Changes to Medicare Physician Fee Schedule Rates

On Friday December 20, 2019 the President singed the Further Consolidated Appropriations Act of 2020 (FCAA), which per some of the Medicare Administrative Contractors (MACs) updates the CY 2020 MPFS rates. As of this date CMS has not issued any correction notice to the MPFS rates; however, review of the rates updated by Wisconsin Physician Services (WPS) reflects updates to rates.

The full bill can be reviewed at https://www.congress.gov/116/bills/hr1865/BILLS-116hr1865enr.pdf

Some of the Medicare Provisions included in FCAA include:

  • Extension of Work GPCI (Geographic Practice Cost Index) Index Floor through May 23, 2020.
    • This was not extended per the final rule released on November 1, 2019 but is being extended for part of the year. This will result in an adjustment to rates for most locales. Since work is tied to the physician component, this means the professional components of codes or codes specifically physician work, will be updated if the work GPCI for a specific location is less than 1.000 starting 1/1/20.
  • Extension of Pass-through Status for Certain Drugs. CMS added the following: 
    • ‘‘(J) ADDITIONAL PASS-THROUGH EXTENSION AND SPECIAL PAYMENT ADJUSTMENT RULE FOR CERTAIN DIAGNOSTIC RADIOPHARMACEUTICALS.—In the case of a drug or biological furnished in the context of a clinical study on diagnostic imaging tests approved under a coverage with evidence development determination whose period of passthrough status under this paragraph concluded on December 31, 2018, and for which payment under this subsection was packaged into a payment for a covered OPD service (or group of services) furnished beginning January 1, 2019, the Secretary shall—
      • ‘‘(i) extend such pass-through status for such drug or biological for the 9-month period beginning on January 1, 2020;
      • ‘‘(ii) remove, during such period, the packaged costs of such drug or biological (as determined by the Secretary) from the payment amount under this subsection for the covered OPD service (or group of services) with which it is packaged; and
      • ‘‘(iii) not make any adjustments to payment amounts under this subsection for a covered OPD service (or group of services) for which no costs were removed under clause (ii).’’
  • Allocation of monies specific for fighting fraud and abuse
    • Among several of the provisions, $786 million dollars is to remain available through September 30, 2021 of which $610 million is for CMS program integrity activities. Of this amount, $93 million is allocated for the Office of Inspector General (OIG) to carry out fraud and abuse activities and $83 million for use by Department of Justice (DOJ) to also carry out fraud and abuse activities.

As the full files for payments are released by CMS, updates will be provided as necessary and appropriate.

Sweeping Changes to many Local Coverage Determinations (LCD)

In compliance with the Centers for Medicare and Medicaid’s change request (CR) 10901, Medicare Administrative Contractors (MACs) have been revising many local coverage determinations (LCDs). According to CMS the changes implemented in CR 10901 will “…help to increase transparency, clarity, consistency, reduce provider burden and enhance public relations while retaining the ability to be responsive to local clinical and coverage policy concerns.” MACs are revising LCDs to remove all billing and coding language and all language not related to reasonable and necessary provisions and placing them in newly created billing and coding local determination articles (LCAs). Within the newly created billing and coding articles, ICD-10-CM diagnosis code ranges are broken out and listed individually. Some of the LCDs which have seen revisions and newly created articles are outlined below.

First Coast Service Options

First Coast has made revisions to their Proton Beam Radiotherapy LCD in addition to the creation of a billing and coding article, several diagnosis codes were removed from the “ICD-10 Codes that Support Medical Necessity/Group 1 Codes” section. There were also diagnosis codes added to Group 2 codes that support medical necessity and many added to the section requiring dual diagnosis to meet medical necessity.

  • Proton Beam Radiotherapy LCD (L33937) 
  • Biling and Coding: Proton Beam Radiotherapy (A57669)

Additional First Coast LCDs revised with newly associated biling and coding articles include: Mohs Microsurgery LCD and associated LCA, Infliximab LCD and associated LCA, and Intravenous Immune Globulin (IVIG) LCD and associated LCA.  

  • Mohs Micrographic Surgery (MMS) (L33689)
  • Biling and Coding: Proton Beam Radiotherapy (MMS) (A57669)
  • Infliximab (L33704)
  • Billing and Coding: Infliximab (A57653)
  • Intravenous Immune Globulin (L34007)
  • Biling and Coding: Intravenous Immune Globulin (A57778)

NGS has made removed all billing and coding language in their Proton Beam Therapy LCD and has moved it to the newly created article; Billing and Coding: Proton Beam Therapy. NGS has done the same to their Drugs and Biologicals, Coverage of, for Label and Off-Label Uses LCD with revisions to the LCA Billing and Coding: Drugs and Biologicals.

  • Proton Beam Radiotherapy LCD (L35075) 
  • Biling and Coding: Proton Beam Radiotherapy (A56827)
  • Drugs and Biologicals, Coverage of, for Labell and Off-Label Uses (L33394)
  • Billing and Coding: Drugs and Biologicals (A52855)

Palmetto GBA

Palmetto removed all billing and coding language from their Rituximab LCD and placed it in the newly created Billing and Coding: Rituximab article which has a January 1, 2020 effective date.

  • Rituximab (L35026)
  • Biling and Coding: Rituximab (A56380)

 Updates to Medicare Claims Processing Manual

There have been updates to Medicare Claims Processing Manual, Chapters 1, 23, and 35. The changes include new sections on global billing and separate Technical Component (TC) and Professional Component (PC) billing instructions. As outlined in MLN Matters (MM10882) Article, global billing is acceptable if both of the TC and PC aspects are furnished in different locations as long as they are within the same MPFS payment locality. When reporting a global diagnostic test code, providers should report the name, address and national Provider Identifier (NPI) of the location where the TC was furnished. Chapter 1, Sections 80.3.2.1.2 and 80.3.2.1.3 have more information regarding the proper reporting of Items 32 and 32a.

When reporting TC and PC separately the location where each component was performed should be reported by the providers along with the name, address, and NPI of the location where the component was performed. The billing provider/supplier may report their own name, address and NPI in Items 32 and 32a if the billing provider has an enrolled practice location at the address where the service was performed with the exception if the service was performed out of jurisdiction and is subject to the anti-markup or reference lab service. Chapter 1, Section 30.2.9 has further information regarding anti-markup and more information regarding reference lab can be found in Chapter 16, Section 40.1 of the Medicare Claims processing Manual.

 Transition to Medicare Beneficiary Identifier (MBI) for claims submission

December 23, 2019 – According the Centers for Medicare and Medicaid Services (CMS) Weekly Digest Bulletin, Medicare providers are required to submit claims for beneficiaries using Medicare Beneficiary Identifier (MBI) cards starting January 1, 2020. The MBI cards will identify beneficiaries without the use of social security numbers (SSNs), which offers better identity protection. This change in identification was a result of a mandate set forth by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) for CMS to remove social security numbers from all Medicare cards by April 2019. CMS replaced the SSN based Health Insurance Claim Numbers (HICNs) with randomly generated MBI. With a few exceptions, both electronic and paper claims without MBI numbers will receive:

  • 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
  • Paper claims notices: 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”

For more information on how to receive and use MBI for payment of Medicare claims, see

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

December Coding Corner

Within this section, current topics will be the focus.  In some cases, the Q&A could reflect common questions received by Revenue Cycle Coding Strategies Inc. and in other cases, represent current issues encountered by Revenue Cycle Coding Strategies Inc. professionals.

Question: For the supervision change Jan 2020 what does this actually mean? For instance. If we have a breast treatment that we are billing tx delivery 77412 and imaging 77387 and pro charge G6017. Can we start treating these breast patients or patients with imaging without MD onsite?

Advice: With the change of supervision requirements starting January 1, 2020 from direct supervision to general supervision for therapeutic services, the physician’s work is still necessary and required for billing professionally. Physician supervision of staff is not the same as physician work. While the changes in the supervision of the staff allows for the physician to be anywhere, the components of the physician’s work are required to be provided at the location where the services take place (address on the claim form). If there is no physician on-site, then no professional charge is billed.

Question:  Regarding Prostate Seed Implants. We were previously told to charge for the number of seeds ordered… for example, we ordered 41 seeds but used 39… is this appropriate? or should we only charge for the seeds inserted into the patient?

Advice:  Yes, Medicare instructs to bill for what was ordered for the patient in Chapter 4 Medicare Claims Processing Manual.