Take 5: Medicare News You Can Use – July 2021



Get caught up on the medical coding and billing news that could affect payment for your professional claims. We cut out the rhetoric and give it to you plain and simple.

OIG Audit Uncovers Overpayments for TCM Services

If your physicians bill for transitional care management (TCM) services, it’s time for an internal audit of those claims. According to an Office of Inspector (OIG) report, the Centers for Medicare & Medicaid Services (CMS) did not have controls in place to prevent and detect improper payments for TCM services and allowed a potential $1.7 million in overpayments in 2015 and 2016. CMS said it will notify applicable providers of the need to “exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule,” according to the July 2021 OIG report.

New HCPCS Codes for COVID-19 Treatments

On June 24, the Food and Drug Administration (FDA) released an Emergency Use Authorization for tocilizumab (Actemra), a monoclonal antibody product used for the treatment of COVID-19. Providers should use the following new HCPCS Level II codes when billing this product:

Q0249     Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

M0249    Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose

M0250    Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

The FDA EUA limits the administration of Actemra to intravenous infusion only. Actemra is supplied in individual single-dose vials. See the EUA for more details.

These codes are effective June 24, 2021, and the EUA is effective until further notice.

COVID-10 Vaccine Reimbursement for HHAs

Effective June 8, 2021, Medicare will pay an additional $35 per dose for administering the COVID-19 vaccine for certain Medicare patients who have difficulties leaving their homes or are hard to reach. This is reported with HCPCS Level II code M0201 Covid-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient’s home. This is in addition to the standard administration amount Medicare pays for the vaccine (approximately $40 per dose).

The Centers for Medicare & Medicaid Services (CMS) has published “Medicare Payment for COVID-19 Vaccination Administration in the Home,” which outlines requirements.

Commercial payers are generally following suit. Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN), for example, are following CMS guidelines, with the exception of implementation dates: The expansion of COVID-19 vaccine coverage is effective on or after June 8, 2021, for patients with Medicare. BCBSM and BCN implemented coverage as of July 1, 2021, according to The Record (August 2021).

CMS Updates Modifiers 59 and X{EPSU} Guidelines

The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 23 – Fee Schedule Administration and Coding Requirements, Section 20.9.1.1 – Instructions for Codes With Modifier (A/B MACs (B) Only).

CMS clarifies, “Use of modifiers 59 or -X{EPSU} does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers -59 or -X{EPSU}.”

CMS also reiterates that these modifiers are not to be used with evaluation and management codes, and not with CPT® code 77427 Radiation treatment management, 5 treatments.

See Transmittal 10878, effective Aug. 16, for more.

Split/Shared E/M Reviews Temporarily Limited

Medicare is limiting review of claims for evaluation and management (E/M) services performed in part by both a physician and non-physician practitioner, and claims relating to critical care services, to applicable statutory and regulatory requirements from May 26 to Dec. 31. The agency will not consider Medicare Claims Processing Manual guidance in Chapter 12 while evaluating the applicable section guidance.

For more on this story, read the May 26 release.

Check Coding and Billing Updates for Revisions

MLN Matters article MM12289 was revised on June 21 to delete HCPCS Level II code J9314 from the Medicare Physician Fee Schedule Database quarterly update for July.

It’s always a good idea to visit the Centers for Medicare & Medicaid Services’ (CMS) website periodically for updates to updates — this goes for code set releases, too. The ICD-10-CM code set, for example, is released in July and implemented in October, but revisions to the code set can occur at any time. CMS updated the 2021 ICD-10-CM coding guidelines, code tables, addendum, and other related files on Dec. 16, 2020. These updates are not in your coding resources.

Evaluation and Management – CEMC

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