The summary of events and newsworthy items for the month of February 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.

Additional E/M Guidance Issued by CMS

The Centers for Medicare and Medicaid Services (CMS) have recently released a Physician Fee schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits Fact Sheet. The fact sheet focuses on the proper use of the add-on code for prolonged visits, HCPCS code G2212. The fact sheet also outlines the delayed reimbursement for HCPCS add-on code G2211 describing visit complexity inherent to office/outpatient E/M visits. While the reimbursement for code G2211 has been delayed until January 1, 2024 or later, the fact sheet states practitioners may report the code for qualifying visits furnished on or after January 1, 2021.   While the code can now be reported when appropriate, it has a payment status indicator of “B” which indicates a bundled service and will not receive separate reimbursement until 2024.

SNMMI Confirms Cerianna Reimbursement Error & CMS Correction Notice for HOPPS

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) confirmed that the Centers for Medicare and Medicaid Services (CMS) has acknowledged the inaccurate publication of the reimbursement rate for Cerianna radiopharmaceutical in January.  Cerianna is a radiolabeled F-18 fluoroestradiol radiotracer indicated for use as an adjunct to biopsy with PET for detection of estrogen receptor-positive lesions in patients with recurrent or metastatic breast cancer. The rate for the radiopharmaceutical was original published in the Hospital Outpatient Prospective Payment System (HOPPS) in January 2021 as $0.75 per millicurie. The correct rate of $626.58 per millicurie is now published by CMS and will be retroactive to January 1, 2021.

Within the correction notice, CMS indicated there were several other errors identified which have been corrected.  Many of these errors were typographical, but there were several HCPCS codes with incorrect status indicators listed. For example, HCPCS codes for brief communication technology-based services (G2010, G2012, G2011) have been corrected to status indicator “B”, which means they are not paid under HOPPS as these are physician service codes recognized under the Medicare Physician Fee Schedule (MPFS).  CMS released a correction notice on their website with the updates.

ASTRO Actions 

ASTRO Continues to Push for RO Model Reforms 

The American Society for Radiation Oncology (ASTRO) is utilizing the delay in the Radiation Oncology Alternative Payment Model (RO Model) implementation to push for key revisions to the model. The delay of implementation to no earlier than January 1, 2022, allowed ASTRO additional time to submit a comment letter to CMS in response to the 2021 Hospital Outpatient Prospective Payment System (HOPPS) final rule.  Within the comment letter, ASTRO encourages changes in the form of discount factor reductions and a change in the quality reporting requirements. ASTRO also pushes for greater transparency associated with the data files and payment methodologies used to formulate the model citing concerning issues with significant fluctuations and subsequent impact on fee-for-service payments when corrections documents are released.

ASTRO Urges Maintenance of Radiopharmaceutical Requirements 

In a collaboration ASTRO, The American College of Radiology (ACR), the American Association of Physicists (AAPM), and the Society of Nuclear Medicine and Molecular Imaging (SNMMI), sent a letter to the U.S Nuclear Regulatory Commission (NRC) emphasizing the importance of maintaining the current training and experience requirement for radiopharmaceuticals. Highlighting the report language in the 2021 House Energy and Water Development and Related Agencies Appropriations Bill to counter the January 2020 NRC staff recommendations to the Commission that would weaken the currently established Training and Experience (T&E) requirements for radiopharmaceuticals. The letter stressed the importance of maintaining the status quo to ensure the safety of patients, the public, and practitioners.    

LCD & LCA Updates

A multitude of relevant Local Coverage Determinations (LCDs) and Articles (LCAs) have been updated across various Medicare Administrative Contractors (MACs). Please see below for the most up to date versions.

Novitas Solutions 

  • Billing and Coding: Biomarkers for Oncology LCA (A52986)
  • Billing and Coding: Multiple Imaging in Oncology LCA (A56848)

First Coast Service Options

Wisconsin Physicians Services Insurance Corporation (WPS)

  • Billing and Coding: Complex Drug Administration Coding LCA (A58544)

Palmetto GBA

  • Billing and Coding: Intraoperative Radiation Therapy (IORT) LCA (A56684)
  • Billing and Coding: Complex Drug Administration LCA (A58527)
  • Billing and Coding: IDTFs and Low Dose CT Scan for Lung Cancer Screening LCA (A58641)
    • RETIRED Billing and Coding: IDTFs and Low Dose CT Scan for Lung Cancer Screening LCA (A55816)

CMS Encourages BLS Survey Participation

The U.S. Bureau of Labor Statistics (BLS) conducts numerous surveys of hospitals and health care providers but have noted that recently, there has been a decline survey participation. BLS’ surveys are utilized by CMS, The Federal Reserve Bank, and the U.S. Congress and survey responses are used to make economic decisions that affect the medical care system. Specifically, CMS uses the survey to adjust the Medicare Fee-for-Service payments each year. While survey participation is voluntary, participation can increase the validity of the data as it has the potential to affect approximately $300 billion in payments. A reduction in responses reduces the representativeness of data and increase the volatility in estimates. For the most accurate data, CMS urges participation in the confidential surveys. More information regarding BLS surveys can be found below.

Letter to Congress Urging Extension of Sequestration Moratorium

As part of the Consolidated Appropriations Act of 2021 Congress had extended the moratorium on the 2 percent sequestration which had been initiated as part of the Interim Final Rules for Covid-19 in March and April 2020.  At that time, the moratorium on the sequestration was to end on 12/31/20; however, due to the law signed on December 27, 2020 it was delayed until second quarter 2021 (April 1, 2021). 

The sequestration is the 2 percent Medicare discount applied to every CPT®/HCPCS code.  Rather than Medicare paying 80 percent and the beneficiary or secondary insurance paying the remining 20 percent, Medicare only pays 78 percent.  The additional 2 percent is not made up by the beneficiary or secondary insurance.  As a response to many providers still feeling the impact of closures, decreased services, and overall financial impact due to Covid-19, the American Medical Association and American College of Radiology, among others, have submitted a letter to Congress urging them to extend the moratorium on the 2 percent sequestration which is scheduled to begin on April 1, 2021.