Industry News, November 2021

CMS Releases 2022 Rulings

On November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) issue the final rule for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (HOPPS) for calendar year (CY) 2022.

The following is a high-level overview of the HOPPS and MPFS final rules. It is recommended to read RCCS’ summary and/or the final rules in their entirety for more information.

  • 0 percent increase to the Outpatient Department (OPD) fee schedule
  • Arrest and reversal of 290 services removed from inpatient only (IPO) list
  • 23 exceptions to the 23 APCs under the 2 times rule violation
  • Continuation of HCPCS C1889 for billing of device for device intensive procedure
  • January 1, 2022, implementation date for RO Model – unless prohibited by law
  • Creation of low-volume APCs for designated clinical, brachytherapy, and new technology services
  • Continuation of 2.0 percent reduction to the conversion factor for failure to meet quality reporting requirements

MPFS Highlights

  • CY 2022 Conversion Factor (CF) = $33.5983
  • Decreases to many Practice Expense (PE) values which results in a cut to specialties such as:
    • Radiation Oncology -1%
    • Hematology/Oncology -1%
    • Interventional Radiology -5%
    • Radiology -1%
  • Implementation of clinical labor pricing update resulting in specialties with lower direct costs associated to clinical labor experiencing a decrease in payment for services
  • Clarification of services which will be added or extended and services to be removed from telehealth list at the end of the public health emergency (PHE)
  • HCPCS code G2252 – communication-based service- permanently added
  • Evaluation and management (E/M) visit changes and updates addressed
  • Delay in penalty payment phase of Appropriate Use Criteria (AUC) finalized
  • Medicare Administrative Contractors (MACs) to make Positron Emission Tomography (PET) Scans determinations of coverage

While decreases are seen across many specialties, the percentages were generally less than what was originally proposed.

Additonal Info

Suit Filed Against Surprise-Billing Provision

The Texas Medical Association (TMA), filed a lawsuit in opposition to the recently released No Surprises Act’s  interim final rule which addresses  the end to surprise-billing and outlining the dispute-resolution process between physician’s and payers.

The No Surprises Act interim final rule, among other things, defines the process in which physicians and payers will settle out-of-network payment disputes.  The Texas Medical Association, representing over 55,000 physicians and medical students making it the largest state medical society in the United States, filed the lawsuit against the department of Health and Human Services and Labor and Treasury. The suit addresses the key provision in the dispute-resolution process that the association believes places too much emphasis on the “qualifying payment amount.” It had been recommended by lawmakers to develop a robust dispute-resolution process, taking several factors into account. However, the medical association believes congressional intent was not followed and favor was given to insurers during the dispute-resolution process. The lawsuit aims to remove the particular portion of the ruling that the association claims go against the fair and balanced resolution process initially intended. The suit additionally claims the interim final rule was in violation of the Administrative Procedure Act.

 Palmetto GBA Post-payment Probe for Keytruda®

Palmetto GBA released results of a post-payment review, including top denial reasons, on HCPCS code J9271 – Keytruda® (Pembrolizumab) for July through September 2021.

With focus on North Carolina, South Carolina, Virginia, and West Virginia a total of two hundred eighty-eight (288) claims for Keytruda® (Pembrolizumab) were reviewed totaling $2,601,140.28. Twenty-five (25) of the claims were either completely or partially denied with a monetary value of $188,844.69, resulting in an 8.68 percent claim denial rate and a 7.26 percent charge denial rate.

The majority (72.0%) of all denials were attributed to “Dependent Services Denied (Qualifying Service Denied Medically).”  Palmetto explains the reason for this particular denial is the charges associated with a service under review will not be allowed and will be denied based on the medical denial of the qualifying service.  For example, the service was denied as documentation did not support the medical necessity, therefore all other charges associated with that service will also be denied.

Palmetto provides the following key steps to avoid this denial:

  • Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
  • Ensure all records are properly and legibly signed
  • Ensure all documentation supports the service(s) was rendered

Proper supporting documentation with appropriate and timely signatures remains the key to timely reimbursement of claims.

Check Out Your MACtivity

General Appeals Information

When you are dissatisfied with an initial claim determination, know the proper appeal levels, thresholds, and time limits for filing appeals.


·         Palmetto GBA ·         Novitas ·         WPS
·         Noridian JE ·         NGS ·         CGS
·         Noridian JF ·         First Coast ·         MLN Booklet


Cancer Centers Slow to Comply with Price Transparency Requirements

Only one in five cancer centers designated by the Nation Cancer Institute (NCI) are currently in compliance with the requirements of the price transparency rules.

The Centers for Medicare and Medicaid Services (CMS) implemented price transparency requirements which mandated hospitals to make available prices they have negotiated with insurers to the public. To fulfill one of the transparency requirements, facilities must provide an easily accessible machine-readable file of 300 “shoppable” services in an easy-to-read format. A study of data of sixty-three National Cancer Institute designated Cancer Centers, only twenty-one percent posted a complete machine-readable file as required by the Centers of Medicare and Medicaid Services (CMS).  While CMS has started sending warning letters to non-compliant organizations, they have yet to issue any financial penalties.

A review of available data indicated that some of the NCI Cancer Centers were charging up to eight times the Medicare maximum allowable rate. If imposed, the financial penalties would be a maximum of $109,500 annually for non-compliance. It is hypothesized many NCI-Cancer Centers will continue to remain non-compliant of CMS’ price transparency requirements given the fact that true transparency may lead to a potential in the reduction in overall reimbursement.

ACR Releases New Appropriateness Criteria

The American College of Radiology (ACR) released new imaging appropriateness criteria to include eighteen new topics and thirteen revisions to previous topics throughout 2021.

The ARC first introduced its imaging appropriateness criteria in 1993, aiming to offer specialty evidence-based guidelines to aid physicians and other providers in selecting the most appropriate imaging exams and guided procedures for a specific clinical condition. Since then, the criteria have grown to offer 216 diagnostic imaging and interventional radiology topics to include 2,400 clinical scenarios. The newly added scenarios include imaging of a child with suspected Crohn’s disease, facial trauma following a primary survey, axillary masses, newly diagnosed scrotal abnormalities, and pediatric musculoskeletal infections. The newest updates to the criteria range from colorectal cancer to imaging after shoulder arthroplasty.

ACR’s imaging appropriateness criteria has been designated as a qualified provider-led entity which meets the requirements outlined in the Protecting Access to Medicare Act, requiring providers consult appropriate-use criteria before ordering imaging.

“These criteria are recognized as the national standard of radiologic care.”

-Mark Lockhard, MD, chair of the Committee on Appropriateness Criteria

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: Advice needed: for the ROM if the physician’s clinical treatment plan is written on same date as the simulation is that a problem for the ROM?  (In some cases, the Rx 77261-77263 would be written on same dos as consult) Does the 77261-77263 need to be always written on consult or is it okay if the 77261-77263 is written on the date of simulation?

Advice: The clinical treatment planning note (77261-77263) is considered the start of episode (SOE) for the professional component and the simulation would usually be the first technical service rendered which would be the start of episode for the technical portion. You would report the appropriate “M” codes with the SOE modifier, both pro and tech.  It should not be an issue if the professional SOE and technical SOE fall on the same date of service. You will need to work through the consent by the patient and their notification of being part of the ROM and the anticipated cost of care etc.  Per CMS they expect this during the clinical treatment planning.

Question: Can I bill the hydration in the following scenario? Kyprolis infusion from 1123-1153, Darzalex SQ injection at 1114, hydration from 1002-1032 and again from 1154-1224. Looking to see if I can bill the hydration as each bag only ran 30 minutes.

Advice: In this scenario, it cannot be charged as hydration.

Question: We recently simulated a patient that has metastasis to both the orbit and the sternum. The Physician would like to use IMRT Technique on the orbit and a 3D technique on the sternum. Can we bill 77301 and 77295 when only one CT sim study set was used?

Advice: If the areas are separate and distinct a plan for each could be billed, but not on same date. Due to edits only one plan is billable per date of service.