Industry News, March 2021

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

Continuation of 2% Sequester Expected; PAYGO Cut in Limbo; MACS to Hold Claims

In the Centers for Medicare and Medicaid Services (CMS) ongoing effort to maintain budget neutrality, providers have traditionally seen an automatic sequestration of 2% in Medicare payments since implemented by the Budget Control Act of 2011.  The Act set the 2% automatic and uniform reduction of Medicare payment cuts for a period of nine years. However, as a result of the COVID-19 pandemic, the payment cuts were temporarily suspended but were expected to be applied again starting April 1, 2021.  A new agreement reached by the Senate proposed a further delay in the reinstatement of the 2% sequestration for an additional nine months through December 31, 2021.  It is now on the House of Representatives to approve and pass the Senate’s legislation. However, due to Easter recess, the House will not vote on the legislation until mid-April, they are back in session for voting April 13, 2021.  Since the 2% sequestration is to go back into effect April 1, CMS announced they expect the House to vote favorably on the legislation and will therefore hold off on processing April’s claims until the time the House votes in an effort to avoid making reduced payments.

The Senate did not address the Pay-As-You-Go (PAYGO) Act of 2010 that would require the cost of the American Recovery Act to be offset to avoid an increase in projected deficits. In order to maintain adherence to the PAYGO rules, a 4% reduction, the highest allowable percentage, of Medicare spending is slated to go into effect at the end of the year.  Since the implementation of the 4% reduction is not scheduled to go into effect until later this year, it is anticipated the Senate will likely wait until the end of the year to address the impending PAYGO sequestration.

Permanent Telehealth Expansion Gains Support

The onset of the COVID-19 pandemic led to emergency temporary flexibilities granted for telehealth services which included traditional fee-for-service reimbursement, relaxation of allowable platforms to be utilized, and the suspension of originating sites and geographic requirements.  These temporary expansions are scheduled to expire with the public health emergency (PHE).  While discussions of permanent telehealth expansion reveal bipartisan support, legislators are having difficulty finding common ground on establishing which telehealth services should remain after the PHE has expired. While there appears to be disagreement in the cost increased telehealth services could burden the system with, there seems to be overall support for the continuation of audio-only telehealth services. There is also agreement on re-establishing stricter HIPAA restrictions for allowable platforms that telehealth services could be performed on. Overall, there is increasing support for the permanent expansion for telehealth services however, it is uncertain if legislators will make headway on the issue in the near future.  

Concerns Over RO Model Sparks Action

On March 1, 2021, The American College of Radiology® (ACR®), the American Society for Radiation Oncology (ASTRO), and other organizations in the RO care community sent a letter to the Centers for Medicare and Medicaid Services (CMS) regarding the Radiation Oncology (RO) Model. Within the letter stakeholders outlined concerns with the RO Model including the payment methodology, quality reporting requirements, clinical data collection and Advanced Alternative Payment Model designation for model participants.  The letter encourages CMS to review the steep discount factors citing the risk of financial viability of and impact on practices and proposes viable revised discount factors. Also addressed in the letter is a push for recognizing the need for a rate review for new equipment and service lines.  Letters have been sent to CMS in March, July, and October of 2020, as well as January 2021.

NCCI Revises Edits for Some Nuclear Medicine Code Pairs Per SNMMI Request

On March 1, 2021, CMS’ National Correct Coding Initiative (NCCI) corrected Procedure to Procedure (PTP) edits for a variety of nuclear medicine CPT® codes and HCPCS codes. These edit corrections had previously been requested by the Society for Nuclear Medicine and Molecular Imaging (SNMMI) and are retroactive for claims with dates of service (DOS) to January 1, 2020.

CMS had previously assigned a PTP modifier indicator of “0” for the following CPT®/HCPCS code pairs, indicating that no modifier was allowed under any circumstances: 78472/A9512, 78802/A9547, 78804/A9521, 78802/A9521. At SNMMI’s urging, CMS implemented the change to a modifier indicator of “1,” which allows an NCCI-approved modifier to be used to bypass the edit in appropriate situations.

Likewise, CMS had previously implemented a PTP modifier indicator of “0” for these code pairs: 78800/A9569, 78802/A9530, 78802/A9531, 78802/78830; 78802/78832.  CMS has removed the edits for these common code pairs at the urging of SNMMI.

Finally, SNMMI has recommended the removal of PTP modifier indicator “0” (as well as any other edits) for these code pairs and several others: 78802/A9570, 78804/A9569, 78804/A9570. CMS agreed to remove the edits but has not yet implemented these changes.

The official update files can be viewed at The SNMMI statement regarding these updates can be found here for additional information.

 AAP Repayment Approaching

As the country has passed the one-year mark of the public health emergency (PHE) declared as a result of the COVID-19 pandemic, many will also see the approaching deadline to begin repaying their Accelerated and Advance Payment (AAP) loan. Under the Continuing Appropriations Act, 2021 and Other Extensions Act, it was outlined that repayment is to begin one year from the issuance date of each provider or supplier’s accelerated or advance payment.  Repayment will automatically be deducted from Medicare payments in an increasing percentage over the course of twenty-nine months. Novitas has provided the following example to illustrate the amended repayment terms for a provider that was issued an AAP on April 1, 2020.

Day One

Further information regarding the AAP repayment terms can be located on the CMS fact sheet and frequently asked questions. CMS instructs you to contact your Medicare Administrative Contractor with questions regarding repayment or to request an Extended Payment Schedule (ERS).

USPSTF Updates Recommendations for LDCT Lung Cancer Screening; Urges CMS to Revise Coverage Determination

Chest CT is very effective at identifying lung cancer.  In December 2013, the U.S. Preventive Services Task Force (USPSTF) awarded a grade of B to screening low-dose CT (LDCT) for patients who meet specific risk criteria. Originally, the recommendation was that adults aged 55 to 80 years who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years should receive an annual screening examination using LCDT. (A “pack-year” is the equivalent of smoking one pack of cigarettes per day for one year.)

On March 9, 2021, the USPSTF recommendation was updated to reflect that adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years should be screened annually using LDCT.

Under the Affordable Care Act, most commercial payers must provide coverage without a deductible for preventive services that have received a grade of A or B from the USPSTF. The Medicare program is allowed but not required to cover USPSTF-recommended services.

On February 5, 2015, CMS issued a Decision Memo (CAG-00439N) establishing a National Coverage Determination (NCD 210.14) for LDCT for lung cancer screening.  Billing guidelines for LDCT can be found in the Medicare Claims Processing Manual, Chapter 18, Section 220.  Also, the ACR has posted Frequently Asked Questions about LDCT on their website.

The American College of Radiology (ACR), the GO2 Foundation for Lung Cancer, and the Society of Thoracic Surgeons have all urged CMS to quickly revise its National Coverage Determination to reflect the updated USPSTF recommendations.

Please see the full recommendation statement for additional details.

Delay in Rule Allowing Rapid Device Coverage Approval

A regulatory rule, set to go into effect March 15, 2021, that would speed up Medicare coverage of devices approved via the Food and Drug Administration’s (FDA) “breakthrough” pathway has been delayed until May 15, 2021.  The FDAs breakthrough pathway is intended to address and unmet medical need. Traditionally, it would take a year or more to get Medicare coverage for new devices after FDA approval or clearance. The newly delayed rule would allow devices approved under the breakthrough pathway to simultaneously get national Medicare coverage for four years as well.  It was initially anticipated that the breakthrough pathway would apply to approximately two to five devices per year. However, data reported by the FDA in February 2021, cited more than 400 devices had been designated as breakthrough.  Concerns over the unanticipated volume of devices approved via the breakthrough pathway as well as possible procedural issues has led to the delay, which is accompanied by a thirty-day comment period. 

LCD & LCA Updates

A variety 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: Hydration Therapy (A56634)
  • IMRT LCD (L36711)


  • Immune Globulins LCD (L34771)
  • Billing and Coding: Immune Globulins LCA (A57554)

As a reminder, on April 30, 2021, the Advanced Search function of the Medicare Coverage Database (MCD) application will be removed. All features related to the Advanced Search have been incorporated into the new Search function, which was released on September 3, 2020. Bookmarks to advanced-search.aspx and search-results.aspx will no longer work after April 30, 2021.