 percent reduction in accordance with Federal law if these accessories were also included in the 2008 CBP. The 9.5 percent fee reduction only applies to these accessories when furnished for use with the base equipment included in the 2008 CBP. Beginning June 1, 2018, in cases where accessories included in the 2008 CBP are furnished for use with base equipment that was not included in the 2008 CBP (e.g., manual wheelchairs, canes and aspirators), for beneficiaries residing in rural or non-contiguous, non-competitive bid areas, suppliers should append the KE modifier to the HCPCS code for the accessory.

Suppliers should not use the KE modifier with accessories that were included in the 2008 CBP and furnished for use with base equipment that was not included in the 2008 CBP when furnishing these accessories to beneficiaries residing in non-rural, non-competitive bid areas. The KE modifier is not billable for items furnished in former competitive bid areas effective January 1, 2019 (see payment methodology below).

3. Fee Schedule Amounts for former Competitive Bidding Areas (CBAs)The Round 2 Recompete, National Mail-Order Recompete, and Round 1 2017 contract periods of performance expired December 31, 2018. Due to a delay, contracts will not be in effect January 1, 2019 – December 31, 2020, resulting in a gap in the CBP. During the gap period in the DMEPOS CBP, any Medicare enrolled DMEPOS supplier may furnish any DMEPOS item, including items that were formerly included in the CBP. In addition, payment for all items and services that were included in the CBP are based on the lower of the supplier’s charge for the item or fee schedule amounts adjusted in accordance with Sections 1834(a)(1)(F) and 1842(s)(3)(B) of the Social Security Act. The fee schedules for

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items and services furnished in former CBAs are based on the SPAs in effect in the CBA on the last day before the CBP contract period of performance ended, increased by the projected percentage change in the CPI-U for the 12-month period on the date after the contract periods ended.

The fee schedule amounts increase once every 12 months on the anniversary date of the first day after the contract period ended with the CPI-U. For CY 2019, the fee schedule amounts for items furnished in areas that were CBAs as of December 31, 2018, adjust based on the Single Payment Amounts (SPAs) for each specific CBA, increased by the projected percentage change in the CPI-U of 2.5 percent for the 12-month period ending January 1, 2019. For CY 2020, the adjusted fee schedule amounts increase by the projected percentage change in the CPI-U of 2.4 percent for the 12-month period ending January 1, 2020.

The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment that applies for codes with rural and non-rural adjusted fee schedule amounts. The DMEPOS Rural ZIP code file contains the ZIP codes designated as rural areas. ZIP codes for non-continental MSA are not included in the DMEPOS Rural ZIP code file. The update to the DMEPOS Rural ZIP code file occurs on a quarterly basis as necessary.

Regulations at Section 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code is outside any MSA. A rural area also includes any ZIP Code within an MSA excluded from a competitive bidding area established for that MSA.

The ZIP code associated with the permanent address of the beneficiary determines applicability of the adjusted fee schedule amounts in former CBAs. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes and the update will occur on a quarterly basis as necessary.

The following CY 2020 DMEPOS fee schedule and ZIP code Public Use Files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the above files on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymenht/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

4. DMEPOS Fee schedule PUF

5. DME PEN Fee schedule PUF

6. DMEPOS Rural ZIP code PUF

7. Former CBA Fee schedule PUF

8. Former CBA National Mail Order diabetic testing supply fee schedule PUF

9. Former CBA ZIP Code PUF

Regulations for Pricing New DMEPOS ItemsEffective January 1, 2020, regulations on methodologies for establishing fees for new DMEPOS items are published in the CY 2020 End-Stage Renal Disease (ESRD)/ DMEPOS final rule, CMS-1713-F, which is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/End-Stage-Renal-Disease-ESRD-Payment-Regulations-and-Notices.html.

CR 11570 KEY POINTS

New Codes AddedNew DMEPOS codes added to the HCPCS file are effective January 1, 2020, where applicable.You can not use the new codes for billing until they are effective on January 1, 2020.

The HCPCS codes listed below are being added to the HCPCS effective January 1, 2020. The Common Working File (CWF) will add the following categories (in parentheses) and payment categories to its system as follows:

http://www.cgsmedicare.comhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/End-Stage-Renal-Disease-ESRD-Payment-Regulations-and-Notices.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/End-Stage-Renal-Disease-ESRD-Payment-Regulations-and-Notices.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/End-Stage-Renal-Disease-ESRD-Payment-Regulations-and-Notices.html

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1. A4226 (60)

2. B4187 (09, 60) PEN

3. E0787 (60)

4. E2398 ( 60)

5. K1001 (60)

6. 6K1002 (60)

7. K1003 (60)

8. K1004 (67)

9. K1005 (60)

10. L2006 (60)

11. L8033 (03,60) PO

There are no fees added to the DMEPOS fee schedule file for new HCPCS codes effective January 1, 2020. The Medicare coverage and payment determinations for these items are made based on the discretion of the DME MACs and A/B MACs Part B processing claims for these items, until national Medicare coverage and payment guidelines have been established for these codes. The DME MACs and A/B MACs Part B will establish local fee schedule amounts to pay claims for the new codes when applicable, and pay in accordance with the payment rules associated with each payment determination (for example, an item determined to be an expensive item of DME that is reasonable and necessary and not otherwise excluded from coverage by statute, regulations, an National Coverage Determination (NCD) or program instructions, must be paid on a capped rental basis in accordance with regulations at CFR 414.229).

Gap-Filled DMEPOS FeesFee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history are established using existing fee schedule amounts for comparable items when items with existing fee schedule amounts are determined to be comparable to the new items and services. CR 11570 also makes changes to the gap-fill and continuity of pricing instructions in Chapter 23, Sections 60.3 and 60.3.1 of the “Medicare Claims Processing Manual.”

For gap filling pricing purposes, before updating to the current year deflation factors apply. The deflation factors to apply to 2019 price information by payment category are:

yy 0.427 for Oxygen

yy 0.430 for Capped Rental

yy 0.431 for Prosthetics and Orthotics

yy 0.547 for Surgical Dressings

yy 0.595 for Parental and Enteral Nutrition

yy 0.912 for Splints and Casts

yy 0.896 for Intraocular Lenses

Codes DeletedEffective January 1, 2020, there are no deleted HCPCS codes from the DMEPOS fee schedule.

Therapeutic Shoe Modification CodesCMS is also adjusting the fee schedule amounts for shoe modification codes A5503 through A5507 as part of this update in order to reflect more current allowed service data.

Section 1833(o)(2)(C) of the Act required that the payment amounts for shoe modification codes A5503 through A5507 be established in a manner that prevented a net increase in expenditures when substituting these items for therapeutic shoe insert codes (A5512 or A5513).

The base fees for codes A5512 and A5513 were weighted based on the approximated total allowed services for each code for items furnished during the second quarter of calendar year 2004 to establish the fee schedule amounts for the shoe modification codes.

For 2020, CMS is updating the weighted average insert fees used to establish the fee schedule amounts for the shoe modification codes with more current allowed service data for each insert code. For 2020, CMS weights the base fees for A5512 and A5513 based on the approximated total allowed services for each code for items furnished during the calendar year 2018. The revised fee schedule amounts for shoe modification codes A5503 through A5507 will reflect this change, effective January 1, 2020.


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Diabetic Testing SuppliesThe fee schedule amounts for non-mail order Diabetic Testing Supplies (DTS) (without KL modifier) for codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, and A4259 are not updated by the annual covered item update. In accordance with Section 1834(a)(1)(H) of the Act, the fee schedule amounts for these codes were adjusted in CY 2013 so that they are equal to the SPAs for mail order DTS established in implementing the national mail order CBP under Section 1847 of the Act. Initial program instructions on these fees are available in Transmittal 2709, CR 8325, dated May 17, 2013 (see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8325.pdf and Transmittal 2661, CR 8204, dated February 22, 2013 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8204.pdf). The National Mail-Order Recompete DTS SPAs are available at the following website: https://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home.

The non-mail order DTS amounts on the fee schedule update each time there is an update to the single payment amounts. This can happen no less often than every time the mail order CBP contracts are recompeted. The National Mail Order Recompete CBP for mail order diabetic supplies was effective July 1, 2016, to December 31, 2018. As of January 1, 2020, payment for non-mail order diabetic supplies at the National Mail Order Recompete SPAs will continue in accordance with Section 1834(a)(1)(H) of the Act and these rates will remain in effect until new SPA rates are established under the national mail order program.

Effective January 1, 2020, there is an adjustment to the fee schedule amounts for mail order DTS (with KL modifier) using the methodology for areas that were formerly CBAs during periods when there is a temporary lapse in the CBP. The National Mail-Order Recompete DTS SPAs of December 31, 2018, are increased by the projected percentage change in the CPI-U for the 12-month period on the date after the contract periods ended.

The fee schedule amounts increase once every 12 months on the anniversary date of the first day after the contract period ended with the CPI-U. For dates of service between January 1, 2019, and December 31, 2019, the National Mail-Order Recompete SPAs change by the projected rate of 2.5 percent. For CY 2020, the adjusted CY 2019 mail order DTS updated fees change by the projected percentage change in the CPI-U of 2.4 percent for the 12-month period ending January 1, 2020. The national mail order adjusted fee schedule amounts will be used in paying mail order diabetic testing supply claims in all parts of the United States, including the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam and the American Samoa.

2020 Fee Schedule Update Factor of 0.9 PercentFor CY 2020, an update factor of 0.9 percent applies to certain DMEPOS fee schedule amounts. Fee schedule amounts that are adjusted using information from CBPs are not subject to the annual DMEPOS covered item update, but updated pursuant to the applicable adjustment methodologies outlined in 42 CFR Section 414.210(g).

In accordance with the statutory Sections 1834(a)(14) of the Act, certain DMEPOS fee schedule amounts change for 2020 by the percentage increase in the CPI for all urban consumers (United States city average). The CPI-U for the 12-month period ending June 30, 2019, adjusts due to the change in the economy-wide productivity equal to the 10-year moving average of changes in annual economy-wide private non-farm business multi-factor productivity (MFP). The MFP adjustment is 0.7 percent and the CPI-U percentage increase is 1.6 percent. Thus, the 1.6 percentage increase in the CPI-U decreases by 0.7 percentage increase in the MFP - a net increase of 0.9 percent for the update factor.

2020 Oxygen and Oxygen Equipment Fee Schedule AmountsConsistent with the requirements set forth in Section 1834(a)(9)(D)(ii) of the Act, a budget neutrality offset must be applied to all oxygen payment classes and items including:

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yy Stationary oxygen equipment and oxygen contents (E0424, E0439, E1390, and E1391)

yy Portable oxygen equipment add-on (E0431 and E0434)

yy OGPE add-on (E0433, E1392, and K0738)

yy Stationary contents (E0441 and E0442)

yy Portable contents (E0443 and E0444) and

yy Portable liquid contents for high flow patients (E0447)

For CY 2020, the offset percentage varies by geographic area and ranges from 7 to 10 percent in areas that are not former CBAs.

2020 Maintenance and Servicing Payment Amount for Certain Oxygen EquipmentAlso updated for 2020 is the payment amount for maintenance and servicing for certain oxygen equipment. The payment for claims for maintenance and servicing of oxygen equipment is in Transmittal 635, CR 6792, dated February 5, 2010 (see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6792.pdf and Transmittal 717, CR 6990, dated June 8, 2010 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM6990.pdf).

To summarize, payment for maintenance and servicing of certain oxygen equipment can occur:

yy Every 6 months beginning 6 months after the end of the 36th month of continuous use, or

yy End of the supplier’s or manufacturer’s warranty, whichever is later for either HCPCS code E1390, E1391, E0433 or K0738, billed with the “MS” modifier

Payment can occur only once per beneficiary, for any 6-month period, regardless of the combination of oxygen concentrator equipment and/or transfilling equipment used by the beneficiary.

Per 42 CFR Section 414.210(e)(5)(iii), the 2010 maintenance and servicing fee for certain oxygen equipment was based on 10 percent of the average price of an oxygen concentrator. For CY 2011 and subsequent years, the maintenance and servicing fee is adjusted by the covered item update for DME as set forth in Section 1834(a)(14) of the Act. Thus, the 2019 maintenance and servicing fee is adjusted by the 0.9 percent MFP-adjusted covered item update factor to yield a CY 2020 maintenance and servicing fee of $73.02 for oxygen concentrators and transfilling equipment.

2020 Update to the Labor Payment RatesIncluded in Attachment A are the CY 2020 allowed payment amounts for HCPCS labor payment codes K0739, L4205 and L7520. Since the percentage increase in the CPI for all urban consumers (CPI-U) for the twelve-month period ending with June 30, 2019, is 1.6 percent, this change applies to the 2020 labor payment amounts to update the rates for CY 2020.

The 2020 labor payment amounts in the Table 1 (Attachment A in CR 11570) are effective for claims submitted using HCPCS codes K0739, L4205, and L7520 with dates of service from January 1, 2020 through December 31, 2020.

Table 1: 2020 Labor Payment AmountsState HCPCS K0739 HCPCS L4205 HCPCS L7520AK $30.04 $34.24 $40.28AL $15.95 $23.77 $32.28AR $15.95 $23.77 $32.28AZ $19.73 $23.74 $39.71CA $24.48 $39.02 $45.47CO $15.95 $23.77 $32.28

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Table 1: 2020 Labor Payment AmountsState HCPCS K0739 HCPCS L4205 HCPCS L7520CT $26.64 $24.30 $32.28DC $15.95 $23.74 $32.28DE $29.36 $23.74 $32.28FL $15.95 $23.77 $32.28GA $15.95 $23.77 $32.28HI $19.73 $34.24 $40.28IA $15.95 $23.74 $38.63ID $15.95 $23.74 $32.28IL $15.95 $23.74 $32.28IN $15.95 $23.74 $32.28KS $15.95 $23.74 $40.28KY $15.95 $30.43 $41.26LA $15.95 $23.77 $32.28MA $26.64 $23.74 $32.28MD $15.95 $23.74 $32.28ME $26.64 $23.74 $32.28MI $15.95 $23.74 $32.28MN $15.95 $23.74 $32.28MO $15.95 $23.74 $32.28MS $15.95 $23.77 $32.28MT $15.95 $23.74 $40.28NC $15.95 $23.77 $32.28ND $19.88 $34.16 $40.28NE $15.95 $23.74 $45.00NH $17.14 $23.74 $32.28NJ $21.52 $23.74 $32.28NM $15.95 $23.77 $32.28NV $25.41 $23.74 $43.98NY $29.36 $23.77 $32.28OH $15.95 $23.74 $32.28OK $15.95 $23.77 $32.28OR $15.95 $23.74 $46.40PA $17.14 $24.46 $32.28PR $15.95 $23.77 $32.28RI $19.02 $24.48 $32.28SC $15.95 $23.77 $32.28SD $17.83 $23.74 $43.15TN $15.95 $23.77 $32.28TX $15.95 $23.77 $32.28UT $15.99 $23.74 $50.25VA $15.95 $23.74 $32.28VI $15.95 $23.77 $32.28VT $17.14 $23.74 $32.28WA $25.41 $34.83 $41.38WI $15.95 $23.74 $32.28WV $15.95 $23.74 $32.28WY $22.25 $31.69 $45.00


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ADDITIONAL INFORMATIONThe official instruction, CR11570, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r4487cp.pdf.


DOCUMENT HISTORY

Date of Change DescriptionJanuary 3, 2020 We revised this article to reflect an updated Change request (CR) that corrected the CY 2020

maintenance and servicing fee for certain oxygen equipment to $73.02 in the CR’ s business requirement 11570.9. The transmittal number, CR release date and link to the transmittal also changed.

December 9, 2019 Initial article released.


MM11596: 2020 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List

MLN Matters Number: MM11596 Related CR Release Date: January 17, 2020 Related CR Transmittal Number: R4496CP Related Change Request (CR) Number: 11596 Effective Date: January 1, 2020 Implementation Date: February 18, 2020

PROVIDER TYPE AFFECTEDThis MLN Matters Article is for providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) including Durable Medical Equipment (DME MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items, or services paid under the DMEPOS fee schedule.

PROVIDER ACTION NEEDEDCR11596 updates the list of HCPCS codes for MACs and DME MACs. Please make sure your billing staffs are aware of these updates.

WHAT YOU NEED TO KNOWThe Centers for Medicare & Medicaid Services (CMS) annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions to reflect codes that are either added or discontinued (deleted) each year. The jurisdiction list is an Excel file and is available at http://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html. The list is also attached to CR11596.

ADDITIONAL INFORMATIONThe official instruction, CR11596, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r4496cp.pdf.


http://www.cgsmedicare.comhttps://www.cms.gov/files/document/r4487cp.pdfhttp://http://go.cms.gov/MAC-website-listhttp://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.htmlhttp://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.htmlhttps://www.cms.gov/files/document/r4496cp.pdfhttp://go.cms.gov/MAC-website-listhttp://go.cms.gov/MAC-website-list

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DOCUMENT HISTORY

Date of Change DescriptionJanuary 17, 2020 Initial article released.


MM11598 Revised: Calendar Year (CY) 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

MLN Matters Number: MM11598 Revised Related CR Release Date: January 22, 2020 Related CR Transmittal Number: R4498CP Related Change Request (CR) Number: 11598 Effective Date: January 1, 2020 Implementation Date: January 6, 2020

Note: We revised this article on January 23, 2020, due to an updated CR 11598 that changed the policy section. Per the CR, the article notes that “Next CLFS Data Reporting Period — DELAYED to January 2021 (page 1).” That is also noted on page 3. The article also has policy changes on page 2. The CR release date, transmittal number and link to the transmittal also changed. All other information remains the same.

PROVIDER TYPE AFFECTEDThis MLN Matters Article is intended for clinical diagnostic laboratories that submit claims to Medicare Administrative Contractors (MACs) for laboratory services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 11598 provides instructions for the Calendar Year (CY) 2020 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. Make sure your billing staffs are aware of these updates.

BACKGROUNDThe CY 2020 updates are as follows:

Next CLFS Data Reporting Period - DELAYED to January 2021Section 1834A of the Social Security Act (the Act), as established by Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. The Centers for Medicare & Medicaid Services (CMS) published the CLFS final rule Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule (CMS-1621-F) in the Federal Register on June 23, 2016. The CLFS final rule implemented section 1834A of the Act.

Under the CLFS final rule, reporting entities must report to CMS certain private payer rate information (applicable information) for their component applicable laboratories. The data collection period (the period where applicable information for an applicable laboratory is obtained from claims for which the laboratory received final payment during the period) was from January 1, 2019, through June 30, 2019.

yy For Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLTs), the data reporting is delayed by one year. CDLT data that was supposed to be reported between January 1, 2020 and March 31, 2020, must now be reported between January 1, 2021, and March 31, 2021. Labs must report data from the original data collection period of January 1, 2019, through June 30, 2019. Data reporting for


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these tests will then resume on a three-year cycle, beginning in 2024. (Section 105(a)(1) of the Further Consolidated Appropriations Act of 2020 (FCAA)).

yy In addition, the statutory phase-in provisions are updated. For 2020, the rates for CDLTs that are not ADLTs or new CLDTs may not be reduced by more than 10 percent of the rates for 2019. There will be a 15 percent reduction cap for each of 2021, 2022, and 2023. (Section 105(a)(2) of FCAA).

Reminder: Revisions to the Definition of Applicable LaboratoryThe Physician Fee Schedule (PFS) final rule entitled Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019 (CMS-1693-F) was displayed in the Federal Register on November 1, 2018, and was published on November 23, 2018. In the CY 2019 PFS final rule, CMS made two revisions to the regulatory definition of applicable laboratory:

1. Effective January 1, 2019, Medicare Advantage plan revenues were excluded from total Medicare revenues (the denominator of the majority of Medicare revenues threshold).

2. Effective January 1, 2019, hospitals that bill for their non-patient laboratory services may use Medicare revenues from the Form CMS 1450 14x Type of Bill (TOB) to determine whether its hospital outreach laboratories meet the majority of Medicare revenues threshold and low expenditure threshold.

Effective January 1, 2019, the regulatory definition of an applicable laboratory is summarized below. An applicable laboratory means an entity that:

1. Is a laboratory as defined under the Clinical Laboratory Improvement Amendments (CLIA) regulatory definition of a laboratory (42 CFR 493.2, https://www.govinfo.gov/app/details/CFR-2010-title42-vol5/CFR-2010-title42-vol5-sec493-2)

2. The laboratory bills Medicare under its own National Provider Identifier (NPI) or

a. For hospital outreach laboratories — bills Medicare Part B on the Form CMS 1450 under TOB.

3. The laboratory must meet a “majority of Medicare revenues” threshold, where it receives more than 50 percent of its total Medicare revenues from one or a combination of the CLFS or the PFS in a data collection period.

For purposes of determining whether a laboratory meets the “majority of Medicare revenues” threshold, total Medicare revenues includes: fee-for-service payments under Medicare Parts A and B, prescription drug payments under Medicare Part D, and any associated Medicare beneficiary deductible or coinsurance. As a reminder, effective January 1, 2019, total Medicare revenues no longer includes Medicare Advantage payments under Medicare Part C.

4. The laboratory must meet a “low expenditure” threshold, where it receives at least $12,500 of its Medicare revenues from the CLFS in a data collection period.

As noted above, the CLFS data collection period was January 1, 2019, through June 30, 2019. All hospital outreach laboratories that bill for non-patient laboratory services using the Form CMS 1450 14x TOB, were required to determine applicable laboratory status from their final paid Medicare claims received during the next data collection period. Hospital outreach laboratories that met the definition of an applicable laboratory will be required to report applicable information to CMS during the next data reporting period, which is January 1, 2021, through March 31, 2021. Additional sub regulatory guidance will be made available on the CLFS website under the PAMA regulations tab at https:/www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-regulations.html.

Advanced Diagnostic Laboratory Tests (ADLTs) Effective January 1, 20201. The ADLT DecisionDx-Uveal Melanoma owned and furnished by Castle Bioscience was

assigned Proprietary Laboratory Analyses (PLA) code 0081U effective January 1, 2019.

http://www.cgsmedicare.comhttps://www.govinfo.gov/app/details/CFR-2010-title42-vol5/CFR-2010-title42-vol5-sec493-2https://www.govinfo.gov/app/details/CFR-2010-title42-vol5/CFR-2010-title42-vol5-sec493-2https:/www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-regulations.htmlhttps:/www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-regulations.html

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This code is being deleted effective December 31, 2019 and replaced by CPT code 81552, effective January 1, 2020.

- CPT Code: 81552

> Short Descriptor: ONC UVEAL MLNMA MRNA 15 GENE

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

2. Existing code 81538 is an ADLT and is priced at its median private payer rate.

3. For additional information regarding other ADLTs, see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations#ADLT_tests.

Update to FeesBased on Section 1833(h)(2)(A)(i) of the Act, available at https://www.ssa.gov/OP_Home/ssact/title18/1833.htm, the annual update to the local clinical laboratory fees for CY 2020 is 0.90 percent. Beginning January 1, 2020, this update applies only to pap smear tests. For a pap smear test, Section 1833(h)(7) of the Act requires payment to be the lesser of the local fee or the National Limitation Amount, but not less than a national minimum payment amount. However, for pap smear tests, payment may also not exceed the actual charge. The CY 2020 national minimum payment amount is $15.12 (This value reflects the CY 2019 national minimum payment with a 0.9 percent increase or $14.99 times 1.0090).

The affected codes for the national minimum payment amount are: 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, Q0111, Q0115, and P3000.

The annual update to payments made on a reasonable charge basis for all other laboratory services for CY 2020 is 1.6 percent (See 42 CFR 405.509(b)(1)).

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

Access to Data FileInternet access to the CY 2020 CLFS data file will be available after December 1, 2019, at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html. It will be available in multiple formats, including Excel, text, and comma delimited.

Public Comments and Final Payment DeterminationsOn June 24, 2019, CMS hosted a public meeting to solicit comments on the reconsidered codes from CY 2019 codes and new CY 2020 CPT codes. Notice of the meeting was published in the Federal Register on April 1, 2019. Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings.html. Additional written comments from the public were accepted until October 27, 2019. CMS also posted a summary of the public comments and the rationale for the final payment determinations at the same CMS web site identified in the previous sentence.

Pricing InformationThe CY 2020 CLFS includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615). The fees have been established in accordance with Section 1833(h)(4)(B) of the Act.

The fees for clinical laboratory travel codes P9603 and P9604 are updated on an annual basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard

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mileage rate for CY 2020, CMS will issue a separate instruction on the clinical laboratory travel fees.

The CY 2020 CLFS may also include codes that have a “QW” modifier to both identify codes and determine payment for tests performed by a laboratory having only a CLIA certificate of waiver. Code will be listed if applicable.

Mapping Information

Calendar Year (CY) 2020 Clinical Laboratory Fee Schedule (CLFS) Mapping Informationyy New code 0064U is priced at the same rate as code 86780 PLUS code 86318

yy New code 0065U is priced at the same rate as code 86318


yy New code 0086U is to be gapfilled.


yy New code 0097U is to be gapfilled




yy New code 87563 is priced at the same rate as code 87491



yy New code 0084U is priced at the same rate as code 0001U























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yy New code 0069U is priced at the same rate as code 0005U TIMES 0.50




yy New code 0111U is priced at the same rate as code 81275 PLUS 81276 PLUS 81311





yy New code 0129U is priced at the same rate as code 81432 PLUS 81433














yy Reconsidered code 81163 is priced at the same rate as code 81406 PLUS 81216

yy Reconsidered code 81165 is priced at the same rate as code 81406

yy Reconsidered code 0046U is to be gapfilled

yy Reconsidered code 0049U is to be gapfilled

yy New code 0070U is priced at the same rate as code 81226 TIMES 1.5



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yy Existing code 0009M is to be deleted

Laboratory Costs Subject to Reasonable Charge Payment in CY 2020Hospital outpatient claims are paid under a reasonable charge basis (See Section 1842(b)(3) of the Act). In accordance with 42 CFR 405.502 through 42 CFR 405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update is calculated using the change in the applicable Consumer Price Index (CPI) for the 12-month period ending June 30 of each year as set forth in 42 CFR 405.509(b)(1). The CPI update for CY 2020 is 1.60 percent.

Manual instructions for determining the reasonable charge payment are available in Chapter 23, Sections 80 through 80.8 of the “Medicare Claims Processing Manual” at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. If there is not sufficient charge data for a code, the instructions permit considering charges for other similar services and price lists.

Services described by HCPCS codes in the following table are performed for independent dialysis facility patents. Chapter 8, Section 60.3 of the Medicare Claims Processing Manual available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf, instructs that the reasonable charge basis applies. However, when these services are performed for hospital-based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the Hospital Outpatient Prospective Payment System (OPPS).

Laboratory Costs Subject to Reasonable Charge Payment in CY 2020Code Category CodesBlood Products P9010 P9011 P9012 P9016 P9017 P9019 P9020 P9021 P9022 P9023 P9031 P9032 P9033

P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9044 P9050 P9051 P9052 P9053 P9054 P9055 P9056 P9057 P9058 P9059 P9060 P9070 P9071 P9073 P9100Also, payment for the following codes should be applied to the blood deductible as instructed in Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Section 20.5 through 20.5.4:P9010 P9016 P9021 P9022 P9038 P9039 P9040 P9051 P9054 P9056 P9057 P9058NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on Section 1842(o) of the Act. The payment limits based on Section 1842(o), including the payment limits for codes P9041, P9045, P9046, and P9047, should be obtained from the Medicare Part B drug pricing files.

Transfusion Medicine 86850 86860 86870 86880 86885 86886 86890 86891 86900 86901 86902 86904 86905 86906 86920 86921 86922 86923 86927 86930 86931 86932 86945 86950 86960 86965 86970 86971 86972 86975 86976 86977 86978 86985

Reproductive Medicine Procedures

89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89335 89337 89342 89343 89344 89346 89352 89353 89354 89356

http://www.cgsmedicare.comhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/