This week in Medicare updates—12/22/2021
Addition of the QW Modifier to HCPCS Code 86328
On December 10, CMS published One-Time Notification Transmittal 11156 regarding the addition of the QW modifier for use with HCPCS code 86328 (test for detection of severe acute respiratory syndrome coronavirus 2 [Covid-19] antibody, qualitative or semiquantitative) for facilities operating under a CLIA Certificate of Waiver. This change is retroactive to September 23, 2020.
On December 13, CMS published MLN Matters 12557 to accompany the transmittal.
Effective date: September 23, 2020
Implementation date: January 3, 2022
Fact Sheet for State and Local Governments About CMS Programs and Payment for Hospital Alternate Care
On December 13, CMS updated a Fact Sheet regarding CMS programs and payment for hospital alternate care during the PHE. The fact sheet has been updated to reflect that CMS is no longer accepting temporary enrollment for ambulatory surgical centers and independent freestanding emergency departments as alternate care sites.
Opioid Treatment Programs (OTPs) Medicare Billing & Payment
On December 13, CMS updated an MLN Booklet on OTP billing and payment to add two new HCPCS codes (G1028 and G2215), include notes about modifiers to report for therapy provided by audio-video telecommunications or audio-only counseling after the end of the PHE, and update Table 1 with updated rates and code changes.
Claims Processing Instructions for the New Pneumococcal 20-valent Conjugate Vaccine Code 90677
On December 14, CMS published Medicare Claims Processing Transmittal 11163, which rescinds and replaces Transmittal 11092, dated October 29, 2021, to add instructions for additional vaccine code 90671 and change the effective date to July 1, 2021 (title and background updated; requirements 1 through 9 updated; requirement 10 removed; business requirement 12 added; and the Claims Processing Manual updated). The original transmittal was published regarding instructions to update the MCS, CWF, and FISS to include the new pneumococcal 20-valent conjugate vaccine code (90677).
CMS updated MLN Matters 12439 on December 15 to accompany the transmittal.
Effective date: October 1, 2021 - Unless otherwise specified, the effective date is the date of service
Implementation date: April 4, 2022
Revisions to Chapters 13, 18, and 32 to Update Coding
On December 14, CMS published Medicare Claims Processing Transmittal 11161, which rescinds and replaces Transmittal 11021, dated October 1, 2021, to update Chapter 18, section 150.3 to ensure the CPM aligns with the NCD quarterly coding CRs. The original transmittal was published regarding updates to Chapters 13, 18, and 32 of the manual to update the codes/code descriptions and certain coding instructions in those chapters. Multiple new coding updates are noted.
Effective date: October 29, 2021 - Unless otherwise specified, the effective date is the date of service
Implementation date: October 29, 2021 - Unless otherwise specified, the effective date is the date of service
National Health Spending in 2020 Increases Due to Impact of COVID-19 Pandemic
On December 15, CMS published a Press Release regarding the 2020 National Health Expenditures (NHE) Report, which found that US health care spending increased in 2020 by 9.7% to reach a total of $4.1 trillion in total national health care spending. The share of the GDP devoted to health increased from 17.6% in 2019 to 19.7% in 2020, the largest jump since the NHE reports were first published in 1960. Medicare spending increased by 3.5% in 2020 while fee-for-service expenditures declined 5.3%, something the NHE attributed to the COVID-19 pandemic.
Advisory Opinion 21-20
On December 16, the OIG published an Advisory Opinion regarding an arrangement in which the requestor would create an online platform for users to search for and contact home-based health care providers where the providers listed on the website would be charged on a per-click basis. Patients would use this platform to find home-based health care providers for a variety of services, and the search results would show providers enrolled in the platform as well as providers who are not enrolled on the platform, but the enrolled providers would appear first. The platform would allow advertising by individuals and entities, but the home-based health care providers would not be allowed to advertise on the platform. The requestor asked whether this arrangement would be grounds for the imposition of sanctions under civil monetary penalties related to the anti-kickback statute and prohibition on beneficiary inducements.
The OIG said that the arrangement would generate prohibited remuneration under the federal anti-kickback statute and the beneficiary inducements CMPs, but it would not impose sanctions in this case because the arrangement presents a minimal risk of fraud and abuse. The OIG cited factors such as fixed fees for enrolled providers that would be charged regardless of whether users ultimately sought services from the enrolled providers, the fact that the requestor is not a provider or supplier that would be involved in the provision of any home-based health care services, the potential base of users being the general public, and more as justification for its decision not to impose sanctions in this case.
Many Medicare Beneficiaries are Not Receiving Medication to Treat Their Opioid Use Disorder
On December 16, the OIG published a Review to determine the extent to which beneficiaries diagnosed with opioid use disorder received medication and behavioral therapy to treat opioid use disorder through Medicare in 2020. The OIG found that fewer than 16% of beneficiaries diagnosed with opioid use disorder in 2020 received medication to treat their opioid use disorder. The OIG also found that fewer than half of the beneficiaries who did receive medication for opioid use disorder also received behavioral therapy. However, the OIG did note that Medicare does not require opioid treatment programs to report whether beneficiaries use telehealth for behavioral therapy, and therefore the OIG cannot know the full extent to which telehealth may be used for this treatment.
The OIG recommends CMS conduct additional outreach to beneficiaries to increase awareness about Medicare coverage for the treatment of opioid use disorder, take steps to increase the number of providers and opioid treatment programs for beneficiaries, assist SAMHSA by providing data about the number of Medicare beneficiaries receiving buprenorphine in office-based settings and the geographic areas where Medicare beneficiaries remain underserved, take steps to increase utilization of behavioral therapy among beneficiaries receiving medication for opioid use disorder, take steps to address disparities in the treatment of opioid use disorder, and collect data on the use of telehealth in opioid treatment programs. CMS concurred with some of the recommendations and did not explicitly indicate whether it concurred with the other recommendations.
January 2022 Update of the Ambulatory Surgical Center (ASC) Payment System
On December 16, CMS published Medicare Claims Processing Transmittal 11164 regarding the January update to the ASC PPS. Updates include changes to device offsets, the addition of 11 new drug and biological HCPCS codes, changes to the covered procedure list as finalized in the CY 2022 OPPS/ASC final rule, and more.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Direct Mailing Notification to Hospice Providers Regarding the Hospice Benefit Component, Value-Based Insurance Design (VBID) Model, Participating Medicare Advantage Organizations (MAO)
On December 16, CMS published One-Time Notification Transmittal 11160 regarding directions to the MACs on the direct mailings that MACs will send to hospice providers to raise general awareness of the hospice benefit component of the VBID model and provide education on participation and billing for Medicare Advantage enrollees.
Effective date: January 31, 2022
Implementation date: January 31, 2022
NCD 220.6.19, Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer
On December 16, CMS published Medicare National Coverage Determinations Transmittal 11158 regarding updates to the NCD manual to reflect that effective December 15, 2017, NCD 220.6.19 reverted to a non-coverage determination following the 24-month extension and absent any published, peer-reviewed journals regarding PET NaF-18 to identify bone metastases of cancer.
Effective date: December 15, 2017
Implementation date: January 17, 2022
Transvenous (Catheter) Pulmonary Embolectomy NCD §240.6
On December 16, CMS published Medicare National Coverage Determinations Transmittal 11159 regarding the removal of NCD 240.6 for transvenous catheter pulmonary embolectomy from the NCD manual, allowing coverage determinations to be made by the Medicare Administrative Contractors. This coverage policy was published via a decision memo in October 2021.
Effective date: October 28, 2021
Implementation date: January 17, 2022
Protecting Medicare and American Farmers from Sequester Cuts Act
On December 16, CMS published a Note in MLN Connects to announce that Congress passed the Protecting Medicare and American Farmers from Sequester Cuts Act on December 10, which extends the Medicare sequester moratorium until March 31, 2022, then re-implements a 1% payment adjustment from April 1 - June 30, 2022, and a 2% payment adjustment beginning on July 1, 2022. The Act also delays implementation of the Radiation Oncology model until 2023 and adjusts the Physician Fee Schedule conversion factor by 3% for CY 2022.