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CMS Finalizes Medicare Reimbursement
On November 2, 2023, CMS published the 2024 Medicare physician fee schedule and outpatient facility fee final rules.
CMS finalized another unsustainable 3.37% cut to reimbursement and decreased conversion factor of $32.74.
Now is the time to inform your Members of Congress about the danger of these looming cuts. You Can Help!
ACG
American College of Gastroenterology
gi.org
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The U.S. Preventive Services Task Force recommends screening for colorectal cancer in adults aged 45 to 49 years.
Screening for Colorectal Cancer
Click here for more Information.
Reference: USPSTF Website
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SelectHealth
Aetna no longer pays for moderate conscious sedation in a facility setting effective Sept 2020
4-17-2020 – Aetna is requesting POS 2 for commercial and POS 11 for Medicare replacement
Aetna – New Telemedicine Policy Update COVID-19 – 3-19-2020
Aetna 3-24-2020
What you need to know about the coronavirus (COVID-19) Aetna Providers
Free tool to find the right COVID-19 vaccine CPT® code
The AMA has developed a free tool to help clinical staff determine the appropriate Current Procedural Terminology (CPT®) code combination for the type and dose of vaccine that they are using.
CPT E/M changes, Effective January 1, 2021
Additional COVID-19 Testing Codes Announced
by Wyn Staheli, Director of Research
The American Medical Association (AMA) announced the addition of three new codes which became effective immediately.
5-4-20
Special coding advice during COVID-19 public health emergency
Information from Anthem for Care Providers about COVID-19
Commercial Reimbursement Policy Effective 9/1/2020
Click here Nurse Practitioner and Physician Assistant Services
Anthem: Information from Anthem for Care Providers that perform ABA Services during COVID-19 – 3-24-2020
Anthem Blue Cross-California 4-1-20 –
Click here: Information Anthem for Care Providers About COVID-19
Anthem – GA – Telehealth Policy 3-24-2020
Anthem Blue Cross- Wisconsin – 4-1-20
Click here: Information Anthem for Care Providers about COVID-19
APRN- (Missouri) – The Governor’s office has temporarily waived the regulation requiring that a collaborating physician and an advanced practice registered nurse (APRN) be within 75 miles of each other.
Statutes and Regulations affected by this waiver:
Click here:
CMS Invites ASCs to Join COVID-19 Call Thursday, April 30, 12:00 pm – 1:00 pm ET
CMS is hosting a call for Ambulatory Surgery Centers (ASCs) and Freestanding Emergency Departments (EDs) to provide targeted updates on the agency’s latest COVID-19 guidance. Agency officials will be available to answer technical and operational questions from providers on this topic.
Click here: To register for CMS Call with ASCs and Freestanding Eds
ASCA has released a checklist ASCs can use to identify the key elements they need to consider as they prepare to resume in-person care of non-COVID-19 patients in regions with a low incidence of COVID-19 disease.
Click here: Use ASCA’s New Checklist to Help Reopen Your ASC
April 17, 2020 -ASCA Release Statement on Resuming Elective Surgery
4-10-2020
$30 billion in grants to healthcare providers, including ASCs
ASCA – COVID-19 Emergency Response Service Expansion Checklist – Updated: April 6, 2020
This checklist, developed by ASCA, is designed to help ASCs identify the basic elements they need to consider before providing expanded services under the temporary rules and waivers the Centers for Medicare & Medicaid Services (CMS) announced during the national emergency declared in response to the COVID-19 pandemic.
The checklist does not cover every circumstance that might warrant consideration and does not represent official ASCA policy or constitute legal advice. ASCs should consult with legal counsel, their financial advisers and clinical experts before proceeding with any expansion of services.
BCBS Telehealth Policy
BCBS of Alabama – 3-26-20
Blue Shield California – 3-17-20
Click here: Using telehealth to provide virtual care for your patients
BCBS of Illinois – 3-18-2020
Click here: BCBS of Illinois Further Expands Telehealth in Response to COVID-19
BCBS Independence – 3-20-20
Click here: Independence expands telemedicine coverage during COVID-19 outbreak
BCBS of Louisiana – 3-20-20
Click here: Expansion of telehealth for remote care during COVID-19
BCBS of Massachusetts – 3-24-20
BCBS of Michigan – 3-30-20
BCBS of North Carolina – 3-18-20
Click here: Temporary Expansion of Reimbursement for Telehealth Services
BCBS of Rhode Island – 3-23-20
Click here: Payment Policy COVID-19 Temporary Provider Telemedicine/Telehealth
BCBS of Vermont – 3-19-20
Click here: TELEMEDICINE PAYMENT POLICY Corporate Payment Policy
4-9-2020
Cigna Quote
“While we encourage providers to bill consistent with an office visit – and understand that certain services can be time consuming and complex even when provided virtually – we strongly encourage providers to be cognizant when billing level four and five codes for virtual services. While we will reimburse these services consistent with face-to-face rates, we will monitor the use of level four and five services to limit fraud, waste, and abuse.”
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COVID-19 and End of Public Health Emergency Update
The federal government confirmed May 11, 2023, as the end of the Public Health Emergency (PHE).
2022 Medicare Physician Fee Schedule
Summary of Policies in the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List
Physician and non-physician practitioner payment policy and payment rates
Telehealth services and telehealth origination site facility fee payment amounts
Medicare Part B policy changes including physician assistant services billing
Release Date- November 16, 2021
Effective Date – January 1, 2022
Click Here -Learn about CY 2022 MPFS updates
Ref:
MLN Matters® Articles
Cms.gov
System processing error delays Medicare payments at Palmetto GBA
Medicare Administrative Contractor Palmetto GBA announced that Medicare payments from July 21-22, 2021, could be delayed because of a “system processing issue,” the company said July 21, 2021.
The resolution time is unknown, the company said.
Click here for Palmettogba.com
References:
Palmettogba.com
Beckerasc.com
CMS Proposes Rule to Increase Price Transparency, Access to Care, Safety & Health Equity CMS is proposing actions to address the health equity gap, ensure consumers have the information they need to make fully informed decisions regarding their health care, improve emergency care access in rural communities, and use lessons learned from the COVID-19 pandemic to inform patient care and quality measurements.
COVID-19 Accelerated and Advance Payments
If you got these payments, learn more about how recoupment works and how it affects your Medicare claims payment amounts.
More Information:
Special Edition – Wednesday, April 14, 2021
J&J COVID-19 Vaccine: Health Alert
The CDC issued a Health Alert, about the CDC and FDA’s recommended pause in the use of the J&J COVID-19 vaccine, in part, to ensure that the health care provider community is aware of the potential for adverse events and can provide proper management due to the unique treatment required with this type of blood clot. This alert includes specific recommendations for clinicians.
Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through December
The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the sequestration payment adjustment percentage of 2% applied to all Medicare Fee-for-Service (FFS) claims from May 1 through December 31, 2020.
Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through December
The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the sequestration payment adjustment percentage of 2% applied to all Medicare Fee-for-Service (FFS) claims from May 1 through December 31, 2020.
Public Health Emergency Extended Another 90 Days
04/19/2021
– As a result of the continued impact of the COVID-19 pandemic, the U.S. Department of Health and Human Services has renewed the January 31, 2020 determination that a public health emergency has existed since January 27, 2020, nationwide.
This action means all HHS/CMS waivers and flexibilities currently in place will continue until July 20, 2021 unless earlier terminated by Secretary Azar. Many waivers and flexibilities put into place by states and commercial payers are tied to these declarations and so will be extended as well.
The renewal determination takes effect on April 21, 2021 and runs through July 20, 2021.
Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021
CMS Announces New Repayment Terms
Reference:
CMS.gov
MLN Matters
CMS.gov press release
Tuesday March 30, 2021
Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension
In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, we instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess if Congress extends the suspension; the MACs will automatically reprocess any claims paid with the reduction applied if necessary.
Reference, click here – CMS.gov
MLNconnects
Monday, March 15, 2021
Biden-Harris Administration Increases Medicare Payment for Lifesaving COVID-19 Vaccine
On March 15, CMS increased the Medicare payment amount for administering the COVID-19 vaccine. This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. At a time when vaccine supply is growing, CMS is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.
For More Information Click Here: Coverage and Reimbursement of COVID-19
Ref:
Centers for Medicare & Medicaid Services (CMS).
mlnconnects
Special Edition-
On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year
(CY) 2021 Medicare Physician Fee Schedule (MPFS):
Provided a 3.75% increase in MPFS payments for CY 2021
Suspended the 2% payment adjustment (sequestration) through March 31, 2021
Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024
CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.
Special Edition – Monday, December 28, 2020
Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through March
The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31. The Consolidated Appropriations Act, 2021, signed into law on December 27, extends the suspension period to March 31, 2021.
COVID-19 Vaccine Codes: Updated Effective Date for Pfizer-BioNTech
On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID‑19 Vaccine for the prevention of COVID-19 for individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.
During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review our updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; do not include the vaccine product codes when vaccines are free.
References:
Thursday, November 12, 2020
COVID-19 Vaccine Codes and PC-ACE Software Update
In anticipation of the availability of a vaccine(s), for the novel coronavirus (SARS-CoV-2) in response to the coronavirus disease 2019 (COVID-19), the American Medical Association (AMA), working with the Centers for Medicare & Medicaid Services (CMS), created new codes for the vaccine and the administration of the vaccine. To prepare for the vaccine administration claims, the PC-ACE software is also updated and ready for providers to download.
Click Here: AMA announces vaccine-specific CPT codes for coronavirus immunizations
CMS Takes Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment
CMS announced that starting November 10, Medicare beneficiaries can receive coverage of monoclonal antibodies to treat COVID-19 with no cost-sharing during the Public Health Emergency (PHE). CMS’ coverage of monoclonal antibody infusions applies to bamlanivimab, which received an Emergency Use Authorization (EUA) from the FDA on November 9.
Click Here: View the Monoclonal Antibody COVID-19 Infusion Program Instruction
New From Coverage to Care Resources on COVID-19
ATTENTION
The Proposed 2021 Medicare Physician Fee Schedule
Let your Voice Be Heard.
Currently, the proposed 2021 Medicare fee schedule contains a significant reduction to the conversion factor by $3.83 from $36.0 to $32.26 per RVU. This can affect some services by a negative 10% or greater.
Please submit comments on the proposed fee schedule, you have until October 5, 2020. Make your voice heard!
Here is how to comment:
Send Comments to The Proposed 2021 Medicare Physician Fee Schedule
Electronically: You may submit electronic comments on this regulation to:
Follow the “Submit a comment” instructions.
Refer to file code CMS-1734-P
If you want to speak to someone concerning the effect of the conversion factor:
Michael Soracoe
(410) 786-6312
For issues related to practice expense, work RVUs,
conversion factor, and specialty-specific impacts of PFS proposals
CMS Implementation Guide for Quality Reporting Document Architecture
Category I, Hospital Quality Reporting Implementation Guide for 2021
Click here: Hospital Quality Reporting Implementation Guide for 2021
MLN Connects – Dated 7-30-20
Update COVID-19: Laboratory Claims Requiring the NPI of the Ordering/Referring Professional
During the COVID-19 Public Health Emergency (PHE), CMS relaxed requirements for a limited number of laboratory tests required for a COVID-19 diagnosis. These tests do not require a practitioner order during the PHE. We added a new test to this list (PDF): CPT 87426 (Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]).
Any health care professional authorized under state law may order these tests. Medicare will pay for these tests without a written order from the treating physician or other practitioner:
If an order is not written, you do not need to provide the National Provider Identifier (NPI) of the ordering or referring professional on the claim
If an order is written, include the NPI of the ordering or referring professional, consistent with current billing guidelines
IMPORTANT: CMS is allowing 99211 for COVID specimen collection!
Click here: CMS: Practices can bill 99211 for COVID-19 Specimen Collection
Medicare News and Web Updates for JH Part B (2020)
Click here: Coronavirus (COVID-19) Information – July 9, 2020
Two New Category I Codes
The CPT Editorial Panel approved two new Category I codes and expedited the publication of these new codes to the AMA website on Tuesday, September 8, 2020.
These codes are effective immediately!
Special Services, Procedures and Reports – 99072
The new code 99072 was established to report additional practice expenses incurred during a Public Health Emergency (PHE), including supplies and additional clinical staff time.
New CPT code 86413 was established to report quantitative antibody detection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Click Here: This article will provide an overview of these new codes.
CMS Relaxing Some Lab Billing Requirements Due to COVID-19
CMS Announces New Repayment Terms for Medicare Loans Made to Providers During COVID-19
New recoupment terms allow providers and suppliers one additional year to start loan payments
CMS Shares Early Insights from the Accountable Health Communities Model
Resubmit claims for telephone E/M’s if you want higher payment!
If you billed Medicare for telephone evaluation and management (E/M) services in the past two months, you’ll need to resubmit affected claims in order to benefit from a recent CMS move to increase payment for CPT codes 99441-99443.
CMS requires that all eligible hospitals and critical access hospitals (CAHs) use 2015 Edition certified electronic health record technology (CEHRT) to meet the requirements of the Promoting Interoperability Programs.
Click here: Medicare Promoting Interoperability Program Hardship Exception Application Details
Click here: Medicare Promoting Interoperability Program Hardship Exception Application
CMS issues Second Round of Sweeping Changes, RHC & FQHC Flexibilities, EMTALACMS is taking action to ensure states and localities have the flexibilities they need to ramp up diagnostic testing and access to medical care, key precursors to ensuring a phased, safe, and gradual reopening of America.
4-28-2020- CMS Adds New COVID-19 Clinical Trials Improvement Activity to the Quality Payment Program
Click here: Additional details on the new Merit-Based Incentive Payment System (MIPS)
CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program
Visit coronavirus.gov for the latest Coronavirus Disease (COVID-19) updates.
Read the 30 Days to Slow the Spread Guidance – PDF
“MIPS” Deadline extended
Quality Payment Program – Merit-based Incentive Payment System
Click here: Deadline extended from March 31, 2020 to April 30, 2020
CMS Issues Recommendations to Re-Open Health Care Systems in Areas with Low Incidence of COVID-19
The new recommendations can be found here:
The Guidelines for Opening Up America Again can be found here:
4-17-2020- CMS and rural health care clinics during telehealth
Click here: New and Expanded Flexibilities for Rural Health Clinics
April 2020 Quarterly Update to the Medicare Physician Fee Schedule
Database (MPFSDB) –
April 15, 2020
CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests
4-13-2020 – Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)
Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.
4-10-2020 – Using CS Modifier When Cost-Sharing is Waived
This clarifies a prior message that appeared in our April 7, 2020 Special Edition.
CMS now waives cost-sharing (coinsurance and deductible amounts) under Medicare Part B for Medicare patients for certain COVID-19 testing-related services. Previously, CMS made available the CS modifier for the gulf oil spill in 2010; however, CMS recently repurposed the CS modifier for COVID-19 purposes. Now, for services furnished on March 18, 2020, and through the end of the Public Health Emergency, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under specific payment systems outlined in the April 7 message should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services and to get 100% of the Medicare-approved amount. Additionally, they should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.
Click here: Update Using CS Modifier When Cost-Sharing is Waived
4-9-2020
CMS Approves Approximately $34 Billion for Providers with the Accelerated/Advance Payment Program for Medicare Provider.
The Centers for Medicare & Medicaid Services (CMS) has delivered nearly $34 billion in the past week to the health care providers on the frontlines battling the 2019 Novel Coronavirus (COVID-19).
Click here: CMS Approves Approximately $34 Billion for Providers
CMS Federal Register Publication: 4-6-20
Announcement 4-6-2020
Open Payments Review & Dispute COVID-19 – CMS is aware that the COVID-19 pandemic is greatly impacting the healthcare community as a whole.
CMS does not have the authority to postpone the Open Payments data publication deadline of June 30 (42 U.S.C § 1320a–7h(c)(1)(C)). Given this statutory requirement for Open Payments data publication, and resource constraints that limit CMS’s ability to deviate from the established schedule for the covered recipient pre-publication review and dispute period, the covered recipient pre-publication review and dispute period will remain April 1, 2020 – May 15, 2020.
CMS Issues New Wave of Infection Control Guidance Based on CDC Guidelines to Protect Patients and Healthcare Workers from COVID-19
Guidance will aid clinicians in various healthcare settings to prevent and mitigate the spread.
Click here: Latest updates to these CMS guidance documents on infection control
CMS – MLN Catalog 2020
CMS- 4-3-2020
CMS is providing needed flexibility to hospitals to ensure they have the ability to expand capacity and to treat patients during the COVID-19 public health emergency. As part of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers CMS is allowing Medicare-enrolled ASCs to temporarily enroll as hospitals and to provide hospital services to help address the urgent need to increase hospital capacity to take care of patients.
CMS- Update 4-2-20
Telemedicine and COVID-19 FAQ
Updated: April 1, 2020 9:45 pm
On March 30, CMS released an interim rule with other changes.
First, all of these changes are effective March 1, 2020. CMS is changing the place of service for claims. Do not use POS 02 for CMS telehealth claims, use the place of service that would have been used if the patient had been seen face-to-face.
This means, if it is an office visit, you will be paid the higher, non-facility rate, not the facility rate. This is about $20 difference for office visits billed with POS 11. CMS now says to use modifier 95 on the claim.
CMS – To enable services to continue while lowering exposure risk, clinicians can now provide – 99441-99443 services by Telehealth – 3-30-2020
Click here: 99441-99443 page 2.
CMS: America’s Hospitals Engage in Unprecedented Data Sharing 3-29-2020
CMS: Financial Relief for Medicare Providers – 3-28-2020
Click here: Fact Sheet for Accelerated and Advanced Payments
CMS – Quality Payment Program and Quality Reporting Program/Value Based Purchasing Program COVID-19 Relief – 3-27-2020
Click here: Memo – Participating in quality reporting programs in response to the 2019 (COVID-19).
CMS – Clinical Laboratory Improvement Amendments (CLIA) Guidance During COVID-19 – 3-26-2020
CMS – Actions taken in response to the Coronavirus- 3-26-2020
Summary of recent CMS actions taken in response to the Coronavirus Disease 2019 (COVID-19)
4-9-2020
Telehealth and Other Virtual Services
Click here: Claims Payment Policy
Humana:
Telehealth Services – 3-2020
Medicaid.gov – Medicaid Individual State Coronavirus
Federal Disaster Resource: Section 1135 – 3-30-2020
MODA – Telehealth and Telemedicine Expanded Services for COVID-19 3-31-2020
Click here: Moda Health is expanding policies around Telehealth services
Tufts – Associated Health Plans, Inc – 3-24-2020
Coronavirus (COVID-19) Updates for Providers
Beginning Oct. 1, 2020, telehealth visits not related to COVID-19 will be covered according to your plan benefits. If you need care related to COVID-19, your cost-share* (copays, deductibles, and coinsurance) for COVID-19 telehealth visits is $0 with network providers until the end of the National Public Health Emergency period, currently scheduled to end Oct. 22, 2020.
UnitedHealthcare is extending many of the COVID-19 temporary coverage changes through October 22, 2020
For the most up-to-date plan and benefit information click here: myuhc.com
UnitedHealthcare will reimburse appropriate claims for telehealth services in accordance with the member’s benefit plan.
Summary of COVID-19 Updates on Dates by Program
4-9-2020
UnitedHealthcare will reimburse appropriate claims for telehealth services for dates of service from March 18, 2020 until June 18, 2020
4-8-2020
United Healthcare Patient Scenarios
4-8-2020
UnitedHealthcare Telehealth Guidance & Services
4-7-20
Important Note About Reimbursement Policy
UnitedHealthcare – 3-24-2020
UHC – 3-30-20
