Avoid Rejected Claims for HCPCS Invoices
The Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, chapter 17, Drugs and Biologicals 20.1.3, Exceptions to Average Sales Price (ASP) Payment Methodology: gives Medicare Administrative Contractors (MACs) discretion to use Wholesale Acquisition Cost (WAC) or invoice pricing when CMS does not provide a limit on the ASP file.
Several MACs direct you to proactively enter the invoice information for certain contractor-priced codes on submitted claims. For these payers, when the claim does not contain information about the invoice or cost associated with specifically outlined codes, the claim will be rejected back for correction.
When reporting the invoice amount for the patient and service, it is imperative to report the amount from the invoice that is applicable for that patient and service on the claim. The retail amount or amount charged for the service is not to be reported, only the invoice amount.
The continually updated list of excepted ASP HCPCS codes that are to be submitted with invoice information includes contrast, drug, radiopharmaceutical, skin substitute, and blood product codes. It is recommended to review your specific MAC instructions and monitor the list of HCPCS codes requiring invoice data to be submitted as listed codes are continually modified. If your MAC is not linked below, instructions were not readily available, it may be advantageous to reach out to a representative to request guidelines.
New US NCCI Edits
Both the October 2022 MPFS (Medicare Physician Fee Schedule) and OPPS (Hospital Outpatient Prospective System) National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edit updates contained a surprise for the radiology coding community.
Previous to the fourth quarter updates, abdominal ultrasound (76700-76705) and retroperitoneal ultrasound (76770-76775) codes could technically be reported together without a modifier as there was no NCCI PTP edit in place. However, after the release of the most recent updates, there is a code pair edit in place between the two procedures when performed during the same encounter or on the same date of service. The modifier indicator for these code pairs was revised to “1,” which indicates a modifier is allowed to bypass the edit when appropriate.
Beginning October 1, if both of these studies are performed and documented, a modifier (either -59, XE, XP, XS, or XU) will be required on the column 2 code – the retroperitoneal ultrasound code. However, specific scenarios in which both a retroperitoneal and abdominal ultrasound would be reported are rare, and both exams should only be reported when the physician order and medical necessity supports both exams, and payer policy allows both to be reported with the appropriate modifier.
Federal Judge Halts 340B Reimbursement Cuts
In a recent ruling, a federal judge has ordered the Department of Health and Human Services (HHS) to immediately halt its average sales price (ASP) minus 22.5% payment cuts to hospitals in the 340B program.
The order denies HHS’s intent to delay reinstatement of full outpatient drug payment rates to 340B hospitals until January 1, 2023, and invalidates the drug reimbursement rate for 340B hospitals as indicated the 2022 Outpatient Prospective Payment System (OPPS) Final Rule.
Judge Rudolph Conteras, with the U.S. District Court for the District of Columbia, said, “HHS should not be allowed to continue its unlawful 340B reimbursements for the remainder of the year just because it promises to fix the problem later.”
As a result, CMS will revert to paying the default (generally ASP plus 6%) to 340B-aquired drugs for the rest of the year. Additionally, CMS will reprocess claims paid on or after September 28, 2022, using the default rate.
In the American Hospital Association v. Becerra, the U.S. Supreme Court previously ruled the 340B cuts for 2018 and 2019 were illegal but had not ruled on 2020 and beyond.
PHE Extended Through January 2023
On October 13, 2022, the public health emergency (PHE) was renewed once again. As part of the continued response to the COVID-19 pandemic, the PHE and included waivers and flexibilities will be renewed for an additional 90 days. The PHE will now be extended to January 13, 2023.
American College of Radiology Releases Updates to Appropriateness Criteria®
On October 4, the American College of Radiology (ACR) released updates to its ACR Appropriateness Criteria® (ACR AC). The ACR AC includes 222 diagnostic imaging and interventional radiology topics, with this update addressing one new and eight revised topics, all of which include a narrative, evidence table, and literature search summary.
The new topic involves non-cerebral systemic arterial embolic source workup. Revised topics include central venous access device and site selection, chronic hip and shoulder pain, lung cancer screening, right upper quadrant pain, and more.
The ACR AC was originally introduced in 1993 and guidelines are reviewed and updated annually.
“The use of ACR Appropriateness Criteria® for guidance can enable consistent medical imaging and interventional radiology care for all patients,” said Mark E. Lockhart, MD, MPH, Chair of the ACR Committee on Appropriateness Criteria. “By applying the information in these documents, providers can enhance and maintain quality of care and contribute to the most effective use of these lifesaving and life-improving exams and procedures.”
Act Increases Payments for Biosimilars
In accordance with section 11403 of the Inflation reduction Act, the Centers for Medicare and Medicaid Services (CMS) is implementing a temporary increase in payment for qualifying biosimilars.
Traditionally, CMS reimbursed biosimilars at a rate of the average sales price (ASP) plus an add-on of 6%. The ASP is calculated based on manufacturer’s sales to all U.S. purchasers minus manufacturer rebates, discounts, and price concessions. Under the newly implemented Inflation Reduction Act, CMS will pay qualifying biosimilars at the product’s ASP plus 8% for a 5-year period. In a press release the stated goal of the temporary increase of the add-on payment is to increase access to biosimilars, as well as encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.
Public payment files for biosimilars in the hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) are now available as well as the October Medicare Part B Drug Average Sales Price, which reflects the increased amount for qualifying biosimilar biological products.
ACR, ACEP, ASA File Joint Amicus Brief Over No Surprises Act Dispute Resolution Process Suit
The American College of Radiology (ACR) has joined with the American College of Emergency Physicians (ACEP) and the American Society of Anesthesiologists (ASA) in taking legal action to resolve an outstanding issue with the No Surprises Act.
On October 19, the groups filed a joint amicus brief with a federal court in Texas offering support of a new lawsuit filed by the Texas Medical Association against HHS, et al, on October 12. This new suit takes issue with the independent dispute resolution (IDR) process laid out in the Surprise Billing Final Rule published in August. The lawsuit asserts that the IDR is non-compliant with the No Surprises Act statutory text.
The three groups will also dismiss their previous lawsuit, filed in the U.S. Court for the Northern District of Illinois, as the interim final IDR rule is no longer applicable.
“Insurers are using the new law to raise profits by initiating reductions in contracted fee schedules and narrowing medical networks, which denies patients their choice of providers and can delay diagnosis and treatment of illness and injury,” the ACR, ASA, and ACEP said in a press release.
The groups will continue to “work to protect patient access to care and stop insurer profit grab at patient and provider expense.”
Trial for Contrast-Enhanced Mammography Beings
The American College of Radiology (ACR), along with the Breast Cancer Research Foundation (BCRF) and GE Healthcare, is planning to begin the Contrast-Enhanced Mammography Imaging Screening Trial (CMIST).
The trial will assist physicians in establishing whether contrast-enhanced mammography (CEM) can decrease false-positives and boost breast cancer detection in patients with dense breasts as compared to digital breast tomosynthesis (DBT).
Detection of breast cancer can be more difficult in patients with dense breasts, which occur in roughly 43 percent of women aged 40 to 72. CEM uses intravenous contrast in addition to a standard digital mammogram. Contrast material can enhance cancers that may not be visible on standard mammography or tomosynthesis.
“In the fight against breast cancer, unfortunately it is all too common for women with dense breasts to face an agonizing wait for answers,” General Manager for Mammography at GE Healthcare Catherine Lezy said. “We know that CEM technology can be a game-changer in helping improve breast cancer outcomes.”
“Through CMIST, we hope to gain increased understanding of the potential role of contrast mammography for women with dense breasts with the goal of developing more individualized breast imaging strategies,” said Etta Pisano, MD, FACR, American College of Radiology Chief Research Officer.