Industry News, December 2021

2022 MPFS & RO Model Updates

On December 10, 2021, the President signed into law the Protecting Medicare and American Farmers from Sequester Cuts Act. This Congressional action directly affects the 2022 Medicare Physician Fee Schedule (MPFS) payment rates and the Radiation Oncology (RO) Model.

In regard to services paid under MPFS, the Act increased the 2021 conversion factor (CF) by 3 percent which is used to set the CF for 2022 from what was previously finalized. Additionally, the Act continued the suspension of the 2 percent sequestration adjustment through March 31, 2022. Beginning on April 1 through June 30, 2022, a 1 percent adjustment will be applied to all payments. Starting July 1, the 2 percent sequestration adjustment will be applied to all payments. To account for the continuation of the sequestration suspension, CMS will adjust the 2030 fiscal year (FY) sequestration for the first six months to 2.25 percent and the final 6 months to 3 percent.

The PAYGO 4 percent adjustment, which was to be applied beginning January 1, 2022, is suspended until January 1, 2023, if needed. This will be an additional decrease to any other sequestration per service as paid by CMS.

After several delays, CMS finalized the start of the RO Model for January 1, 2022. However, the law signed on December 10, overrode the 2022 finalized rules and further delayed the implementation of the RO Model to January 1, 2023.

New Telemedicine Modifier OK’d

The CPT® Editorial Panel accepted a new Modifier during their September 2021 Meeting. The new modifier will be utilized to describe real-time telemedicine services between a patient and a physician or other qualified health care professional.

The use of Modifier 93 will be effective January 1, 2022 and will be applied to indicate the utilization of synchronous telemedicine services rendered via telephone or other real-time interactive audio-only telecommunications system.

Per the American Medical Association (AMA) “Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified healthcare professional and a patient who is located away at a distant site from the physician or other qualified health care professional.

Additionally, the AMA stresses “The totality of the communication of information exchanged between a physician or other qualified healthcare professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.”

Suits Pile up Against Surprise-Billing Provision

In addition to those already filed, the American Medical Association (AMA) and the American Hospital Association (AHA) have filed a lawsuit in opposition to the No Surprises Act’s  interim final rule.

Citing support for the effort of reducing surprise-billing for out-of-network services, the AMA and AHA believe the departments of Health and Human Services, Treasury and Labor are failing to implement the original intent of the law. The two lobbying groups, which represent physicians and hospitals, are the country’s largest and argue the law clearly favors health insurers and therefore will reduce patients’ access to care.

Legal action was sparked when  health insurer Blue Cross Blue Shield of North Carolina started issuing a letter to physicians indicating a change in their contracting approach and cited existing contracted  reimbursements for certain services they considered “inflated” for certain providers. The letter indicates a reduction in contracted rates is warranted and if unable to reach an agreement a termination of contract is planned.

In addition to actions already taken, the American College of Radiology (ACR) is investigating several different avenues to work on revising the dispute resolution section of the rule. ARC is working with House representatives on a letter to urge key agencies to fix the legislation, they have also not ruled out the possibility of filing or joining a lawsuit.

Palmetto Emphasizes Documentation Compliance

Palmetto GBA has released several reminders and educational material regarding documentation and compliance.

Palmetto GBA emphasizes the importance of submitting complete documentation to ensure proper and timely reimbursement. Palmetto points out, Centers for Medicare and Medicaid Services (CMS) utilize several review contractors who measure, prevent and identify improper payments by manually reviewing claims against submitted medical documentation. These contractors include Palmetto GBA, Comprehensive Error Rate Testing Contractors (CERT), Recovery Auditor Contractor (RA) and Unified Program Integrity Contractors (UPIC), ensure documentation submitted aligns with reimbursement of services.

Palmetto also recently outlined the most common issues that lead to incorrect coding and resulted in CERT error which indicates the documentation submitted for review does not match the codes billed for the claim. Among the most common issues were:

·         Incomplete notes ·         Care that was provided but not documented
·         Missing test results ·         Post-operative complications not documented
·         Documentation not completed timely ·         Illegible documentation
·         Inconsistent documentation


Top tips to prevent these errors include:

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure are coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of doubled sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation.

CMS Program Integrity Manual Update

CMS has made extensive updates to Chapter 3 –Amendments, Corrections and Delayed Entries in Medical Documentation. In part to include:

“Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service.”

A review of all updates is highly recommended as the updates outline the proper record keeping principles for Amendments, Corrections and Delayed Entries in Medical Documentation.

MFN Model Officially Rescinded

On December 29, 2021, CMS published the final rule rescinding the Most Favored Nation (MFN) Model interim final rule.

In November 2020, the MFN Model interim final rule was released, outlining a seven-year mandatory model to evaluate an alternative payment model for Medicare Part B single source drugs and biologicals. The MFN Model was slated to begin January 1, 2021, but was delayed after four lawsuits, resulted in a nationwide preliminary injunction. After evaluating stakeholders concerns regarding the model start date and after multiple courts identified procedural issues with the November 2020 interim final rule, a proposal to rescind the MFN Model rule was included in the August 2021 proposed rule.

As with all proposed rulings, the August 2021 proposed rule requested public comment on the proposed recension of the MFN Model. Thirty-four comments were submitted from health care providers, physician specialty groups, drug manufacturers, pharmaceutical industry groups, pharmacy benefit managers, patient advocacy groups and individuals during the allotted comment period. Generally speaking, the comments trended with general support for lowering drug prices, but most did not support implementing the MFN Model.  Additional comments included concern regarding the projected financial impact data, citing concerns that the estimated savings would be directly related to reduced access of care.

After reviewing all information and comments, CMS officially rescinded the MFN Model interim final rule effective February 28, 2022.

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 and in other cases, represent current issues encountered by Revenue Cycle Coding Strategies professionals.

Question: Can the sim orders and clinical treatment plan note (77263) be combined as a hyrbrid? Or do we need to have two separate documents. One for sim order and one for the clinical treatment plan until the final ARIA Rx is created?

Advice: The simulation orders can be housed within the clinical treatment planning note. To meet the requirements of the clinical treatment planning note (77261-77263) the physician must complete a document that should include: therapeutic technique, special considerations, such as previous treatment, tests reviewed, and other treatment modalities, such as chemotherapy or surgery. This document should reflect the physician’s overall plan for treatment and is an appropriate place to also include things such as the physician’s intent for treatment, orders, the treatment area, the goals and dose constraints as well as the medical necessity for the treatment course chosen. This is not the same as the prescription which would be completed later after planning is complete and include details for the dose and fractionation.

Question: Is there a code that we can use for a treatment planning MRI for SRS patients? We are having issues with insurance companies because we are using the same code for the MRI with screening for mets and then when we need to do the treatment planning MRI

Advice: If an MRI is obtained for treatment planning, the appropriate code is 76498-TC, an unlisted code. There is no dedicated MRI treatment planning code at this time. As an unlisted code many payers will not reimburse or recognize. You can work to appeal the denial and submit your definition of the code, your documentation and rate assigned (similar to other work with similar rate) and see if they will accept.

Question: One or our patients had an allergic reaction to Eligard, therefore cannot continue with this Hormone drug.  Our MD is asking if the patient can be financially cleared for the drug Relugovix.  The patient is insured by Medicare A & B which normally does not require auth for drugs.  Do you know if we would get paid by MC if we administered this drug to this patient?  This is an oral medication & therefore may not need to be administered in the office.  Do you know if we can get it pre-approved with proof of medical necessity or if that is not an option?

Advice: There are no LCDs or NCDs specific to the use of Relugovix. It likely falls under Medicare Part D, which does not appear to cover it. You will likely have to work with Novitas directly for this scenario or in event of denial (1- 877-235-8073). There is also a link on the drug site for assistance for pts on Medicare Part D @ or 1-877-674-6899.