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

CMS Intends to Delay RO Model Implementation

On October 21, 2020, CMS released a statement stating they intend to delay the RO Model start date to July 1, 2021. CMS cites stakeholder feedback outlining the challenges of preparing to implement the RO Model by January 1, 2021, as the driving force behind the intended delay. CMS states they are pursuing rulemaking to make this change. Updates can be monitored through the RO Model web page.

COVID-19 Public Health Emergency Extended

On October 2, 2021, Alex M. Azar II, Secretary of Health and Human Services (HHS) announced the renewal of the public health emergency (PHE) declared due to the Coronavirus Disease 2019 (COVID-19). The PHE was originally declared on January 31, 2020; renewed on April 21, 2020 and then on July 25, 2020. These extensions were in place for 90 days. The July extension made the new expiration date October 23, 2020.

With the latest extension, the PHE expiration date is now January 21, 2021. The extension of the PHE                                   allows for the flexibilities implemented by CMS, including telehealth services and other provisions related to the April 2020 Interim Final Rule. The renewal information can be found here.

CMS Announces New Repayment Terms for COVID Accelerated/Advance Payments

The Centers for Medicare and Medicaid Services (CMS) announced amended terms for loan payments issued under the Accelerated and Advance Payment (AAP) Program during the COVID-19 pandemic. Repayment of the accelerated or advance payment will now begin one year from the issuance date to the provider or supplier.  The loans were provided in an attempt to relieve the financial burden health care providers and suppliers faced while experiencing cash flow issues in the early stages of the COVID-19 public health emergency. CMS issued $106 billion in payments to providers and suppliers. Initially, providers and suppliers were required to start repaying the loans starting in August of 2020 but the new act allows repayments to be delayed until the one year mark of issuance. There is an opportunity for providers and suppliers to request and Extended Repayment Schedule (ERS) if they are having difficulties repaying the loans. More information can be found on the Accelerated and Advance Payment Fact Sheet and FAQs.

Medicare Telehealth Services Expanded

CMS has utilized the new expedition process outlined in the COVID-19 Interim Final Rule for the first time and has added 11 new services to the Medicare telehealth services list.  With the addition of 11 new codes, CMS has added a total of 144 services to the Medicare telehealth services list in an effort to increase Medicare beneficiaries’ access to telehealth services during the COVID-19 public health emergency. Effective immediately, Medicare will begin paying eligible practitioners who furnish these newly added telehealth services through the end of the public health emergency.  The new services include certain neurostimulator analysis and programming services as well as cardiac and pulmonary rehabilitation services. The newly revised list of Medicare telehealth services can be located here.

NGS Incorrect Denials for Pegfilgrastim and Biosimilars – Update

NGS has resolved the issue surrounding the incorrect denials for Pegfilgrastim and Biosimilars. After discovering and reviewing incorrect denial errors, NGS completed mass adjustments on October 20, 2020, to impacted claims. NGS states that no provider action is necessary at this time.

National Government Services Reports Physician Fee Schedule Error

National Government Services, Inc. (NGS) has reported a Physician Fee Schedule posting error affecting certain diagnostic imaging CPT® codes.  

NGS is the Medicare Administrative Contractor (MAC) for Jurisdictions 6 and K, which include Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin. The MAC released an urgent news update on October 28 to inform Part B providers in those jurisdictions of an error impacting CT, MRI, and nuclear medicine CPT® codes 76496-TC, 76497-TC, 76498-TC, 78429, 78429-TC, 78430, 78430-TC, 78431, 78431-TC, 78432, 78432-TC, 78433, and 78433-TC.

The error, dating back to January 2020, caused NGS MPFS search results for these contractor-priced CPT® codes to incorrectly display outpatient prospective payment system (OPPS) fees. The incorrect information has now been removed. NGS has indicated that despite this incorrectly posted information, claims for these CPT® codes were not impacted and were processed and paid correctly, so no further action is needed on the part of the provider.

Physician Congressman Introduces Bill to Delay Radiology Reimbursement Cuts in 2021

Physician and lawmaker Rep. Michael Burgess, MD, R-Texas has introduced bipartisan legislation to avoid hundreds of millions of dollars in upcoming proposed cuts to Medicare payments for radiology and other specialty services.

H.R. 8505, introduced October 2nd by Burgess and Rep. Bobby Rush, D-Ill., proposes a one-year waiver of the budget neutrality requirements specified in Section 1848(c)(2) of the Social Security Act. The bill has been referred to multiple House committees for consideration. According to the American College of Radiology (ACR), diagnostic radiology is in danger of losing $450 million in reimbursement in 2021 alone if no action is taken to avert the payment cuts.

In an update to members on October 7, the ACR wrote: “Introduction of the bill represents a positive step in the ongoing effort to highlight the expected negative impact of the looming cuts and spur congressional intervention before the end of the year.”

The ACR has been active supporter of the legislation, recently joining a coalition of professional organizations representing 1.4 million physicians and other providers in sending a letter to CMS Administrator Seema Varma condemning the reimbursement cuts and supporting the bipartisan bill.

OIG Active Work Plan Items

The Office of Inspector General’s (OIG) Active Work Plan Items reflect OIG audits, evaluations, and inspections that are underway or planned. A couple of relevant items are outlined below.

Comparison of Average Sales Prices and Average Manufacturer Prices

When the average sales price (ASP) for Medicare Part B drug reimbursement was established by Congress, it provided a mechanism for monitoring market prices along with limiting potentially excessive Medicare payment amounts. The Social Security Act mandates the OIG compare ASPs with average manufacturer prices (AMPs). If, during the comparison, the OIG finds that the ASP for a drug exceeds the AMP by 5 percent in the two previous quarters or three of the previous four quarters, the Secretary of Health and Human Services may substitute the reimbursement amount with a lower calculated rate. Quarterly memos report the number of drugs the OIG identified during their analysis that met the criteria for substitution of a lower reimbursement amount. The expected issue date of the work plan item is 2021.

Nationwide Review of the Administration and Oversight of Physician-Administered Drugs

Previous OIG work has identified significant concerns with the efforts States have been making to collect the required rebates on covered outpatient drugs administered by physicians. In order to be eligible for Federal matching funds, States are required to collect these rebates on covered drugs that are administered by physicians. In an effort to ensure States compliance in collecting Medicaid rebates on physician-administered drugs, the OIG will summarize their findings and identified issues as well as examine CMS’s policies and procedures. The expected issue date of this work plan item is 2021.

Changes to Medicare Coverage Database

The Medicare Coverage Database (MCD) will be undergoing some changes in the coming months. On December 11, 2020, the Overview page will be removed and you will be directed to the Search page by default. This change is in an effort to streamline the site. A second change will be implemented on April 30, 2021, with the removal of the Advanced Search function of the MCD application. Although the Advanced Search will be phased out, all of its features were integrated into the new Search that was released on September 3, 2020.  CMS states the new Search function is both faster and easier to use than the Advanced Search. While the website will address will remain cms.gov/medicare-coverage-database, bookmarks to advanced-search.aspx and search-results.aspx will no longer work after April 30, 2021.

October 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 was recently brought to our attention that CMS is bundling 77295 with radiation planning services. We are looking for some clarification on this.

  1. 77295 is now bundled with 77014 and 77336. States it Can’t be billed within 14 days. Can you clarify the 14 day guideline? After the 14 days can we bill some of the charges if they are being performed?
  2. If providers want to do a CBCT, 77014, can we still perform it but not charge for it since it’s considered to be bundled.
  3. The weekly physics QA, 77336, can be charged every 5 fractions. Beyond the 14 days can this be charged?

Advice: A few of the MACs have taken the OIG report on their findings of the potential savings if CMS had implemented the same bundling edits with 77295 as they did with 77301 and applied them as coding edits.  CMS agreed with OIG, but they did not implement the same edits or bundling of codes outside the already established PTP dates of service. Not all MACs have applied these edits or listed this language on their websites, also there is no official guidance or statement from CMS these 14-day edits are in place or exist. ASTRO has been contacted about this to assist.  They have reached out to the MACs on different occasions who have implemented this even though no official statement by CMS it is in fact applicable, as of yet there has not been a change. Bill for what is supported and appeal any denials.  Recommend asking for the LCD or Article or information from CMS that states the codes cannot be billed within 14 days, the OIG report is only the findings if it had been enacted, but CMS did not indicate they would enact the suggestions.

Question: For a Medicare patient who is enrolled in a clinical trial, does the Q1 modifier and Z00.6 dx code apply to inpatient charges when the patient is admitted for the express purpose of chemotherapy?

Advice: Inpatient Clinical Trial Claims/Institutional providers billing clinical trial service(s) must report ICD-10 diagnosis code Z00.6 in either the primary or secondary position and a condition code 30 (qualifying clinical trial) regardless of whether all services are related to the clinical trial or not. HCPCS codes are not reported on inpatient claims. Therefore, the HCPCS modifier requirements (i.e., Q0/Q1) are not applicable to inpatient clinical trial claims.

Question: We have several ortho physicians whose protocol for knees include 4 views of the affected side and an AP and/or PA of the unaffected side for comparison. How should we be coding these? 73564 + 73560?

Since we are taking an AP and/or PA of both knees, should these be performed bilaterally or unilaterally? If performed bilaterally, the image would have to be copied over to the other CPT code- is this acceptable?

Advice: If the referring physician orders an exam of the symptomatic side and the contralateral side is examined for comparison purposes, then only the symptomatic side should be billed.  However, if the referring physician orders exams of both sides for diagnostic purposes, then both sides should be billed.  Each side should be separately documented. See CPT® Assistant, May 2015 and February 2015, and Clinical Examples in Radiology, Winter 2015 and Fall 2008.

If the referring physician orders exams of both sides for diagnostic purposes, then the 4 views of the affected side would be billed as 73564 and the AP/PA of the unaffected side would be billed as 73560. A -59 modifier is required on 73560 per NCCI edits to show that this is a di