Activation of Validation Edits – Industry News, August 2023

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Providers with Multiple Service Locations See Activation of Validation Edits

After being delayed multiple years and completing five rounds of testing, the Centers for Medicare and Medicaid Services (CMS) will begin deploying validation edits for providers with multiple service locations beginning August 1, 2023.

There are an increasing number of hospitals which operate off-campus, outpatient, provider-based departments of the hospital. Since there is the possibility for these additional locations to be in a different payment locality than the main provider, CMS uses the service facility address of the off-campus, outpatient, provider-based department to determine the locality. CMS also requires non-excepted services provided at these locations to be identified, so that the payment rate for non-excepted items and services billed are paid under the Medicare physician fee schedule (MPFS), and not the outpatient prospective payment system (OPPS).

Medicare will validate service facility locations to ensure services are being provided in a Medicare-enrolled location. Validation of claims submission will be exact matching based on the information on the CMS-855A form submitted by the provider and entered into PECOS. Claims data must match PECOS data.

Medicare Administrative Contractors (MACs) were tasked with developing implementation plans to permanently implement the six reason codes and ensure claims that do not exactly match are returned to provider (RTP). Some MACs have set up different implementation timelines, please visit your MACs website for further information.

IMRT Pre-Payment Review Results

Palmetto GBA has published their pre-payment review results for intensity modulated radiotherapy (IMRT) for targeted probe and educate (TPE).

The Centers for Medicare and Medicaid Services (CMS) implemented a TPE for CPT® code 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications) for North Carolina, South Carolina, Virginia and West Virginia.

The review included 689 claims, with 61 claims being denied, totaling $119,364.73 in denials. The highest percentage of total denials (59%) were attributed to no documentation of medical necessity. The recommended protocol not being ordered and/or followed accounted for the second highest percentage (29%) of denials. The untimeliness of submission of requested records accounted for the lowest percentage (12%) of denials.

Palmetto provides the following guidance:

To avoid denials on the basis of no documentation of medical necessity:

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed
    • A physician/NPP is managing the care of the covered indication or condition
    • Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the service
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necess[i]ty
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

To avoid denials based on the recommended protocol not ordered and/or followed:

    • Clear physician/radiation oncologist orders for radiation treatment course, including specific anatomical target volumes, treatment technique, current dosage, type of radiation measuring and monitoring devices to be used and treatment fields
    • Relevant medical history documented prior to the DOS and signed by the physician/radiation oncologist or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis being treated and medical necessity of the services
    • Supporting reports such as dosimetry, physicist, simulation, oncology and radiology
    • Documentation of design and construction of Multi-Leaf Collimator
    • Detailed itemized bill and supporting documentation of all billed services
    • Documentation of treatment plan, including goals, treatment notes, specific dose constraints for the target and administration
  • Ensure the service was provided per the coverage guidelines for the service

Additional information can be found on Palmetto’s website.

Gold Card Act Looking to Exempt Prior Auth Requirements

The bipartisan GOLD CARD Act of 2023 will exempt qualifying providers from Medicare Advantage prior authorization requirements on a federal level, as already enacted in multiple states.

Prior authorizations are a way for insurers to monitor and control the utilization of healthcare services. However, the practice of prior authorizations has been plagued with issues including delays in patient care, burdensome reporting requirements and questionable denial practices, to name a few.

In a 2021 analysis, JAMA Health Forum concluded radiation oncology (97%), cardiology (93%) and diagnostic radiology (91%) face the highest rate of services subjected to prior authorizations. Provider prior authorization exemptions, as outlined in the bill, would be for physicians who had at least 90% of prior authorization requests approved the prior year. Exemptions could be revoked by Medicare Advantage plans if a provider falls below the 90% threshold.

The bill is supported by many provider groups representing radiologists, orthopedic surgeons, emergency physicians, dermatologists, neurological surgeons, and ophthalmologists.

“Year after year, medical practices identify prior authorization requirements as the most challenging and burdensome obstacle to delivering high-quality patient care,” Anders Gilberg, senior VP of government affairs for the MGMA.

UHC Eliminating a Slew of Prior Authorizations

Effective September 1, 2023, UnitedHealthcare (UHC) is eliminating prior authorization requirements for its Medicare Advantage, commercial, Oxford and individual exchange plans. Effective November 1, 2023, prior authorization requirements will change for UnitedHealthcare Community Plans.

UnitedHealthcare, the nation’s largest commercial insurer, announced the total reductions across all specialties represent approximately 20% of overall procedural volumes. UHC emphasizes that while they will remove some codes across benefit plans, there will be differences. UHC encourages you to consult the list that aligns with each specific benefit plan. Some impacted services under commercial plans include breast MRI with contrast, bone marrow imaging, gastroesophageal reflux studies and cardiac shut detection. There is also a slew of genetic testing codes, echocardiography codes, and several physical and occupational therapies codes according to the published list.

“While prior authorization remains an important tool to address clinical quality and safety, as well as fraud, waste and abuse, we also know that fewer prior authorizations can help streamline care delivery.”
 – UnitedHealthcare

ASTRO Joins Radiology Health Equity Coalition

The American Society of Radiologic Technologists (ASRT) has recently joined the American College of Radiology’s (ACR) Radiology Health Equity Coalition as part of the mobilization team, to define goals and develop future initiates.

The Coalition was established in 2022 and is comprised of 11 organizations with the goal of positively impacting health care equity in radiology by addressing systemic changes to health inequalities for underserved populations and communities. The Radiology Health Equity Coalition provides extensive resources to the radiology community, include access to the recordings of their webinar series, a library of resources, and opportunities to become involved.

ACR’s Coalition currently includes the American Board of Radiology, American College of Radiology, American Medical Association Section Council on Radiology, Association of University Radiologists, National Medical Association Section on Radiology and Radiation Oncology, Radiological Society of North America, Society of Chairs of Academic Radiology Departments, Society of Interventional Radiologists, Society of Nuclear Medicine and Molecular Imaging, American Association of Physicists in Medicine, American Society of Radiologic Technologists and other specialty and state Radiology organizations already joining the initiative.

Y-90 Radioembolizations Can Pose Exposure Risk to Medical Personnel

According to a study published on August 16 in the Journal of Nuclear Medicine Technology, contamination during yttrium-90 (Y-90) radioembolization procedures can lead to high levels of exposure, surpassing yearly recommended occupation exposure limits within seconds.

Through computer simulated situations, researchers calculated the radiation doses to medical personnel from various contamination scenarios. The results of the calculated simulations showed the annual radiation dose limit to the skin and lens of the eye was exceeded within 23 seconds of direct exposure to a droplet containing 18 gigabecquerel (GBq) of radioactivity. A separate simulation found the attenuation properties of a gown and surgical gloves provided some protection to exposure, but the exposure dose was still considerable, surpassing the yearly occupational limit within 1 minute. The research group stated, “Personal protective equipment such as surgical gloves and gowns must not be relied on as a means of shielding since they provide only partial attenuation of the radiation from direct contamination.” The resulting recommendations include wearing double layers of surgical gloves and level 3 gowns, which provided some attenuation by reducing the dose rate by 39% and 44%, respectively. Researchers concluded two layers of surgical gloves offered the best ratio of radiation protection without compromising dexterity.

Researchers encourage interventional radiology and nuclear medicine personnel to be mindful of the risks, to follow strategies to prevent spills, and be familiar with decontamination procedures for spills.

ACR Doesn’t Want PET Decisions in the Hands of MACs

The American College of Radiology (ACR) is urging the Centers for Medicare and Medicaid Services (CMS) to reconsider their proposal to leave positron emission tomography (PET) reimbursement at the discretion of local Medicare Administrative Contractors (MACs).

In July, CMS proposed removing the national coverage determination (NCD) which limits patients to one amyloid-detecting PET scan in their lifetime. Within the proposal, CMS outlines their intentions of turning over determinations to the MACs. ACR would instead like to see a national coverage ruling to thwart any possibility of coverage variances across geographic locations, inequality to access, and delays in imaging. The ACR, led by CEO William T. Thorwarth Jr., MD, believes there is sufficient evidence to enact  a nationwide reimbursement or beta-amyloid. PET. ACR encourages CMS to ensure payment of beta-amyloid PET for both the initial diagnostic evaluation of cognitive decline, such as Alzheimer’s as well as the follow-up PET to gauge the therapies’ effectiveness.

Within their comment letter to CMS, the ACR acknowledged MACs’ experience in PET scans for non-oncologic indications but raised concerns of potential delay in coverage decisions by the MACs. Commenting on CMS’ proposal is now closed. A final decision is anticipated in October.

New POS Code

The Place of Service Committee has created a new place of service (POS) code to identify Outreach Site/Street. The new place of service code 27 will be effective October 1, 2023, with implementation January 2, 2024.

The Outreach Site/Street is defined as: A non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventative, screening, diagnostic and/or treatment services to unsheltered homeless individuals.

Further information can be found within the instruction to the Medicare Administrative Contractors (MACs).