Industry News, April 2021

The summary of events and newsworthy items for the month of April is provided on the following pages.  In most instances, the link to the full document of information is provided.  Any of the contents may be further discussed by reaching out to Revenue Cycle Coding Strategies LLC.

Public Health Emergency (PHE) Renewed

Effective April 21, 2021, the Secretary of Health and Human Services renewed the public health emergency (PHE) as a result of the continued consequences of the COVID-19 pandemic. The PHE was initially declared January 31, 2020, and had been previously renewed on April 21, 2020, July 23, 2020, October 2, 2020, and January 7, 2021. The most recent renewal will extend the PHE for an additional 90 days which would make the next end date at approximately July 20, 2021. To review the renewal, click on the link:  PHE Extension Apr 15 2021.

2% Sequestration Suspended Through December

The Medicare sequestration is a 2% payment adjustment applied to all Fee-for-Service (FFS) claims that was suspended as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act in an effort to ease the financial burden of physicians and facilities caused by the COVID-19 pandemic. The CARES Act placed a moratorium of the 2% payment cut from May 1, 2020, through December 31, 2020. The consolidated Appropriations Act, 2021, extended the suspension of the sequestration until March 31, 2021. Due to Easter break, the vote on the Act to Prevent Across-the-Board Direct Spending Cuts, and for Other Purposes, which would extend the moratorium, was delayed until mid-April. In anticipation of the Act passing and, in an attempt, to reduce confusion and claims reprocessing, The Centers for Medicare and Medicaid Services (CMS) suspended the processing of claims starting April 1, 2021, until the Act was voted on. On April 14, 2021, the Act was passed by Congress and signed into Law by the President. It is now expected Medicare Administrative Contractors (MACs) will release any previously held claims with the date of service on or after April 1 or reprocess any claims paid with the reduction applied. The new Law extends the 2% sequestration moratorium through December 31, 2021. To review the newsletter, click here.  To review the bill, click here.

Medically Unlikely Edits (MUEs) Denials for Drugs

Medicare Administrative Contractor (MAC) Palmetto GBA sent out a reminder if providers are receiving Medically Unlikely Edits (MUEs) denials for drugs to determine if the appropriate number of units were in fact billed.  MUEs for drugs are typically based on the package inserts for the drugs from the manufacturer.  If a provider receives a drug MUE denial Palmetto GBA recommended checking the following items:

  • Verify that charges are being entered correctly by reviewing the medical records and noting the dosage listed in the code description
  • Ensure that the unit conversion factors are correct for the drug description
  • Determine if there is a medically necessary reason to exceed the recommended dosage
  • Contact your Medicare contractor if you believe an MUE is unreasonable by emailing The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) mailbox at
  • Ensure that the correct modifiers are being used
    • The JW HCPCS modifier is required for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. Providers are required to document the discarded drug or biological in the patient’s medical record. The JW HCPCS modifier is only applied to the amount of the drug or biological that is discarded

Following the above steps does not guarantee no MUE denials; however, if a MUE denial is received Palmetto GBA instructs providers to file an appeal with documentation to support the reason the drug was administered.  Documentation should also include physician orders, dosage and amount given, amount of drug waste and any other necessary documentation to support the number of units billed and medical necessity. 

Novitas No Longer Requiring Invoices for some HCPCS Codes

Novitas, implementing a new process in an attempt to reduce provider burden, no longer requires a paper invoice for certain contractor priced HCPCS codes. Instead of submitting paper invoices for the established HCPCs codes, narrative information will need to be included in item 19 of the CMS-1500 claim form. Providers will be required to include: (1) invoice dollar amount and quantity, (2) name of drug or biological, (3) dosage of medication or size of biological administered and (4) route of administration.  Additional instructions and a comprehensive list of applicable HCPCs codes can be found on the Novitas website.

NGS Administration Codes Billed with No Drugs

The MAC, NGS, has noted that recently there has been a trend of only billing administration codes for drugs whose costs are not covered. For example, when a patient purchases the drug and the physician administers it, the cost of the drug is not covered but the services or supplies for the drug administration is reimbursable.  The administration of a drug or biological, regardless of the source is a service that represents an expense to the physician and would be considered reimbursable if the drug would have been covered.  Instead of only billing for the administration code, NGS directs to bill the drug with a $0.00 fee to inform them if the drug would have been considered payable or covered.

Additionally, NGS directs, when billing a not otherwise classified drug such as J3490, J3590, or J9999, you must provide the name and dose of the drug on the claim comment screen or item 19 for claims billed on CMS-1500.  It is of note, NGS makes it clear this is not necessary when billing for the COVID-19 vaccine and hospital settings are exempt from this Part B instruction.

In order to avoid denials, these billing instructions will be a requirement effective for June 1, 2021 regardless of the date of service. After this date, claims billed with an administration code and no drug will be denied. 

Permanent Telehealth Expansion Discussions Continue

The House Committee on Energy and Commerce’s Subcommittee on Health invited health care industry witnesses to comment on the impact of telehealth and to respond to lawmakers’ questions to try to better understand the role telehealth should play in the Medicare program after the pandemic. The hearing on “The Future of Telehealth: How COVID-19 is Changing the Delivery of Virtual Care” aimed to better understand the potential benefits, pitfalls, and hurdles permanently expanding telehealth could bring.

The hearing solidified bipartisan support from both health care industry witnesses and representatives in extending access to telehealth after the public health emergency (PHE) ends; however, it still remains unclear how this will be achieved.  The hearing produced disagreement on how the reimbursement of telehealth services should be structured and if audio-only telehealth should remain an option after the PHE. This tied into discussions regarding equitable access to telehealth, citing the potential for expanded telehealth’s ability to address health care disparities but also addressing the potential for the most vulnerable populations being left behind due to cost, digital literacy, broadband access and other barriers. Even with these hurdles, there was fervent support for the expansive opportunity for mental and behavioral health care.

Discussions also centered around limitations of physician licensure rules and potential expansion, how to determine which specialties or services should be accessible via telehealth and the care, and coordination challenges telehealth expansion could pose.

During the hearing concerns of the convenience of telehealth services leading to potential overutilization were raised. This was incorporated into the discussion of the need to transition away from the Medicare fee-for-service payment model and toward a value-based payment model. Discussions emphasized that reimbursement based on value could discourage overutilization.

Legislation in the News

North Dakota Governor recently signed Senate Bill (SB) 2122 into law, permitting physical therapists to order musculoskeletal imaging. Physical therapists will now be able to order plain film radiographs if they have a clinical doctorate degree in physical therapy or if they have completed a board-approved formal medical imaging training program. While the physical therapists may now order the imaging, it is required to be interpreted by a licensed physician trained in radiology interpretation.