EDITION 15 | WINTER 2020Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH)

EDI T ION 15 | W IN TER 2020

This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters

issued after 2014 are available at no cost from our website.

© 2020 Copyright, CGS Administrators, LLC

EDITION 15 ∙ WINTER 2020 2© 2020 Copyright, CGS Administrators, LLC. Back to Table of Contents

Table of Contents

from the Medical Directorfrom the Medical Director ........................................................4

News from the InsideBrand New Tool Now Available on cgsmedicare.com: Introducing AME! .....................................................................5

Why Resubmitting Claims is a Better Option ...........................5

Important Information Regarding Telephone Claim Denial Resolutions ..............................................................................6

MBI Now Required on all Transactions ....................................7

Coverage & BillingImplementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System (MM11003) .....................................................8

RT LT Modifier Billing Changes: Vision and Therapeutic Shoes for Persons with Diabetes — DME MAC Joint Publication ................................................9

Functional Electrical Stimulation (FES) - Coverage and HCPCS Coding – Revised — DME MAC Joint Publication ................................................9

Articulating Digit(s) and Prosthetic Hands — Correct Coding (Revised) — DME MAC Joint Publication .................11

Continuous Glucose Monitor Supplies — Correct Coding and Billing — DME MAC Joint Publication ...........................13

Medical PolicyPolicy Article Revisions Summary for September 5, 2019 ....14

AppealsNotification of the 2020 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review — CGS Publication ................................................................15

MiscellaneousInternational Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) — January 2020 Update (MM11392 Revised) ...............................................................16

Claim Status Category and Claim Status Codes Update (MM11467) .............................................................................16

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update (MM11489) .....................17

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE (MM11490) ..................................................................17

Financial Accounting System Changes Advance Notification - Healthcare Integrated General Ledger Accounting System (HIGLAS) – CGS Publication .................................................18

Fees & PricingOctober 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM11343 Revised) ..........................19

October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule (MM11433) ...................................19

January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM11495) ........................................20

HCPCS UpdatesQuarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update (MM11422 Revised)...................................................21

2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update (MM11441) .............21

The 2020 HCPCS Updates – New and Revised HCPCS Codes — CGS Publication ....................................................22

Competitive BiddingQuarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) — January 2020 (MM11462) ..................................................23

Temporary Gap in Competitive Bidding: Modifiers — CGS Publication ................................................................23

MLN ConnectsNew Medicare Card: Get Paid January 1, 2020 — Use MBIs Now ...................................................................24

Hospital Price Transparency Requirements ..........................25

MLN Connects® for November 14, 2019 ...............................26

HICN Claims Reject ...............................................................27

MLN Connects® for November 7, 2019 .................................27

Physician Fee Schedule and OPPS/ASC Final Rules Call — November 6 .......................................................................28

Physician Fee Schedule, Hospital OPPS, and ASC Final Rules ......................................................................................29

MLN Connects® for Thursday, October 31, 2019 ..................30

Final Payment Rules for HH, ESRD, and DMEPOS ..............31




Modernizing and Clarifying the Physician Self-Referral Regulations Proposed Rule ...................................................34


Table of Contents continued...

MLN Connects® for Thursday, October 3, 2019 ....................35

New HCPCS Code J0642 for Levoleucovorin Injection ........36

MLN Connects® for Thursday, September 26, 2019 .............36

Omnibus Burden Reduction & Discharge Planning Rules .....37



MLN Connects® for Thursday, September 5, 2019 ...............40

MLN Connects® for Thursday, August 29, 2019 ...................41

DME MAC Jurisdiction B Contact Information ................................................... 43

The CMS articles in this edition of the Insider are current as of November 18, 2019


FROM THE MEDICAL DIRECTOR Happy New Year 2020! With abundant discussions of resolutions these days, we all should consider how old habits (including processes!) can be modified with that which is new and innovative. We at CGS are all about helping our valued suppliers submit claims correctly the first time for quick and accurate payment, so we have an exciting program to share with you for Jurisdiction B. It is called “TPE Plus”. Perhaps you have heard of it; our JC and J15 contracts initiated this program under a different name in 2017, and have had much success with “TPE Plus” for nearly 3 years.

This invitation-only program is offered to selected DMEPOS suppliers within the Targeted Probe and Educate (TPE) program. Factors considered by us at CGS in determining a candidate company is the claims error rate and the types of errors in the documentation. Once identified, CGS reaches out to the company via a letter or phone call, with details of the program and what it offers.

This program offers the supplier a special quality improvement process that supports them in identifying root causes of errors, opportunities for improvement, and processes to correct actions in order to reduce error rates. Our team assigned to each enrolled company consists of process improvement specialists, medical review management, expert subject matter clinicians, Provider and Supplier Education Outreach (POE) consultants and me as the JB Medical Director.

Our TPE Plus program has provided improved outcomes for the participants. Here are some success stories:

CPAP Supplier: Before TPE Plus, claims error denial error rate = 48.37%. After participating in the TPE Plus process, their next TPE Round claims denial error rate = 0%!

Surgical Dressing Supplier: Before TPE Plus, claims denial error rate = 64.89%. After participating in the TPE Plus process, their next TPE Round claims denial error rate = 23%.

Oxygen Supplier: Before TPE Plus, claims denial error rate = 46%. After participating in the TPE Plus process, their next TPE Round claims denial error rate = 16%.

The goal for this program, for TPE error outcomes, is to have suppliers achieve a 25% or lower claims denial error rate.

There is no cost to participate in TPE Plus. In general, the time from acceptance of the invitation to completion of the process takes about 4 months. The program consists of on-line conference calls, a two day site visit, and claims process reviews determined for the selected policy type. There is customized education provided during this period, addressing internal strategic processes and offering answers to any questions that arise.

Following this, the supplier enters the next round of TPE. The ultimate goal is to reduce future claims errors and avoid additional rounds of TPE. Importantly, this program is not an audit; it is a support service that showcases collaboration to improve the selected supplier’s error rate.

Look for further updates on this program as it expands within JB. Have a happy and productive New Year!

Stacey V. Brennan MD, FAAFP


NEWS FROM THE INSIDE

Brand New Tool Now Available on cgsmedicare.com: Introducing AME!

- CGS Publication

Introducing the Advanced Modifier Engine (AME). This brand new self-service tool recommends the modifiers to append on claim line(s), depending on a combination of specific claim details.

With AME, modifiers can be specified by DMEPOS Category, HCPCS, Scenario and Sub-scenario.

The applicable modifier(s) will display along with information about each. You can find the tool at the Online Tools & Calculators Page (https://www.cgsmedicare.com/jb/help/tools.html) on cgsmedicare.com. It’s the best thing to happen to modifiers!

Why Resubmitting Claims is a Better Option

- CGS Publication

The first step to resolving a claim denial is to send the claim back to the MAC so we can receive it in the system. Choosing to “resubmit” your claim rather than sending it as a Reopening, is a much more efficient process for you.

When you choose to “resubmit” claims, you receive the following benefits:

y Faster Processing – the DME MAC has up to 30 days to process a clean claim (the majority are electronic and processed within 14 days), while a Reopening request may take up to 60 days to process.

y Receive Payment Faster – since claims are processed faster than Reopenings, you will receive your claim payment sooner.

For assistance in determining the best resolution to your claim denial, be sure to use our Claim Denial Resolution Tool (https://www.cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp), which will tell you the best way to resolve your issue quickly. For more information on resubmitting claims, refer to our Submitting Your Claims page (https://www.cgsmedicare.com/jb/claims/sub/subclm.html).

https://www.cgsmedicare.com/jb/help/tools.html

https://www.cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp

https://www.cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp

https://www.cgsmedicare.com/jb/claims/sub/subclm.html

https://www.cgsmedicare.com/jb/claims/sub/subclm.html


Important Information Regarding Telephone Claim Denial Resolutions

- CGS Publication

Link to current version on the CGS website: https://www.cgsmedicare.com/jb/pubs/news/2019/09/cope14009.html

CGS is making some changes in regards to claim denial resolutions over the phone.

Historically, suppliers have had the option to get claims resolved over the phone which appeared to have denied in error. If the DME MAC cannot clearly identify the claim denied in error, you will be asked to take a different set of steps alternative to calling the customer service line.

Although you will still have the option to call in, because the resolution involves more research, we will not be able to resolve it immediately. Please see below for examples of this, with resolutions.

y A claim is denied by Medical Review or denied due to previous supplier’s audit, submit a request for Redetermination.

y Ventilator claims are denied as duplicate and are not billed according to the Correct Coding and Coverage of Ventilators article (https://cgsmedicare.com/jb/pubs/news/2019/04/cope11985.html), submit a request for Redetermination.

y For bundled denials for which the payment of an item is included in the allowance for another item, submit a request for Redetermination.

y For invalid HCPCS/procedure code denials which you believe the correct code was billed, submit a request for Redetermination.

Alternatively, please use the Claim Denial Resolution tool (https://cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp) or the Appeals Decision Tree (https://cgsmedicare.com/jb/claims/appeals/decision_tree.html).

For denials where the payment form is updated after the claim processes, please visit our Claims Payment alerts page (https://cgsmedicare.com/jb/claims/payment_alerts.html) for insight on how to have it pay correctly. We apologize for any inconvenience.

https://www.cgsmedicare.com/jb/pubs/news/2019/09/cope14009.html


https://cgsmedicare.com/jb/pubs/news/2019/04/cope11985.html


https://cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp

https://cgsmedicare.com/medicare_dynamic/jb/claim_denial_resolution_tool.asp

https://cgsmedicare.com/jb/claims/appeals/decision_tree.html

https://cgsmedicare.com/jb/claims/appeals/decision_tree.html

https://cgsmedicare.com/jb/claims/payment_alerts.html


MBI Now Required on all Transactions

- CGS Publication

Suppliers are now required to use Medicare Beneficiary Identifiers (MBIs) when billing Medicare regardless of the date of service.

After January 1, 2020: y MBIs must be used for all dates of service on:

� DMEPOS claim submissions

� Reopening requests

� Prior Authorization requests

� Eligibility inquiries: What to do if the MBI Changes (https://www.cgsmedicare.com/jb/pubs/news/2019/11/cope14782.html)

y Claims received with HICNs will be rejected, even for dates of service prior to January 1, 2020.

y Electronic claims reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)

y Paper claim rejections: Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier

y All eligibility transactions, reopening requests, and prior authorization requests submitted with Health Insurance Claim Numbers (HICNs) will also be rejected.

Need an MBI? y Ask your patients for their cards. If they did not get a new card, give them the Get Your New Medicare Card flyer in English (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf) or Spanish (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf).

y Use the MBI Lookup Tool in myCGS. Sign up for myCGS (https://cgsmedicare.com/jb/mycgs/index.html) to use the tool.

y Check the remittance advice. We returned the MBI on the remittance advice for every claim with a valid and active HICN through December 31, 2019. The MBI will be in the same place you currently get the “changed HICN”: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (Identification Code). If you submit a claim using your patient’s MBI, this field will be blank.

Click here for all things MBI! https://cgsmedicare.com/jb/claims/sub/mbi.html



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


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


https://cgsmedicare.com/jb/mycgs/index.html

https://cgsmedicare.com/jb/mycgs/index.html

https://cgsmedicare.com/jb/claims/sub/mbi.html


COVERAGE & BILLING

Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) SystemMLN Matters® Number: MM11003 RevisedRelated CR Release Date: April 16, 2019 Related CR Transmittal Number: R2281OTN

Related Change Request (CR) Number: 11003Effective Date: July 1, 2019Implementation Date: July 1, 2019

Note: We revised this article on November 1, 2019, to update and clarify information regarding the eMDR registration/enrollment to indicate the provider and the HIH roles with more detail. All other information is unchanged

CR 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. Read more…

View the entire article on the CMS website at https://www.cms.gov/files/document/MM11003

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html

https://www.cms.gov/files/document/MM11003



RT LT Modifier Billing Changes: Vision and Therapeutic Shoes for Persons with Diabetes

- CGS Publication

The DME MACs issued a “Correct Coding - RT and LT Modifier Usage Change” joint publication on December 6, 2018 (https://cgsmedicare.com/jb/pubs/news/2018/12/cope10157.html), which provided instructions for billing right (RT) and left (LT) modifiers on separate claim lines. This is applicable when two of the same items or accessories (same HCPCS codes) are provided on the same date of service (DOS) and the items are being used bilaterally and was effective for DOS on or after 3/1/19. Applicable Policy Articles have been updated to include these instructions.

Effective October 15th, bilateral items not billed on separate claim lines will be returned as unprocessable. Claims returned as unprocessable must be resubmitted. Unprocessable claims do not have appeal rights and cannot be reopened or submitted for adjustment. This includes RT LT modifiers for Eye Prosthesis, Refractive lenses, and Therapeutic Shoes for persons with Diabetes.

Note: When same HCPCS code inserts are provided on the same date of service, bill the total number of units provided for the right side on a single claim line and the total number of units for the left side on a separate claim line.

Click here for the full list of HCPCS codes (https://cgsmedicare.com/jb/pubs/news/2019/05/cope12669.html) requiring RT and LT modifiers and impacted by the updated Policy Articles.

Functional Electrical Stimulation (FES) - Coverage and HCPCS Coding – Revised

- DME MAC Joint Publication


In April 2003 the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) establishing coverage for functional electrical stimulation (FES) to enable spinal cord injured (SCI) patients to walk (see National Coverage Determinations Manual 100-3 Chapter 1, Part 2, Section 160.12 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf)).

Functional electrical stimulation is a technique that uses electrical impulses to activate paralyzed or weak muscles in precise sequence. The FES device transmits these electrical impulses via surface electrodes in the same manner as neuromuscular electrical stimulation (NMES). For example, through selective and sequential stimulation of various lower extremity muscle groups, FES can enable spinal cord injured (SCI) patients to walk.

Coverage of NMES (other than FES) to treat muscle atrophy is limited to the treatment of patients with disuse atrophy where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse atrophy. There has been no change in coverage criteria when NMES is used to treat disuse atrophy.

COVERAGE OF FESMedicare will consider coverage of FES for SCI patients who have completed a training program







http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf


consisting of at least 32 physical therapy sessions with the device, over a period of three months.

Per the CMS NCD 160.12, coverage for FES to enhance walking will be limited to SCI patients with ICD-10 codes G04.1 –Tropical spastic paraplegia, G82.21 - Paraplegia, complete, G82.22 - Paraplegia, incomplete, and with all of the following characteristics:

1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve); and,

2. Persons with muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently; and,

3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception of electrical stimulation sufficient for muscle contraction; and,

4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking; and,

5. Persons that can transfer independently and can demonstrate standing independently for at least three minutes; and,

6. Persons that can demonstrate hand and finger function to manipulate controls; and,

7. Persons with at least six-month post recovery spinal cord injury and restorative surgery; and,

8. Persons without hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and,

9. Persons who have demonstrated a willingness to use the device long-term.

FES used to enhance walking for SCI patients with any of the following conditions, will not be covered:

1. Presence of cardiac pacemakers;

2. Severe scoliosis or severe osteoporosis;

3. Irreversible contracture;

4. Autonomic dysreflexia; or

5. Skin disease or cancer at area of stimulation

Indications for FES other than to enable SCI patients to walk will be denied as not medically necessary.

The only settings where therapists with the sufficient skills to provide these services are employed are inpatient hospitals, outpatient hospitals, comprehensive outpatient rehabilitation facilities and outpatient rehabilitation facilities. The physical therapy necessary to perform this training must be part of a one-on-one training program.

HCPCS CODINGTwo codes are used to bill for FES:

E0764 FUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIAL MUSCLE GROUPS OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM

E0770 FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHERWISE SPECIFIED


Note that HCPCS codes E0764 and E0770 represent the “entire system” for the FES devices. Therefore, individual components such as walkers, crutches or other supplies must not be billed separately.

Manufacturers of products billed with code E0770 must have the code(s) verified by the Pricing, Data Analysis, and Coding (PDAC). Currently, the only products that are coded E0770 are:

y WalkAide (Innovative Neurotronics)

y Odstock DROP FOOT STIMULATOR PACE (Odstock Medical/Boston Brace)

y NESS L300 and H200 devices (Bioness)

y Deluxe Digital Electronic Muscle Stimulator (Drive medical)

Code E0764 does not require code verification by the PDAC; however, currently the only product that is coded E0764 is the Parastep I (Sigmedics).

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 or e-mail the PDAC by completing the DME PDAC Contact form located on the PDAC website (https://www.dmepdac.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=04).

Please refer to the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426 (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55426&ver=62&ContrID=140)) for additional coding and documentation requirements.

Publication HistorySeptember 5, 2019 Revised to remove ICD 9 codes, PDAC verified items, and refer reader to SDR

July 10, 2014 Revised to incorporate ACA 6407 requirements as applicable

March 2003 Originally Published

Articulating Digit(s) and Prosthetic Hands—Correct Coding (Revised)



On January 1, 2015, HCPCS code L6025 was crosswalked to HCPCS code L6026. This article is a Correct Coding update to the December 30, 2011 article, which was retired due to HCPCS code changes.

HCPCS code L6026 (TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE, EXCLUDES TERMINAL DEVICE(S)) describes a base code for a transcarpal/metacarpal or a partial hand disarticulation, myoelectric-controlled prosthesis which includes all necessary components besides the terminal device.

These are 5 external powered terminal devices which are available to be used with L6026:

1. L6715 TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S),

https://www.dmepdac.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=04

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55426&ver=62&ContrID=140

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55426&ver=62&ContrID=140




INITIAL ISSUE OR REPLACEMENT

y HCPCS code L6715 describes one complete multiple articulating digit (finger or thumb) and the necessary motors. If more than one digit is billed, use the appropriate Units of Service (UOS) for code L6715. With initial issue, L6715 is only to be paired with L6026; however, the articulating digit(s) can also be used as a “replacement digit(s)” with the use of the RB modifier as part of a prosthetic repair.

2. L6880 ELECTRIC HAND, SWITCH OR MYOLELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, ANY GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S)

y HCPCS code L6880 describes a complete terminal device that can only be used with HCPCS code L6026 when a partial hand residual limb contains no digits. HCPCS code L6880 has all of the following characteristics:

a. Includes all necessary components. This L code describes a product that is all-inclusive. Billing of any additional features or functions used to describe a manufacturer’s terminal device is considered unbundling.

b. Comprised of five (5) articulating digits and the necessary motors.

c. All grasp patterns are included in the L6880 HCPCS code language. The use of HCPCS code L6881 (AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE) would be considered unbundling.

d. Use of HCPCS code L6880 is only appropriate with externally powered custom fabricated sockets such as HCPCS codes L6026, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, and L6975.

y The use of HCPCS code L6715 on initial issue will be denied as unbundling. However, the articulating digit(s) can also be used as a “replacement digit(s)” with the use of the RB modifier as part of a prosthetic repair.

y If L6880 is under the manufacturer’s warranty, HCPCS code L6715 as a replacement should not be billed to Medicare.

3. L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT

4. L7008 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC

5. L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT

Billing of more than one terminal device with HCPCS code L6026 is considered incorrect coding.

HCPCS code L7499 (UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used for the billing of any additional features or components, programming, adjustment, etc. with HCPCS codes L6026, L6715, L6880, or L7007-L7009 as these codes are considered all-inclusive. The use of HCPCS code L7499 on initial issue, with the any of the above HCPCS codes, is considered unbundling.

For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com.

Publication HistoryOctober 3, 2019 Revised and Republished*

*This article is a Correct Coding update to the December 30, 2011 article, which was retired due to HCPCS code changes.

https://www.dmepdac.com

https://www.dmepdac.com


Continuous Glucose Monitor Supplies - Correct Coding and Billing



The DME MACs have recently noticed an increase in denials for HCPCS code K0553 (SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH SUPPLY = 1 UNIT OF SERVICE) due to suppliers billing more frequently than once per month (e.g., billing K0553 every 28 days). Suppliers must not bill more than one (1) unit of service of HCPCS code K0553 per thirty (30) days.

Information about billing of K0553 may be found in the Glucose Monitors LCD-related Policy Article (A52464 (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52464)). As a reminder, the Glucose Monitors Policy Article states (emphasis added):

For claims with dates of service on or after July 1, 2017, a therapeutic CGM must be billed with code K0554 and code K0553 for the supply allowance. Only one (1) month of the supply allowance (one (1) Unit of Service) may be billed to the DME MACs at a time.

Code K0553 describes a supply allowance used with a therapeutic CGM device. The supply allowance includes all items necessary for the use of the device and includes, but is not limited to: CGM sensor, CGM transmitter, home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries. K0553 must not be used for supplies used with CGM coded as A9278.

A supplier does not have to deliver supplies used with a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month following the DOS on the claim. Suppliers must monitor usage of supplies. Billing for code K0553 may continue on a monthly basis as long as sufficient supplies remain to last for one (1) full month as previously described. If there are insufficient supplies to be able to last for one (1) full month, additional supplies must be provided before the supply allowance is billed.

No more than 1 unit of service (UOS) for code K0553 per month is billable at a time.

Therefore, in order to avoid denials for excess utilization, suppliers must ensure that they are billing for no more than one (1) UOS of K0553 per thirty (30) days. Refer to the Glucose Monitors LCD (L33822 (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33822)) and related Policy Articles (A52464 (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52464) and A55426 (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=55426)) for additional coverage, coding and documentation requirements.

Publication HistoryOctober 17, 2019 Originally Published



https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52464


https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33822

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33822






MEDICAL POLICY

Policy Article Revisions Summary for September 5, 2019


Outlined below are the principal changes to the DME MAC Policy Article (PA) that has been revised and posted. The policy included is Therapeutic Shoes for Persons with Diabetes. Please review the entire LCD and related PA for complete information.

Therapeutic Shoes for Persons with Diabetes

PAhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52501

Revision Effective Date: 01/01/2019

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Added: HCPCS A5514 to the reference of “inserts” for which impressions, casts, or CAD-CAM images, of the beneficiary’s feet, are to be obtained by the supplier at the time of item selection

09/05/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and PAs. For complete information on any topic, you must review the LCDs and/or PAs.





APPEALS

Notification of the 2020 Dollar Amount in Controversy Required to Sustain Appeal Rights for an Administrative Law Judge (ALJ) Hearing or Federal District Court Review

Link to current version on the CGS website: https://www.cgsmedicare.com/jb/claims/appeals/timelines.html

Each Appeals process has specific timelines and requirements. Review the table below for specific timelines and monetary thresholds applied to each of the Appeals processes:

Appeal Level Time Limit for Filing Where to File an Appeal

Monetary Threshold

Redetermination 120 days from the date of receipt of the initial determination or overpayment demand letter

CGS Jurisdiction B DME MAC

None

Reconsideration 180 days from the date of receipt of the Medicare Redetermination Notice

C2C Innovative Solutions, Inc.

None

Administrative Law Judge (ALJ)

60 days from the date of receipt of the Reconsideration notice

Follow the instructions in your Reconsideration decision letter.

For requests filed prior to January 1, 2020, at least $160 remains in controversy.

For requests filed on or after January 1, 2020, at least $170 remains in controversy.

Departmental Appeals Board (DAB) Review/Appeals Council

60 days from the date of receipt of the ALJ decision/dismissal

Follow the instructions in your ALJ decision letter.

None

Federal Court (Judicial) Review

60 days from the date of the DAB decision or declination of review by the DAB

For requests filed prior to January 1, 2020, at least $1,630 remains in controversy.

For requests filed on or after January 1, 2020, at least $1,670 remains in controversy.

https://www.cgsmedicare.com/jb/claims/appeals/timelines.html

https://www.cgsmedicare.com/jb/claims/appeals/timelines.html


MISCELLANEOUS

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 UpdateMLN Matters® Number: MM11392 RevisedRelated CR Release Date: September 19, 2019Related CR Transmittal Number: R2362OTN

Related Change Request (CR) Number: 11392Effective Date: January 1, 2020, unless otherwise noted in CR11392Implementation Date: Implementation Date: January 6, 2020 -MAC local edits 45 days from date of this CR

Note: We revised this article on October 1, 2019, to clarify that the effective date is January 1, 2020, unless noted otherwise in CR11392. All other information remains the same.

CR 11392 constitutes a maintenance update of International Classification of Diseases (ICD)-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. Please make sure your billing staffs are aware of these updates. Read more…


Claim Status Category and Claim Status Codes UpdateMLN Matters® Number: MM11467Related CR Release Date: November 15, 2019 Related CR Transmittal Number: R4460CP

Related Change Request (CR) Number: 11467Effective Date: April 1, 2020Implementation Date: April 6, 2020

CR 11467 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. Make sure your billing staff is aware of this update. Read more…







Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print UpdateMLN Matters® Number: MM11489Related CR Release Date: November 15, 2019 Related CR Transmittal Number: R4461CP


CR 11489 updates the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs the ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) to update the Medicare Remit Easy Print (MREP) and PC Print software. Be sure your billing staffs are aware of these changes and obtain the updated MREP and PC Print if they use that software. Read more…


Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) COREMLN Matters® Number: MM11490Related CR Release Date: November 15, 2019Related CR Transmittal Number: R4463CP


CR 11490 instructs MACs and Medicare’s Shared System Maintainers (SSMs) to update systems based on the Committee on Operating Rules for Information Exchange (CORE) 360 Uniform use of Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Claim Adjustment Group Code (CAGC) rule publication. These system updates are based on the CORE Code Combination List scheduled to be published on or about February 1, 2020. Make sure your billing staffs are aware of these updates. Read more…







Financial Accounting System Changes Advance Notification- Healthcare Integrated General Ledger Accounting System (HIGLAS)

- CGS Publication

CGS will soon be transitioning our financial accounting system from the DME Shared System (VMS) to the Healthcare Integrated General Ledger Accounting System (HIGLAS). Suppliers will receive letters before the change which will include specific dates that this is occurring.

This transition will enable Centers for Medicare & Medicaid Services (CMS) to track Medicare payments and accurately pay claims for over 40 million Medicare beneficiaries. Note that this change is only affecting the financial accounting system, not claims processing.

It will include a temporary reduction of the payment floor, which will result in payments being issued early (checks and Electronic Funds Transfers). This may give the appearance that cash revenues have increased when in fact some claims payments may simply have been made earlier than normal. Suppliers are encouraged to monitor payments and make adjustments as necessary once transition begins.

CGS is committed to keeping suppliers informed on the HIGLAS transition. Updated information regarding HIGLAS will continue to be provided on the Jurisdiction B website.


FEES & PRICING

October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesMLN Matters® Number: MM11343 RevisedRelated CR Release Date: September 13, 2019Related CR Transmittal Number: R4395CP

Related Change Request (CR) Number: 11343Effective Date: October 1, 2019Implementation Date: October 7, 2019

Note: We revised this article on September 16, 2019, to reflect the revised CR11343 issued on September 13. The CR revision had no impact on the substance of the article. We did update the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

CR11343 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after September 13, 2019. CMS gives MACs the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions available in Chapter 4, Section 50 of the Medicare Claims Processing Manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Make sure that your billing staffs are aware of these changes. Read more…


October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee ScheduleMLN Matters® Number: MM11433Related CR Release Date: August 30, 2019

Related CR Transmittal Number: R4386CP

Related Change Request (CR) Number: 11433Effective Date: September 1, 2019 for implementation of fees for code E0766; October 1, 2019 for all other changesImplementation: October 7, 2019

CR 11433 informs DME MACs about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. Make sure your billing staff are aware of these changes. Read more…


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







January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesMLN Matters® Number: MM11495Related CR Release Date: September 27, 2019 Related CR Transmittal Number: R4404CP

Related Change Request (CR) Number: 11495Effective Date: January 1, 2020Implementation Date: January 6, 2020

CR11495 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after December 16, 2019. CMS gives MACs the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions available in Chapter 4, Section 50 of the Medicare Claims Processing Manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Make sure that your billing staffs are aware of these changes. Read more…

View the entire article on the CMS website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11495.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11495.pdf




HCPCS UPDATES

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 UpdateMLN Matters® Number: MM11422 RevisedRelated CR Release Date: November 4, 2019Related CR Transmittal Number: R4443CP

Related Change Request (CR) Number: 11422Effective Date: October 1, 2019Implementation Date: October 7, 2019

Note: We revised this article on November 5, 2019, to reflect the revised CR11422 issued on November 4, 2019. The revised CR added HCPCS code J0642, and we added that code in the article. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

CR 11422 updates the HCPCS code set for codes related to drugs and biologicals. Make sure your billing staffs are aware of these updates. Read more…


2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) UpdateMLN Matters® Number: MM11441Related CR Release Date: August 30, 2019 Related CR Transmittal Number: R4385CP


CR 11441 makes changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that will be used to revise Medicare’s Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF Consolidated Billing (CB) in Chapter 6, Section 110.4.1 and Chapter 6, Section 20.6 in the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf). Make sure your billing staffs are aware of these changes. Read more…




https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf





The 2020 HCPCS Updates – New and Revised HCPCS Codes

- CGS Publication


The 2020 Healthcare Common Procedure Coding System (HCPCS) File has been published. There are several additions and revised HCPCS codes. The changes are effective January 1, 2020. Please keep in mind, the appearance of a HCPCS code is not an indication of coverage by the DME MAC.

The first listing contains the added HCPCS Codes that will take effect on January 01, 2020.

HCPCS DESCRIPTION

A4226 Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week

B4187 Omegaven, 10 grams lipids

E0787 External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing

E2398 Wheelchair accessory, dynamic positioning hardware for back

J0179 Injection, brolucizumab-dbll, 1 mg

J9199 Injection, gemcitabine hydrochloride (infugem), 200 mg

J9309 Injection, polatuzumab vedotin-piiq, 1 mg

K1001 Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type

K1002 Cranial electrotherapy stimulation (ces) system, includes all supplies and accessories, any type

K1003 Whirlpool tub, walk-in, portable

K1005 Disposable collection and storage bag for breast milk, any size, any type, each

L2006 Knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated

L8033 Nipple prosthesis, custom fabricated, reusable, any material, any type, each

The listing of HCPCS Codes with description/verbiage changes that will take effect January 01, 2020 is as follows:

HCPCS DESCRIPTION

B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids

J9201 Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg

L8032 Nipple prosthesis, prefabricated, reusable, any type, each

Q5106 Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units




COMPETITIVE BIDDING

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – January 2020MLN Matters® Number: MM11462Related CR Release Date: September 20, 2019 Related CR Transmittal Number: R4397CP


Medicare updates the DMEPOS Competitive Bidding Program (CBP) files on a quarterly basis to implement necessary changes to the Healthcare Common Procedure Coding System (HCPCS), ZIP code, and supplier files. CR11462 provides specific instruction for implementing the DMEPOS CBP files.

The Round 1 2017, Round 2 Recompete, and National Mail Order (NMO) Recompete CBP contracts expired on December 31, 2018. Due to a delay in the announcement of the next round of the CBP, contracts are not in effect in Round 1, Round 2, or the NMO Competitive Bidding Areas (CBAs) as of January 1, 2019, resulting in a temporary gap period in the CBP. Read more…

View the entire article on the CMS website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11462.pdf

Temporary Gap in Competitive Bidding: Modifiers

- CGS Publication

All Medicare Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Competitive Bidding Program (CBP) contracts expired on December 31, 2018. Effective January 1, 2019 there is a temporary gap in the DMEPOS CBP that CMS expects will last until December 21, 2020. As a supplier; you may be questioning which modifier is appropriate under the Competitive Bidding Program (CBP).

On January 4, 2019 CGS published an article titled “Appropriate Modifiers during the Temporary Gap in Competitive Bidding”.

This article outlines the specific modifier usage during the temporary gap as well Self-Service tools that are available to the supplier community. We encourage you to view this informative article on cgsmedicare.com: https://cgsmedicare.com/jb/pubs/news/2019/01/cope10661.html.







MLN CONNECTS®

MLN Connects® Special Edition for Tuesday, November 19, 2019

New Medicare Card: Get Paid January 1, 2020 – Use MBIs NowHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2019-11-19

PDF: https://www.cms.gov/files/document/2019-11-19-enews-se

Do not wait. Update your patients’ records and use Medicare Beneficiary identifiers (MBIs) now, before you are busy with other patient insurance changes in January.

We encourage people with Medicare to carry their cards with them since we removed the Social Security Number-based number; if your patients do not bring their Medicare cards with them:

y Give them the Get Your New Medicare Card flyer in English (or Spanish). y Use your Medicare Administrative Contractor’s look-up tool. Sign up (PDF) for the Portal to use the tool.

y Check the remittance advice. Until December 2019, we return the MBI on the remittance advice for every claim with a valid and active Health Insurance Claim Number (HICN).

Starting January 1, you must use MBIs to bill Medicare regardless of the date of service:

y We will reject claims submitted with HICNs with a few exceptions y We will reject all eligibility transactions submitted with HICNs

See the MLN Matters Article (PDF) for answers to your questions on using MBIs.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2019-11-19


https://www.cms.gov/files/document/2019-11-19-enews-se



https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf

https://www.cms.gov/Medicare/New-Medicare-Card/index

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf


MLN Connects® Special Edition for Friday, November 15, 2019

Hospital Price Transparency RequirementsHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2019-11-15

PDF: https://www.cms.gov/files/document/2019-11-15-enews-se

CY 2020 Hospital Outpatient Prospective Payment System Policy ChangesOn November 15, CMS finalized policies that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.

The policies in the final rule will further advance the agency’s commitment to increasing price transparency. It includes requirements that would apply to each hospital operating in the United States. In response to comments, CMS is extending the effective date to January 1, 2021 to ensure hospital compliance with these regulations.

The final rule includes:

y Definitions of “hospital,” “standard charges,” and “items and services” y Requirements for making public all standard charges for all items and services in a machine-readable format

y Requirements for displaying shoppable services in a consumer-friendly manner. y Monitoring and enforcement

For More Information:

y View the final rule (CMS-1717-F2): This HHS-approved document has been submitted to the Office of the Federal Register (OFR) for publication and has not yet been placed on public display or published in the Federal Register. The document may vary slightly from the published document if minor editorial changes have been made during the OFR review process. The document published in the Federal Register is the official HHS-approved document.

y Press Release. y Registration opening soon for December 3 Call.

See the full text of this excerpted CMS Fact Sheet (Issued November 15).



https://www.cms.gov/files/document/2019-11-15-enews-se

https://www.hhs.gov/sites/default/files/cms-1717-f2.pdf

https://www.federalregister.gov/documents/2019/11/27/2019-24931/medicare-and-medicaid-programs-cy-2020-hospital-outpatient-pps-policy-changes-and-payment-rates-and

https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDIsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkIjoiMjAxOTExMTUuMTI5NTg1ODEiLCJ1cmwiOiJodHRwczovL3d3dy5jbXMuZ292L25ld3Nyb29tL3ByZXNzLXJlbGVhc2VzL3RydW1wLWFkbWluaXN0cmF0aW9uLWFubm91bmNlcy1oaXN0b3JpYy1wcmljZS10cmFuc3BhcmVuY3ktcmVxdWlyZW1lbnRzLWluY3JlYXNlLWNvbXBldGl0aW9uLWFuZCJ9.hxk5osrehCvZWQ5VNBtm5pxpzQQ_JDHlR38fTUdphRA/br/71445944221-l

https://blh.ier.intercall.com/

https://www.cms.gov/newsroom/fact-sheets/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price


MLN Connects® for Thursday, November 14, 2019

HTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-14-eNews

PDF: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-11-14-eNews.pdf

News

y New Medicare Card: If an MBI Changes y Medicare Shared Savings Program: Application Deadlines for January 1, 2021, Start Date y Drug Units in Excess of MUE: Comparative Billing Report in November y Person-Centered Planning: Comment on Performance Measurement by December 2 y Emergency Preparedness Resources y Raising Awareness of Diabetes in November y Recognizing Lung Cancer Awareness Month and the Great American Smokeout

Compliance

y Skilled Nursing Facility 3-Day Rule Billing

Claims, Pricers & Codes

y MACRA Patient Relationship Categories and Codes: Reporting HCPCS Level II Modifiers

Events

y Kidney Care Choices Model Webinars — November 15 and 22 y 2020 Quality Payment Program Final Rule Webinar — November 19 y Drug Units in Excess of MUE: Comparative Billing Report Webinar — December 4 y Ground Ambulance Organizations: Data Collection System Call — December 5

MLN Matters® Articles

y International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) — April 2020 Update

y Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)

y Display PARHM Claim Payment Amounts — Revised y October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

y Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update — Revised

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-14-eNews


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-11-14-eNews.pdf



MLN Connects® Special Edition for Tuesday, November 12, 2019

HICN Claims RejectHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-12-eNews-SE

PDF: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-11-12-eNews-SE.pdf

We are 50 days out from the end of the Medicare Beneficiary Identifier (MBI) transition period. Use the MBI on Medicare claims and other transactions now. Starting January 1, regardless of the date of service:

y We will reject claims submitted with Health Insurance Claim Numbers (HICNs) with a few exceptions.

y We will reject all eligibility transactions submitted with HICNsSee the MLN Matters Article to learn how to get and use MBIs.

MLN Connects® for Thursday, November 7, 2019



News

y New Medicare Card: HICN Claims Reject January 1, 2020 y IRF/LTCH/SNF Quality Reporting Program: Submission Deadline Extended to November 18 y MIPS Heart Failure Measure: Call for Public Comment Closes November 27 y CAHs: Hardship Exception Application Deadline December 2 y DMEPOS Competitive Bidding Surveys: Comment by December 20 y MIPS: Virtual Group Election Period Open Through December 31 y Medicare Ground Ambulance Data Collection System: Starts January 1, 2020 y Home Health Agency: Final OASIS D-1 Data Submission Specifications y MACRA Patient Relationship Categories and Codes: Learn More y Recommend Influenza Vaccination: Each Office Visit is an Opportunity

Compliance

y Bill Correctly for Medicare Telehealth Services


y Skilled Nursing Facility Claims Hold

Events

y Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14 y Ground Ambulance Organizations: Data Collection System Call — December 5

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-12-eNews-SE


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-11-12-eNews-SE.pdf


https://www.cms.gov/Medicare/New-Medicare-Card/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf







y Addition of Medical Severity Diagnosis Related Groups (MS-DRG) Subject to Inpatient Prospective Payment System (IPPS) Replaced Devices Offered Without Cost or With a Credit Policy

y Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties

y Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.0, Effective January 1, 2020

y April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

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

Publications

y Opioid Treatment Programs (OTPs) Medicare Enrollment y Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B — Revised

Multimedia

y Medicare Telehealth Services Video

MLN Connects® Special Edition for Monday, November 4, 2019

Physician Fee Schedule and OPPS/ASC Final Rules Call — November 6HTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-04-eNews-SE


Wednesday, November 6 from 2:15 to 3:45 pm ET

Register for Medicare Learning Network events.

During this call, learn about the provisions in two CMS CY 2020 final rules:

y Physician Fee Schedule and Quality Payment Program: Final Rule, Press Release, Physician Fee Schedule Fact Sheet, and Quality Payment Program Fact Sheet

y Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment systems: Final Rule and Fact Sheet

Changes to the Physician Fee Schedule are aimed at reducing burden, recognizing clinicians for the time they spend taking care of patients, removing unnecessary measures, and making it easier for clinicians to be on the path towards value-based care. Topics include:

y Payment and supervision policy updates y Merit-based Incentive Payment System Value Pathways: Streamlining the Quality Payment Program to reduce clinician burden





https://blh.ier.intercall.com/

https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

https://www.cms.gov/newsroom/press-releases/trump-administration-strengthens-medicare-reducing-provider-burden-and-valuing-time-spent-patients

https://www.cms.gov/newsroom/fact-sheets/finalized-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar

https://qpp-cm-prod-content.s3.amazonaws.com/uploads/737/2020%20QPP%20Final%20Rule%20Fact%20Sheet.pdf

https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center

https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0


y Creating the new Opioid Treatment Program benefit in response to the opioid epidemic In addition, updates and policy changes under the Medicare OPPS and ASC payment systems lay the foundation for a patient-driven health care system.

A question and answer session follows the presentation. We encourage you to review the final rules prior to the call.

Target Audience: Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent health care providers; all hospitals operating in the United States; and other stakeholders.

MLN Connects® Special Edition for Friday, November 1, 2019

Physician Fee Schedule, Hospital OPPS, and ASC Final RulesHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-11-01-eNews-SE


News

y Physician Fee Schedule: Finalized Policy, Payment, and Quality Provisions for CY 2020 y Medicare Hospital OPPS and ASC Payment System Final Rule for CY 2020






MLN Connects® for Thursday, October 31, 2019



News

y Protect Your Patients’ Identities: Use the MBI Now y Hospital Value-Based Purchasing Program Results for FY 2020 y IRF/LTCH/SNF Quality Reporting Program Submission Deadline: November 15 y Nursing Home Compare Refresh y Influenza Vaccination: Protect Your Patients this Season

Compliance

y DMEPOS: Bill Correctly for Items Provided During Inpatient Stays


y Liver Transplant Claims: Possible Overpayment

Events

y Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5 y Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14 y Success with the Hospice Quality Reporting Program Webinar — November 14


y Billing Instructions for Beneficiaries Enrolled in Medicare Advantage (MA) Plans for Services Covered by Decision Memo CAG-00451N

y Overview of the Repetitive, Scheduled Non-emergent Ambulance Prior Authorization Model — Revised

y What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight — Revised

Multimedia

y Medicare Fraud & Abuse: Prevent, Detect, and Report Web-Based Training Course y Quality Payment Program: MIPS 2019 Web-Based Training Courses






MLN Connects® Special Edition for Thursday, October 31, 2019

Final Payment Rules for HH, ESRD, and DMEPOSHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-10-31-eNews-SE


News

y HHAs: CY 2020 Payment and Policy Changes and CY 2021 Home Infusion Therapy Benefit y ESRD and DMEPOS CY 2020 Final Rule




News

y New Medicare Card: Claim Reject Codes After January 1 y Take Medicare Fraud, Waste and Abuse Fighting Further, Through Innovation y Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier

Compliance

y Proper Coding for Specimen Validity Testing Billed in Combination with Urine Drug Testing


y ICD-10 Vaping Coding Guidance

Events

y Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5 y Clinical Diagnostic Laboratory Test Payment System: Data Reporting Call — November 14


y Updating Calendar Year (CY) 2020 Medicare Diabetes Prevention Program (MDPP) Payment Rates

Multimedia

y CDC Opioids Training Module for Nurses y Quality Payment Program: APMs Web-Based Training













News

y New Medicare Card: MBI Transition Ends in Less Than 10 Weeks y Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use y ICD-10 Coordination and Maintenance: Deadline for Comments November 8 y CMS Health Equity Award: Submit Nomination by November 15 y Quality Payment Program: Participation Status Tool Includes Second Snapshot of Data y Atherectomy: Comparative Billing Report in October y Protect Your Patients from Influenza this Season

Compliance

y Cardiac Device Credits: Medicare Billing

Events

y Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5 y Atherectomy: Comparative Billing Report Webinar — November 6 y Provider Compliance Focus Group Meeting — November 12


y 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

y Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

y Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model

y Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised

y October 2019 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised y October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) — Revised

Publications

y Quality Payment Program: MIPS and APM Resources y Roster Billing for Mass Immunizers — Revised y Acute Care Inpatient Hospital Prospective Payment System — Reminder y Hospice Payment System— Reminder y Hospital Outpatient Prospective Payment System— Reminder y Inpatient Psychiatric Facility Prospective Payment System— Reminder y Inpatient Rehabilitation Facility Prospective Payment System— Reminder y Long-Term Care Hospital Prospective Payment System— Reminder y Telehealth Services — Reminder









News

y New Medicare Card: 80% of Claims Submitted with MBI y Nursing Homes: Enhancing Transparency about Abuse and Neglect y Quality Payment Program: MIPS Dates and Deadlines y October is National Breast Cancer Awareness Month

Compliance

y Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims


y FY 2020 IPPS and LTCH PPS Claims Hold

Events

y Submitting Your Medicare Part A Cost Report Electronically Webcast — November 5


y Ambulance Inflation Factor for Calendar Year (CY) 2020 and Productivity Adjustment y Provider Enrollment Rebuttal Process y Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised

y International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) – January 2020 Update — Revised

y Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2020 — Revised

Publications

y Medicare Preventive Services — Revised y Medicare Enrollment for Providers Who Solely Order or Certify — Reminder y Medicare Fraud & Abuse Poster — Reminder y Medicare Fraud & Abuse: Prevent, Detect, Report — Reminder y Medicare Overpayments — Reminder y PECOS for DMEPOS Suppliers — Reminder y PECOS for Physicians and NPPs — Reminder y PECOS for Provider and Supplier Organizations — Reminder

Multimedia

y Opioid Treatment Program Listening Session: Audio Recording and Transcript






MLN Connects® Special Edition for Wednesday, October 9, 2019

Modernizing and Clarifying the Physician Self-Referral Regulations Proposed RuleHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-10-09-eNews-SE


News

On October 9, CMS issued a proposed rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the “Stark Law”), which has not been significantly updated since it was enacted in 1989. The proposed rule supports the CMS “Patients over Paperwork” initiative by reducing unnecessary regulatory burden on physicians and other health care providers while reinforcing the Stark Law’s goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest. Through the Patients over Paperwork initiative, the proposed rule opens additional avenues for physicians and other health care providers to coordinate the care of the patients they serve – allowing providers across different health care settings to work together to ensure patients receive the highest quality of care.

For More information:

y Proposed Rule: Public comments due by December 31 y Press Release

See the full text of this excerpted CMS Fact Sheet (Issued October 9).





https://www.federalregister.gov/documents/2019/10/17/2019-22028/medicare-program-modernizing-and-clarifying-the-physician-self-referral-regulations

https://www.hhs.gov/about/news/2019/10/09/hhs-proposes-stark-law-anti-kickback-statute-reforms.html

https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule





News

y New Medicare Card: Do You Refer Patients? y Opioid Treatment Programs: Get Ready to Participate in the New Benefit y Home Health Preview Reports for January 2020 Refresh y LTCH Provider Preview Reports: Review Your Data by October 11 y IRF Provider Preview Reports: Review Your Data by October 11 y Hospice Provider Preview Reports: Review Your Data by October 11 y CLFS CY 2020 Preliminary Payment Determinations: Comment by October 27 y MIPS: Virtual Group Election Period Open Through December 31 y LTCH Compare Refresh y IRF Compare Refresh y Qualified Medicare Beneficiary Billing Requirements y Ostomies are Life-Savers y Looking for Educational Materials?

Compliance

y Outpatient Services Payment: Beneficiaries Who Are Inpatients of Other Facilities


y Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020

y January 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

y International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) - January 2020 Update — Revised

Publications

y Quality Payment Program: 2019 APM Incentive Payment Fact Sheet y Billing Information for Rural Providers and Suppliers — Revised

Multimedia

y Reducing Opioid Misuse Listening Session: Audio Recording and Transcript y SNF PPS: Patient Driven Payment Model Videos






MLN Connects® Special Edition for Monday, September 30, 2019

New HCPCS Code J0642 for Levoleucovorin InjectionHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-09-30-eNews-SE


For dates of service on or after October 1, use HCPCS code J0642 for levoleucovorin injection products marketed under the brand name of Khapzory.

MLN Connects® for Thursday, September 26, 2019



News

y New Medicare Card: More Questions about Using the MBI? y Quality Payment Program: Submit Comments on 2020 Proposed Rule by September 27 y SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 y 2019 QRDA I Implementation Guide and Sample File for Hospital Quality Reporting: Updated

y Post-Acute Care and Hospice Utilization and Payment Public Use Files y Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS y Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier y Hospice Quality Reporting Program Quarterly Updates y National Cholesterol Education Month and World Heart Day

Compliance

y DME Proof of Delivery Documentation Requirements


y Medicare Diabetes Prevention Program: Valid Claims

Events

y IRF/LTCH: Reporting Health Care Personnel Influenza Vaccination Data Webinars — October 1, 3, or 9


y Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2020

y October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and










Revisions to Prior Quarterly Pricing Files — Revised y Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – October 2019 Update — Revised

Publications

y Quality Payment Program: Resources for Clinicians New to the Program in 2019 y Medicare Enrollment for Physicians and Other Part B Suppliers — Reminder y Medicare Preventive Services Poster — Reminder y Safeguard Your Identity and Privacy Using PECOS — Reminder

Multimedia

y Quality Payment Program: All-Payer Combination Option in 2019 Web-Based Training Course

y Quality Payment Program Merit-based Incentive Payment System (MIPS): Promoting Interoperability Performance Category in 2019 Web-Based Training Course

y Dementia Care Call: Audio Recording and Transcript y Quality Payment Program for Advanced APMs in 2019 Web-Based Training Course — Revised

y Quality Payment Program Merit-based Incentive Payment System (MIPS): Participation in 2019 Web-Based Training Course — Revised

y Transitioning to an Advanced APM: 2019 Update Web-Based Training Course — Revised

MLN Connects® Special Edition for Thursday, September 26, 2019

Omnibus Burden Reduction & Discharge Planning RulesHTML: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2019-09-26-eNews-SE


News

y Omnibus Burden Reduction (Conditions of Participation) Final Rule y Discharge Planning Rule Supports Interoperability and Patient Preferences









News

y New Medicare Card: Why Use the MBI? y Proposed Opioid Treatment Program Policies: Comment Deadline September 27 y Quality Payment Program: MIPS Targeted Review Request Deadline September 30 y SNF PPS Patient Driven Payment Model Resources: Get Ready for October 1 y Emergency Triage, Treat, and Transport Model: Apply by October 5 y LTCH Provider Preview Reports: Review Your Data by October 11 y IRF Provider Preview Reports: Review Your Data by October 11 y Hospice Provider Preview Reports: Review Your Data by October 11 y Prostate Cancer Awareness Month

Compliance

y Improper Payment for Intensity-Modulated Radiation Therapy Planning Services


y 2019-2020 Influenza (Flu) Resources for Health Care Professionals y Billing for Hospital Part B Inpatient Services

Publications

y Medicare Enrollment for Institutional Providers — Reminder y Medicare Enrollment Resources Educational Tool — Reminder y PECOS FAQs Booklet — Reminder y PECOS Technical Assistance Contact Information Fact Sheet — Reminder




News

y New Medicare Card: Transition Period Ends in Less Than 4 Months y New Enforcement Authorities to Reduce Criminal Behavior in Medicare, Medicaid, and CHIP

y Different-Day Upper and Lower Endoscopy: Comparative Billing Report in September y Hospices: Call for Panel on Assessment Instrument and Quality Measures — Nominations due September 30

y Local Coverage Determination Meetings y Pain Management: CDC Conversation Starters for Patients and Their Doctors










y Healthy Aging® Month: Discuss Preventive Services with your Patients

Compliance

y Bill Correctly for Device Replacement Procedures


y Average Sales Price Files: October 2019

Events

y Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17 y Different-Day Upper and Lower Endoscopy: Comparative Billing Report Webinar — September 24


y Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims y Additional Instructions to Hospitals on the Election of a Medicare-Supplemental Security Income (SSI) Component of the Disproportionate Share (DSH) Payment Adjustment for Cost Reports that Involve SSI Ratios for Fiscal Year (FY) 2004 and Earlier, or SSI Ratios for Hospital Cost-Reporting Periods for Patient Discharges Occurring Before October 1, 2004

y October 2019 Update of the Ambulatory Surgical Center (ACS) Payment System y Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations - Update — Revised

y Medicare Part B Clinical Laboratory Fee Schedule: Revised Information for Laboratories on Collecting and Reporting Data for the Private Payor Rate-Based Payment System — Revised

y 2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments — Revised

Publications

y Medicare Part A Cost Report Electronic Filing y Quality Payment Program: 2019 MIPS Resources y Advance Care Planning — Revised y Medicare Billing: CMS Form CMS-1500 and the 837 Professional — Revised y Medicare Secondary Payer— Revised y Roadmap to Behavioral Health — Updated

Multimedia

y Home Health Call: Audio Recording and Transcript y Radiation Oncology Listening Session: Audio Recording and Transcript y SNF Value-Based Purchasing Call: Audio Recording and Transcript y Medicare Secondary Payer Provisions Web-Based Training Course — Revised y Quality Payment Program for Merit-based Incentive Payment System (MIPS) APMs in 2019 Web-Based Training Course — Revised

y SNF PPS: Patient Driven Payment Model Videos





News

y New Medicare Card: Do You Refer Patients? y IRF Appeals Settlement Option: Deadline September 17 y Quality Payment Program: MIPS Targeted Review Request Deadline September 30 y SNF PPS Patient Driven Payment Model: Get Ready for Implementation on October 1 y PEPPERs for Short-term Acute Care Hospitals y DME QIC Contract Award y Health Care Supply Chain, Provider Self-Care, and Emergency Preparedness Resources y September is Pain Awareness Month

Compliance

y Chiropractic Services: Comply with Medicare Billing Requirements

Events

y Dementia Care: Supporting Comfort and Resident Preferences Call — September 10 y Health Coaching and Wellness Planning for Self-Management Webinar — September 10 y New Medicare Card: Open Door Forum — September 11 y Developing a Hospice Patient Assessment Tool Special Open Door Forum — September 12 y Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17 y CMS Public Meeting: Action Plan to Prevent and Manage Opioid Use Disorder and Substance Use Disorder and Address Pain Management — September 20


y Hurricane Dorian and Medicare Disaster Related State of Florida Claims y Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims

y Hurricane Dorian and Medicare Disaster Related Commonwealth of Puerto Rico Claims y 2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

y Annual Clotting Factor Furnishing Fee Update 2020 y Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season y October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3 y October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) y October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Multimedia

y CMS: Beyond the Policy Podcast: Dispatches from the Blue Button Developers Conference






MLN Connects® for Thursday, August 29, 2019



News

y Promoting Interoperability: 2019 PDMP Bonus Measure y Beneficiary Notices Initiative Mailbox Portal y Promoting Interoperability: 2020 Eligible Hospital eCQM Flows y DMEPOS: Nationwide Expansion of Required PA of Pressure Reducing Support Surfaces

Compliance

y IRF Services: Follow Medicare Billing Requirements

Events

y MIPS Value Pathways RFI Webinar — September 4 y Venipuncture: Comparative Billing Report Webinar — September 5 y Dementia Care: Supporting Comfort and Resident Preferences Call — September 10 y New Medicare Card: Open Door Forum— September 11 y Hospice Outcomes & Patient Evaluation Tool ODF – September 12 y Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17 y Overall Hospital Star Ratings Listening Session - September 19


y New Documentation Requirements for Filing Medicare Cost Reports y Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020

y Claim Status Category and Claim Status Codes Update y Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE

y Home Health (HH) Patient-Driven Groupings Model (PDGM) - Revised and Additional Manual Instructions

y 2020 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments y Healthcare Provider Taxonomy Codes (HPTCs) October 2019 Code set Update y Implementation to Exchange the List of Electronic Medical Documentation Requests (eMDR) for Registered Providers via the Electronic Submission of Medical Documentation (esMD) System — Revised

Publications

y Inpatient Rehabilitation Facility Prospective Payment System Booklet — Revised

Multimedia

y Physician Fee Schedule Listening Session: Audio Recording and Transcript y IRF Appeals Settlement Call: Audio Recording and Transcript y OPPS and ASC Listening Session: Audio Recording and Transcript






y ESRD QIP Call: Audio Recording and Transcript y SNF PPS: Patient Driven Payment Model Videos y Inpatient Rehabilitation Facilities (IRFs): Improving Documentation Positively Impacts CERT Web-Based Training Course — Revised


Contact for: Contact Information:EDI – Electronic Claim Submission; Electronic Remittance Notices

Jurisdiction B CEDI website: https://www.ngscedi.com E-mail: [email protected]

Jurisdiction B CEDI (toll-free): 1.866.311.9184 Mon - Fri, 8:00 a.m. - 6:00 p.m. CT

Paper Claim Submission Address: CGS - Jursidiction B PO Box 20013 Nashville, TN 37202

Provider Customer Service Calls IVR (Interactive Voice Response): 1.877.299.7900 Mon - Fri, 6:00 a.m. - 8:00 p.m. CT; Sat, 6:00 a.m. - 4:00 p.m. CT

Customer Service: 1.866.590.6727 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Hearing Impaired: 1.888.897.7534 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Beneficiary Customer Service Calls Phone: 1.800.Medicare

Written Inquiries Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Claim Reopenings (Adjustments) Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Fax (for underpayments): 1.615.660.5978 Fax (for overpayments): 1.615.782.4508

Telephone requests for Reopenings: 1.866.240.7490 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Claim Status Inquiry Security Access Issues/Password Reset, E-mail: [email protected]

Enrollment Status: 1.866.270.4909

Appeals – Redetermination Requests

Address: CGS - Jurisdiction B PO Box 23070 Nashville, TN 37202

Fax: 1.615.660.5976

Electronic Funds Transfer Address: CGS Attn: EFT-DME PO Box 20013 Nashville, TN 37202

Refunds Address: CGS DME MAC Jurisdiction B PO Box 953479 St. Louis, MO 63195-3479

Overnight or Special Shipping Address: CGS DME MAC Jurisdiction B Two Vantage Way Nashville, TN 37228

DME MAC Jurisdiction B Website Website: https://www.cgsmedicare.com/jb/index.htmlAdvance Determination of Medicare Coverage (ADMC) - Requests

Address: CGS - Jurisdiction B Attn: ADMC PO Box 20007 Nashville, TN 37202

Fax: 1.615.660.5988

Prior Authorization Address: CGS Medical Review - Prior Authorization PO Box 23110 Nashville, TN 37202

Fax: 1.615.660.5992

Supplier Enrollment Address: National Supplier Clearinghouse Palmetto GBA * AG-495 PO Box 100142 Columbia, SC 29202-3142

Phone: 1.866.238.9652

https://www.ngscedi.com

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

Documents

EDITION 15 | WINTER 2020Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH)