The summary of events and newsworthy items for the month of July is provided in 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.
CMS Urged to Reevaluate AUC Program
The Committee on Appropriations submitted a report urging the Centers for Medicare and Medicaid Services (CMS) to reevaluate the long-delayed Appropriate Use Criteria (AUC) Program.
Established in 2014, the AUC Program requires physicians to consult a support system when ordering advanced diagnostic imaging such as MR, CT, or other scans. The program has been repeatedly delayed and within CMS’ 2022 proposed rules, there is an additional delay of the penalty phase to January 1, 2023.
While the members of the Committee on Appropriations admit there is value in physicians consulting AUC and clinical guidelines to support medical decision making, they also highlight the lack of advancement beyond the educational and operations testing phase of the AUC Program.
Members of Congress, within the report, encourage CMS to analyze existing quality improvement programs or payment models and their influence on encouraging appropriate use of advanced diagnostic imaging. Additionally, CMS is being urged to consult stakeholders such as professional medical societies.
The Committee on Appropriations also expressed their concerns over high lung cancer morbidity and mortality rates and believe CMS should promote CT screening while identifying any barriers. Within the report is a request for CMS to compile their own report within 180 days on the implementation of the AUC program to include its challenges and successes.
2022 Proposed Rules Released
The Centers for Medicare and Medicaid Services (CMS) issued the proposed rules for the Medicare Physician Fee Schedule (MPFS) as well as for the Hospital Outpatient Prospective Payment System (HOPPS). Key highlights are outlined below.
MPFS
- CY 2022 Conversion Factor (CF) of $33.5848
- Decrease in many of the Practice Expense (PE) values for specialties
- Clinical labor value and pricing updates
- Clarification on added/extended and removed telehealth list
- E/M changes addressed
- Permanently adopting HCPCS code G2252
- Seeking comments on infection disease codes and ratesetting
- Seeking feedback on PE flexibilities on physician supervision
- Seeking comments regarding use of algorithms and AI technology
HOPPS
- 3% increase to Outpatient Department (OPD) fee schedule
- 2% reduction in CF for hospitals that fail to meet quality reporting requirements
- Utilization of CY 2019 claims data for ratesetting
- Stop and reverse 298 services previously removed from inpatient only (IPO) list
- 23 exceptions of the 2 times rule violation
- Continuation of 340B Drug Payment policy
- Extend pass-through status on 27 drugs and biologicals
- Continue packaging threshold for drug administration < $130
- Continuation of additional payments to designated cancer hospitals
- Creation of low volume APCs for designated clinical, brachytherapy, and new technology
- Updates to requirements for public standard charges and penalties
- RO Model Updates
- Seeking comments on extension of telehealth beyond PHE
- Seeking comments on new HCPCS codes
PA Scope of Practice Expanded
On June 29, 2021, Florida Governor Ron DeSantis signed into law House Bill (HB) 431. Within the law were provisions to increase the number of physician assistants (PAs) a physician can legally supervise from four at any one time to ten. The law also removes the requirement that a PA must notify a patient of the right to see a physician prior to them prescribing or dispensing a prescription. PAs may now also directly bill and receive payment from third-party payers for their services rendered. Additionally, a provision within the newly passed law will allow PAs to supervise medical assistants.
Continuation of Telehealth
Receiving bipartisan support within Congress is the potential of the permanent expansion of virtual care after the end of the public health emergency (PHE). Lawmakers believe they will have the necessary votes to pass legislation this year.
With the declaration of the public health emergency due to the COVID-19 pandemic, many waivers and flexibilities were granted surrounding telehealth medicine which resulted in a dramatic uptick in virtual care. Congress is now working to decide what telehealth coverage policies Medicare will permanently adopt after the expiration of the PHE.
A Senate plan, introduced by Brian Schatz, proposes to preserve may of the current but temporary payment rules Medicare has in place for the duration of the PHE. The plan would end all location-based restrictions, allow patients to originate care from home and let rural health clinics and health centers use telehealth permanently. The plan would also mandate a study on telehealth usage during the COVID-19 pandemic.
While the Senate plan has attracted 59 co-sponsors and commercial payers have already started to offer or broaden coverage for virtual visits, skeptics cite the concern over increased health spending as well as overuse and fraudulent billing. The Congressional Budget Office has emphasized the potential of increased financial burden to payers if there is an increase in payment for virtual care.
If the permanent legislation falls through, lawmakers could decide to move forward on temporary extensions beyond the PHE in an effort to avoid the “telehealth cliff” so beneficiaries do not see immediate roll backs in expanded access while allowing more time for additional data on telehealth usage.
LCD/LCA Updates
WPS
- Complex Drug Administration (A58544)
First Coast
- PET for Oncological Conditions (A58826)
Palmetto
- Billing & Coding Rituximab (A56380)
- Intraoperative Radiation Therapy (A56684)
- Billing & Coding IVIG (A56718)
NGS
- Denosumab (Prolia™, Xgeva™) (A52399)
Noridian
Jurisdiction E
Jurisdiction F
Note Bloat and Clinical Burnout
A recent study indicates clinical progress notes housed within Electronic Health Record (EHR) systems have grown by 60 percent and are 11 percent more redundant, supporting clinical burnout concerns.
A cross-sectional study published in JAMA Network Open, which analyzed 2.7 million clinical progress notes over a decade following the 2009 passage of Health Information Technology for Economic and Clinical Health (HITECH) Act. The research found there was a 60.1 percent increase in the median note length as well as an increase by 10.9 percent in note redundancy.
While templated notes were implemented with the intentions of improving data standardization and prevent clinical burnout, the study found that EHR clinician notes that included a higher proportion of templated or copied text were significantly longer and more redundant. This leads to not only the concern over the value of the patient health record but also the concern that long or repetitive notes may allow important patient information to get lost, leading to the increased potential of clinical and diagnostic errors.
Additional studies have found a multifaceted note to include template redesign to assist clinicians to write shorter, higher quality notes paired with text prompts that encourage independent clinician input and reduce the import of large data fields could help combat note bloat and reduce the amount of repetitive and templated information within the EHR clinician notes.
WPS Issues Phishing Warning
Wisconsin Physician Services (WPS) has released a warning of a phishing email that is circulating posing as the Medicare Administrative Contractor (MAC). The fraudulent email indicates there are funds owned or due as a result of advance/accelerated COVID payments. WPS emphasizes they will never require providers to identify back account information via email and all official email correspondence will always include @wpsic.com
WPS encourages the remittance of funds owed be submitted via their secure portal or via mail to:
WPS GHA
P.O. Box 8550
Madison, WI 53708-8550
ACR Issues New Guidance for Incidental Findings on Lung CT Scans
In early July, the American College of Radiology (ACR) issued updated guidance to assist providers in documenting and reporting incidental findings detected on CT examinations.
As low dose lung CT (LDCT) screening has increased, so has the occurrence of incidentally discovered abnormalities on imaging of the chest and lungs, with an estimated 1.5 million pulmonary nodules identified on thoracic CT scans each year. Disagreements regarding how to manage these findings and low patient follow-up rates have been a bane for radiologists.
The ACR’s Incidental Findings Committee’s CT Chest Subcommittee, comprised of thoracic radiologists and national experts, published a 13-page white paper in the Journal of the American College of Radiology (JACR) outlining a standardized framework for managing recommendations related to incidental findings. According to the document’s abstract, “The recommendations address commonly encountered incidental findings in the lungs and are not intended to be a comprehensive review of all pulmonary incidental findings. The goal is to improve the quality of care by providing guidance on management of incidentally detected thoracic findings.” The recommendations make a distinction between lung nodules and other incidental lung findings. The guidance applies to asymptomatic adults aged 35 years and older who have received imaging for a reason unrelated to the incidental finding.
Several objectives and points of interest are characterized within the document, including the need to develop standardization for recognizing patient features and imaging findings necessary to identify an incidental abnormality, offering a balanced patient risk/benefit assessment for managing such findings, and directing future research through a generalized process that can be applied across practice settings.
To view the white paper in its entirety, please click here.
AMA Approves First Radiology-Specific Artificial Intelligence CPT® Code
In a landmark decision, the American Medical Association (AMA) has approved the first CPT® code specific to a radiology artificial intelligence (AI) application, the group announced on Wednesday, July 7.
Several imaging specialty societies and organizations contributed to the development & creation of this new code, including the American College of Radiology, Radiological Society of North America, American Roentgen Ray Society, and Association of University Radiologists.
The Category III CPT® code pertains specifically to Israeli AI software developer Zebra Medical Vision’s AI1™️ tool used to perform automated analysis of vertebral compression fractures, an early sign of osteoporosis. In a statement on their website, Zebra-Med said of the code’s creation, “This is an important step in proper risk-adjustment of populations towards widespread preventative care, and a game changer in the long-term management of this terrible disease.”
Roughly 50% of women and almost a quarter of men over age 50 will suffer an osteoporotic fracture, costing the U.S. healthcare system around $52 billion each year, according to the National Osteoporosis Foundation.
The new code, 0691T, was released on July 1, with an effective date of Jan. 1, 2022. Creation of a Category III CPT® code does not guarantee or imply reimbursement, so it is important to review local payer policy with regard to this new code.
For more information about the Category III codes released earlier this month, please visit the following link.
CMS Opens NCD into Amyloid PET Scans
The Centers for Medicare and Medicaid Services’ (CMS) recent approval of Aduhelm for the treatment of Alzheimer’s disease has been followed by requests for coverage of amyloid positron emission tomography (PET) scans.
In response to the Food and Drug Administration’s (FDA) recent approval of Biogen’s monoclonal antibody treatment for Alzheimer’s, imaging advocates are calling on CMS to mandate beta-amyloid PET results to qualify for Aduhlem. In response, CMS is opening a National Coverage Determination (NCD) into amyloid PET’s role in guiding treatment decision making.
The Society of Nuclear Medicine & Molecular Imaging (SNMMI) and the Medical Imaging & Technology Alliance have pressed CMS to revise it coverage and payment policies restricting access to amyloid PET and are urging the mandate of amyloid results to qualify for Aduhelm.
CMS is seeking public comment until August 11, 2021. They are specifically interested in comments that include scientific evidence that address a set of five specific questions.
PHE Extended
Effective July 20,2021, the Public Health Emergency (PHE) has been renewed for an additional 90 days. This most recent renewal will extend the declared PHE, including waivers and flexibilities in place, through October 18, 2021.