CPT codes, descriptors, and other data only are copyright 2021 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

This Bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Bulletins are available at no-cost from our website at: http://med.noridianmedicare.com

Don’t be left in the dark, sign up for the Noridian e-mail listing to receive updates that contain the latest Medicare news. Visit the Noridian website and select “Subscribe” on the bottom right-hand corner of any page.

https://www.cms.gov/Outreach-

and-Education/Medicare-Learning-Network-MLN/MLNGenInfo

Noridian Healthcare Solutions, LLC

Medicare B News In This Issue…

NEWS ............................................................................ 6

Noridian Part B Customer Service Contact .............................................................................. 6

MLN Matters Disclaimer Statement ........................................................................................ 6

Sources for “Medicare B News” Articles ................................................................................. 6

Quarterly Provider Update from CMS ..................................................................................... 6

Unsolicited or Voluntary Refunds Reminder ........................................................................... 7

Do Not Forward Initiative Reminder ....................................................................................... 7

2021 JE Part B Quarterly Ask-the-Contractor Teleconferences .............................................. 8

2020 1099 Tax Forms Available on NMP ................................................................................. 9

ACT Questions and Answers - March 10, 2021 ....................................................................... 9

Annual Wellness Visit (AWV) in the New Year ...................................................................... 12

Best Enrollment Best Practices to Assist Providers with Timely Processing ......................... 12

Billing Units in Excess of Medically Unlikely Edit (MUE) - On-Demand Tutorials Available .. 13

C1734 - Priced per invoice ..................................................................................................... 13

Clinicians Ordering Oxygen and Oxygen Equipment - COVID-19 public health emergency (PHE) Reference Guide .......................................................................................................... 13

CMS-855B Application Form Updated - Effective January 4, 2021 ....................................... 14

CMS-1500 Claim Form Submission Items 1-16 - On-Demand Tutorials Available ................ 14

CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment .............................................................................................................. 14

COVID-19: Revised Clinician Codes Accepted with CS Modifier ............................................ 15

COVID-19 Vaccine for Mass Immunizer - On-Demand Tutorials Available ........................... 15

Duplicate Claim Reminders ................................................................................................... 15

Electronic Funds Transfer: Revised CMS-588 ........................................................................ 16

Evaluation and Management -On-Demand Tutorials Available ............................................ 16

HCPCS Code G2211 is a bundled service and not separately paid ........................................ 16

Identifying Managed Care Plans ............................................................................................ 16

Identifying Procedure to Procedure (PTP) Edit Claim Errors - On-Demand Tutorials Available ............................................................................................................................................... 17

Influenza and Pneumococcal Immunizations Roster Billing - On-Demand Tutorials Available ............................................................................................................................................... 17

Jurisdiction E

April 2021

2

License and Certificate Renewals .......................................................................................... 17

Locating Medically Unlikely Edits (MUEs) - On-Demand Tutorials Available ........................ 18

Medically Unlikely Edit (MUE) Overview - On-Demand Tutorials Available .......................... 18

Medicare Participating Physician Directory Information for 2021 ........................................ 18

Modifier 59 and National Correct Coding Initiative (NCCI) - On Demand Tutorial ............... 19

National Correct Coding Initiative (NCCI) - Modifier 59 Reminder ....................................... 19

Noridian Medicare Contact and Interactive Voice Response Pages Updated ....................... 19

Noridian Medicare Portal to Verify HMO Eligibility and Reduce Claim Errors ...................... 20

Nutrition-related Health Conditions: Medicare Covers Preventive Services ........................ 20

Overpayment Results for Part A and Part B users Available ................................................. 20

PFS Payment for Office and Outpatient Evaluation and Management Visits ....................... 21

Practitioners, Are You Ordering Lower Limb Orthoses for Your Patients? ........................... 21

Procedure to Procedure (PTP) Edits - On-Demand Tutorials Available ................................. 22

Professional Services during a Hospice Election ................................................................... 22

Signature Requirements - On-Demand Tutorials Available ................................................... 25

MEDICAL POLICIES AND COVERAGE ............................ 26

Billing and Coding: Allergy Testing - R2 - Effective January 1, 2021 ...................................... 26

Billing and Coding: Billing Limitations for Pharmacies - R4 -Effective January 1, 2021 ......... 26

Billing and Coding: Billing Medicare for the SphenoCath and Other Similar Devices - R4 - Effective April 29, 2020 ......................................................................................................... 26

Billing and Coding: Complex Drug Administration Coding - R1 - Effective January 01, 2021 27

Billing and Coding: Complex Drug Administration Coding - R2 - Effective February 18, 2021 ............................................................................................................................................... 27

Billing and Coding: Complex Drug Administration Coding - R3- Effective February 18, 2021 27

Billing and Coding: Complex Drug Administration Coding - R4 - Effective February 18, 2021 ............................................................................................................................................... 28

Billing and Coding: High Compression Bandage System Clarification - R3 - Effective April 29, 2020 ....................................................................................................................................... 28

Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding - R1 - Effective April 29, 2020 ................................................................................................................................. 28

Billing and Coding: Intensity Modulated Radiation Therapy (IMR) - R1 - Effective December 20, 2020 ................................................................................................................................. 28

Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays - R3 - Effective January 1, 2020 ...................................................................................................................... 29

Billing and Coding: Lab: Bladder/Urothelial Tumor Markers - R5 - Effective February 11, 2021 ....................................................................................................................................... 29

Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse- R9 - Effective January 1, 2021 ...................................................................................................................... 29

Billing and Coding: Lumbar Epidural Injections - R1 - Effective October 1, 2019 .................. 30

3

Billing and Coding: Lumbar Epidural Injections - R2 - Effective January 1, 2021................... 30

Billing and Coding: MolDX: Afirma™ Assay by Veracyte - R5 - Effective January 1, 2021 ..... 30

Billing and Coding: MolDX: APC and MUTYH Gene Testing- R2 - Effective March 4, 2021 ... 31

Billing and Coding: MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test - Effective May 10, 2021 ......................................................................................................................... 31

Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility - R1 - Effective February 11, 2021 .................................................................................................................. 31

Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) - R3 - Effective January 1, 2021 ....................................................................................................................................... 32

Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels- R11 - Effective January 01, 2021 ............................................................................... 32

Billing and Coding: MolDX: TP53 Gene Tests - R4 - Effective January 01, 2021 .................... 33

Billing and Coding: Mometasone Furoate Sinus Implant (Sinuva, Propel family of Implants) Retirement - Effective April 1, 2021 ...................................................................................... 33

Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy - R3 - Effective January 1, 2021 ....................................................................................................... 33

Billing and Coding: Percutaneous Endovascular Cardiac Assist Procedures and Devices - R6 - Effective January 1, 2021 ....................................................................................................... 34

Billing and Coding: Plastic Surgery - R3 - Effective January 1, 2021 ...................................... 34

Billing and Coding: Positron Emission Tomography Scans Coverage - R24 - Article effective April 01, 2021 and Update effective January 01, 2021 ......................................................... 35

Billing and Coding: Pulmonary Function Testing - R3- Effective January 1, 2021 ................. 36

Billing and Coding: Respiratory Care (Respiratory Therapy) - R7- Effective January 1, 2021 36

Billing and Coding: Routine Foot Care - R4 - Effective January 1, 2021 ................................ 37

Final Facet Joint Interventions for Pain Management LCD and Associated Billing and Coding: Facet Joint Interventions for Pain Management - Effective April 25, 2021 ........................... 38

Final LCD Colon Capsule Endoscopy (CCE); Billing and Coding: Colon Capsule Endoscopy -Effective March 28, 2021 ....................................................................................................... 38

In Vitro Chemosensitivity & Chemoresistance Assays - R5 - Effective February 25, 2021 .... 39

Lab: Coenzyme Q10 (CoQ10) - R6 ......................................................................................... 39

Lab: Controlled Substance Monitoring and Drugs of Abuse Testing - R10 - Effective April 08, 2021 ....................................................................................................................................... 39

Lumbar Epidural Injections LCD - R8 - Effective October 1, 2019 ......................................... 40

MolDX: Algorithm Definition ................................................................................................. 40

MolDX: APC and MUTYH Gene Testing LCD - R6 - Effective April 01, 2021 ........................... 40

MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test Final LCD - Effective May 10, 2021 ....................................................................................................................................... 41

MolDX: Prometheus IBD sgi Diagnostic LCD - R6 - Effective February 25, 2021 ................... 41

MolDX: Repeat Germline Testing - R1 - Effective January 1, 2021 ........................................ 41

Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease LCD and Billing and Coding Article - April 26, 2021 ............................................................................. 42

4

Revision(s) for MolDX Billing and Coding Articles - Effective January 1, 2021 ...................... 43

Self-Administered Drug Exclusion List - R19, Effective January 1, 2021 ................................ 43

Self-Administered Drug Exclusion List - R20, Effective April 5, 2021 .................................... 43

MLN CONNECTS .......................................................... 45

MLN Connects - January 7, 2020 ........................................................................................... 45

MLN Connects Special Edition - January 7, 2020 - Physician Fee Schedule Update.............. 46

MLN Connects - January 14, 2020 ......................................................................................... 46

MLN Connects - January 21, 2021 ......................................................................................... 47

MLN Connects - January 28, 2021 ......................................................................................... 47

MLN Connects - February 4, 2021 ......................................................................................... 48

MLN Connects - February 11, 2021 ....................................................................................... 48

MLN Connects - February 18, 2021 ....................................................................................... 48

MLN Connects - February 25, 2021 ....................................................................................... 49

MLN Connects - March 4, 2021 ............................................................................................. 49

MLN Connects Special Edition - March 10, 2021 - CMS Updates Nursing Home Guidance with Revised Visitation Recommendations ........................................................................... 50

MLN Connects - March 11, 2021 ........................................................................................... 51

MLN Connects Special Edition - March 15, 2021 - Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine .......................................................... 51

MLN Connects - March 18, 2021 ........................................................................................... 52

MLN Connects - March 25, 2021 ........................................................................................... 53

MLN Connects Special Edition - March 30, 2021 - Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension ................................. 53

MLN MATTERS ............................................................ 54

2021 Annual Update to the Therapy Code List ..................................................................... 54

April 2021 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files ............................................................................................................................ 54

April Quarterly Update for 2021 DMEPOS Fee Schedule ...................................................... 54

Billing For Services When Medicare Is a Secondary Payer .................................................... 55

CLFS - Medicare Travel Allowance Fees for Collection of Specimens ................................... 55

CWF Edits for Medicare Telehealth Services and Manual Update ........................................ 55

CY 2021 Annual Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment - Revised ................................................................................................................. 56

HCPCS Codes Subject to and Excluded from CLIA Edits......................................................... 56

January 2021 Update of the ASC Payment System ............................................................... 56

Quarterly Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment ............................................................................................................................................... 57

5

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update ................................................................................................................................... 57

RARC, CARC, MREP & PC Print Update .................................................................................. 57

Updated Billing Requirements for HIT Services on or After January 1, 2021 ........................ 58

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 6

NEWS .........................................................................................

Noridian Part B Customer Service Contact General IVR Inquiries Available 24/7

Phone Number Inquiry Hours (PT)

855-609-9960 Claim Specific Monday - Friday 6 a.m. - 5 p.m.

• Interactive Voice Response (IVR) • Provider Contact Center (PCC) • Provider Enrollment • EDISS • User Security (including NMP)

Text Teletype Calls (TTY) - 855-549-9874

Monday - Friday 8a.m. - 5 p.m. PT

MLN Matters Disclaimer Statement Below is the CMS Medicare Learning Network (MLN) Matters Disclaimer statement that applies to all MLN Matters articles in this bulletin.

“This article was prepared as a service to the public and is not intended to grant rights or impose obligations. MLN Matters articles may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.”

Sources for “Medicare B News” Articles The purpose of “Medicare B News” is to educate the Noridian Medicare Part B provider community. The educational articles can be advice written by Noridian staff or directives from CMS. Whenever we publish material from CMS, we will do our best to retain the wording given to us; however, due to limited space in our bulletins, we will occasionally edit this material. Noridian includes “Source” following CMS derived articles to allow for those interested in the original material to research it at the CMS website https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index. The CMS Change Request (CR) and the date issued will be referenced within the “Source” portion of applicable articles.

CMS publishes a series of educational articles within their Medicare Learning Network (MLN), titled “MLN Matters.” These “MLN Matters” articles are also included in Noridian bulletins. The Medicare Learning Network is a brand name for official CMS national provider education products designed to promote national consistency of Medicare provider information developed for CMS initiatives.

Quarterly Provider Update from CMS The Quarterly Provider Update is a comprehensive resource published by CMS on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including Change Requests (CRs), 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;

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 7

• 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; and • Communicate the specific days that CMS business will be published in the Federal Register.

Sign up for the Quarterly Provider Update listserv to receive notification when regulations and program instructions are added throughout the quarter, (electronic mailing list) at https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/EmailUpdates. Indicate that you wish to receive the CMS-QPU Listserv on the list of available publications.

The Quarterly Provider Update can be accessed on the CMS website at https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index. We encourage you to bookmark this website and visit it often for this valuable information.

Source: PM AB-03-075, CR 2686 dated May 23, 2003

Unsolicited or Voluntary Refunds Reminder All Medicare providers need to be aware that the acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.

BACKGROUND

Medicare carriers and intermediaries and AB MACs receive unsolicited or voluntary refunds from providers. These voluntary refunds are not related to any open accounts receivable. Providers billing intermediaries typically make these refunds by submitting adjustment bills, but they occasionally submit refunds via check. Providers billing carriers usually send these voluntary refunds by check.

Related Change Request (CR) 3274 is intended mainly to provide a detailed set of instructions for Medicare carriers and intermediaries regarding the handling and reporting of such refunds. The implementation and effective dates of that CR apply to the carriers and intermediaries. But, the important message for providers is that the submission of such a refund related to Medicare claims in no way limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to those or any other claims.

ADDITIONAL INFORMATION

The official CMS CR3274 instruction may be viewed in the Medicare Learning Network (MLN) Matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm3274.pdf.

Effective Date: January 1, 2005

Implementation Date: January 4, 2005

Sources: Transmittal 50, CR 3247 dated July 30, 2004; Internet Only Manual (IOM) Medicare Financial Management Manual, Publication 100-06, Chapter 5, Section 410

Do Not Forward Initiative Reminder The Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04 instructs Part A and Part B Medicare Administrative Contractors (A/B MACs) and carriers to use “return service requested” envelopes when mailing paper checks and remittance advices to providers.

When the post office returns a “return service requested” envelope, the A/B MAC/carrier applies a “do not forward” (DNF) flag to the provider's Medicare enrollment file. The A/B MAC/carrier will not generate any additional checks for that provider until the provider sends a properly completed change of address form back to the A/B MAC/carrier. We are not required to contact the provider to notify them that the flag has been added to their file.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 8

Upon verifying the new address, the A/B MAC/carrier removes the DNF flag and can again generate payments for the provider. Electronic Funds Transfer (EFT) is required; therefore, when the address change update is completed, the provider will be set up to use EFT and will no longer receive paper checks.

NOTE: Because many providers get paid through EFT, there may be cases where a provider does not have a correct address on file, but the A/B MAC/carrier continues to pay the provider through EFT. It is still the provider’s responsibility to submit and address change update so that remittance notices and special checks would be sent to the proper address.

Noridian encourages providers to enroll or make changes using Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for faster processing time. Applications and changes completed online currently have an average processing time of 10 days. All Medicare providers may use the new enrollment process on the CMS website https://pecos.cms.hhs.gov. To log into this internet-based PECOS, providers will use their NPI Userid and password.

POLICY

Effective October 1, 2002, A/B MACs/carriers must use “return service requested” envelopes for hardcopy remittance advices and checks, with respect to providers that have elected to receive hardcopy remittance advices. (PM B-02-023, CR 2038 dated April 12, 2002; Transmittal 1794, CR 2684 dated May 2, 2003)

IMPLEMENTATION PROCESS

1. “Return service requested” envelopes are used for all hardcopy remittance advices starting October 1, 2002. These envelopes will be used for all providers.

2. “Return service requested” envelopes will not be used for beneficiary correspondence, such as Medicare Summary Notices (MSNs) or for overpayment demand letters.

3. When the post office returns a remittance advice due to an incorrect address, A/B MACs/carriers will follow the same procedures as followed for returned checks, that is:

o Flag the provider’s file DNF. o A/B MAC/carrier staff will notify provider enrollment team. o A/B MAC/carriers will cease generating any further payments or remittance advice to that provider or

supplier until furnished with a new, verified address. 4. When the provider establishes a new, verified address, A/B MACs/carriers will remove the DNF flag and pay the

provider any funds which are still being held due to a DNF flag. A/B MAC/carriers must also reissue any remittance advices, which have been held.

5. Previously, CMS only required corrections to the “pay to” address. However, with the implementation of this initiative, CMS requires corrections to all addresses before the contractor can remove the DNF flag and begin paying the provider or supplier again. Therefore, A/B MAC/carriers cannot release any payments to DNF providers until the provider enrollment department has verified and updated all addresses for that provider's location.

IRS-1099 REPORTING

Provider or supplier checks returned and voided during the same year they were issued are not reported on the Internal Revenue Service (IRS) Form 1099 until the returned check is reissued (i.e., the DNF flag is removed and the A/B MAC/carrier reissues payment to the provider.) Checks returned and voided in the current year that were issued in prior years are not netted from the current year's IRS Form 1099.

Monies withheld because a DNF flag exists on a provider or supplier record are not reported on IRS-1099s until the calendar year in which payment is made (i.e., the point at which the A/B MAC/carrier pays the provider once the DNF flag is removed.) If DNF amounts are erroneously included on IRS-1099 forms, A/B MACs/carriers will issue corrected IRS Form 1099s to affected providers.

Source: IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 22, Section 50.1

2021 JE Part B Quarterly Ask-the-Contractor Teleconferences Below is the listing of the 2021 Part B Quarterly Ask-the-Contractor Teleconferences (ACTs).

• October 13, 2021

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 9

ACTs are designed to open communication between providers and Noridian, which allows for timely identification of problems, and sharing information in an informal and interactive question and answer (Q&A) format. No Personal Health Information (PHI) is allowed.

Noridian representatives from various Part B departments are available to address your Medicare questions and concerns. All questions are entertained and the Q&As are posted on our website for provider convenience.

To view ACT dates, times, toll-free number, and Q&As, go to https://med.noridianmedicare.com/web/jeb/education/act.

Attendees must register through a free web-based training tool (GoToWebinar) which requires an Internet connection and a toll-free telephone number (provided in confirmation email). Allow email registrations@noridian.com. Unless otherwise specified, ACTs are general in nature. No CEUs are provided.

By completing and submitting the Noridian “Ask the Contractor Teleconference Question Submission Form,” providers may ask question(s), up to five (5) days prior, to be answered during the next ACT. Questions submitted with this form will be answered first. Lines will then be opened for additional questions, as time permits. Do not include any Personal Health Information (PHI) or claim specific inquiries on this form. If you have claim specific questions, contact the Provider Contact Center. Providers will need to have Version 7 or higher of Adobe Reader to use this form.

We look forward to your participation in these important calls.

Medicare Part B ACTs do not address Medicare Part A or Durable Medical Equipment (DME) inquiries. If you are interested in attending a Part A or a DME ACT, select the appropriate link below for more information.

• JE Part A - https://med.noridianmedicare.com/web/jea/education/act • JD DME - https://med.noridianmedicare.com/web/jddme/education/act • JA DME - https://med.noridianmedicare.com/web/jadme/education/act

2020 1099 Tax Forms Available on NMP The 2020 1099-INT and 1099-MISC are now available on the Noridian Medicare Portal (NMP). The 1099 inquiry is available through the Financials function.

1099s on the portal are a courtesy copy of the official 1099 form that was mailed to your facility. View the 1099 Inquiry section of the Portal Guide to download your copy today.

ACT Questions and Answers - March 10, 2021 The following questions and answers (Q&As) are cumulative from the general Part B Ask the Contractor Teleconference (ACT) that were specific to Evaluation and Management (E/M) Codes 99202-99215. Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed directly with the provider. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

Q1. How many Medical Decision Making (MDM) elements must be met to qualify for a particular level of medical decision making? A1. To qualify for a particular level of MDM, two of the three elements for that level of medical decision making must be met or exceeded.

Q2. What is considered each unique source or test? A2. A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a complete blood count (CBC), with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 10

Q3. Do translators count as “independent historians”? A3. No. Independent historians are defined as follows: “An individual (e.g., caregiver, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.” A translator is repeating verbatim information from the beneficiary.

Q4. Can providers receive credit in MDM for reviewing a test if they don’t bill the professional component? A4. If the provider’s organization neither ordered the test nor billed for the diagnostic test, then the provider may receive credit in MDM. If the diagnostic service is rendered in-house, the provider may not receive credit for the order and review. If it is a service that allows the professional component to be separately billed, the provider who performed the professional component may submit the professional component for payment. If the test was not billed by the provider’s organization, the credit for the review would normally be included in the credit for the order. When a test or procedure is explained or planned and the beneficiary decides to refuse the test or service, the treatment decision can receive decision making credit when included in the documentation.

Q5. Deciphering low, moderate, or high risk from a Noridian standpoint would you accept when a physician documents the risk? A5. Documentation would have to indicate why the physician determined it to be at that level. The documentation cannot just say high. There would need to be a thought process documented. The AMA provides examples of risks in the documentation guidelines.

Q6. Can providers receive credit for ordering a test if they don’t order it the same day as seeing the patient? A6. A provider may only count the work involved on the date of service of the face-to-face evaluation. If billing by time, the time involved in writing the order cannot be counted if performed on a different day. If billing by MDM, the medical decision involved in deciding if the test is necessary may be included.

Q7. What are the guidelines regarding prescription drug management in the MDM? A7. Credit is given for prescription drug management when documentation indicates medical decision making for the management of a prescription drug by the physician who is rendering the service. Medical management could include a new drug being prescribed, a change to an existing prescription, verification of any side effects or problems with the drug, or simply refilling a current medication. The drug and dosage must be documented as well as the drug management.

Q8. Services for established patient, less than 30 minutes, with one or more new acute uncomplicated or minor problems. In the 1995/1997 guidelines, this was 99214. In 2021 guidelines, this is 99213. Are there plans to address this? A8. We are unable to answer scenario questions as there are too many variables in the beneficiary symptoms, age, other conditions, and the provider documentation. Refer to the 22 definitions in the 2021 AMA CPT book and on our website to determine appropriate level of E/M to submit. CMS and AMA would be the source to make changes to the guidelines.

Q9. If point of care testing (i.e., strep test, influenza test etc.), is billed by a different provider or specialty than the ordering provider in the same clinic, can we count data points in MDM for the order by the ordering provider conducting the patient visit? A9. If the professional interpretation of the test/study is billed by your entity, credit in the MDM cannot be included. When billed by an external provider who is not in the same group practice or is of a different specialty, it may meet the external provider definition. See pages 8, 13 and 15 in the 2021 AMA CPT book.

Q10. If the clinician pre-screens a patient by telephone before seeing face-to-face (FTF), can this be bundled with the appointment? Can providers use documentation time combined with FTF time for appropriate level of E/M service? A10. Yes, to both questions when performed on the same day as the encounter date. Although the time can be bundled, a telephone or telehealth code cannot be billed separately on the same day when submitting an E/M service for the same beneficiary.

Q11. If a provider confers with another provider (same specialty) regarding patient management options, would this count under Category 3 in MDM? A11. Yes, if medically necessary for the beneficiary treatment plan and documentation supports. Per AMA, “This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately.”

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 11

Q12. Do providers receive credit in MDM for referring a patient to another provider? A12. Yes, this would meet patient management for treatment when it is necessary to refer to another provider.

Q13. Do providers receive credit in MDM when ordering a vaccine or immunization for the patient? What about the same question if ordering an injection in the office? A13. If the vaccine, immunization, or injection administration is billed by your office, the order would be included in the reimbursement for the separately billed service.

Q14. Is medical review of time-based coding and billing solely on prolonged services codes? Does CMS and/or Noridian agree with past AMA statements that time-based billing should be the exception? A14. Yes, prolonged code G2212 can only be billed when service is based on time. Noridian will accept services billed either by time or MDM, whichever is the most advantageous, meets medical necessity and included in the documentation.

Q15. Can a provider receive MDM credit for lab tests ordered and/or reviewed during a visit when billed by same facility but not individual provider? A15. No. If the provider is in the same entity, the entity would receive reimbursement for both the lab tests and the provider service under reassignment. When the lab or image service is billed by an outside entity, the provider may include credit in MDM decision when documentation supports medical necessity.

Q16. Would a patient’s history of drug and alcohol abuse fall under Social Determinants of Health (SDoH), if it affects treatment options? A16. It may, depending on the documentation. CPT book defines SDoH as economic and social conditions that influence the health of people and communities. Examples include food or housing insecurity.

Q17. Patient comes in for a visit and the physician orders a diagnostic test (mammogram). The patient then returns a year later for a review of the mammography, can we count that as time for the later visit? A17. Order and review can only be counted once. For example, if a provider is following a patient who receives diagnostic tests for what is believed to be benign issues, the provider may compare the old image to the new image, and that time can be counted. However, the services can only be billed once.

Q18. When we see there is a diagnostic data dump, providers are documenting many or all the diagnoses, but the reason for the visit is only related to one or two of the diagnosis. If the provider has gone over the information can we count them or is the level based off the reason for the encounter? A18. This would be based off the documentation for the visit. If they are clearly documenting the underlying conditions are part of the visit, then you can include all appropriate diagnoses.

Q19. If an attending physician discusses needed treatment and the patient declines can that be counted as part of the risk complication based off what they are recommending? A19. It can be included in the MDM as long as the documentation supports it. Any recommendations are considered in the MDM even if the beneficiary denies or wants to wait.

Q20. If an urgent care provider receives the x-ray they ordered but do not have the results right away, how do they document as they still have to read it later? A20. Reimbursement for the test includes the order and the interpretation. In the note, it would say results pending. If there is a professional portion to the test, they can bill using the modifier 26.

Q21. If you order the lab on a specific day, you receive credit that day. If you order an x-ray, do you receive credit? A21. Providers would receive credit for either as an order is an order. If you bill the lab or x-ray separately, then it will be included in the reimbursement for that services. Refer to pages 8 and 15 of the 2021 CPT book.

Q22. Where can we include the referral, under risk or data and how can we use that? A22. A referral could fall under risk depending on the documentation and decision process. Discussion of management could fall under data. Example: If referring a patient for major surgery that could be high risk. If you are referring for minor surgery that could be a lower risk. This will all depend on the situation and what the risk to the patient is.

Q23. Can external data received and reviewed in relation to the patient’s visit, even if done on a different date, be counted as an external review? A23. Yes. Necessary data reviewed needs to be within the date of the encounter when billing based on time. When billing

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based on MDM, the review must be on the date of the patient visit and the data reviewed is necessary to determine the treatment for the patient or the treatment plan.

RESOURCES • CMS Fact Sheet • AMA 2021 Guidelines • AMA Risk Table • AMA March 2021 Errata • Noridian Evaluation and Management Specialty webpage

Annual Wellness Visit (AWV) in the New Year January is Annual Wellness Visit (AWV) awareness month. Providers should encourage their patients to start 2021 out right. As part of Medicare's preventive services program, the AWV is to develop and update a prevention plan that is tailored to the patient on an ongoing basis. This program is called a Personalized Prevention Plan Service (PPPS). The AWV is not a "routine physical". Medicare does not provide coverage for routine physicals. Keeping patients up to date on the AWV visit helps detect early health risks and illnesses.

The initial AWV is provided to a beneficiary who is no longer within their first 12 months of Medicare Part B coverage and has not received an initial preventive physical examination (IPPE). Medicare Part B covers one initial AWV in a lifetime and subsequent AWVs every 12 months. Medicare provides this benefit without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.

References

Medicare Wellness Visits

Preventive Services Chart

This document was developed through the A/B Medicare Administrative Contractor Provider Outreach & Education Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

Best Enrollment Best Practices to Assist Providers with Timely Processing Below are common errors found when a provider is enrolling in Medicare, and the solutions to prevent those errors. Following these best practices shorten processing time frames and reduce requests for information.

• Missing application signature. o Electronically sign or upload paper signature page within 48 hours after submission.

• Missing required supporting documents such as Certifications, IRS Letters, Voided Check/Bank Letter and Diplomas. o Upload appropriate supporting documents at the time of application submission.

Once uploaded all supporting documents stay on your Medicare Enrollment for quick and easy access.

• Non-response to a Request for Information (RFI). o While allowed thirty calendar days to respond to an RFI, it is always best practice to respond as quickly as

possible to ensure prompt and continued processing of your application.

More information can be found in the YouTube tutorial: PECOS: How to Correct and Resubmit, Submit, Delete, Continue Working and Signed.

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Billing Units in Excess of Medically Unlikely Edit (MUE) - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding billing units in excess of Medically Unlikely Edit (MUE).

Education on Demand Tutorials • Billing Units in Excess of Medically Unlikely Edit (MUE)

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

C1734 - Priced per invoice Effective March 1, 2021 status C code C1734, Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable), will be priced per invoice. More information on how to submit an invoice can be found on our Avoiding Denials on Priced per Invoice Claims page.

Clinicians Ordering Oxygen and Oxygen Equipment - COVID-19 public health emergency (PHE) Reference Guide As a result of the COVID-19 PHE, CMS has issued waivers and flexibilities to assist Medicare beneficiaries in obtaining the services they need and allowing practitioners to utilize home oxygen therapy when they determine it is warranted.

While the coverage criteria for home oxygen have not changed, CMS-1744-IFC and CMS-5531-IFC have provided direction regarding use of telemedicine in place of face-to-face requirements and non-enforcement of the clinical indications for coverage of home oxygen therapy. The Centers for Medicare and Medicaid Services (CMS) has also emphasized that the oxygen must be reasonable and necessary for the condition for which it is being prescribed and that condition must be documented in a medical record.

This documentation may be in the form of a prescription written by the patient’s attending physician who has recently examined the patient (normally within a month of the start of therapy) and must specify:

• A diagnosis of the disease requiring home use of oxygen; • The oxygen flow rate; and, • An estimate of the frequency, duration of use (e.g., 2 liters per minute, 10 minutes per hour, 12 hours per day), and

duration of need (e.g., 6 months or lifetime).

Note: A prescription for “Oxygen PRN” or “Oxygen as needed” does not meet this last requirement. Neither provides any basis for determining if the amount of oxygen is reasonable and necessary for the patient.

It is important to note that the National Coverage Determination (NCD) for oxygen, along with the Local Coverage Determination (LCD) and Policy Article (PA) have not changed. The only allowance during the COVID-19 PHE is that the clinical indications of coverage will not be enforced. When the PHE ends, these requirements will resume.

For additional information, please visit the appropriate DMEPOS website and view their information on COVID-19. • Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia) • Jurisdiction B (IL, IN, KY, MI, MN, OH, WI) • Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands) • Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern

Mariana Islands)

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CMS-855B Application Form Updated - Effective January 4, 2021 Effective January 4, 2021, an updated version of the CMS-855B (07/23) application form will be available for clinics, group practices, and other suppliers who have a Type 2 NPI.

Medicare will accept version (07/11) of the CMS-855B application form until March 31, 2021; however, will be returned to the provider if submitted after this date.

Visit the Noridian Enrollment Forms webpage to access the updated CMS-855B application form.

CMS-1500 Claim Form Submission Items 1-16 - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding claim submission.

Education on Demand Tutorials • CMS-1500 Claim Form Submission Items 1-16

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment The U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab and etesevimab, administered together, for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Bamlanivimab and etesevimab, administered together, may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the Emergency Medical System (EMS), as necessary. Review the Fact Sheet for Health Care Providers EUA of Bamlanivimab and Etesevimab regarding the limitations of authorized use when administered together.

During the COVID-19 Public Health Emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).

CMS identified specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment: Eli Lilly and Company’s Antibody Bamlanivimab and Etesevimab, (ZIP) EUA effective February 9, 2021:

Q0245: • Long descriptor: Injection, bamlanivimab and etesevimab, 2100 mg • Short descriptor: bamlanivimab and etesevima

M0245: • Long Descriptor: intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration

monitoring • Short Descriptor: bamlan and etesev infusion

Additional Resources: • List COVID-19 monoclonal antibody infusion billing codes, payment allowances, and effective dates • Monoclonal Antibody COVID-19 Infusion Program Instruction (PDF) • CMS COVID-19 Vaccine Provider Toolkit

Source: CMS MLN Connects dated February 18, 2021

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COVID-19: Revised Clinician Codes Accepted with CS Modifier Effective March 18, 2020, the Families First Coronavirus Response Act requires Medicare Part B to cover beneficiary cost-sharing for provider visits when a COVID-19 diagnostic test is administered or ordered. CMS updated the list of codes (ZIP) that physicians and non-physician practitioners can use with the Cost-Sharing (CS) modifier. For dates of service on or after January 1, 2021, through the end of the public health emergency, we will accept these codes with the CS modifier:

• HCPCS codes G2250, G2251, and G2252 • CPT codes 98970, 98971, and 98972 (These replace HCPCS codes G2061 - G2063, which are accepted for services

provided in 2020.)

CPT codes 98966, 98967, and 98968 are accepted for services with the CS modifier provided on or after March 18, 2020.

CMS provides more information about cost-sharing in the Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF) MLN Matters Article.

Source: CMS MLN Connects, February 11, 2021

COVID-19 Vaccine for Mass Immunizer - On-Demand Tutorials Available Noridian offers two self-paced training tutorials to assist providers and facilities in better understanding of overview, mass immunizer enrollment, coverage, billing, and roster forms.

Education on Demand Tutorials • Preventive - COVID-19 Mass Immunizer Overview Enrollment • Preventive - COVID-19 Mass Immunizer Coverage Billing

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

Duplicate Claim Reminders Duplicate claims are one of Noridian’s top denials. A resubmitted claim that appears the same as the original claim will deny as Medicare contractors cannot override or bypass exact duplicate edits in the claims processing system. In order to reduce the number of duplicate denials in your practice, please review the suggestions below.

Make sure that your practice is: • Waiting for remittance advice before correcting claim via rebilling or appealing • Talking to the clearinghouse or vendor to only auto-rebill after 30 days • Using repeat modifiers (76, 77 or 91) when repeating procedures or labs • Utilizing the Noridian Medicare Portal (NMP) to check claim status

Avoid the following: • Resubmitting claims unless rejected unprocessable • Adding or deleting procedure or diagnosis codes • Splitting claims for resubmission • Resubmitting entire claim when partial payment made • Appending modifier 59 unless it meets National Correct Coding Initiative (NCCI) Edits • With indicator 1

Resources: • Internet Only Manual (IOM) Publication, 100-04, Chapter 1, Section 120 “Detection of Duplicate Claims” • Noridian Denial Code Resolution page

o JE https://med.noridianmedicare.com/web/jeb/topics/claim-submission

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Electronic Funds Transfer: Revised CMS-588 A new version of the CMS-588 Electronic Funds Transfer (EFT) for Medicare payments will be posted on the CMS website in February.

Noridian will be accepting either the current or revised versions of the CMS-588 EFT form through February 27, 2021. Starting February 28, 2021, Noridian will only accept the new, revised version and will be returning all older versions.

Below are updates made to the CMS-588 Electronic Funds Transfer Form: • Moving the instructions to the first page • Changing “Medicare fee-for-service contractor” to “Medicare Administrative Contractor (MAC). • Removing requests for irrelevant information: cancelation as a reason for submission, change of ownership or change

of practice location, additional data fields for National Provider Identifiers (NPIs) • Removing references to indirect payment procedures billers • Adding two additional data fields for Medicare Identification Numbers (if issued) (one NPI can be linked to multiple

Medicare Identification Numbers) • Updating the link for MAC contacts

Evaluation and Management -On-Demand Tutorials Available Noridian offers three self-paced training tutorials to assist providers and facilities in better understanding of the 2021 Evaluation and Management guideline changes.

Education on Demand Tutorials • Evaluation and Management 99202-99215 • Evaluation and Management 99202-99215 Medical Decision Making • Evaluation and Management 99202-99215 Time-Based

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

HCPCS Code G2211 is a bundled service and not separately paid Medicare Administrative Contractors are denying separate payment for HCPCS code G2211 ("Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.")). Under Section 113 of the Consolidated Appropriations Act, HHS is not paying for this code under the Physician Fee Schedule until January 1, 2024. HCPCS code G2211 is a bundled service. Medicare Administrative Contractors will automatically reprocess claims that were paid. You don’t need to do anything.

Identifying Managed Care Plans Noridian receives numerous claims each month submitted incorrectly for managed care plans (HMO) or Medicare Part C plans.

It is the responsibility of the facility staff to routinely check the beneficiary’s Medicare coverage and inquire on any newly enrolled HMO plans. Beneficiaries should have a benefit card for Medicare and any HMO plans.

The Noridian Medicare Portal (NMP) provides HMO plan information if the beneficiary is enrolled. Using the Eligibility inquiry on NMP will ensure the claim is being sent to the proper payer the first time. Visit the Portal Guide to view instructions on how to use the Eligibility inquiry and check out the many Education on Demand videos on other NMP related topics.

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Identifying Procedure to Procedure (PTP) Edit Claim Errors - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding locating medically unlikely edits (MUEs).

Education on Demand Tutorials • Identifying Procedure to Procedure (PTP) Edit Claim Errors

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

Influenza and Pneumococcal Immunizations Roster Billing - On-Demand Tutorials Available Noridian offers a self-paced training tutorial to assist providers and facilities in better understanding of influenza and pneumonia vaccine overview, mass immunizer enrollment, coverage, billing, and roster forms.

Education on Demand Tutorials • Preventive Services - Influenza and Pneumococcal Immunizations Roster Billing

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

License and Certificate Renewals Whether you are an individual, a group or a facility, it is a best practice to submit licenses and certifications upon their renewal to keep your enrollment up to date. This helps avoid potential claim denials, deactivations, or revocations.

License and certification updates may be submitted at any time as no application is required. Licenses and certifications may be mailed or faxed, include a cover letter that includes legal business name and NPI/PTAN to indicate the enrollment it applies to.

FAX number: • Part B 701-277-7868

If you are unable to fax, please provide the information outlined below and return to our office by mail. Mail the completed license or certification(s) to:

USPS: Medicare Part B Attn: Provider Enrollment PO Box XXXX Fargo, ND 58108-XXXX

FedEx/Ups: Medicare Part B Attn: Provider Enrollment 900 42nd St S Fargo, ND 58103

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Replace XXXX above with the PO Box and Zip Code Extension State PO Box/Zip Ext

N CA (CA) 6774

S CA (CB) 6775

HI 6777

NV 6776

Locating Medically Unlikely Edits (MUEs) - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding locating medically unlikely edits (MUEs).

Education on Demand Tutorials • Locating Medically Unlikely Edits (MUEs)

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

Medically Unlikely Edit (MUE) Overview - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding locating medically unlikely edits (MUEs).

Education on Demand Tutorials • Medically Unlikely Edit (MUE) Overview

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

Medicare Participating Physician Directory Information for 2021 The Medicare Participating Physician Directory (MEDPARD) is a list of physicians, suppliers and practitioners (Medicare health care providers) who have signed an agreement to accept assignment on all claims. When a Medicare provider accepts assignment, they agree to accept the Medicare approved amount as payment in full for a covered service and can only bill the patient for deductible, coinsurance, and any non-covered services.

CMS has instructed carriers to no longer print paper copies of the MEDPARD. Noridian, however, does have the MEDPARD database available on our website with a search capability that will allow the requestor to search for a participating provider by specialty, state and city.

The MEDPARD database is located on the Noridian website at: http://norweb.noridian.com/medpard/main.aspx

Participating providers should visit the MEDPARD directory to check their practice information for accuracy. Your participation information should appear on the website defined above. Contact Provider Enrollment directly if specific information appearing is incorrect, has changed or is not present. The information in the database is based upon information Noridian receives when initially enrolling providers in the Medicare program.

ONLINE ASSISTANCE FOR BENEFICIARIES

As part of the ongoing effort to provide Medicare beneficiaries with information to help them make health care choices, CMS has a participating physician directory at http://www.medicare.gov, the CMS beneficiary website. The directory information can be found by selecting “Find doctors & other health professionals.” The directory contains names, addresses, and

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specialties of Medicare participating physicians who have agreed to accept assignment for all covered services. You may search the directory by specialty, physician or non-physician practitioner, location, gender or last name.

Modifier 59 and National Correct Coding Initiative (NCCI) - On Demand Tutorial Noridian offers self-paced training tutorials to assist providers and facilities in better understanding Modifier 59 and National Correct Coding Initiative.

Education on Demand Tutorials - JE Part B - Noridian (noridianmedicare.com) • Modifier 59 and National Correct Coding Initiative - On Demand Tutorial

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to update to the most current information.

National Correct Coding Initiative (NCCI) - Modifier 59 Reminder This article is a reminder that modifier 59 should only be used if no other suitable modifier is available. Evaluate other modifiers, such as RT/LT to identify right and left, FA, F1-F9 to identify fingers, TA, T1-T9 to identify toes and E1-E4 to identify eyelids. Also check repeat modifiers (76, 77 or 91) to avoid duplicate denial.

It is important that providers follow the NCCI instructions (link below), before appending modifier 59. It can only be appended if the indicator is “1”.

Appropriate Uses of Modifier 59: • Different session (documentation must support) • Different procedure or surgery • Different sites or organ systems: If two procedures performed at separate anatomical sites or separate patient

encounters on same date of service • Separate lesions or injuries not ordinarily performed on same day by same individual • Second initial injection procedure when protocol requires two separate sites or when the patient returns for a

separately identifiable service

Inappropriate Uses of Modifier 59: • Cannot bypass NCCI Procedure-to-Procedure (PTP) edit

o Unless proper criteria with indicator one “1” • NCCI tables indicator of zero (0) - cannot unbundle • Valid modifier exists to identify services (repeat modifiers) • Documentation does not support separate and distinct • Indicate multiple injection administrations of same drug (use repeat modifiers) • When used with E/M service • To report separate and distinct E/M service with non-E/M procedure performed on the same date (append modifier

25)

Resources: • Medicare Learning Network (MLN) Matters Special Edition (SE) 1418 • National Correct Coding Initiative (NCCI) Edits

Noridian Medicare Contact and Interactive Voice Response Pages Updated The Noridian Medicare contact pages have been updated because providers spoke, and Noridian listened. Through your valued feedback provided to us through the website survey, we have made it easier to locate our contact information and hours of operation.

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The Interactive Voice Response (IVR) phone number as well as the Provider Contact Center phone number are now listed in the Contact section of the website along with the hours of operation. Thank you for taking the time to help us improve the website.

Noridian Medicare Portal to Verify HMO Eligibility and Reduce Claim Errors Every month Noridian receives thousands of claims sent in error. Many beneficiaries choose a Medicare replacement plan for their coverage, instead of Noridian Fee-For-Service Medicare. These claims should be sent to the appropriate Health Maintenance Organization (HMO), Medicare Advantage Plan or Preferred Provider Organization (PPO) for processing.

You will see a claim denial on your remittance advice with the codes CO-24, or a CO-109.

To avoid this error and shorten the amount of time it takes to get paid for claims, use the Noridian Medicare Portal (NMP) to identify Primary and Secondary payers before billing.

You can learn how to do this by reviewing our Tutorial on YouTube: Noridian Medicare Portal: Eligibility - YouTube

For additional information on the various topics check out the Webinars put on by Provider Outreach on utilizing the Noridian Medicare Portal on the Schedule of Events page.

Nutrition-related Health Conditions: Medicare Covers Preventive Services Did you know that Medicare covers the following preventive services for nutrition-related health conditions like diabetes, chronic kidney disease, and obesity?

• Medical nutrition therapy • Diabetes screening • Diabetes self-management training • Intensive behavioral therapy for obesity • Intensive behavioral therapy for cardiovascular disease • Annual wellness visit

During National Nutrition Month®, encourage your patients to develop healthy eating patterns and make food choices to meet their individual nutrient needs, goals, backgrounds, and tastes.

More Information: • Medicare Preventive Services educational tool • Preventive Services webpage • National Nutrition Month website - “Personalize Your Plate” • National Institute of Diabetes and Digestive and Kidney Diseases website • Million Hearts® website • Find a Registered Dietitian/Nutritional Professional • Information for your patients on nutritional therapy services, diabetes screenings, diabetes self-management training,

obesity behavioral therapy, cardiovascular behavioral therapy, and yearly “wellness” visits

Source: CMS MLN Connects dated March 4, 2021

Overpayment Results for Part A and Part B users Available The Noridian Medicare Portal (NMP) provides users the overpayment results for Part A and Part B services. The overpayment results inquiry provides information on claims that resulted in overpayment(s) and the steps being taken to satisfy that them. The overpayment results inquiry is available for any user that already has access to the Financials tab within NMP.

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Users can search for an overpayment by a letter or claim number. The results can also be downloaded and viewed in an Excel file.

To begin viewing overpayments, view the overpayments section of the Portal Guide or view the overpayments tutorial.

PFS Payment for Office and Outpatient Evaluation and Management Visits Effective January 1, 2021, for Physician Fee Schedule (PFS) payment of office and outpatient Evaluation and Management (E/M) visits (CPT codes 99201 through 99215), Medicare generally adopted the new AMA coding, language, and interpretive guidance framework. See the fact sheet (PDF) for more information, including:

• PFS payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211)

• Medical review when time is used to select visit level

Source: CMS MLN Connects dated February 11, 2021

Practitioners, Are You Ordering Lower Limb Orthoses for Your Patients? Medicare coverage requires the patient's medical record to show the orthosis is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

For coverage criteria related to lower limb orthoses, review Local Coverage Determinations (LCD) and Policy Articles for Ankle-Foot Orthoses/Knee-Ankle-Foot Orthoses (L33686 and A52457) and Knee Orthoses (L33318 and A52465).

The supplier must have a Standard Written Order (SWO) prior to submitting a claim to Medicare. The SWO must contain the elements listed below. Assist your patient by providing the order and documentation to substantiate need in a timely manner. In addition to the "reasonable and necessary" criteria outlined in the LCD there are further payment rules related to documentation requirements. For details related to those documentation requirements, review the Local Coverage Article (LCA) for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).

STANDARD WRITTEN ORDER (SWO) ELEMENTS

An order must contain the following elements to be considered a valid SWO: • Beneficiary’s name or Medicare Beneficiary Identifier (MBI) • Order date • General description of the item

o The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number

o For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).

o For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)

• Quantity to be dispensed, if applicable • Treating practitioner name or NPI • Treating practitioner’s signature

LCDs and Policy Articles for lower limb orthoses can be located on the DME MAC contractor websites. • Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia) • Jurisdiction B (IL, IN, KY, MI, MN, OH, WI) • Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands) • Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern

Mariana Islands)

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Procedure to Procedure (PTP) Edits - On-Demand Tutorials Available Noridian offers self-paced training tutorials to assist providers and facilities in better understanding Procedure to Procedure (PTP) edits.

Education on Demand Tutorials • Procedure to Procedure (PTP) Edits

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

Professional Services during a Hospice Election When a patient chooses to elect Medicare hospice coverage, they waive all rights to Medicare Part B payments for services related to the treatment and management of the terminal illness during any period in which the hospice election is in force.

Medicare can allow some services by the attending physician, nurse practitioner, or physician assistant. This instruction provides an overview of Medicare payment when a patient elects their hospice benefit. This data also instructs physicians and non-physician practitioners (NPPs) on providing services under arrangement/contract with the hospice agency.

HOSPICE ELECTION

The patient can elect to use their hospice benefit when a physician certifies they have a terminal illness. The patient would have a life expectancy of six months or less if the illness runs its normal course. The hospice agency must submit a Notice of Election (NOE) to Medicare. This NOE updates the Medicare processing files.

MEDICARE PAYMENT DURING HOSPICE ELECTION

Once the patient elects the hospice benefit, Medicare can allow: • Services provided by a Medicare certified hospice agency • Services related to the terminal condition made under arrangement/contract with the hospice:

o Related services are part of the hospice claim to Medicare o Medicare professional would make arrangements with the hospice

Medicare will deny related services The denied services could be patient liability

• Services provided by the patient-designated attending physician, nurse practitioner, or physician assistant, (if one has been designated) and

• Services unrelated to the terminal condition

Professionals can submit unrelated services to Medicare separately.

DETERMINING THE CORRECT ENTITY TO BILL

Providers must verify the correct entity to bill for their services. Billing Medicare without determining the correct billing method is inappropriate.

You can find more information in the CMS Internet-Only Manuals (IOMs) • Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 40.1.3 • Publication 100-02, Medicare Benefit Policy Manual, Chapter 9.

SEPARATELY PAYABLE PART B SERVICES

Use the following tips to help determine if submission to Part B is correct: • Is the patient in a Medicare-certified hospice coverage period? Verify this by using the following:

o Noridian Medicare Portal (NMP) o Contact the patient or representative o Contact the hospice

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• Is the patient reporting they are no longer in hospice? o The hospice notifies the Home Health and Hospice MAC of the disenrollment o Verify the hospice end date is in the NMP Portal

If the record does not contain the exit date: • Contact the hospice or • Contact the patient to request the hospice update the file

o Once the NMP Portal shows the exit date, bill the claim. Providers must file the claim timely. • Service related to the hospice condition. Determine if Medicare pays for the services separately:

o Bill services related to the terminal illness to the hospice for reimbursement When the hospice arranges for the services

• The entity will look to the hospice for payment • Services not covered and patient liable if related services not under arrangement with the

hospice When not employed by the hospice, submit to Medicare services provided by the patient-designated

attending physician/nurse practitioner/physician assistant • Submit using Modifier GV

o Bill services unrelated to the terminal illness to Medicare for reimbursement o Submit using Modifier GW

HOSPICE AND MEDICARE ADVANTAGE

Once a Medicare Advantage patient elects hospice coverage, Medicare Fee-For-Service (FFS) (i.e. Original Medicare) becomes the payer. This applies to all services provided to the patient under the normal hospice processing instructions.

A patient may revoke their hospice benefit in the middle of the month. Submit charges to Medicare FFS (under all hospice instructions) until the first day of the following month. All claims after the first of the month go to the elected Medicare Advantage plan.

For more information, visit the CMS IOM Publication 100-04, Chapter 11, Section 30.4.

ATTENDING PHYSICIAN

A patient may elect hospice coverage. Upon election, the patient waives their right to payment for professional services for management of the terminal illness. The exception is for the professional services of an attending physician chosen by the patient who is not an employee of the hospice. Medicare considers physicians volunteering as Medicare hospice as hospice employees.

The attending physician, chosen by the patient and not a hospice agency employee is the medical professional with the most significant role in the patient’s care. Submit services related to the terminal illness with the GV Modifier. Professionals recognized as attending physicians include:

• Doctor of medicine or osteopathy • Nurse practitioner • Physician Assistant

To locate instructions on physician billing for hospice care, use the CMS IOM Publication 100-04, Chapter 11, Section 40.

SERVICES UNRELATED TO HOSPICE

Medicare considers separate payment for services not related to the terminal illness. Before billing Medicare, it is the provider’s responsibility to determine the relationship of the service to the terminal illness.

Use the following to determine whether the claim’s diagnosis relates to the hospice diagnosis: • Determine if the patient has elected hospice • Determine if the hospice notified Medicare of the hospice election by checking with:

o The patient

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o A patient’s representative o The hospice o The NMP

• On the claim, append modifier GW indicating the service’s diagnosis does not relate to the hospice diagnosis • If submitting charges not related to hospice on a UB-04 (or 837I electronic), append condition code 07.

Contractors may conduct prepayment development or post payment reviews to validate the appropriate use of the modifier.

If you believe Medicare denied a claim in error, you can request a redetermination.

For more information on unrelated hospice services, see the CMS IOM Publication 100-04, Chapter 11, Section 50.

EVALUATION AND MANAGEMENT CODES FOR HOSPICE

Providers not employed by a hospice agency may bill for evaluation and management services during respite care in a facility. The physician determines the type of facility in order to submit the correct procedure code. Providers use place of service (POS) 34 to represent a patient in hospice. The claims processing system recognizes POS 34 with two sets of inpatient CPT codes:

• Inpatient (99221-99239) - services in a hospice or facility • Nursing facility (99304-99318) - freestanding hospice or part of a skilled nursing facility (SNF)

We do not recognize POS 34 with the following: • Office or other outpatient (99201 - 99215) • Observation (99217 - 99226) • Domiciliary care CPT codes 99324-99340

Use POS 21 (inpatient) when: • The patient remains in the same hospital bed or unit • The patient elect’s hospice coverage • The hospital did not discharge the patient

Use POS 12 (home) when: • Hospice services are in the home (99341 - 99350)

HOSPICE MODIFIERS

Consider using the following modifiers when billing Medicare. • GV - Attending physician not employed or paid under agreement by the patient's hospice provider • GW - Service not related to the hospice patient's terminal condition • Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement • Q6 - Service furnished by a Fee-For-Time Compensation Arrangements physician

The following tips may help you avoid denials: • Append either modifier GV or GW only when a patient enrolls in a Medicare-certified hospice • Use modifier GV to bill attending physician services to Medicare Part B when:

o The attending physician is not a hospice employee o Payment to the attending physician is not under agreement by the patient's hospice agency

If payment is under arrangement, then the hospice agency includes the attending physician’s services in its Medicare Part A bill

Medicare considers a physician volunteer with the hospice to be an employee o If a substitute or Fee-For-Time Compensation Arrangements physician provides services:

The designated attending physician bills the services The designated attending physician appends the modifier GV The designated attending physician appends either the Q5 or the Q6 modifier

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For more information on hospice services, please see the CMS IOM Publication 100-02, Chapter 9 and Publication 100-04, Chapter 11.

The A/B Medicare Administrative Contractor Home Health and Hospice Collaboration Team developed this document. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and assists the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

Signature Requirements - On-Demand Tutorials Available Noridian offers three self-paced training tutorials to assist providers and facilities in better understanding valid signatures, authentication and medical record entries.

Education on Demand Tutorials • Signature Requirements: Valid Signatures and Authentication • Signature Requirements: Medical Record Entries • Signature Requirements: Examples and Common Questions

Providers and facilities are encouraged to attend our webinars and/or to view other tutorials available to assist with proper billing and team member education.

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MEDICAL POLICIES AND COVERAGE ...........................................

Billing and Coding: Allergy Testing - R2 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: January 01, 2021 Summary of Article Changes: Deletion of coding to Group 1: 95071: INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH ANTIGENS OR GASES, SPECIFY

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Billing Limitations for Pharmacies - R4 -Effective January 1, 2021 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

LCA Medicare Coverage Database Number: A56119 Effective Date: January 1, 2021 Summary of Changes: The Billing and Coding Article has been updated with a CPT Code addition and descriptor change:

• CPT codes added: o J7212 - FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT)-JNCW (SEVENFACT), 1 MICROGRAM

• CPT Code Descriptors were changed for the following: o J7189

Old Description New Description

FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM

FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), (NOVOSEVEN RT), 1 MICROGRAM

Visit the Medicare Coverage Articles webpage to view the locally hosted Active LCA or access it via the CMS MCD.

Billing and Coding: Billing Medicare for the SphenoCath and Other Similar Devices - R4 - Effective April 29, 2020 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: April 29, 2020 Summary of Article Changes: Converted to a Billing and Coding Article and added 64999 to the CPT/HCPCS Codes Section. No change in coverage was made.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

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Billing and Coding: Complex Drug Administration Coding - R1 - Effective January 01, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: January 01, 2021 Summary of Article Changes: Corrected the link to the CMS Publication 100-02 Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 50 Drugs and Biologicals and 50.3 Incident to Requirements in the first CMS Manual Explanations URLs section listed below under Associated Documents.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Complex Drug Administration Coding - R2 - Effective February 18, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: February 18, 2021 Summary of Article: Added Q5122-pegfilgrastim-apgf, biosimilar (Nyvepria®) to Subcutaneous and Intramuscular Injection Non-Chemotherapy Generic/Trade Names Table in the Article Text; and Group 1 Codes and the statement "...and Ulcerative Colitis was approved on 10/21/2019" to the asterisked section for Stelara in the Article Text and Group 2 Paragraph.

Removed the statement "On and after July 31, 2017, both the drug and administration should be billed on the same claim with no other drugs or administration to prevent inappropriate claim rejection." underneath the Infusions Non-Chemotherapy Generic/Trade Name Table in the Article Text and the Group 2 Paragraph and removed J0894 - decitabine injection (Dacogen®) from Infusions Non-Chemotherapy Generic/Trade Table in the Article Text, Group 2 Paragraph and Codes and removed J1447 - tbo-filgrastim (Granix®) throughout the Article text and tables; from Group 1 Paragraph and Codes sections; and Group 2 Paragraph and Codes section effective 01/10/2021.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Complex Drug Administration Coding - R3- Effective February 18, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: February 18, 2021 Summary of Article: In the Article Text the statement, “The subcutaneous or intravenous formulation of abatacept is billed using HCPCS code J1029 with the JA (intravenous) or JB (subcutaneous) modifier”; was corrected to change J1029 to J0129.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

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Billing and Coding: Complex Drug Administration Coding - R4 - Effective February 18, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: February 18, 2021 Summary of Article: Added J1447 - tbo-filgrastim (Granix®) back into the Subcutaneous and Intramuscular Injection Non-Chemotherapy table in Article Text and the Group 1 CPT/HCPCS Codes table. This code was deleted in error in a previous update.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: High Compression Bandage System Clarification - R3 - Effective April 29, 2020 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: April 29, 2020 Summary of Article Changes: Converted to Billing and Coding article and added 29580, 29581, 29584, 97140, 97535 and 97597 to the CPT/HCPCS Codes section. No change in coverage was made.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding - R1 - Effective April 29, 2020 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: April 29, 2020 Summary of Article Changes: Converted to Billing and Coding article and added G0249 to the CPT/HCPCS Codes section and 52- modifier to the CPT/HCPCS Modifiers section. No change in coverage was made.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Intensity Modulated Radiation Therapy (IMR) - R1 - Effective December 20, 2020 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: December 20, 2020 Summary of Article Changes: This article was revised to add diagnosis code C77.3 with an effective date of December 20, 2020. Effective February 2, 2021, the following codes had CPT Long Descriptor changes: 77385 and 77386.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

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Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays - R3 - Effective January 1, 2020 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: January 1, 2020 Summary of Article Changes: Under Article Text, revised the first bullet point to read “CPT® code” and removed 84999 & 89240 because they are in the CPT/HCPCS Codes section and to be consistent with other contractors. Under CPT/HCPCS Codes Group 1: Codes added 0083U and 0564T. The addition of 0564T is due to the 2020 Annual CPT/HCPCS Code Update and is effective on January 1, 2020.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Lab: Bladder/Urothelial Tumor Markers - R5 - Effective February 11, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: February 11, 2021 Summary of Article Changes:

Under Article Text inserted UroVysion™ where applicable. In paragraphs 3 and 5 revised 1st bullet points to read "Select CPT® code 88120 or 88121 as appropriate," and 2nd and 3rd bullet points to read "Enter the appropriate DEX Z-CODE™ Identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:". Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted C7A.00, C7A.019, C7A.029, C7A.094, C7A.095, C7A.096, C7B.00, C78.00 and R31.9. Formatting, punctuation, and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the article.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse- R9 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Title: Billing and Coding: Lab: Controlled Substance Monitoring and Drugs of Abuse Effective Date: January 01, 2021 Summary of Article Changes: Under CMS National Coverage Policy: Added the regulation for CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 - A/B MAC (B) Contacts with Independent Clinical Laboratories to this section. This revision has a retroactive effective date of 1/1/21. Under CPT/HCPCS Codes Group 1 Codes: Added code 0227U due to the Q1 2021 CPT/HCPCS code update and has a retroactive effective date of 1/1/21.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

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Billing and Coding: Lumbar Epidural Injections - R1 - Effective October 1, 2019 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: October 1, 2019 Summary of Article Changes: Corrected grammatical errors in the first sentence of the Article Text by changing the statement from “The following coding and billing guidance is to be used with its associated Local Coverage Determination” to “The following coding and billing guidance shall be used with its associated Local Coverage Determination” and corrected the spelling of ‘steroid’ in the Key Words.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Lumbar Epidural Injections - R2 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: CPT descriptions changed for the following CPT® codes per the 2021 Annual CPT/HCPCS Code Update.

• 64483 from INJECTION(S), ANESTHETIC AGENT AND/ OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL to INJECTION(S) ANESTHETIC AGENT(S) AND/ OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL and

• 64484 from INJECTION(S), ANESTHETIC AGENT(S) AND/ OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) to INJECTION(S), ANESTHETIC AGENT(S) AND/ OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL. (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE).

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: MolDX: Afirma™ Assay by Veracyte - R5 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Billing and Coding: MolDX: Afirma™ Assay by Veracyte Effective Date: January 01, 2021 Summary of Article Changes: Deletion of Code to Group I: 81545: ONCOLOGY (THYROID), GENE EXPRESSION ANALYSIS OF 142 GENES, UTILIZING FINE NEEDLE ASPIRATE, ALGORITHM REPORTED AS A CATEGORICAL RESULT (EG, BENIGN OR SUSPICIOUS)

Addition of Code to Group I: 81546: ONCOLOGY (THYROID), MRNA, GENE EXPRESSION ANALYSIS OF 10,196 GENES, UTILIZING FINE NEEDLE ASPIRATE, ALGORITHM REPORTED AS A CATEGORICAL RESULT (EG, BENIGN OR SUSPICIOUS)

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” or the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

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Billing and Coding: MolDX: APC and MUTYH Gene Testing- R2 - Effective March 4, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Title: Billing and Coding: MolDX: APC and MUTYH Gene Testing Effective Date: March 04, 2021 Summary of Article Changes: Under CMS National Coverage Policy: Added CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5, §60.1.2, §60.2, corrected regulation CMS Internet-Only Manual, Pub. 100-02, Chapter 15 from §80.2 to §80.1.2, moved §80 and §80.1.1 to the related LCD and added section headings to the regulations.

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted C18.9 and D12.6 Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” and the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Billing and Coding: MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test - Effective May 10, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: March 25, 2021 Summary of Article: Coding and billing guidance is to be used with its associated Local coverage determination.

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” or the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility - R1 - Effective February 11, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Title: Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility Effective Date: February 11, 2021 Summary of Article Changes: Under Article Text: First bullet point revised verbiage to read “The MolDX: Pharmacogenomics Testing L38335 LCD addresses limited coverage for gene-drug interactions.”

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” and the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

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Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) - R3 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Title: Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) Effective Date: January 01, 2021 Summary of Article Changes: Under CPT/HCPCS Codes Group 1: Codes added: 81374, 81377, 81381, 81383, 0069U, 0133U, 0168U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U 0201U, 0203U, 0204U, 0205U, 0208U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, and 0222U and deleted 81490, 81500, 81503, 81506, 81508, 81509, 81510, 81511, 81512, 81535, 81536, 81538, 81539, 84999, 85999, 86152, 86153, 86849, 87999, 0003U, 0009U, 0021U, 0024U, 0039U, 0053U, 0054U, 0058U, 0059U, 0062U, 0067U, 0068U, 0080U, 0083U, 0092U, 0107U, and 0108U.

Under CPT/HCPCS Codes Group 1: Codes added: 81168, 81191, 81192, 81193, 81194, 81278, 81279, 81338, 81339, 81347, 81348, 81351, 81352, 81353, 81357, 81360, 81419, 81529, 81546, 81554, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, deleted 81545.

Under CPT/HCPCS Codes Group 2: Codes moved: 81401, 81403, 81406, 81407, 81412 to CPT/HCPCS Codes Group 1: Codes. CPT® code verbiage was removed.

This revision is due to coding that is applicable to the MolDX program and is retroactive effective for dates of service on or after 1/1/2021.

This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” and the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels- R11 - Effective January 01, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: January 01, 2021 Summary of Article Changes: Addition of Codes to Group I: 87636: INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) AND INFLUENZA VIRUS TYPES A AND B, MULTIPLEX AMPLIFIED PROBE TECHNIQUE

87637: INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), INFLUENZA VIRUS TYPES A AND B, AND RESPIRATORY SYNCYTIAL VIRUS, MULTIPLEX AMPLIFIED PROBE TECHNIQUE

0240U: INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 3 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED

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0241U: INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 4 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B, RESPIRATORY SYNCYTIAL VIRUS [RSV]), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: MolDX: TP53 Gene Tests - R4 - Effective January 01, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Title: Billing and Coding: Billing and Coding: MolDX: TP53 Gene Tests Effective Date: January 01, 2021 Summary of Article Changes:

• Under Article Text: Revised the verbiage under the first bullet to read, “Select the appropriate CPT® code” • Under CPT/HCPCS Codes Group 1: Codes deleted 81404 and 81405. The revision is retroactive effective for dates of

services on or after 1/1/2021. • Under CPT/HCPCS Codes Group 1: Codes added 81351 and 81352. This revision is due to the Quarter 1 2021

CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” and the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Billing and Coding: Mometasone Furoate Sinus Implant (Sinuva, Propel family of Implants) Retirement - Effective April 1, 2021 This coverage article will be retired under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: April 1, 2021 Summary: This billing and coding article will be retired secondary to recent deletions and additions of new HCPCS coding for mometasone furoate sinus implant which includes Sinuva and the Propel family of implants. Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is a coverage article in place.

Visit the Noridian Medicare Coverage Articles webpage to access the Retired articles in the CMS MCD.

Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy - R3 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: The code descriptions changed for the following CPT® codes per the 2021 Annual CPT/HCPCS Codes Update.

• 64479 from INJECTION(S), ANESTHETIC AGENT AND/ OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL to INJECTION(S), ANESTHETIC AGENT(S) AND/ OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR

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THORACIC, SINGLE LEVEL and • 64480 from INJECTION(S), ANESTHETIC AGENT AND/ OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING

GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) to INJECTION(S), ANESTHETIC AGENT(S) AND/ OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE).

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Percutaneous Endovascular Cardiac Assist Procedures and Devices - R6 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: Added ICD-10-PSC Code 5A02216 - Assistance with Cardiac Output using Other Pump, Continuous for Part A Providers. The following CPT® code additions and code description changes were also made per the 2021 Annual CPT/HCPCS Codes Update.

• Added: o 33995 - INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS, INCLUDING RADIOLOGICAL

SUPERVISION AND INTERPRETATION; RIGHT HEART, VENOUS ACCESS ONLY o 33997 - REMOVAL OF PERCUTANEOUS RIGHT HEART VENTRICULAR ASSIST DEVICE, VENOUS CANNULA, AT

SEPARATE AND DISTINCT SESSION FROM INSERTION • Code description changes:

o 33990-from INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ARTERIAL ACCESS ONLY to INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LEFT HEART, ARTERIAL ACCESS ONLY

o 33991 from INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; BOTH ARTERIAL AND VENOUS ACCESS, WITH TRANSSEPTAL PUNCTURE to INSERTION OF VENTRICULAR ASSIST DEVICE, PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LEFT HEART, BOTH ARTERIAL AND VENOUS ACCESS, WITH TRANSSEPTAL PUNCTURE

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Plastic Surgery - R3 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: January 01, 2021 Summary of Article Changes: Deletion of coding to Group 1: 19324: MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT 19366: BREAST RECONSTRUCTION WITH OTHER TECHNIQUE

Group III paragraph of ICD-10 codes that support medical necessity: Removed 19324 and 19366

Description change of coding to Group 1: 19318: BREAST REDUCTION

19325: BREAST AUGMENTATION WITH IMPLANT

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 35

19328: REMOVAL OF INTACT BREAST IMPLANT

19330: REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)

19340: INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)

19342: INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY

19357: TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)

19361: BREAST RECONSTRUCTION; WITH LATISSIMUS DORSI FLAP

19364: BREAST RECONSTRUCTION; WITH FREE FLAP (EG, FTRAM, DIEP, SIEA, GAP FLAP)

19367: BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP

19368: BREAST RECONSTRUCTION; WITH SINGLE-PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP, REQUIRING SEPARATE MICROVASCULAR ANASTOMOSIS (SUPERCHARGING)

19369: BREAST RECONSTRUCTION; WITH BIPEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP

19370: REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY

19371: PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS

19380: REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)

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Billing and Coding: Positron Emission Tomography Scans Coverage - R24 - Article effective April 01, 2021 and Update effective January 01, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: April 01, 2021 Summary of Article Changes: The following information was added effective for dates of service on or after January 01, 2021 in CPT/HCPCS Codes the ICD-10 Codes that Support Medical Necessity sections respectively.

• Group 1 o A9591- Fluoroestradiol f 18, diagnostic, 1 millicurie and o C9068 - Copper Cu64 Dotatate diagnostic, 1 millicurie in the OPPS setting

• Group 10 Contractor Determined Coverage for FDA Labeled Indications of Proprietary Radiopharmaceuticals Paragraph

o Fluoroestradiol f 18, diagnostic, 1 millicurie o Copper Cu64 Dotatate diagnostic, 1 millicurie

• Added the statements and diagnosis codes to Group 13 o The following diagnoses are applicable to Fluoroestradiol f 18 injections when billed with 78811, 78812,

78813, 78814, 78815 or 78816. Use A9591 to bill for this service per CR 9861, effective 1/1/2021. Use the PS modifier and NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D, or R diagnosis codes.

o Added diagnosis codes: C79.81 - Secondary malignant neoplasm of breast Z85.3 - Personal history of malignant neoplasm of breast

• Added the statements and diagnosis codes to Group 14

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 36

o The following diagnoses are applicable to A9597 (C9068 in the OPPS setting) for Copper Cu64 Dotatate injections when billed with 78811, 78812, 78813, 78814, 78815 or 78816. Use A9597/C9068 to bill for this service per CR 9861, effective 1/1/2021. Use the PI or PS modifier.

o NOTE: Whenever a personal history diagnosis code (Z85.XXX) is on a claim, the claim must also contain a diagnosis code from the list of covered C, D, or R diagnosis codes.

o Added diagnosis codes C7A.010, C7A.011, C7A.012, C7A.020, C7A.021, C7A.022, C7A.023, C7A.024, C7A.025, C7A.026, C7A.090, C7A.091, C7A.092, C7A.093, C7A.094, C7A.095, C7A.096, C7A.098, C7A.1, C7A.8, Z85.020, Z85.030, Z85.040, Z85.060, Z85.110, Z85.230 and Z85.520

Visit the Noridian Medicare Coverage Articles webpage and scroll to the bottom of the page to view this Future article available in the CMS MCD.

Billing and Coding: Pulmonary Function Testing - R3- Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: The following updates were made per the 2021 Annual CPT/HCPCS Code Update and additional ICD-10-CM updates.

• In the Group 3 Paragraph of the ICD-10 Codes that Support Medical Necessity and Article Text sections, added procedure code:

o 94619 - Exercise tst brncspsm wo ecg • In the Groups 1, 2 and 3 Paragraphs of the ICD-10 Codes that Support Medical Necessity and Article Text sections,

deleted procedure codes: o 94250 - Expired gas collection o 94400 - CO2 breathing response curve o 94750 - Pulmonary Compliance study

• Code description change: o 94617 -Exercise tst brncspsm was changed to Exercise tst brncspsm w/ecg

• In the Groups 1, 2 and 3 of the ICD-10 Codes that Support Medical Necessity added diagnosis codes: o J12.82 - Pneumonia due to coronavirus disease 2019 o Z86.16 - Personal history of COVID-19

• In the Group 1 of the ICD-10 Codes that Support Medical Necessity section: o Replaced diagnosis code M35.8 with M35.89 - Other specified systemic involvement of connective tissue.

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Respiratory Care (Respiratory Therapy) - R7- Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: The following updates were made per the 2021 Annual CPT/HCPCS Code Update and additional ICD-10-CM updates.

• Added procedure code: o 94619 - Exercise tst brncspsm wo ecg

• Deleted procedure codes:

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 37

o 94250 - Expired gas collection o 94400 - CO2 breathing response curve o 94750 - Pulmonary Compliance study

• Code description change: o 94617 -Exercise tst brncspsm was changed to Exercise tst brncspsm w/ecg

• Added diagnosis codes: o J12.82 - Pneumonia due to coronavirus disease 2019 o Z86.16 - Personal history of COVID-19

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Billing and Coding: Routine Foot Care - R4 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 1, 2021 Summary of Article: Updated article to correct typographical errors throughout the article. Added the following diagnosis codes to the following groups.

• In Group 2 ICD-10 Codes list, added A52.17, E08.00*, E08.10*, E08.21*, E08.22*, E08.29*, E08.41*, E08.43*, E08.44*, E08.618*, E09.21*, E09.22*, E09.29*, E09.39*, E09.40*, E09.41*, E09.43*, E09.44*, E09.49*, E09.610*, E09.618*, E09.620*, E09.628*, E09.649*, E09.65*, E09.69*, E09.9*, ,E10.10*, E10.21*, E10.22*, E10.29*, E10.41*, E10.43*, E10.44*, E10.618*, E10.620*, E10.628*, E10.649*, E10.65*, E10.69*, E10.9*, E11.00*, E11.10*, E11.21*, E11.22*, E11.29*, E11.41*, E11.43*, E11.44*, E11.618*, E11.620*, E11.628*, E11.649*, E11.65*, E11.69*, E13.00*, E13.10*, E13.21*,E13.22*, E13.29*, E13.41*, E13.43*, E13.44*, E13.620*, E13.628*, E13.649*, E13.65*, E13.69*, E85.1, E85.2, E85.3, E85.4, E85.81, E85.82, E85.9, G12.21, G12.25, G13.1*, G64, G90.09, G99.0, M05.511, M05.512, M05.521, M05.522, M05.531, M05.532, M05.541, M05.542, M05.551, M05.552, M05.561, M05.562, M05.571, M05.572 and M05.59.

• In Group 3 ICD-10 Codes list, added E08.311*, E08.319*, E08.3211*, E08.3212*, E08.3213*, E08.3291*, E08.3292*, E08.3293*, E08.3311*, E08.3312*, E08.3313*, E08.3391*, E08.3392*, E08.3393*, E08.3411*, E08.3412*, E08.3413*, E08.3491*, E08.3492*, E08.3493*, E08.3511*, E08.3512*, E08.3513*, E08.3521*, E08.3522*, E08.3523*, E08.3531*, E08.3532*, E08.3533*, E08.3541*, E08.3542*, E08.3543*, E08.3551* , E08.3552*, E08.3553*, E08.3591*, E08.3592*, E08.3593*, E08.36*, E08.37X1*, E08.37X2*, E08.37X3*, E08.39*, E08.311*, E09.311*, E09.319*, E09.3211*, E09.3212*, E09.3213*, E09.3291*, E09.3292* , E09.3293*, E09.3311*, E09.3312*, E09.3313*, E09.3391*, E09.3392*, E09.3393*, E09.3411*, E09.3412*, E09.3413*, E09.3491*, E09.3492*, E09.3493*, E09.3511*, E09.3512*, E09.3513*, E09.3521*, E09.3522*, E09.3523*, E09.3531*, E09.3532*, E09.3533*, E09.3541*, E09.3542*, E09.3543*, E09.3551*, E09.3552*, E09.3553*, E09.3591*, E09.3592*, E09.3593*, E09.36*, E09.37X1*, E09.37X2*, E09.37X3*], E09.51*, E09.52*, E09.59*, E09.621*, E09.622*, E10.311*, E10.319*, E10.3211*, E10.3212*, E10.3213*, E10.3291*, E10.3292*, E10.3293*, E10.3311*, E10.3312*, E10.3313*, E10.3391*. E10.3392*, E10.3393*, E10.3411*, E10.3412*, E10.3413*, E10.3491*, E10.3492*, E10.3493*, E10.3511*, E10.3512*, E10.3513*, E10.3521*, E10.3522*, E10.3523*, E10.3531*, E10.3532*, E10.3533*, E10.3541*, E10.3542*, E10.3543*, E10.3551*, E10.3552*, E10.3553*, E10.3591*, E10.3592*, E10.3593*, E10.36*, E10.39*, E11.311*, E11.319*, E11.3211*, E11.3212*, E11.3213*, E11.3291*, E11.3292*, E11.3293*, E11.3311*, E11.3312*, E11.3313*, E11.3391*, E11.3392*, E11.3393*, E11.3411*, E11.3412*, E11.3413*, E11.3491*, E11.3492*, E11.3493*, E11.3511*, E11.3512*, E11.3513*, E11.3521*, E11.3522*, E11.3523*, E11.3531*, E11.3532*, E11.3533*, ,E11.3541*, E11.3542*, E11.3543*, E11.3551*, E11.3552*, E11.3553*, E11.3591*, E11.3592*, E11.3593*, E11.36*, E11.37X1*, E11.37X2*, E11.37X3*, E11.39*, E13.311*, E13.319*, E13.3211*, E13.3212*, E13.3213*, E13.3291*, E13.3292*, E13.3293*, E13.3311*, E13.3312*, E13.3313*, E13.3391*, E13.3392*, E13.3393* , E13.3411*, E13.3412*, E13.3413*, E13.3491*, E13.3492*, E13.3493*, E13.3511*, E13.3512*, E13.3513*, E13.3521*, E13.3522*, E13.3523*, E13.3531*, E13.3532*, E13.3533*, E13.3541*, E13.3542*, E13.3543*, E13.3551*, E13.3552*, E13.3553*, E13.3591*, E13.3592*, E13.3593*, E13.36*, E13.37X1*, E13.37X2*, E13.37X3*, E13.39*, I70.201, I70.202, I70.203, I70.231, I70.232, I70.238, I70.241, I70.242, I70.248, I70.25, I70.268, I70.291, I70.292, I70.293, I70.298, I70.91, I73.9, I80.11*, I80.12*, I80.13*, I80.231*, I80.232*, I80.233*, I80.241*, I80.242*, I80.243*, I87.001and I87.002.

• In Group 4 ICD-10 Codes list, added Q82.0, R60.0 and R60.1.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 38

Visit the Noridian Medicare Coverage Articles webpage to view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD.

Final Facet Joint Interventions for Pain Management LCD and Associated Billing and Coding: Facet Joint Interventions for Pain Management - Effective April 25, 2021 This Local Coverage Determination (LCD) has completed the Open Public Meeting comment period and is now finalized under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV). Responses to comments received may be found as a link at the bottom of the final LCD.

Medicare Coverage Database Number LCD Title

L38801 Facet Joint Interventions for Pain Management

Medicare Coverage Database Number Billing and Coding Article Title

A58403 Billing and Coding: Facet Joint Interventions for Pain Management

Effective Date: April 25, 2021

Summary: The LCD discusses when Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain. The associated Billing and Coding article provide the medically reasonable and necessary billing and coding guidelines for these services.

Visit the Future LCDs webpage to access this LCD.

Final LCD Colon Capsule Endoscopy (CCE); Billing and Coding: Colon Capsule Endoscopy -Effective March 28, 2021 This Local Coverage Determination (LCD) has completed the Open Public Meeting comment period and is now finalized under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV). Responses to comments received may be found as a link at the bottom of the final LCD.

Medicare Coverage Database Number LCD Title

L38824 Colon Capsule Endoscopy (CCE)

Medicare Coverage Database Number Billing and Coding Article Title

A58436 Billing and Coding Article: Colon Capsule Endoscopy (CCE)

Effective Date: March 28, 2021 Summary: Colon Capsule Endoscopy (CCE) is a noninvasive procedure that does not require air inflation or sedation and allows for minimally invasive and painless colonic evaluation. For diagnostic and/or surveillance purposes, Colon Capsule Endoscopy (CCE) is medically necessary when certain criteria are met.

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Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 39

In Vitro Chemosensitivity & Chemoresistance Assays - R5 - Effective February 25, 2021 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L37628 LCD Title: In Vitro Chemosensitivity & Chemoresistance Assays Effective Date: February 25, 2021 Summary of Changes:

• Under CMS National Coverage Policy updated description for regulation Title XVIII of Social Security Act, §1862(a)(1)(D) and revised regulation 42 CFR §410.32(d)(3) to read “42 CFR §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions”.

• Under Summary of Evidence subheading Studies corrected the broken hyperlink in 12th paragraph. • Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and

typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

Visit the Active LCDs webpage to view the locally hosted Active LCD or access it via the CMS MCD.

Lab: Coenzyme Q10 (CoQ10) - R6 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L37066 LCD Title: Lab: Coenzyme Q10 (CoQ10) Effective Date: February 25, 2021 Summary of Changes: Under CMS National Coverage Policy updated description for regulation Title XVIII of the Social Security Act, §1862(a)(1)(A) to read "allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and treatment of illness or injury to improve the functioning of a malformed body member" and updated description for regulation 42 CFR §410.32(a) to read "indicates that diagnostic tests may be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements" Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation, and typographical errors were corrected throughout the LCD.

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Lab: Controlled Substance Monitoring and Drugs of Abuse Testing - R10 - Effective April 08, 2021 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L36668 LCD Title: Lab: Controlled Substance Monitoring and Drugs of Abuse Testing Effective Date: April 08, 2021 Summary of Changes:

• Under CMS National Coverage Policy revised the verbiage for the CMS Internet Only Manual (IOM) regulation Chapter 15 by removing §80.2 of this regulation.

• References were moved from the Sources of Information section to the Bibliography section and related links were removed or replaced as appropriate. Formatting, punctuation, and typographical errors were corrected, and acronyms were defined where appropriate throughout the policy.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 40

Visit the Active LCDs webpage to view the locally hosted Active LCD or access it via the CMS MCD.

Lumbar Epidural Injections LCD - R8 - Effective October 1, 2019 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L34982 LCD Title: Lumbar Epidural Injections Effective Date: October 1, 2019 Summary of Changes: Added a hyphen between 4 and week in the statement “Exceptions to the 4-week wait may include” under Indications and corrected the spelling of ‘paresthesia’ and “dysesthesia” in #4 under Limitations in the Coverage Guidance section.

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MolDX: Algorithm Definition This coverage article has been created and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: 03/11/2021 Summary of Article: Conditions when an algorithm may be considered a clinically valuable and independent component of a laboratory process.

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” or the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

MolDX: APC and MUTYH Gene Testing LCD - R6 - Effective April 01, 2021 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L36882 LCD Title: MolDX: APC and MUTYH Gene Testing Effective Date: April 01, 2021 Summary of Changes:

• Under CMS National Coverage Policy updated descriptions and moved regulation CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5, §60.1.2, §60.2 to the related billing and coding article. Added regulation CMS Internet-Only Manual, Pub. 100-02, Chapter 15, §80 and §80.1.1.

• Under Bibliography source #5 deleted “Version 1.2016” as this is no longer accessible and updated hyperlink. Formatting, punctuation, and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Local Coverage Determination from the “Active LCD” Webpage.

Visit the Active LCDs webpage to view the locally hosted Active LCD or access it via the CMS MCD.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 41

MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test Final LCD - Effective May 10, 2021 This Local Coverage Determination (LCD) has completed the Open Public Meeting and is now finalized under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV). Responses to comments received may be found as a link at the bottom of the final LCD.

Medicare Coverage Database (MCD) Number/Contractor Determination Number: L37822 LCD Title: MolDX: Breast Cancer IndexTM (BCI) Gene Expression Test Effective Date: March 25, 2021 Summary of LCD: This Medicare contractor will provide limited coverage for the Breast Cancer Index® (BCI) gene expression test (Biotheranostics, Inc., San Diego, CA). The BCI test is used by physicians to provide a genomic-based estimate of distant recurrence risk when considering addition of chemotherapy, and/or late distant recurrence risk and endocrine responsiveness when considering extension of endocrine therapy, depending upon when in the continuum of care testing is requested.

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MolDX: Prometheus IBD sgi Diagnostic LCD - R6 - Effective February 25, 2021 This Local Coverage Determination (LCD) has been revised under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV).

Medicare Coverage Database (MCD) Number: L37299 LCD Title: MolDX: Prometheus IBD sgi Diagnostic® Policy Effective Date: February 25, 2021 Summary of Changes:

• Under LCD Title added registered mark to Prometheus IBD sgi Diagnostic and where applicable throughout the LCD. • Under CMS National Coverage Policy updated descriptions and added section headings to regulations. Revised

section in regulation CMS Internet-Only Manual, Pub 100-02, Chapter 15, from 80.2 to 80.1.2. • Under Bibliography changes were made to citations to reflect AMA citation guidelines and broken hyperlink was

corrected for citation #6. Formatting, punctuation, and typographical errors were corrected throughout the LCD. Acronyms were defined and inserted where appropriate throughout the LCD.s

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Local Coverage Determination from the “Active LCD” Webpage.

Visit the Active LCDs webpage to view the locally hosted Active LCD or access it via the CMS MCD.

MolDX: Repeat Germline Testing - R1 - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: January 01, 2021 Summary of Article Changes: Addition of Code to Group I: 81168: CCND1/IGH (T(11;14)) (EG, MANTLE CELL LYMPHOMA) TRANSLOCATION ANALYSIS, MAJOR BREAKPOINT, QUALITATIVE AND QUANTITATIVE, IF PERFORMED

81191: NTRK1 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 1) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS

81192: NTRK2 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 2) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS

81193: NTRK3 (NEUROTROPHIC RECEPTOR TYROSINE KINASE 3) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 42

81194: NTRK (NEUROTROPHIC-TROPOMYOSIN RECEPTOR TYROSINE KINASE 1, 2, AND 3) (EG, SOLID TUMORS) TRANSLOCATION ANALYSIS

81278: IGH@/BCL2 (T(14;18)) (EG, FOLLICULAR LYMPHOMA) TRANSLOCATION ANALYSIS, MAJOR BREAKPOINT REGION (MBR) AND MINOR CLUSTER REGION (MCR) BREAKPOINTS, QUALITATIVE OR QUANTITATIVE

81279: JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARGETED SEQUENCE ANALYSIS (EG, EXONS 12 AND 13)

81338: MPL (MPL PROTO-ONCOGENE, THROMBOPOIETIN RECEPTOR) (EG, MYELOPROLIFERATIVE DISORDER) GENE ANALYSIS; COMMON VARIANTS (EG, W515A, W515K, W515L, W515R)

81339: MPL (MPL PROTO-ONCOGENE, THROMBOPOIETIN RECEPTOR) (EG, MYELOPROLIFERATIVE DISORDER) GENE ANALYSIS; SEQUENCE ANALYSIS, EXON 10

81347: SF3B1 (SPLICING FACTOR [3B] SUBUNIT B1) (EG, MYELODYSPLASTIC SYNDROME/ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, COMMON VARIANTS (EG, A672T, E622D, L833F, R625C, R625L)

81348: SRSF2 (SERINE AND ARGININE-RICH SPLICING FACTOR 2) (EG, MYELODYSPLASTIC SYNDROME, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, COMMON VARIANTS (EG, P95H, P95L)

81351: TP53 (TUMOR PROTEIN 53) (EG, LI-FRAUMENI SYNDROME) GENE ANALYSIS; FULL GENE SEQUENCE

81352: TP53 (TUMOR PROTEIN 53) (EG, LI-FRAUMENI SYNDROME) GENE ANALYSIS; TARGETED SEQUENCE ANALYSIS (EG, 4 ONCOLOGY)

81353: TP53 (TUMOR PROTEIN 53) (EG, LI-FRAUMENI SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL VARIANT

81357: U2AF1 (U2 SMALL NUCLEAR RNA AUXILIARY FACTOR 1) (EG, MYELODYSPLASTIC SYNDROME, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, COMMON VARIANTS (EG, S34F, S34Y, Q157R, Q157P)

81360: ZRSR2 (ZINC FINGER CCCH-TYPE, RNA BINDING MOTIF AND SERINE/ARGININE-RICH 2) (EG, MYELODYSPLASTIC SYNDROME, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS, COMMON VARIANT(S) (EG, E65FS, E122FS, R448FS)

81419: EPILEPSY GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE ANALYSES FOR ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, AND ZEB2

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” or the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease LCD and Billing and Coding Article - April 26, 2021 This Local Coverage Determination (LCD) has completed the Open Public Meeting comment period and is now finalized under contractor numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, and NMI), and 01312 (NV). Responses to comments received may be found as a link at the bottom of the final LCD.

Medicare Coverage Database Number LCD Title

L38613 Non-Invasive Fractional Flow Reservice (FFR) for Stable Ischemic Heart Disease

Medicare Coverage Database Number Billing and Coding Article Title

A58095 Billing and Coding: Non-Invasive Fractional Flow Reservice (FFR) for Stable Ischemic Heart Disease

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 43

Effective Date: April 26, 2021 Summary: FDA-approved FFRCT technology may be considered reasonable and necessary in the management of patients with symptomatic, stable ischemic heart disease (SIHD) when the CCTA analysis is completed and demonstrates certain criteria are met.

Visit the Future LCDs webpage to access this LCD.

Revision(s) for MolDX Billing and Coding Articles - Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Medicare Coverage Database Number Billing and Coding Article Title and Revision Number

A57509 MolDX: Prolaris™ Prostate Cancer Genomic Assay - R2

A57514 MolDX: Prolaris™ Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease - R1

A57372 MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease -R1

Effective Date: January 01, 2021 Summary of Article Changes: Addition of Code to Group I: 0228U: ONCOLOGY (PROSTATE), MULTIANALYTE MOLECULAR PROFILE BY PHOTOMETRIC DETECTION OF MACROMOLECULES ADSORBED ON NANOSPONGE ARRAY SLIDES WITH MACHINE LEARNING, UTILIZING FIRST MORNING VOIDED URINE, ALGORITHM REPORTED AS LIKELIHOOD OF PROSTATE CANCER

Visit the Molecular Diagnostic Services (MolDX) webpage to access the locally hosted MolDX Medicare Coverage Article from the “Covered Tests” or the “Excluded Tests” webpage.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Self-Administered Drug Exclusion List - R19, Effective January 1, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: 01/01/2021 Summary of Changes: Based on Transmittal 10463 (CR11880) (Billing for Home Infusion Therapy Services On or After January 1, 2021), which includes changes to the Medicare home infusion therapy services benefit, the article has been updated to move Hizentra® (J1559) to the Non-Excluded CPT/HCPCS Codes-Table with an Exclusion End Date of 12/31/2020.

Visit the Self-Administered Drugs (SADs) webpage to view the locally hosted Self-Administered Drug Exclusion List.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Self-Administered Drug Exclusion List - R20, Effective April 5, 2021 This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (AS, GU, HI, NMI), and 01312 (NV).

Effective Date: 04/05/2021 Summary of Changes: The article is updated to add: J0129 (Orencia®, subcutaneous use*), C9399.J3490 and J3590 Sogroya® (somapacitan-beco), effective 4/5/2021.

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Removed the following drug to the Non-Excluded CPT/HCPCS Codes - Table Format: C9399 and J3590, Zinbryta (daclizumab), effective 2/18/2021. This drug was taken of the market.

J2354 has been updated to add asterisk criteria in the "Descriptor Brand Name" section.

Added the following in Article Guidance:

ROUTE OF ADMINISTRATION MODIFIER

The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with JA modifier for the intravenous infusion of the drug or billed with the JB modifier for subcutaneous injection of the drug. Claims billed with the JA modifier are not part of the SAD exclusion. The Contractor will process claims with the JA modifier applying the policy that not only the drug is medically reasonable and necessary, but also that the route of administration is medically reasonable and necessary. Claims for drugs marked with an asterisk (*) billed without a JA or JB modifier will be denied.

CPT/HCPCS MODIFIERS

Group 1 Paragraph: Claim denials may occur when the appropriate modifier is not applied to a J code/medication, which has more than one route off administration. Group 1 Codes: JA - Intravenous administration JB - Subcutaneous administration

Added a notice at the beginning of the article:

Noridian decided to defer additions to the Usually Self-Administered Drug (USAD) list at the start of the public health emergency (PHE) to decrease potential patient care burden. The PHE has now lasted nearly one year and will likely continue for some time. With this notice we will begin to add drugs to the USAD list when appropriate which may facilitate the ability of patients to self-inject and avoid further trips to offices and facilities and potential Covid-19 exposure.

Visit the Self-Administered Drugs (SADs) webpage to view the locally hosted Self-Administered Drug Exclusion List.

To view the complete listing of locally hosted coverage articles and/or access the Active, Future, or Retired articles available in the CMS MCD, visit the Medicare Coverage Articles webpage.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 45

MLN CONNECTS .........................................................................

MLN Connects - January 7, 2020 COVID-19 Vaccines: CDC Long-Term Care Facility Toolkit

MLN Connects® for Thursday, January 7, 2020

View this edition as a: Webpage | PDF

NEWS • COVID-19 Vaccines: CDC Long-Term Care Facility Toolkit • MLN Web-Based Training: Complete Training & Save Certificates by January 31 • 2020 MIPS Extreme and Uncontrollable Circumstances Exception Application: Deadline February 1 • Extension of Medicare IVIG Demonstration through December 31, 2023 • Teaching Hospitals Receiving FTE Resident Caps Under Section 5506 of the Affordable Care Act • Cervical Health: Medicare Covers Screening Services

COMPLIANCE • Importance of Proper Documentation: Provider Minute Video

EVENTS • CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call - January 7

MLN MATTERS® ARTICLES • Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Codes 87811 and 87428 • 2021 Annual Update to the Therapy Code List • Instructions to Medicare Administrative Contractors (MACs) on COVID-19 Emergency Declaration Blanket Waivers for

Medicare-Dependent, Small Rural Hospitals and Sole Community Hospitals • Quarterly Update to Home Health (HH) Grouper • Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 27.1,

Effective April 1, 2021 • Updating Calendar Year (CY) 2021 Medicare Diabetes Prevention Program (MDPP) Payment Rates • Billing for Home Infusion Therapy Services on or After January 1, 2021 - Revised • Telehealth Expansion Benefit Enhancement under the Pennsylvania Rural Health Model (PARHM) - Implementation -

Revised

PUBLICATIONS • Complying with Laboratory Services Documentation Requirements - Revised

MULTIMEDIA • Enroll in Medicare to Administer COVID-19 Vaccine Shots: Information for Health Care Providers Video • Hospital Price Transparency Webcast: Audio Recording & Transcript • Promoting Interoperability Listening Session: Audio Recording & Transcript

INFORMATION FOR MEDICARE PATIENTS • From Coverage to Care Resources Help Navigate Health Coverage

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 46

MLN Connects Special Edition - January 7, 2020 - Physician Fee Schedule Update Physician Fee Schedule Update

On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS):

• Provided a 3.75% increase in MPFS payments for CY 2021 • Suspended the 2% payment adjustment (sequestration) through March 31, 2021 • Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023 • Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211)

until CY 2024

CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

MLN Connects - January 14, 2020 Ensuring our Nation’s Seniors Have Access to Latest Advancements

MLN Connects® for Thursday, January 14, 2021

View this edition as a: Webpage | PDF

NEWS • Ensuring our Nation’s Seniors Have Access to Latest Advancements • Opioid Treatment Programs: New for 2021 • Electronic Funds Transfer: Revised CMS-588 Required on February 28 • Recommend Glaucoma Screening for High-Risk Patients

COMPLIANCE • Inhalant Drugs: Bill Correctly

CLAIMS, PRICERS & CODES • Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments • ASC Payment System Update Effective January 1, 2021

MLN MATTERS® ARTICLES • January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.0 • January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System • January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

PUBLICATIONS • Clinical Laboratory Fee Schedule - Revised

MULTIMEDIA • Achieving Health Equity Web-Based Training Course

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MLN Connects - January 21, 2021 Give Flu Shots through January & Beyond

MLN Connects® for Thursday, January 21, 2021

View this edition as a: Webpage | PDF

NEWS • Hospital IPPS: FAQs on Market-Based MS-DRG Relative Weights • MLN Web-Based Training: Complete Training & Save Certificates by January 31 • Intensity-Modulated Radiation Therapy: Comparative Billing Report in January • 2020 MIPS Extreme & Uncontrollable Circumstances Exception Application: Deadline February 1 • Give Flu Shots through January & Beyond

COMPLIANCE • SNF 3-Day Rule: Bill Correctly

EVENTS • COVID-19 Listening Sessions with CMS Office of Minority Health - January 22, 26, & 28 • Physicians, Nurses & Allied Health Professionals Open Door Forum - January 27

CLAIMS, PRICERS, & CODES • ESRD Facilities: Machine Reported Dialysis Treatment Time on the 072X Bill Type • Therapy Claims: Reprocessing Dates of Service from January 1 through February 15 • Home Health RAP Workaround

MLN MATTERS® ARTICLES • Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment

for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021 - Revised

MULTIMEDIA • Quality Reporting Programs: From Data Elements to Quality Measures Web-Based Training • Section M: Assessment and Coding of Pressure Ulcers & Injuries Web-Based Training

MLN Connects - January 28, 2021 Medicare Wellness Visits: Get Your Patients Off to a Heathy Start

MLN Connects® for Thursday, January 28, 2021

View this edition as a: Webpage | PDF

NEWS • Care Compare: 2019 Preview Period Open through March 25 • Open Payments Data • Medicare Wellness Visits: Get Your Patients Off to a Heathy Start

COMPLIANCE • Hospice Care: Safeguards for Medicare Patients

CLAIMS, PRICERS, & CODES • Drug Claims Rejected in Error

MLN MATTERS® ARTICLES • Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 48

Reasonable Charge Payment - Revised

MLN Connects - February 4, 2021 Improving Accuracy of Medicare Payments

MLN Connects® for Thursday, February 4, 2021

View this edition as a: Webpage | PDF

NEWS • Improving Accuracy of Medicare Payments • Cardiovascular Health: Medicare Covers Screening & Therapy

CLAIMS, PRICERS, & CODES • OPPS Pricer File: January 2021 • FQHC Claims: Retroactive Adjustment for Geographic Adjustment Factor • HCPCS Code G2211 is a Bundled Service & Not Separately Paid

EVENTS • ICD-10 Coordination & Maintenance Committee Meeting - March 9-10

MLN Connects - February 11, 2021 PFS Payment for Office & Outpatient E/M Visits

MLN Connects® for Thursday, February 11, 2021

View this edition as a: Webpage | PDF

NEWS • Flu & Pneumococcal Shots: Protect Your Patients

COMPLIANCE • Hospices: Create an Effective Plan of Care

CLAIMS, PRICERS, & CODES • COVID-19: Revised Clinician Codes Accepted with CS Modifier • PFS Payment for Office & Outpatient E/M Visits • ESRD: Claims Processing Issues for Type of Bill 072X

MLN Connects - February 18, 2021 COVID-19: EUA for Antibody Treatment

MLN Connects® for Thursday, February 18, 2021

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NEWS • CMS Takes Further Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment • IPPEs & AWVs: Comparative Billing Report in February • American Heart Month & Black History Month

COMPLIANCE • Hospice Aide Services: Enhancing RN Supervision

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 49

CLAIMS, PRICERS, & CODES • FQHC & RHC Claims: Retroactive Rate Adjustment for Code G2025

MULTIMEDIA • Section N: Medications - Drug Regimen Review Web-Based Training

MLN Connects - February 25, 2021 Medicare Secondary Payer: Billing for Services

MLN Connects® newsletter for Thursday, February 25, 2021

View this edition as a: Webpage | PDF

NEWS • CMS Offers Comprehensive Support to the State of Texas to Combat Winter Storm

COMPLIANCE • Post-Acute Care Transfers: Bill Correctly

MLN MATTERS® ARTICLES • Billing for Services when Medicare is a Secondary Payer • April 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly

Pricing Files • Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory

Improvement Amendments (CLIA) Edits • Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive

Bidding Program (CBP) - April 2021

MLN Connects - March 4, 2021 COVID-19 Vaccine Codes: EUA for Janssen Biotech

MLN Connects® newsletter for Thursday, March 4, 2021

View this edition as a: Webpage | PDF

NEWS • COVID-19 Vaccine Codes: EUA Effective Date for Janssen Biotech Inc. • COVID-19 Vaccine Administration: Insurance Coverage, MBI, & MSP • COVID-19 FAQs on Medicare FFS Billing to Administer Vaccines • COVID Vaccine Resources for Hard to Reach Patients • Cybersecurity Resources • Nutrition-related Health Conditions: Medicare Covers Preventive Services

COMPLIANCE • IRF Services: Follow Medicare Billing Requirements

CLAIMS, PRICERS, & CODES • DMEPOS: Corrected 2021 Fee Schedule Amounts

EVENTS • Medicare Part A Cost Report Appeals Listening Session - March 16 • Long-Term Care: Dementia-related Psychosis Call - March 23 • Open Payments & You Call - March 25

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PUBLICATIONS • Intravenous Immune Globulin Demonstration

MULTIMEDIA • Section J: Health Conditions: Coding the SPADEs Related to Falls Web-Based Training

MLN Connects Special Edition - March 10, 2021 - CMS Updates Nursing Home Guidance with Revised Visitation Recommendations On March 10, CMS, in collaboration with the CDC, issued updated guidance for nursing homes to safely expand visitation options during the COVID-19 pandemic public health emergency.

This latest guidance comes as more than 3 million doses of vaccines have been administered within nursing homes, thanks in part to the CDC’s Pharmacy Partnership for Long-Term Care Program, following the FDA authorization for emergency use of COVID-19 vaccines.

According to the updated guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation for:

• Unvaccinated residents, if the COVID-19 county positivity rate is greater than 10 percent and less than 70 percent of residents in the facility are fully vaccinated,

• Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue transmission-based precautions, or

• Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine

The updated guidance also emphasizes that “compassionate care” visits should be allowed at all times, regardless of a resident’s vaccination status, the county’s COVID-19 positivity rate, or an outbreak. Compassionate care visits include visits for a resident whose health has sharply declined or is experiencing a significant change in circumstances.

CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated.

“CMS recognizes the psychological, emotional, and physical toll that prolonged isolation and separation from family have taken on nursing home residents and their families,” said Dr. Lee Fleisher, MD, CMS Chief Medical Officer and Director of CMS’ Center for Clinical Standards and Quality. “That is why, now that millions of vaccines have been administered to nursing home residents and staff, and the number of COVID cases in nursing homes has dropped significantly, CMS is updating its visitation guidance to bring more families together safely. This is an important step that we are taking, as we continue to emphasize the importance of maintaining infection prevention practices, given the continued risk of transmission of COVID-19.”

High vaccination rates among nursing home residents, and the diligence of committed nursing home staff to adhere to infection control protocols, which are enforced by CMS, have helped significantly reduce COVID-19 positivity rates and the risk of transmission in nursing homes.

Although outbreaks increase the risk of COVID-19 transmission, as long as there is evidence that the outbreak is contained to a single unit or separate area of the facility, visitation can still occur.

More Information: • Nursing Home Visitation - COVID-19 webpage • Fact sheet

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MLN Connects - March 11, 2021 Hospitals: Are You Using Your PEPPER Data?

MLN Connects newsletter for Thursday, March 11, 2021

View this edition as a: Webpage | PDF

NEWS • PEPPERs for Short-term Acute Care Hospitals • Colorectal Cancer: Medicare Covers Screening

COMPLIANCE • Ambulance Services & SNF Consolidated Billing Requirements: Avoid Improper Payments

CLAIMS, PRICERS, & CODES • Average Sales Price Files: April 2021

EVENTS • Medicare Part A Cost Report Appeals Listening Session - March 16 • Long-Term Care: Dementia-related Psychosis Call - March 23 • Open Payments & You Call - March 25

MLN MATTERS® ARTICLES • April 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.1 • April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS) • Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes -

Revised

MLN Connects Special Edition - March 15, 2021 - Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine On March 15, CMS increased the Medicare payment amount for administering the COVID-19 vaccine. This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. At a time when vaccine supply is growing, CMS is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

These updates to the Medicare payment rate for COVID-19 vaccine administration reflect new information about the costs involved in administering the vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.

CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare, or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

Coverage of COVID-19 Vaccines:

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 52

As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance, or deductible.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

Medicaid: State Medicaid and Children’s Health Insurance Program agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the Public Health Emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit.

Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the PHE. Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More Information: • Medicare COVID-19 Vaccine Shot Payment webpage: Payment for COVID-19 vaccine administration, including a list of

billing codes, payment allowances, and effective dates • CDC COVID-19 Vaccination Program Provider Requirements and Support webpage: How the COVID-19 vaccine is

provided at 100% no cost to recipients • HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine

Administration for the Uninsured webpage

MLN Connects - March 18, 2021 Open Payments & You - Register for March 25 Call

MLN Connects newsletter for Thursday, March 18, 2021

View this edition as a: Webpage | PDF

NEWS • Clinical Laboratory Data Reporting Delayed Until 2022: Reminder • Comprehensive Eye Examinations: Comparative Billing Report in March

COMPLIANCE • Polysomnography Services: Bill Correctly

EVENTS • Long-Term Care: Dementia-related Psychosis Call - March 23 • Open Payments & You Call - March 25 • SNF Quality Reporting Program: Achieving a Full APU Webinar- March 30

MLN MATTERS® ARTICLES

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 53

• April 2021 Update to the Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) • April Quarterly Update for 2021 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee

Schedule • Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of Specimens • Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment • Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update • Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP)

& PC Print Update

PUBLICATIONS • Medicare Quarterly Provider Compliance Newsletter

MLN Connects - March 25, 2021 Home Health Payment Corrections

MLN Connects newsletter for Thursday, March 25, 2021

View this edition as a: Webpage | PDF

NEWS • Medicare Shared Savings Program: Application Deadlines for January 1, 2022, Start Date • Repetitive, Scheduled Non-Emergent Ambulance Transport: Documentation Requirements • PT During COVID-19 & Response to Texas Storm

COMPLIANCE • Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly

CLAIMS, PRICERS, & CODES • Home Health Payment Corrections

MLN MATTERS® ARTICLES • Common Working File (CWF) Edits for Medicare Telehealth Services and Manual Update • Correction to Period Sequence Edits on Home Health Claims • Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment

for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2021 • Updated Billing Requirements for Home Infusion Therapy (HIT) Services on or After January 1, 2021 • Update to Rural Health Clinic (RHC) Payment Limits

MLN Connects Special Edition - March 30, 2021 - Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, we instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess if Congress extends the suspension; the MACs will automatically reprocess any claims paid with the reduction applied if necessary.

Medicare B News | Noridian Medicare Part B Jurisdiction E | April 2021 54

MLN MATTERS ...........................................................................

2021 Annual Update to the Therapy Code List MLN Matters Number: MM12126 Related CR Release Date: December 31, 2020 Related CR Transmittal Number: R10542CP Related Change Request (CR) Number: 12126 Effective Date: January 1, 2021 Implementation Date: January 4, 2021 CR 12126 informs you of updates to the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2021 CPT and Level II HCPCS. Make sure your billing staffs are aware of these updates.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12126.

April 2021 Quarterly ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files MLN Matters Number: MM12133 Related CR Release Date: January 20, 2021 Related CR Transmittal Number: R10562CP Related Change Request (CR) Number: 12133 Effective Date: April 1, 2021 Implementation Date: April 5, 2021 CR 12133 informs you about the Average Sales Price (ASP) methodology, which is based on quarterly data manufacturers submit to CMS. CMS gives the MACs ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Please make sure your billing staffs are aware of these updates.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12133.

April Quarterly Update for 2021 DMEPOS Fee Schedule MLN Matters Number: MM12193 Related CR Release Date: March 12, 2021 Related CR Transmittal Number: R10681CP Related Change Request (CR) Number: 12193 Effective Date: April 1, 2021 Implementation Date: April 5, 2021 CR 12193 tells you about the changes to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedules that Medicare updates on a quarterly basis, when necessary, to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. Make sure your billing staffs are aware of these changes.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12193.

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Billing For Services When Medicare Is a Secondary Payer MLN Matters Number: SE21002 Article Release Date: February 23, 2021 Don’t deny treatment, entry to a SNF or hospital, or services based on an open or closed Liability (L), No-Fault (NF) or Workers’ Compensation (WC) Medicare Secondary Payer (MSP) record on the beneficiary’s Medicare file or if a claim was inappropriately denied. You must continue to see or provide services to the beneficiary.

If services relate to an open MSP accident or injury incident, first bill the other insurer as primary.

View the complete CMS Medicare Learning Network (MLN) Matters (SE)21002.

CLFS - Medicare Travel Allowance Fees for Collection of Specimens MLN Matters Number: MM12140 Related CR Release Date: March 9, 2021 Related CR Transmittal Number: R10615CP Related Change Request (CR) Number: 12140 Effective Date: January 1, 2021 Implementation Date: No later than March 19, 2021 CR 12140 informs you about the Calendar Year (CY) 2021 changes to travel allowances when billed:

• On a per mileage basis using HCPCS code P9603 • On a flat rate basis using HCPCS code P9604

Medicare Part B allows payment for a specimen collection fee and travel allowance, when medically necessary, for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under Section 1833(h)(3) of the Act. Payment for these services is made based on the Clinical Laboratory Fee Schedule (CLFS).

Make sure that your billing staffs are aware of these changes.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12140.

CWF Edits for Medicare Telehealth Services and Manual Update MLN Matters Number: MM12068 Related CR Release Date: March 16, 2021 Related CR Transmittal Number: R10168CP Related Change Request (CR) Number: 12068 Effective Date: January 1, 2021 Implementation Date: July 6, 2021 CR 12068 tells you about claims frequency editing changes that Medicare’s Common Working File (CWF) performs based on relevant policy limitations for subsequent nursing facility care services. The article also tells you of updates to the Medicare Claims Processing Manual to reflect these changes. Make sure that your billing staffs are aware of these changes.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12068.

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CY 2021 Annual Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment - Revised MLN Matters Number: MM12080 Revised Related CR Release Date: January 20, 2021 Related CR Transmittal Number: R10575CP Related Change Request (CR) Number: 12080 Effective Date: January 1, 2021 Implementation Date: January 4, 2021 Note: CMS revised this article to reflect a revised CR 12080, that CMS issued on January 20, 2021. In the CR, CMS changed the payment determination for code 0177U in the crosswalk from 81310 to 81309. CMS made that same change as shown in red print on page 6. Also, CMS changed the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

CR 12080 provides instructions for the Calendar Year (CY) 2021 Clinical Laboratory Fee Schedule (CLFS), mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. Make sure your billing staffs are aware of these updates.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12080.

HCPCS Codes Subject to and Excluded from CLIA Edits MLN Matters Number: MM12131 Related CR Release Date: January 20, 2021 Related CR Transmittal Number: R10564CP Related Change Request (CR) Number: 12131 Effective Date: April 1, 2021 Implementation Date: April 5, 2021 CR 12131 tells you about the new Healthcare Common Procedure Coding System (HCPCS) codes for 2021 that are subject to and excluded from Clinical Laboratory Improvement Amendments (CLIA) edits. Make sure your billing staffs are aware of these updates.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12131.

January 2021 Update of the ASC Payment System MLN Matters Number: MM12129 Related CR Release Date: December 31, 2020 Related CR Transmittal Number: R10546CP Related Change Request (CR) Number: 12129 Effective Date: January 1, 2021 Implementation Date: January 4, 2021 CR 12129 describes changes to and billing instructions for various payment policies implemented in the January 2021 Ambulatory Surgical Center (ASC) payment system update. CR 12129 also includes updates to HCPCS. Make sure that your billing staffs are aware of these changes.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12129.

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Quarterly Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment MLN Matters Number: MM12178 Related CR Release Date: March 9, 2021 Related CR Transmittal Number: R10656CP Related Change Request (CR) Number: 12178 Effective Date: April 1, 2021 Implementation Date: April 5, 2021 CR 12178 gives you details of the quarterly update to the Clinical Laboratory Fee Schedule (CLFS). Please be sure your billing staff is aware of these updates.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12178.

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2021 Update MLN Matters Number: MM12155 Related CR Release Date: March 10, 2021 Related CR Transmittal Number: R10631CP Related Change Request (CR) Number: 12155 Effective Date: January 1, 2021 Implementation Date: April 5, 2021 CR 12155 is for physicians, hospitals, and other providers billing Medicare Administrative Contractors (MACs) for services they provide to Medicare patients that Medicare pays using the Medicare Physician Fee Schedule (MPFS).

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12155.

RARC, CARC, MREP & PC Print Update MLN Matters Number: MM12102 Related CR Release Date: March 11, 2021 Related CR Transmittal Number: R10650CP Related Change Request (CR) Number: 12102 Effective Date: July 1, 2021 Implementation Date: July 6, 2021 CR 12102 tells you of updates to the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs Medicare’s Shared System Maintainers (SSMs) to update Medicare Remit Easy Print (MREP) and PC Print. Make sure billing staffs are aware of these updates. If you use the MREP or PC Print software, be sure to get the updated software.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12102.

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Updated Billing Requirements for HIT Services on or After January 1, 2021 MLN Matters Number: MM12108 Related CR Release Date: March 15, 2021 Related CR Transmittal Number: R10621CP Related Change Request (CR) Number: 12108 Effective Date: January 1, 2021 Implementation Date: July 6, 2021 CR 12108 informs you of new changes to Medicare claims processing for Home Infusion Therapy (HIT) services on or after January 1, 2021. Make sure your billing staffs are aware of this change.

View the complete CMS Medicare Learning Network (MLN) Matters (MM)12108.