NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by

Transcription

1 NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

2 JJ Part A Medicare Advisory Latest Medicare News for JJ Part A May 2018 Volume 2018, Issue 03 What s Inside... MLN Connects...3 Weekly Articles...3 Special Edition Aritcles...4 CMS Proposes Changes to Empower Patients and Reduce Administrative Burden...4 Multiple Provider Information...5 Unsolicited Voluntary Refunds...5 Institutional Billing for No Cost Items...6 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes July 2018 Update...7 Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esmd) System...9 Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)...11 Claims Processing Actions to Implement Certain Provisions of the Bipartisan Budget Act of We d Love Your Feedback!...19 Get Your Medicare News Electronically...20 Medicare Learning Network (MLN)...21 End Stage Renal Disease (ESRD) Information...22 Increased Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities...22 Learning and Education Information...24 May 15, 2018, Part A Ask the Contractor Teleconference (ACT): Specialty Clinical Topic - Hyperbaric Oxygen (HBO) Therapy...24 May 23, 2018, Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast...25 June 13, 2018, Part A Quarterly Updates Webcast...25 Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA...26 Medical Policy Information...27 Part A Local Coverage Determinations (LCDs) Updates...27 palmettogba.com/jja The JJ Part A Medicare Advisory contains coverage, billing and other information for Jurisdiction J Part A. 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 JJ Part A 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 CPT only copyright 2017 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 schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, 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 2012 American Dental Association (ADA). All rights reserved.

3 Medical Policy Information (continued) Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) Updates...28 Noninvasive Peripheral Arterial and Venous Studies Local Coverage Determination (LCD Number: L37639) - Retired...30 Intensity Modulated Radiation Therapy (IMRT) Local Coverage Determination (LCD Number L37640) - Retired...30 Part A/B Local Coverage Determinations (LCDs) Article Updates...31 MolDX Local Coverage Determinations (LCDs) Updates...36 MolDX Local Coverage Determinations (LCDs) Article Updates...37 MolDX: Chromosome 1p/19q Deletion Analysis Local Coverage Determination (LCD Number: L36483) - Retired...38 MolDX: NSCLC, Comprehensive Genomic Profile Testing Local Coverage Determination (LCD Number: L36143) - Retired...38 Skilled Nursing Facility (SNF) Information...38 Ambulance Transportation for a SNF Resident in a Stay Not Covered by Part A Medicare Benefit Policy Manual, Chapter 10, and Medicare Claims Processing Manual, Chapter Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN)...40 Skilled Nursing Facility Value-Based Purchasing Program Updated...42 Tools You Can Use...45 Religious Nonmedical Health Care Institution Overview Module...45 New Medicare Card Information...46 Helpful Information...47 Contact Information for Palmetto GBA Part A...47 May and June 2018 Part A Educational Events May 15, 2018, Part A Ask the Contractor Teleconference (ACT): Specialty Clinical Topic - Hyperbaric Oxygen (HBO) Therapy Palmetto GBA will host the Part A Ask the Contractor Teleconference (ACT) on Tuesday, May 15, 2018, from 11 a.m. 12 p.m. ET. May 23, 2018, Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast Join Palmetto GBA in an informative Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation webcast on Wednesday, May 23, 2018, at 10 a.m. ET! June 13, 2018, Part A Quarterly Updates Webcast Palmetto GBA will host the Medicare Administrative Contractor Part A Quarterly Updates, Changes and Reminders Webcast from 10 a.m. to 11 a.m. on Wednesday, June 13, For more information and registration instructions to attend these education sessions, please go to Page 24 of this issue. 2 05/2018

4 MLN CONNECTS MLN Connects will contain Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicarerelated topics. Please share with appropriate staff. To view the most recent issues, please copy and paste the following links into your Web browser: Weekly Articles April 26, pdf April 19, pdf April 12, pdf April 5, pdf March 29, pdf 3 05/2018

5 Special Edition Articles CMS Proposes Changes to Empower Patients and Reduce Administrative Burden Changes in IPPS and LTCH PPS would advance price transparency and interoperability On April 24, CMS proposed changes to empower patients through better access to hospital price information, improve patients access to their electronic health records, and make it easier for providers to spend time with their patients. The proposed rule proposes updates to Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). We seek to ensure the health care system puts patients first, said Administrator Seema Verma. Today s proposed rule demonstrates our commitment to patient access to high quality care while removing outdated and redundant regulations on providers. We envision a system that rewards value over volume and where patients reap the benefits through more choices and better health outcomes. Secretary Azar has made such a value-based transformation in our health care system a top priority for HHS, and CMS is taking important, concrete steps toward achieving it. The policies in the IPPS and LTCH PPS proposed rule would further advance the agency s priority of creating a patient-driven health care system by achieving greater price transparency and interoperability essential components of value-based care while also significantly reducing the burden for hospitals so they can operate with better flexibility and patients have the information they need to become active health care consumers. While hospitals are already required under guidelines developed by CMS to either make publicly available a list of their standard charges, or their policies for allowing the public to view a list of those charges upon request, CMS is updating its guidelines to specifically require that hospitals post this information. The agency is also seeking comment on what price transparency information stakeholders would find most useful and how best to help hospitals create patient-friendly interfaces to make it easier for consumers to access relevant health care data so they can more readily compare providers. The proposed policies begin implementing core pieces of the government-wide MyHealthEData initiative through steps to strengthen interoperability or the sharing of health care data between providers. Specifically, CMS is proposing to overhaul the Medicare and Medicaid Electronic Health Record Incentive Programs (also known as the Meaningful Use program) to: * Make the program more flexible and less burdensome * Emphasize measures that require the exchange of health information between providers and patients * Incentivize providers to make it easier for patients to obtain their medical records electronically To better reflect this new focus, we are renaming the Meaningful Use program Promoting Interoperability. In addition, the proposed rule reiterates the requirement for providers to use the 2015 Edition of certified electronic health record technology in 2019 as part of demonstrating meaningful use to qualify for incentive payments and avoid reductions to Medicare payments. This updated technology includes the use of 4 05/2018

6 application programming interfaces, which have the potential to improve the flow of information between providers and patients. In the proposed rule, CMS is requesting stakeholder feedback through a Request for Information on the possibility of revising Conditions of Participation to revive interoperability as a way to increase electronic sharing of data by hospitals. As part of its commitment to burden reduction, CMS is proposing in the FY 2019 IPPS/LTCH PPS proposed rule to remove unnecessary, redundant, and process-driven quality measures from a number of quality reporting and pay-for-performance programs. The proposed rule would eliminate a significant number of measures acute care hospitals are currently required to report and remove duplicative measures across the 5 hospital quality and value-based purchasing programs. This would remove 19 measures from the programs and de-duplicate another 21 measures while still maintaining meaningful measures of hospital quality and patient safety. Additionally, CMS is proposing a variety of other changes to reduce the number of hours providers spend on paperwork. CMS is proposing this new flexibility so that hospitals can spend more time providing care to their patients thereby improving the quality of care their patients receive. In sum, this results in the elimination of 25 measures across the 5 programs with well over 2 million burden hours reduced for hospital providers impacted by the IPPS proposed rule, saving them $75 million. For More Information: * Proposed Rule * Fact Sheet See the full text of this excerpted CMS Press Release (issued April 24). MULTIPLE PROVIDER INFORMATION Unsolicited Voluntary Refunds The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims. 5 05/2018

7 Institutional Billing for No Cost Items MLN Matters Number: MM10521 Related CR Release Date: March 30, 2018 Related CR Transmittal Number: R4013CP Related Change Request (CR) Number: Effective Date: January 1, 2009 Implementation Date: June 29, 2018 Provider Types Affected This MLN Matters article is intended for Institutions (Part A) billing Medicare Administrative Contractors (MACs) for no cost items provided to Medicare beneficiaries. What You Need To Know Change Request (CR) provides clarification of the billing instructions specific to drugs provided at no cost when claims processing edits prevent drug administration charges from being billed when the claim does not contain a covered/billable drug charge. This is not a new policy but a reminder of the policy in place. Please make sure your billing staffs are aware of this clarification. Background The Medicare Claims Processing Manual Chapter 32 - Billing Requirements for Special Services section 67.2 outlines institutional billing for no cost items as follows. Institutional providers should not have to report the usage of a no cost item. However, for some claims (for example, Outpatient Prospective Payment System (OPPS) claims), providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service (for example, a specified device must be reported along with a specified implantation procedure). For OPPS claims, when a drug is provided at no cost, claims processing edits prevent drug administration charges from being billed when the claim does not contain a covered/billable drug charge. Therefore, for drugs provided at no cost in the hospital outpatient department, providers must report the applicable drug HCPCS code and appropriate units with a token charge of less than $1.01 for the item in the covered charge field and mirror this less than $1.01 amount reported in the non-covered charge field. Providers must also bill the corresponding drug administration charge with the appropriate drug administration CPT or HCPCS code. Additional Information The official instruction, MM10521, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r4013cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. 6 05/2018

8 Document History Date of Change March 30, 2018 Description Initial article released. Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes July 2018 Update MLN Matters Number: MM10624 Related CR Release Date: April 20, 2018 Related CR Transmittal Number: R4025CP Related Change Request (CR) Number: Effective Date: July 1, 2018 Implementation Date: July 2, 2018 Provider Types Affected This MLN Matters Article is intended for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) informs MACs of updated drug/biological HCPCS codes. The HCPCS code set is updated on a quarterly basis. The July 2018 HCPCS file includes 4 new HCPCS codes: Q9991, Q9992, Q9993 and Q9995. Please make sure your billing staffs are aware of these updates. Background The July 2018 HCPCS file includes four new HCPCS codes, which are payable by Medicare, effective for claims with dates of service on or after July 1, These codes are: Q9991 o Short Description: Buprenorph xr 100 mg or less o Long Description: Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg o Type of Service (TOS) Code: 1 o Medicare Physician Fee Schedule Data Base (MPFSDB) Status Indicator: E Q9992 o Short Description: Buprenorphine xr over 100 mg o Long Description: Injection, buprenorphine extended-release (sublocade), greater than 100 mg 7 05/2018

9 o TOS Code: 1 o MPFSDB Status Indicator: E Q9993 o Short Description: Inj., triamcinolone ext rel o Long Description: Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg o TOS Code: 1,P o MPFSDB Status Indicator: E Q9995 o Short Description: Inj. emicizumab-kxwh, 0.5 mg o Long Description: Injection, emicizumab-kxwh, 0.5 mg o TOS Code: 1 o MPFSDB Status Indicator: E Additional Information The official instruction, CR 10624, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r4025cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change April 20, 2018 Description Initial article released. 8 05/2018

10 Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esmd) System MLN Matters Number: MM10397 Revised Related CR Release Date: April 3, 2018 Related CR Transmittal Number: R2050OTN Related Change Request (CR) Number: Effective Date: July 1, 2018 Implementation Date: July 2, 2018 Note: This article was revised on April 4, 2018, to reflect a revised CR issued on April 3. In the article, the CR release date, transmittal number, and the Web address of the CR are revised. All other information is the same. Provider Type Affected This MLN Matters Article is intended for physicians, suppliers, and providers submitting electronic medical documentation to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) updates the business requirements to enable MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esmd) system. CR10397 is for esmd purposes only. Please make sure your billing staffs are aware of these updates. Background CR10397 also contains attachments that include cover sheets that must be used for electronic, fax, or mail submissions of documentation. There are three cover sheets, one each for Part A and Part B providers, as well as one for durable medical equipment (DME) suppliers. In addition, there are two companion guides attached to CR10397, one for institutional claims and one for professional claims. A link to CR10397 is available in the Additional Information section of this article. With CR10397, MACs will modify PWK, also known as unsolicited documentation procedures to include electronic submission(s) via esmd. Also, Medicare systems will accept PWK 02 values EL and FT for those MACs in a CMS-approved esmd system. This mechanism will suppress initial auto letter generation, if applicable, when PWK 02 is EL or FT, and is present at any level of the claim or line. Providers will receive communication from MACs via companion documents for 5010 X to include: The value EL (electronic) in PWK 02 to represent an esmd submission for sending the documentation using X12 Standards (6020 X12 275) The value FT (file transfer) in PWK 02 to represent an esmd submission for sending the documentation in PDF format using XDR specifications. 9 05/2018

11 MACs will allow 7 calendar waiting days (from the date of receipt) for additional information to be submitted when the PWK 02 value is EL or FT. MACs will use RC Client to reject the PWK data submissions as administrative error(s) when the received cover sheet (via esmd) is incomplete or incorrectly filled out as applicable to current edits. Providers can expect to see new generic reason statements introduced to convey these errors as follows (Codes for these statements will be finalized and sent along with the RC implementation guide): The date(s) of service on the cover sheet received is missing or invalid. The NPI on the cover sheet received is missing or invalid. The state where services were provided is missing or invalid on the cover sheet received. The Medicare ID on the cover sheet received is missing or invalid. The billed amount on the cover sheet received is missing or invalid. The contact phone number on the cover sheet received is missing or invalid. The beneficiary name on the cover sheet received is missing or invalid. The claim number on the cover sheet received is missing or invalid. The Attachment Control Number (CAN) on the cover sheet is missing or invalid. Once again, examples of the cover sheet are included as an attachment to CR Additional Information The official instruction, CR 10397, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r2050otn.pdf. The X Companion Guides are available at If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change April 3, 2018 February 16, 2018 Description The article was revised to reflect a revised CR. In the article, the CR release date, transmittal number, and the Web address of the CR are revised. All other information is the same. Initial article released /2018

12 Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) MLN Matters Number: MM10295 Revised Related CR Release Date: April 3, 2018 Related CR Transmittal Number: R206NCD and R4016CP Related Change Request (CR) Number: Effective Date: May 25, 2017 Implementation Date: July 2, 2018 Note: The article was revised on April 11, 2018, to clarify that the SET program must be provided in a physician s office (Place of Service code 11). All other information remains the same. Provider Types Affected This MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) informs MACs that effective May 25, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) to cover Supervised Exercise Therapy (SET) for beneficiaries with Intermittent Claudication (IC) for the treatment of symptomatic Peripheral Artery Disease (PAD). Make sure your billing staffs are aware of these changes. Background SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-tomaximum claudication, with rest. SET has been recommended as the initial treatment for patients suffering from IC, the most common symptom experienced by people with PAD. Despite years of high-quality research illustrating the effectiveness of SET, more invasive treatment options (such as, endovascular revascularization) have continued to increase. This has been partly attributed to patients having limited access to SET programs. There is currently no NCD in effect. CMS issued the NCD to cover SET for beneficiaries with IC for the treatment of symptomatic PAD. Up to 36 sessions over a 12-week period are covered if all of the following components of a SET program are met: The SET program must: Consist of sessions lasting minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication Be conducted in a physician s office Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD 11 05/2018

13 Be under the direct supervision of a physician (as defined in Section 1861(r)(1)) of the Social Security Act (the Act), physician assistant, or nurse practitioner/clinical nurse specialist (as identified in Section 1861(aa)(5) of the Act)) who must be trained in both basic and advanced life support techniques. Beneficiaries must have a face-to-face visit with the physician responsible for PAD treatment to obtain the referral for SET. At this visit, the beneficiary must receive information regarding cardiovascular disease and PAD risk factor reduction, which could include education, counseling, behavioral interventions, and outcome assessments. MACs have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time. MACs shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the services that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12-week period meets the requirements of the medical policy. SET is non-covered for beneficiaries with absolute contraindications to exercise as determined by their primary attending physician. Coding Requirements for SET Providers should use Current Procedural Terminology (CPT) (Under Peripheral Arterial Disease Rehabilitation) to bill for these services with appropriate International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Code as follows: I right leg I left leg I bilateral legs I other extremity I right leg I left leg I bilateral legs I other extremity I right leg I left leg I bilateral legs I other extremity I right leg 12 05/2018

14 I left leg I bilateral legs I other extremity Medicare will deny claim line items for SET services when they do not contain one of the above ICD-10 codes using the following messages: Claim Adjustment Reason Code (CARC) 167 This (these) diagnosis (es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the NCD. Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. MACs will accept claims for CPT only when services are provided in Place of Service (POS) code 11. MACs will deny claims for SET if services are not provided in POS 11 using the following remittance messages: CARC 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present. RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the NCD. Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. Institutional claims for SET must be submitted on Type of Bills (TOB) 13X or 85X. MACs will deny line items on institutional claims that are not submitted on TOB 13X or 85X using the following messages: CARC 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present /2018

15 RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the NCD. Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. Medicare will pay claims for SET services containing CPT code on Types of Bill (TOBs) 13X under OPPS and 85X on reasonable cost, except it will pay claims for SET services containing CPT with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II Critical Access Hospitals (CAHs) based on 115% of the lesser of the fee schedule amount or the submitted charge. Medicare will reject claims with CPT which exceed 36 sessions within 84 days from the date of the first session when the KX modifier is not included on the claim line OR any SET session provided after 84 days from the date of the first session and the KX modifier is not included on the claim and use the following messages: CARC 96: Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. RARC N640: Exceeds number/frequency approved/allowed within time period. Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file. MACs will deny/reject claim lines for SET exceeding 73 sessions using the following codes: CARC 119: Benefit maximum for this time period or occurrence has been reached. RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at If you do not have web access, you may contact the contractor to request a copy of the NCD. Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file. Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file /2018

16 Medicare s Common Working File (CWF) will display remaining SET sessions on all CWF provider query screens (HIQA, HIQH, ELGH, ELGA, and HUQA). The Multi-Carrier System Desktop Tool will also display remaining SET sessions in a format equivalent to the CWF HIMR screen(s). Additional Information The official instruction, CR10295, was issued to your MAC via two transmittals. The first updates the Medicare Claims Processing Manual and it is available at The second updates the NCD Manual and it is available at Transmittals/2018Downloads/R206NCD.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Systems/Monitoring-Programs/Medicare- FFS-Compliance-Programs/Review-Contractor-Directory- Interactive-Map/. Document History Date of Change April 11, 2018 April 5, 2018 March 5, 2018 February 6, 2018 Description The article was revised to clarify that the SET program must be provided in a physician s office (Place of Service code 11). All other information remains the same. The article was revised to reflect a revised CR. The MAC implementation date, CR release date, transmittal numbers and the Web addresses of the transmittals were revised. In addition, the article and CR were revised to delete place of service codes 19 and 22 as acceptable places of service for CPT All other information remains the same. The article was revised to reflect a revised CR. The MAC implementation date, CR release date, transmittal numbers and the Web addresses of the transmittals were revised. All other information remains the same. Initial article released. Claims Processing Actions to Implement Certain Provisions of the Bipartisan Budget Act of 2018 MLN Matters Number: MM10531 Revised Related CR Release Date: April 4, 2018 Related CR Transmittal Number: R2051OTN Related Change Request (CR) Number: Effective Date: January 1, 2018 Implementation Date: April 2, 2018 date to begin reprocessing claims 15 05/2018

17 Note: This article was revised on April 5, 2018, to reflect a revised CR10531, which was revised on April 4 to include page 2 of Attachment B - Rural Add on Rate Tables. In the article, the CR release date, transmittal number, and the Web address for CR10531 are revised. All other information remains the same. Provider Type Affected This MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need To Know Change Request (CR) provides direction to MACs to reprocess claims related to several provisions of the Bipartisan Budget Act of 2018, referred to as Medicare Extenders. Specifically, the CR provides guidance to MACs regarding Medicare Fee For Service (FFS) claims reprocessing requirements and timeframes. Make sure your billing staffs are aware of these changes. Background On February 9, 2018, Congress passed the Bipartisan Budget Act of 2018 which contains a number of provisions that extend certain Medicare FFS policies, including Ambulance add-on payment provisions, the Work Geographic Practice Cost Index (GPCI) Floor, and the three percent Home Health (HH) Rural Add-on Payment. In addition, the Act permanently repeals the outpatient therapy caps beginning on January 1, 2018, while retaining the requirement to submit the KX modifier for services in excess of the prior cap amounts. Due to the retroactive effective dates of these provisions, your MAC will reprocess various Medicare FFS claims impacted by this legislation. Section 421(a) of the Medicare Modernization Act (MMA), as amended by Section of the Social Security Act, provides an increase of 3 percent of the payment amount otherwise made under Section 1895 of the Social Security Act for home health services furnished in a rural area (as defined in Section 1886(d) (2)(D) of the Act), with respect to episodes and visits ending on or after April 1, 2010, and before January 1, The statute waives budget neutrality related to this provision. As a result of the Work GPCI floor changes, certain Federally Qualified Health Center (FQHC) Geographic Adjustment Factors (GAFs) will change, which may result in a change to some FQHC payments. For Inpatient Prospective Payment System (IPPS) hospitals, temporary changes to the low-volume hospital payment adjustment and the Medicare-Dependent Hospital (MDH) program have been extended. In addition, for the Long-Term Care Hospital Prospective Payment (LTCH PPS), the blended payment rate for site neutral payment rate cases is extended for certain LTCH hospital discharges. Separate instructions addressing these payment updates are forthcoming. On January 25, 2018, the Centers for Medicare & Medicaid Services (CMS) instructed MACs to release for processing held therapy claims with the KX modifier with dates of receipt January 1-10, CMS also instructed the MACs to institute a rolling hold for all new therapy claims with the KX modifier. On February 12, 2018, CMS provided direction regarding new Medicare Physician Fee Schedule (MPFS) files and abstract files due to the extension of the Work GPCI Floor, as well as a revised 2018 Ambulance Fee Schedule (AFS) file. CMS also instructed the MACs to ensure legislative effective indicators were set 16 05/2018

18 correctly in Medicare systems to apply therapy policies. Given that legislation has been enacted, CMS is instructing the MACs to reprocess effected claims that were processed using the previous MPFS files. As stipulated in Section 421(a) of the MMA, the 3 percent rural add-on is applied to the national, standardized episode rate, national per-visit payment rates, Low-Utilization Payment Adjustment (LUPA add-on payments, and the Non-Routine Supplies (NRS) conversion factor when home health services are provided in rural (non-cbsa) areas for episodes and visits ending on or after April 1, 2010, and before January 1, Refer to Tables 1 through 4 of the attachment to CR10531 for the Calendar Year (CY) 2018 rural payment rates. CR10531 is available at Transmittals/2018Downloads/R2047OTN.pdf. Section 1848(e)(1)(E) of the Social Security Act stipulates that after calculating the work geographic index for purposes of MPFS payment for services furnished, the Secretary shall increase the work geographic index to 1.00 for any locality for which such work geographic index is less than This provision expired on December 31, 2017, and the locality-specific anesthesia conversion factors for CY 2018 were calculated without this work geographic index floor of 1.00 in place. Section of the Bipartisan Budget Act of 2018 restored the work geographic index floor of 1.00 and retroactively dated this restoration to January 1, In accordance with the law, CMS has updated the locality-specific anesthesia conversion factors for CY 2018 to include the work geographic index floor of These updated locality-specific anesthesia conversion factors also have a retroactive effective date of January 1, CR10531 reminds the MACs to be aware that Section 1848(b)(4) of the Social Security Act limits MPFS payment for the technical portion of most imaging procedures to the amount paid under the Outpatient Prospective Payment System (OPPS) system. This policy applies to the technical component (and technical portion of global payment) of imaging services, including X-ray, ultrasound, nuclear medicine, MRI, CT, and fluoroscopy services. The MPFS payment rates for some of these services does not reflect the most recent updates to the OPPS rates that were updated in December of CMS corrected these rates in new MPFS files and informed the MACs of the corrections on February 12, These MPFS files also contain the updates for the GPCI. This correction is unrelated to the passage of this Act, but CMS is taking the opportunity to address this issue now since new MPFS files are required as a result of the Act. The instructions to the MACs to reprocess claims contain the following specifics: The MACs will reprocess therapy claims with the KX modifier containing Dates of Service in Calendar Year 2018, which were denied prior to the implementation of the updated legislative effective dates issued on January 25, NOTE: For institutional claims, these claims will include revenue codes 042x, 043x, or 044x and modifiers GN, GO, or GP. The MACs will reprocess therapy claims with the KX modifier which were denied due to an invalid date provided by CMS on February 12, The MACs will reprocess 2018 therapy claims which cannot be automatically reprocessed only if you bring such claims to the attention of your MAC /2018

19 The MACs reprocess MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor 2018 in CR The MACs will reprocess 2018 MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018 which cannot be automatically reprocessed only if you bring such claims to your MAC s attention. Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor The MACs will reprocess ground AFS claims using the revised 2018 AFS file for Dates of Service in Calendar Year The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC s attention. MACs will reprocess home health claims with the following criteria: o Type of Bill 32X o Claim Through dates on or after January 1, 2018 o Value code 61 amounts in the range 999xx o Receipt dates prior to the installation of the revised home health Pricer, which reflects the extension of the 3% rural add-on for CY MACs will automatically reprocess claims impacted by the OPPS cap for Dates of Service in Calendar Year The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC s attention. The MACs will automatically reprocess anesthesia claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC s attention. MACs shall ensure all reprocessing actions have been initiated within 6 months of the issuance of CR10531: o For therapy and MPFS adjustments o For ground ambulance service claims with a date of service on or after 1/1/2018 o For OPPS adjustments o For anesthesia adjustments 18 05/2018

20 MACs shall ensure all reprocessing actions have been initiated within 6 months of the implementation date of the Pricer for HH rural add-on adjustments. Additional Information The official instruction, CR10531, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r2051otn.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change April 5, 2018 March 26, 2018 Description The article was revised to reflect a revised CR10531, which was revised to include page 2 of Attachment B - Rural Add on Rate Tables. In the article, the CR release date, transmittal number, and the Web address for CR10531 are revised. All other information remains the same. Initial article released. We d Love Your Feedback! Palmetto GBA is committed to continuously improve your customer experience. We welcome your feedback on your experiences with the PalmettoGBA.com website and the eservices portal. As a visitor to the Palmetto GBA s website, you may be presented with an opportunity to take the website satisfaction survey. The next time the survey is offered to you, please agree to participate and provide us with your feedback. You have the opportunity to explain your comments, share your honest opinions, and tell us what you like and what you would like to see us improve. If you find a feature or tool specifically helpful, let us know including any suggestions for making them simpler to use. We continuously analyze your feedback and develop enhancements plans to better assist you with your experience. We value your opinion and look forward to hearing from you /2018

21 Get Your Medicare News Electronically The Palmetto GBA Medicare 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 and select Register Now. Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent /2018

22 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. 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: 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: 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 /2018

23 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 when new and revised MLN products are released. Note: This article was revised on August 8, 2017, to reflect an updated Change Request (CR) In the article, the CR release date, transmittal numbers, and the Web address of the CR are revised. Also, a clarification was made on page 3 to denote that HBV is not separately payable for ESRD TOB 72X unless reported with modifier AY. Another bullet point was added on page 3 to show that contractor pricing applies to G0499 with dates of service September 28, 2016 through December 31, All other information is unchanged. To subscribe to the service: 1. Go to 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 CMS at MLN@cms.hhs.gov. END STAGE RENAL DISEASE FACILITIES (ESRD) INFORMATION Increased Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities MLN Matters Number: MM10549 Related CR Release Date: April 6, 2018 Related CR Transmittal Number: R4017CP Related Change Request (CR) Number: Effective Date: October 1, 2018 Implementation Date: October 1, 2018 Provider Types Affected This MLN Matters Article is intended for providers and suppliers billing Medicare Administrative Contractors (MACs) for ambulance transport services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) provides instructions regarding Section of the Bipartisan Budget Act of This section reduces the ambulance payment by 23 percent for non-emergency Basic Life Support (BLS) transports of individuals with End-Stage Renal Disease (ESRD), to and from renal dialysis treatment (at both hospital-based and freestanding renal dialysis treatment facilities). Please make sure your billing staffs are aware of these changes /2018

24 Background Payment for ambulance transports (including items and services furnished in association with such transports) are based on the Ambulance Fee Schedule (AFS) and include a base rate payment plus a separate payment for mileage. This raised payment reduction for non-emergency BLS transports to and from renal dialysis treatment applies to both the base rate and the mileage reimbursement. CR8269, issued May 10, 2013, implemented Section 637 of the American Taxpayer Relief Act of 2012, which, for transports occurring on and after October 1, 2013; required a 10-percent reduction in fee schedule payments for non-emergency (BLS transports of beneficiaries with ESRD); to and from both hospital-based and freestanding renal dialysis treatment facilities, for non-emergent dialysis services. The MLN Matters article associated with this CR is available at Learning-Network-MLN/MLNMattersArticles/Downloads/MM8269.pdf. CR10549 provides instructions regarding Section of the Bipartisan Budget Act of 2018, (signed into law on February 9, 2018), which requires that, effective October 1, 2018, the reduction of fee schedule payments for BLS transports to and from renal dialysis treatments be increased to 23 percent. Non-emergency BLS ground transports are identified by Healthcare Common Procedure Coding System (HCPCS) code A0428 (Ambulance service, basic life support, non-emergency transport, (bls)). Ambulance transports to and from renal dialysis treatment are further identified by origin/destination modifier codes G (hospital-based ESRD) and J (freestanding ESRD facility), in either the origin or destination position of an ambulance modifier. Specific Details Effective for claims with dates of service on and after October 1, 2018, payment for non-emergency BLS transports to and from renal dialysis treatment facilities will be reduced by 23 percent. The reduced rate will be calculated after the normal payment rate (including any applicable add-on payments) is calculated, and will be applied to the base rate for non-emergency BLS transports (identified by HCPCS code A0428 when billed with the indicated modifier codes) and the associated, separate mileage payment (identified by HCPCS code A0425). Payment for emergency transports and non-emergency BLS transports to other destinations (rural and urban) will remain unchanged. The AFS will also remain unchanged. For ambulance services, suppliers and hospital-based ambulance providers must report an accurate origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin code or a destination code. The pair of alpha codes creates a modifier. The first position alpha code equals origin; the second position alpha code equals destination. The reduction will be applied on claim lines containing HCPCS code A0428 with modifier code G or J, in either the first position (origin code) or second position (destination code) within the two-digit ambulance modifier code and HCPCS code A /2018

25 MACs will keep in place all existing edits and logic (implemented previously via CMS CR 8269) that currently apply to the reduced AFS payment rates; however, effective for claims with dates of service on or after October 1, 2018, will increase the reduction from 10 percent to 23 percent. Additionally, they will continue to use the claim adjustment reason code, group code and Medicare Summary Notice messages that are currently used for the reduced AFS payment methodology Note: This 23-percent reduction applies to beneficiaries with ESRD that are receiving a non-emergency BLS transport to and from renal dialysis treatment. While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and from renal dialysis treatment, it is highly unlikely. However, MACs have the discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation. Additional Information The official instruction, CR10549, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r4017cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change April 6, 2018 Description Initial article released. LEARNING AND EDUCATION INFORMATION May 15, 2018, Part A Ask the Contractor Teleconference (ACT): Specialty Clinical Topic - Hyperbaric Oxygen (HBO) Therapy Palmetto GBA will host the Part A Ask the Contractor Teleconference (ACT) on Tuesday, May 15, 2018, from 11 a.m. 12 p.m. ET. This ACT is designed to open communication channels between Palmetto GBA and our JJ and JM Part A provider community. The ACT Specialty Topic is Hyperbaric Oxygen (HBO) Therapy. Join our clinical consultants as they provide information concerning Medical Review Targeted Probe & Educate (TPE) findings for HBO and how to improve your documentation. All provider questions will be responded to during the call regardless of whether they concern this topic or not /2018

26 Conference Call Information Date: May 15, 2018 Time: 11 a.m. 12 p.m. ET Teleconference Number: (877) Confirmation Code: Submit Your Questions You are encouraged to submit questions prior to the call. Just fill out the ACT Request for Inquiry Items Form ( pdf?open&) located in the Forms web page. This form may be sent via fax to (803) , Attention: Part A Ask-the-Contractor Teleconference. All questions must be received at least five business days prior to the teleconference. To help ensure your access to this conference call we ask that you dial in five to 10 minutes prior to the scheduled start time. May 23, 2018, Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast Join Palmetto GBA in an informative Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation webcast on Wednesday, May 23, 2018, at 10 a.m. ET! This webcast is designed to provide overview of IPF coverage, billing and documentation requirements. We will also discuss Medical Review data related to DRG 885 Psychoses and valuable tips to prevent errors. To register to attend this class, please copy and paste the link below: Note: If you do not have a PTAN/NPI please enter none or n/a. June 13, 2018, Part A Quarterly Updates Webcast Palmetto GBA will host the Medicare Administrative Contractor Part A Quarterly Updates, Changes and Reminders Webcast from 10 a.m. to 11 a.m. on Wednesday, June 13, This 60-minute Webcast is designed to provide pertinent updates, changes and reminders to assist the provider community in staying compliant with Medicare rules and regulations and will include: Any new billing regulations Hot topics that impact provider billing 25 05/2018

27 Note: An NPI and PTAN are required to register. You should only enter n/a if you do not have an NPI or PTAN. To register to attend this class, please copy and paste the link below: wcc/r/ /a21013d6b8926c263ad8a405c65e787c 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: Quarterly Ask the Contractor Teleconferences (ACTs) Quarterly Updates Webcasts Event Registration Portal 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. Preceding 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). Once the form is completed, please fax it to (803) , Attention: Askthe-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. Visit our Event Registration Portal to find information on upcoming educational events and seminars. 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 /2018

28 MEDICAL POLICY INFORMATION Part A Local Coverage Determinations (LCDs) Updates Revised ICD-10 LCDs The table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view these revised LCDs, go to Under the Medical Policies section, select Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order. Title LCD Number Revision Number Magnetic Resonance Angiography LCD Number: L34424 Revision Number: 9 Changes/Additions/Deletions Under CMS National Coverage Policy updated 42 CFR, Sec with the most current information and corrected the title on the CMS Internet-Only Manual, Publication , Chapter 1, Part 4, Sec Under Bibliography changes were made to citations to reflect AMA citation guidelines and all American College of Radiology references were updated to the most current year. Effective Date 04/12/ /2018

29 Part A/B Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs) Updates Revised ICD-10 LCDs The table below provides a summary of recent Part A/B MAC ICD-10 LCD revisions/updates. To view these revised LCDs, go to Under the Medical Policies section, select Active LCD Policies. Scroll down to the LCDs for Contractor Browser section and make sure the Active LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order. Title LCD Number Revision Number Application of Skin Substitutes LCD Number: L36466 Revision Number: 9 Cosmetic and Reconstructive Surgery LCD Number: L33428 Revision Number: 15 Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Lift (Urolift ) LCD Number: L36109 Revision Number: 9 Changes/Additions/Deletions Under Coverage Indications, Limitations and/or Medical Necessity in the first paragraph deleted the second and third sentence. Under Bioengineered Skin/Cultured Epidermal Autografts (CEA) corrected widespread. Under Regulatory Status- US Food and Drug Administration (FDA) Governing Skin Substitute Products revised AHRS in the 7 th paragraph to now read AHRQ and in the second and fourth sentences of the eleventh paragraph corrected the spelling of re-epithelialization. Under Indications in the second sentence of the fifth paragraph revised systematic to now read systemic. Under Limitations-Note added the second sentence The coding in this policy. Under Limitations in the last paragraph italicized manual verbiage. Under Associated Information-Documentation Requirements 6. corrected the section of the LCD cited. Under Utilization Guidelines in the seventh paragraph corrected include to now read includes. Under Bibliography author initials and punctuation was corrected for Greer N, Foman NA, MacDonald R, et al. Advanced Wound Care Therapies for Nonhealing Diabetic, Venous, and Arterial Ulcers: A Systematic Review. Annals of Internal Medicine. 2013;159(8): Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph added CPT code Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph removed the existing verbiage and replaced with NOTE: The CPT code and following diagnoses, limit the use of reconstructive surgeries of the head and neck to the repair of injuries due to trauma or ablative surgery. These revisions are retroactive on or after 10/01/17. Under Associated Information- Documentation Requirements removed the verbiage, Absence of obstructive median lobe. Effective Date 03/29/ /01/ /12/ /2018

30 Noncovered Services other than CPT Category III Noncovered Services LCD Number: L36954 Revision Number: 9 Retroperitoneal Ultrasound LCD Number: L34577 Revision Number: 19 Somatosensory Testing LCD Number: L34433 Revision Number: 10 Under CMS National Coverage Policy in the first paragraph, the second and third sentences were deleted. Under Coverage Indications, Limitations and/or Medical Necessity, in the second set of bullet points, A was added at the beginning of the sentence in the fourth bullet. In the seventh paragraph, the word an was changed to a in the last sentence. In the eighth paragraph, the acronym for Medicare Administrative Contractors was added. In the last sentence of the tenth paragraph, J was added as a Jurisdiction. Corrections were made to the bullet points after the twelfth paragraph. Cormatrix was changed to CorMatrix. Gliasite was changed to GliaSite. Under CPT/ HCPCS Codes Group 1 Not Proven Effective, Not Medically Reasonable and Necessary myringectomy was changed to myringotomy and Rezum was removed as this is now a covered service. Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes N30.01, N30.11, N30.21, N30.31, N30.41, N30.81 and N Under CMS National Coverage Policy deleted the second and third sentences NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. 05/07/ /10/ /12/2018 Total Joint Arthroplasty LCD Number: L33456 Revision Number: 14 Under CMS National Coverage Policy corrected the title for CMS Internet-Only Manual, Pub , Ch 6, Sec Under Coverage Indications, Limitations and/or Medical Necessity removed verbiage and and or after multiple bullets throughout the section. In the fourth paragraph, replaced total knee replacement with (TKR) and moved before the word surgery. Replaced total knee replacement with TKR in the last sentence. In the fifth paragraph, replaced activities of daily living with ADLs in the fourth sentence. Replaced total hip replacement with THR in all applicable areas of the paragraph. Under Total Knee Arthroplasty (TKA) removed activities of daily living from the third bullet of the second paragraph. In the first sentence of the third paragraph, added the acronym ADLs and removed activities of daily living. Under Total Hip Arthroplasty (THA) removed activities of daily living in the third bullet in the second set of bullets. Under ICD-10 Codes that Support Medical Necessity added codes Z47.32 to groups 1 and 2, Z47.33 to groups 3 and 4, and Z and Z to groups 1 and 2. Under Associated Information Documentation Requirements added a comma in the first sentence after provider services. Under Bibliography made changes to citations to reflect AMA citation guidelines. Changed the access date to 4/1/2018 on all URLs listed (this includes the second, fifth, tenth and eleventh source listed). Changed InterQual procedures criteria and Milliman Care Guidelines from 2011 to Corrected the URL link for the last citation. 05/14/ /2018

31 White Cell Colony Stimulating Factors LCD Number: L37176 Revision Number: 5 Wireless Capsule Endoscopy LCD Number: L36427 Revision Number: 8 Under Coverage Indications, Limitations and/or Medical Necessity in the first sentence added the word granulocyte in front of colony stimulating factors to define the acronym G-CSF. The following three revisions are due to Change Request 10515, Transmittal 3988 and Change Request 10454, Transmittal 3997: Under CPT/HCPCS Codes Group 1: Paragraph removed the verbiage Effective for dates of service on or after January 1, 2016 claims for Q5101 must use the ZA modifier (Q5101ZA) and replaced with the verbiage Effective for dates of service on or after January 1, 2016 through March 31, 2018 claims for Q5101 must use the ZA modifier (Q5101ZA). On or after April 1, 2018 no modifier is required to report Q5101. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added D70.1 and D70.2. Under Group 8: Paragraph added J2505. Under Group 1-11: Paragraphs deleted the ZA modifier on HCPC code Q5101ZA. These three revisions are effective on 04/01/2018. Under Sources of Information Bibliography corrected a title and capitalization to various references. Under Coverage Indications, Limitations and/or Medical Necessity added (GI) after the word gastrointestinal in the first sentence and subsequently replaced this word with GI each time the word was used. Under Coverage Indications, Limitations and/or Medical Necessity Indications for wireless capsule endoscopy replaced EGD with esophagogastroduodenoscopy (EGD), and removed or from the end of each bullet with the exception of the seventh bullet. Under Coverage Indications, Limitations and/ or Medical Necessity Limitations of use corrected the spelling for intussusception. Under Bibliography changes were made to citations to reflect AMA citation guidelines. The first reference was replaced with the current citation information. The authors names were corrected on the fourth and eighth reference, and the titles were corrected on the fifth, sixth and seventh reference. 04/01/ /19/2018 Noninvasive Peripheral Arterial and Venous Studies Local Coverage Determination (LCD Number: L37639) - Retired The Noninvasive Peripheral Arterial and Venous Studies Local Coverage Determination (LCD) L37639 is being retired effective 04/03/18 as the information in the LCD is no longer the current standard of practice and major coding updates are required. Effective Date: 04/03/2018. Intensity Modulated Radiation Therapy (IMRT) Local Coverage Determination (LCD Number L37640) - Retired The Intensity Modulated Radiation Therapy (IMRT) Local Coverage Determination (LCD) L37640 is being retired effective 04/03/18 as the information in the LCD is no longer the current standard of practice and major coding updates are required. Effective Date 04/03/ /2018

32 Part A/B Local Coverage Determinations (LCDs) Article Updates Revised ICD-10 LCD Article Updates The table below provides a summary of a recent Part A/B MAC ICD-10 LCD article revision/updates. To view these revised LCD articles, go to In the Articles section select Coverage Articles. Under the Articles for Contractor Browser section, make sure the Active Articles category is selected and the click on the Submit button. The LCD articles are listed in alphabetical order. Title LCD Article ID Number Revision Number Accreditation and Credentialing Requirements for Polysomnography LCD Number: L36593 LCD Article Number: A55945 New Changes/Additions/Deletions Revision effective date: For services performed on or after 07/01/2018 Accreditation and credentialing requirements: Please be aware of the following changes to accreditation and credentialing requirements: Palmetto GBA Local Coverage Determination L36593 sets forth the following standards for sleep centers that perform the technical component (TC) of polysomnography (PSG) and sleep testing (including home sleep testing) 1. The sleep center or laboratory must maintain documentation on file that indicates it is accredited by either: the American Academy of Sleep Medicine (AASM), or theaccreditation Commission for Health Care (ACHC), or the Ambulatory Care Accreditation Program of the Joint Commission This documentation must be available on request. The AASM, ACHC, or Joint Commission accreditation applies to the hospital and freestanding facilities (including sleep clinics that are part of a physician s office, and all other non-hospital-based facilities where sleep studies are performed. Diagnostic testing performed in an Independent Diagnostic Testing Facility (IDTF) must follow the supervision and credentialing guidelines set forth by CMS and/or Palmetto GBA. Effective Date 04/05/ /2018

33 Accreditation and Credentialing Requirements for Polysomnography LCD Number: L36593 LCD Article Number: A55945 New (continued) The sleep laboratory or testing facility must be affiliated with a hospital or be under the direction and control of a physician (MD/ DO) who meets one of the following requirements, even though the diagnostic test may be performed in the absence of direct physician supervision. The raw data from all sleep tests must be reviewed and the tests must be interpreted by a physician who meets at least one of the following requirements: o Certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM) or by a member board of either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) o A completed fellowship in sleep medicine through an Accreditation Council for Graduate Medical Education (ACGME) accredited program. Following the completed fellowship, certification in sleep medicine is completed within two examination cycles through the American Board of Sleep Medicine (ABSM) or a member board of either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) Sleep centers in Jurisdiction M have been subject to these regulations since the implementation of the LCD on October 1, 2015 and similar regulations that appeared in previous versions of the Polysomnography LCD. Sleep centers in Jurisdiction J prior to February 26, 2018 were not required to meet similar standards by the previous contractor. All sleep centers in Jurisdiction J must now obtain accreditation by one of the three organizations listed above by July 1, 2018 in order to continue to render services to Medicare beneficiaries and submit claims to Palmetto GBA. Revision effective date: For services performed on or after 10/01/ As noted above in section 1, outpatient sleep centers affiliated with a hospital which is currently accredited by The Joint Commission (formerly JCAHO) through the hospital s accreditation will now be required to obtain separate ambulatory care accreditation for the sleep center if ambulatory services accreditation for the sleep center is not currently in place. This accreditation must be obtained by October 1, 2018 in order to continue to render services to Medicare beneficiaries and submit claims to Palmetto GBA. 04/05/ /2018

34 Accreditation and Credentialing Requirements for Polysomnography LCD Number: L36593 LCD Article Number: A55945 New (continued) 3. There is a new physician-credentialing standard published by The Joint Commission (formerly JCAHO) for ambulatory care organizations providing sleep center services that reduces quality variation and aligns credentialing requirements for all sleep testing facilities defined by the Polysomnography LCD. Specifically, as of January 1, 2018, the Joint Commission requires that organizations verify that physicians have at least one of the following qualifications before granting initial or revised privileges to physicians responsible for interpreting sleep studies: o Certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM) or by a member board of either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) OR o A completed fellowship in sleep medicine through an Accreditation Council for Graduate Medical Education (ACGME) accredited program. Following the completed fellowship, certification in sleep medicine is completed within two examination cycles through the American Board of Sleep Medicine (ABSM) or a member board of either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). The above language is not a new requirement under the Polysomnography LCD L Since its implementation on October 1, 2015, this LCD has required and continues to require, regardless of the standards put forth by any of the three listed accrediting organizations, that the sleep laboratory or testing facility be affiliated with a hospital or be under the direction and control of a physician (MD/DO) who meets one of the above requirements. The raw data from all sleep tests must be reviewed and the tests must be interpreted by a physician who meets at least one of the above requirements. This documentation must be available upon request. Please review the entire LCD (L36593) for complete information regarding polysomnography testing and billing requirements. Bibliography The Joint Commission Perspectives New Requirement for Ambulatory Care Organizations Providing Sleep Center Services June 6, /05/ /2018

35 Billing and Coding for the Rezum System for Benign Prostatic Hyperplasia (BPH) LCD Number: A55944 NEW On August 27, 2015, the FDA cleared for marketing the Rezum System to relieve lower urinary tract symptoms secondary to benign prostatic hyperplasia. This procedure involves the transurethral injection of steam into the prostate. Once injected, the steam condenses to water, imparting convective energy to the tissue, causing cell death and damage. The technology uses radiofrequency (RF) to boil the water to create the steam that is injected, but does not impart radiofrequency directly to the prostate tissue. Claims for procedures involving Rezum steam injection should NOT be coded as CPT because the technology does not apply radiofrequency energy to the prostate. Prostatic tissue destruction is accomplished via steam generated by RF, not by the RF itself. Rezum received FDA 510(k) clearance on February 27, Available evidence has shown that the Rezum procedure for treatment of BPH is reasonable and necessary. The procedure is covered for FDA approved indications if the appropriate criteria are met. Reportedly, a new CPT code for this procedure (proposed 538x3 Water Vapor Thermotherapy for destruction of prostate tissue) will be released in the 2019 Update. For Medicare Billing: Hospital Outpatient Setting or Ambulatory Surgical Center: Effective January 1, 2018, claims billed for procedures involving Rezum should be coded as HCPCS C9748. Documentation must be included in the remarks field (Field Locator 80) on the UB-04 (CMS 1450 form) or the equivalent 5010 electronic claims field to indicate the Rezum procedure was performed. Physician s Office: Claims billed for procedures involving Rezum should be coded as CPT Until the 2019 updates become effective, when submitting a Not Otherwise Classified (NOC) claim, documentation must be included in Box 19 on the CMS 1500 form or the electronic equivalent to indicate that the Rezum procedure was performed. 05/07/ /2018

36 Billing and Coding for the Rezum System for Benign Prostatic Hyperplasia (BPH) LCD Number: A55944 NEW (continued) Sources of Information: 1. McVary KT, Gange SN, Gittelman MC, et al. Erectile and Ejaculatory Function Preserved With Convective Water Vapor Energy Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Randomized Controlled Study. J Sex Med. 2016;13(6): McVary KT, Gange SN, Gittelman MC, et al. Minimally Invasive Prostate Convective Water Vapor Energy Ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. J Urol. 2016;195(5): /07/ Dixon CM, Rijo Cedano E, Pacik D, et al. Efficacy and Safety of Rezūm System Water Vapor Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Urology. 2015;86(5): Mynderse LA, Hanson D, Robb RA, et al. Rezūm System Water Vapor Treatment for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: Validation of Convective Thermal Energy Transfer and Characterization With Magnetic Resonance Imaging and 3-Dimensional Renderings. Urology. 2015;86(1): Billing Requirements for Application of Skin Substitutes (Part B Only Services) LCD Article Number: A55135 Revision Number: 8 Self-Administered Drug Exclusion List LCD Article Number: A53066 Revision Number: Dixon CM, Rijo Cedano E, Pacik D, et al. Two-year results after convective radiofrequency water vapor thermal therapy of symptomatic benign prostatic hyperplasia. Research and Reports in Urology. 2016;8: Under CPT/HCPCs Codes - Group 1: Codes we are adding the CPT Codes included in the article text. Under Excluded CPT/HCPCS Codes-Table Format added J0604 Sensipar (cinacalcet). 03/29/ /09/ /2018

37 MolDX Local Coverage Determinations (LCDs) Updates Revised ICD-10 LCDs The table below provides a summary of recent Part A MolDX ICD-10 LCD revisions/updates. To view these revised LCDs, go to Select MolDX LCDs under the Topics section. Go to your state and select Active. Scroll down to the Final LCDs for Contractor Results section and make sure the Active LCDs category is selected. Then select the Submit button. The LCDs are listed in alphabetical order. Title LCD Number Revision Number Coenzyme Q10 (CoQ10) LCD Number: L37022 Revision Number: 4 Controlled Substance Monitoring and Drugs of Abuse Testing LCD Number: L35724 Revision Number: 15 MolDX: HLA-B*15:02 Genetic Testing LCD Number: L36033 Revision Number: 6 MolDX: Molecular Diagnostic Tests (MDT) LCD Number: L35025 Revision Number: 18 MolDX: Oncotype DX Genomic Prostate Score for Men with Favorable Intermediate Risk Prostate Cancer LCD Number: L37262 Revision Number: 7 Changes/Additions/Deletions Removed reference #9 in the Bibliography section because it was withdrawn. Also removed the content referencing #9. Corrected bibliography numbering and references throughout the policy. The effective date of M54.12 was erroneously stated as 10/1/15 in Revision History 14. The correct effective date is 1/1/17. DX coverage was not applied until dates of service on and after 1/1/17. The effective date of M54.12 is 1/1/17. Added M and M to ICD-10 Group 1: Codes. This code was inadvertently left off during the ICD-10 transition. The effective date of M and M is 1/1/17. Corrected bullets and reference numbering. No changes in policy content. Effective Date 04/12/ /22/ /12/2018 The following CPT/HCPCS codes were deleted: 0008M was 04/05/2018 deleted from Group 1. This deletion was effective 1/25/2018 as part of the 2018 Q1 Update. The DEX web address was updated to: Removed G0452, 88380, from CPT/HCPCS Group 1 because they do not require Z-Codes. The removal of CPT/HCPCS codes G0452, 88380, is effective 1/1/2018. Removed reference #7 from the LCD. 04/12/ /2018

38 MolDX Local Coverage Determinations (LCDs) Article Updates Revised ICD-10 LCD Article Updates The table below provides a summary of recent Part A MolDX ICD-10 LCD article revisions/updates. To view these revised LCD articles, go to Select MolDX LCDs under the Topics section. Go to your state and select Active. Scroll down to the Final LCDs for Contractor Results section and make sure the Active LCDs category is selected. Scroll down to the Associated Documents section and access the link. Then select the Submit button. The LCDs are listed in alphabetical order. Title LCD Article ID Number Revision Number Controlled Substance Monitoring and Drugs of Abuse Coding and Billing Guidelines LCD Article Number: A54799 Revision Number: 9 MolDX: CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response Coding and Billing Guidelines LCD Article Number: A53524 Revision Number: 8 MolDX: ENG and ACVRL1 Gene Tests Coding and Billing Guidelines LCD Article Number: A53536 Revision Number: 6 MolDX: Fragile X Coding and Billing Guidelines Update LCD Article Number: A53638 Revision Number: 7 MolDX: GBA Genetic Testing Coding and Billing Guidelines LCD Article Number: A53542 Revision Number: 6 Changes/Additions/Deletions Effective Date Removed 2017 from the title. 04/05/2018 Conducted annual validation and corrected bullet issues. No change in article content. Conducted annual validation and corrected bullet issues. No change in article content. Conducted annual validation and removed an extraneous bullet that did not contain content. 04/12/ /12/ /12/2018 Completed the annual validation and corrected bullets. 04/12/ /2018

39 MolDX: HERmark Assay by Monogram Update LCD Article Number: A53103 Revision Number: 9 MolDX: SULT4A1 Genetic Testing Coding and Billing Guidelines LCD Article Number: A53538 Revision Number: 6 Completed the annual validation and corrected bullets. 04/12/2018 Conducted annual validation and corrected bullet issues. No change in article content. 04/12/2018 MolDX: Chromosome 1p/19q Deletion Analysis Local Coverage Determination (LCD Number: L36483) - Retired In reviewing our LCD: L MolDX: Chromosome 1p/19q Deletion Analysis, we have found a number of operational issues. The policy is scientifically correct. Physician FISH codes 8836X are appropriate service codes for the analysis. However, the use of these generic FISH codes has expanded to include a number of additional conditions and the edits generated by the LCD are causing problems with appropriate use of the codes. Therefore, we are retiring this policy. The effective date will be February 27, MolDX: NSCLC, Comprehensive Genomic Profile Testing Local Coverage Determination (LCD Number: L36143) - Retired Removed reference to M00118 in the Under the section MolDX CGP Analysis Coverage. M00118 has been retired. The effective date is April 12, SKILLED NURSING FACILITY (SNF) INFORMATION Ambulance Transportation for a SNF Resident in a Stay Not Covered by Part A Medicare Benefit Policy Manual, Chapter 10, and Medicare Claims Processing Manual, Chapter 15 MLN Matters Number: MM10550 Related CR Release Date: April 13, 2018 Related CR Transmittal Number: R243BP and R4021CP Related Change Request (CR) Number: Effective Date: July 16, 2018 Implementation Date: July 16, /2018

40 Provider Types Affected This MLN Matters Article is intended for Skilled Nursing Facilities (SNF), ambulance providers and suppliers providing ambulance services to patients and billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries who are not in a covered Part A stay. Provider Action Needed Change Request (CR) provides clarification on coverage of an ambulance transport for a SNF resident in a stay not covered by Part A, who has Part B benefits, to the nearest supplier of medically necessary services not available at the SNF, including the return trip. These clarifications relate to Chapter 10 of the Medicare Benefit Policy Manual, and Chapter 15, of the Medicare Claims Processing Manual. The revised manual sections are attachments to CR Make sure your billing staffs are aware of these clarifications. Background In the June 17, 1997, ambulance proposed rule (62 FR 32720), the Centers for Medicare & Medicaid Services (CMS) proposed a provision under Part B that permits ambulance transportation from a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is an inpatient, including the return trip. CMS finalized this proposal in the January 25, 1999, final rule (64 FR 3648) at 42 CFR (e)(3). CMS is revising the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to clarify that a medically necessary ambulance transport from an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident (including the return trip) may be covered under Part B. This applies to beneficiaries who are in an SNF stay not covered by Part A, but who has Part B benefits. For example, this includes ambulance transport of such residents from the SNF (modifier N) to the nearest diagnostic or therapeutic site, other than a physician s office or hospital, such as an Independent Diagnostic Testing Facility (IDTF), cancer treatment center, radiation therapy center, or wound care center, as reported with ambulance modifier D. For SNF residents receiving Part A benefits, this type of ambulance service is subject to SNF consolidated billing. Additional Information The official instruction, CR10550, issued to your MAC regarding this change, consists of two transmittals. The first updated the Medicare Claims Processing Manual and it is available at Regulations-and- Guidance/Guidance/Transmittals/2018Downloads/R4021CP.pdf. The second transmittal updates the Medicare Benefit Policy Manual and it is at Guidance/Guidance/Transmittals/2018Downloads/R243BP.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Programs/Medicare-FFS- Compliance-Programs/Review-Contractor-Directory-Interactive-Map/ /2018

41 Document History Date of Change April 13, 2018 Description Initial article released. Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) MLN Matters Number: MM10567 Related CR Release Date: March 30, 2018 Related CR Transmittal Number: R4011CP Related Change Request (CR) Number: Effective Date: April 30, 2018 Implementation Date: April 30, 2018 Provider Type Affected This MLN Matters Article is intended for Skilled Nursing Facilities (SNFs) billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed This article informs you about Change Request (CR) 10567, which advises you that the Centers for Medicare & Medicaid Services (CMS) has revised the Skilled Nursing Facility Notice of Non-coverage (SNF ABN), Form CMS With this revision, CMS is discontinuing the five Skilled Nursing Facility (SNF) Denial Letters (namely, the Intermediary Determination of Noncoverage, the UR Committee Determination of Admission, the UR Committee Determination on Continued Stay, the SNF Determination on Admission and the SNF Determination on Continued Stay), and the Notice of Exclusion from Medicare Benefits (NEMB-SNF), Form CMS Please ensure that your billing staffs are aware of these changes. Please note that the Notice of Medicare Non-Coverage (NOMNC), Form CMS is not being discontinued with this revised SNF ABN. More information on the NOMNC is available at cms.gov/medicare/medicare-general-information/bni/ffs-expedited-determination-notices.html. Background The authorization for these requirements are Section 1879 of the Social Security Act and 42 Code of Federal Regulations (CFR) (b) and (c), which specify written notice requirements. These requirements are fulfilled by the SNF ABN. In order for SNFs to transfer liability to an Original Medicare beneficiary for items or services paid under Medicare Part A (SNF Prospective Payment System (PPS)), the SNF must issue a SNF ABN for: An item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or Custodial care /2018

42 Attached to CR10567 is a revised Chapter 30 of the Medicare Claims Processing Manual. This revised manual chapter provides details on SNF ABN standards and also provides information about: Situations in which a SNF ABN should be given Situations in which a SNF ABN Is not needed to transfer financial liability to the beneficiary SNF ABN specific delivery issues Special rules for SNF ABNs Establishing when beneficiary is on Notice of Non-coverage Note: Further details are available at Information/BNI/FFS-SNFABN-.html. You may download the revised Form CMS in the Downloads section of that webpage. SNFs will continue to use the Advance Beneficiary Notice of Non-coverage (ABN, Form CMS-R-131) for items or services that Medicare may be deny under Medicare Part B. Please note that SNFs may start to implement this new notice any time up to the implementation date of CR Upon the CR10567 implementation on April 30, 2018, the use of the new notice is mandatory. The revised notice incorporates suggestions for changes made by users of the ABN and by beneficiary advocates based on experience with the current form, refinements made to similar liability notices through consumer testing and other means, as well as related Medicare policy changes and clarifications. Additional Information The official instruction, CR10567, issued to your MAC regarding this change is available at cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r4011cp.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change March 30, 2018 Description Initial article released /2018

43 Skilled Nursing Facility Value-Based Purchasing Program Updated MLN Matters Number: SE18003 Article Release Date: March 28, 2018 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A Provider Type Affected This MLN Matters Article is intended for physicians, clinical staff, and administrators of Skilled Nursing Facilities (SNFs) submitting claims under the SNF Prospective Payment System (PPS) to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries during an SNF stay. Provider Action Needed Special Edition article SE18003 informs providers about the SNF Value-Based Purchasing (VBP) Program. The VBP Program is one of many VBP programs that aim to reward quality and improve health care. Beginning October 1, 2018, SNFs will have an opportunity to receive incentive payments based on their performance in the program. Background On August 4, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1679-F) outlining Fiscal Year (FY) 2018 Medicare payment rates for SNFs. This final rule finalized SNF VBP Program scoring and operational policies, including an exchange function approach to implement incentive payment adjustments beginning October 1, Scoring and Operational Updates The SNF VBP Program s scoring and operational policies affecting payment determination in FY 2019 include: The adjusted Federal per diem rate applicable to each SNF in an FY will be reduced by 2 percent to fund incentive payments for that FY. The total amount of incentive payments distributed to SNFs will be 60 percent of the total amount withheld from SNFs Medicare payments for that FY. Facilities with SNF VBP performance scores ranked in the lowest 40 percent nationally will receive a payment rate lower than they would otherwise receive without the SNF VBP Program. SNF 30-Day All-Cause Readmission Measure (SNFRM) rates from the baseline year (Calendar Year 2015) affecting FY 2019 payment determinations are now publicly available on the Nursing Home Compare and SNF VBP Program websites. Payment Exchange Function CMS finalized a logistic exchange function to translate SNF performance scores into value-based incentive payments beginning in the FY 2019 SNF VBP Program. The logistic function maximizes the number of SNF with positive payment adjustment at a 60-percent payback percentage, while balancing Medicare s 42 05/2018

44 long-term sustainability. For more information about the logistic exchange function, refer to the FY 2018 SNF PPS Final Rule at Review and Corrections Process CMS clarified the Review and Corrections process for SNFs performance data that will be made publicly available on Nursing Home Compare. During the annual Review and Corrections 30-day period, the review scope is limited to correction requests regarding SNFs performance score and ranking information. FY 2020 Performance and Baseline Periods CMS adopted FY 2018 as the performance period and FY 2016 as the baseline period for the FY 2020 SNF VBP Program. The transition from measuring SNFs performance during a CY period to a Federal FY period allows for a 12-month performance period and baseline period for both program years. Table 1 provides details on the performance periods and baseline periods for the FY 2019 and FY 2020 program years. Table 1: Performance and Baseline Periods for FY 2019 & 2020 Program Years Period FY 2019 Program Year FY 2020 Program Year Performance Period CY 2017 (Jan. 1, 2017-Dec. 31, 2017) FY 2018 (Oct. 1, 2017-Sept. 30, 2018) Baseline Period CY 2015 (Jan. 1, 2015-Dec. 31, 2015) FY 2016 (Oct. 1, 2015-Sept. 30, 2016) Public Reporting CMS will rank SNFs for the FY 2019 program year and publish the rankings after the Review and Corrections process has completed. The published file will include, but may not be limited to, the following data elements to provide consumers and other stakeholders the necessary information to evaluate SNFs performance in the Program: Rank Provider ID Facility name Address Each SNF s baseline period (CY 2015) and performance period (CY 2017) Risk Standardized Readmission Rate (RSRR) National average baseline period (CY 2015) and performance period (CY 2017) RSRR Achievement score Improvement score Performance score 43 05/2018

45 The range of performance scores The number of SNFs receiving value-based payments The range and total amount of value-based payments Additional Information For more information about the SNF VBP Program, go to Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html and refer to FY 2018 SNF PPS Final Rule at pdf. If you have additional questions, please them to: You may also direct questions to your MAC at their toll-free number. That number is available at This advisory should be shared with all health care practitioners and managerial members of the provider/ supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www. PalmettoGBA.com/jja. Address Changes Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to on the CMS website. To obtain the hard copy form plus information on how to complete and submit it visit the Palmetto GBA website ( /2018

46 TOOLS THAT YOU CAN USE Religious Nonmedical Health Care Institution Overview Module This module provides an overview of Religious Nonmedical Instruction Overview (RNHCIs). You may select any of the options from the menu to view a specific section of this course. this module focuses on the following RNHCIs topics: Basics Elections Medical Care How to Bill Claims Processing To access this page, copy and paste the following link in your browser: /2018

47 New Medicare Card Information For more information about the new Medicare card, please go to the New Medicare cards Web Page on the CMS Website. To access this page, copy and paste the following link in your browser: /2018

48 HELPFUL INFORMATION Contact Information for Palmetto GBA Part A Department Contact Information Type of Inquiry Appeals Palmetto GBA Request for Redeterminations Part A Appeals - JJ Mail Code: AG-630 Redetermination Form P.O. Box Columbia, SC Fax: (803) Checks For Overpayments For Fed Ex/UPS/Certified Mail Palmetto GBA Part A Appeals - JJ Mail Code: AG-630 Building One 2300 Springdale Drive Camden, SC Palmetto GBA Medicare Part A Overpayments Mail Code: AG-340 P.O. Box Columbia, SC Provider Inquiries: For inquiries regarding overpayments, please call the Provider Contact Center at Fax Numbers: To send any financial correspondence to the overpayment department by fax, please fax this information to (803) To request an immediate offset, fax your request to (803) Overpayments Checks for cost report and credit balances 47 05/2018

49 Cost Report Credit Balance Reporting Customer Service Center (Beneficiary) Cost Report Filing Mailing Address Palmetto GBA Attn: Cost Report Acceptance Mail Code: AG-390 P.O. Box Columbia, SC Fed Ex/UPS/Certified Mail Address Palmetto GBA Attn: Cost Report Acceptance Mail Code: AG Springdale Drive Building One Camden, SC Cost Report Overpayment Address (checks only) Palmetto GBA JJA Checks PO Box Columbia, SC Regular and Certified Mail Palmetto GBA, LLC Attn: Credit Balance Reporting Mail Code: AG-340 P.O. Box Columbia, SC Fed Ex/UPS/Overnight Courier Palmetto GBA, LLC Attn: Credit Balance Reporting Mail Code: AG Springdale Drive Building One Camden, SC Credit Balance Overpayment Address(checks only): Palmetto GBA, LLC Medicare Finance Mail Code: AG-260 P.O. Box Columbia, SC Reports may be faxed to: MCBR Receipts Attn: Credit Balance Reporting (803) If you have questions about your Credit Balance Report, please call the Provider Contact Center at Medicare ( ) TTY: Visit the Medicare website at Cost Reports Checks Questions or concerns regarding credit balance reports All questions related to the Medicare program 48 05/2018

50 Electronic Data Interchange (EDI) Phone number: EDI enrollment Administrative Simplification and Compliance Act (ASCA) Electronic Remittance Advice (ERA) PC-ACE Pro 32 (billing software) Direct Data Entry (billing software) Other EDI-related issues DDE Hours of Availability Monday to Friday 6 am-8 pm ET Saturday 6 am- 4 pm ET Medical Affairs Medical Review Medicare Secondary Payer (MSP) Palmetto GBA Medical Affairs Mail Code: AG-275 P.O. Box Columbia, SC Fax: (803) Send s to A.Policy@palmettogba.com. Palmetto GBA Part A Medical Review Mail Code: AG-230 P.O. Box Columbia, SC Please call the Provider Contact Center (PCC) at for Medical Review questions. Fed Ex/UPS/Overnight Courier Palmetto GBA Mail Code: AG Springdale Drive, Building One Camden, SC Fax: (803) For questions/concerns related to MSP records, contact the Benefits Coordination & Recovery Center (BCRC) at: (TTY/TDD at for the hearing and speech impaired). Customer Service Representatives are available to provide you with quality service Monday through Friday from 8 a.m. to 8 p.m. ET, except holidays.. Mailing addresses are available on the CMS website. Sunday: Not Available Local coverage determinations (LCDs) Responding to Additional Documentation Requests (ADRs) Responses to our requests for medical records MSP questions Questions regarding beneficiary s primary or secondary records 49 05/2018

51 Provider Audit Provider Enrollment Provider Outreach and Education (POE) Palmetto GBA Provider Audit Mail Code: AG-390 P.O. Box Columbia, SC Palmetto GBA Cost Report Appeals and Reopenings Mail Code: AG-380 P.O. Box Columbia, SC Filing of Cost Report Appeals Filing of Cost Report Reopenings Palmetto GBA Part A Provider Enrollment 2300 Springdale Dr. Bldg. One Camden, SC For inquiries regarding provider enrollment, please call the PCC at Palmetto GBA Part A POE Mail Code: AG-830 P.O. Box Columbia, SC For education, please complete the Education Request Form. To access this document, go to the Forms Web page at forms Issues related to cost reports, desk reviews, audits and settlements Issues related to the filing of cost report appeals and reopenings Enrollment (credentialing) questions Request CMS-855 B, I or R forms Change address, add a location or add a new member to a provider group Independent Diagnostic Testing Facility (IDTF) enrollment Electronic Funds Transfer (EFT) CMS 588 form Medicare Participating Physician or Supplier Agreement (PAR) CMS 460 form How to obtain a National Provider Identifier (NPI) Participation corrections IRS 1099 tax form corrections Consent forms Educational training requests Request a speaker for association meetings in your state 50 05/2018

52 Provider Reimbursement Zone Program Integrity Contractor (ZPIC) Part A Provider Reimbursement Mail Code: AG-390 P.O. Box Columbia, SC Fax updated certificates for diabetes education, mammography and PET scan to the reimbursement department at (803) AdvancedMed, an NCI Company 520 Royal Parkway, Suite 100 Nashville, TN Phone Number: (615) Website: Submission of interim rate information Reimbursement issues Reimbursement specialist Submission of certificates Fraud Abuse Questionable billing practices 51 05/2018