Take 5: Medicare News Flash – June 2021



Who has time to read all those wordy news releases and transmittals? Here’s news you can use in under 5 minutes.

Catch up on the latest coding and billing updates that will affect your Medicare Part A/B claims. Below are summaries of timely coding and billing changes.

AMA Releases Q4 2021 PLA Changes, CPT® Errata

The American Medical Association (AMA) released a quarterly update to its proprietary laboratory analyses (PLA) codes. Changes include one revised code (0051U), two deleted codes (0139U, 0168U), and 30 new PLA codes. Code changes are effective Oct. 1 and will be included in CPT® 2022.

On June 7, the AMA also released errata and technical corrections for CPT 2021. If you rely on the CPT® code book (in lieu of coding software), download the document for easy reference. The June 7 post address only technical corrections.

3 Codes Added to SNF CB Exclusion List

Three HCPCS Level II codes will be added to the list of codes Medicare excludes from Skilled Nursing Facility (SNF) Consolidated Billing (CB) enforcement, effective Oct. 1.

The Centers for Medicare & Medicaid Services (CMS) is updating the list of codes subject to the CB provisions of the SNF Prospective Payment System (PPS) to allow physicians to be paid for the following:

J7200 Injection, factor IX, (antihemophilic factor, recombinant), Rixubis, per IU

J7204 Injection, factor viii, antihemophilic factor (recombinant), (esperoct), glycopegylated-exei, per iu

Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg

HCPCS Level II code Q5123 is effective for claims with dates of service on or after July 1, 2021. Providers should either hold claims until Oct. 1 or request the Medicare Administrative Contractor to reprocess any incorrectly denied claims for Q5123 processed between July 1 and the Oct. 1 implementation date.

See MLN Matters MM12272 Revised for complete details.

Medicare Implements “Lesser-Of” Methodology to Certain Drug Payments

Effective July 1, Medicare will apply the lesser-of methodology to the payment limit calculations for HCPCS Level II J0717 and J0129.

Section 405 of the Consolidated Appropriations Act, 2021, requires the average sales price (ASP)-based payment for billing codes that include self-administered products identified in a July 2020 OIG report adhere to the lesser-of methodology.

The Medicare payment amount for J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) and J0129 Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) will be the lesser of the payment limit determined using the current ASP+6 percent or the ASP+6 percent amount obtained by excluding the self-administered products identified in the OIG study.

See MLN Matters article MM12244 for more information.

July Medicare Policy Updates Arrive

Lastly, remember to update your coding and billing software with the latest updates to ensure proper claims payment. CMS has released the following July quarterly files via transmittals:

  • July Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
  • July 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
  • Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) – July 2021 Update
  • Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
  • July 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.2
  • July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Until next month!

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