Industry News, June 2020

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

Public Health Emergency Extension of Waivers

On January 31, 2020 Secretary Alex Azar, Health and Human Services (HHS), declared a public health emergency (PHE). Per the PHE declaration, “A PHE declaration lasts until the Secretary declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist, and may terminate the declaration whenever he determines that the PHE has ceased to exist.”

The original expiration of the PHE, if not extended, was set to be April 30, 2020; however, on April 21, 2020 CMS did extend the PHE which went into effect April 26, 2020.With this extension the PHE is set to expire on July 25, 2020. Several specialty organizations have written CMS requesting an extension of the PHE stating most providers are simply not ready to revert to “life as we knew it”prior to March 1, 2020 when the waivers and expansions went into effect.*

*UPDATE** Michael R. Caputo, HHS Assistant Secretary for Public Affairs,posted a statement on Twitter late on June 29, 2020, that there is indication the PHE will be extended. Caputo tweeted, “Enough already. @HHSGov expects to renew the PublicHealth Emergency due to COVID-19 before it expires. We have already renewed the PHE once. Learn more here:”. As of the writing of this update the website does not yet reflectthe officialrenewal of the PHE.

CMS Announces Hardship Relief for 2020 Merit-Based Incentive Program

CMS announced physicians will have the option to opt-out completely or partially from the 2020 Merit-Based Incentive Program (MIPS).In order to do this a hardship exemption must be completed and indicate the hardship is due to the COVID-19 Public Health Emergency (PHE) Individuals and groups will have until December 31, 2020 to compete the application.
Physicians or groups filing hardship exemptions will have a few options for the 2020 performance year:1) the practice can indicate they wish to not be scored on Cost and Quality,score only calculated based on re-weighting of Promoting Interoperability and Improvement Activities or 2) opt-out of all four performance categories and be held harmless for the 2022 payment adjustment.
There will be an impact to physicians and/or groups opting out of MIPS. With a smaller pool of participants to pull monies from, the money allocated or available for payments to those that met or exceeded reporting will be reduced. The expected payouts projected originally by CMS will be much less
The American Medical Association (AMA) in a post on their website indicated they will be monitoring the impact COVID-19 has on physicians and practices and continue to work with CMS “to ensure CMS liberally grants hardship requests due to the COVID-19 PHE”.
CMS put together a fact sheet which outlines the changes in response to COVID-19 here.

July 2020 Update to Hopital Outpatient Prospective Payment System (OPPS)

On June 5, 2020 The Centers for Medicare and Medicaid Services (CMS) released MLN Matters:MM11814 which outlines the changes to various payment policies and related billing instructions implemented in the July 2020 OPPS update.The article outlines the status indicator changes for certain virtual services reflecting the interim final rule changes implemented as a response to the COVID-19 Public Health Emergency(PHE). The status indictor changes signal reimbursement for additional virtual services including those related to telephone assessment and management services, remote evaluation of a prerecorded video or image anda virtual check-in.The status indicator and other changes for OPPS are reflected in Table 2. Tables 3 and 4 reflect changes for rural health clinics (RHC) or federally qualified health centers (FQHC) only.

Also included in the update are the CPT® Category III Codes that go into effect July 1, 2020. CMS will implement twenty-five(25)Category III codes released by the American Medical Association (AMA) in January 2020 for July 1, 2020 implementation. Table 5 in the article reflects the status indicators and APC assignments for the codes.

Additionally, effective July 1, 2020, are CPT® Proprietary Laboratory Analyses (PLA) Coding Changes. Five (5) PLA codes have been deleted by the AMA CPT® Editorial Panel, specifically CPT® codes 0124U through 0128U while thirty (30) new PLA codes have been established. Table 6 within the update outline the deleted codes as well as the newly created codes.

In the hospital outpatient setting, eleven (11) new HCPCS codes have been created for reporting drugs and biologicals where there have not previously been specific codes available. The newly listed drugs and biologicals will receive drug pass-through status starting July 1, 2020. The codes are listed on Table 10, embedded in the article. Table 11 is reflective of the currently existing HCPCS codes receiving pass-through status beginning July 1, 2020.Forty-two (42) other CY 2020 HCPCS and CPT® code changes for certain drugs, biologicals and radiopharmaceuticals effective starting July 1, 2020 are reflected in Table 19..

WPS encourages IVIG Review

Wisconsin Physicians Service (WPS) is encouraging entities that bill for Intravenous Immunoglobulin Therapy (IVIG) to review Local Coverage Article: Billing and Coding: Immune Globulins (A57554).CMS identified a potential vulnerability in the WPS GHA jurisdictions;it is being recommended a review of and adherence to the guidance in the local coverage article in order to receive paymentfor IVIG services.

Audit Set for Advanced Care Planning Services

Medicare has been paying for Advanced Care Planning (ACP), the face-to-face discussion between a Medicare physician and patient to review the patient’s wishes for health care if he or she becomes unable to make decisions, since 2016. ACP is a valuable service that allows Medicare beneficiaries to make important decisions to have control over the type of care they receive and when they receive it. However, previous reviews conducted have shown improper payments due to lack of clinical documentation to support face-to-face services, time spent discussing ACP, or both. The Office of Inspector General plans on performing a nationwide audit to determine whether Medicare providers complied with Federal regulations when billing for ACP services. The expected issued date for the report is FY 2021.

FDA Approves an In-home Breast Cancer Treatment

On June 29, 2020 theUS Food and Drug Administration (FDA) approved a combinationof pertuzumab (Perjeta, Genentech/Roche), trastuzumab (Herceptin, Genentech/Roche),and hyaluronidase (Phesgo, Genentech/Roche) administered subcutaneously, rather than intravenously(IV), for treatment of early and metastatic HER2-positive breast cancers.

The administration would take only 8 minutes for the initial dose and approximately 5 minutes for maintenance doses according to Genetech. Currently the IV dose takes approximately 150 minutes for the combined pertuzumab and trastuzumab dose and 60-150 minutesfor the maintenancedose by infusion.

According to Genetech “the new product uses a drug delivery technology (Enhanze, Halozyme Therapeutics) that employs a proprietary enzyme that temporarily degrades hyaluronan, a glycosaminogly can or chain of natural sugars in the body, to facilitate the dispersion and absorption of injected therapeutic drugs”.

While several are touting the transition of administering this chemotherapy regimen in the patient’s home, not everyone is on board. Some oppose the administration of chemotherapy, cancer immunotherapy, and cancer treatmentsupportive drugsdue to serious safety concerns for patients.

June 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: Patient was receiving Avastin -her insurance changed at beginning of the year and UHC required use of Mvasi instead -Avastin was given 3x -are we able to “down code” and bill Mvasi?

Advice: Medical coding should reflect services rendered and be supported by clinical documentation. If Avastin was given that is what one would code for. To “down code” to a different drug (albeit a biosimilar to Avastin) could give a misleading appearance from anaudit perspective. I would encourage working with the payer to see if an appeal is a viable option at this point.

Question: Can we charge an intermediate sim for a bilateral breast (each breast with its own iso and tx plan) count?

Answer: If the simulation does not meet any of the requirements to elevate the level of simulation to complex (use of contrast, creation of complex immobilization device, etc.), since the breasts are two separate areas of malignancy, then 77285, intermediate simulation could be supported as documented and appropriate.