Resource AAPC articles

CMS Releases ICD-10 MS-DRG V38.1. For ICD-10-CM, this version includes new Covid 19 codes that went into effect on October 1, 2020. For ICD-10-PCS, this version includes 21 new codes for introduction or infusion of therapeutics and includes monoclonal antibodies and vaccines for COVID-19 treatment which is effective January 1, 2021.

CMS Releases ICD-10 MS-DRG V38.1

Latest update includes assignments for new COVID-19-related diagnoses and procedures. The ICD-10 Medicare Severity-Diagnosis Related Group (MS-DRG) V38.1

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[Lori]

Convalescent Plasma code C9507

This plasma product is authorized for treatment ofCOVID-19 in patients with immunosuppressive disease or getting immunosuppressive treatment in the outpatient or inpatient setting.

HCPCS Level II codes that begin with a C are used primarily by Outpatient Prospective Payment System (OPPS) hospitals to report new technology procedures, drugs, biologicals, radiopharmaceuticals, services, and devices that do not have other HCPCS Level II code assignments.

Code C9507 for Convalescent Plasma

Expect a payment rate of $750.50 for this outpatient code. Medicare announced a new HCPCS Level II code for COVID-19 convalescent plasma for use in the New HCPCS Level II code for COVID-19 convalescent plasma for use in the outpatient setting.

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[Lori]

Medicare Hospital Payment Cuts.

1% cut.

HAC reduction program for 2022.

Hospitals Face Medicare Payment Cuts

Low-performing hospitals to see a 1 percent cut in Medicare payments under HAC Reduction Program in 2022. The Centers for Medicare & Medicaid Services 764 hospitals will face Medicare payment cuts in fiscal year (FY) 2022 under the HACRP.

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[Lori]

Pulmonary Rehabilitation Policies Revamped​

• Removal of the PR requirement for direct physician-patient contact
• Expansion of coverage of PR to patients who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks.

According to CMS, these changes are aimed at improving consistency and accuracy across the PR and cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR) conditions of coverage.

Report HCPCS Level II code G0424 for PR services furnished on or after Jan. 1, 2010, through Dec. 31, 2021. Effective Jan. 1, 2022, two new CPT 94625 & 94626 codes replace G0424.

Details for eligibility include:

• Confirmed or suspected COVID-19
• Persistent symptoms that include respiratory dysfunction for at least four weeks

CPT® code	Descriptor	Time (minutes)	Ambulatory Payment Classification (APC)	Payment	Co-pay	RVU
94625	Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)	60	5733 (Level 3 Minor Procedures)	$56.85	$11.37	0.36
94626	Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)	60	5733 (Level 3 Minor Procedures)	$56.85	$11.37	0.56

Pulmonary Rehabilitation Policies Revamped

Revisions to coverage and payment guidelines for outpatient pulmonary rehabilitation expand eligibility and introduce two new codes for reporting these services.

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[Lori]

Code Colonoscopies With Precision​

Reasons for a colonoscopy are -preventive, diagnostic, therapeutic, or surveillance — you can select the appropriate procedure code based on the patient’s age, the risk for colorectal cancer, and insurance (not to mention fee schedule).

Four basic encounter types for Colonoscopies:

Diagnostic colonoscopy is performed when the patient has physical symptoms such as rectal bleeding or pain and the test is necessary to either rule out or confirm a suspected condition. Signs and symptoms are used to explain the reason for the test.

Screening colonoscopy is provided to a patient in the absence of signs or symptoms based on the patient’s age, gender, medical history, and family history according to medical guidelines. It is defined by the population on which the test is performed, not the results or findings of the test. As such, “screening” describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps.

Surveillance colonoscopy is when the patient is asymptomatic but has a personal history of gastrointestinal disease, colon polyps, or cancer. Technically, this is a screening test with different diagnostic coding and frequency guidelines.

Therapeutic colonoscopy is performed when the abnormalities are treated for the purpose of biopsy, tumor ablation, or other therapy.

Code Colonoscopies With Precision

Accurate billing of these procedures requires attention to detail. Colonoscopy is a medical procedure in which the physician inserts a long, flexible, Accurate billing of colonoscopy procedures requires attention to detail.

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[Lori]

MIPS's goal is to reign in government spending by improving the health outcomes of Medicare patients.

Participation in MIPS is measured in four performance categories: Quality, Cost, Improvement Activities, and Promoting Interoperability.

200 quality measures from which clinicians can select in 2022, including the addition of four high priority quality measures:

Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer
Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate
Person-Centered Care Measure Patient-Reported Outcome Performance Measure
Person-Centered Care Measure Patient-Reported Outcome Performance Measure for Patients with Multiple Chronic Conditions (administrative claims measure with an 18-case minimum for groups with at least 16 clinicians)

CMS removed 13 pre-existing quality measures and revised 87 measures. Nine of the revised measures will not be eligible for a historical benchmark this year, so the scoring of these measures may be affected.

An individual clinician, clinician group, or virtual group need only collect data on six quality measures (including at least one outcome or high priority measure) during the calendar year.

What’s New for the Cost Performance Category?
What’s New for Improvement Activities?
What’s New for Promoting Interoperability?
What Will it Take to Meet Data Completeness Criteria?

Learn What’s New for MIPS in 2022

Stay on top of the latest changes to help your providers earn positive payment adjustments and favorable consumer ratings this year. The Centers for 2022 MIPS update helps providers earn positive payment adjustments and favorable consumer ratings this year.

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[Lori]

High Gas costs squeeze healthcare workers.

Tips to help:

• Geographic scheduling: If you don’t do so already, schedule your employees’ visits very carefully to minimize travel.
• Mileage rate: Increase your mileage reimbursement rate to the IRS maximum.
• Gas gift cards: If you don’t want to permanently increase your travel reimbursement rate, give gas gift cards to employees.
• Add-ons: Rather than change the mileage rate, offer a per-visit bonus until gas prices come down.
• Group discounts: Try to secure a fleet discount rate in your community.
• Providing cars: Soaring gas prices will seem even worse for employees driving gas guzzlers. Consider furnishing fuel-efficient cars for some or all of your employees to use for work.

Soaring Gas Prices Squeeze Home Health, Hospice Workers

Prices at the pump set shocking new records. Increased gas prices are a headache for nearly everyone, but they are especially burdensome for home health Prices at the pump hit hard for home health and hospice workers.

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[Lori]

A first for Medicare -beneficiaries will be eligible to receive eight over-the-counter COVID-19 tests at no cost starting in early spring.

• Request four free OTC tests for home delivery at covidtests.gov.
• Access low-to-no-cost COVID-19 tests through healthcare providers at over 20,000 free testing sites nationwide. A list of community-based testing sites can be found here.
• Access lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized healthcare professionals at no cost. In addition to accessing a COVID-19 lab test ordered by a healthcare professional, people with Medicare can also access one lab-performed test without an order, also without cost-sharing, during the public health emergency.

Medicare to Cover Free Over-the-Counter COVID Tests

Medicare beneficiaries will be able to get over-the-counter COVID-19 tests at no cost starting in early spring. A new Medicare initiative will soon allow Medicare beneficiaries will be able to get over-the-counter COVID-19 tests at no cost starting in early spring.

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[Lori]

Coding for ASD​

When the physician documents a diagnosis of ASD, use ICD-10-CM code F84.0 Autistic disorder. The Code also note in the Tabular List under subsection F84, Pervasive developmental disorders, instructs you to report codes for any associated medical conditions such as an intellectual disability (F70-F79).

A type 1 exclusion note indicates not to report F84.0 with F84.5 Asperger’s syndrome; the code set considers them to be mutually exclusive. The difference, according to ICD-10-CM, is that Asperger’s is milder, and while it shares some symptoms with autism, people with Asperger’s syndrome don’t have the language and cognitive impairments that are usual in other autism spectrum disorders.

The CPT® code for both general developmental screening and for autism screening is 96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument. When billing for ASD screening, report 96110 with modifier KX Requirements specified in the medical policy have been met. For general developmental screenings, use 96110 without modifier KX. When more comprehensive developmental testing is performed — assessment of fine and/or gross motor, language, cognitive level, social, memory, and/or executive functions — look to CPT® codes 96112 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour and +96113 … each additional 30 minutes (List separately in addition to code for primary procedure).

To enhance specificity, there are Z codes you can use to identify the screening performed during the visit. Check with your payer to verify these codes are accepted and reimbursable:

Z13.41 Encounter for autism screening

Z13.42 Encounter for screening for global developmental delays (milestones)

When a screening test is performed with a significant, separate evaluation and management (E/M) service, append modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the E/M code to specify the E/M service was distinct and necessary during the same visit.

Encourage Awareness and Acceptance of Autism

Spot the signs of ASD early to minimize challenges and maximize potential. Autism spectrum disorder (ASD) is a complex neurodevelopmental condition that Spot the signs of autism spectrum disorder (ASD) early to minimize challenges and maximize potential.

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[Lori]

These Updates Clarify Medicare Split/Shared Billing.

Learn what a split/shared visit is.

What are the new billing guidelines?

Determine what providers can share split /shared visits and determine the substantive portion of a split/shared visit.

Updates Clarify Medicare Split/Shared Billing

Know the facts for ensuring proper payment of these claims in 2022. New policy for split/shared evaluation and management (E/M) visits (including critical Know the facts for ensuring proper payment of split/shared claims in 2022.

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[Lori]

CMS is ending a temporary emergency declaration section 1135 waivers for certain types of facilities in two parts.

The first part will occur 30 days following the April 7 memorandum and apply to skilled nursing facilities (SNFs) and nursing facilities (NFs).

The second part will occur 60 days after the April 7 memorandum and apply to:

• Inpatient hospices
• Intermediate care facilities
• End-stage renal dialysis (ESRD) facilities

CMS Terminating Certain Section 1135 Waivers

Some facility types will need to reinstate waived requirements as early as May 7 to maintain compliance. The Centers for Medicare & Medicaid Services CMS will be phasing out some of the temporary emergency declaration section 1135 waivers that have been in effect throughout the COVID-19 PHE.

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[Lori]

Challenged in Court
No Surprises Act IDR Process

No surprise Act is legislation that regulates surprise billing in emergency and out-of-network healthcare settings to protect patients from unexpected medical expenses.

Contending that the September Rule conflicts with the NSA by taking the fair and balanced independent arbitration process set down by Congress and instead establishing a presumption in favor of qualifying payment amounts (QPAs), thus skewing the intended neutral arbitration to always favor the insurance companies.

AMA and AHA filed a motion in the U.S. District Court for the District of Columbia to halt implementation of the IDR process of the NSA, pending judicial review contending that the September Rule “directs the IDR entities to presume that the Qualifying Payment Amount (QPA) (considered the plan’s median in-network rate) is the appropriate out-of-network rate.

AMA and AHA contend that the IDR process set forth in the September Rule not only fell outside the scope of Congress’s original intent but also exceeded the government’s statutory authority.

The federal IDR process does not supersede state laws.

No Surprises Act IDR Process Challenged in Court

Legal actions continue concerning the NSA’s independent dispute resolution process. The second interim final rule (IFR) related to the No Surprises Act Legal actions continue concerning the NSA’s independent dispute resolution process.

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[Lori]

The deadline for requesting late Provider Relief Fund (PRF) reporting for Period 1 has passed.

For those who missed the Provider Relief Fund (PRF) reporting deadline for Period 1, you have until May 18 by 11:59 p.m. ET to submit a request to report late for Period 2 due to extenuating circumstances.

Extenuating circumstances, allowed by the federal HRSA, are:

1. Severe illness or death: a severe medical condition or death of a provider or key staff member responsible for reporting hindered the organization’s ability to complete the report during the Reporting Period.

2. Impacted by natural disaster: a natural disaster occurred during or in close proximity of the end of the Reporting Period damaging the organization’s records or information technology.

3. Lack of receipt of reporting communications: an incorrect email or mailing address on file with HRSA prevented the organization from receiving instructions prior to the Reporting Period deadline.

4. Failure to click “Submit”: the organization registered and prepared a report in the PRF Reporting Portal, but failed to take the final step to click “Submit” prior to deadline.

5. Internal miscommunication or error: internal miscommunication or error regarding the individual who was authorized and expected to submit the report on behalf of the organization and/or the registered point of contact in the PRF Reporting Portal.

6. Incomplete Targeted Distribution payments: the organization’s parent entity completed all General Distribution payments, but a Targeted Distribution(s) was not reported on by the subsidiary.

PRF Period 2 Reporting Deadline Approaches

Recipients still have time to report Provider Relief Fund payments if they can prove extenuating circumstances. The deadline for requesting late Provider Providers have until May 13 by 11:59 p.m. ET to submit a PRF request to report late for Period 2 due to extenuating circumstances.

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[Lori]

The quarterly update to the Medicare Physician Fee Schedule Database (MPFSDB) requires Medicare Administrative Contractors (MACs) to make several changes to their claims processing systems, many of which are effective prior to July 1.

MACs are not required to search their files to retract payment for claims or to retroactively pay claims but they must adjust claims brought to their attention.

Retroactive Changes
The July 2022 update to the MPFSDB changes the bilateral surgery indicator to 2 Bilateral surgery rules do not apply for two CPT® codes, effective Jan. 1, 2022:

• 30468
• 70336

For Medicare, do not append modifier 50 to either of these codes. In the 2022 CPT® codebook, we are instructed in a parenthetical note under 30468 to use modifier 52 when this service is performed unilaterally.

Dates of service

• The modifier and payment policy indicators for CPT® Category III code 0398T are changed.
• New dental codes D1708-D1714 are added for COVID-19 vaccination

Deleted Codes

• A9574, effective April 1, 2022
• G1009, effective April 1, 2022
• M1145, effective Feb. 28, 2022

New Codes

• A9596
• A9601
• G0308
• G0309
• J0739
• J1306
• J1551
• J2356
• J2779
• J2998
• J3299
• J9331
• J9332
• Q4259
• Q4260
• Q4261
• 90584

CMS Updates the MPFSDB for July '22

But many of the changes to the Medicare Claims Processing System are retroactive. A quarterly update to the Medicare Physician Fee Schedule Database Review the changes to the MPFSDB and determine if any action is required at your practice.

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[Lori]

ICD-10-PCS Code Changes for 2023​

There are hundreds of new procedure codes.

Several new prostatic artery occlusion codes.

Several for the destruction of various anatomical regions using laser interstitial thermal therapy.

New procedure codes for reporting the ISS500, used to increase cerebral blood flow and reduce disability in adult patients with acute ischemic stroke. Facilities currently report implantation of a sphenopalatine ganglion stimulator for ischemic stroke using 01HY3MZ. Beginning Oct. 1, you will instead use X0HK3Q8 or X0HQ3R8.

Changes to the guidelines for procedure coding.
Be sure to review new guideline B3.19 for detachment procedures of extremities and revised general guidelines at B4.1c (Body Part) and B6.1a (Device).

New Procedure Codes Coming This Fall

Look for them at a hospital near you. The ICD-10-PCS update for fiscal year 2023 is now available. To prevent coding errors that result in claim denials, The ICD-10-PCS update for fiscal year 2023 is now available with hundreds of new procedure codes.

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[Lori]

Improving Provider Trust Tips.

How To Use:
Facts & Date
Respect
Concise Timing
Recommendations & Goals
Focus
Offer Solution
Understand & Be Understood
Focus on Positives

10 Tips to Improve Provider Trust

Your words will carry more weight when you approach doctors in a thoughtful, respectful way. In the coding and auditing world, the provider is in the As coders and auditors, you must approach each healthcare provider in a thoughtful, respectful way.

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[Lori]

The Centers for Medicare & Medicaid Services (CMS) initiated the Comparative Billing Report (CBR) program in 2010 to evaluate claims submission data, develop provider education, and raise awareness of peer-to-peer billing patterns.

CBRs are designed to protect the Medicare Trust Fund by focusing on areas vulnerable to compliance, billing, and coding issues.

Read more here on areas of vulnerability:

How to Use Comparative Billing Reports as an Educational Tool

Improve your billing practices and avoid compliance issues byutilizing this Medicare program. The Centers for Medicare & Medicaid Services (CMS) Improve your billing practices and avoid compliance issues by utilizing the Medicare CBR program.

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[Lori]

The 2023 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program final rule, was released Nov. 1 2022.

See the changes to:
Behavioral Health and Substance Abuse
Colon Cancer Screening
Dental Coverage
Audiology Services
E/M
Telehealth Services
Skin Substitutes
Refunds for Discarded Drug Waste
Preventive Vaccinations
Part B Physician Payment Rates

Read more here:

2023 Medicare Physician Payment Policies Finalized

The conversion factor is down but certain public health emergency flexibilities will continue. The 2023 Medicare Physician Fee Schedule (MPFS) and Quality 2023 Medicare physician payment explained as it pertains to coders and billers.

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[Lori]

A provision of the Consolidated Appropriations Act (CAA) of 2021 has put Medicare patients on a gradual coinsurance reduction plan for certain colorectal cancer screening tests that turn into a diagnostic or therapeutic service.

Related procedures will soon see a change in Medicare coinsurance from 2023 through 2029 resulting in zero coinsurance copay by 2030.

Service Year	Copay
2022	20%
2023-2026	15%
2027-2029	10%
2030 and beyond	0%

Read more here:

Colorectal Screening Cost-Sharing Changes Are Coming

Colonoscopies that require additional related procedures will soon see a change in Medicare coinsurance. A provision of the Consolidated Appropriations Colonoscopies that require additional related procedures will soon see a change in Medicare coinsurance.

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[Lori]

What is the rationale behind the legislation and learn the reason for the update.​

The drug spending dashboards are online tools that analyze drug spending trends. Access to this information allows patients, policymakers, and other stakeholders insight into changes to Medicare Part B, Medicare Part D, and Medicaid prescription drug spending.

The most recent update incorporates data from Jan. 1, 2017 to Dec. 31, 2021.

The biggest takeaway from this update is that the information added to the dashboard will not be utilized by the Medicare Drug Price Negotiation program.

This is because the first 10 Part D drugs selected for 2026 negotiations are based on Part D expenditure data between June 2022 and May 31, 2023. Medicare will later select and negotiate 15 more Part D drugs for 2027, 15 more Part B or Part D drugs for 2028, and 20 more Part B or Part D drugs for each year after that.

CMS Updates Drug Spending Dashboards

Review the rationale behind the legislation and learn the reason for the update. The Centers for Medicare & Medicaid Services (CMS) recently released CMS recently released its seventh annual update to the Drug Spending Dashboards.

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[Lori]

Medicare states the appropriate time frame for completing medical record documentation in the office setting, “The service should be documented during, or as soon as practicable after it is provided, in order to maintain an accurate medical record.” Providers should comply with this guideline and complete documentation in a timely manner.

Timely documentation helps to:

Provide the physician and others with a more accurate and informed timeline of patient services and encounters.

Help the provider mitigate the risk of malpractice allegations.

Help avoid revenue losses when charts are missed.

Don’t Let Untimely Documentation Hurt Your Practice

Timely, thorough medical record charting guards against lawsuits and revenue loss. What is the appropriate time frame for completing medical record Timely, thorough medical record charting/documentation guards against lawsuits and revenue loss.

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