This week in Medicare updates—12/9/2020

2021 Medicare Physician Fee Schedule (MPFS) Final Rule

On December 1, CMS published a draft copy of the 2021 MPFS Final Rule. The rule finalizes a 10.2% decrease in the conversion factor from $36.09 in 2020 down to $32.41 in 2021 while revising RVUs for certain E/M code categories, a move which will result in significant payment changes for certain specialties. CMS is moving forward with its changes to documentation guidelines for office/outpatient E/M codes, effective January 1, 2021, to align with changes made by the AMA. Other policies that were finalized in the rule include:

• Creating a third temporary category of telehealth services, Category 3, which will list services that are added to the telehealth list during the PHE and will remain on the list through the calendar year in which the PHE ends
• Adding nine codes to the telehealth list as Category 2 telehealth-eligible codes
• Clarifying policies regarding remote physiologic monitoring services
• Finalizing a number of policies regarding professional scope of practice and related issues
• Delaying the Quality Payment Program’s (QPP) MIPS Value Pathways (MVP) overhaul by at least a year so it will now be implemented no sooner than the 2022 performance year
• Revising certain Medicare Diabetes Prevention Program (MDPP) policies during the remainder of the PHE and for any future applicable 1135 waiver event

CMS will also commission a study of telehealth flexibilities provided during the PHE to explore opportunities for ways to use telehealth to care for patients more effectively and enhance program integrity. In addition, the rule also contains two interim final rules with comment--one on coding and payment for personal protective equipment (PPE) as a bundled service and one on coding and payment of virtual check-in services. Both rules will have 60-day comment periods beginning on the date of publication in the Federal Register.  

CMS published a Fact Sheet and Press Release on the rule on the same date as well as a Fact Sheet on MDPP policies. CMS also published downloadable QPP files, including a fact sheet and FAQ document, in the QPP resource library. The final rule is effective January 1, 2021, with the exception of certain policies as noted in the applicability date section of the rule.

 

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

On December 1, CMS updated the blanket waivers for health care providers Fact Sheet to announce that it is delaying the data collection period and data reporting period for ground ambulance organizations that had been selected to collect data in 2020 or 2021. These organizations can now select a new 12-month data collection period beginning January 1, 2022 in order to focus in 2020/2021 on operations and patient care during the PHE.   

CMS continues to update this document, and organizations should review regularly for any changes.

 

Final Decision Memo: Artificial Hearts and Related Devices, Including Ventricular Assist Devices (VAD) for Bridge-to-Transplant and Destination Therapy

On December 1, CMS published a Final Decision Memo regarding two changes to cardiac NCDs. CMS is ending coverage with evidence development for artificial hearts under NCD 20.9 and is relegating coverage instead to the MACs’ decision. CMS is also revising coverage for VADs for Bridge-to-Transplant and Destination Therapy under NCD 20.9.1. The decision is limited to durable, intracorporeal, left VADs (LVAD) and does not include temporary VADs or ECMO. CMS is changing patient selection criteria and is expanding coverage to include all LVAD procedures approved by the FDA for short-term or long-term mechanical circulatory support.

CMS published a Press Release on the NCD on the same date. 

 

Review of Hospital Compliance with Medicare’s Transfer Policy with the Resumption of Home Health Services and the Use of Condition Codes

On December 1, CMS published Special Edition MLN Matters 20025 regarding proper coding of the patient discharge status code and the use of condition codes 42 and 43. The article is being published in light of a recent OIG audit of Medicare overpayments to hospitals that did not comply with the post-acute care transfer policy. 

 

Medicare Provider Enrollment

On December 1, CMS revised an MLN Booklet on Medicare provider enrollment. There are no substantive changes to the guidance. CMS instead redesigned the layout of the booklet to create a webpage that allows for easier navigation through the booklet.

 

2021 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Prospective Payment System (ASC PPS) Final Rule

On December 2, CMS published a draft copy of the 2021 OPPS and ASC PPS Final Rule. CMS finalized updates to both OPPS and ASC PPS payment rates by 2.4% for 2021. CMS also finalized a proposal which will eliminate the inpatient-only (IPO) list over a three-year period, beginning with the removal of almost 300 musculoskeletal-related services in 2021. The list will be completely phased out by CY 2024, but Medicare will continue to pay for these services in an inpatient setting when inpatient care is appropriate. CMS also created an indefinite exemption from certain medical reviews for procedures removed from the list beginning January 1, 2021. The exception applies to reviews related to the 2-midnight rule and patient status and will continue until Medicare claims data indicates those procedures are more commonly performed in the outpatient setting rather than the inpatient setting. Other finalized policies include:   

• Continuing to reimburse hospitals for 340B drugs at average sales price (ASP) minus 22.5% instead of adopting a proposal from the proposed rule which would reimburse at ASP minus 28.7%.
• Expanding prior authorization to include two additional service categories (cervical fusion with disc removal and implanted spinal neurostimulators) effective for dates of service on or after July 1, 2021. CMS stated it is moving forward with this because its analysis shows an unnecessary increase in these types of procedures. It also said that the increase in these services cannot be attributed to other factors such as the opioid crisis because the opioid crisis was not declared a PHE until October 2017, and CMS data shows an increase in these procedures from 2007-2018.  
• Changing supervision levels for non-surgical extended duration therapeutic services (NSEDTS) to general supervision for the entire service as a minimum requirement.
• Adding 11 procedures to the ASC covered procedures list and revising the criteria used to add covered surgical procedures to the ASC CPL. 

The rule also includes an interim final rule with comment on new requirements for the hospital and critical access hospital Conditions of Participation. These hospitals will be required to track and report the incidence and impact of acute respiratory illnesses during the COVID-19 PHE. The rule will have a 60-day comment period beginning on the date of publication in the Federal Register. There is also a separate 30-day comment period for comments on payment classifications assigned to interim APC assignments as well as status indicators of new or replacement Level II HCPCS codes.   

CMS published a Fact Sheet and Press Release as well as Download Links to various OPPS files on the same date. The rule is effective January 1, 2021, except for certain policies described within the text of the rule. 

 

Fall 2020 Semiannual Report to Congress

On December 2, the OIG published the Fall 2020 Semiannual Report to Congress regarding the year’s achievements and an overview of OIG activities for April 1 through September 30. The OIG said it identified $337 million in expected recoveries and identified $2 billion in potential savings for HHS during this period. It also highlighted significant actions, including conducting a rapid survey on hospital experiences during the COVID-19 PHE and coordinating with law enforcement in a massive national health care fraud takedown in September. That takedown resulted in charges against more than 345 defendants for participating in health care fraud schemes involving more than $6 billion in alleged losses to federal health care programs.

The OIG published a News Release on the Semiannual Report on the same date.

 

Correction Notice: Specialty Care Models to Improve Quality of Care and Reduce Expenditures Final Rule

On December 2, CMS published a Correction Notice in the Federal Register regarding the Specialty Care Models final rule, which established the Radiation Oncology and End-Stage Renal Disease Treatment Choices Models. The notice corrects a handful of technical and typographical errors made in the rule. 

Effective date: This correcting document is effective on December 2, 2020.

 

Correction Notice: 2021 IPPS Final Rule

On December 3, CMS published a draft copy of the 2021 IPPS Final Rule Correction Notice, which is scheduled to be published in the Federal Register on December 7. The notice corrects various technical and typographical errors from the rule, including errors in MS-DRG relative weight calculations, which caused CMS to have to correct calculation of total payments, budget neutrality factors, and the final outlier threshold. The notice also contains corrections to various parts of the preamble, addendum, appendices, and files and tables posted on the CMS website. 

Effective date: This correcting document is effective on the date of publication in the Federal Register.

Applicability date: The corrections in this document are applicable to discharges occurring on or after October 1, 2020.

 

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

On December 3, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. This round of updates included information on the new COVID-19 treatments add-on payment (NCTAP) policy under the IPPS; what happens to a product’s NCTAP status if the product loses its EUA status; details on billing and payment for monoclonal antibody products on Part B, SNF, and home health claims; a table of payment rates per provider type for vaccines and their administration; guidance on documentation for billing monoclonal antibodies; and a new section for Indian Health Service hospitals.  

CMS continues to update this document on a regular basis. Providers should review frequently for new information.  

 

Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction

On December 3, CMS revised a Program Instruction document regarding monoclonal antibody treatments for COVID-19. CMS added information on the EUA issued by the FDA on November 21 for the Regeneron combination treatment of casirivimab and imdevimab, which is administered together for treatment of mild to moderate COVID-19 in high risk adults and pediatric patients. There are two codes available for the injection of casirivimab and imdevimab (Q0243) and the IV infusion/post-infusion monitoring of casirivimab and imdevimab (M0243). The program instruction also reviews billing and payment for these products. Medicare beneficiaries will not have to pay cost sharing for these products.

CMS updated the COVID-19 section of its website with this information on the same date. 

 

New ICD-10-CM Codes for COVID-19

On December 3, the CDC published an Announcement regarding the creation of additional codes to report for conditions resulting from COVID-19. These codes include:

• J12.82, Pneumonia due to coronavirus disease 2019
• M35.81, Multisystem inflammatory syndrome (MIS)
• M35.89, Other specified systemic involvement of connective tissue
• Z11.52, Encounter for screening for COVID-19
• Z20.822, Contact with and (suspected) exposure to COVID-19
• Z86.16, Personal history of COVID-19

The codes are effective January 1, 2021. The CDC also published download links to revised ICD-10-CM files to accompany the changes.

 

FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients

On December 3, CMS published Special Edition MLN Matters 20024 regarding the 3-day payment window. The article serves as an informational FAQ document to explain billing procedures and provide resources on this topic. It includes information on the basics of the 3-day payment window, what types of providers are subject to this policy, when the 3-day payment window would and would not apply, how to use modifier PD, and more.

 

2021 Annual Update of Per-Beneficiary Threshold Amounts

On December 3, CMS published Medicare Claims Processing Transmittal 10464 regarding the KX modifier threshold amounts for 2021. The threshold is $2,110 for physical therapy and speech-language pathology services combined and $2,110 for occupational therapy services. This transmittal is no longer sensitive and is now being posted to the internet. 

Effective date: January 1, 2021

Implementation date: January 4, 2021

 

Update to Rural Health Clinic (RHC) All-Inclusive Rate (AIR) Payment Limit for CY 2021

On December 3, CMS published Medicare Claims Processing Transmittal 10413 regarding the 2021 update to the RHC AIR rate. The RHC payment limit per visit for CY 2021 is $87.52. This transmittal is no longer sensitive and is now being posted to the internet. 

Effective date: January 1, 2021

Implementation date: January 4, 2021

 

Update to the FISS Integrated Outpatient Code Editor (IOCE) Claim and Return Buffer Interface Changes

On December 3, CMS published One-Time Notification Transmittal 10508, which rescinds and replaces Transmittal 10417, dated October 30, 2020, to split the effective and implementation dates between April 2021 and July 2021. The original transmittal was issued regarding changes to the claim receipt date field in the IOCE Control Block Table and payment adjustment flag 2 from the APC Return Buffer Table. 

Effective date: April 1, 2021 - Analysis, Design, and Coding for screen changes, ECPS, and IDR; July 1, 2021 - Analysis, Design, and Coding for IOCE, OPPS Pricer, and OPPS Cloud Pricer. Testing and Implementation of all CR components in July. 

Implementation date: April 5, 2021 - Analysis, Design, and Coding for screen changes, ECPS, and IDR; July 6, 2021 - Analysis, Design, and Coding for IOCE, OPPS Pricer, and OPPS Cloud Pricer. Testing and Implementation of all CR components in July.

 

Geographic Direct Contracting Model

On December 3, CMS published a Press Release and Fact Sheet to announce the creation of a new voluntary payment model, the Geographic Direct Contracting Model. This model will test whether a regional approach to value-based care can improve quality of care while reducing costs across an entire region of Original Medicare beneficiaries. The model will work by having Direct Contracting Entities (DCE)--which may include ACOs, health systems, health care provider groups, and health plans--work with providers and community organizations to better coordinate care and address clinical and social needs for the Original Medicare beneficiaries they serve. DCEs will have three tools to use to improve quality and lower costs: relationships with Geo Preferred Providers, implementation of care coordination and clinical management programs, and the ability to perform certain program integrity functions to ensure adherence to Original Medicare policies. 

The model’s payment methodology will be based on a DCE’s performance against a region’s performance year benchmark, which will be set using a geographic rate book. The DCE will bid a discount against the region’s benchmark, then will be responsible for 100% of savings or losses above or below that discount. There are two three-year performance periods (January 1, 2022 through December 31, 2024; January 1, 2025 through December 31, 2027). Letters of interest for the first performance period are due by December 21, 2020. The Innovation Center said it expects to release a request for applications in January 2021.

 

Updates to the Nursing Home Compare Website and Five Star Quality Rating System

On December 4, CMS published a Memorandum to nursing home stakeholders and state survey agencies regarding updates to the Five Star Quality Rating System’s health inspection and quality measure domains as well as information on the transition to the new Care Compare website. CMS will resume calculating nursing home health inspection ratings on January 27, 2021 based on findings from focused infection control inspections. While CMS had waived data reporting through the Minimum Data Set during the pandemic, nursing homes continued to report that data. Therefore, CMS will use that data based on the data collection period ending on June 30, 2020, to update quality measures on January 27, 2021. In addition, due to the transition to the new Care Compare website, CMS will be sunsetting Nursing Home Compare and the data.medicare.gov website as of December 1, 2020.

 

FY 2021 Quarter 1/Quarter 2 Dialysis Facility Report (DFR) - Update

On December 4, CMS published a Memorandum to CMS locations, state survey agency directors, and dialysis providers regarding the distribution of DFRs. Because CMS waived data reporting requirements for dialysis facilities from January 1, 2020 through June 30, 2020 due to the PHE, CMS was unable to collect the data necessary to produce the FY 2021 Quarter 1 and Quarter 2 DFRs. CMS is therefore canceling those updates, which had previously been scheduled for release in December 2020 and March 2021.

Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/CMS locations within 30 days of this memorandum. 

 

Updated Corporate Integrity Agreement Documents

On December 4, the OIG published information on closed Corporate Integrity Agreements with the following entities:

• Balboa Ambulance Services, Inc., of El Cajon, CA
• Century Ambulance Service, Inc., of Jacksonville, FL
• AA Healthcare Management, see Extendicare Health Services, Inc., of Skokie, IL
• Beloit Operations, LLC see Extendicare Health Services, Inc., of Milwaukee, WI
• Novartis Pharmaceuticals Corporation, of East Hanover, NJ

 

Comment Request: Application for Enrollment in Medicare Part A internet Claim (iClaim) Application Screen Modernized Claims System and Consolidated Claim Experience Screens

On December 4, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Application for Enrollment in Medicare Part A internet Claim (iClaim) Application Screen Modernized Claims System and Consolidated Claim Experience Screens.” Comments are due by February 2, 2021.

 

Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for CY 2021

On December 4, CMS published Medicare Claims Processing Transmittal 10498 regarding updates to the FQHC PPS for 2021. This updates the FQHC market basket update (1.7%) and base payment rate ($176.45). 

Effective date: January 1, 2021

Implementation date: January 4, 2021

 

CY 2021 Update for DMEPOS Fee Schedule

On December 4, CMS published Medicare Claims Processing Transmittal 10504 regarding updates to the DMEPOS fee schedule for CY 2021. Due to the PHE, the update for the 2021 DMEPOS and Parenteral and Enteral Nutrition (PEN) fee schedule files will continue to include the rural and non-contiguous non-CBA 50/50 blended fees and the non-rural contiguous non-CBA 75/25 blended fees as required by the Cares Act. The update also includes details on the KE and KU modifiers, therapeutic shoe modification codes, diabetic testing supply codes, and more. 

Effective date: January 1, 2021

Implementation date: January 4, 2021

 

CY 2021 Update for DMEPOS Fee Schedule

On December 4, CMS published Medicare Claims Processing Transmittal 10504 regarding updates to the DMEPOS fee schedule for CY 2021. Due to the PHE, the update for the 2021 DMEPOS and Parenteral and Enteral Nutrition (PEN) fee schedule files will continue to include the rural and non-contiguous non-CBA 50/50 blended fees and the non-rural contiguous non-CBA 75/25 blended fees as required by the Cares Act. The update also includes details on the KE and KU modifiers, therapeutic shoe modification codes, diabetic testing supply codes, and more. 

Effective date: January 1, 2021

Implementation date: January 4, 2021