This week in Medicare updates—2/5/2020
OIG Advisory Opinion No. 20-02
On January 24, the OIG published an Advisory Opinion regarding whether an arrangement in which a pharmaceutical manufacturer provides financial assistance with travel, lodging, and other expenses for certain patients who have been prescribed the manufacturer’s drug would constitute grounds for sanctions under the civil monetary penalty provisions prohibiting inducements to beneficiaries or in relation to the anti-kickback statute. The drug involved in the arrangement contains a black box warning of certain life-threatening or fatal reactions, and the FDA requires that physicians monitor the patients two to three times during the first week of administration. It also requires patients to be within close proximity of the administering facility for at least four weeks after infusion. However, this drug is a personalized medicine made from the patient’s own cells and is a one-time, potentially curative treatment for a certain type of refractory or relapsed disease. As such, the manufacturer assists eligible patients with travel, lodging, meals, and certain out-of-pocket expenses they incur during the period of time surrounding the infusion when the patients must be close to the administering facility.
The OIG determined that in this case, it would not impose sanctions on the requestor under the anti-kickback statute or beneficiary inducements civil monetary penalties due to a variety of reasons discussed within the opinion.
Safeguards for Medicare Patients in Hospice Care
On January 27, CMS published an MLN Fact Sheet regarding hospice provider responsibilities for protecting patients from abuse and neglect, hospice survey and certification requirements, and methods for reporting abuse. The fact sheet also contains a table of additional resources for safeguards relevant to hospice care.
Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B
On January 27, CMS published an MLN Booklet regarding a variety of information about billing for immunizations under Part B. The booklet contains tables of codes to use to report vaccinations, a list of which type of bill to use depending on the provider type for vaccinations, a table of billing information for rural health clinics and federally qualified health centers, and an FAQ on billing and payment for vaccinations.
Final Decision Memo: NCD for Diagnostic Laboratory Tests Using Next Generation Sequencing (NGS)
On January 27, CMS published a Final Decision Memo regarding expanded coverage of NGS as a diagnostic lab test for germline breast and ovarian cancers. This change will apply to NCD 90.2, which previously covered NGS as a diagnostic lab test for recurrent, relapsed, refractory, metastatic, or advanced stage III or stage IV cancer. The test can now be used for germline breast and ovarian cancer as a way to help the treating physician determine management of and treatment options for the patient.
CMS published a Press Release on the policy change on the same date.
2020 Annual Update to the Therapy Code List
On January 28, CMS published Medicare Claims Processing Transmittal 4501, which rescinds and replaces Transmittal 4421, dated October 25, 2019, to remove the sentence from the policy section about how two new biofeedback codes are paid when furnished to a hospital outpatient. The codes will be paid under the Medicare Physician Fee schedule. The original transmittal was issued regarding updates to the list of codes that sometimes or always describe therapy services.
On January 29, CMS revised MLN Matters 11501 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type
On January 29, CMS published Special Edition MLN Matters 20001 regarding an issue where providers are incorrectly coding electro-acupuncture devices applied behind the ear as implantable neurostimulators under HCPCS L8679. Beginning March 1, 2020, MACs will reject claims for L8679 which do not have an appropriate HCPCS/CPT surgical procedure code, and claims for L8679 which do have an appropriate HCPCS/CPT surgical procedure code will be suspended for medical review to ensure all requirements are met. The article includes a list of appropriate HCPCS/CPT surgical procedure codes.
Quarterly Influenza Virus Vaccine Code Update - July 2020
On January 31, CMS published Medicare Claims Processing Transmittal 4508 regarding payment and edit updates in the FISS and CWF to include and update new or existing flu vaccine codes. It also instructs contractors to modify existing editing to allow a flu and PPV vaccination on the same date on separate roster bills.
CMS published MLN Matters 11603 on the same date to accompany the transmittal.
Effective date: July 1, 2020
Implementation date: July 6, 2020
Implementation of Usage of the K3 Segment for Reporting Line Level Ordering Provider on Institutional Claims for Advanced Diagnostic Imaging
On January 31, CMS published One-Time Notification Transmittal 2425 regarding implementation of the usage of the K3 segment for transmitting ordering provider information for appropriate use criteria reporting on claims. The transmittal includes the values for each service line that needs an ordering provider reported.
Effective date: January 1, 2020
Implementation date: July 6, 2020
Updates to the Prior Authorization (PA) Guidance Within Publication 100-08
On January 31, CMS published Medicare Program Integrity Transmittal 937 regarding updates to the manual in accordance with the implementation of prior authorization for certain hospital outpatient department services. This includes a new section 3.10.2 in the manual focusing specifically on this type of prior authorization.
Effective date: March 3, 2020
Implementation date: March 3, 2020
Medicare Provider Enrollment
On January 31, CMS published an MLN Educational Tool regarding provider and supplier enrollment policies for Medicare. The page includes details on enrollment, revalidation, ways to use PECOS, DMEPOS supplier requirements, and more.
Medicare Mental Health
On January 31, CMS published an MLN Booklet regarding coding, billing, and reporting requirements for Medicare mental health services in the inpatient and outpatient settings. The booklet details the types of services covered (as well as what is not covered under fee-for-service Medicare), prescription drug coverage, commonly reported CPT codes, and more. It also provides a table on the types of providers for mental health services as well as the required qualifications, coverage, and payment policies for each provider type.