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JM PART B MEDICARE ADVISORY Latest Medicare News for JM Part B What’s Inside...

AdministrationHow Can We Be of “eService” to You? ...................................................................................3 Get Your Medicare News Electronically ePass is Now Available to Ease the Burden of Repeated Authentication When Calling

.................................................................................4

Palmetto GBA’s Provider Contact Center ............................................................................6 CMS Quarterly Provider Update .............................................................................................7 New Medicare Card: Transition Period Ends in Less Than Five Months ...............................7 Medicare Beneficiary Identifier (MBI) Look-up Tool .............................................................8 New Medicare Beneficiary Identifier (MBI) Get It, Use It ....................................................10

Drugs and BiologicalsManual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims

Processing Manual .............................................................................................................15 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code

Changes - October 2019 Update ........................................................................................16

EducationEducational Events Where You Can Ask Questions ..............................................................22 JJ/JM Part B MACtoberfest® Conference ..............................................................................23

Fee Schedules and ReimbursementQuarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) –

October 2019 Update..........................................................................................................24

MedicineMedicare Coverable Services for Integrative and Nonpharmacological Chronic Pain

Management .......................................................................................................................27 International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions

to National Coverage Determination (NCDs) – January 2020 Update ..............................31 Documentation of Medical Necessity of the Home Visit; and Physician Management

Associated with Superficial Radiation Treatment .............................................................33

Continued >>

palmettogba.com/jmb

The JM Part B Medicare Advisory contains coverage, billing and other information for Part B. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM Part B Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at https://www.PalmettoGBA.com/JMB.

CPT only copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee sched-ules, relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2018 American Dental Association (ADA). All rights reserved.

September 2019 Volume 2019, Issue 9

https://www.PalmettoGBA.com/JMB

Laboratory New Waived Tests .........................................................................................................................................................35 Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment ......37 Instructions for Use of Informational Remittance Advice Remark Code Alert on Laboratory Service

Remittance Advices ...................................................................................................................................................43

Nephrology Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services ..................................45

Radiology Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period -

Claims Processing Requirements ..............................................................................................................................47

Skilled Nursing Facility (SNF) October Quarterly Update to 2019 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF)

Consolidated Billing (CB) Enforcement ...................................................................................................................52 Medicare Shared Savings Program (Shared Savings Program) Skilled Nursing Facility (SNF) Affiliates’ Requirement

to Include Demonstration Code 77 on SNF 3- Day Rule Waiver Claims .................................................................54

Etcetera Medical Director’s Desk ...............................................................................................................................................57 MLN ConnectsTM ..........................................................................................................................................................73

CMS Provider Minute Videos

The Medicare Learning Network has a series of CMS Provider Minute Videos (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.html) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting documentation. Check the site often as CMS adds new videos periodically to further help you navigate the Medicare program.

CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2018 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

2 9/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia.html

How Can We Be of “eService” to You? You may have noticed that over the past year we have been busy upgrading our secure web portal, eServices. Designed specifically with you, the provider, in mind, we have added many new features to help you manage patient accounts and practice information in a more efficient manner.

How Does eServices Help You? Palmetto GBA’s eServices is a free internet-based, provider self-service secure application. Palmetto GBA’s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eServices application. Our innovative tool allows you to access a wide range of information — from looking up patient eligibility to retrieving a variety of detailed provider reports. The best part is…we are not finished yet! Keep an eye out for more improvements in the near future. Let’s revisit the many features the eServices application provides. Over the next few months we will delve deeper into several key features. • Eligibility • Claims Status • eClaim Submissions — available for Part B and Railroad Medicare providers • Clerical Error Claim Reopening Requests — available for Part B • Remittances Online • Financial Information — payment floor and last three checks paid • Financial Forms — eOffset requests, eCheck payments and CMS-838 Credit Balance form (Part A and

HHH only) • Secure Forms — Appeals, Medical Review ADR Response Form, Prior Authorization Form (JM Part B

and HHH), Wage Index Form (Part A only) and General Inquiry Form • eDelivery • eReview — eCBR, eUtilization and eAudit (JM, JJ Part A and RRB only) • Additional Documentation Form — available for JJ Part B and JM Part B • MBI (Medicare Beneficiary Identifier) Lookup

You can participate in eServices if you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA and have payment amounts on file. This agreement with instructions to complete can be found at, https://www.PalmettoGBA.com under the EDI section for your line of business.

The eServices home page is: https://www.palmettogba.com/eServices. If you are not taking advantage of the many benefits of eServices, what are you waiting for? Get started today!


3 9/2019

https://www.PalmettoGBA.comhttps://www.palmettogba.com/eServices

Get Your Medicare News Electronically The Palmetto GBAMedicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: • Medicare incentive programs • Fee Schedule changes • New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv: Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

eServices Eligibility eServices, by Palmetto GBA, allows you to search for patient eligibility, which is a functionality of HETS. HETS requires you to enter beneficiary last name and Medicare ID Number, in addition to either the birth date or first name. See options below:

• Medicare ID Number, Last Name, First Name, Birth Date • Medicare ID Number, Last Name, Birth Date • Medicare ID Number, Last Name, First Name

For more information about eServices and the many services it offers, please visit our website at http://www.PalmettoGBA.com/eServices.


4 9/2019

http://tinyurl.com/PalmettoGBAListservhttp://www.PalmettoGBA.com/eServices

Medicare Learning Network® (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims

processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.html • MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To

access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”

• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources: • MLN Publications List: contains the electronic versions of the downloadable publications. These products

are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.html. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service: 1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or

Unsubscribe’ link under the ‘Options’ tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].


5 9/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.htmlhttps://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-lmailto:[email protected]

ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider

Contact Center Authentication is required before Palmetto GBA is authorized to discuss Medicare information with a provider. The ePass is an eight-digit code providers can elect to receive, per each NPI and PTAN combination, following their first-time authentication when they call the Provider Contact Center (PCC). This ePass can then be used for the remainder of the day in order to authenticate. This code will be delivered in one of two ways: • Through the IVR, follow the first-time authentication steps by selecting Option 5 for ePass and then Option

2 to receive ePass; or • Request your ePass verbally while speaking with a Customer Service Agent (CSA) following first-time

authentication

The goal of the ePass is to ease provider burden by eliminating the need to repeatedly authenticate each time you contact the PCC in a given day. The ePass can then be used for the remainder of that business day in order to authenticate. Simply select Option 5 for ePass and Option 1 to enter your 8-digit ePass number.

This enhancement is in direct response to provider feedback with the goal of improving your provider experience with Palmetto GBA.


6 9/2019

CMS Quarterly Provider Update The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to: • Inform providers about new developments in the Medicare program • Assist providers in understanding CMS programs and complying with Medicare regulations and instructions • Ensure that providers have time to react and prepare for new requirements • Announce new or changing Medicare requirements on a predictable schedule • Communicate the specific days that CMS business will be published in the ‘Federal Register’

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.

We encourage you to bookmark the Quarterly Provider Update Web site at www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html and visit it often for this valuable information.

New Medicare Card: Transition Period Ends in Less Than Five Months

Starting January 1, 2020, you must use the Medicare Beneficiary Identifier (MBI). We will reject claims you submit with the Health Insurance Claim Number (HICN), with a few exceptions (https://www.cms.gov/ Medicare/New-Medicare-Card/index.html), and reject all eligibility transactions.

Many providers are using the MBI for Medicare transactions. For the week ending August 2, providers submitted 77 percent of fee-for-service claims with the MBI. Protect your patients’ identities by using MBIs now for all Medicare transactions.

Don’t have an MBI? • Ask your patients for their cards. If they did not get a new card, give them the “Get Your New

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

• Use your Medicare Administrative Contractor’s lookup tool. Sign up (https://www.cms.gov/Medicare/ New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf) for the portal to use the tool.

• Check the remittance advice. We return the MBI on the remittance advice for every claim with a valid and active HICN.

For more information, see the MLN Matters Article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ downloads/SE18006.pdf).


7 9/2019

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.htmlhttps://www.cms.gov/Medicare/New-Medicare-Card/index.htmlhttps://www.cms.gov/Medicare/New-Medicare-Card/index.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdfhttps://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdfhttps://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf

Medicare Beneficiary Identifier (MBI) Look-up Tool The Medicare Beneficiary Identifier (MBI) Look-up tool allows providers to use our secure eServices online portal to obtain the new MBI number when patients do not present their Medicare card. The MBI Look-up tool will only return an MBI if the new Medicare card has been mailed to avoid potential confusion if the MBI is used before the beneficiary receives their new Medicare card.

As background, the New Medicare Card Project, was established in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which mandates the removal of the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) from Medicare cards by April 2019. CMS began mailing new Medicare cards with the MBI on April 2, 2018. The Railroad Retirement Board mailed new Medicare cards with the MBI to all Railroad Medicare beneficiaries in June 2018.

From April 1, 2018 to December 31, 2019, CMS will offer a transition period during which the system will accept both HICNs and MBIs on Medicare transactions (including eligibility requests and claims) for beneficiaries in the Medicare program prior to April 1, 2018 (i.e., those who received a HICN on their Medicare card). Note: Providers should not submit both numbers on the same transaction.

Beginning in January 2020, physicians may only use MBIs, with limited exceptions.

When the new Medicare card is mailed to people with Medicare, you will be able to use the eServices MBI Look-Up Tool to obtain a patient’s MBI. To submit an inquiry you must do the following: • Once logged into eServices, click on the MBI LOOKUP tab located in the header of the portal • Complete the required* fields:

• Beneficiary’s Last Name • First Name • Date of birth and • Social security number. NOTE: The social security number must be in the XXX-XX-XXXX format

• To meet our CAPTCHA requirements, you must select the I’M NOT A ROBOT checkbox • Click SUBMIT INQUIRY

Continued >> CPT codes, descriptors and other data only are copyright 2018 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2018 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

8 9/2019

Figure 1: MBI Lookup Tab

Look-Up Tool Status Results If the inquiry successfully returns an MBI, the screen will refresh with the data at the bottom.

Figure 2: MBI Lookup Successful Response Screenshot

In the event that your MBI lookup request does not result in a successful response, eServices will display error messages to assist you. If any required fields are left blank or are not in a proper format, a message will appear advising you which fields to correct.

Figure 3: MBI Lookup Unsuccessful Response Screenshot

Ch eck the CMS New Medicare Card Project Outreach & Education webpage at https://www.cms.gov/Medicare/ New-Medicare-Card/Outreach-and-Education/Outreach-and-education.html and the Medicare Beneficiary Identifier (MBI) Look-up Tool Clarification article at https://www.cms.gov/Outreach-and-Education/Outreach/ FFSProvPartProg/Downloads/2018-05-17-eNews.pdf for additional information.


9 9/2019

https://www.cms.gov/Medicare/New-Medicare-Card/Outreach-and-Education/Outreach-and-education.htmlhttps://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-17-eNews.pdf

New Medicare Beneficiary Identifier (MBI) Get It, Use It MLN Matters Number: SE18006 Reissued Article Release Date: August 19, 2019 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We reissued this article on August 19, 2019, 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.

Provider Type Affected This 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 Needed Use MBIs now for all Medicare transactions. The Centers for Medicare & Medicaid Services (CMS) finished mailing new Medicare cards. The new cards without Social Security Numbers (SSNs) offer better identity protection. Help protect your patients’ personal identities by getting their MBIs and using them for Medicare business, including claims submission and eligibility transactions.

Starting January 1, 2020, even for services provided before this date, you must use MBIs. 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 new Medicare cards when they come for care. If they didn’t get a new card, give them the Get Your New Medicare Card flyer in English (https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-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. You can use this tool even after the end of the transition period – the tool doesn’t end on December 31, 2019. Even if your patients are in a Medicare Advantage Plan, you can look up their MBIs to bill for things like indirect medical education.


10 9/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdfhttps://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdf

You must have your patient’s SSN for the search and it 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 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.

3. Check the remittance advice We’ll also return the MBI on every remittance advice when you submit claims with valid and active HICNs through December 31, 2019. Get the MBI from the remittance advice and save it in your systems to use with your next Medicare transaction.

Background The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) required CMS to remove SSNs from all Medicare cards by April 2019. CMS replaced the SSN-based HICN with a new, randomly generated MBI. The new MBI is noticeably different than the HICN. Just like with the HICN, 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”).

The Railroad Retirement Board (RRB) also mailed new Medicare cards with MBIs. The RRB logo will be 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’ll be able to identify them by the RRB logo on their card, and we’ll return a “Railroad

Retirement Medicare Beneficiary” message on the Fee-For-Service (FFS) MBI eligibility transaction response.


11 9/2019

http:mymedicare.gov

Use the MBI the same way you used the HICN. Put the MBI in the same field where you’ve always put 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. The MBI replaces the HICN on Medicare transactions including Billing, Eligibility Status, and Claim Status. The effective date of the MBI, like the old HICN, is the date each beneficiary was or is eligible for Medicare. After January 1, 2020, we will reject claims submitted with HICNs, with few exceptions. You will get: • 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)

• 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. There are different scenarios for using the old or new MBIs:

FFS claims submissions with: • Dates of service before the MBI change date – use old or newMBIs. • Span-date claims with a “From Date” before the MBI change date – use old or newMBIs. • Dates of service that are entirely on or after the effective date of the MBI change – use new MBIs.

FFS eligibility transactions when the: • Inquiry uses new MBI – we’ll return all eligibility data. • 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. • 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.


12 9/2019

Exceptions There are a few exceptions when you can use either the HICN or MBI on or after January 1, 2020: • Appeals – You can use either HICNs or MBIs for claim appeals and related forms. • Claim status query – You can use the HICN or MBI to check the status of a claim (276 transactions) 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.

• Span-date claims – You can use HICNs or MBIs for 11X-Inpatient Hospital, 32X- Home Health (home health 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, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019. Since you submit home health claims for a 60-day payment episode, you can send in the episode’s RAP with either the HICN or the MBI, but after the transition period ends on December 31, 2019, you have to use the MBI when you send in the final claim that goes with it.

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

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 Information If 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.

A fact sheet discussing the transition to the MBI and the new cards is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ TransitiontoNewMedicareNumbersandCards-909365.pdf.

Document History Date of Change Description 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.


13 9/2019

http://go.cms.gov/MAC-website-listhttps://www.cms.gov/Medicare/New-Medicare-Card/Providers/MACs-Provider-Portals-by-State.pdfhttps://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Date of Change March 6, 2019

Description 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.

Medicare Diabetes Prevention Program Booklet Medicare Diabetes Prevention Program booklet is available from the Centers for Medicare & Medicaid Services webiste at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ MDPP-MLN34893002.pdf


14 9/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MDPP-MLN34893002.pdf

Manual Update to Sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual

MLN Matters Number: MM11403 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4364CP Related Change Request (CR) Number: 11403 Effective Date: November 18, 2019 Implementation Date: November 18, 2019

Provider Types Affected This MLN Matters Article is for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11403 updates the language in sections 1.2 and 10.2.1 in Chapter 18 of the Medicare Claims Processing Manual to add a link to the current influenza codes and payment rates. Make sure your billing staffs are aware of these updates. For the Medicare-covered codes for the influenza vaccines approved by Food and Drug Administration (FDA) for the current influenza vaccine season, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/ VaccinesPricing.html.

Additional Information The official instruction, CR11403, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4364CP.pdf.

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

Document History Date of Change Description August 16, 2019 Initial article released.


15 9/2019

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.htmlhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4364CP.pdfhttp://go.cms.gov/MAC-website-list

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019

Update MLN Matters Number: MM11422 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4367CP Related Change Request (CR) Number: 11422 Effective Date: October 1, 2019 Implementation Date: October 7, 2019

Provider Types Affected This MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for drug and biological services.

Provider Action Needed CR 11422 updates the HCPCS code set for codes related to drugs and biologicals. Make sure your billing staff s are aware of these updates.

Background The HCPCS code set is updated quarterly. CR 11422 informs MACs and providers of the latest updates to specifi c drug/biological HCPCS codes. The October 2019 quarterly HCPCS file includes forty-four (44) new HCPCS codes. Effective for claims with dates of service on or after October 1, 2019, you may use, as appropriate, the following HCPCS codes on claims for Medicare: 1) J0121

a. Short Descriptor: Inj., omadacycline, 1 mg b. Long Descriptor: Injection, omadacycline, 1 mg c. Type of Service (TOS): 1,P

2) J0122 a. Short Descriptor: Inj., eravacycline, 1 mg b. Long Descriptor: Injection, eravacycline, 1 mg c. TOS: 1,P

3) J0222 a. Short Descriptor: Inj., patisiran, 0.1 mg b. Long Descriptor: Injection, Patisiran, 0.1 mg c. TOS: 1

4) J0291 a. Short Descriptor: Inj., plazomicin, 5 mg b. Long Descriptor: Injection, plazomicin, 5 mg c. TOS: 1

5) J0593 a. Short Descriptor: Inj., lanadelumab-flyo, 1 mg b. Long Descriptor: Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug

administered under direct supervision of a physician, not for use when drug is self-administered) c. TOS: 1


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6) J1096 a. Short Descriptor: Dexametha opth insert 0.1 mg b. Long Descriptor: Dexamethasone, lacrimal ophthalmic insert, 0.1 mg c. TOS: 1

7) J1097 a. Short Descriptor: Phenylep ketorolac opth soln b. Long Descriptor: Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solu-

tion, 1 ml c. TOS: 1

8) J1303 a. Short Descriptor: Inj., ravulizumab-cwvz 10 mg b. Long Descriptor: Injection, ravulizumab-cwvz, 10 mg c. TOS: 1,P

9) J1943 a. Short Descriptor: Inj., aristada initio, 1 mg b. Long Descriptor: Injection, aripiprazole lauroxil, (aristada initio), 1 mg c. TOS: 1

10) J1944 a. Short Descriptor: Inj., aripirazole lauroxil 1 mg b. Long Descriptor: Injection, aripiprazole lauroxil, (aristada), 1 mg c. TOS: 1

11) J2798 a. Short Descriptor: Inj., perseris, 0.5 mg b. Long Descriptor: Injection, risperidone, (perseris), 0.5 mg c. TOS: 1,P

12) J3031 a. Short Descriptor: Inj., fremanezumab-vfrm 1 mg b. Long Descriptor: Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug

administered under the direct supervision of a physician, not for use when drug is self-administered) c. TOS: 1, P

13) J3111 a. Short Descriptor: Inj. romosozumab-aqqg 1 mg b. Long descriptor: Injection, romosozumab-aqqg, 1 mg c. TOS: 1

14) J7314 a. Short Descriptor: Inj., yutiq, 0.01 mg b. Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg c. TOS: 1

15) J7331 a. Short Descriptor: Synojoynt, inj., 1 mg b. Long Descriptor: Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg c. TOS: 1

16) J7332 a. Short Descriptor: Inj., triluron, 1 mg


17 9/2019

b. Long Descriptor: Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg c. TOS: 1

17) J7401 a. Short Descriptor: Mometasone furoate sinus imp b. Long Descriptor: Mometasone furoate sinus implant, 10 micrograms c. TOS: 1

18) J9118 a. Short Descriptor: Inj. Calaspargase pegol-mknl b. Long Descriptor: Injection, calaspargase pegol-mknl, 10 units a. TOS: 1,P

19) J9119 a. Short Descriptor: Inj., cemiplimab-rwlc, 1 mg b. Long Descriptor: Injection, cemiplimab-rwlc, 1 mg c. TOS: 1

20) J9204 a. Short Descriptor: Inj, mogamulizumab-kpkc, 1 mg b. Long Descriptor: Injection, mogamulizumab-kpkc, 1 mg c. TOS: 1,P

21) J9210 a. Short Descriptor: Inj., emapalumab-lzsg, 1 mg b. Long Descriptor: Injection, emapalumab-lzsg, 1 mg c. TOS: 1

22) J9269 a. Short Descriptor: Inj. tagraxofusp-erzs 10 mcg b. Long Descriptor: Injection, tagraxofusp-erzs, 10 micrograms c. TOS: 1

23) J9313 a. Short Descriptor: Inj., lumoxiti, 0.01 mg b. Long Descriptor: Injection, moxetumomab pasudotox-tdfk, 0.01 mg c. TOS: 1,P

24) Q4205 a. Short Descriptor: Membrane graft or wrap sq cm b. Long Descriptor: Membrane graft or membrane wrap, per square centimeter c. TOS: 1

25) Q4206 a. Short Descriptor: Fluid flow or fluid gf 1 cc b. Long Descriptor: Fluid flow or fluid GF, 1 cc c. TOS: 1

26) Q4208 a. Short Descriptor: Novafix per sq cm b. Long Descriptor: Novafix, per square centimeter c. TOS: 1

27) Q4209 a. Short Descriptor: Surgraft per sq cm


18 9/2019

b. Long Descriptor: Surgraft, per square centimeter c. TOS: 1

28) Q4210 a. Short Descriptor: Axolotl graf dualgraf sq cm b. Long Descriptor: Axolotl graft or axolotl dualgraft, per square centimeter c. TOS: 1

29) Q4211 a. Short Descriptor: Amnion bio or axobio sq cm b. Long Descriptor: Amnion bio or Axobiomembrane, per square centimeter c. TOS: 1

30) Q4212 a. Short Descriptor: Allogen, per cc b. Long Descriptor: Allogen, per cc c. TOS: 1

31) Q4213 a. Short Descriptor: Ascent, 0.5 mg b. Long Descriptor: Ascent, 0.5 mg c. TOS: 1

32) Q4214 a. Short Descriptor: Cellesta cord per sq cm b. Long Descriptor: Cellesta cord, per square centimeter c. TOS: 1

33) Q4215 a. Short Descriptor: Axolotl ambient, cryo 0.1 mg b. Long Descriptor: Axolotl ambient or axolotl cryo, 0.1 mg c. TOS: 1

34) Q4216 a. Short Descriptor: Artacent cord per sq cm b. Long Descriptor: Artacent cord, per square centimeter c. TOS: 1

35) Q4217 a. Short Descriptor: Woundfix biowound plus xplus b. Long Descriptor: Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioW-

ound Xplus, per square centimeter c. TOS: 1

36) Q4218 a. Short Descriptor: Surgicord per sq cm b. Long Descriptor: Surgicord, per square centimeter c. TOS: 1

37) Q4219 a. Short Descriptor: Surgigraft dual per sq cm b. Long Descriptor: Surgigraft-dual, per square centimeter c. TOS: 1

38) Q4220 a. Short Descriptor: Bellacell HD, Surederm sq cm


19 9/2019

b. Long Descriptor: BellaCell HD or Surederm, per square centimeter c. TOS: 1

39) Q4221 a. Short Descriptor: Amniowrap2 per sq cm b. Long Descriptor: Amniowrap2, per square centimeter c. TOS: 1

40) Q4222 a. Short Descriptor: Progenamatrix, per sq cm b. Long Descriptor: Progenamatrix, per square centimeter c. TOS: 1

41) Q4226 a. Short Descriptor: Myown harv prep proc sq cm b. Long Descriptor: MyOwn skin, includes harvesting and preparation procedures, per square centime-

ter c. TOS: 1

42) Q5116 a. Short Descriptor: Inj., trazimera, 10 mg b. Long Descriptor: Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg c. TOS: 1,P

43) Q5117 a. Short Descriptor: Inj., kanjinti, 10 mg b. Long Descriptor: Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg c. TOS: 1,P

44) Q5118 a. Short Descriptor: Inj., zirabev, 10 mg b. Long Descriptor: Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg c. TOS: 1,P

HCPCS codes J1942 (Aripiprazole lauroxil 1mg/Injection, aripiprazole lauroxil, 1 mg) and S1090 (Mometasone sinus implant/Mometasone furoate sinus implant, 370 micrograms) are being discontinued effective October 1, 2019; and may not be used in submitting claims to Medicare with dates of service on or after that date.

Effective for claims with dates of service on or after October 1, 2019, the long and short descriptors for the following HCPCS codes will be modified. The TOS and all other indicators will remain the same. 1) J0641

a. New Short Descriptor: Inj., levoleucovorin, 0.5 mg b. New Long Descriptor: Injection, levoleucovorin, 0.5 mg

2) J2794 a. New Short Descriptor: Inj., risperdal consta, 0.5 mg b. New Long Descriptor: Injection, risperidone (risperdal consta), 0.5 mg

3) J7311 a. New Short Descriptor: Inj., retisert, 0.01 mg b. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (retisert), 0.01 mg


20 9/2019

4) J7313 a. New Short Descriptor: Inj., iluvien, 0.01 mg b. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg

5) Q4122 a. New Short Descriptor: Dermacell, awm, porous sq cm b. New Long Descriptor: Dermacell, dermacell awm or dermacell awm porous, per square centimeter

6) Q4165 a. New Short Descriptor: Keramatrix, Kerasorb sq cm b. New Long Descriptor: Keramatrix or kerasorb, per square centimeter

7) Q4184 a. New Short Descriptor: Cellesta or duo per sq cm b. New Long Descriptor: Cellesta or cellesta duo, per square centimeter

Additional Information The official instruction, CR 11422, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4367CP.pdf.




21 9/2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4367CP.pdfhttp://go.cms.gov/MAC-website-list

Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA

Don’t Miss this Wonderful Opportunity! If you are in search of an opportunity to interact with and get answers to your Medicare billing,

coverage and documentation questions from Palmetto GBA’s Provider Outreach and Education (POE) department, please see these educational offerings which have a question and answer session:

Event Title 2019 Medical Review (MR) Hot Topic Targeted Probe and Educate (TPE) Teleconference Schedule Jurisdiction J and M Part B Hot Topic Teleconference: Let’s Talk E/M Changes, What We Know So Far Physicians! Collaborative Spinal Orthosis Webinar Scheduled for September 19! MACtoberfest® Conference

Check out these resources

Date/Time September 3, 2019, 2-3 p.m. ET

September 24, 2019, 11 a.m. – 12 p.m. ET

September 19, 2019, 2 p.m. ET

October 8-9, 2019

Address, phone number (or link if Webinar) Teleconference Number: (877) 789-3907 Pass Code: 5369828

Teleconference Number: (866) 745–0425 Pass Code: 8069869

https://attendee.gotowebinar.com/register/3562474149465060610

Asheville, North Carolina Registration: https://www.MACtoberfest.com

Quarterly Ask the Contractor Teleconferences (ACTs)

http://tinyurl.com/jkb4458

Quarterly Updates Webcasts

http://tinyurl.com/gsrb8gt

ACTs are intended to open the communication channels between providers and Palmetto GBA, which allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference.

Proceding the presentation, providers are given an opportunity to ask questions both on the topics discussed as well as any other question they may have. While we encourage providers to submit questions prior to the call, this is not required. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form (http://tinyurl.com/hjq84dg). Once the form is completed, please fax it to (803) 935-0140, Attention: Ask-the-Contractor Teleconference The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements.

Providers are able to type a question and have it responded to by the POE department throughout the webcast. At the end of the presentation the moderator will also read and respond to questions submitted by attendees in order to share the responses with the group at large.


22 9/2019

https://attendee.gotowebinar.com/register/3562474149465060610https://www.MACtoberfest.comhttp://tinyurl.com/jkb4458http://tinyurl.com/hjq84dghttp://tinyurl.com/gsrb8gt

Event Registration Portal Visit our Event Registration Portal to find information on upcoming educational events and seminars.

http://tinyurl.com/gsrb8gt This is a complete listing of both our face-to-face outreach opportunities as well as our teleconference and webcast listings. Providers are able to dialogue with POE and get answers to their questions at all of these educational events.

If you have a question that you need an answer to today or a claims specific question which requires the disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at 1-855-696-0705 for Jurisdiction M or 877-567-7271 for Jurisdiction J.

JJ/JM Part B MACtoberfest® Conference The JJ/JM Part and Part B MACtoberfest® Conference will be held October 8-9, 2019, in Asheville, North Carolina.

Registration for the event is available on Palmetto GBA’s MACtoberfest website at https://www.MACtoberfest.com.

Reservations at the Asheville Crowne Plaza Hotel must be made by 12 a.m. ET, September 7, 2019, in order to receive the discounted rate. Reservations may be made on the Asheville Crowne Plaza website at https://tinyurl.com/y67f55b8.


23 9/2019

http://tinyurl.com/gsrb8gthttps://www.MACtoberfest.comhttps://tinyurl.com/y67f55b8

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – October 2019 Update

MLN Matters Number: MM11402 Related CR Release Date: August 16, 2019 Related CR Transmittal Number: R4362CP Related Change Request (CR) Number: 11402 Effective Date: January 1, 2019 Implementation Date: October 7, 2019

Provider Types Affected This MLN Matters article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed CR 11402 informs providers that the Centers for Medicare & Medicaid Services (CMS) issued payment files to the MACs based on the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. CR 11402 amends those payment files. Please make sure your billing staffs are aware of these changes.

Background The updated payment files are effective for services you deliver from January 1, 2019, through December 31, 2019.

Section 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.

Summary of Changes for October 2019 1. Codes 96931 and 96934 (the global components) are changing their Relative Value Units (RVUs) as in-

dicated in Table 1. The rationale behind this change is that the global codes (96931/96934) need to sum to the values of the professional and technical component codes (96932 and 96933 for 96931, respec-tively; and 96935 and 96936 for 96934, respectively). These changes apply to services as of January 1, 2019.

Table 1: Changes for the October Update to the 2019 MPFSDB

Code Action 96931 Malpractice RVU = 0.06

Non-Facility and Facility PE RVU = 1.71; Malpractice RVU = 0.05

2. The short descriptor for HCPCS Code Q5115 is being updated (as shown in Table 2) to coincide with the changes published in CR 11296, and is effective for claims with dates of service on and after July 1, 2019. You can review the article related to CR 11296 at https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf.


24 9/2019

96934

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11296.pdf

Table 2: Updated Short Descriptor

Code Action Q5115 Short descriptor = Inj truxima 10 mg

The following “J” and “Q” code updates are effective for dates of service October 1, 2019, and after. See CR 11422 for additional information. (An MLN Matters article related to CR 11422 will be available at https:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/ MM11422.pdf.) See Table 3 for a list of the code updates.

Table 3: Code Updates

Code Action J0121 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0122 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0222 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0291 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0593 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J0641 Short Descriptor = Inj., levoleucovorin, 0.5 mg J1096 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1097 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1303 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1942 Procedure Status = I J1943 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J1944 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J2794 Short Descriptor = Inj risperdal consta, 0.5mg J2798 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J3031 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J3111 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7311 Short Descriptor = Inj., retisert, 0.01 mg J7313 Short Descriptor = Inj., iluvien, 0.01 mg J7314 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7331 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7332 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J7401 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9118 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9119 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9204 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9210 Procedure Status = E; there are no RVUs, payment policy indicators do not apply. J9269 Procedure Status = E; there are no RVUs, payment policy indicators do not apply.


25 9/2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11422.pdf

Code J9313 Q4122 Q4165 Q4184 Q4205 Q4206 Q4208 Q4209 Q4210 Q4211 Q4212 Q4213 Q4214 Q4215 Q4216 Q4217 Q4218 Q4219 Q4220 Q4221 Q4222 Q4226 Q5116 Q5117 Q5118

Action Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Short Descriptor = Dermacell, awm, porous sq cm Short Descriptor = Keramatrix, Kerasorb sq cm Short Descriptor = Cellesta or duo per sq cm Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply. Procedure Status = E; there are no RVUs, payment policy indicators do not apply.

Note: MACs will not search their files to retract payment for claims already paid or to retroactively pay claims. However, they will adjust claims that you bring to their attention.

Additional Information The official instruction, CR 11402, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4362CP.pdf.




26 9/2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4362CP.pdfhttp://go.cms.gov/MAC-website-list

Medicare Coverable Services for Integrative and Nonpharmacological Chronic Pain Management

MLN Matters Number: SE19008 Article Release Date: August 19, 2019 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Provider Types Affected This MLN Matters Article is for physicians, non-physician practitioners (NPPs), hospitals, and other providers furnishing and billing Medicare Administrative Contractors (MACs) for chronic pain management services for Medicare beneficiaries.

What You Need To Know Given the issues associated with using opioids for acute and chronic pain, this article summarizes some other treatment options to consider when you treat Medicare patients for chronic pain. This article is informational only and does not convey any new or revised Medicare policies.

Background The Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force Report states, “The experience of pain has been recognized as a national public health problem with profound physical, emotional, and societal costs. Although estimates vary depending on the methodology used to assess pain, it is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities.” In addition to opioids and other prescription medications, there are non-pharmacologic treatment options for pain. The Food and Drug Administration (FDA) approved several drug treatments that beneficiaries enrolled in Medicare Part D plans may use alone or as part of an integrative and comprehensive pain management plan. Medicare also covers certain non-pharmacologic options for pain management. Consider the following treatments and services to help treat patients who have chronic pain.

National Coverage Determinations National Coverage determinations (NCDs) are policies CMS issues that cover, noncover, or limit coverage of items, new technologies or services on a national basis. CMS develops NCDs through an evidence-based process. The evidence must show the services meaningfully improve health outcomes for Medicare beneficiaries. The process developing NCDs encourages public participation. Medicare has issued NCDs for the following chronic pain treatment services: • Electrical nerve stimulation (NCD 160.7 at

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf) • Induced lesions of nerve tracts (NCD 160.1 at

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf) • Inpatient hospital pain rehabilitation (NCD 10.3 at

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)


27 9/2019

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf

• Outpatient hospital pain rehabilitation (NCD 10.4 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)

• Supervised exercise therapy for symptomatic peripheral artery disease (NCD 20.35 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf)

• Screening for depression (NCD 210.9 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf)

Each of these nationally covered services has some coverage limitations based on beneficiary criteria. Some of the longer-standing NCDs have complementary LCDs, which clarify coverage. Find all NCDs at https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. You may search for NCDs using our Medicare Coverage Database at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

Local Coverage Determinations (LCDs) MACs develop LCDs through a process similar to NCDs, but with LCDs, MACs determine whether to cover a particular item or service within their geographic region (as opposed to a national basis). To find the MAC for your state, please see http://go.cms.gov/MAC-website-list.

While local coverage may differ slightly from state to state, there are also many similarities around covered services. Here are some examples of local coverage of services to treat chronic pain that may be available in your geographic area: • Lumbar epidural injections • Nerve blockade for chronic pain and neuropathy • Spinal cord stimulators • Peripheral nerve stimulation • Facet join injections • Physical or occupational therapy • Injections – tendons, ligaments • Psychiatry and psychology services for pain disorders related to psychological factors

These are general examples. Each LCD has detailed information and may include a description of covered indications, related coding information and any coverage restrictions. See all LCDs at https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx. You may search for LCDs using our Medicare Coverage Database at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

As with NCDs, each of these services has some limitations to coverage. Be sure to review LCDs completely. If you have questions about an LCD, your MAC can help.

Additional National Policies to Care for Medicare Beneficiaries with Chronic Pain Beneficiaries with multiple (two or more) chronic conditions that you expect will last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline can get Chronic Care Management (CCM) services, or Complex CCM services. An MLN booklet is available at https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf. CCM services are extensive and include:


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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdfhttps://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspxhttps://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspxhttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspxhttps://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspxhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdfhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdfhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf

• Structured recording of patient health information, including recording the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology.

• Maintaining a comprehensive electronic care plan • Managing transitions of care and other care management services • Coordinating and sharing patient health information timely within and outside thepractice

Medicare also covers Behavioral Health Integration Services for treatment of behavioral health, or psychiatric conditions, including substance use disorders. These services use a care team approach to facilitate and coordinate behavioral health treatment regardless of if the diagnosis or diagnoses are pre-existing or newly diagnosed. These services may benefit some beneficiaries who have a co-occurring behavioral health condition(s). Please see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ BehavioralHealthIntegration.pdf for more information.

These and other care management services can give your patients the medical care and coordination services they need to help manage their pain, and other chronic conditions. You can bill these services for 30-day or one month periods and may include activities you or your clinical staff perform. You can get more information at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management. html.

Preventive Services You can use Medicare’s Initial Preventive Physical Exam (IPPE) and subsequent Annual Wellness Visits (AWV) to help detect illnesses in the earliest stages to evaluate your patients’ pain severity, and to review the current treatment plan. If your patient is using prescription opioids, you can assess the benefit of other, non-opioid pain treatments and therapies that could be used in conjunction with, or in lieu of opioid medication, review with patients the benefits and risks of continuing opioid treatment, provide your interested and motivated patients with support to slowly taper opioid dosages, mitigate overdose risk for patients who take high-dose opioids, and offer or arrange for medication-assisted treatment when opioid use disorder is identified.

Reviewing opioid use is an important and routine part of your patient’s medical history, and it is helpful to diagnose and then treat patients with pain, patients with a substance use disorder including opioid use disorder, and those who may have both. You can refer your patients, as appropriate, under the IPPE and AWV based on information you discussed as part of the visit. While Medicare works toward implementing some additional services (such as from the SUPPORT for Patients and Communities Act), many are already available through the IPPE and AWV. Read more about coverage of these services at https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf.

Additional Information If you have questions, your MAC may have more information. Find a list of MAC websites at http://go.cms.gov/MAC-website-list.

Review CMS’list of opioid resources at https://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers/Opioid-Resources-Page.html.

Also, consider the following:


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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdfhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.htmlhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdfhttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/hcps-and-researchers/Opioid-Resources-Page.htmlhttps://www.cms.gov/About-CMS/Agency-Information/OMH/resource-center/Continued

Technical Assistance for providers • CMS Quality Improvement Organization: https://qioprogram.org/locate-your-qio?map=qin • CMS Hospital Innovation and Improvement Network:https://partnershipforpatients.cms.gov/

wherepartnershipsareinaction/wherepartnershipsareinaction.html#HIINs • Transforming Clinical Practice Initiative: https://innovation.cms.gov/initiatives/Transforming-Clinical-

Practices

Other relevant MLN Matters Articles and Publications • AWV MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/

MLNMattersArticles/downloads/SE18004.pdf) • IPPE MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/

MLNMattersArticles/downloads/SE18004.pdf) • Substance abuse MLN article - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/SE1604.pdf • Transitional Care services fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

• Telehealth services fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf

• DME fact sheet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/DME_Physicians_Other_Pract_Factsheet_ICN900926.pdf

• Eldercare locator - https://eldercare.acl.gov/Public/Index.aspx

Other Background References 1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention,Care, Educa-

tion, and Research. Washington (DC): National Academies Press (US); 2011. http://www.ncbi.nlm.nih.gov/books/NBK91497/. Accessed January 7, 2018.

2. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact ChronicPain Among Adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. doi:10.15585/ mmwr.mm6736a2

3. National Academies. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington DC: National Academies of Sciences, Engi-neering, and Medicine; 2017.

4. Pain Management Best Practices Inter-Agency Task Force final report -https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf

5. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for ChronicPain: https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids. html



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https://qioprogram.org/locate-your-qio?map=qinhttps://partnershipforpatients.cms.gov/wherepartnershipsareinaction/wherepartnershipsareinaction.html#HIINshttps://innovation.cms.gov/initiatives/Transforming-Clinical-Practiceshttps://innovation.cms.gov/initiatives/Transforming-Clinical-CPThttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdfhttps://www.cms.gov/Outreach-and-Education/

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