The summary of events and newsworthy items for the month of December 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.
Consolidated Appropriations Act, 2021 Affects Oncology and Radiology
The recent signing of the Consolidated Appropriations Act, 2021, which includes the COVID-relief package, will prove to have a significant impact on oncology and radiology. Along with changes to the Radiation Oncology (RO) APM Model timeline, there will also be significant changes to reimbursement under the Medicare Physician Fee Schedule (MPFS). The Consolidated Appropriations Act, 2021 can be found in its entirety here.
RO APM Model
As part of the COVID-relief package found within the Consolidated Appropriations Act, 2021, is an additional delay of the RO APM Model. As part of the response to the COVID-19 pandemic and stakeholder feedback, the implementation of the RO Model had already been delayed once from its initial January 1, 2021 start date to July 1, 2021. However, the new Appropriations Act has now set the start date back to no sooner than January 1, 2022. Additional information, updates, and resources on the RO APM Model cab be found on CMS’ dedicated website.
MPFS Reimbursement Changes
The publication of the 2021 finalized Medicare Physician Fee Schedule (MPFS) rules on December 1, 2020, brought significant reimbursement cuts for many specialties. To ease the financial impact of the 2021 ruling, the COVID-relief package outlined certain reimbursement changes under MPFS. There will be a delay in reimbursement for the new add-on HCPCS code G2211 for complex services at the time of evaluation and management until January 1, 2024. Additionally, there will be an extension of the suspension of the 2% sequestration through March 31, 2021, and the extension of the 1.000 work RVU geographic index floor through January 1, 2024.
As a result of these changes to MPFS reimbursements outlined in the Consolidated Appropriations Act, 2021, radiation oncology will see a 1% increase in overall reimbursement rather than the 5% decrease. Hematology/oncology will see a 13% overall increase in reimbursement as opposed to the 14% increase. Radiology will see a reduction in the planned cuts from a 10% decrease to now an approximate 4% decrease in reimbursement.
77295 Bundled Denials UPDATE
A 2019 report issued by the Office of Inspector General (OIG) concluded that the Centers for Medicare and Medicaid (CMS) could have saved a significant amount of money if services were bundled into CPT® code 77295 3D radiotherapy plan in a similar manner as services bundled into CPT® 77301 IMRT treatment plan. While CMS agreed with the OIG report, they did not release any official billing changes or bundling of codes into 77295. However, many Medicare Administrative Contractors (MACs) used the OIG report as an opportunity to begin denying simulation codes 77280, 77285, and 77290 as well as continuing medical physics services, 77336, when billed with 3D treatment planning code 77295.
Many specialty societies, including ASTRO worked to address these denials. As a result, the National Correct Coding Initiative (NCCI) has issued a notice regarding the previously implemented procedure-to-procedure (PTP) edits between 3D planning code 77295 and simulation codes 77280, 77285, 77290 and continuing physics code 77336. The PTP edit between the planning code and simulation codes will deleted, retroactive to January 1, 2020. Meaning the simulation codes are now considered billable on the same date of service as the 3D planning code 77295 and the denials seen because of this PTP were incorrectly denied when billed on the same date of service for CY 2020. Additionally, the PTP edit between 77295 and 77336 will remain but there will be an opportunity to append a modifier as supported and appropriate.
CY 2021 Final Rule Rundown
Below is a quick rundown of highlights of the CY 2021 final rules. More in-depth summaries of the rules can be located in Client Resource Center (CRC), under the Client Resources tab in the Resources section. Additionally, it is recommended to review the MPFS and HOPPS final rules in their entirety. Keeping in mind some of the information has been affected by the Consolidated Appropriations Act, 2021 as outlined previously.
The Evaluation and Management (E/M) guideline overhaul will go into effect January 1, 2021. Some major changes include the following:
- Deletion of code 99201
- Creation of HCPCS code G2211- Payment for this code is delayed until January 1, 2024
- Creation of CPT® add-on prolonged services code 99417
- Creation of HCPCS add-on prolonged services code G2212
Within the final rules, CMS addressed misvalued and/or proposed value changes to new and established CPT® codes. The following is a list of some pertinent codes addressed by CMS in the final rule:
- Fine Needle Aspiration (CPT® codes 10004-10012 and 10021)
- Lung Biopsy-CT Guidance Bundle (CPT® code 32408)
- Medical Physics Dose Evaluation (CPT® code 76145)
- Radiation Treatment Delivery (CPT® 77401)
- Proton Beam Treatment Delivery (CPT® codes 77520, 77522, 77523, 77525)
CMS also addressed telehealth services after the end of the public health emergency (PHE) declared as a result of the COVID-19 pandemic.
- Category 3 level services will remain on the telehealth list through the calendar year in which the PHE for COVID-19 ends
- 77427, Radiation treatment management, 5 treatments will end as a telehealth service 1/21/21
- Permanent update to the telehealth services technology requirements definition; removing verbiage that previously prohibited telephones as an acceptable form of technology
- Telephone Codes (99441-99443) will not be recognized or reimbursed at the end of the PHE; instead, newly created G-codes (G2250 and G2251) should be utilized outside of the PHE
- Extension of the definition of direct supervision to include the use of real-time audio and video technology to end in later in the calendar year in which the PHE ends or 12.31.21
Some notable payment rate information under the Outpatient Department (OPD) fee schedule is listed below.
- Increase in payments rates by 2.4 percent to the conversion factor (CF)
- 2% reduction to the CF for hospitals that fail to meet the OQR Program requirements
- Frontier state hospitals will continue to see a 1.000 wage index
- Adjustment of wage indexes for IPPS and OPPS/ASC based on the Office of Management Budget (OMB) with a 5% cap on wage index decrease
- Relative payment weight of 1.00 assigned to APC 5012; the geometric mean cost of each APC will be divided by geometric mean cost of APC 5012 to derive the unscaled relative payment weight for each APC
- Effective 2021, CMS will include all claims for cost-to-charge reporting, even those utilizing “square feet”
CMS also finalized changes to Ambulatory Payment Classifications (APCs). CMS made 23 exceptions to the 2 times rule for CY 2021. CMS also addressed some APC assignment changes, those of note are listed below.
- Nuclear Medicine Services: Single-Photon Emission Computed Tomography (SPECT) Studies will remain in APC 5593 and not be moved to APC 5592 as proposed
- Payment for Radioisotopes Derived From Non-Highly Enriched Uranium (non-HEU) Sources will be paid an additional $10 per dose for doses of radioisotopes (like Tc99m) certified to be at least 95 percent produced form non-HEU sources
- Remote Physiological Monitoring will see some modifications in 2021 with a few codes being elevated to billable to MACS with payment being at their discretion
For CY 2021, CMS finalized reimbursement for drugs, biologicals and radiopharmaceuticals. The following is a brief highlight addressing some of those reimbursements.
- CMS will continue to package drugs and biologicals estimated at a per day administration cost less than or equal to $130
- CMS will continue to make separate payments for items with an estimated per day cost of more than $130 with the exception of: diagnostic radiopharmaceuticals, contrast agents, anesthesia drugs, drugs, biologicals and radiopharmaceuticals that function as supplies
- CMS will continue to base packaging determinations on a drug-specific basis rather than by HCPCS code
- CMS will continue to pay non-pass-through biosimilars acquired under the 340B Program at ASP minus 22.5% of the reference product’s ASP
- 15 drugs and biologicals were removed from the pass-through list
- CAR T-cell HCPCS codes can be reported for tracking purposes
- Blood clotting factors will continue to be reimbursed at ASP+6 with updated furnishing fee
- HCPCS P9099 will be separately reimbursed with SI of “R”
- Starting CY 2021, NSEDTS supervision level changed to general for the entire service
Novitas Revise Multiple Policies
Novitas has revised the following LCDs and LCAs:
- BRACA1 and BRCA2 Genetic Testing (L36715)
- Billing and Coding: BRACA1 and BRACA2 Genetic Testing (A56542)
- Billing and Coding: Hydration Therapy (A56634)
- Biomarkers for Oncology (L35396)
- Billing and Coding: Biomarkers for Oncology (A52986)
Advice: Billing both a verification simulation (77280) and IGRT code 77387 is allowable on the same date of service for non-IMRT treatments if the verification simulation and IGRT are separate and distinct procedures. The verification simulation would include checking blocking and verifying other parameters and would need to be performed and completed separate from the IGRT. If the IGRT is part of the verification simulation process, then only billing of the verification simulation (77280) would be allowable.