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NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.
JJ PART B MEDICARE ADVISORY December 2020
Volume 2020, Issue 12
Latest Medicare News for JJ Part B
What’s Inside...
Administration
eServices: COVID-19 Transition .............................................................................................3
eServices and Google Authenticator ........................................................................................4
Get Your Medicare News Electronically .................................................................................6
ePass is Now Available to Ease the Burden of Repeated Authentication When Calling
Palmetto GBA’s Provider Contact Center ............................................................................8
eTicket Enables Providers to Save Time with Every Call .......................................................8
CMS Quarterly Provider Update .............................................................................................9
Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the
Coronavirus (COVID-19)...................................................................................................11
Update to Chapter 10 of Publication (Pub.) 100-08 - Enrollment Policies for Home Infusion
Therapy (HIT) Suppliers ....................................................................................................28
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule ....................................................................................31
Education
Educational Events Where You Can Ask Questions .............................................................35
Fee Schedules and Reimbursement
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) –
October 2020 Update..........................................................................................................38
Continued >>
palmettogba.com/jjb
The JJ Part B Medicare Advisory contains coverage, billing and other information for Part B. This information is
not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities
and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no
cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow
the guidelines. The JJ Part B Medicare Advisory includes information provided by the Centers for Medicare &
Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any
time. This bulletin should be shared with all health care practitioners and managerial members of the provider
staff. Bulletins are available at no-cost from our website at https://www.PalmettoGBA.com/JJB.
CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of
the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee sched-
ules, relative value units, conversion factors and/or related components are not assigned by the AMA, and are
not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data contained or not contained
herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT),
Copyright © 2019 American Dental Association (ADA). All rights reserved.Medicine
International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage
Determination (NCDs)--April 2021 ..........................................................................................................................41
Billing for Home Infusion Therapy Services on or After January 1, 2021 ...................................................................43
National Coverage Determination (NCD 90.3): Chimeric Antigen Receptor (CAR) T-cell Therapy ..........................51
Radiology
Special Provisions for Radiology Additional Documentation Requests.......................................................................55
Etcetera
Medical Director’s Desk ...............................................................................................................................................57
MLN ConnectsTM ..........................................................................................................................................................62
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
2 12/2020eServices: COVID-19 Transition
In light of the COVID-19 pandemic, organizations are proactively transitioning employees across the health
care industry back into the office.
Palmetto GBA is providing a quick reference eServices guide to assist with common issues you may experi-
ence if you have not logged into your eServices account in the past 30-60 days.
If you are not currently registered to use eServices, we have also included some resources to get you started.
Jurisidiction J:
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BQUPHE00&url=yes
Jurisdiction M:
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BQUPJ705&url=yes
Railroad Medicare
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BRKJM375&url=yes
CMS Provider
Minute Videos
The Medicare Learning Network has a series of CMS Provider Minute Videos
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-
Multimedia) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much
more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting
documentation. Check the site often as CMS adds new videos periodically to further help you navigate the
Medicare program.
Do You Have a Question Regarding eServices? We Can Help!
Palmetto GBA has dedicated representatives available to provide technical assistance and answer
questions about our secure online portal — eServices. Our Provider Contact Center (PCC) representatives
can be reached at 877–567–7271 (Monday – Friday, 8 a.m. to 6 p.m. ET).
To connect with an eServices representative:
• Press/say 1 or EDI
• Press/say 1 or eServices
IVR Call Flow Chart:
https://www.palmettogba.com/Palmetto/Providers.Nsf/files/IVR_JJ_Call_Flow.pdf/$File/IVR_JJ_Call_Flow.pdf
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
3 12/2020eServices and Google Authenticator
To enhance the security of Medicare information, the Centers for Medicare & Medicaid Services (CMS) requires
the use of multi-factor authentication (MFA) each time you log in to eServices. We're excited to announce a
new option to protect your account - Google Authenticator.
You now have three options to receive an MFA code:
• Email
• Text
• Google Authenticator
Are you new to eServices? Or maybe you already have an eServices account...no worries! In just a few quick
steps, you can set up Google Authenticator. This two-step verification is available when initially registering
for eServices or if you already have an existing eServices account.
Initial Registration
Upon initial registration to eServices, you must complete the fields on the MFA Setup screen.
The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google
Authenticator option.
After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These
steps are based on your device - iPhone or Android:
• iPhone users must access iTunes
• Android users must access Google Play
A successful installation prompts this screen showing your device is now linked. Select Submit to save the
changes.
At your initial login to eServices, you are asked to choose your preferred method for receiving your MFA code.
Select the Use the app button to receive the MFA code via the Google Authenticator app.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
4 12/2020After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will
renew every 30 seconds.
Enter the code in the available field and select the Submit button.
Existing Account
At your next login to eServices, you are asked to choose your preferred method for receiving your MFA code.
You must choose from the text or email options since you haven’t set up the Google Authenticator option yet.
After verification, go to the My Account tab to change your account settings.
From the My Account tab, scroll down until you see the MFA Setup options.
The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google
Authenticator option.
After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These
steps are based on your device - iPhone or Android:
• iPhone users must access iTunes
• Android users must access Google Play
A successful installation prompts this screen showing your device is now linked. Select Submit to save the
changes.
At your next login to eServices, you are again asked to choose your preferred method for receiving your MFA
code. But not you’ll notice you can also choose to receive your code with the Google Authenticator app.
Select the Use the app button to receive the MFA code via the Google Authenticator app.
After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will
renew every 30 seconds.
Enter the code in the available field and select the Submit button.
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
5 12/2020Get Your Medicare News Electronically
The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity
to stay informed about:
• Medicare incentive programs
• Fee Schedule changes
• New legislation concerning Medicare
• And so much more!
How to register to receive the Palmetto GBA Medicare Listserv: Go to
http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be
sure to select the specialties that interest you so information can be sent.
Note: Once the registration information is entered, you will receive a confirmation/welcome message informing
you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three
days of your registration.
eServices Eligibility
eServices, by Palmetto GBA, allows you to search for patient eligibility, which is a functionality of HETS.
HETS requires you to enter beneficiary last name and Medicare ID Number, in addition to either the birth
date or first name. See options below:
• Medicare ID Number, Last Name, First Name, Birth Date
• Medicare ID Number, Last Name, Birth Date
• Medicare ID Number, Last Name, First Name
For more information about eServices and the many services it offers, please visit our website at
http://www.PalmettoGBA.com/eServices.
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
6 12/2020Medicare Learning Network® (MLN)
Want to stay informed about the latest changes to the Medicare Program? Get
connected with the Medicare Learning Network® (MLN) – the home for education,
information, and resources for health care professionals.
The Medicare Learning Network® is a registered trademark of the Centers for
Medicare & Medicaid Services (CMS) and the brand name for official CMS education
and information for health care professionals. It provides educational products on
Medicare-related topics, such as provider enrollment, preventive services, claims
processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of
formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses
(many of which offer continuing education credits) – all available to you free of charge!
The following items may be found on the CMS web page at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index
• MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To
access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the
catalog, you may either click on the title of a product or you can click on the type of “Formats Available.”
This will link you to an online version of the product or the Product Ordering Page.
• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products
are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and
select “MLN Product Ordering Page.”
• MLN Product of the Month: highlights a Medicare provider education product or set of products each
month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!
Other resources:
• MLN Publications List: contains the electronic versions of the downloadable publications. These products
are available to you for free. To access the MLN Publications go to:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-
Publications. You will then be able to use the “Filter On” feature to search by topic or key word or you
can sort by date, topic, title, or format.
MLN Educational Products Electronic Mailing List
To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN
Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive
an e-mail when new and revised MLN products are released.
To subscribe to the service:
1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or
Unsubscribe’ link under the ‘Options’ tab on the right side of the page.
2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!
If you would like to contact the MLN, please email CMS at MLN@cms.hhs.gov.
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
7 12/2020ePass is Now Available to Ease the Burden of Repeated
Authentication When Calling Palmetto GBA’s Provider
Contact Center
Authentication is required before Palmetto GBA is authorized to discuss Medicare information with a provider.
The ePass is an eight-digit code providers can elect to receive, per each NPI and PTAN combination, following
their first-time authentication when they call the Provider Contact Center (PCC). This ePass can then be used
for the remainder of the day in order to authenticate. This code will be delivered in one of two ways:
• Through the IVR, follow the first-time authentication steps by selecting Option 5 for ePass and then Option
2 to receive ePass; or
• Request your ePass verbally while speaking with a Customer Service Agent (CSA) following first-time
authentication
The goal of the ePass is to ease provider burden by eliminating the need to repeatedly authenticate each time
you contact the PCC in a given day. The ePass can then be used for the remainder of that business day in order
to authenticate. Simply select Option 5 for ePass and Option 1 to enter your 8-digit ePass number.
This enhancement is in direct response to provider feedback with the goal of improving your provider experience
with Palmetto GBA.
eTicket Enables Providers to Save Time with Every Call
Palmetto GBA continues to develop tools to improve service and efficiency, and our new eTicket is no exception.
eTicket, like the recently introduced ePass, will save you time when contacting the Provider Contact Center
(PCC) about a particular issue on multiple occasions. While ePass provides you with a code to bypass
authentication on subsequent calls to the PCC during a single day, eTicket enables our representatives to serve
you quickly and with greater effectiveness.
When you speak to a customer care representative by phone, a numeric inquiry number or eTicket is generated
which provides a reference to the subject matter of your conversation with our PCC. When you call us with
additional follow-up questions or for more information specific to a prior call, you can input your eTicket
number into the IVR. Upon being transferred to a service representative, your topic of inquiry and data related
to your previous call with Palmetto GBA will automatically be presented on the service representative’s screen,
expediting their ability to serve you.
Palmetto GBA welcomes you to eTicket. Look for additional information at www.PalmettoGBA.com, in our
Listserv newsletters and on Palmetto GBA’s social media channels.
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
8 12/2020CMS Quarterly Provider Update
The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid
Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare
including program memoranda, manual changes and any other instructions that could affect providers.
Regulations and instructions published in the previous quarter are also included in the update. The purpose of
the Quarterly Provider Update is to:
• Inform providers about new developments in the Medicare program
• Assist providers in understanding CMS programs and complying with Medicare regulations and instructions
• Ensure that providers have time to react and prepare for new requirements
• Announce new or changing Medicare requirements on a predictable schedule
• Communicate the specific days that CMS business will be published in the ‘Federal Register’
To receive notification when regulations and program instructions are added throughout the quarter, sign up
for the Quarterly Provider Update listserv (electronic mailing list) at
https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.
We encourage you to bookmark the Quarterly Provider Update Web site at
www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index and
visit it often for this valuable information.
eServices Extends Administrator Unlock Feature Beyond 30
Days
Palmetto GBA has implemented new “Disable User” functionality in eServices that will disable a user that has
been inactive for 30 days instead of terminating the User ID. Administrators will now be able to enable the
user up to 120 days after 30 days of inactivity. If the user ID is not enabled within this time, the account will
be terminated. We will send notification to providers through a series of periodic emails (up to the 120-day
limit) to remind the user of their status and provide instructions to re-enable eServices IDs.
In short, provider administrators can now simply unlock users as well as other administrators. This is a significant
change from past guidelines. Previously:
• Provider Administrators and users were required to login at least once every 30 days
• Accounts in which users did not login past 30 days were deactivated/terminated
• If the provider admin did not login, all user accounts associated with the provider admin were also
deactivated/terminated
• This created additional work for administrators as they were required to create new accounts for deactivated/
terminated users
The Provider Contact Center eServices Helpdesk is also able to assist if the provider administrator is unable
to complete this task.
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
9 12/2020You Can Track Your Enrollment Application
Palmetto GBA makes it easy for you to track your enrollment application with our Application Status Lookup
Tool. This tool provides tracking data for application types 855A, 855B, 855I, 855R and 855O, and Medicare
Diabetes Prevention Program. Additionally, the tool will provide updates on submitted CMS 588 (EFT), CMS
460 (Participating Agreement), reconsideration requests, opt-out affidavits, license updates and voluntary
terminations requests.
• Jurisdiction J, Part B:
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yes
• Jurisdiction M, Part B:
https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yes
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
10 12/2020Medicare Fee-For-Service (FFS) Response to the Public
Health Emergency on the Coronavirus (COVID-19)
MLN Matters Number: SE20011 Revised
Article Release Date: November 9, 2020
Related CR Transmittal Number: N/A
Related Change Request (CR) Number: N/A
Effective Date: N/A
Implementation Date: N/A
Note: We revised the article to clarify the billing instructions in the Skilled Nursing Facility (SNF)
Benefit Period Waiver - Provider Information section. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition Article is for physicians, providers and suppliers who bill Medicare Fee-
For-Service (FFS).
Provider Information Available
The Secretary of the Department of Health & Human Services declared a public health emergency (PHE)
in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and
modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020.
The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued
for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the
emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.
More Information:
• Coronavirus Waivers and Flexibilities
(https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/
coronavirus-waivers) webpage
• Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-
an-1135-Waiver-Updated-11-16-2016.pdf) to request an individual waiver if there is no blanket waiver
Background
Section 1135 and Section 1812(f) Waivers
As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal
waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:
1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC
X12 837 institutional claims format or paper Form CMS-1450.
2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institutional,
i.e., claims submitted using the ASC X12 837 professional claim formator paper Form CMS-1500 or, for
pharmacies, in the NCPDP format.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
11 12/2020Clarification for Using the “CR” Modifier and “DR” Condition Code
When a PHE is declared and section 1135 authority is invoked, CMS has the authority to take proactive
steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Act,
to approve blanket waivers of certain Social Security Act requirements. These waivers help prevent gaps in
access to care for beneficiaries impacted by the emergency. In previous emergencies, CMS issued a limited
number of waivers for the Medicare Fee-for-Service program. In order to allow CMS to assess the impact
of prior emergencies, CMS has required the use of modifier “CR” and condition code “DR” for all services
provided in a facility operating pursuant to CMS waivers that typically were in place, for limited geographical
locations and durations of time.
For the COVID-19 PHE, CMS has issued many additional blanket waivers, flexibilities and modifications to
existing deadlines and timetables that apply to the whole country. The full list of waivers and flexibilities can be
found here. Due to the large volume and scope of these new blanket waivers and flexibilities, CMS is clarifying
which require the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare. The
chart below identifies those blanket waivers and flexibilities for which CMS requires the use of the modifier
or condition code. Submission of the modifier or condition code is not required for any waivers or flexibilities
not included in this chart.
Please note that CMS will not deny claims due to the presence of the “CR” modifier or “DR” condition code
for services/items related to a COVID-19 waiver that are not on this list, or for services/items that are not
related to a COVID-19 waiver. There may be potential claims implications, such as claims denials, for claims
that do not contain the modifier or condition code as required in the below chart. However, providers do not
need to resubmit or adjust previously processed claims to conform to the requirements below, unless claims
payment was affected.
Waiver/Flexibility Summary CR DR
Care for Excluded Allows acute care hospitals with excluded distinct part inpatient
Inpatient Psychiatric psychiatric units to relocate inpatients from the excluded distinct
Unit Patients in the part psychiatric unit to an acute care bed and unit as a result of a X
Acute Care Unit of a disaster or emergency.
Hospital
Housing Acute Care Allows acute care hospitals to house acute care inpatients in excluded
Patients in the IRF or distinct part units, such as excluded distinct part unit IRFs or IPFs,
Inpatient Psychiatric where the distinct part unit’s beds are appropriate for acute care
X
Facility (IPF) inpatients.
Excluded Distinct Part
Units
Care for Excluded Allows acute care hospitals with excluded distinct part inpatient
Inpatient rehabilitation units to relocate inpatients from the excluded distinct
Rehabilitation Unit part rehabilitation unit to an acute care bed and unit as a result of
X
Patients in the Acute this PHE.
Care Unit of a
Hospital
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
12 12/2020Waiver/Flexibility Summary CR DR
Supporting Care for CMS has determined it is appropriate to issue a blanket waiver to long-
Patients in Long Term term care hospitals (LTCHs) where an LTCH admits or discharges
Care Acute Hospitals patients in order to meet the demands of the emergency from the
(LTCHs) 25-day average length of stay requirement at § 412.23(e)(2), which
allows these hospitals to participate in the LTCH PPS. In addition,
during the applicable waiver time period, CMS has determined it is
X
appropriate to issue a blanket waiver to hospitals not yet classified
as LTCHs, but seeking classification as an LTCH, to exclude patient
stays where the hospital admits or discharges patients in order to
meet the demands of the emergency from the 25-day average length
of stay requirement, which must be met in order for these hospitals
to be eligible to participate in the LTCH PPS.
Care for Patients in Allows extended neoplastic disease care hospitals to exclude inpatient
Extended Neoplastic stays where the hospital admits or discharges patients in order to
Disease Care Hospital meet the demands of the emergency from the greater than 20-day
average length of stay requirement, which allows these facilities to
X
be excluded from the hospital inpatient prospective payment system
and paid an adjusted payment for Medicare inpatient operating and
capital-related costs under the reasonable cost-based reimbursement
rules.
Skilled Nursing Using the authority under Section 1812(f) of the Act, CMS is waiving
Facilities (SNFs) the requirement for a 3-day prior hospitalization for coverage of a
SNF stay, which provides temporary emergency coverage of SNF
services without a qualifying hospital stay, for those people who
experience dislocations, or are otherwise affected by COVID-19.
In addition, for certain beneficiaries who exhausted their SNF
X
benefits, it authorizes renewed SNF coverage without first having
to start a new benefit period (this waiver will apply only for those
beneficiaries who have been delayed or prevented by the emergency
itself from commencing or completing the process of ending their
current benefit period and renewing their SNF benefits that would
have occurred under normal circumstances).
Durable Medical When DMEPOS is lost, destroyed, irreparably damaged, or otherwise
Equipment, rendered unusable, allow the DME Medicare Administrative
Prosthetics, Orthotics, Contractors (MACs) to have the flexibility to waive replacements
and Supplies requirements such that the face-to-face requirement, a new
(DMEPOS) physician’s order, and new medical necessity documentation are not
X
required. Suppliers must still include a narrative description on the
claim explaining the reason why the equipment must be replaced
and are reminded to maintain documentation indicating that the
DMEPOS was lost, destroyed, irreparably damaged, or otherwise
rendered unusable or unavailable as a result of the emergency.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
13 12/2020Waiver/Flexibility Summary CR DR
Modification of Modifies the 60-day limit to allow a physician or physical therapist
60-Day Limit for to use the same substitute for the entire time he or she is unavailable
Substitute Billing to provide services during the COVID-19 emergency, plus an
Arrangements (Locum additional period of no more than 60 continuous days after the
Tenens) public health emergency expires. On the 61st day after the public
health emergency ends (or earlier if desired), the regular physician X
or physical therapist must use a different substitute or return to work
in his or her practice for at least one day in order to reset the 60-day
clock. Physicians and eligible physical therapists must continue to
use the Q5 or Q6 modifier (as applicable) and do not need to begin
including the CR modifier until the 61st continuous day.
Critical Access Waives the requirements that Critical Access Hospitals limit the
Hospitals number of inpatient beds to 25, and that the length of stay, on an X
average annual basis, be limited to 96 hours.
Replacement Prescrip- Medicare payment may be permitted for replacement prescription
tion Fills fills (for a quantity up to the amount originally dispensed) of covered
Part B drugs in circumstances where dispensed medication has been X
lost or otherwise rendered unusable by damage due to the disaster
or emergency.
Hospitals Classified Waives certain eligibility requirements for hospitals classified as
as Sole Community SCHs prior to the PHE, specifically the distance requirements and X
Hospitals (SCHs) the “market share” and bed requirements (as applicable).
Hospitals Classified as For hospitals classified as MDHs prior to the PHE, waives the
Medicare-Dependent, eligibility requirements that the hospital has 100 or fewer beds
Small Rural Hospitals during the cost reporting period and that at least 60 percent of the
X
(MDHs) hospital’s inpatient days or discharges were attributable to individuals
entitled to Medicare Part A benefits during the specified hospital cost
reporting periods.
IRF 60 Percent Rule Allows an IRF to exclude patients from its inpatient population for
purposes of calculating the applicable thresholds associated with the
requirements to receive payment as an IRF (commonly referred to as
the “60 percent rule”) if an IRF admits a patient solely to respond to X
the emergency. In addition, during the applicable waiver time period,
we would also apply the exception to facilities not yet classified as
IRFs, but that are attempting to obtain classification as an IRF.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
14 12/2020Waiver/Flexibility Summary CR DR
Waivers of certain Allows a hospital or Community Mental Health Center (CMHC)
hospital and to consider temporary expansion locations, including the patient’s
Community Mental home, to be a provider-based department of the hospital or extension
Health Center of the CMHC, which allows institutional billing for certain outpatient
(CMHC) Conditions services furnished in such temporary expansion locations. If the X X
of Participation and entire claim falls under the waiver, the provider would only use the
provider-based rules DR condition code. If some claim lines fall under this waiver and
others do not, then the provider would only append the CR modifier
to the particular line(s) that falls under the waiver.
Billing Procedures for In an effort to keep patients in their SNF/NF and decrease their risk
ESRD services when of being exposed to COVID-19, ESRD facilities may temporarily
the patient is in a SNF/ furnish renal dialysis services to ESRD beneficiaries in the SNF/
NF NF instead of the offsite ESRD facility. The in-center dialysis center
should bill Medicare using Condition Code 71 (Full care unit. Billing
X X
for a patient who received staff-assisted dialysis services in a hospital
or renal dialysis facility). The in-center dialysis center should also
apply condition code DR to claims if all the treatments billed on the
claim meet this condition or modifier CR on the line level to identify
individual treatments meeting this condition.
Clinical Indications for In the interim final rule with comment period (CMS-1744-IFC and
Certain Respiratory, CMS-5531-IFC) CMS states that clinical indications of certain
Home Anticoagulation national and local coverage determinations will not be enforced
Management, Infusion during the COVID-19 public health emergency. CMS will not
Pump and Therapeutic enforce clinical indications for respiratory, oxygen, infusion pump X
Continuous Glucose and continuous glucose monitor national coverage determinations
Monitor national and local coverage determinations.
and local coverage
determinations
Face-to-face and In- In the interim final rule with comment period (CMS-1744-IFC) CMS
person Requirements states that to the extent a national or local coverage determination
for national and would otherwise require a face-to-face or in-person encounter for
X
local coverage evaluations, assessments, certifications or other implied face-to-face
determinations services, those requirements would not apply during the COVID-19
public health emergency.
Requirement for The requirement to submit a prior authorization request for certain
DMEPOS Prior DMEPOS items and services was paused. Suppliers were given the
Authorization option to voluntary continue submitting prior authorization requests
or to skip prior authorization and have the claim reviewed through X
post payment review at a later date. Claims that would normally
require prior authorization, but were submitted without going
through the process should be submitted with a CR modifier.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
15 12/2020Waiver/Flexibility Summary CR DR
Signature The signature requirement for Part B drugs and certain Durable
requirements for proof Medical Equipment (DME) that require a proof of delivery and/
of delivery or a beneficiary signature was waived. Providers should use a CR
X
modifier on the claim and document in the medical record the
appropriate delivery date and that a signature could not be obtained
because of COVID-19.
Part B Prescription MACs may exercise flexibilities regarding the payment of Medicare
Drug Refills Part B claims for drug quantities that exceed usual supply limits, and
X
to permit payment for larger quantities of drugs, if necessary. MACs
may require the use of the CR modifier in these cases.
Services provided During the COVID-19 PHE, hospitals may furnish clinical staff
by the hospital in services in the patient’s home as a provider-based outpatient
the patient’s home department and bill and be paid for these services as Hospital
as a provider-based Outpatient Department (HOPD) services when the patient is
outpatient department registered as a hospital outpatient. Hospitals should bill as if the X
when the patient is services were furnished in the hospital, including appending the
registered as a hospital PO modifier for excepted items and services and the PN modifier
outpatient. for non-excepted services. The DR condition code should also be
appended to these claims.
Medicare FFS Questions & Answers (FAQs) available on the Waivers and Flexibilities webpage
(https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-
flexibilities) apply to items and services for Medicare beneficiaries in the current emergency. These FAQs are
displayed in these files:
• COVID-19 FAQs (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf)
• FAQs that apply without any Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/
Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.
• FAQs apply only with a Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/
Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf) waiver or, when applicable, a Section 1812(f)
waiver.
Blanket Waivers Issued by CMS
View the complete list
(https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) of COVID-19
blanket waivers.
Counseling and COVID-19 Testing
To prevent further spread of COVID-19, a key strategy includes quarantine and isolation while patients wait
for test results or after they get positive test results – regardless of showing symptoms.
Physicians and other health care practitioners who counsel patients during their medical visits have an opportunity
to decrease the time between patient-testing and quarantine/isolation, especially when this counseling happens
concurrent with COVID-19 testing. Working in partnership with public health personnel, providers could speed
the counseling, testing, and referrals for case tracing initiation to reduce potential exposures and additional cases
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
16 12/2020of COVID-19. By having patients isolated 1-2 days earlier, spread of COVID-19 can be reduced significantly.
Modeling shows early isolation can reduce transmission by up to 86 percent.
Through counseling, providers can discuss with patients:
1. The signs and symptoms of COVID-19.
2. The immediate need to separate from others by isolation or quarantine, particularly while awaiting test
results.
3. The importance of informing close contacts of the person being tested (e.g., family members) to separate
from the patient awaiting test results.
4. If the patient tests positive, the patient will be contacted by the public health department to learn the
names of the patient’s close contacts. The patient should be encouraged to speak with the health depart-
ment
5. The services that may be available to assist the patient in successfully isolating or quarantining at home.
6. This early intervention of counseling steps and isolation can reduce spread of COVID-19.
How to Bill for Counseling Services
These counseling services are covered by Medicare. Physicians and other practitioners furnishing counseling
services to people with Original Medicare should use existing and applicable coding and payment policies to
report services, including evaluation and management
(https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-
mgmt-serv-guide-icn006764.pdf) visits.
When furnishing these services during 2020, when physicians and other practitioners spending more than
50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for
inpatient services) providing counseling or coordination of care, use time to select the level of visit reported.
Please review the following provider resources:
Provider Counseling Q&A:
https://www.cms.gov/files/document/covid-provider-counseling-qa.pdf
Provider Counseling Talking Points:
https://www.cms.gov/files/document/covid-provider-patient-counseling-talking-points.pdf
Provider Counseling Check List:
https://www.cms.gov/files/document/covid-provider-patient-counseling-checklist.pdf
Handout for Patients to Take Home:
https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/318271-A_FS_
KeyStepsWhenWaitingForCOVID-19Results_3.pdf
Please also review the following information from the Centers for Disease Control and Prevention:
Overall:
https://www.cdc.gov/coronavirus/2019-nCoV/index.html
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
17 12/2020Testing:
https://www.cdc.gov/coronavirus/2019-ncov/testing/index.html
Symptoms:
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Self Care:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/index.html
Care at Home:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.html
Contact Tracing:
https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html
https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/principles-contact-tracing-booklet.pdf
https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf
Billing for Professional Telehealth Distant Site Services During the Public Health Emergency
CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and
Coronavirus Preparedness and Response Supplemental Appropriations Act.
View a complete list of services
(https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) payable under
the Medicare Physician Fee Schedule when furnished via telehealth.
When billing professional claims for all telehealth services with dates of services on or after March 1, 2020,
and for the duration of the PHE, bill with:
• Place of Service (POS) equal to what it would have been had the service been furnished in-person
• Modifier 95, indicating that the service rendered was actually performed via telehealth
As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current
rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth
professional claims:
• Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous
(store and forward) technology, use GQ modifier
• Furnished for diagnosis and treatment of an acute stroke, use G0 modifier
There are no billing changes for institutional claims; critical access hospital method II claims should continue
to bill with modifier GT.
CMS released a video providing answers to common questions about the Medicare telehealth services benefit.
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
18 12/2020Video (https://www.youtube.com/watch?v=Bsp5tIFnYHk)
Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifier
Teaching physicians and residents: Expansion of CPT codes that may be billed with the GE modifier under
42 CFR 415.174 on and after March 1, 2020, for the duration of the public health emergency:
• Residents furnishing services at primary care centers may provide an expanded set of services to beneficiaries,
including levels 4-5 of an office/outpatient Evaluation and Management (E/M) visit, telephone E/M, care
management, and some communication technology-based services
• This expanded set of services are CPT codes 99204-99205, 99214-99215, 99495-99496, 99421-99423,
99452, and 99441-99443 and HCPCS codes G2010 and G2012
• Teaching physicians may submit claims for these services furnished by residents in the absence of a teaching
physician using the GE modifier
Medicare Administrative Contractors will automatically reprocess claims billed with the GE modifier on or
after March 1, 2020, that were denied. You do not need to do anything.
Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19
Related Services
The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and
deductible amounts) for Medicare patients who receive COVID-19 testing-related services. These services
are medical visits under the HCPCS evaluation and management categories described below when outpatient
providers, physicians, or other providers and suppliers who bill Medicare for Part B services order or administer
COVID-19 lab tests regardless of the HCPCS codes they use to report the tests.
Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished
between March 18, 2020 and the end of the PHE; that result in an order for or administration of a COVID-19
test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes
of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and
management codes:
• Office and other outpatient services
• Hospital observation services
• Emergency department services
• Nursing facility services
• Domiciliary, rest home, or custodial care services
• Home services
• Online digital evaluation and management services
Cost-sharing does not apply to the above medical visit services for which payment is made to:
• Hospital Outpatient Departments paid under the Outpatient Prospective Payment System
• Physicians and other professionals under the Physician Fee Schedule
• Critical Access Hospitals (CAHs)
• Rural Health Clinics (RHCs)
• Federally Qualified Health Centers (FQHCs)
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
19 12/2020Previously, CMS provided the CS modifier for the gulf oil spill in 2010; however, CMS recently repurposed
the CS modifier for COVID-19 purposes. Now, for services furnished on March 18, 2020, and through the
end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part
B services under these payment systems should use the CS modifier on applicable claim lines to identify the
service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge
Medicare patients any co-insurance and/or deductible amounts for those services.
Use these HCPCS codes for billing:
• Physicians and non-physician practitioners
• Outpatient Prospective Payment System (OPPS)
• RHCs and FQHCs
• CAHs: use OPPS codes
• Method II CAHs: use the OPPS list or the physician and non-physician practitioner list, as appropriate.
COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers
During the COVID-19 PHE, Medicare will cover a medically necessary emergency and non-emergency ground
ambulance transportation from any point of origin to a destination that is equipped to treat the condition of
the patient consistent with state and local Emergency Medical Services (EMS) protocols where you provide
services. On an interim basis, we are expanding the list of destinations that may include but are not limited to:
• Any location that is an alternative site determined to be part of a hospital, Critical Access Hospital (CAH),
or Skilled Nursing Facility (SNF)
• Community mental health centers
• Federally Qualified Health Centers (FQHCs)
• Rural health clinics (RHCs)
• Physicians’ offices
• Urgent care facilities
• Ambulatory Surgery Centers (ASCs)
• Any location furnishing dialysis services outside of an End-Stage Renal Disease (ESRD) facility when an
ESRD facility is not available
• Beneficiary’s home
CMS expanded the descriptions for these origin and destination claim modifiers to account for the new covered
locations:
• Modifier D - Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC
or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility
• Modifier E – Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the
beneficiary’s home
• Modifier H - Alternative care site for hospital, including CAH, provider-based ASC, or freestanding
emergency center
• Modifier N - Alternative care site for SNF
• Modifier P - Physician’s office
• Modifier R - Beneficiary’s home
Continued >>
CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
20 12/2020You can also read
