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

Most Favored Nation Interim Final Rule

On November 20, 2020, CMS announced the Most Favored Nation (MRN) Model, a new Medicare payment model related to payments for Part B drugs.  This model is in response to President Trump’s September 13, 2020 Executive Order on Lowering Drug Prices by Putting America First.  This model tests the method of lowering drug costs by paying no more than the lowest price drug manufacturers receive in other similar countries, specifically any country in the Organisation for Economic Co-operation and Development (OECD) that has a Gross Domestic Product (GDP) per capita that is at least 60 percent of the U.S. GDP per capita. 

Drug spending in the U.S. has steadily increased and significantly outpaces spending on other Part B services, and U.S. drug prices surpass other countries.  Per the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Medicare Part B Fee-for-Service (FFS) drug spending per enrollee for 2006-2017, grew 8.1 percent.  This is more than twice the per capita spending on Medicare Part D, which is 3.4 percent and almost three times the overall retail prescription per capita drug spending, which is 2.9 percent. It is expected  per capita spending on Medicare Part B physician-administered drugs and separately-payable hospital outpatient drugs will grow at a similar annual rate of 8 percent between 2020 and 2027, not including potential increases related to the  COVID-19 pandemic.

Overall, OACT estimates the MFN Model will result in savings of $85.5 billion and beneficiaries will save a total of $28.5 billion from a reduction in the Medicare Part B premium and will also see their coinsurance reduced.

Rulemaking related to this model was published within the MFN Model Interim Final Rule with Comment Period and includes a 60-day public comment period.  This is intended to serve as a summary of the published rule, and it is recommended to review the publication in its entirety, as well as locate and review other resources provided by CMS.   The Interim Final Rule is 258 pages in length, and the complete document can be located here.

The model is scheduled to go into effect January 1, 2021 and will run through December 31, 2027.  The model is considered a nationwide, mandatory model and includes the following key elements.

MedPAC Discusses Telehealth Expansion in Medicare

The Medicare Payment Advisory Commission (MedPCA) met at the beginning of November to discuss possible policy options and the expansion of telehealth in Medicare after the end of the COVID-19 public health emergency (PHE).  CMS granted providers board access to telehealth services for the duration of the PHE which is set to expire January 21, 2021. While MedPAC explained that there was increasing interest in expanding telehealth coverage before the PHE, some individuals pointed out that permanently expanding telehealth coverage beyond the PHE could potentially increase use and spending under the Medicare fee-for-service payment system. MedPAC outlined the following telehealth policy options post-PHE:

  • Expansion of Medicare beneficiaries covered;
  • Coverage of many but not all of the telehealth services paid for during the PHE;
  • Elimination of temporary coverage of audio-only services after the PHE;
  • Lower rate for telehealth services than for in-person services;
  • HIPAA compliance for telehealth technology, cost sharing for telehealth services; and
  • Other safeguards to protect Medicare and beneficiaries from unnecessary spending and potential fraud.

While these potential policies were discussed, there was not universal agreement. There was divisiveness amongst the staff regarding audio-only visits and the need to maintain them to address access to care and equity concerns. MedPAC will continue its discussion on telehealth expansion in future meetings.

Historical Changes Made to “Stark Law”

On November 20, 2020, The Centers for Medicare and Medicaid Services (CMS) finalized changes to the Physician Self-Referral Law, also known as the “Stark Law.” The law was enacted in 1989 and has not seen any significant updates since that time. When enacted, most healthcare was paid on a fee-for-service basis and aimed to prohibit physicians from making referrals based on financial self-interest rather than the good of the patient. The Stark Law prohibits physicians from making referrals for certain healthcare services payable by Medicare if the physician has a financial relationship with the entity performing the service.

Since there has been a shift from fee-for-service payment to value-based healthcare delivery and payment systems, the out-of-date Stark Law regulations, which was tailored to a fee-for-service system, proved to be problematic by potentially hindering arrangements that are designed to enhance care coordination, improve quality, and reduce waste.  The finalized rule creates new, permanent exceptions to the Stark Law for value-based arrangements while providing guidance on several key requirements that physicians must meet in order to be in compliance with the law. The value-based exceptions have safeguards in place to ensure the Stark Law continues to provide protection against overutilization and other harms while providing flexibilities for certain non-abusive, beneficial arrangements between physicians and other healthcare providers. More regarding the changes can be found in the final rule, the press release and the fact sheet.

ICD-10 Revisions to NCDs Relevant to Radiology

The Centers for Medicare and Medicaid Services (CMS) issued a Change Request (CR 12027) containing coding updates to various radiology-relevant National Coverage Determinations (NCD). The International Classification of Diseases, 10th Revisions (ICD-10) updates can be found in the following NCDs:

  • NCD 220.13 Percutaneous Image-Guided Breast Biopsy: Medicare administrative contractors (MACs) are instructed to add ICD_10 codes N61.21, N61.22, N61.23 effective Oct. 1, 2020.
  • NCD 220.4 Mammograms: The CR instructs MACs to add ICD-10 codes N61.21, N61.22, N61.23 effective Oct. 1, 2020.
  • NCD 220.6.17 PET for Oncologic Conditions: CMS instructs MACs to add ICD-10 codes C79.51, C94.40, C94.41, C94.42, D47.Z2, D47.Z9, G13.0 effective April 1, 2021.

Further information regarding these changes as well as a full list of affected NCDs can be found within the Medicare Learning Network Matters article MM12027.

Special Provisions for Radiology Additional Documentation Requests

Medicare Administrative Contractors (MACs) have the ability to auto-deny a radiology claim if a benefit category, statutory exclusion, or coding issue is in question. MACs may also send an Additional Documentation Request (ADR) to the provider selected for review, in order to review records to determine whether the claim is payable and medically necessary.  When issued an ADR, it was the responsibility of the provider selected for review to obtain supporting documentation as needed from the treating/ordering practitioner’s office or from an inpatient facility.  CMS notes there are instances in which radiology service providers selected for review are unable to acquire supporting documentation, possibly retained by the treating/ordering practitioner.  Because of this, CMS is piloting an approach that will enable MACs to receive pertinent documentation from the treating/ordering practitioner during medical review, in an effort to support the necessity and payment for radiology service(s)/item(s) billed to Medicare. Therefore, CMS issued a One Time Notification to require MACs to conduct third-party ADRs for radiology service claims, when necessary from the treating/ordering practitioner. Further information can be located in the MLN Matters Article as well as the official change request issued to the MACs.

ACR Submits New Code Proposals to CPT® Editorial Panel

The American College of Radiology (ACR) presented several new CPT® codes for consideration at the October meeting of the AMA CPT® Editorial Panel. The meeting, held virtually, was the final meeting to update codes for the 2022 code cycle.

The radiology CPT® advisors requested CPT® Category I codes for Trabecular Bone Score (TBS) and Category III codes for Quantitative Multiparametric Magnetic Resonance (MR), an emerging technology. If approved, the new TBS Category I codes will be effective Jan. 1, 2022, and the new Quantitative Multiparametric MR Category III codes will be released early to the AMA website on Jan. 1, 2021, with an effective date of July 1, 2021.

Additionally, the radiology CPT® advisors consulted with several specialty societies on code proposals to delete code 72275 (Epidurography, radiological supervision and interpretation) due to low volume. The group also worked to edit the Automated Coronary Analysis Guidelines to coincide with the new 2021 Category III codes for automated quantification and characterization of coronary atherosclerotic plaque.

The CPT® Editorial Panel previously met in February and May 2020. At previous meetings, CPT® code 76970, Ultrasound study follow-up (specify) was referred for deletion, as it was no longer being used by radiologists (and was being misused by other specialties). Category III codes were also requested for percutaneous injection of allogenic injection of lumbar spine, automated advanced coronary analysis, and breast computed tomography.  Those deletions and additions will go into effect with the 2021 CPT® changes on January 1, 2021.

AMA Releases New CPT® Codes for COVID-19 Vaccines

In anticipation of the distribution of upcoming COVID-19 vaccines, the American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC) have worked together to develop two new Category I CPT® codes and four new vaccine administration codes to report these services. The early creation and release of these codes ensures that providers across the country have sufficient time to update their billing and claims software accordingly before the vaccine is made available for distribution.

The two new Category I codes are:

91300 – Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use

91301 – Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use

Code 91300 is intended for use with the administration of the Pfizer-BioNTech® COVID-19 vaccine, while 91301 is to be used for the Moderna® vaccine. Additional vaccine administration codes 0001A – 0012A are to be reported to indicate specificity and dosing. At this time, no CPT® code has been created for the AstraZeneca-Oxford® COVID-19 vaccine.

For additional information about the new vaccine codes and how to use them appropriately, please visit the AMA’s website.

SMRC Audit Material More Easily Identifiable

The Centers for Medicare & Medicaid Services (CMS) contracts with a Supplemental Medical Review Contractor (SMRC) to help lower improper payment rates and protect the Medicare Trust Fund. The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment and billing requirements. The SMRC will send HIPPA compliant requests to providers and suppliers for additional documentation on claims selected for medical review. The SMRC has begun mailing all additional document request (ADR) letters in green envelopes to make them easily identifiable and to assist with proper notification.  Making the ADRs more easily identifiable is an attempt to allow the SMRC requests to be received by the appropriate departments in a timely manner. 

LCD & LCA Updates

There have been several noteworthy Local Coverage Determination (LCD) and Local Coverage Article (LCA) updates. Below is a list of some of the relevant updates with links to the documents.

Palmetto GBA has updated the following:

  • Billing and Coding LCA: Chemotherapy (A56141)
  • Billing and Coding LCA: Intravenous Immunogloulin (IVIG) (A56718)

WPS has updated the following:

  • Billing and Coding LCA: Category III Codes (A56902)

WPS has retired:

  • Billing and Coding LCA: Drug Administration (A54176)

WPS will have a new policy effective January 10, 2021, the document is not yet available:

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

November 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: It A Patient supplied their own Zarxio injection. We do not bill for the injection, but can we bill for the administration if it was given by one of our outpatient nurses?

Advice: It is recommended to confirm payer guidelines on what kind of documentation is needed in this situation because there would not be corresponding HCPCS codes with the administration. According to the Medicare Benefit Policy Manual, Chapter 15: “In some instances, A/B MACs (B) may have provided payment for one or perhaps several doses of a drug that would otherwise not be paid for because the drug is usually self-administered. A/B MACs (B) may have exercised this discretion for limited coverage, for example during a brief time when the patient is being trained under the supervision of a physician in the proper technique for self-administration. Medicare will no longer pay for such doses. In addition, A/B MACs (B) may no longer pay for any drug when it is administered on an outpatient emergency basis, if the drug is excluded because it is usually self-administered by the patient.” 

Question: If we have a 3D patient that we are CBCTing we can only charge a IGRT charge or a verification sim charge on day 1, not both correct?

Advice: Billing both a verification simulation (77280) and IGRT code 77387 is allowable on the same date of service for non-IMRT treatments if the verification simulation and IGRT are separate and distinct procedures. The verification simulation would include checking blocking and verifying other parameters and would need to be performed and completed separate from the IGRT. If the IGRT is part of the verification simulation process, then only billing of the verification simulation (77280) would be allowable.