Industry News, June 2021

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

UHC Changes Prior Auth Tool

United Healthcare Responds to Stakeholder Pushback on Burdensome Prior Authorization Tool; Makes Changes

After receiving pushback from The American College of Radiology® (ACR®), the American Society for Radiation Oncology (ASTRO) and the Association of Community Cancer Centers, United Healthcare (UHC) has updated its radiation therapy prior authorization tool.

After UHC launched the prior authorization and notification tool on April 1, 2021, providers experienced issues with the utilization and burdensome process of the tool which spurred the action of multiple associations to work to persuade UHC to make modifications to the tool.

After feedback, UHC removed techniques that were not relevant for specific tumor types and clinical scenarios to decrease confusion and burden for practice staff who are entering the required information.  UHC will continually develop ways to allow the selection of multiple CPT® delivery codes as a standard process, where appropriate. UHC states they will continue to make changes to refine the platform in order to meet the needs of radiation oncology practices and their members.

Additional Information

Needed Information for UHC Prior Authorization Tool:

  • Tumor Stage
  • Treatment Site
  • Radiation Dose Prescribed
  • Number of Fractions

UHC Radiation Therapy Prior Authorization Tool Support

CMS Urged to Eliminate Lung CA Screening Barriers

CMS is being urged to eliminate payment barriers to lung cancer screening by the American College of Radiology® (ACR®), Society of Thoracic Surgeons, and GO2 Foundation for Lung Cancer.

The Centers for Medicare and Medicaid Services (CMS) initiated a National Coverage Analysis to evaluate the possibility of expanding coverage of low-dose CT exams for lung cancer screening. The Analysis was launched in response to revised guidance from the U.S. Preventative Services Task Force (USPSTF) which recommended dropping the eligible age from 55 down to 50 for the screening.

While lowering the eligible age is a positive recommendation, the joint societies are urging CMS to further expand coverage to beneficiaries.  Current guidelines limit eligibility of the low-dose CT screening to current smokers or those who have quit smoking within 15 years. The societies disagree with this criteria and state there is no substantive data that supports the reduction in lung cancer risk following a 15-year quit date.  Additionally, the societies expressed “substantial concerns” that counselling and shared decision-making proposed criteria could pose a “major barrier” to lung cancer screening and are urging the eradication of that provision as well.


What: Complying with Medicare Signature Requirements            When: March 2021

What’s Changed: Information added about signing documentation written by a medical student (below)

Do I need to re-document a medical student’s documentation of an Evaluation & Management (E/M) visit before I sign the record?

If you rely on the medical student’s documentation, it’s unnecessary to re-document the E/M service, but you must review and verify (sign and date) the student’s medical record entry.

OIG Investigates Accuracy of POS Codes for Part A Inpatients

The Office of Inspector General (OIG) has announced a new work plan entitled Accuracy of Place-of-Service Codes on Claims for Medicare Part B Physician Services When Beneficiaries Are Inpatients Under Part A.

When a patient stays at inpatient facilities such as skilled nursing facilities (SNFs) and hospitals, typically Medicare will make payments under Part B for physicians and payments under Part A for the costs associated with the inpatient stay.  The amount Medicare reimburses physician service providers can vary based on where (i.e., SNF, hospital, or physician’s office) the service is rendered. There are three categories that affect physician services reimbursement: practice expense, physician work, and malpractice insurance. The practice expense is aimed to compensate for the overhead costs involved in providing a service. Typically, physicians incur a higher practice expense by performing services in their offices and other non-facility settings, therefore Medicare generally reimburses physicians at a higher rate compared to services performed in a facility setting as the prospective payment system payment to the facility will cover the overhead expense.

To ensure that Medicare properly reimburses the physician at either the facility or non-facility rate, a two-digit place-of-service (POS) code is appended to the physicians Medicare claim.  When a physician provides services to a registered inpatient beneficiary, the physician services should always be coded with a facility place-of-service code and therefore paid at the facility rate, regardless of where the patient receives the face-to-face encounter.

The OIG’s preliminary data analysis of claims from 2018 and 2019 indicate that Medicare may have paid a significant number of Part B physician service claim lines at the non-facility rate when the beneficiary was a Part A inpatient. The work plan intends to determine whether Medicare appropriately paid claims for Part B physician services based on the correct place-of-service code when a beneficiary was a registered inpatient. The expected issue date of the report is FY 2022.

LCD/LCA Updates

·         Billing and Coding: Complex Drug Administration Coding (A58620)
·         Billing and Coding: Rituximab, biosimilars and Rituximab and hyaluronidase human (Rituxan Hysela™) (A52452)
·         Billing and Coding: Cardiovascular Nuclear Medicine (A56743)


Palmetto GBA
·         Billing and Coding: Rituximab (A56380)


2019 QPP Performance Information Now Available

The Centers for Medicare & Medicaid Services (CMS) provides a public report of Quality Payment Program (QPP) performance information for doctors, clinicians, groups, and Accountable Care Organizations (ACOs) on the Medicare Care Compare website and in the Provider Data Catalog (PDC).

CMS is required to report Merit-based Incentive Payment System (MIPS) eligible clinicians’ Final Scores, MIPS eligible clinicians’ performance under each MIPS performance category, names of eligible clinicians in Advanced Alternative Payment Models (APMs) and, to the extent feasible, the name and performance of such Advanced APMs. The performance information for doctors and clinicians is displayed using measure-level star ratings, percent performance scores, and checkmarks.

The Medicare Care Compare website can be used by Medicare patients to search for and compare doctors, clinicians, and groups who are enrolled in Medicare.

The following is the published 2019 QPP performance information:

·         2019 QPP Presentation ·         2019 ACO Performance Info
·         2019 QPP Info on Care Compare Fact Sheet ·         2019 Dr. & Clinicians Star Ratings Fact Sheet
·         2019 Clinician Performance Info ·         2019 Clinician & Group Star Rating Cut-offs
·         2019 Group Performance Info ·         2019 Dr. & Clinician Measures and Activities


NGS Provides Reminder on Amending Records

National Government Services (NGS) provides a beneficial reminder on the correct way to amend medical records within their Comprehensive Error Rate Testing (CERT) Index.

This publication addresses how to make amendments, corrections and delayed entries in documentation as well as outlines proper recordkeeping principles. The article emphasizes that all services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered but provides the correct way to amend, correct or enter documentation after rendering the service when documenting in either paper medical records or electronic health records.

ACR®, SBI Update Recommendations for Breast Screening

The American College of Radiology® and the Society for Breast Imaging released updated guidance for breast cancer screening.

On June 18, the American College of Radiology® and the Society for Breast Imaging released updated guidance for breast cancer screening. The updated recommendation states women at average risk should begin receiving annual mammograms at age 40, with particular focus on populations where disparities in care exist, such as women of color.

The guidance, published in the Journal of the American College of Radiology (JACR), is based on widespread data from randomized controlled trials and peer-reviewed literature.

“With this guideline, we offer recommendations more inclusive of all women of average risk for breast cancer,” the study authors wrote, adding that postponing the age to begin screening “will result in unnecessary loss of life to breast cancer and will disadvantage minority women in particular.”

To review the study in its entirety, please click here.

Be In the Know

Newly published guidance from CMS and MACs

  • MLN Matters article (MM12177) released regarding National Coverage Determination (NCD 110.24):Chimeric Antigen Receptor (CAR) T-cell Therapy. This article is for physicians, hospitals, other providers, and suppliers billing MACs for CAR T-cell therapy services provided to Medicare patients.

Change request (CR) 12177 rescinds and fully replaces CR 11783 [MM12134]

  • MLN Matters article (MM12280) released regarding National Coverage Determination (NCD 210.3)- Screening for Colorectal Cancer (CRC)- Blood-Based Biomarker Tests. This article is for physicians and providers who bill MACs for CRC screening tests provided to Medicare patients.
  • First Coast Service Options has published information on how to avoid Medicare as the secondary payer (MSP) claim rejects. Some of the guidance provided includes MSP web-based training, FAQs, and an MSP billing tool.

Changes to NCCI Edits

Changes to edits allow for CT (77014) and Isodose Planning (77306, 77307, 77316, 77317, 77318) to be billed on the same date as 3D plan (77295) with a modifier applied.

The edits related to CPT® 77295 previously did not allow for the services listed in Column 2 (77014, 77306, 77307, 77316, 77317, 77318) to be billed on same dates as the 3D planning code.  With the updates to the NCCI edits, the codes can be billed on the same date as 77295, with use of a modifier.  The changes are retroactive to January 1, 2020, with a deletion date listed as December 31, 2019.  In review of the new edits for January 1, 2021, the edit was still in place to not allow the services of 77014, 77306, 77307, 77316, 77317, or 77318 to be billed on same date as 77295.

These edit revisions are in addition to the earlier changes that were made between 3D planning code 77295 and simulation codes 77280-77290, which went into effect January 1, 2021 and were retroactive to January 1, 2020. The edits between 3D planning code and simulation codes were deleted and the code pairs can now be billed on the same date of service without the need for a modifier.  Keeping in mind the edit deletion is only between 3D planning code 77295 and simulation codes 77280-77290. The edits remain between simulation codes 77280 and 77290; in that only one simulation code is billable per date of service with the exception of some BID brachytherapy courses.

It is of note that commercial payers may not follow the updated edits.