may 2020 • medicare bulletin · yyif the claim matches an assessment that is for another reason,...

MedicareBulletin

JURISDICTION 15HOME HEALTH & HOSPICE

MAY 2020 • WWW.CGSMEDICARE.COM

GR 2020-05ORIGINATED APRIL 15, 2020

© 2020 Copyright, CGS Administrators, LLC.

Reaching Out to the Medicare Community

http://www.cgsmedicare.com

Medicare BulletinJurisdiction 15

Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyright 2020 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN GR 2020-05 MAY 2020 2

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HOME HEALTH PROVIDERSReason Code 37253: What to Look For 3

HOME HEALTH AND HOSPICE PROVIDERSCGS Website Updates 4

Contact Information for CGS Medicare Home Health and Hospice Providers 5

MLN Connects® Weekly News 5

MM11335 (Revised): Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS 6

MM11661 (Revised): Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update 7

MM11680: April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1 10

MM11701: April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files 12

MM11702: April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule 13

MM11745: July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files 15

Provider Contact Center (PCC) Training 16

Reminder: Where to Send Refund Checks 16

SE18006 (Revised): New Medicare Beneficiary Identifier (MBI) Get It, Use It 17

SE20007: Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements 21

SE20009: Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare 24

SE20011 (Revised): Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) 25

Upcoming Educational Events 30

New Medicare Beneficiary Identifier (MBI)USE IT NOW!

#NewCardNewNumber Learn more by visting:

https://www.cms.gov/Medicare/ New-Medicare-Card/index.html

https://www.onlineproviderservices.com/cgs_ops/initLogin.do

myCGS is a secure Internet-based application where you can view beneficiary eligibility, claims status, online remittances, financial information, and much more!

my

go.cms.gov/mln

https://www.cms.gov/Medicare/New-Medicare-Card/index.html

https://www.cms.gov/Medicare/New-Medicare-Card/index.html



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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters issued after February 1997 are available at no cost from our website at https://www.cgsmedicare.com. © 2020 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN GR 2020-05 MAY 2020

RETURN TO TABLE OF CONTENTS

3

FO R H O M E H E A LT H P R OV I D E R S

Reason Code 37253: What to Look For

For home health claims with From dates on or after January 1, 2020, matching your claim with the Outcome and Assessment Information Set (OASIS) is more important than ever. Based on the claim submission error data, the reason code 37253 (no OASIS found) is one of the top errors for home health providers. To help prevent your claims from going to the Return to Provider (RTP) file with 37253, we have provided an example of the Internet Quality Improvement and Evaluation System (iQIES) validation report showing what must match between the claim and the OASIS.

OASIS FINAL VALIDATION REPORT (FVR) EXAMPLE

Step 1 – Before submitting your claim, review the OASIS FVR Report to ensure the OASIS assessment was successfully accepted.

Step 2 – Check the FVR to confirm the receipt date shows the OASIS was accepted by iQIES before you submitted your claim. This date is shown on Page 1 of the report, in the “Completion Date/Time” field. Also ensure that the assessment has not been inactivated.

yy If the OASIS was submitted after the claim, resubmit the claim. If the claim is in the RTP file (T B9997), press F9.

yy If the assessment was inactivated, resubmit the assessment.

Step 3 – Check the Reason for Assessment (RFA) (OASIS Item M0100). It must be equal to 01, 03, 04, or 05.

yy If the claim matches an assessment that is for another reason, update the occurrence code 50 date on the claim to correspond to the M0090 date of the applicable assessment and resubmit the claim.

THE MEDICARE LEARNING NETWORK®

A Valuable Educational Resource! The Medicare Learning Network® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more.

Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

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Step 4 – Check the occurrence code 50 and ensure that you are reporting the assessment completion date (Item M0090).

Step 5 – Check the claim you submitted with the OASIS to ensure the following items match.

yy CMS Certification Number (OASIS Item M0010) – This is your agency’s Medicare provider number, (often referred to as PTAN).

yy Medicare Beneficiary Identifier (MBI) (OASIS Item M0063) – Effective January 1, 2020, regardless of the dates of service, all claims must be submitted with the new MBI. If the OASIS was submitted with the Health Insurance Claim Number (HICN), the OASIS will need to be corrected.

y� Changes to a beneficiary’s MBI may occur. Verify the MBI using the MBI look-up tool via myCGS. Refer to the myCGS MBI Look-up Tool (https://www.cgsmedicare.com/hhh/pubs/news/2018/0518/cope7584.html) for details on how to verify the MBI. If the MBI has changed, update Item M0063 on the OASIS and resubmit the claim.

yy Assessment Completion Date (OASIS Item M0090) – This is the date submitted on the claim with occurrence code 50.

If the claim and OASIS have correct and matching information, contact the Provider Contact Center (PCC) at 1.877.299.4500 (Option 1).

References

yy Quick Reference Guide to OASIS Submissions and Final Validation Reports - https://qtso.cms.gov/reference-and-manuals/quick-reference-guide-oasis-submissions-and-final-validation-reports

yy SE20010 MLN Matters article, Ensure Required Patient Assessment Information for Home Health Claims - https://www.cms.gov/files/document/se20010.pdf

FO R H O M E H E A LT H A N D H O S P I C E P R OV I D E R S

CGS Website Updates

CGS has recently made updates to their website, giving providers additional resources to assist with billing Medicare-covered services appropriately.

Please review the following updates:

yy The Claims Processing Issues Log Web page at https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html was updated with the most recent updates.

yy The Top Claim Submission Errors (Reason Codes) and How to Resolve Web page at https://www.cgsmedicare.com/hhh/education/materials/cses.html has been updated with the most recent data.

yy The Part A East (PAE) Appeal Demonstration Web page at https://www.cgsmedicare.com/hhh/appeals/demo.html has been updated to include a link to the February 2020 C2C Phone Demo Summary of Results.

yy A link to COVID-19 resources at https://www.cgsmedicare.com/hhh/topic/covid-19.html has been updated with various CMS resources.

yy The J15 HHH home page at https://www.cgsmedicare.com/hhh/index.html now includes a Disaster Resources widget on the right side navigation, that will direct you to resources for all current emergencies at https://www.cgsmedicare.com/hhh/topic/disaster_resources.html.

yy The Home Health Denial Reason Codes at https://www.cgsmedicare.com/hhh/medreview/hh_drc.html and the Hospice Denial Reason Codes at https://www.cgsmedicare.com/hhh/medreview/hos_drc.html web pages were updated by adding references to each of the denials codes. Now you can review the references and determine the reason for your denial.


https://www.cgsmedicare.com/hhh/pubs/news/2018/0518/cope7584.html

https://www.cgsmedicare.com/hhh/pubs/news/2018/0518/cope7584.html

https://qtso.cms.gov/reference-and-manuals/quick-reference-guide-oasis-submissions-and-final-validation-reports

https://qtso.cms.gov/reference-and-manuals/quick-reference-guide-oasis-submissions-and-final-validation-reports

https://www.cms.gov/files/document/se20010.pdf

https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html

https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html

https://www.cgsmedicare.com/hhh/education/materials/cses.html

https://www.cgsmedicare.com/hhh/appeals/demo.html

https://www.cgsmedicare.com/hhh/appeals/demo.html

https://www.cgsmedicare.com/hhh/topic/covid-19.html

https://www.cgsmedicare.com/hhh/index.html

https://www.cgsmedicare.com/hhh/topic/disaster_resources.html

https://www.cgsmedicare.com/hhh/topic/disaster_resources.html

https://www.cgsmedicare.com/hhh/medreview/hh_drc.html

https://www.cgsmedicare.com/hhh/medreview/hh_drc.html

https://www.cgsmedicare.com/hhh/medreview/hos_drc.html

https://www.cgsmedicare.com/hhh/medreview/hos_drc.html

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yy The new Hospice Caps quick resource tool at https://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_caps_jobaid.pdf was developed in collaboration with National Government Services (NGS), and Palmetto GBA, to assist with hospice providers understanding of the hospice cap process.


Contact Information for CGS Medicare Home Health and Hospice Providers

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center (PCC) at 1.877.299.4500. Listen carefully and choose the option most appropriate for the reason you are calling.

yy 1 – Claims

yy 2 – Electronic Data Interchange (EDI)

yy 3 – Provider Enrollment

yy 4 – Overpayment Recovery

yy 9 – General Inquiries

Access the Home Health and Hospice “Contact Information” web page at https://www.cgsmedicare.com/hhh/cs/index.html for information about the Interactive Voice Response (IVR) system, as well as telephone numbers, fax numbers, and mailing addresses for other CGS departments.

BEFORE YOU CALLAccess the “How Do I…?” icon (https://www.cgsmedicare.com/hhh/cs/howdoi.html) from the Home Health & Hospice Contact Information page at https://www.cgsmedicare.com/hhh/cs/index.html. In addition, refer to the “Education & Resources Options” icon (https://www.cgsmedicare.com/hhh/education/index.html) to access resources that may be able to answer your question.


MLN Connects® Weekly News

The MLN Connects® is the official news from the Medicare Learning Network and contains a weeks’ worth of Medicare-related messages. These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html.

yy March 13, 2020 (Special Edition) - https://www.cms.gov/files/document/2020-03-13-mlnc-se.pdf


yy March 17, 2020 (Special Edition) - https://www.cms.gov/files/document/2020-03-17-mlnconnects-se.pdf

yy March 19, 2020 - https://www.cms.gov/files/document/2020-03-19-mlnc.pdf



yy March 26, 2020 - https://www.cms.gov/files/document/2020-03-26-mlnc.pdf

yy March 26, 2020 (Special Edition) - https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf


https://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_caps_jobaid.pdf

https://www.cgsmedicare.com/hhh/education/materials/pdf/hospice_caps_jobaid.pdf

https://www.cgsmedicare.com/hhh/cs/index.html

https://www.cgsmedicare.com/hhh/cs/howdoi.html



https://www.cgsmedicare.com/hhh/education/index.html

https://www.cgsmedicare.com/hhh/education/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/files/document/2020-03-13-mlnc-se.pdf




https://www.cms.gov/files/document/2020-03-17-mlnconnects-se.pdf

https://www.cms.gov/files/document/2020-03-17-mlnconnects-se.pdf

https://www.cms.gov/files/document/2020-03-19-mlnc.pdf






https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf

https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf

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yy March 31, 2020 (Special Edition) - https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf

yy April 2, 2020 - https://www.cms.gov/files/document/2020-04-02-mlnc.pdf

yy April 3, 2020 (Special Edition) - https://www.cms.gov/files/document/2020-04-03-special-edition.pdf

yy April 7, 2020 (Special Edition) - https://www.cms.gov/files/document/2020-04-07-mlnc-se.pdf

yy April 9, 2020 - https://www.cms.gov/files/document/2020-04-09-mlnc.pdf

yy April 10, 2020 (Special Edition) - https://www.cms.gov/files/document/2020-04-10-mlnc-se.pdf


MM11335 (Revised): Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCSThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11335 Revised Related Change Request (CR) Number: 11335 Related CR Release Date: January 22, 2020 Effective Date: April 1, 2020 Related CR Transmittal Number: R2422OTN Implementation Date: April 6, 2020

Note: We revised this article on March 19, 2020, and updated the Provider Types Affected, What You Need to Know, and Background sections.

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers and suppliers checking Medicare Fee-for-Service (FFS) beneficiary eligibility for Pneumococcal Pneumonia Vaccination (PPV) services provided to Medicare FFS beneficiaries.

WHAT YOU NEED TO KNOWBeginning April 13, 2020, for both PPV Healthcare Common Procedural Coding System (HCPCS) codes (90670 and 90732), CMS will return for all FFS beneficiary eligibility transactions Dates of Service (DOS) and institutional National Provider Identifier (NPI) for Part A or rendering NPI for Part B, depending on the provider type who administered the service; instead of next eligibility dates, as previously returned. During the transition to return PPV dates of service vs next eligible dates, Medicare FFS will not return any PPV data from March 14, 2020, through April 12, 2020.

BACKGROUNDCurrently, after processing the Medicare FFS claim, the claims processing system groups these two HCPCS codes under the PPV HCPCS group code and sends a single next eligible date from the claims processing system to the data store used by Medicare FFS eligibility transactions. There is no logic for the eligibility systems to differentiate between the initial vaccine (code 90670) and the second vaccine (code 90732). With this change, Medicare FFS




https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf

https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf


https://www.cms.gov/files/document/2020-04-03-special-edition.pdf

https://www.cms.gov/files/document/2020-04-03-special-edition.pdf






https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


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will return eligibility transactions with the PPV DOS as well as the related National Provider Identifier (NPI) for both of these PPV HCPCS codes (90670 and 90732) for a beneficiary, so that a provider may determine if the beneficiary already received either or both vaccines, as well as when, and from which provider.

Medicare FFS eligibility transactions will give providers more PPV details for a Beneficiary, including up to 10 occurrences of historical PPV HCPCS codes, NPI, and DOS for each beneficiary. If providers don’t see a DOS/NPI for a particular beneficiary, Medicare FFS didn’t pay a claim for a PPV service; providers may administer the vaccine as medically appropriate and bill for the service.

ADDITIONAL INFORMATIONThe official instruction, CR11335, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r2422otn.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.

DOCUMENT HISTORY

Date of Change DescriptionMarch 19, 2020 We revised the article and updated the Provider Types Affected, What You Need to Know,

and Background sections.January 23, 2020 We revised the article due to an updated CR 11335 that deleted references to certain

inquiry screens. In the article, we changed the CR release date, transmittal number and link to the transmittal. All other information remains the same.

December 13, 2019 We revised this article due to an updated CR that added business requirement 11335.9 in the CR for contractor integration testing. We also changed the CR release date, transmittal number and link to the transmittal.

October 11, 2019 Initial article released.


MM11661 (Revised): Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 UpdateThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11661 Revised Related Change Request (CR) Number: 11661 Related CR Release Date: February 27, 2020 Effective Date: January 1, 2020 Related CR Transmittal Number: R4540CP Implementation Date: April 6, 2020

Note: We revised this article on February 27, 2020, to reflect the revised CR11661 issued on that date. In the article, we changed the MP RVU for code G2013 in Table 2 to 0.28. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries and reimbursed using the Medicare Physician Fee Schedule (MPFS).


https://www.cms.gov/files/document/r2422otn.pdf

http://go.cms.gov/MAC-website-list



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PROVIDER ACTION NEEDEDCR 11661 informs you that the Centers for Medicare & Medicaid Services (CMS) issued payment files to the MACs based upon the 2020 MPFS Final Rule, published in the Federal register on November 15, 2019. CR 11661 amends those payment files. Make sure your billing staffs are aware of these changes.

BACKGROUNDSection 1848(c)(4) of the Social Security Act authorizes the Secretary of the Department of Health and Human Services (HHS) to establish ancillary policies necessary to implement relative values for physicians’ services. The updated payment files are effective for services you furnish between January 1, 2020 and December 31, 2020.

Summary of Changes for April 2020Below is a summary of the changes for the April update to the 2020 MPFS. Unless otherwise stated, these changes are effective for dates of service on and after January 1, 2020.

1. The G codes listed in Table 1 are new codes, effective January 1, 2020.

Table 1: New Codes effective January 1, 2020Code ActionG2168 Status indicator = E; there are no RVUs, payment policy indicators do not apply.G2169 Status indicator = E; there are no RVUs, payment policy indicators do not apply.

Note: For new codes, please refer to the following link for more information: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

2. The HCPCS codes listed in Table 2 have revisions to Relative Value Units, effective for dates of service on and after January 1, 2020.

Table 2: HCPCS Codes with Revisions to Relative Value UnitsCode Modifier ActionG0105 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.20G0121 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.2144388 53 Non-Facility PE RVU change = 2.79, MP RVU change = 0.2045378 53 Non-Facility PE RVU change = 2.88, MP RVU change = 0.21G2001 MP RVU change = 0.05G2002 MP RVU change = 0.08G2003 MP RVU change = 0.13G2004 MP RVU change = 0.22G2005 MP RVU change = 0.28G2006 MP RVU change = 0.05G2007 MP RVU change = 0.09G2008 MP RVU change = 0.13G2009 MP RVU change = 0.22G2013 MP RVU change = 0.28

3. The HCPCS codes listed in Table 3 have been revised, effective for dates of service on and after January 21, 2020. Please see the following link for more information regarding these codes: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295.

Table 3: Revised HCPCS codesCode Action20560 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator =

0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0


https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update


https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295

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Table 3: Revised HCPCS codesCode Action20561 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator =

0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

97810 Status Code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

97811 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical component indicator = 0

97813 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

97814 Status code indicator change = A, Multiple Procedure indicator = 0, Bilateral Surgery indicator = 0, Assistant at Surgery indicator = 1, Co-Surgeons indicator = 0, Team Surgeons indicator = 0, Professional/Technical Component indicator = 0

The Relative Value Units (RVU) for these codes are listed below.

Code Work RVU Non Facility PE RVU Facility PE RVU MP RVU20560 0.32 0.39 0.12 0.0320561 0.48 0.57 0.18 0.0597810 0.60 0.40 0.23 0.0597811 0.50 0.25 0.19 0.0597813 0.65 0.47 0.25 0.0597814 0.55 0.36 0.21 0.05

4. The G code listed in Table 4 is no longer valid on the MPFS effective for dates of service on and after April 01, 2020.

Table 4: G Code No Longer ValidCode ActionG1000 Status Change to I

5. The G codes listed in Table 5 are new codes, effective April 01, 2020. CR 11550 implemented these codes.

Table 5: New G CodesCode ActionG1012 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1013 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1014 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1015 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1016 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1017 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1018 Status indicator = X, there are no RVUs, payment policy indicators do not applyG1019 Status indicator = X, there are no RVUs, payment policy indicators do not apply

Please see https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update for more information on the above new codes.

ADDITIONAL INFORMATIONThe official instruction, CR11661, issued to your MAC regarding this change, is available at https://www.cms.gov/files/document/r4540cp.pdf.




https://www.cms.gov/files/document/r4540cp.pdf

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DOCUMENT HISTORY

Date of Change DescriptionFebruary 27, 2020 We revised this article to reflect the revised CR11661 issued on that date. In the article, we

changed the MP RVU for code G2013 in Table 2 to 0.28. Also, we revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

February 18, 2020 Initial article released.


MM11680: April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11680 Related Change Request (CR) Number: 11680 Related CR Release Date: March 6, 2020 Effective Date: April 1, 2020 Related CR Transmittal Number: R4543CP Implementation Date: April 6, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, hospitals, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 11680 provides the Integrated OCE (I/OCE) instructions and specifications for the I/OCE that is being updated for April 1, 2020. Please make sure your billing staff is aware of this update.

BACKGROUNDCR 11680 informs the MACs and the Fiscal Intermediary Shared System (FISS) maintainer that the I/COE is being updated for April 1, 2020. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated I/OCE.

This I/OCE will be used in the Outpatient Prospective Payment System (OPPS) and for non-OPPS claims for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a Home Health Agency (HHA) not under the HH PPS or to a hospice beneficiary for the treatment of a non-terminal illness.

The I/OCE specifications will be posted on the Centers for Medicare & Medicaid Services website at http://www.cms.gov/OutpatientCodeEdit/.

Table 1: Summary of Quarterly Release Modifications

TypeEffective Date

Edits Affected Modification

Logic 04/01/2020 24 Modify the software to maintain 28 prior quarters (7 years) of programs in each release. Remove older versions with each release. The earliest date included for this release is 07/01/2013.






http://www.cms.gov/OutpatientCodeEdit/

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Table 1: Summary of Quarterly Release Modifications

TypeEffective Date

Edits Affected Modification

Logic 01/01/2017 Add new payment method flag of X (Contractor bypass applied to Section 603 service with no reduction applied in OPPS Pricer) to be returned on output to identify a line(s) that have had a Contractor bypass applied to a Section 603 item or service that is not applicable for a reduction in Pricer.

Note: The Contractor Bypass function is a CMS/Contractor related function and is not meant to be used by other end users or providers. See Contractor (MAC) Actions Impacting IOCE Processing for more information.

Logic 01/21/2020 68 Apply mid-quarter edit 68 (Service provided prior to date of NCD approval) to HCPCS 20560, 20561, 97810, 97811, 97813, 97814, if reported before 01/21/2020.

Logic 04/01/2020 1 Update diagnosis code editing for validity, based on the FY 2020 ICD-10-CM code update to include diagnosis code U07.0 (Vaping-related disorder) effective 04/01/2020.

Docu-mentation

04/01/2020 10, 23, 24, 44, 84

Update notes within edit descriptions for edits 10, 23, and 24, 44 and, 84.

Content 04/01/2020 Make all HCPCS/APC/SI changes as specified by CMS.

Updates were made to the following lists (please review the Quarterly Data Table Reports for additional detail). Due to the new table and file structure for January 2020, the tables that are updated which reference a list are specified below.

MAP_ADDON_TYPE I• Addon Type I procedures (edit 106)

MAP_ADDON_TYPE III • Addon Type III procedures (edit 108)

DATA_HCPCS• Information Only Service list (edit 112) • FQHC Non-Covered list • Device Procedure Edit 92 Bypass list (edit 92) • Non-covered services lists (SI = E1, for edits 9)• Non-reportable for OPPS list (SI = B, edit 62) • Procedure and Sex Conflict list (female only) (edit 8) • Terminated Device Procedure flag

OFFSET_HCPCS • Terminated Device Procedure Offset (Retroactively deleted 2 codes from table)

MAP CONFLICT RHC • RHC CG modifier non-payable conflict

Content 04/01/2020 20, 40 Implement version 26.1 of the NCCI (as modified for applicable outpatient institutional providers).

ADDITIONAL INFORMATIONThe official instruction, CR 11680, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r4543CP.pdf.



DOCUMENT HISTORY

Date of Change DescriptionMarch 6, 2020 Initial article released.


https://www.cms.gov/files/document/r4543CP.pdf



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MM11701: April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 11701 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.

BACKGROUNDThe ASP methodology is based on quarterly data manufacturers submit to CMS. CR 11701 instructs MACs to download and implement the April 2020 and, if released, the revised January 2020, October 2019, July 2019, and April 2019 ASP drug pricing files for Medicare Part B drugs.

CR 11701 addresses the following pricing files:

yy File: April 2020 ASP and ASP NOC — Effective Dates of Service: April 1, 2020, through June 30, 2020

yy File: January 2020 ASP and ASP NOC — Effective Dates of Service: January 1, 2020, through March 31, 2020

yy File: October 2019 ASP and ASP NOC — Effective Dates of Service: October 1, 2019, through December 31, 2019

yy File: July 2019 ASP and ASP NOC — Effective Dates of Service: July 1, 2019, through September 30, 2019

yy File: April 2019 ASP and ASP NOC — Effective Dates of Service: April 1, 2019, through June 30, 2019.

ADDITIONAL INFORMATIONThe official instruction, CR 11701, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10003cp.pdf.





https://www.cms.gov/files/document/r10003cp.pdf



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DOCUMENT HISTORY



MM11702: April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee ScheduleThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index


PROVIDER TYPES AFFECTEDThis MLN Matters® Article is for providers and suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services that Medicare reimburses under the DMEPOS fee schedule.

PROVIDER ACTION NEEDEDCR 11702 informs DME MACs about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. The update process for the DMEPOS fee schedule is available in the Medicare Claims Processing Manual, Chapter 23, Section 60 at: https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf. Make sure your billing staff is aware of this update.

BACKGROUNDCR 11702 provides instructions for the April 2020 DMEPOS Rural ZIP code file containing the Quarter 2, 2020 Rural ZIP code changes. Also included in the update is the former Competitive Bidding Area (CBA) ZIP code file containing the Quarter 2, 2020 Round 1 2017 and Round 2 Re-compete CBA ZIP codes. An April update to the 2020 DMEPOS and PEN fee schedule files is not required.

The following DMEPOS fee schedule and ZIP code Public Use Files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested parties shortly after the release of the data files at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html:

1. DMEPOS Fee schedule PUF

2. DME PEN Fee schedule PUF

3. DME Rural Zip code PUF

4. Former CBA Fee schedule PUF




https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf

https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

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5. Former CBA National Mail Order Diabetic Testing Supply (DTS) Fee schedule PUF

6. Former CBAZIP code PUF

Payment on a fee schedule basis is required for DME, prosthetic devices, orthotics, prosthetics and surgical dressings by Section 1834(a), (h), and (i) of the Social Security Act (the Act). Additionally, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulations (CFR) Section 414.102 for Parenteral and Enteral Nutrition (PEN), splints, casts, and Intraocular Lenses (IOLs) inserted in a physician's office. The DMEPOS and PEN fee schedule files contain Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the adjusted fee schedule amounts under 1834(a)(1)(F) of the Act, as well as codes that are not subject to the fee schedule Competitive Bidding Program (CBP) adjustments.

Section 1834(a)(1)(F)(ii) of the Act mandates adjustments to the fee schedule amounts for certain items furnished on or after January 1, 2016, in areas that are not Competitive Bid Areas (CBAs), based on information from CBPs for DME. Section 1842(s)(3)(B) of the Act provides authority for making adjustments to the fee schedule amount for enteral nutrients, equipment and supplies (enteral nutrition) based on information from CBPs.

The established methodologies for adjusting DMEPOS fee schedule amounts under this authority are at 42 CFR Section 414.210(g). Additional information on adjustments to the fee schedule amounts based on information from CBPs is available in Transmittal 4487, CR 11570, January 3, 2020 at: https://www.cms.gov/files/document/mm11570.pdf. Also, CR 11570 provides information on the adjusted fee payment basis for items and services furnished from January 1, 2019, through December 31, 2020, in the following three areas: rural and noncontiguous non-CBAs, non-rural and contiguous non-CBAs and in former CBAs during a temporary gap in the DMEPOS CBP.

Due to a delay in announcement of the next round of the CBP, contracts are not in effect in Round 1, Round 2, or the National Mail Order CBAs beginning January 1, 2019, resulting in a temporary gap period in the CBP. Additional program instructions for payment of items furnished in former CBAs is available in Transmittal 4275, CR 11233, April 5, 2019 at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11233.pdf

The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. The DMEPOS Rural ZIP code file contains the ZIP codes designated as rural areas. ZIP codes for non-continental Metropolitan Statistical Areas (MSA) are not included in the DMEPOS Rural ZIP code file. The DMEPOS Rural ZIP code file updates on a quarterly basis as necessary. Regulations in Section 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code estimated to be outside any MSA. A rural area also includes any ZIP Code within an MSA excluded from a competitive bidding area established for that MSA. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes and a quarterly update as necessary.

ADDITIONAL INFORMATIONThe official instruction, CR 11702, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/10004cp.pdf.




https://www.cms.gov/files/document/mm11570.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11233.pdf



https://www.cms.gov/files/document/10004cp.pdf



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DOCUMENT HISTORY



MM11745: July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: MM11745 Related Change Request (CR) Number: 11745 Related CR Release Date: March 27, 2020 Effective Date: July 1, 2020 Related CR Transmittal Number: R10017CP Implementation Date: July 6, 2020

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDCR 11745 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf). Make sure your billing staffs are aware of these changes.

BACKGROUNDThe ASP methodology is based on quarterly data manufacturers submit to CMS. CR 11745 instructs MACs to download and implement the July 2020 and, if released, the revised April 2020, January 2020, October 2019, and July 2019 drug pricing files for Medicare Part B drugs.

CR 11745 addresses the following pricing files:


yy File: April 2020 ASP and ASP NOC — Effective Dates of Service: April 1, 2020, through June 30, 2020

yy File: January 2020 ASP and ASP NOC — Effective Dates of Service: January 1, 2020, through March 31, 2020

yy File: October 2019 ASP and ASP NOC — Effective Dates of Service: October 1, 2019, through December 31, 2019





https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

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ADDITIONAL INFORMATIONThe official instruction, CR 11745, issued to your MAC regarding this change is available at https://www.cms.gov/files/document/r10017CP.pdf.



DOCUMENT HISTORY



Provider Contact Center (PCC) Training

Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs). The list below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will be closed for training.

Date PCC Training/ClosuresThursday, May 14, 2020 8:00 a.m. – 10:00 a.m. Central Time Monday, May 25, 2020 Office Closed for Memorial Day

The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For additional information, go to https://www.cgsmedicare.com/hhh/index.html and click the “myCGS” button on the left side of the web page.

For your reference, access the “Home Health & Hospice 2020 Holiday/Training Closure Schedule” at https://www.cgsmedicare.com/hhh/help/pdf/2020_hhh_calendar.pdf for a complete list of PCC closures.


Reminder: Where to Send Refund Checks

CGS often receives Medicare refund checks mailed to their corporate office instead of the appropriate PO Box. This causes a delay in processing of your check. As a reminder, when you need to send a check to make a payment as a result of a Medicare demand letter, or if you have identified a Medicare overpayment and are sending a voluntarily refund check, be sure to mail it to the appropriate PO Box below.

E-OFFSET myCGS OPTIONProviders may also use the myCGS Web Portal to request an immediate offset related to a demand letter, or authorize a permanent request for all future demand overpayments. Refer to the myCGS eOffsets Job Aid at https://www.cgsmedicare.com/pdf/eOffsetsJobAid.pdf for additional information.


https://www.cms.gov/files/document/r10017CP.pdf



https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

https://www.cgsmedicare.com/hhh/index.html

https://www.cgsmedicare.com/hhh/help/pdf/2020_hhh_calendar.pdf

https://www.cgsmedicare.com/pdf/eOffsetsJobAid.pdf

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DEMAND LETTER REFUNDS Home Health and Hospice PO Box 957124 St. Louis, MO 63195-7124

VOLUNTARY REFUNDSHome Health and Hospice PO Box 957124 St. Louis, MO 63195-7124

Please refer to the following CGS web pages for additional information and helpful tips.

yy Home Health and Hospice Refund Check for Demand Letters - https://www.cgsmedicare.com/hhh/overpay/refund_check.html

yy Home Health and Hospice Voluntary Refunds - https://www.cgsmedicare.com/hhh/overpay/voluntary_refunds.html

yy HHH Offsets - https://www.cgsmedicare.com/hhh/overpay/offsets.html


SE18006 (Revised): New Medicare Beneficiary Identifier (MBI) Get It, Use ItThe Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: SE18006 Revised Related Change Request (CR) Number: N/A Article Release Date: March 19, 2020 Effective Date: N/A Related CR Transmittal Number: N/A Implementation Date: N/A

Note: We revised the article on March 19, 2020, to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool. All other information remains the same.

PROVIDER TYPES AFFECTEDThis Special Edition MLN Matters® Article is for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs) and Home Health and Hospice MACs, for services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDUse MBIs for all Medicare transactions. The Centers for Medicare & Medicaid Services (CMS) replaced the Social Security Number (SSN)-based Health Insurance Claim Numbers (HICNs) with the MBI and mailed new Medicare cards to all Medicare beneficiaries. The cards with MBIs offer better identity protection.

With a few exceptions, Medicare will reject claims you submit with Health Insurance Claim Numbers (HICNs). Medicare will reject all eligibility transactions you submit with HICNs.

There are 3 ways you and your office staff can get MBIs:

1. Ask your Medicare patients

Ask your Medicare patients for their Medicare cards when they come for care. If they don’t bring it with them when they come for care, give them the Get Your New Medicare Card flyer in English (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-


https://www.cgsmedicare.com/hhh/overpay/refund_check.html

https://www.cgsmedicare.com/hhh/overpay/refund_check.html

https://www.cgsmedicare.com/hhh/overpay/voluntary_refunds.html

https://www.cgsmedicare.com/hhh/overpay/voluntary_refunds.html

https://www.cgsmedicare.com/hhh/overpay/offsets.html



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf

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Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf) or Spanish (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf).

2. Use your MAC's secure MBI look-up tool

You can look up MBIs for your Medicare patients when they don’t or can’t give them. Sign up (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf) for the Portal to use the tool. Even if your patients are in a Medicare Advantage Plan, you can look up their MBIs to bill for things like indirect medical education.

You must have your patient’s first name, last name, date of birth and Social Security Number (SSN) to search. The SSN may differ from the HICN, which uses the SSN of the primary wage earner. If your Medicare patient doesn’t want to give the SSN, tell your patient to log into mymedicare.gov (https://www.mymedicare.gov/) to get the MBI.

If the look-up tool returns a last name matching error and the beneficiary’s last name includes a suffix, such as Jr. Sr. or III, try searching without and with the suffix as part of the last name. You won’t get an MBI from the look-up tool if the beneficiary has a date of death greater than 13 months from the date of your search. Instead, we return the date of death. This aligns with timely filing for a claim.

3. Check the remittance advice

If you previously saw a patient and got a claim payment decision based on a claim submission with a HICN before January 1, 2020, look at that remittance advice. We returned the MBI on every remittance advice when a provider submitted a claim with a valid and active HICN from October 1, 2018 through December 31, 2019.

BACKGROUNDThe Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required CMS to remove SSNs from all Medicare cards. CMS replaced the SSN-based HICN with a new, randomly generated MBI. The MBI hyphens on the card are for illustration purposes: don’t include the hyphens or spaces on transactions. The MBI uses numbers 0-9 and all uppercase letters except for S, L, O, I, B, and Z. We exclude these letters to avoid confusion when differentiating some letters and numbers (for example, between “0” and “O”). Review the MBI specifications format (https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf).

The Railroad Retirement Board (RRB) also mailed Medicare cards with MBIs. There is a RRB logo in the upper left corner and “Railroad Retirement Board” at the bottom, but you can’t tell from looking at the MBI if your patient is eligible for Medicare because they’re a railroad retiree. You can identify them by the RRB logo on their card, and we return a “Railroad Retirement Medicare Beneficiary” message on the Fee-For-Service (FFS) MBI eligibility transaction response.

RRB Issued Medicare Card


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf

https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf


http://mymedicare.gov

https://www.mymedicare.gov/

https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf

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Use the MBI the same way you used the HICN. This also applies to reporting informational only and no-pay claims. Don’t use hyphens or spaces with the MBI to avoid rejection of your claim. Use the MBI on Medicare transactions including Billing, Eligibility Status, and Claim Status. The effective date of the MBI is the date each beneficiary was or is eligible for Medicare. If you don’t use the MBI, we will reject claims, with few exceptions. You will get:

yy Electronic claims - Reject codes: Claims Status Category Code of A7 (acknowledgment rejected for invalid information), a Claims Status Code of 164 (entity’s contract/member number), and an Entity Code of IL (subscriber)

yy Paper claims - Paper notice; Claim Adjustment Reason Code (CARC) 16 “Claim/service lacks information or has submission/billing error(s)” and Remittance Advice Remark Code (RARC) N382 “Missing/incomplete/invalid patient identifier”

The beneficiary or their authorized representative can request an MBI change. CMS can also change an MBI. An example is if the MBI is compromised. It’s possible for your patient to seek care before getting a new card with the new MBI.

If you get a HETS eligibility transaction error code (AAA 72) of “invalid member ID,” your patient’s MBI may have changed. There are different scenarios for using the old or new MBIs:

FFS claims submissions with:

yy Dates of service before the MBI change date – use old or new MBIs.

yy Span-date claims with a “From Date” before the MBI change date – use old or new MBIs

yy Dates of service that are entirely on or after the effective date of the MBI change – use new MBIs.

FFS eligibility transactions when the:

yy Inquiry uses new MBI – we’ll return all eligibility data

yy Inquiry uses the old MBI and request date or date range overlap the active period for the old MBI – we’ll return all eligibility data. We’ll also return the old MBI termination date.

yy Inquiry uses the old MBI and request date or date range are entirely on or after the effective date of the new MBI – we’ll return an error code (AAA 72) of “invalid member ID.”

When the MBI changes, we ask the beneficiary to share the new MBI with you. You can also get the MBI from your MAC’s secure MBI lookup tool.

ExceptionsYou MUST submit claims using MBIs, no matter what date you performed the service, with a few exceptions:

yy Appeals – You can use either HICNs or MBIs for claim appeals and related forms.

yy Claim status query – You can use the HICN or MBI to check the status of a claim (276transactions) if the earliest date of service on the claim is before January 1, 2020. If you are checking the status of a claim with a date of service on or after January 1, 2020, you must use the MBI.

yy Span-date claims – You can use HICNs or MBIs for 11X-Inpatient Hospital, 32X- Home Health (home health final claims and Request for Anticipated Payments [RAPs])and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (December 31, 2019). If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019.

Medicare crossover claimsMedicare's Coordination of Benefits Agreement (COBA) trading partners (supplemental insurers, Medigap plans, Medicaid, etc.) must submit the MBI to get Medicare crossover claims.


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Exceptions (https://www.cms.gov/Medicare/New-Medicare-Card/index) on use of HICN on outbound Medicare crossover claims will apply.

Remember

The MBI doesn’t change Medicare benefits. Protect the MBI as Personally Identifiable Information (PII); it is confidential.

Medicare Advantage and Prescription Drug plans continue to assign and use their own identifiers on their health insurance cards. For patients in these plans, continue to ask for and use the plans’ health insurance cards.

ADDITIONAL INFORMATIONIf you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

To sign up for your MAC's secure portal MBI look-up tool, visit https://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf.

The MBI format specifications, which provide more details on the construct of the MBI, are available at https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf.


DOCUMENT HISTORY

Date of Change DescriptionMarch 19, 2020 We revised the article to clarify that you need the beneficiary’s first name, last name, date

of birth, and SSN to use MBI look-up tool. All other information remains the same.February 12, 2020 We revised the article to add a sentence to the MBI look-up tool option for getting an MBI

to show what happens if the beneficiary record has a date of death. All other information remains the same.

January 2, 2020 We reissued the article to update certain language to show the use of the MBI is fully implemented.

August 19, 2019 We reissued this article to show that all new Medicare cards have been mailed, to encourage providers to use MBIs now to protect patients’ identities, to emphasize that providers must use MBIs beginning January 1, 2020, and to explain the rejection codes providers will get if they submit a HICN after January 1, 2020.

March 6, 2019 We revised this article to add language that the MBI look-up tool can be used to obtain an MBI even for patients in a Medicare Advantage Plan. All other information remains the same.

December 10, 2018 The article was revised to update the language regarding when MACs can return an MBI through the MBI look up tool (page 1). All other information remains the same.

July 11, 2018 This article was revised to provide additional information regarding the format of the MBI not using letters S, L, O, I, B, and Z (page 2).

June 25, 2018 This article was revised to provide additional information regarding the ways your staff can get MBIs (page 1).

June 21, 2018 The article was revised to emphasize the need to submit the MBI without hyphens or spaces to avoid rejection of your claim.

May 25, 2018 Initial article released.


https://www.cms.gov/Medicare/New-Medicare-Card/index





https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf

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SE20007: Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization RequirementsThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: SE20007 Related Change Request (CR) Number: N/A Article Release Date: February 24, 2020 Effective Date: January 1, 2020 Related CR Transmittal Number: N/A Implementation Date: January 1, 2020

PROVIDER TYPES AFFECTEDThis Special Edition Article is for providers and suppliers who bill Medicare Administrative Contractors (MACs) for Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) provided to Medicare beneficiaries.

PROVIDER ACTION NEEDEDSE20007 informs providers that the Calendar Year (CY) 2020 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule CMS-1713-F (84 Fed. Reg Vol 217) (https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis) goes into effect January 1, 2020.

This rule, in part, streamlines the requirements for ordering DMEPOS items through the identification of a standard set of elements to be included in a written order/prescription. It also develops a new Master List of DMEPOS items potentially subject to a face-to-face encounter, written orders prior to delivery and, or prior authorization requirements as a condition of payment (thereby harmonizing prior lists). This standard written order and Master list will simplify the ordering of DMEPOS items and eliminate multiple lists of DMEPOS items potentially subject to conditions of payment.

BACKGROUNDIn an April 2006 final rule (71 FR 17021), the Centers for Medicare & Medicaid Services (CMS) established face-to-face examination and written order prior to delivery requirements for power mobility devices. In a November 2012 final rule (77 FR 68892), CMS separately created a list of Specified Covered Items to be subject to a face-to-face encounter and written order prior to delivery requirements. In a December 2015 final rule (80 FR 81674), CMS created a “Master List” of items that are potentially subject to prior authorization. Final Rule CMS-1713-F (84 Fed. Reg Vol 217) harmonizes these lists created by the former rules and developed one “Master List” which serves as a library of items from which items may be selected to be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements.

Similarly, while written order/prescription requirements aim to create uniformity and exactness in healthcare delivery, over time the implementation of overlapping instructions created various requirements for written orders/prescriptions, depending upon the type of DMEPOS being ordered. Final Rule CMS-1713-F (84 Fed. Reg Vol 217) creates one standard set of required elements for all DMEPOS orders.




https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis



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KEY POINTSRequired Elements of a Standard Written Order/Prescription for all DMEPOS items:

yy The standard written order/prescription must include the following elements:

A. Beneficiary Name or Medicare Beneficiary Identifier (MBI)

B. General Description of the item

C. Quantity to be dispensed, if applicable

D. Order Date

E. Treating Practitioner Name or National Provider Identifier (NPI)

F. Treating Practitioner Signature

Standard Written Order/Prescription Definitions and General Requirements

yy A written order/prescription is a written communication from a treating practitioner to a supplier of the DMEPOS item(s).

yy Treating practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act (the Act), or physician assistant, nurse practitioner, or clinical nurse specialist, as those terms are defined in Section 1861(aa)(5) of the Act.

yy All DMEPOS items require a written order/prescription from the treating practitioner to be communicated to the supplier prior to submitting a claim for Medicare payment.

yy Items selected to be subject to the face-to-face encounter and written order prior to delivery requirements, as a condition of payment, will be published via no less than a 60-day Federal Register Notice and included on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, which will be posted on the CMS and DME MAC websites.

y� Items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List (i.e., Power Mobility devices (PMDs) and any other items selected from the Master List and published via Federal Register Notice) require the written order/prescription to be communicated to the supplier prior to delivery.

y� Items requiring a face-to face encounter and written order per statute will always require such conditions of payment, and will remain on the Required Face-to-Face Encounter and Written Order Prior to Delivery List (i.e., PMD).

Master List of items requiring a face-to-face encounter and written order prior to delivery and, or prior authorization.

yy The November 2019 Final Rule CMS-1713-F created one DMEPOS list titled Master List of DMEPOS Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements.

y� The master list of DMEPOS items potentially subject to face-to-face encounter and written order prior to delivery and, or prior authorization requirements, is available in the Final Rule CMS-1713-F (84 Fed. Reg Vol 217) on page 60756.

yy The Master List will serve as a library of DMEPOS items. From this Master List, items may be selected for inclusion on the Required Face-to-Face Encounter and Written Order Prior to Delivery List or the Required Prior Authorization List or items may be included on both Required Lists. Items included in either Required List are subject to the requirements of the list as a condition of payment.

y� Items selected and included in the Required Face-To-Face Encounter and Written Order Prior to Delivery List will be published in the Federal Register with no less than 60 days’ notice and posted on CMS’ and its contractors’ websites.

y� Items selected and included in the Required Prior Authorization List will be published in the Federal Register with no less than 60 days’ notice and posted on CMS’ and its contractors’ websites.


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The Face-to-Face Encounter- Definition, Timeframes and Documentation:

yy For DMEPOS items appearing on the Required Face-to-Face and Written Order Prior to Delivery List, the treating practitioner must document and communicate to the DMEPOS supplier that the treating practitioner has conducted a face-to-face encounter with the beneficiary within the 6 months preceding the date on the written order/prescription.

y� Note: The 6-month timing requirement does not supplant other CMS policies. For example, the National Coverage Determination Manual, Section 240.2 “Home use of Oxygen” requires a face-to-face examination within a month of starting home oxygen therapy.

yy A face-to-face encounter means an in-person or telehealth encounter between the treating practitioner and the beneficiary. The face-to-face encounter shall be used for the purpose of gathering subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.

yy If a telehealth encounter is used to satisfy the face-to-face encounter requirement for a DMEPOS item(s), it also must meet the requirements of 42 CFR §§ 410.78 and 414.65.

yy Suppliers must maintain, and upon request by CMS or its contractors, provide the face-to-face documentation, as well as the written order/prescription, and the supporting documentation provided by the treating practitioner to support payment for the item(s) of DMEPOS.

yy The face-to-face encounter shall be documented in the pertinent portion of the medical record and supports payment for the item(s). For example:

y� History

y� Physical examination

y� Diagnostic tests

y� Summary of findings

y� Progress notes

y� Treatment plans

y� Other sources of information that may be appropriate

yy The supporting documentation includes subjective and objective beneficiary-specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.

Prior Authorization

The final rule CMS-1713-F also updates the prior authorization process to allow CMS to more nimbly respond to billing concerns in its selection of items subject to prior authorization. This is because the list may be updated in a timelier manner, accounts for lower dollar but high volume items that pose vulnerabilities, and adjusts the cost thresholds to account for recent changes in policy that lowered their prior costs.

The rule does not impact the supplier process for submitting prior authorization requests, or receiving contractor feedback, for those items subject to prior authorization.

In response to industry feedback on the prior authorization process, CMS is working on systems changes to allow suppliers to voluntarily add accessories that do not appear on the Required Prior Authorization List to their request for prior authorization of the base device, if they so wish. This will be a voluntary process and would not impose prior authorization of these accessories as a condition of payment.

ADDITIONAL INFORMATIONCMS Final Rule 1713-F, (84 Fed.Reg Vol 217), titled: Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program,


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Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for a DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements, is available at https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis.



DOCUMENT HISTORY

Date of Change DescriptionFebruary 24, 2020 Initial article released.


SE20009: Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original MedicareThe Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: SE20009 Related Change Request (CR) Number: N/A Article Release Date: March 3, 2020 Effective Date: N/A Related CR Transmittal Number: N/A Implementation Date: N/A

PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, non-physician practitioners, other providers, and suppliers who may bill Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries who are enrolled in Health Maintenance Organization (HMO) Medicare Non-Risk plans.

WHAT YOU NEED TO KNOWThis MLN Matters article reinforces existing Medicare policy that allows non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees.

BACKGROUNDThe Centers for Medicare & Medicaid Services’ (CMS) has received reports from Medicare cost plans (under Sections 1876 (https://www.ssa.gov/OP_Home/ssact/title18/1876.htm) and 1833 (https://www.ssa.gov/OP_Home/ssact/title18/1833.htm) of the Social Security Act) that non-network providers sometimes will not treat cost plan members because the providers do not realize that the payer may be either the cost plan or original Medicare.

For example, when a Medicare cost plan enrollee visits a non-network physician, the physician’s office typically queries CMS’ HIPAA Eligibility Transaction System (HETS) to determine the eligibility of the patient. Currently, HETS specifies that cost plan enrollees are an “HM,” where HM refers to a “Health Maintenance Organization (HMO) Medicare Non-Risk” enrollee. As a result, some non-network physicians may not understand that the system is referring to an enrollee in a Medicare cost plan under Section 1876 or Section 1833 of the Social Security Act and therefore the provider will be paid by original Medicare.







https://www.ssa.gov/OP_Home/ssact/title18/1876.htm

https://www.ssa.gov/OP_Home/ssact/title18/1833.htm

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CMS is reminding all providers that Medicare cost plan enrollees have coverage both through the Medicare cost plan and through original Medicare. Non-network physicians may bill the CMS MAC and these claims will be processed in the same manner as claims submitted on behalf of original Medicare enrollees.

ADDITIONAL INFORMATIONIf you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.


DOCUMENT HISTORY



SE20011 (Revised): Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index

MLN Matters Number: SE20011 Revised Related Change Request (CR) Number: N/A Article Release Date: March 20, 2020 Effective Date: N/A Related CR Transmittal Number: N/A Implementation Date: N/A

Note: We revised this article on March 20, 2020, to add a note in the Telehealth section to cover the use of modifiers on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same.

PROVIDER TYPES AFFECTEDThis MLN Matters® Special Edition Article is for providers and suppliers who bill Medicare Fee-For-Service (FFS).

PROVIDER INFORMATION AVAILABLEThe Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.

More Informationyy Current Emergencies web page - https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page






https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page


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yy Instructions to request an individual waiver if there is no blanket waiver - https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf

BACKGROUNDSection 1135 and Section 1812(f) WaiversAs a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.

2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.

Medicare FFS Questions & Answers (Q&As) available on the Waivers and Flexibilities web page (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities) apply to items and services for Medicare beneficiaries in the current emergency. These Q&As are displayed in two files:

yy Q&As that apply without any Section 1135 or other formal waiver

yy Q&As apply only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver.

Blanket Waivers Issued by CMSYou do not need to apply for the following approved blanket waivers:

Skilled Nursing Facilities (SNFs)yy Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

yy 42 CFR 483.20: This waiver provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission (Blanket waiver for all impacted facilities).

Home Health Agenciesyy 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Blanket waiver for all impacted agencies)

yy To ensure the correct processing of home health emergency related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

Critical Access HospitalsThis action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours. (Blanket waiver for all impacted hospitals)

Housing Acute Care Patients in Excluded Distinct Part UnitsCMS has determined it is appropriate to issue a blanket waiver to inpatient prospective payment system (IPPS) hospitals that, as a result of the emergency, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of


https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf



https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities

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capacity issues related to the emergency. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients.)

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility (IRF) prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.

IRFs may exclude patients from the hospital’s or unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF.

Care for Patients in Long-Term Care Acute Hospitals (LTCH)sCMS has determined it is appropriate to issue a blanket waiver to long-term care hospitals (LTCHs) to exclude patient stays where an LTCH admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement which allows these facilities to be paid as LTCHs.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by the EmergencyCMS has determined it is appropriate to issue a blanket waiver where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable, contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.

For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at


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https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Medicare Advantage Plan or other Medicare Health Plan BeneficiariesCMS reminds suppliers that Medicare beneficiaries enrolled in a Medicare Advantage or other Medicare Health Plans should contact their plan directly to find out how it replaces DMEPOS damaged, lost, or unavailable in an emergency. Beneficiaries who do not have their plan’s contact information can contact 1-800-MEDICARE (1-800-633-4227) for assistance.

Replacement Prescription FillsMedicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable or unavailable due to the emergency.

Telehealth

Note: Unlike other claims for which Medicare payment is based on a “formal waiver,” telehealth claims don’t require the “DR” condition code or “CR” modifier. CMS is not requiring additional or different modifiers associated with telehealth services furnished under these waivers. However, consistent with current rules, there are three scenarios where modifiers are required on Medicare telehealth claims. In cases when a telehealth service is furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii, the GQ modifier is required. When a telehealth service is billed under CAH Method II, the GT modifier is required.

Finally, when telehealth service is furnished for purposes of diagnosis and treatment of an acute stroke, the G0 modifier is required.

Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Prior to this waiver Medicare could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.

There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries:

yy Medicare telehealth visits

yy Virtual check-ins

yy e-visits

For more information, review the Medicare Telemedicine Health Care Provider Fact Sheet at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet and Medicare Telehealth Frequently Asked Questions at: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf.


https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

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Summary of Medicare Telemedicine Services

Type of Service What is the Service? HCPCS/CPT CodePatient Relationship with Provider

MEDICARE TELEHEALTH VISITS

A visit with a provider that uses telecommunication systems between a provider and a patient.

Common telehealth services include:• 99201-99215 (Office or other

outpatient visits)• G0425-G0427 (Telehealth

consultations, emergency department or initial inpatient)

• G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs).

For a complete list: https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes

For new* or established patients.

* To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

VIRTUAL CHECK-IN

A brief (5-10 minutes) check in with your practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient.

HCPCS code G2012

HCPCS code G2010

For established patients

E-VISITS A communication between a patient and their provider through an online patient portal

• 99421 • 99422 • 99423 • G2061 • G2062 • G2063

For established patients

ADDITIONAL INFORMATIONReview information on the current emergencies web page at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.



Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html.

DOCUMENT HISTORY

Date of Change DescriptionMarch 20, 2020 We revised the article to add a note in the Telehealth section to cover the use of modifiers

on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same.

March 19, 2020 We corrected a typo in the article. One of the e-visit codes was incorrectly stated as 99431 and we corrected it to show 99421.

March 18, 2020 We revised this article to include information about the Telehealth waiver. All other information remains the same.

March 16, 2020 Initial article released.


https://www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes







https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html

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Upcoming Educational Events

The CGS Provider Outreach and Education (POE) department offers educational events through webinars and teleconferences throughout the year. Registration for these events is required. For upcoming events, please refer to the Calendar of Events Home Health & Hospice Education Web page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.

If you have a topic that you would like the CGS POE department to present, send us your suggestion to [email protected].

TEST YOUR KNOWLEDGE AND EARN CREDIT!https://www.surveymonkey.com/r/M6QC5WG

Do you need to earn education credit? Launch the “Test your Knowledge” exercise! Correctly answer eight of ten questions based on this month’s Medicare Bulletin to earn a certificate that may be used to obtain education credit through coding and/or specialty societies. Good luck!


https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx

mailto:[email protected]

https://www.surveymonkey.com/r/M6QC5WG

may 2020 • medicare bulletin · yyif the claim matches an assessment that is for another reason,...

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