Surprise-Billing Act – Win for Insurers?
On September 30, 2021, a second interim final rule was issued including implementation of the No Surprises Act. However, many believe the ruling favors insurers over providers when it comes to claim dispute resolutions.
The No Surprise Act is intended to protect consumers against surprise medical billing when there is a dispute between providers and payers regarding out-of-network (OON) rates. The interim rule, among other things, outlines the process for payment dispute resolution, the requirement for providing healthcare cost estimates, promote price transparency and protections to assist consumers to challenge denied payments. The ruling, which is expected to take effect January 1, 2022, will ban surprise billing for emergency services and some non-emergency services by limiting the high OON cost-sharing.
Under the proposal, insurers and providers are given 30 days to negotiate an out-of-network rate for a service. If they cannot come to an agreed rate, an independent third party will determine the payment amount. However, many are debating the use of the “qualifying payment amount” or the insurer’s median contracted rate for the geographical area, as the primary factor in the independent dispute resolution arbitration. By placing a profound emphasis on the median contracted rate as the appropriate out-of-network figure, it is speculated that the independently contracted resolution process is tipped heavily to the insurers benefit.
- Comments on the interim final rule can be made no later than December 6, 2021
Requirements Related to Surprise Billing; Part II
Requirements Related to Surprise Billing; Part I
FDA Approves CT technology Upgrade
Breaking a near decade long drought, the U.S. Food and Drug Administration (FDA) has cleared new CT technology.
The FDA has provided clearance to Siemens Medical Solutions Inc. for the CT technology known as photon-counting. The emerging technology utilizes photon-counting detectors which have the ability to measure each individual x-ray that passes through a patient’s body, a contrast to the current systems which can only measure the combined total energy of all x-rays at once. The FDA reviewed and approved the Siemens NAEOTOM Alpha through the 510(k) premarket clearance pathway which provides a submission pathway to demonstrate a new device is equivalent to an existing, legally marketed device.
Laurel Burk, Ph.D., assistant director of the Diagnostic X-ray Systems Team in the FDA’s Center for Devices and Radiological Health says, “Today’s action represents the first major new technology for computed tomography imaging in nearly a decade and underscores the FDA’s efforts to encourage innovation in areas of scientific and diagnostic progress.”
Check Out Your MACtivity
|· Billing and Coding BRCA1 and BRCA2 LCA (A57449) rev. 10.1.21
· Billing and Coding IMRT LCA (A56746) rev. 10.1.21
· Billing and Coding Pegfilgrastim -Neulasta- LCA (A57725) rev. 10.1.21
|· Billing and Coding Proton Beam Radiotherapy LCA (A57669) eff. 10.1.21
· Billing and Coding SRS&SBRT LCA(A57275) rev. 10.1.21
· Billing and Coding Trastuzumab LCA (A56660) rev. 10.1.21
|· Erythropoiesis Stimulating Agents LCD (L36276) rev. 9.7.21|
|· Billing and Coding IVIG LCA (A56718) rev. 10.1.21||· Billing and Coding Rituximab LCA (A56380) rev. 10.1.21
|· Billing and Coding Radiopharmaceutical Agents LCA (A55052) rev. 7.1.21|
|MLN Matters NCD: Chimeric Antigen Receptor (CAR) T-cell Therapy revised 10.6.21
Make sure you use the KX modifier when you send claims for CAR T-cell therapy services. This tells your MAC that you did that service in an FDA REM approved facility. Your MAC only allows CAR T-cell therapy services when the line item contains the KX modifier.
CMS Releases Fourth Quarter NCCI Edit Update
Effective October 1, 2021, the Centers for Medicare & Medicaid Services (CMS) released several significant National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) updates for nuclear medicine procedures and radiopharmaceuticals utilized in the outpatient hospital setting (OPPS). These changes pertain specifically to code combinations for radiopharmaceutical localization of tumors, inflammatory processes, or distribution of radiopharmaceutical agents. Please see the table below for additional information.
|Column 1||Column 2||Previous
Public Health Emergency Renewed
On October 15, 2021, the public health emergency (PHE) was renewed once again. Effective October 18, 2021, as part of the continued response to the COVID-19 pandemic, the PHE and included waivers and flexibilities be renewed for additional 90 days. The PHE will now be extended through January 17, 2022.
Telehealth POS Changes
Effective January 1, 2022, there will be the implementation of a new telehealth Place of Service (POS) code as well as a revision to another POS code.
The Centers for Medicare and Medicaid Services (CMS) maintain the two-digit code set which are placed on professional health care claims to identify the setting in which a service was provided. The POS codes provides the necessary setting information in order for claims to be paid correctly. In order to provide a more precise specificity in identifying the setting in which a telehealth service was rendered, CMS is revising the description of POS code 02 and has newly created POS code 10. The revision and new code definition are as follows:
POS 02: Telehealth Provided Other than in Patient’s Home
Descriptor: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located I their home when receiving health services or health related services through telecommunication technology.
POS 10: Telehealth Provided in Patient’s Home
Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
The MLN Matters article outlining the information surrounding these POS codes states the creation of POS 10 was to “meet the overall industry needs” but that Medicare has not identified a need for the new POS code 10. The Medicare Administrative Contractors (MACs) are to instruct the continuation of the Medicare billing instructions for Telehealth claims within the Medicare Claims Processing Manual, Chapter 12.
Brush Up on What you Know or Learn Something New
- First Coast: What’s new for E/M office visit coding in 2021
- CGS: Medicare Minute MDSM Telehealth
- Palmetto GBA: MACtoberfest on Demand
- ASTRO: Model Policies
- Palmetto GBA: Hot Topic Tuesday Teleconferences
- Noridian: Education on Demand Tutorials
- CMS: RO Model Clinical Data Elements and Quality Measures Reporting Requirements Webinar
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: Hello, I wanted to check to see if it is a requirement that the physician dictate a Radiation Oncology completion note after completion of external treatment?
Advice: Per the ACR–ASTRO PRACTICE PARAMETER FOR RADIATION ONCOLOGY “After a course of treatment is completed, the radiation oncologist should document a summary of the treatment delivered including site treated, modality used, dose per fraction, total dose, elapsed time, dates of treatment, concurrent therapy, treatment response (if applicable), relevant side effects (if applicable), and other observations. This should be communicated to the referring physician and any other physicians involved in the care of the patient in a timely fashion. Radiation treatment records should be retained for at least 5 years after the death of the patient or according to state law(s).”
Question: Do we bill an administration charge for Propofol, or other anesthesia medication administered during a bone marrow aspiration?
Advice: Moderate sedation or general anesthesia codes would be utilized for the administration of anesthesia drugs, which is dependent on the level of anesthesia performed and the individual that performed the work. For administration of topical or local anesthesia, this is considered part of the minor procedure and not separately billable.
Question: Can you please tell me if we can legitimately bill for a Leipzig HDR treatment (77767 & C1717) and an external beam treatment (77412) on a patient on the same day, same patient, 2 separate areas?
Advice: If provided as two separate sessions, they could be billed. There is not a restriction placed on delivering a brachytherapy treatment on the same date of service as an external beam treatment delivery. Additionally, there are no NCCI edits in place between the two codes. The treatment deliveries can be billed on the same date of service as ordered, supported and appropriate.