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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


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Medicare Updates

  • 31 May 2022 4:07 PM | Zachary Edgar (Administrator)

    Dually eligible beneficiaries are low-income beneficiaries enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A, Part B, or both, and getting full Medicaid benefits or only help with Medicare premiums or cost-sharing.

    Billing Dual Eligible/QMBs

    Medicare providers cannot bill QMB beneficiaries for Medicare cost-sharing. This includes Medicare deductibles, coinsurance, and copayments. In some cases, a beneficiary may owe a small Medicaid copayment. Medicare and Medicaid payments are considered payment in full.

    This prohibition applies even if the provider or supplier doesn’t participate in Medicaid.

    Providers are subject to sanctions if they bill a QMB above the total Medicare and Medicaid payments, even when Medicaid pays nothing.

    If a provider bills a QMB for Medicare cost-sharing, or turn a bill over to collections, the provider must recall it. If a provider collecst any QMB cost-sharing money, it must be refunded.

    Verifying Dual Eligible/QMB

    Providers should use the Medicare 270/271 HIPAA Eligibility Transaction System (HETS) and the Medicare Remittance Advice to identify if a beneficiary is a QMB and owes no Medicare cost-sharing.

    Advanced Beneficiary Notification of Non-Coverage (ABNs)

    Providers cannot bill the dually eligible beneficiary up front when an ABN is provided.

    Once Medicare and Medicaid adjudicates the claim, the provider may only charge the beneficiary in these circumstances:

    • If the beneficiary has QMB coverage without full Medicaid coverage and Medicare denies the claim, the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy.
    • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy, subject to state laws that limit beneficiary responsibility.

    Types of Dually Eligible Beneficiaries

    1. Full Medicaid (only)

    Benefits

    Full Medicaid coverage refers to the package of services beyond Medicare premiums coverage and cost-sharing certain beneficiaries get when they qualify for certain eligibility groups under a state’s Medicaid Program. States must cover some of these groups (like Supplemental Security Income [SSI] recipients). States have the option to cover others, like the special income level institutionalized beneficiary group, home- and community-based waiver participants, and medically needy individuals.

    Dually eligible beneficiaries who get Medicaid only are enrolled in Part A and or Part B and qualify for full Medicaid benefits but not for MSP groups. States may pay their Part B premium.

    Qualifications

    States decide income and resource criteria.

    States can require Part A or B enrollment if they pay the beneficiary’s premiums for these parts.

    Beneficiaries must show they need a certain level of care or meet state-specific medical criteria to qualify for certain categories.

    2. Qualified Medicare Beneficiary (QMB) Only Without Other Medicaid

    Benefits

    Medicaid pays Part A (if any) and Part B premiums.

    Medicaid is liable for Medicare deductibles, coinsurance, and copayments

    for Medicare-covered items and services. Even if Medicaid doesn’t fully

    cover these charges, the QMB isn’t liable for them.

    Qualifications

    Income can be up to 100% of the Federal Poverty Level (FPL).

    Resources can’t be more than 3 times the SSI resource limit, increased

    annually by the Consumer Price Index (CPI).

    QMB qualifications include enrollment in Part A (or if uninsured for Part

    A, have filed for premium Part A on a conditional basis).

    3. Qualified Medicare Beneficiary Plus (QMB+)

    Benefits

    Medicaid pays Part A (if any) and Part B premiums.

    Medicaid is liable for Medicare deductibles, coinsurance, and copayments

    for Medicare-covered items and services. Even if Medicaid doesn’t fully

    cover these charges, the QMB+ isn’t liable for them.

    Get full Medicaid coverage plus Medicare premiums and cost-sharing coverage.

    Qualifications

    Meet QMB-related eligibility requirements described in Table 2 and full Medicaid eligibility requirements in Table 1.

    4. Specified Low-Income Medicare Beneficiary (SLMB) Only Without Other Medicaid

    Benefits

    Medicaid pays Part B premium.

    Qualifications

    Income between 100%–120% of FPL.

    Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

    Enrolled in Part A.

    5. Specified Low-Income Medicare Beneficiary Plus (SLMB+)

    Benefits

    Medicaid pays Part B premium.

    Get full Medicaid coverage plus Medicare Part B premium coverage (see Table 1 for a definition of full Medicaid coverage).

    Qualifications

    Meet SLMB-related eligibility requirements described in Table 4 and full Medicaid eligibility requirements in Table 1.

    6. Qualifying Individual (QI)

    Benefits

    Medicaid pays Part B premium.

    Benefits limited to first-come, first-served.

    Qualifications

    Income between 120%–135% of FPL.

    Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

    Enrolled in Part A.

    QI beneficiaries aren’t eligible for any other Medicaid coverage.

    7. Qualified Disabled Working Individual (QDWI)

    Benefits

    Medicaid pays Part A premium.

    Qualifications

    Income up to 200% of FPL.

    Resources up to 2 times the SSI resource limit.

    Individuals under 65 with a qualifying disability who lost premium-free Part A coverage after returning to work and now must pay a premium to enroll in Part A.

    QDWI beneficiaries aren’t eligible for any other Medicaid coverage.


  • 5 Mar 2022 3:15 PM | Zachary Edgar (Administrator)

    Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22

    30.6.12.1 – Definition

    For payment under the Medicare Physician Fee Schedule (PFS), Medicare adopts the definition of critical care services in the CPT Codebook, and the CPT listing of bundled services, unless otherwise specified. This includes the CPT prefatory language stating that critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life threatening deterioration of the patient’s condition. It involves high complexity decision-making to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

    Bundled services that are included by CPT in critical care services and therefore not separately payable include interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures. As a result, these codes are not separately billable by a practitioner during the time-period when the practitioner is providing critical care for a given patient. Time spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.

    Because critical care services are delivered by a physician(s) or QHP(s), critical care may be reported by physicians and other practitioners who are qualified by education, training, licensure/regulation (when applicable), facility privileging (when applicable), and the applicable Medicare benefit category to perform critical care services and independently report them, referred to in this manual section as physicians and non-physician practitioners (NPPs).

    As specified in CPT prefatory language, critical care may be furnished on multiple days, and is typically furnished in a critical care area, which can include an intensive care unit or emergency care facility. Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time.

    30.6.12.2 - Critical Care by a Single Physician or NPP

    For payment of critical care by a single physician or NPP, we are adopting CPT’s reporting rules. When a single physician or NPP furnishes 30 -74 minutes of critical care services to a patient on a given date, the physician or NPP will report CPT code 99291. CPT code 99291 will be used only once per date even if the time spent by the practitioner is not continuous on that date. Thereafter, the physician or NPP will report CPT code 99292 for additional 30- minute time increments provided to the same patient.

    CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or NPP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Noncontinuous time for medically necessary critical care services may be aggregated.

    Regarding critical care services crossing midnight, CPT guidance defines how a service is to be billed when the service extends across calendar dates. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service. We are adopting this rule for critical care being furnished by a single physician or NPP when the critical care crosses midnight.

    30.6.12.3 - Critical Care Visits Furnished Concurrently by Different Specialties

    Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. The reasonable and necessary services of each physician furnishing concurrent care is covered when each plays an active role in the patient’s treatment. In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment.

    Medicare policy allows critical care visits furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services. Additionally, these critical care visits need to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

    30.6.12.4 - Critical Care Furnished Concurrently by Practitioners in the Same Specialty and Same Group (Follow-Up Care)

    Physician(s) or NPP(s) in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit. This may be as part of continuous staff coverage or follow-up care to critical care services furnished earlier in the day on the same calendar date.

    In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the same date report their time using the code for subsequent time intervals (CPT code 99292). CPT code 99291 will not be reported more than once for the same patient on the same date by these practitioners. This policy recognizes that multiple practitioners in the same specialty and the same group can maintain continuity of care by providing follow-up care for the same patient on a single date.

    When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date. The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).

    The aggregated time spent on critical care visits must be medically necessary and each visit must meet the definition of critical care in order to add the times for purposes of meeting the time requirement to bill CPT code 99291.

    For purposes of payment under the Physician Fee Schedule, Medicare classifies NPPs in a specialty that is not the same as a physician with whom the NPP is working, so the policies above would not apply to the situation where an NPP provides the follow-up care to a physician, or vice versa. Instead, see the section below regarding split (or shared) critical care services

    30.6.12.5 - Split (or Shared) Critical Care Visits

    Critical care visits may be furnished as split (or shared) visits, defined in section 30.6.18. The rules described in section 30.6.18 for other types of split (or shared) visits apply (except for the listing of qualifying activities for determining the substantive portion, discussed below), and service time is counted for CPT code 99292 in the same way as for prolonged E/M services. Specifically, the billing practitioner bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292). Also, the substantive portion for critical care services is defined as more than half of the total time spent by the physician and NPP beginning January 1, 2022. In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s).

    As stated earlier, when critical care services are furnished as a split (or shared) visit, the substantive portion is defined as more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292. Since, unlike other types of E/M visits, critical care services can include additional activities that are bundled into the critical care visits code(s), there is a unique listing of qualifying activities for split (or shared) critical care. These qualifying activities are described in the prefatory language for critical care services in the CPT Codebook.

    To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 75 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.

    The same documentation rules apply for split (or shared) critical care visits as for other types of split (or shared) E/M visits. Consistent with all split (or shared) visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit

    30.6.12.6 - Critical Care and Other Same-Day Evaluation and Management (E/M) Visits

    Our general policy, as described in section 30.6.5, states that physicians in the same group who are in the same specialty must bill and be paid for services under the PFS as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.

    However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation supports: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later in the day. Practitioners must use modifier -25 (same-day significant, separately identifiable evaluation and management service) on the claim when reporting these critical care services.

    30.6.12.7 - Critical Care Visits and Global Surgery

    Critical care visits are sometimes needed during the global period of a procedure, whether pre-operatively, on the same day, or during the post-operative period. In some cases, preoperative and postoperative critical care visits are included in procedure codes that have a global surgical period.

    In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (for example, trauma, burn cases). When the critical care service is unrelated to the procedure, append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.)) to the critical care CPT code(s).

    If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), modifiers -54 (surgical care only) and -55 (postoperative management only) must also be reported to indicate the transfer of care. The surgeon will report modifier -54. The intensivist accepting the transfer of care will report both modifier -55 and modifier -FT. As usual, medical record documentation must support the claims.

    30.6.12.8 - Medical Record Documentation

    Critical care is a time-based service, and therefore, practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner. Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member.

    To support coverage and payment determinations regarding concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient).

    When critical care services are reported the same date as another E/M visit, the medical record documentation must support: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later on that date. When critical care services are furnished in conjunction with a global procedure, the medical record documentation must support that the critical care was unrelated to the procedure, as discussed above.

    Reference

    Pub 100-04 Medicare Claims Processing Manual Ch. 12

    Transmittal 11181

  • 4 Mar 2022 5:09 PM | Zachary Edgar (Administrator)

    Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22

    30.6.18 - Split (or Shared) Visits

    A. Definition of Split (or Shared) Visit

    A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.

    Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations.

    B. Definition of Substantive Portion

    (1) More Than Half of the Total Time

    Beginning January 1, 2023, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit.

    During a transitional year from January 1, 2022 through December 31, 2022, except for critical care visits, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making (MDM)), or more than half of the total time spent by the physician and NPP performing the split (or shared) visit. In other words, for calendar year 2022, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit. When one of the three key components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety in order to bill. For example, if history is used as the substantive portion and both practitioners take part of the history, the billing practitioner must perform the level of history required to select the visit level billed. If physical exam is used as the substantive portion and both practitioners examine the patient, the billing practitioner must perform the level of exam required to select the visit level billed. If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.

    For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time. A unique listing of qualifying activities for purposes of determining the substantive portion of critical care visits applies.

    Definition of Substantive Portion for E/M Visit Code Families

    E/M Visit Code Family

    2022 Definition of Substantive Portion

    2023 Definition of Substantive Portion

    Other Outpatient*

    History, or exam, or MDM, or more than half of total time

    More than half of total time

    Inpatient/Observation/ Hospital/SNF

    History, or exam, or MDM, or more than half of total time

    More than half of total time

    Emergency Department

    History, or exam, or MDM, or more than half of total time

    More than half of total time

    Critical Care

    More than half of total time

    More than half of total time

    Acronyms: E/M (Evaluation and Management), MDM (medical decision-making), SNF (Skilled Nursing Facility)

    *Office visits are not billable as split (or shared) services.

    (2) Distinct Time

    In accordance with the CPT E/M Guidelines, only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.

    Example: If the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit, since they spent more than half of the total time (15 of 25 total minutes). If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit. The total time would be 30 minutes, and the physician would bill for the visit, since they spent more than half of the total time (20 of 30 total minutes).

    (3) Qualifying Time

    Drawing on the CPT E/M Guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:

    • Preparing to see the patient (for example, review of tests).
    • Obtaining and/or reviewing separately obtained history.
    • Performing a medically appropriate examination and/or evaluation.
    • Counseling and educating the patient/family/caregiver.
    • Ordering medications, tests, or procedures.
    • Referring and communicating with other health care professionals (when not separately reported).
    • Documenting clinical information in the electronic or other health record.
    • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
    • Care coordination (not separately reported).

    Practitioners cannot count time spent on the following:

    • The performance of other services that are reported separately.
    • Travel.
    • Teaching that is general and not limited to discussion that is required for the management of a specific patient.

    See section 30.6.12 for a listing of qualifying activities for purposes of determining the substantive portion of critical care services.

    For all split (or shared) visits, one of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician, nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.

    (4) Application to Prolonged Services

    Beginning January 1, 2023, the physician or practitioner who spent more than half the total time (the substantive portion starting in 2023) will bill for the primary E/M visit and the prolonged service code(s) when the service is furnished as a split (or shared) visit, if all other requirements to bill for split (or shared) services are met. The physician and NPP will add their time together, and whomever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) will report both the primary service code and the prolonged services add-on code(s), assuming the time threshold for reporting prolonged services is met.

    During the transitional calendar year 2022, when practitioners use a key component as the substantive portion, there will need to be different approaches for hospital outpatient E/M visits than other kinds of E/M visits:

    • For shared hospital outpatient visits where practitioners use a key component as the substantive portion, prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged hospital outpatient services (HCPCS code G2212).
    •  For all other types of E/M visits (except emergency department and critical care visits), prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged E/M services other than office/outpatient E/M visits (60 or more minutes beyond the typical time in the CPT code descriptor of the primary service). (Emergency department and critical care visits are not reported as prolonged services).

    Reporting Prolonged Services for Split (or Shared) Visits

    E/M Visit Code Family

    2022

    2023

    If Substantive Portion is a Key Component…

    If Substantive Portion is Time…

    Substantive Portion Must Be Time

    Other Outpatient*

    Combined time of both practitioners must meet the threshold for reporting HCPCS G2212

    Combined time of both practitioners must meet the threshold for reporting HCPCS G2212

    Combined time of both practitioners must meet the threshold for reporting HCPCS G2212

    Inpatient/Observation

    /Hospital/SNF

    Combined time of both practitioners must meet the threshold for reporting CPT 99354-9 (60+ minutes > typical)

    Combined time of both practitioners must meet the threshold for reporting CPT 99354-9 (60+ minutes > typical)

    Combined time of both practitioners must meet the threshold for reporting prolonged services

    Emergency Department

    N/A

    N/A

    N/A

    Critical Care

    N/A

    N/A

    N/A

    Acronyms: E/M (Evaluation and Management); SNF (Skilled Nursing Facility)

    *Office visits are not billable as split (or shared) services.

    C. New and Established Patients, and Initial and Subsequent Visits

    Split (or shared) visits may be billed for new and established patients, as well as for initial and subsequent visits, that otherwise meet the requirements for split (or shared) visit payment.

    D. Settings of Care

    Split (or shared) visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations at 42 CFR § 410.26.

    Accordingly, split (or shared) visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not billable as split (or shared) services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split (or shared) visit (see Section 30.6.13).

    E. Medical Record Documentation

    Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.

    F. Claim Identification

    Modifier -FS (Split or Shared E/M Visit) must be reported on claims for split (or shared) visits, to identify that the service was a split (or shared) visit. The modifier identified by CPT for purposes of reporting partial services (modifier -52 (reduced services)) cannot be used to report partial E/M visits, including any partial services furnished as split (or shared) visits. Medicare does not pay for partial E/M visits.

    Reference

    Pub 100-04 Medicare Claims Processing Manual Ch. 12

    Transmittal 11181

  • 13 Nov 2021 11:29 AM | Zachary Edgar (Administrator)

    On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2022 Medicare Part D income-related monthly adjustment amounts.

    Medicare Part B Premium and Deductible

    Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A. 

    Each year the Medicare Part B premium, deductible, and coinsurance rates are determined according to the Social Security Act. The standard monthly premium for Medicare Part B enrollees will be $170.10 for 2022, an increase of $21.60 from $148.50 in 2021. The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.

    The increases in the 2022 Medicare Part B premium and deductible are due to:

    • Rising prices and utilization across the health care system that drive higher premiums year-over-year alongside anticipated increases in the intensity of care provided.
    • Congressional action to significantly lower the increase in the 2021 Medicare Part B premium, which resulted in the $3.00 per beneficiary per month increase in the Medicare Part B premium (that would have ended in 2021) being continued through 2025.
    • Additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™, by people with Medicare. In July 2021, CMS began a National Coverage Determination analysis process to determine whether and how Medicare will cover Aduhelm™ and similar drugs used to treat Alzheimer’s disease. As that process is still underway, there is uncertainty regarding the coverage and use of such drugs by Medicare beneficiaries in 2022. While the outcome of the coverage determination is unknown, our projection in no way implies what the coverage determination will be, however, we must plan for the possibility of coverage for this high cost Alzheimer’s drug which could, if covered, result in significantly higher expenditures for the Medicare program.

    Medicare Part B Income-Related Monthly Adjustment Amounts

    Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 7 percent of people with Medicare Part B. The 2022 Part B total premiums for high-income beneficiaries are shown in the following table:

    Beneficiaries who file individual tax returns with modified adjusted gross income:

    Beneficiaries who file joint tax returns with modified adjusted gross income:

    Income-related monthly adjustment amount

    Total monthly premium amount

    Less than or equal to $91,000

    Less than or equal to $182,000

    $0.00

    $170.10

    Greater than $91,000 and less than or equal to $114,000

    Greater than $182,000 and less than or equal to $228,000

    $68.00

    $238.10

    Greater than $114,000 and less than or equal to $142,000

    Greater than $228,000 and less than or equal to $284,000

    $170.10

    $340.20

    Greater than $142,000 and less than or equal to $170,000

    Greater than $284,000 and less than or equal to $340,000

    $272.20

    $442.30

    Greater than $170,000 and less than $500,000

    Greater than $340,000 and less than $750,000

    $374.20

    $544.30

    Greater than or equal to $500,000

    Greater than or equal to $750,000

    $408.20

    $578.30

    Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

    Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, with modified adjusted gross income:

    Income-related monthly adjustment amount

    Total monthly premium amount

    Less than or equal to $91,000

    $0.00

    $170.10

    Greater than $91,000 and less than $409,000

    $374.20

    $544.30

    Greater than or equal to $409,000

    $408.20

    $578.30

    Medicare Part A Premium and Deductible

    Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, inpatient rehabilitation, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

    The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,556 in 2022, an increase of $72 from $1,484 in 2021. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2022, beneficiaries must pay a coinsurance amount of $389 per day for the 61st through 90th day of a hospitalization ($371 in 2021) in a benefit period and $778 per day for lifetime reserve days ($742 in 2021). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $194.50 in 2022 ($185.50 in 2021).

    Part A Deductible and Coinsurance Amounts for Calendar Years 2021 and 2022
    by Type of Cost Sharing

    2021

    2022

    Inpatient hospital deductible

    $1,484

    $1,556

    Daily coinsurance for 61st-90th Day

    $371

    $389

    Daily coinsurance for lifetime reserve days

    $742

    $778

    Skilled Nursing Facility coinsurance

    $185.50

    $194.50

    Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $274 in 2022, a $15 increase from 2021. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $499 a month in 2022, a $28 increase from 2021.

    Medicare Part D Income-Related Monthly Adjustment Amounts

    Since 2011, a beneficiary’s Part D monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 8 percent of people with Medicare Part D. These individuals will pay the income-related monthly adjustment amount in addition to their Part D premium. Part D premiums vary from plan to plan and roughly two-thirds are paid directly to the plan, with the remaining deducted from Social Security benefit checks. The Part D income-related monthly adjustment amounts are all deducted from Social Security benefit checks. The 2022 Part D income-related monthly adjustment amounts for high-income beneficiaries are shown in the following table:

    Beneficiaries who file individual tax returns with modified adjusted gross income

    Beneficiaries who file joint tax returns with modified adjusted gross income

    Income-related monthly adjustment amount

    Less than or equal to $91,000

    Less than or equal to $182,000

    $0.00

    Greater than $91,000 and less than or equal to $114,000

    Greater than $182,000 and less than or equal to $228,000

    $12.40

    Greater than $114,000 and less than or equal to $142,000

    Greater than $228,000 and less than or equal to $284,000

    $32.10

    Greater than $142,000 and less than or equal to $170,000

    Greater than $284,000 and less than or equal to $340,000

    $51.70

    Greater than $170,000 and less than $500,000

    Greater than $340,000 and less than $750,000

    $71.30

    Greater than or equal to $500,000

    Greater than or equal to $750,000

    $77.90

    Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

    Beneficiaries who are married and lived with their spouses at any time during the year, but file separate tax returns from their spouses, with modified adjusted gross income:

    Income-related monthly adjustment amount

    Less than or equal to $91,000

    $0.00

    Greater than $91,000 and less than $409,000

    $71.30

    Greater than or equal to $409,000

    $77.90

    Reference

    Centers for Medicare and Medicare.  2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.

    https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-and-deductibles2022-medicare-part-d-income-related-monthly-adjustment


  • 3 Nov 2021 11:50 AM | Zachary Edgar (Administrator)

    CY 2022 PFS Ratesetting and Conversion Factor

    CMS finalized a series of standard technical proposals involving practice expense, including standard rate-setting refinements, the implementation of the fourth year of the market-based supply and equipment pricing update, and changes to the practice expense for many services associated with the update to clinical labor pricing. We are finalizing our proposal to update the clinical labor rates for CY 2022 through the addition of a four-year transition period as requested by public commenters. We have used a four-year transition to incorporate new pricing data in the past, such as for the previous supply and equipment pricing update, and we believe that it will help provide payment stability and maintain beneficiary access to care.

    With the budget neutrality adjustment to account for changes in RVUs (required by law), and expiration of the 3.75 percent temporary CY 2021 payment increase provided by the Consolidated Appropriations Act, 2021 (CAA), the CY 2022 PFS conversion factor is $33.59, a decrease of $1.30 from the CY 2021 PFS conversion factor of $34.89. The PFS conversion factor reflects the statutory update of zero percent and the adjustment necessary to account for changes in relative value units and expenditures that would result from our finalized policies.

    Evaluation and Management (E/M) Visits

    CMS is engaged in an ongoing review of payment for E/M visit code sets. For CY 2022, we finalized several policies that take into account the recent changes to E/M visit codes, as explained in the AMA CPT Codebook, which took effect January 1, 2021. We are also clarifying and refining policies that were reflected in certain manual provisions that were recently withdrawn. Specifically, we are making a number of refinements to our current policies for split (or shared) E/M visits, critical care services, and services furnished by teaching physicians involving residents.

    Split (or shared) E/M visits 

    We are refining our longstanding policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the CY 2022 PFS final rule, we are establishing the following:

    • Definition of split (or shared) E/M visits as E/M visits provided in the facility setting by a physician and an NPP in the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit.
    • By 2023, the substantive portion of the visit will be defined as more than half of the total time spent. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time).
    • Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
    • A modifier is required on the claim to identify these services to inform policy and help ensure program integrity. 
    • Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
    • Codifying these revised policies in a new regulation at 42 CFR 415.140.

    Critical Care Services

    For critical care services, we are refining our longstanding policies, establishing that:

    • Critical care services are defined in the CPT Codebook prefatory language for the code set.
    • The CPT Codebook listing of bundled services are not separately payable.
    • When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits. 
    • Critical care services may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier -25 on the claim when reporting these critical care services. 
    • Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). We are creating a new modifier for use on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims. 

    Teaching Physician Services

    The AMA CPT office/outpatient E/M visit coding framework that CMS finalized for CY 2021 provides that practitioners can select the office/outpatient E/M visit level to bill based either on either the total time personally spent by the reporting practitioner or medical decision making (MDM). Under our existing regulations, if a resident participates in a service furnished in a teaching setting, a teaching physician can bill for the service only if they are present for the key or critical portion of the service. Under the so-called “primary care exception,” in certain teaching hospital primary care centers, the teaching physician can bill for certain services furnished independently by a resident without the physical presence of a teaching physician, but with the teaching physician’s review. 

    CMS finalized and clarified that when time is used to select the office/outpatient E/M visit level, only the time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection. Under the primary care exception, time cannot be used to select visit level. Only MDM may be used to select the E/M visit level, to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services. 

    Telehealth Services under the PFS

    As CMS continues to evaluate the inclusion of telehealth services that were temporarily added to the Medicare telehealth services list during the COVID-19 PHE, we finalized that certain services added to the Medicare telehealth services list will remain on the list through December 31, 2023, allowing additional time for us to evaluate whether the services should be permanently added to the Medicare telehealth services list.

    We finalized that we will extend, through the end of CY 2023, the inclusion on the Medicare telehealth services list of certain services added temporarily to the telehealth services list that would otherwise have been removed from the list as of the later of the end of the COVID-19 PHE or December 31, 2021. We also have extended inclusion of certain cardiac and intensive cardiac rehabilitation codes through the end of CY 2023. This will allow for more time for CMS and stakeholders to gather data, for stakeholders to submit support for requesting that services(s) be permanently added to the Medicare telehealth services list, and to reduce uncertainty regarding the timing of our processes with regard to the end of the PHE. Additionally, we are adopting coding and payment for a longer virtual check-in service on a permanent basis.

    Section 123 of the CAA removed the geographic restrictions and added the home of the beneficiary as a permissible originating site for telehealth services furnished for the purposes of diagnosis, evaluation, or treatment of a mental health disorder. Section 123 requires for these services that there must be an in-person, non-telehealth service with the physician or practitioner within six months prior to the initial telehealth service and requires the Secretary to establish a frequency for subsequent in-person visits. We are implementing these statutory amendments, and finalizing that an in-person, non-telehealth visit must be furnished at least every 12 months for these services, that exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record), and that more frequent visits are also allowed under our policy, as driven by clinical needs on a case-by-case basis.  

    CMS is amending the current definition of interactive telecommunications system for telehealth services  ̶  which is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner  ̶  to include audio-only communications technology when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders furnished to established patients in their homes under certain circumstances.

    CMS is limiting the use of an audio-only interactive telecommunications system to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology. CMS also finalized a requirement for the use of a new modifier for services furnished using audio-only communications, which would serve to verify that the practitioner had the capability to provide two-way, audio/video technology, but instead, used audio-only technology due to beneficiary choice or limitations. We are also clarifying that mental health services can include services for treatment of substance use disorders (SUDs).

    Billing for Physician Assistant (PA) Services

    CMS is implementing section 403 of the CAA, which authorizes Medicare to make direct payment to PAs for professional services that they furnish under Part B beginning January 1, 2022. Medicare currently can only make payment to the employer or independent contractor of a PA. Beginning January 1, 2022, PAs may bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs and bill Medicare for PA services.  

    Vaccine Administration Services

    Administration of Preventive Vaccines

    Effective January 1, 2022, CMS will pay $30 per dose for the administration of the influenza, pneumococcal and hepatitis B virus vaccines. In addition, CMS will maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the ongoing PHE ends. Effective January 1 of the year following the year in which the PHE ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines.

    In-Home Administration of COVID-19 Vaccines

    CMS will continue the additional payment of $35.50 for COVID-19 vaccine administration in the home under certain circumstances through the end of the calendar year in which the PHE ends.

    COVID-19 Monoclonal Antibody Products

    CMS will continue to pay for COVID-19 monoclonal antibodies under the Medicare Part B vaccine benefit through the end of the calendar year in which the PHE ends. During this interim time, we will maintain the $450 payment rate for administering a COVID-19 monoclonal antibody in a health care setting, as well as the payment rate of $750 for administering a COVID-19 monoclonal antibody therapy in the home.

    Effective January 1 of the year following the year in which the PHE ends, CMS will pay physicians and other suppliers for COVID-19 monoclonal antibody products as biological products paid under section 1847A of the Act; health care providers and practitioners will be paid under the applicable payment system, and using the appropriate coding and payment rates, for administering COVID-19 monoclonal antibodies similar to the way they are paid for administering other complex biological products.

    Coverage and Payment for Medical Nutrition Therapy (MNT) Services and Related Services

    The statute provides coverage of MNT services furnished by registered dietitians and nutrition professionals when the patient is referred by a physician (an M.D. or D.O.) and also establishes the professional qualifications for these practitioners. Since January 1, 2002, registered dietitians and nutrition professionals have been recognized to provide and bill for MNT services, meaning nutritional diagnostic, therapeutic, and counseling services. For CY 2022, in response to stakeholder concerns about parity of registered dietitians and nutrition professionals with other types of NPPs, we established regulations at § 410.72 to describe their services. The addition of this regulation parallels the regulations in place for other types of NPPs listed at section 1842(b)(18)(C) of the Act. We also finalized regulatory text at § 410.72(f) to state the requirements for these NPPs to bill on an assignment-related basis by cross-reference to our general assignment regulation at § 424.55. For consistency in our regulations, we made conforming amendments to our regulations regarding assignment requirements for PAs, nurse practitioners, clinical nurse specialists, and certified nurse mid-wives at §§ 410.74(d)(2), 410.75(e)(2), 410.76(e)(2) and 410.77(d)(2), respectively.

    We also updated the payment regulation for MNT services at § 414.64 to clarify that MNT services are, and have been, paid at 100 percent (instead of 80 percent) of 85 percent of the PFS amount, without any cost-sharing, since CY 2011. While we implemented this change through our usual change request process, we neglected to update this regulation when the Affordable Care Act amended the statute to except the coinsurance and deductible for preventive services defined under section 1861(ddd)(3) of the Act that have a grade of A or B from the United States Preventive Services Task Force and MNT services received a grade of B. We also finalized removing the requirement that the medical nutrition therapy referral be made by the “treating” physician which allows for additional physicians to make a referral to MNT services. Finally, we updated the glomerular filtration rate (GFR) to reflect current medical practice and align with accepted chronic kidney disease staging which slightly moved the upper GFR range to 59 mL/min/1.72m² from 50 mL/min/1.72m².

    Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as a Colorectal Cancer Screening

    CMS finalized implementation of Section 122 of the CAA, which provides a special coinsurance rule for procedures that are planned as colorectal cancer screening tests but become diagnostic tests when the practitioner identifies the need for additional services (e.g., removal of polyps). At present, the addition of any procedure beyond the planned colorectal screening (for which there is no coinsurance) results in a beneficiary’s having to pay coinsurance. 

    Section 122 of the CAA reduces, over time, the amount of coinsurance a beneficiary will pay for such services. That is, for services furnished on or after January 1, 2022, the coinsurance amount paid for planned colorectal cancer screening tests that require additional related procedures shall be equal to a specified percent (i.e., 20 percent for CY 2022, 15 percent for CYs 2023 through 2026, 10 percent for CYs 2027 through 2029, and zero percent beginning CY 2030)  of the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to the test. 

    The reduction over time of the coinsurance percentage holds true regardless of the code that is billed for establishment of a diagnosis, for removal of tissue or other matter, or for another procedure that is furnished in connection with and in the same clinical encounter as the screening. Thus, beginning CY 2022, the coinsurance required of Medicare beneficiaries for planned colorectal cancer screening tests that result in additional procedures furnished in the same clinical encounter will be gradually reduced, and beginning January 1, 2030, will be zero percent.

    Opioid Treatment Program (OTP) Payment Policy

    CMS finalized its proposal to allow OTPs to furnish counseling and therapy services via audio-only interaction (such as telephone calls) after the conclusion of the COVID-19 PHE in cases where audio/video communication is not available to the beneficiary, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction, provided all other applicable requirements are met. CMS also finalized a requirement that OTPs use a service-level modifier for audio-only services billed using the counseling and therapy add-on code in order to facilitate program integrity activities.

    Additionally, in order to avoid a significant decrease in the payment amount for methadone that could negatively affect access to methadone for beneficiaries receiving services at OTPs, CMS is issuing an interim final rule with comment to maintain the payment amount for methadone at the CY 2021 rate for the duration of CY 2022. CMS is also seeking comment on OTP utilization patterns for methadone, particularly, the frequency with which methadone oral concentrate is used compared to methadone tablets in the OTP setting, including any applicable data on this topic. 

    Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

    CMS finalized several provisions aimed at bolstering the abilities of RHCs and FQHCs to furnish care to underserved Medicare beneficiaries. The following provisions demonstrate CMS’ commitment to addressing health equities in rural and vulnerable populations.

    Mental Health Services Furnished via Telecommunications Technologies for RHCs and FQHCs

    CMS finalized its proposal to revise the current regulatory language for RHC or FQHC mental health visits to include visits furnished using interactive, real-time telecommunications technology. This change will allow RHCs and FQHCs to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the beneficiary is not capable of, or does not consent to, the use of video technology. CMS also finalized that an in-person, non-telehealth visit must be furnished at least every 12 months for these services; however, exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record) and more frequent visits are also allowed under our policy, as driven by clinical needs on a case-by-case basis. 

    Rural Health Clinic (RHC) Payment Limit Per-Visit

    Section 130 of the CAA as amended by section 2 of Pub. Law 117-7, requires that, beginning April 1, 2021, already-enrolled independent RHCs and provider-based RHCs in larger hospitals receive an increase in their payment limit per visit over an 8-year period, with a prescribed amount for each year from 2021 through 2028. Then, in subsequent years, the limit is updated by the percentage increase in Medicare Economic Index (MEI). Also beginning April 1, 2021, section 130 as amended requires that a payment limit per-visit be established for most provider-based RHCs in a hospital with fewer than 50 beds enrolled before January 1, 2021 be subject to a payment limit based on their 2020 per-visit rate, updated annually by the percentage increase in MEI. Lastly, section 130 of the CAA subjects all newly enrolled RHCs (as of January 1, 2021, and after), both independent and provider-based, to a national payment limit per-visit.

    Payment for Attending Physician Services Furnished by RHCs or FQHCs to Hospice Patients

    CMS finalized its proposal to implement section 132 of the CAA, which makes FQHCs and RHCs eligible to receive payment for hospice attending physician services when provided by a FQHC/RHC physician, nurse practitioner, or physician assistant who is employed or working under contract for an FQHC or RHC, but is not employed by a hospice program, starting January 1, 2022.

    Concurrent Billing for Chronic Care Management Services (CCM) and Transitional Care Management (TCM) Services for RHCs and FQHCs

    CMS finalized its proposal to allow RHCs and FQHCs to bill for TCM and other care management services furnished for the same beneficiary during the same service period, provided all requirements for billing each code are met.

    COVID-19 Vaccines Furnished in RHCs and FQHCs (Technical Updates)

    Section 3713 of the CARES Act established Medicare Part B coverage and payment for a COVID-19 vaccine and its administration. CMS finalized its proposal to make conforming technical changes to the regulatory text related to COVID-19 vaccines for RHCs and FQHCs.

    Tribal FQHC Payments – Comment Solicitation

    Outpatient clinics operated by a tribal organization under the Indian Self-Determination Education and Assistance Act or by an Urban Indian organization receiving funds under title V of the Indian Health Care Improvement Act are eligible to become FQHCs. FQHCs are paid under the FQHC Prospective Payment System (PPS) under Medicare Part B based on the lesser of the FQHC PPS rate or their actual charges. There is an exception for payment under the FQHC PPS for certain tribal FQHCs in operation on or before April 7, 2000. Under the exception, grandfathered tribal FQHCs bill as if they were provider-based to an Indian Health Service (IHS) hospital and are paid the Medicare outpatient per visit rate, also referred to as the IHS all-inclusive rate (AIR).

    CMS received a request from American Indian and Alaska Native communities to amend its Medicare regulations to make all IHS- and tribally-operated outpatient facilities/clinics eligible for payment at the Medicare outpatient per visit/AIR, if they were owned, operated, or leased by IHS. In addition, we have been asked to consider certain flexibilities regarding the cost reporting requirement for these types of facilities. Therefore, we solicited comment on these topics. We plan to further review the comments received and may consider them for potential future payment policy decisions. 

    Electronic Prescribing of Controlled Substances-Section 2003 of the SUPPORT Act

    Section 2003 of the SUPPORT Act requires electronic prescribing of controlled substances (EPCS) for schedule II, III, IV, and V controlled substances covered through Medicare Part D. The statute provides the Secretary with discretion on whether to grant waivers or exceptions to the EPCS requirement and specifies several types of exceptions that may be considered. It also gives the Secretary authority to enforce non-compliance with the requirement and to specify appropriate penalties for non-compliance through rulemaking. In December 2020, CMS implemented the first phase of this mandate by naming the standard that prescribers must use for EPCS transmissions and delaying compliance actions until January 1, 2022.

    In the PFS final rule, we are implementing the second phase of this mandate by finalizing in regulation certain exceptions to the EPCS requirement. An exception will apply if a prescriber meets any of the following:

    • the prescriber and dispensing pharmacy are the same entity;
    • the prescriber issues 100 or fewer controlled substance prescriptions for Part D drugs per calendar year; and
    • the prescriber is in the geographic area of an emergency or disaster declared by a federal, state or local government entity, or
    • the prescriber has been granted a CMS-approved waiver based on extraordinary circumstances, such as technological failures or cybersecurity attacks or other emergency.

    We are allowing prescribers to request a waiver where circumstances beyond the prescriber’s control prevent the prescriber from being able to electronically prescribe controlled substances covered by Part D.

    CMS is also delaying the start date for compliance actions to January 1, 2023, in response to stakeholder feedback. We are also delaying the start date for compliance actions for Part D prescriptions written for beneficiaries in long-term care facilities to January 1, 2025. We will initially enforce compliance by sending compliance letters to prescribers violating the EPCS mandate.

    Requiring Certain Manufacturers to Report Drug Pricing Information for Part B

    Drug manufacturers with Medicaid Drug Rebate Agreements are required to submit Average Sales Price (ASP) data for their Part B products in order for their covered outpatient drugs to be payable under Part B. To date, manufacturers without such agreements have had the option to voluntarily submit ASP data. For calendar quarters beginning January 1, 2022, section 401 of the CAA requires manufacturers of drugs or biologicals payable under Part B without a Medicaid Drug Rebate Agreement to report ASP data. CMS is making regulatory changes to implement this new reporting requirement.

    Determination of ASP for Certain Self-administered Drug Products

    Section 405 of the CAA requires the Office of Inspector General (OIG) to conduct periodic studies on non-covered, self-administered versions of drugs or biologicals that are included in the calculation of payment under section 1847A of the Social Security Act. This provision permits CMS to apply a payment limit calculation methodology (the “lesser of” methodology) to applicable billing codes, if deemed appropriate. That is, the Medicare payment limit for the drug or biological billing code would be the lesser of: (1) the payment limit determined using the current methodology (where the calculation includes the ASPs of the self-administered versions), or (2) the payment limit calculated after excluding the non-covered, self-administered versions. CMS finalized the “lesser of” methodology for drug and biological products that may be identified by future OIG reports.

    Section 405 of the CAA also requires that beginning July 1, 2021, the ASP-based payment limit for billing codes representing Cimzia® (certolizumab pegol) and Orencia® (abatacept) as identified in a July 2020 OIG report adhere to the “lesser of” methodology. CMS has applied this methodology for these billing codes beginning in the July 2021 ASP Drug Pricing files.

    Part B Drug Payment for Section 505(b)(2) Drugs

    Some drugs approved through the pathway established under section 505(b)(2) of the Federal Food, Drug, and Cosmetic Act share similar labeling and uses with generic drugs that are assigned to multiple source drug codes. In the CY 2022 PFS proposed rule, CMS solicited comment on a decision framework under which certain section 505(b)(2) drug products could be assigned to existing multiple source drug codes. This approach would be applied to section 505(b)(2) drug products where a billing code descriptor for an existing multiple source code describes the product and other factors, such as the product’s labeling and uses, are similar to products already assigned to the code. The framework approach is consistent with the concept of paying similar amounts for similar services and with efforts to curb drug prices. CMS received feedback from stakeholders in response to the comment solicitation and will continue to evaluate this approach. 

    Clinical Laboratory Fee Schedule: Laboratory Specimen Collection Fee and Travel Allowance

    The Clinical Laboratory Fee Schedule (CLFS) provides for a nominal fee for specimen collection for laboratory testing and a fee to cover transportation and personnel expenses (generally referred to as the travel allowance) for trained personnel to collect specimens from homebound patients and inpatients (except hospital inpatients). The travel allowance is paid only when the nominal specimen collection fee is also payable. 

    In an effort to be as expansive as possible within the current authorities to make diagnostic testing available to Medicare beneficiaries during the COVID-19 PHE, we changed the Medicare payment rules to provide payment to independent laboratories for specimen collection from beneficiaries who are homebound or inpatients (not in a hospital) for COVID-19 clinical diagnostic laboratory tests (CDLTs) under certain circumstances and increased payments from $3-5 to $23-25. Although the increased specimen collection fees for COVID-19 CDLTs will end at the termination of the COVID-19 PHE, in the CY 2022 PFS proposed rule, we sought comments on our policies for specimen collection fees and the travel allowance as we consider updating these policies in the future through notice and comment rulemaking. Specifically, we requested comments regarding the nominal specimen collection fees related to the calculation of costs for transportation and personnel expenses for trained personnel to collect specimens from homebound patients and inpatients (not in a hospital), how specimen collection practices may have changed because of the PHE, and what additional resources might be needed for specimen collection for COVID-19 CDLTs and other tests after the PHE ends.

    We received feedback from stakeholders in response to the comment solicitation, which we plan to take into consideration for possible future rulemaking for the CLFS laboratory specimen collection fee and travel allowance.

    CMS also clarified that we are making permanent the option for laboratories to maintain electronic logs of miles traveled for the purposes of covering the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect a specimen sample.

    Appropriate Use Criteria (AUC) Program

    CMS finalized our proposal to begin the payment penalty phase of the AUC program on the later of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19. This flexible effective date is intended to take into account the impact that the PHE for COVID-19 has had and may continue to have on practitioners, providers and beneficiaries. Previously, the payment penalty phase of the AUC program was set to begin January 1, 2022.

    Pulmonary Rehabilitation

    CMS proposed to expand coverage of outpatient pulmonary rehabilitation services, paid under Medicare Part B, to beneficiaries who were hospitalized with COVID-19 and experience persistent symptoms, including respiratory dysfunction, for at least four weeks after hospitalization. We finalized coverage for outpatient pulmonary rehabilitation services, paid under Medicare Part B, to beneficiaries who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks.

    Medicare Shared Savings Program

    CMS finalized a longer transition for Accountable Care Organizations (ACOs) to prepare for reporting electronic clinical quality measures/Merit-based Incentive Payment System clinical quality measures (eCQM/MIPS CQM) under the Alternative Payment Model (APM) Performance Pathway (APP), by extending the availability of the CMS Web Interface collection type for an additional three years, through performance year (PY) 2024. This policy responds to ACOs’ concerns about the transition to all-payer eCQM/MIPS CQMs, including aggregating all-payer data across multiple health care practices that participate in the same ACO and across multiple electronic health record (EHR) systems. 

    We are also finalizing delaying the increase in the quality performance standard ACOs must meet to be eligible to share in savings until PY 2024, by maintaining the 30th percentile of the MIPS quality performance category score for PY 2023, and additional revisions to the quality performance standard to encourage ACOs to report all-payer measures. These changes, in addition to existing policies, provide four years for ACOs to transition to reporting the three eCQM/MIPS CQMs under the APP. For more details on Shared Savings Program quality policies, please refer to the Quality Payment Program PFS final rule fact sheet: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1654/2022%20Quality%20Payment%20Program%20Final%20Rule%20Resources.zip

    ACOs accepting performance-based risk must establish a repayment mechanism (i.e., escrow, line of credit, surety bond) to assure CMS that they can repay losses for which they may be liable upon reconciliation. CMS finalized revisions to the repayment mechanism arrangement policy to reduce by 50 percent the percentage used in the existing methodology for determining the repayment mechanism amount. We also specified how we identify the number of assigned beneficiaries used in the repayment mechanism amount calculation and the annual repayment mechanism amount recalculation. We also finalized modifications to the threshold for determining whether an ACO is required to increase its repayment mechanism amount during its agreement period. These changes will result in lower required initial repayment mechanism amounts and less frequent repayment mechanism amount increases during an ACO’s agreement period, thereby lowering potential barriers for ACOs’ participation in two-sided models and increasing available resources for investment in care coordination and quality improvement activities. We also finalized a one-time opportunity for certain ACOs that established a repayment mechanism to support their participation in a two-sided model beginning on July 1, 2019; January 1, 2020; or January 1, 2021; to elect to decrease the amount of their existing repayment mechanisms.

    CMS finalized policies that reduce burden and streamline the Shared Savings Program application process by modifying the prior participation disclosure requirement, so that the disclosure is required only at the request of CMS during the application process, and by reducing the frequency and circumstances under which ACOs submit sample ACO participant agreements and executed ACO participant agreements to CMS. We also finalized the proposal to amend the beneficiary notification requirement to set forth different notification obligations for ACOs depending on the assignment methodology selected by the ACO to help avoid unnecessary confusion for beneficiaries.

    CMS finalized revisions to the definition of primary care services that are used for purposes of beneficiary assignment. The updated definition will be applicable for determining beneficiary assignment beginning with PY 2022.

    In this final rule we also provide a summary of public comments on the Shared Savings Program’s benchmarking methodology received in response to the comment solicitations in the CY 2022 PFS proposed rule on calculation of the regional adjustment, and blended national-regional growth rates for trending and updating the benchmark, as well as on the risk adjustment methodology. We appreciate the ongoing dialogue between CMS, ACOs, and other program stakeholders on considerations for improving the Shared Savings Program’s benchmarking policies. We will take these comments into consideration as we contemplate additional refinements to the Shared Savings Program’s benchmarking methodologies and will propose any specific policy changes, as appropriate, in future notice and comment rulemaking.

    Updates to the Open Payments Financial Transparency Program

    Open Payments is a national transparency program that requires drug and device manufacturers and group purchasing organizations (known as “reporting entities”) to report payments or transfers of value to physicians, teaching hospitals, and other providers (known as “covered recipients”) to CMS. CMS finalized as proposed several changes to the Open Payments program to support the usability and integrity of the data for the public, researchers, and CMS, including the following:

    • Adding a mandatory payment context field for records to teaching hospitals;
    • Adding the option to recertify annually even when no records are being reported;
    • Disallowing record deletions without a substantiated reason;
    • Adding a definition for a physician-owned distributorship as a subset of applicable manufacturers and group purchasing organizations and updating the definition of ownership interest;
    • Requiring reporting entities to update their contact information;
    • Disallowing publication delays for general payment records;
    • Clarifying the exception for short-term loans; and
    • Removing the option to submit and attest to general payment records with an “Ownership” Nature of Payment category.

    Medicare Provider Enrollment

    CMS finalized all of its proposed provider enrollment regulatory provisions. These involve:

    • Exempting independent diagnostic testing facilities (IDTF) that only perform services that do not require direct or in-person beneficiary interaction, treatment, or testing from several of our IDTF supplier standards in 42 CFR § 410.33. 
    • Expanding our authority to deny or revoke a provider’s or supplier’s Medicare enrollment in order to protect the Medicare program and its beneficiaries.
    • Establishing specific rebuttal procedures in regulation for providers and suppliers whose Medicare billing privileges have been deactivated. 

    Medicare Ground Ambulance Data Collection System

    CMS finalized our proposed changes to the Medicare Ground Ambulance Data Collection System including:

    • Finalizing our proposal for a new data collection period beginning between January 1, 2023, and December 31, 2023, and a new data reporting period beginning between January 1, 2024, and December 31, 2024, for selected ground ambulance organizations in year 3; 
    • Revisions to the timeline for when the payment reduction for failure to report will begin aligning the timelines for the application of penalties for not reporting data with our new timelines for data collection and reporting and when the data will be publicly available beginning in 2024; and
    • Revisions to the Medicare Ground Ambulance Data Collection Instrument. These changes and clarifications to the instrument will improve its clarity and make the instrument less burdensome for respondents to complete.


  • 3 Jul 2019 3:38 PM | Zachary Edgar (Administrator)

    Related CR Release Date: July 3, 2019

    Effective Date: October 1, 2019

    MLN Matters Number: MM11230

    Providers Affected

    Providers and suppliers who serve Qualified Medicare Beneficiaries (QMBs).

    Changes

    Modifications to Medicare’s claims processing systems to ensure that the Medicare Summary Notice (MSN) appropriately differentiates between QMB claims that are paid and denied and to show accurate patient payment liability amounts for beneficiaries enrolled in QMB.

    The MSN generated for all QMB individuals includes information regarding their QMB status and lack of liability for Medicare cost-sharing amounts for covered Parts A and B items and services However, CMS has recently learned that the claims processing systems do not differentiate between paid and fully denied claims or denied service lines, and initiate the changes whenever an individual is enrolled in QMB.

    MSNs with QMB claims that are paid:

    • If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will use MSN Message 62.0 to briefly explain the QMB billing protections (in the "Be Informed!" section).
    • Also, on page one, the patient’s total liability amount (in the “Total You May Be billed” field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.
    • Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the “Maximum You May Be Billed” field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections.

    MSNs with QMB claims that are denied

    •  In the claim detail pages of the MSN, if a detail line is for a QMB and contains an allowed amount of zero, the MSN:
      • Will reflect the beneficiary's total liability amount in the “Maximum You May Be Billed” field and
      • Include new MSN 11.21 message to inform the beneficiary that even though Medicare has denied the claim, Medicaid may pay for the care.
    • Since most QMBs also have full Medicaid coverage, it’s important to convey that their full Medicaid coverage may cover care that Medicare has denied.


  • 10 May 2019 3:41 PM | Zachary Edgar (Administrator)

    Related CR Release Date: May 10, 2019

    Effective Date: January 1, 2018

    Implementation Date: August 12, 2019

    MLN Matters Number: MM11259

    Providers Affected

    Physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

    Changes Made

    During this initial period of implementation, reporting of the PRC on claims is voluntary. In the future, it will be mandatory and tied to cost measures preceded by rulemaking. As of January 1, 2018, Medicare Part B Merit-Based Incentive Payment System (MIPS)-eligible clinicians may now report their patient relationships on Medicare claims using the PRC codes.

    Below is the description of the PRC Code Modifiers X1, X2, X3, X4 and X5:

    • X1 - Continuous/Broad services = For reporting services by clinicians who provide the principal care for a patient, with no planned endpoint of the relationship
    • X2- Continuous/Focused services = For reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.
    • X3 -Episodic/Broad services = For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patients, that is limited to a defined period and circumstance, such as a hospitalization.
    • X4 - Episodic/Focused services = For reporting services by specialty focused clinicians who provide time-limited care. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention.
    •  X5 - Only as Ordered by Another Clinician = For reporting services by a clinician who furnishes care to the patient only as ordered by another clinician. This patient relationship category is reported for patient relationships that may not be adequately captured in the four categories described above.

    The Centers for Medicare & Medicaid Services (CMS) has several goals for the voluntary reporting period:

    • For clinicians to gain familiarity with the categories and experience submitting the codes
    • To collect data on the use and submission of the codes for analyses to inform the potential future use of these codes in cost measure attribution methodology in the Quality Payment Program.

    The codes are currently in a voluntary reporting period. Whether and how the codes are reported on claims will not affect Medicare reimbursement. For now, the modifiers have no impact on beneficiaries.


  • 26 Apr 2019 3:37 PM | Zachary Edgar (Administrator)

    Related CR Release Date: April 26, 2019

    Effective Date: January 1, 2019

    MLN Matters Number: MM11171

    Providers Affected

    Teaching physicians billing Medicare Administrative Contractors (MACs) for Evaluation and Management (E/M) services provided to Medicare beneficiaries.

    Changes Made

    It clarifies existing language in the Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 100.1.1 (Evaluation and Management (E/M) Services) to bring it in line with current documentation policy for teaching physicians and E/M services.

    The following provides these policy clarifications:

    For the purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate: 1) that the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and 2) the participation of the teaching physician in the management of the patient.

    The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurse

    Note that MACs will not search their files to reprocess claims impacted by this change. However, they will adjust such claims that you bring to their attention.



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