NOVEMBER 2019 • …...Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 15 MM11441: 2020 Annual Update of Healthcare Common Procedure Coding System

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Medicare BulletinJurisdiction 15

NOVEMBER 2019 • WWW.CGSMEDICARE.COM

Reaching Out to the Medicare

Community

© 2019 Copyright, CGS Administrators, LLC.

Medicare BulletinJurisdiction 15

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Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2019 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

yy NOVEMBER 2019 2

HOME HEALTH

Home Health Agencies Need to Register for an Internet Quality Improvement and Evaluation System (iQIES) Account 3

Register Today to Attend the Part I and Part II Home Health Patient-Driven Groupings Model (PDGM) Webcast 4

HOME HEALTH AND HOSPICE

CGS Website Updates 4

Contact Information for CGS Medicare Home Health and Hospice Providers 5

It’s Flu season again: Use Medicare Beneficiary Identifiers to bill Medicare 5

MLN Connects® Weekly News 6

MM11343 (Revised): October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files 6

MM11412: October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3 8

MM11422 (Revised): Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update 10

MM11433: October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 15

MM11441: 2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update 17

MM11451: October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) 18

Provider Contact Center (PCC) Training 26

SE19018: Hurricane Dorian and Medicare Disaster Related State of Florida Claims 27

SE19019: Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims 30

SE19020: Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims 33

SE19022: 2019-2020 Influenza (Flu) Resources for Health Care Professionals 37

Upcoming Educational Events 39

https://www.cgsmedicare.com/mycgs/index.html myCGS is a secure Internet-based application where you can view beneficiary eligibility, claims status, online remittances, financial information, and much more!

my

NEW MEDICARE BENEFICIARY IDENTIFIER (MBI) GET IT! USE IT! #NewCardNewNumberLEARN MORE BY VISTING: https://www.cms.gov/Medicare/New-Medicare-Card/index.html

https://www.cgsmedicare.com/mycgs/index.html

go.cms.gov/mln

https://www.cms.gov/Medicare/New-Medicare-Card/index.html

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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters are available at no cost from our website at https://www.cgsmedicare.com. © 2019 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN • GR 2019-11 NOVEMBER 2019

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For Home Health Providers

Home Health Agencies Need to Register for an Internet Quality Improvement and Evaluation System (iQIES) Account

The Quality Improvement and Evaluation System (QIES), which providers and vendors use to submit assessment data, is being upgraded to make the system more reliable, scalable, secure, and accessible. The enhancements will occur in phases (by provider type) and began with Long- Term Care Hospitals (LTCHs) in March 2019, to be followed by Inpatient Rehabilitation Facilities (IRFs) in October 2019 and Home Health Agencies (HHAs) in January 2020. The enhanced system is referred to as the Internet Quality Improvement and Evaluation System (iQIES).

The initial rollout of iQIES will not change how providers or vendors submit data. However, iQIES will require a new user management system because virtual private network (VPN) and CMSNet are no longer needed to access this system. All users will have to create an account and establish credentials in the Healthcare Quality Information System (HCQIS) Access, Roles and Profile system (HARP). HARP is a secure identity management portal that the Centers for Medicare and Medicaid Services (CMS) provides.

Through HARP, the level of access for iQIES will be similar to the roles that exist in QIES but with the addition of a Provider Security Official (PSO). The individual designated as the PSO will be responsible for approving or rejecting iQIES user access requests for their respective organizations, including vendors.

For your organization to receive access to iQIES, you must first complete the steps below according to the following schedule:

1. Identify an individual who will be the Provider Security Official (PSO).

2. Register the PSO in the Healthcare Quality Information System (HCQIS) Access Roles and Profile (HARP) system at: https://harp.qualitynet.org/register/profile-info.

3. After your MFA (Multi-Factor Authentication) is complete, choose the iQIES application presented to you to request your Security Official role. Alternatively, you can access iQIES at the following URL: https://iqies.cms.gov/ to complete your role request.

Please note that at this time, only certified HHAs will be onboarded to iQIES. For assistance with HARP onboarding or other questions, users can call the QTSO Helpdesk at 1.800.339.9313 or email [email protected]. If you have any questions related to iQIES, please send them to [email protected].

The information in this article and more can be found on the CMS website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/DataSpecifications.html.

The Medicare Learning Network® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more.

Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.

A Valuable Educational Resource!THE MEDICARE LEARNING NETWORK®

http://www.cgsmedicare.com

https://harp.qualitynet.org/register/profile-info

https://iqies.cms.gov/

mailto:[email protected]


https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/OASIS/DataSpecifications.html



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html



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For Home Health Providers

Register Today to Attend the Part I and Part II Home Health Patient-Driven Groupings Model (PDGM) Webcast

Your Home Health Medicare Administrative Contractors (MACs), CGS, National Government Services and Palmetto GBA will host a two part collaborative webcast to help your agency prepare to implement billing changes for the PDGM on January 1, 2020. The Centers for Medicare & Medicaid Services (CMS) will use the PDGM to reimburse home health agencies.

Home Health Patient-Driven Groupings Model (PDGM) Webcast Part IDuration: 60 MinutesDate: November 21, 2019Time: 2:00 p.m. Eastern Daylight TimeRegistration: https://event.on24.com/wcc/r/2102883/B5891153B2D7176F464B35EEBBC02B90During this webcast, you will receive the following information:

yy Overview of the PDGMyy PDGM vs. Current PPSyy 30-Day Periods

yy Billing and claims processing overviewyy Requests for Anticipated Payment (RAPs)yy Reporting new occurrence codes

Home Health Patient-Driven Groupings Model (PDGM) Webcast Part IIDuration: 60 MinutesDate: December 5, 2019Time: 2:00 p.m. Eastern Daylight TimeRegistration: https://event.on24.com/wcc/r/2102905/CD018AD7FA5EAD5F11CA3B5200B8F7C3During this webcast, you will receive the following information:

yy Admission Source andTimingyy Clinical Groupsyy Functional Impairment Levels

yy Comorbidity Groupyy Case-Mix Weightsyy Other Adjustments

yy Diagnosis Informationyy How OASIS data will

be used

AudioThe audio for the Part I and Part II presentation is broadcast through your computer speakers or headphones. Please test your audio device(s) prior to the start of the presentation. A telephone conference line is not used for the webcast.

HandoutsA copy of the presentations and addition resources will be available in the webcast once it begins.

Refer to the Home Health and Hospice Calendar of Events Web page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx for a full list of upcoming educational opportunities.

For Home Health and Hospice Providers

CGS Website Updates

CGS has recently made updates to their website, giving providers additional resources to assist with billing Medicare-covered services appropriately.

Please review the following updates:

yy The Claims Processing Issues Log Web page at https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html was updated with the most recent updates.

yy The Top Claim Submission Errors (Reason Codes) and How to Resolve Web page at https://www.cgsmedicare.com/hhh/education/materials/cses.html has been updated with the most recent data.


https://event.on24.com/wcc/r/2102883/B5891153B2D7176F464B35EEBBC02B90

https://event.on24.com/wcc/r/2102905/CD018AD7FA5EAD5F11CA3B5200B8F7C3

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/hhh_report/hhh_report.aspx

https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html

https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html

https://www.cgsmedicare.com/hhh/education/materials/cses.html

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yy The Home Health Patient Driven Groupings Model (PDGM) Web page at https://www.cgsmedicare.com/hhh/education/materials/pdgm.html was updated to include link to the CMS August 21, 2019, Home Health Patient-Driven Groupings Model: Operational Issues presentation, clarification, audio recording and transcript. A link to the CMS Calendar Year (CY) 2020 PDGM Grouper Tool is also available.

yy The following Web pages were updated to include the MLN Matters articles MM11428 “Influenza Vaccine Payment Allowances – Annual Update for 2019-2020 Season” and SE19022 “2019-2020 Influenza (Flu) Resources for Health Care Professionals” in the Additional Resources section.

y� Home Health Immunization Reimbursement - https://www.cgsmedicare.com/hhh/claims/fees/hh_ir.html

y� Billing Individual Influenza and Pneumococcal Pneumonia Vaccines - https://www.cgsmedicare.com/hhh/education/materials/biippv.html

y� Roster Billing for Mass Influenza and Pneumococcal Pneumonia Vaccines - https://www.cgsmedicare.com/hhh/education/materials/rbmippv.html

yy A quarterly review of the Frequently Asked Questions (FAQs) https://www.cgsmedicare.com/medicare_dynamic/faqs/J15hhh.asp was completed. Updates were made as necessary.

yy The Customer Services Home Health & Hospice Contact Information Web page at https://www.cgsmedicare.com/hhh/cs/index.html now shows details about the information available for each icon when you move your mouse over the icon.


Contact Information for CGS Medicare Home Health and Hospice Providers

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center (PCC) at 1.877.299.4500 and choose Option 1. Access the Home Health and Hospice “Contact Information” Web page at https://www.cgsmedicare.com/hhh/cs/index.html for information about the Interactive Voice Response (IVR) system, as well as telephone numbers, fax numbers, and mailing addresses for other CGS departments.

Before You CallAccess the new “How Do I…?” icon (https://www.cgsmedicare.com/hhh/cs/howdoi.html) and the “Education & Resources Options” icon (https://www.cgsmedicare.com/hhh/education/index.html) to access resources that may be able to answer your question.


It’s Flu season again: Use Medicare Beneficiary Identifiers to bill Medicare

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (https://www.congress.gov/bill/114th-congress/house-bill/2/text) requires The Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards. CMS mailed new cards to all people with Medicare which have randomly generated Medicare Beneficiary Identifiers (MBIs) (https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf) instead of SSN-based Health Insurance Claim Numbers (HICNs).

Use MBIs to check eligibility and bill for influenza vaccinations to protect Medicare beneficiaries’ personal identities. Get the MBI:

yy Ask people with Medicare for their cards. If they did not get a new card, give them the Get Your New Medicare Card flyer in English (https://www.cms.gov/Outreach-


https://www.cgsmedicare.com/hhh/education/materials/pdgm.html

https://www.cgsmedicare.com/hhh/claims/fees/hh_ir.html

https://www.cgsmedicare.com/hhh/education/materials/biippv.html

https://www.cgsmedicare.com/hhh/education/materials/rbmippv.html

https://www.cgsmedicare.com/medicare_dynamic/faqs/J15hhh.asp

https://www.cgsmedicare.com/medicare_dynamic/faqs/J15hhh.asp

https://www.cgsmedicare.com/hhh/cs/index.html



https://www.cgsmedicare.com/hhh/cs/howdoi.html

https://www.cgsmedicare.com/hhh/cs/howdoi.html

https://www.cgsmedicare.com/hhh/education/index.html

https://www.cgsmedicare.com/hhh/education/index.html

https://www.congress.gov/bill/114th-congress/house-bill/2/text

https://www.congress.gov/bill/114th-congress/house-bill/2/text

https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf

https://www.cms.gov/Medicare/New-Medicare-Card/Understanding-the-MBI.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf

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and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCard.pdf) or Spanish (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf).

yy Check the remittance advice. CMS included the new MBI on the remittance advice for each claim you submitted with a valid and active HICN since October, 2018, and will continue to return MBIs through December 31, 2019. Get the MBI from the remittance advice, save it in your systems, and use it to bill for this year’s flu vaccinations.

Tips for using MBIs:

yy Don’t use hyphens or spaces to avoid rejection of your claim.

yy MBIs use numbers 0-9 and all uppercase letters except for S, L, O, I, B, and Z. We exclude these letters to avoid confusion when differentiating some letters and numbers (for example, between “0” and “O”).

Starting January 1, 2020, you must use the MBI:

yy We will reject claims you submit with HICNs with a few exceptions (https://www.cms.gov/Medicare/New-Medicare-Card/index.html).

yy We will reject all eligibility transactions you submit with HICNs.

For more information, please review CMS’ New Medicare Beneficiary Identifier (MBI), Get It, Use It article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf).


MLN Connects® Weekly News

The MLN Connects® is the official news from the Medicare Learning Network and contains a weeks worth of Medicare-related messages. These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html.

yy September 12, 2019 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-09-12-eNews.pdf



yy October 3, 2019 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-10-03-eNews.pdf

yy October 10, 2019 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-10-10-eNews.pdf


MM11343 (Revised): October 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles




https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GetYourNewMedicareCardSpanish.pdf





https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18006.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2019-09-12-eNews.pdf










https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles


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MLN Matters Number: MM11343 Revised Related Change Request (CR) Number: 11343 Related CR Release Date: September 13, 2019 Effective Date: October 1, 2019 Related CR Transmittal Number: R4395CP Implementation Date: October 7, 2019

Note: We revised this article on September 16, 2019, to reflect the revised CR11343 issued on September 13. The CR revision had no impact on the substance of the article. We did update the CR release date, transmittal number, and the Web address of the CR. All other information remains the same.

Provider Type AffectedThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for Medicare Part B drugs provided to Medicare beneficiaries.

Provider Action NeededCR11343 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) will make files available for download on or after September 13, 2019. CMS gives MACs the ASP and 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 available in Chapter 4, Section 50 of the Medicare Claims Processing Manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf. Make sure that your billing staffs are aware of these changes.

BackgroundThe ASP methodology is based on quarterly data submitted to CMS by manufacturers. CR11343 instructs MACs to download and implement the October 2019 and, if released, the revised July 2019, April 2019, January 2019, and October 2018 ASP drug pricing files for Medicare Part B drugs.

CR11343 addresses the following pricing files:

yy File: October 2019 ASP and ASP NOC — Effective Dates of Service: October 1, 2019, through December 31, 2019

yy File: July 2019 ASP and ASP NOC — Effective Dates of Service: July 1, 2019, through September 30, 2019

yy File: April 2019 ASP and ASP NOC — Effective Dates of Service: April 1, 2019, through June 30, 2019

yy File: January 2019 ASP and ASP NOC -- Effective Dates of Service: January 1, 2019, through March 31, 2019

yy File: October 2018 ASP and ASP NOC — Effective Dates of Service: October 1, 2018, through December 31, 2018

For any drug or biological not listed in the ASP or NOC drug pricing files, your MACs will determine the payment allowance limits in accordance with the policy in the Medicare Claims Processing Manual, Chapter 17, Section 20.1.3 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf.

For any drug or biological not listed in the ASP or NOC drug pricing files that you bill with the KD modifier, MACs will determine the payment allowance limits in accordance with instructions for pricing and payment changes for infusion drugs furnished through an item of Durable Medical Equipment (DME) on or after January 1, 2017, associated with the passage of the 21st Century Cures Act which is available at https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf.

Note: MACs will not search and adjust claims that have already been processed unless you bring such claims to their attention.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf




https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf

https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf

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Additional InformationThe official instruction, CR11343, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4395CP.pdf.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

To contact a CGS Customer Service Representative, call the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.

Document History

Date of Change DesscriptionSeptember 16, 2019 We revised this article on September 16, 2019, to reflect the revised CR11343 issued

on September 13. The CR revision had no impact on the substance of the article. We did update the CR release date, transmittal number, and the Web address of the CR. All other information remains the same.

July 9, 2019 Initial article released.


MM11412: October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3

The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles

MLN Matters Number: MM11412 Related Change Request (CR) Number: 11412 Related CR Release Date: August 30, 2019 Effective Date: October 1, 2019 Related CR Transmittal Number: R4383CP Implementation Date: October 7, 2019

Provider Types AffectedThis MLN Matters Article is for institutional providers and suppliers billing Medicare Administrative Contractors (MACs), including the Home Health and Hospice MACs, for services provided to Medicare beneficiaries.

Provider Action NeededCR 11412 provides the Integrated Outpatient Code Editor (I/OCE) instructions and specifications for the Medicare Integrated OCE version 20.3 used as follows:

yy Under the Outpatient Prospective Payment System (OPPS)

yy For Non-OPPS hospital outpatient departments, community mental health centers and all non-OPPS providers

yy For limited services when provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System

yy For a hospice patient for the treatment of a non-terminal illness

Make sure your billing staffs are aware of these changes.

BackgroundCR11412 informs the MACs and the Fiscal Intermediary Shared System (FISS) maintainer that the Centers for Medicare & Medicaid Services (CMS) is updating the I/OCE for October 1, 2019. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4395CP.pdf


http://go.cms.gov/MAC-website-list



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The following table summarizes the modifications of the I/OCE for the October 2019 V20.3 release. Readers should review the entire CR 11412 document and note the highlighted sections, which also indicate changes from the prior release of the software. CMS has added some I/OCE modifications in the update retroactively to prior releases. If so, the retroactive date appears in the ‘Effective Date’ column of the below table. CMS will post the I/OCE specifications at http://www.cms.gov/OutpatientCodeEdit/.

Effective Date

Edits Affected Modification

10/1/2019 Update the Claim Return Buffer Table to add new field “Return Code”10/1/2019 1, 3, 5 Update diagnosis code editing for validity, gender, and external cause of morbidity, based on the

FY 2020 ICD-10-CM code revisions to the Medicare Code Editor (MCE).10/1/2019 2 Update the age range for Maternity diagnoses to a low age of 9 and a high age of 64. If outside

this range an age conflict exists and edit 2 is returned. This change is based on the FY 2020 ICD-10-CM code revisions to the MCE.

10/1/2019 109 Update the Code first list for mental health diagnosis reporting, based on the FY 2020 ICD-10-CM code revisions.

1/01/2019 92 Implement logic to bypass edit 92 when a device procedure is reported with modifier CG. The edit is bypassed only if the device procedure reported with modifier CG is on the “Edit 92 Modifier Bypass” list. See Device Dependent Procedure Editing and Processing in the I/OCE specification document attached to CR 11412 for more information.

7/01/2019 Update logic to Return Payer Value Code QW and the applicable Value Code amount on an adjusted Partial Hospitalization Program (PHP) interim claim, if Condition Code MW is supplied on input. See Partial Hospitalization and CMHC Processing logic in the I/OCE specifications for more information.

7/01/2019 110 Apply mid-quarter edit 110 (Service provided prior to initial marketing date) to HCPCS Q5107, if reported before 07/18/2019.

7/01/2019 22 Remove modifier CB from the list of Valid Modifiers retroactive to July 1, 20194/01/2019 13 Add edit 13 to the list of edits that can be bypassed when using the Contractor Bypass logic.1/01/2016 93 Update edit 93 to return a line item denial or rejection flag of 1, retroactive to its effective date

(1/1/2016).10/1/2019 Revised documentation on the processing action of HCPCS 94762 when it is reported without

critical care. See Critical Care Processing for documentation update.10/1/2019 Make all HCPCS/Ambulatory Payment Classification (APC)/Status Indicator (SI) changes as

specified by CMS (quarterly data files)yy Comprehensive APC Exclusion listyy Device Procedure lists (edit 92)yy Terminated Device Procedure for offset APCyy Edit 99 Exclusions listyy FQHC Non-Covered list

yy Non-Covered Service list (edit 9)yy Service not billable to the MAC (edit 72)yy Edit 92 Modifier bypass listyy Low cost skin substitute list (edit 87)

10/1/2019 20, 40 Implement version 25.3 of the NCCI (as modified for applicable outpatient institutional providers).

Additional InformationThe official instruction, CR 11412, issued to your MAC regarding this change, is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4383CP.pdf.



Document History

Date of Change DesscriptionSeptember 3, 2019 Initial article released.


http://www.cms.gov/OutpatientCodeEdit/





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MM11422 (Revised): Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - October 2019 Update

The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles

MLN Matters Number: MM11422 Revised Related Change Request (CR) Number: 11422 Related CR Release Date: September 17, 2019 Effective Date: October 1, 2019 Related CR Transmittal Number: R4396CP Implementation Date: October 7, 2019

Note: We revised this article on September 18, 2019, to reflect the revised CR11422 issued on September 17. The revised CR did not impact the content of the article. In the article, we revised the CR release date, transmittal number, and the Web address of the CR. All other information remains the same.

Provider Types AffectedThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for drug and biological services.

Provider Action NeededCR 11422 updates the HCPCS code set for codes related to drugs and biologicals. Make sure your billing staffs are aware of these updates.

BackgroundThe HCPCS code set is updated quarterly. CR 11422 informs MACs and providers of the latest updates to specific drug/biological HCPCS codes. The October 2019 quarterly HCPCS file includes forty-four (44) new HCPCS codes. Effective for claims with dates of service on or after October 1, 2019, you may use, as appropriate, the following HCPCS codes on claims for Medicare:

1. J0121a. Short Descriptor: Inj., omadacycline, 1 mgb. Long Descriptor: Injection, omadacycline, 1 mgc. Type of Service (TOS): 1,P

2. J0122a. Short Descriptor: Inj., eravacycline, 1 mgb. Long Descriptor: Injection, eravacycline, 1 mgc. TOS: 1,P

3. J0222a. Short Descriptor: Inj., patisiran, 0.1 mgb. Long Descriptor: Injection, Patisiran, 0.1 mgc. TOS: 1

4. J0291a. Short Descriptor: Inj., plazomicin, 5 mgb. Long Descriptor: Injection, plazomicin, 5 mgc. TOS: 1

5. J0593a. Short Descriptor: Inj., lanadelumab-flyo, 1 mgb. Long Descriptor: Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare

when drug administered under direct supervision of a physician, not for use when drug is self-administered)




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c. TOS: 1

6. J1096a. Short Descriptor: Dexametha opth insert 0.1 mgb. Long Descriptor: Dexamethasone, lacrimal ophthalmic insert, 0.1 mgc. TOS: 1

7. J1097a. Short Descriptor: Phenylep ketorolac opth solnb. Long Descriptor: Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic

irrigation solution, 1 mlc. TOS: 1

8. J1303a. Short Descriptor: Inj., ravulizumab-cwvz 10 mgb. Long Descriptor: Injection, ravulizumab-cwvz, 10 mgc. TOS: 1,P

9. J1943a. Short Descriptor: Inj., aristada initio, 1 mgb. Long Descriptor: Injection, aripiprazole lauroxil, (aristada initio), 1 mgc. TOS: 1

10. J1944a. Short Descriptor: Inj., aripirazole lauroxil 1 mgb. Long Descriptor: Injection, aripiprazole lauroxil, (aristada), 1 mgc. TOS: 1

11. J2798a. Short Descriptor: Inj., perseris, 0.5 mgb. Long Descriptor: Injection, risperidone, (perseris), 0.5 mgc. TOS: 1,P

12. J3031a. Short Descriptor: Inj., fremanezumab-vfrm 1 mgb. Long Descriptor: Injection, fremanezumab-vfrm, 1 mg (code may be used for

Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

c. TOS: 1, P

13. J3111a. Short Descriptor: Inj. romosozumab-aqqg 1 mgb. Long descriptor: Injection, romosozumab-aqqg, 1 mgc. TOS: 1

14. J7314a. Short Descriptor: Inj., yutiq, 0.01 mgb. Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Yutiq),

0.01 mgc. TOS: 1

15. J7331a. Short Descriptor: Synojoynt, inj., 1 mgb. Long Descriptor: Hyaluronan or derivative, synojoynt, for intra-articular injection,

1 mgc. TOS: 1

16. J7332a. Short Descriptor: Inj., triluron, 1 mgb. Long Descriptor: Hyaluronan or derivative, triluron, for intra-articular injection,

1 mgc. TOS: 1


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17. J7401a. Short Descriptor: Mometasone furoate sinus impb. Long Descriptor: Mometasone furoate sinus implant, 10 microgramsc. TOS: 1

18. J9118a. Short Descriptor: Inj. Calaspargase pegol-mknlb. Long Descriptor: Injection, calaspargase pegol-mknl, 10 unitsc. TOS: 1,P

19. J9119a. Short Descriptor: Inj., cemiplimab-rwlc, 1 mgb. Long Descriptor: Injection, cemiplimab-rwlc, 1 mgc. TOS: 1

20. J9204a. Short Descriptor: Inj, mogamulizumab-kpkc, 1 mgb. Long Descriptor: Injection, mogamulizumab-kpkc, 1 mgc. TOS: 1,P

21. J9210a. Short Descriptor: Inj., emapalumab-lzsg, 1 mgb. Long Descriptor: Injection, emapalumab-lzsg, 1 mgc. TOS: 1

22. J9269a. Short Descriptor: Inj. tagraxofusp-erzs 10 mcgb. Long Descriptor: Injection, tagraxofusp-erzs, 10 microgramsc. TOS: 1

23. J9313a. Short Descriptor: Inj., lumoxiti, 0.01 mgb. Long Descriptor: Injection, moxetumomab pasudotox-tdfk, 0.01 mgc. TOS: 1,P

24. Q4205a. Short Descriptor: Membrane graft or wrap sq cmb. Long Descriptor: Membrane graft or membrane wrap, per square centimeterc. TOS: 1

25. Q4206a. Short Descriptor: Fluid flow or fluid gf 1 ccb. Long Descriptor: Fluid flow or fluid GF, 1 ccc. TOS: 1

26. Q4208a. Short Descriptor: Novafix per sq cmb. Long Descriptor: Novafix, per square centimeterc. TOS: 1

27. Q4209a. Short Descriptor: Surgraft per sq cmb. Long Descriptor: Surgraft, per square centimeterc. TOS: 1

28. Q4210a. Short Descriptor: Axolotl graf dualgraf sq cmb. Long Descriptor: Axolotl graft or axolotl dualgraft, per square centimeterc. TOS: 1


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29. Q4211a. Short Descriptor: Amnion bio or axobio sq cmb. Long Descriptor: Amnion bio or Axobiomembrane, per square centimeterc. TOS: 1

30. Q4212a. Short Descriptor: Allogen, per ccb. Long Descriptor: Allogen, per ccc. TOS: 1

31. Q4213a. Short Descriptor: Ascent, 0.5 mgb. Long Descriptor: Ascent, 0.5 mgc. TOS: 1

32. Q4214a. Short Descriptor: Cellesta cord per sq cmb. Long Descriptor: Cellesta cord, per square centimeterc. TOS: 1

33. Q4215a. Short Descriptor: Axolotl ambient, cryo 0.1 mgb. Long Descriptor: Axolotl ambient or axolotl cryo, 0.1 mgc. TOS: 1

34. Q4216a. Short Descriptor: Artacent cord per sq cmb. Long Descriptor: Artacent cord, per square centimeterc. TOS: 1

35. Q4217a. Short Descriptor: Woundfix biowound plus xplusb. Long Descriptor: Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix

Xplus or BioWound Xplus, per square centimeterc. TOS: 1

36. Q4218a. Short Descriptor: Surgicord per sq cmb. Long Descriptor: Surgicord, per square centimeterc. TOS: 1

37. Q4219a. Short Descriptor: Surgigraft dual per sq cmb. Long Descriptor: Surgigraft-dual, per square centimeterc. TOS: 1

38. Q4220a. Short Descriptor: Bellacell HD, Surederm sq cmb. Long Descriptor: BellaCell HD or Surederm, per square centimeterc. TOS: 1

39. Q4221a. Short Descriptor: Amniowrap2 per sq cmb. Long Descriptor: Amniowrap2, per square centimeterc. TOS: 1

40. Q4222a. Short Descriptor: Progenamatrix, per sq cmb. Long Descriptor: Progenamatrix, per square centimeterc. TOS: 1


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41. Q4226a. Short Descriptor: Myown harv prep proc sq cmb. Long Descriptor: MyOwn skin, includes harvesting and preparation procedures,

per square centimeterc. TOS: 1

42. Q5116a. Short Descriptor: Inj., trazimera, 10 mgb. Long Descriptor: Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mgc. TOS: 1,P

43. Q5117a. Short Descriptor: Inj., kanjinti, 10 mgb. Long Descriptor: Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mgc. TOS: 1,P

44. Q5118a. Short Descriptor: Inj., zirabev, 10 mgb. Long Descriptor: Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mgc. TOS: 1,P

HCPCS codes J1942 (Aripiprazole lauroxil 1mg/Injection, aripiprazole lauroxil, 1 mg) and S1090 (Mometasone sinus implant/Mometasone furoate sinus implant, 370 micrograms) are being discontinued effective October 1, 2019; and may not be used in submitting claims to Medicare with dates of service on or after that date.

Effective for claims with dates of service on or after October 1, 2019, the long and short descriptors for the following HCPCS codes will be modified. The TOS and all other indicators will remain the same.

1. J0641a. New Short Descriptor: Inj., levoleucovorin, 0.5 mgb. New Long Descriptor: Injection, levoleucovorin, 0.5 mg

2. J2794a. New Short Descriptor: Inj., risperdal consta, 0.5 mgb. New Long Descriptor: Injection, risperidone (risperdal consta), 0.5 mg

3. J7311a. New Short Descriptor: Inj., retisert, 0.01 mgb. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (retisert),

0.01 mg

4. J7313a. New Short Descriptor: Inj., iluvien, 0.01 mgb. New Long Descriptor: Injection, fluocinolone acetonide, intravitreal implant (Iluvien),

0.01 mg

5. Q4122a. New Short Descriptor: Dermacell, awm, porous sq cmb. New Long Descriptor: Dermacell, dermacell awm or dermacell awm porous,

per square centimeter

6. Q4165a. New Short Descriptor: Keramatrix, Kerasorb sq cmb. New Long Descriptor: Keramatrix or kerasorb, per square centimeter

7. Q4184a. New Short Descriptor: Cellesta or duo per sq cmb. New Long Descriptor: Cellesta or cellesta duo, per square centimeter


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Additional InformationThe official instruction, CR 11422, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4396CP.pdf.



Document History

Date of Change DesscriptionSeptember 18 2019 We revised the article to reflect the revised CR11422 issued on September 17. The

revised CR had no impact on the content of the article. In the article, we revised the CR release date, transmittal number, and the Web address of the CR. All other information remains the same.

August 16 2019 Initial article released.


MM11433: October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule


MLN Matters Number: MM11433 Related Change Request (CR) Number: 11433 Related CR Release Date: August 30, 2019 Effective Date: September 1, 2019 for Related CR Transmittal Number: R4386CP October 1, 2019 for all other changes Implementation: October 7, 2019 implementation of fees for code E0766;

Provider Types AffectedThis MLN Matters® Article is for providers and suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items or services that Medicare pays for under the DMEPOS fee schedule.

What You Need to KnowCR 11433 informs DME MACs about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. Make sure your billing staff are aware of these changes.

BackgroundSections 1834(a), (h), and (i) of the Social Security Act (the Act) requires payment on a fee schedule basis for DMEPOS and surgical dressings. Also, payment on a fee schedule basis is a regulatory requirement at 42 Code of Federal Regulations (CFR) Section 414.102 for Parenteral and Enteral Nutrition (PEN), splints, casts, and Intraocular Lenses (IOLs) inserted in a physician’s office (https://www.govinfo.gov/app/details/CFR-2012-title42-vol3/CFR-2012-title42-vol3-sec414-102). The DMEPOS and PEN fee schedule files contain HCPCS codes subjected to the adjusted fee schedule amounts under Section 1834(a)(1)








https://www.govinfo.gov/app/details/CFR-2012-title42-vol3/CFR-2012-title42-vol3-sec414-102

https://www.govinfo.gov/app/details/CFR-2012-title42-vol3/CFR-2012-title42-vol3-sec414-102

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(F) of the Act as well as codes not subject to the fee schedule Competitive Bidding Program (CBP) adjustments.

Fee Schedule Adjustment MethodsSection 1834(a)(1)(F)(ii) of the Act requires adjustments to the fee schedule amounts for certain items furnished on or after January 1, 2016, in areas that are not competitive bid areas based on information from CBPs for DME. Section 1842(s)(3)(B) of the Act provides authority for making adjustments to the fee schedule amount for enteral nutrients, equipment, and supplies (enteral nutrition) based on information from CBPs.

The methods for adjusting DMEPOS fee schedule amounts under this authority are at 42 CFR Section 414.210(g). Additional information on adjustments to the fee schedule amounts based on information from CBPs is available in:

1. Transmittal 3551, Change Request (CR) 9642, June 23, 2016: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9642.pdf

2. Transmittal 3416, CR 9431, November 23, 2015: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9431.pdf

3. Transmittal 4209, CR 11064, January 18, 2019: See related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11064.pdf Also, CR 11064 provides information on the adjusted fee payment basis for items and services furnished from January 1, 2019,through December 31, 2020, in the following three areas:

- Rural and noncontiguous non-Competitive Bidding Areas (CBAs)

- Non-rural and contiguous non-CBAs

- Former CBAs during a temporary gap in the DMEPOS CBP

Because of a delay in the announcement of the next round of the CBP, contracts will not be in effect in Round 1, Round 2, or the National Mail Order CBAs beginning January 1, 2019, resulting in a temporary gap period in the CBP. Additional program instructions for payment of items furnished in former CBAs is available in Transmittal 4275, CR 11233, and dated April 5, 2019. See the related article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11233.pdf.

Fee Schedule and ZIP Code FilesCR 11433 provides instructions for the October 2019 DMEPOS Rural ZIP code file containing the Quarter 4 2019 Rural ZIP code changes. Also, in the update is the Former CBA ZIP code file containing the Quarter 4, 2019, Round 1 2017, and Round 2 Re-compete CBA ZIP codes.

The ZIP code associated with the address used for pricing a DMEPOS claim determines the rural fee schedule payment applicability for codes with rural and non-rural adjusted fee schedule amounts. The DMEPOS Rural ZIP code file contains the ZIP codes designated as rural areas. ZIP codes for non-continental Metropolitan Statistical Areas (MSAs) are not included in the DMEPOS Rural ZIP code file. Medicare updates the DMEPOS Rural ZIP code file quarterly on an as-needed basis. Regulations at 42 CFR Section 414.202 define a rural area to be a geographical area represented by a postal ZIP code where at least 50 percent of the total geographical area of the ZIP code is estimated to be outside any MSA. A rural area also includes any ZIP Code within an MSA excluded from a CBA established for that MSA.

The ZIP code associated with the permanent address of the beneficiary determines the applicability of the adjusted fee schedule amounts in former CBAs. During a gap in the CBP, a former CBA ZIP code file will contain the ZIP codes for Round 1 2017 and Round 2 Re-compete CBAs and will be updated on a quarterly basis as necessary.

The following DMEPOS fee schedule and ZIP code Public Use Files (PUFs) will be available for State Medicaid Agencies, managed care organizations, and other interested


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9642.pdf










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parties shortly after the release of the data files on the CMS Website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/index.html

1. DMEPOS FeeschedulePUF2. DME PEN FeeschedulePUF3. DME RuralcodePUF4. Former CBA FeeschedulePUF5. Former CBA National Mail Order Diabetic Testing Supply (DTS) FeeschedulePUF6. Former CBA ZIPcodePUF

Specific Coding and Pricing IssuesAs part of this update, the fee schedule amounts for the HCPCS code E0766 (electrical stimulation device used for cancer treatment, includes all accessories, any type) is included in the DMEPOS fee schedule file effective September 1, 2019. Suppliers should add the Class III ‘KF’ modifier when billing HCPCS code E0766.




Document History



MM11441: 2020 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update


MLN Matters Number: MM11441 Related Change Request (CR) Number: 11441 Related CR Release Date: August 30, 2019 Effective Date: January 1, 2020 Related CR Transmittal Number: R4385CP Implementation Date: January 6, 2020

Provider Types AffectedThis MLN Matters Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice (HH&H) MACs and Durable Medical Equipment (DME) MACs, for services provided to Medicare beneficiaries who are in a Part A covered Skilled Nursing Facility (SNF) stay.

Provider Action NeededCR 11441 makes changes to HCPCS codes and Medicare Physician Fee Schedule (MPFS) designations that will be used to revise Medicare’s Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/index.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/index.html







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Consolidated Billing (CB) in Chapter 6, Section 110.4.1 and Chapter 6, Section 20.6 in the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf). Make sure your billing staffs are aware of these changes.

BackgroundCWF currently has edits in place for claims received for beneficiaries in a Part A covered SNF stay, as well as for beneficiaries in a non-covered stay. These edits allow only those services excluded from CB to be separately paid. Barring any delay in the MPFS, the Centers for Medicare & Medicaid Services (CMS) will provide the new code files to CWF by November 1, 2019.

As soon as possible after the final MPFS is released, CMS will post the new code files at http://www.cms.gov/SNFConsolidatedBilling/. It is important and necessary for the provider/MAC community to view the “General Explanation of the Major Categories” file located at the bottom of each year’s update in order to understand the Major Categories including additional exclusions not driven by HCPCS codes.

Additional InformationThe official instruction, CR11441, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4385CP.pdf.



Document History



MM11451: October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)


MLN Matters Number: MM11451 Related Change Request (CR) Number: 11451 Related CR Release Date: August 30, 2019 Effective Date: October 1, 2019 Related CR Transmittal Number: R4387CP Implementation Date: October 7, 2019

Provider Types AffectedThis MLN Matters article is for hospital outpatient facilities, physicians, providers, including home health and hospice providers, and suppliers billing Medicare Administrative Contractors (MACs) for hospital outpatient services provided to Medicare beneficiaries.

Provider Action NeededCR 11451 describes changes to and billing instructions for various payment policies that Medicare is implementing in the October 2019 Outpatient Prospective Payment System (OPPS) update. Make sure your billing staffs are aware of these changes.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c06.pdf

http://www.cms.gov/SNFConsolidatedBilling/







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BackgroundThe October 2019 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 11451.

The October 2019 revisions to I/OCE data files, instructions, and specifications are provided in the October 2019 I/OCE CR, which will be available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R4383CP.pdf.

1. CPT Proprietary Laboratory Analyses (PLA) Coding Changes Effective Oct 1, 2019The American Medical Association (AMA) CPT Editorial Panel deleted one PLA code (0104U) and established 34 new PLA codes (CPT codes 0105U-0138U), effective October 1, 2019. Table 1 lists the long descriptors and status indicators for the codes.

For more information on OPPS status indicators “A,” “D,” “E1,” “N,” and “Q4,” refer to OPPS Addendum D1 (https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1695-FC-2019-OPPS-FR-Addenda.zip) of the Calendar Year (CY) 2019 OPPS/ASC final rule for the latest definitions. CPT codes 0105U-0138U are in the October 2019 I/OCE with an effective date of October 1, 2019.

Table 1: Newly Established PLA CodesCPT Code Long Descriptor

OPPS SI

OPPS APC

0104U Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (32 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only])

D N/A

0105U Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD)

Q4 N/A

0106U Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13CO2 excretion

Q4 N/A

0107U Clostridium difficile toxin(s) antigen detection by immunoassay technique, stool, qualitative, multiple-step method

Q4 N/A

0108U Gastroenterology (Barrett’s esophagus), whole slide–digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX-2, CD45RO, HIF1a, HER-2, K20) and morphology, formalin-fixed paraffin-embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer

Q4 N/A

0109U Infectious disease (Aspergillus species), real-time PCR for detection of DNA from 4 species (A. fumigatus, A. terreus, A. niger, and A. flavus), blood, lavage fluid, or tissue, qualitative reporting of presence or absence of each species

A N/A

0110U Prescription drug monitoring, one or more oral oncology drug(s) and substances, definitive tandem mass spectrometry with chromatography, serum or plasma from capillary blood or venous blood, quantitative report with steady-state range for the prescribed drug(s) when detected

Q4 N/A

0111U Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed paraffin-embedded tissue

A N/A

0112U Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene

A N/A

0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score

A N/A




https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1695-FC-2019-OPPS-FR-Addenda.zip



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OPPS SI

OPPS APC

0114U Gastroenterology (Barrett’s esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett’s esophagus

A N/A

0115U Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets, amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected

A N/A

0116U Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with LC-MS/MS, oral fluid, algorithm results reported as a patient-compliance measurement with risk of drug to drug interactions for prescribed medications

Q4 N/A

0117U Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain

Q4 N/A

0118U Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA

A N/A

0119U Cardiology, ceramides by liquid chromatography–tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events

Q4 N/A

0120U Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter

A N/A

0121U Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood Q4 N/A0122U Sickle cell disease, microfluidic flow adhesion (P-Selectin), whole blood Q4 N/A0123U Mechanical fragility, RBC, shear stress and spectral analysis profiling Q4 N/A0124U Fetal congenital abnormalities, biochemical assays of 3 analytes (free beta-hCG,

PAPP-A, AFP), time-resolved fluorescence immunoassay, maternal dried-blood spot, algorithm reported as risk scores for fetal trisomies 13/18 and 21

E1 N/A

0125U Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, maternal serum, algorithm reported as risk scores for fetal trisomies 13/18, 21, and preeclampsia

Q4 N/A

0126U Fetal congenital abnormalities and perinatal complications, biochemical assays of 5 analytes (free beta-hCG, PAPP-A, AFP, placental growth factor, and inhibin-A), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk scores for fetal trisomies 13/18, 21, and preeclampsia

Q4 N/A

0127U Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia

Q4 N/A

0128U Obstetrics (preeclampsia), biochemical assays of 3 analytes (PAPP-A, AFP, and placental growth factor), time-resolved fluorescence immunoassay, includes qualitative assessment of Y chromosome in cell-free fetal DNA, maternal serum and plasma, predictive algorithm reported as a risk score for preeclampsia

Q4 N/A

0129U Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and eletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53)

A N/A

0130U Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure)

N N/A


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OPPS SI

OPPS APC

0131U Hereditary breast cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure)

N N/A

0132U Hereditary ovarian cancer–related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure)

N N/A

0133U Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)

N N/A

0134U Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure)

N N/A

0135U Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure)

N N/A

0136U ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

0137U PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure)

N N/A

2. New CPT Category II Codes Effective October 1, 2019For the October 2019 update, the Centers for Medicare & Medicaid Services (CMS) is implementing five new CPT Category II codes that the AMA released on July 8, 2019, for implementation on October 1, 2019. New CPT codes 2023F, 2025F, 2033F, 3051F, and 3052F are in the October 2019 I/OCE with an effective date of October 1, 2019.

Also, the AMA is revising the code descriptors for CPT codes 2022F, 2024F, 2026F, and deleting 3045F on September 30, 2019. The status indicators and APC assignments for the codes are shown in Table 2 These codes, along with their short descriptors, status indicators, and payment rates are listed in the October 2019 OPPS Addendum B that is posted at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html. For information on the OPPS status indicator “M”, refer to OPPS Addendum D1 of the CY 2019 OPPS/ASC final rule for the latest definition.

Table 2: New, Revised, and Deleted CPT Category II CodesCPT Code Status Long Descriptor

OPPS SI

OPPS APC

2022F REVISE Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)2

M N/A

2023F NEW Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)2

M N/A

2024F REVISE 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)2

M N/A

2025F NEW 7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM)2

M N/A

2026F REVISE Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (DM)2

M N/A


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html



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Table 2: New, Revised, and Deleted CPT Category II CodesCPT Code Status Long Descriptor

OPPS SI

OPPS APC

2033F NEW Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy (DM)2

M N/A

3045F DELETE Most recent hemoglobin A1c (HbA1c) level 7.0–9.0% (DM) D N/A3051F NEW Most recent hemoblobin A1c (HbA1c) level greater than or equal to 7.0% and

less than 8.0% (DM)M N/A

3052F NEW Most recent hemoblobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% (DM)2

M N/A

3. Advanced Diagnostic Laboratory Tests (ADLT) Under the Clinical Lab Fee Schedule (CLFS)

On May 17, 2019, CMS announced the approval of three laboratory tests as ADLTs under paragraph (1) of the definition of an ADLT in 42 CFR Section 414.502. CMS notes that under the OPPS, tests that receive ADLT status under Section 1834A(d)(5)(A) of the Social Security Act (the Act) are assigned to status indicator “A.” These laboratory tests are listed in Table 3.

Based on the ADLT designation, CMS revised the OPPS status indicator for HCPCS codes 0080U and 81599 to “A” (Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS) effective July 1, 2019. However, because the ADLT designation was made in May 2019, it was too late to include this change in the July 2019 I/OCE Release and the July 2019 OPPS update; therefore, we are including this change in the October 2019 I/OCE Release with an effective date of July 1, 2019.

Note that the DecisionDx-UM test, as described by HCPCS code 0081U, was also approved for ADLT status on May 17, 2019, however it was already assigned OPPS SI “A” based on being a molecular pathology test.

The latest list of ADLTs under the CLFS is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/List-of-Approved-ADLTs.pdf. For more information on the OPPS status indicator “A”, refer to OPPS Addendum D1 of the CY 2019 OPPS/ASC final rule for the latest definitions.

Table 3: ADLT Codes and Long DescriptorsLab Name Test Name CPT Code CPT Code Long DescriptorBiodesix BDX-XL2 0080U Oncology (lung), mass spectrometric analysis of galectin-

3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy

Castle BioSciences, Inc.

DecisionDX-Melanoma

81599* Unlisted multianalyte assay with algorithmic analysis

Castle BioSciences, Inc.

DecisionDx-UM

0081U Oncology (uveal melanoma), mRNA, gene-expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping genes), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis.

* DecisionDx-Melanoma is currently described by HCPCS codes 81599 and identifier ZB1D4.

4. Drugs, Biologicals, and Radiopharmaceuticalsa. HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and

Radiopharmaceuticals with Pass-through Status


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/List-of-Approved-ADLTs.pdf



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For October 2019, two HCPCS codes have received pass-through status for reporting drugs and biologicals in the hospital outpatient setting. These new codes are in Table 4.

Table 4: Codes Receiving Pass-Through StatusHCPCS Code Long Descriptor SI APCJ3111 Injection, romosozumab-aqqg, 1 mg G 9327J9356 Injection, trastuzumab, 10 mg and Hyaluronidase-oysk G 9314

b. Separately Payable Drugs and Biologicals that Will Receive Pass-Through Status (Status Indicator = “G”) for the Period of April 1, 2019, Through June 30, 2019

The status indicator for HCPCS code C9042 (Injection, bendamustine hcl (belrapzo), 1 mg) for the period of April 1, 2019, through June 30, 2019, will be changed retroactively from status indicator = “E2” to status indicator = “G.” This drug is in Table 5.

Table 5: C9042 Updated Status IndicatorHCPCS Code Long Descriptor Old SI New SI APCC9042 Injection, bendamustine hcl (belrapzo), 1 mg E2 G 9313

c. Drugs and Biologicals that Will Change from Non-Payable Status (Status Indicator = “E2”) to Separately Payable Status (Status Indicator = “K”) for the Period of July 18, 2019, through September 30, 2019

The status indicator for HCPCS code Q5107 (Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg) for the period of July 18, 2019, through September 30, 2019, will be changed retroactively from status indicator = “E2” to status indicator = “K”. This drug is in Table 6.

Table 6: Q5107 Updated Status IndicatorHCPCS Code Long Descriptor Old SI New SI APCQ5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg E2 K 9329

d. New Established HCPCS Codes for Drugs, Biologicals, and Radiopharmaceuticals as of October 1, 2019

There are 45 new drug, biological, and radiopharmaceutical HCPCS codes that will be established on October 1, 2019. The new codes are in Table 7.

Table 7: New Drug, Biological, and Radiopharmaceutical Codes to be Established on October 1, 2019New HCPCS Code Old HCPCS Code Long Descriptor SI APCJ1943 C9035 Injection, aripiprazole lauroxil (aristada initio), 1 mg G 9179J0222 C9036 Injection, Patisiran, 0.1 mg G 9180J2798 C9037 Injection, risperidone, (perseris), 0.5 mg G 9181J9204 C9038 Injection, mogamulizumab-kpkc, 1 mg G 9182J0291 C9039 Injection, plazomicin, 5 mg G 9183J3031 C9040 Injection, fremanezumab-vfrm, 1 mg (code may be

used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

G 9197

J0641 C9043 Injection, levoleucovorin, 0.5 mg G 9323J9119 C9044 Injection, cemiplimab-rwlc, 1 mg G 9304J9313 C9045 Injection, moxetumomab pasudotox-tdfk, 0.01 mg G 9305J1096 C9048 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg G 9308J9269 C9049 Injection, tagraxofusp-erzs, 10 micrograms G 9309J9210 C9050 Injection, emapalumab-lzsg, 1 mg G 9310


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Table 7: New Drug, Biological, and Radiopharmaceutical Codes to be Established on October 1, 2019New HCPCS Code Old HCPCS Code Long Descriptor SI APCJ0121 C9051 Injection, omadacycline, 1 mg G 9311J1303 C9052 Injection, ravulizumab-cwvz, 10 mg G 9312J1097 C9447 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/

ml ophthalmic irrigation solution, 1 mlG 9324

J0122 Injection, eravacycline, 1 mg K 9325J0593 Injection, lanadelumab-flyo, 1 mg (code may be

used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)

K 9326

J1944 J1942 Injection, aripiprazole lauroxil, (aristada), 1 mg K 9470J7314 Injection, fluocinolone acetonide, intravitreal implant

(Yutiq), 0.01 mgK 9328

J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg

E2 N/A

J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg

E2 N/A

J9118 Injection, calaspargase pegol-mknl, 10 units E2 N/AQ4205 Membrane graft or membrane wrap, per square

centimeterN N/A

Q4206 Fluid flow or fluid GF, 1 cc N N/AQ4208 Novafix, per square centimeter N N/AQ4209 Surgraft, per square centimeter N N/AQ4210 Axolotl graft or axolotl dualgraft, per square

centimeterN N/A

Q4211 Amnion bio or Axobiomembrane, per square centimeter

N N/A

Q4212 Allogen, per cc N N/AQ4213 Ascent, 0.5 mg N N/AQ4214 Cellesta cord, per square centimeter N N/AQ4215 Axolotl ambient or axolotl cryo, 0.1 mg N N/AQ4216 Artacent cord, per square centimeter N N/AQ4217 Woundfix, BioWound, Woundfix Plus, BioWound

Plus, Woundfix Xplus or BioWound Xplus, per square centimeter

N N/A

Q4218 Surgicord, per square centimeter N N/AQ4219 Surgigraft-dual, per square centimeter N N/AQ4220 BellaCell HD or Surederm, per square centimeter N N/AQ4221 Amniowrap2, per square centimeter N N/AQ4222 Progenamatrix, per square centimeter N N/AQ4226 MyOwn skin, includes harvesting and preparation

procedures, per square centimeterN N/A

Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

K 9329

Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg

E2 N/A

Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg

K 9330

Q5118 Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mg

E2 N/A

J7401 S1090 Mometasone furoate sinus implant, 10 micrograms N N/A


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e. Ambulatory Payment Classification (APC) Assignment Change for HCPCS code J9030, BCG live intravesical instillation, 1 mg, Effective July 1, 2019, in the October 2019 I/OCE Release

See Table 8 for the APC assignment change for HCPCS code, J9030, effective July 1, 2019, in the October 2019 I/OCE Release.

Table 8: J9030 – APC Assignment ChangeHCPCS Code Long Descriptor Old APC Assignment New APC Assignment Effective DateJ9030 BCG live intravesical instillation, 1 mg 0809 9322 07/01/19

f. Drugs and Biologicals with Payments Based on Average Sales Price (ASP)

For CY 2019, payment for nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that were not acquired through the 340B Program is made at a single rate of ASP + 6 percent (or ASP - 22.5 percent if acquired under the 340B Program), which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug, biological, or therapeutic radiopharmaceutical. In CY 2019, a single payment of ASP + 6 percent for pass-through drugs, biologicals, and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items.

Payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later-quarter ASP submissions become available. Effective October 1, 2019, payment rates for some drugs and biologicals have changed from the values published in the July 2019 update of the OPPS Addendum A and Addendum B. CMS is not publishing the updated payment rates in this CR implementing the October 2019 update of the OPPS. However, the updated payment rates effective October 1, 2019, can be found in the October 2019 update of the OPPS Addendum A and Addendum B on the CMS website at http://www.cms.gov/HospitalOutpatientPPS/.

g. Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates

Some drugs and biologicals based on ASP methodology will have payment rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis. The list of drugs and biologicals with corrected payments rates will be accessible on the CMS website on the first date of the quarter at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates.html. Providers may resubmit claims that were impacted by adjustments to previous quarter’s payment files.

5. Clarification on the Guidance for Intraocular or Periocular Injections of Combinations of Anti- Inflammatory Drugs and Antibiotics

On September 15, 2015, CMS issued CR 9298 (Transmittal R3352CP), which provided guidance for “dropless cataract surgery.” ( See related MLN Matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9298.pdf. CR 11451 is a clarification to CR 9298 on “dropless cataract surgery.” Intraocular or periocular injections of combinations of anti-inflammatory drugs and antibiotics are being used with increased frequency in ocular surgery (primarily cataract surgery). One example of combined or compounded drugs includes, triamcinolone and moxifloxacin with or without vancomycin. Such combinations may be administered as separate injections or as a single combined injection. Because such injections may obviate the need for post-operative anti-inflammatory and antibiotic eye drops, some have referred to cataract surgery with such injections as “dropless cataract surgery.” However, nothing in this CR is intended to preclude physicians or other professionals from discussing the potential benefits and drawbacks of dropless therapy with their patients and prescribing it if the patient so elects.


http://www.cms.gov/HospitalOutpatientPPS/

http://www.cms.gov/HospitalOutpatientPPS/

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/OPPS-Restated-Payment-Rates.html





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6. OPPS Pricer logic and data changes for OctoberThere are no OPPS PRICER logic or data changes for October; therefore, there is no OPPS PRICER release for October.

7. Coverage DeterminationsAs a reminder, the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.




Document History



Provider Contact Center (PCC) Training

Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs). The list below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will be closed for training.

Date PCC Training/ClosuresMonday, November 11, 2019 - Veterans Day PCC Closed, 8:00 a.m.– 4:30 p.m. Central Time

The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For additional information, go to https://www.cgsmedicare.com/hhh/index.html and click the “myCGS” button on the left side of the Web page.

For your reference, access the “Home Health & Hospice 2019 Holiday/Training Closure Schedule” at https://www.cgsmedicare.com/hhh/help/pdf/2019_hhh_calendar.pdf for a complete list of PCC closures.






https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf

https://www.cgsmedicare.com/hhh/index.html

https://www.cgsmedicare.com/hhh/help/pdf/2019_hhh_calendar.pdf

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SE19018: Hurricane Dorian and Medicare Disaster Related State of Florida Claims


MLN Matters Number: SE19018 Related Change Request (CR) Number: N/A Article Release Date: September 3, 2019 Effective Date: N/A Related CR Transmittal Number: N/A Implementation Date: N/A

Provider Types AffectedThis MLN Matters® Special Edition Article is for providers and suppliers who bill Medicare Fee-For-Service (FFS).

Provider Information AvailableThe Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the State of Florida on August 30, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 28, 2019, and are in effect for 90 days.

The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the disaster/emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.

More Information:

yy Current Emergencies Web page (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.html)

yy Instructions to request an individual waiver if there is no blanket waiver (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf)

Background

Section 1135 and Section 1812(f) WaiversAs a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.

2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.

Medicare FFS Questions & Answers (Q&As) available on the Waivers and Flexibilities Web page (https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities.html) apply to items and services for Medicare beneficiaries in the current disaster or emergency. These Q&As are displayed in two files:

yy Q&As that apply without any Section 1135 or other formal waiver. (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf)

yy Q&As apply only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver. (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf)




https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.html


https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf



https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities.html


https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf



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Blanket Waivers Issued by CMSYou do not need to apply for the following approved blanket waivers:

Skilled Nursing Facilities (SNFs)yy Section 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).

yy 42 CFR 483.20: This waiver provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission (Blanket waiver for all impacted facilities).

Home Health Agenciesyy 42 CFR 484.20(c)(1): This waiver provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Blanket waiver for all impacted agencies).

yy To ensure the correct processing of home health disaster related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs).

Critical Access HospitalsThis action waives the requirements that Critical Access Hospitals limit the number of beds to 25, and that the length of stay be limited to 96 hours. (Blanket waiver for all impacted hospitals)

Housing Acute Care Patients In Excluded Distinct Part UnitsCMS has determined it is appropriate to issue a blanket waiver to inpatient prospective payment system (IPPS) hospitals that, as a result of disaster or emergency, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. The IPPS hospital should bill for the care and annotate the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit because of capacity issues related to the disaster or emergency. (Blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients.)

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective


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payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.

Emergency Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or DisasterCMS has determined it is appropriate to issue a blanket waiver where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the disaster or emergency.

For more information refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for Medicare Beneficiaries Impacted by an Emergency or Disaster fact sheet at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf.

Extension for Medicare Geographic Classification Review Board (MGCRB) ApplicationsCMS has granted an extension to the deadline of application re-classification requirements located at 42 CFR § 412.256 for the affected areas due to the disaster or emergency. Applications for reclassifications from hospitals in these areas must be received by the MGCRB not later than October 1, 2019.

Extension for Inpatient Prospective Payment System (IPPS) Wage Index RevisionsAllows Hospital Wage Index Development Time Table for hospitals in a disaster or emergency area to request revisions to and provide documentation for their Worksheet S-3 wage data and occupational mix data as included in the preliminary Public Use Files (PUFs), respectively.

CMS has granted an extension for hospitals in the affected area. MACs must receive the revision requests and supporting documentation by October 1, 2019. If hospitals encounter difficulty meeting this extended deadline, hospitals should communicate their concerns to CMS via their MAC, and CMS may consider an additional extension if CMS determines it is warranted.

Medicare Advantage Plan or other Medicare Health Plan BeneficiariesCMS reminds suppliers that Medicare beneficiaries enrolled in a Medicare Advantage or other Medicare Health Plans should contact their plan directly to find out how it replaces DMEPOS damaged or lost in an emergency or disaster. Beneficiaries who do not have their plan’s contact information can contact 1.800.MEDICARE (1.800.633.4227) for assistance.

Replacement Prescription FillsMedicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.

Additional InformationIf you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.



https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Emergency-DME-Beneficiaries-Hurricanes.pdf




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The Centers for Disease Control and Prevention released ICD-10-CM coding advice (https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdf) to report healthcare encounters.

Providers may also want to review the CMS Emergency and Preparedness Web page at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.html.

Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html.

Document History



SE19019: Hurricane Dorian and Medicare Disaster Related States of Georgia and South Carolina Claims




Provider Information AvailableThe Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the States of Georgia and South Carolina on September 2, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to August 29, 2019, for Georgia, and retroactive to August 31, 2019, for South Carolina. The PHE is in effect for 90 days.


More Information:



Background



https://www.cdc.gov/nchs/data/icd/Hurricane_coding_guidance.pdf

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html









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yy Q&As that apply without any Section 1135 or other formal waiver (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf).

yy Q&As apply only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf).








Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of







https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf


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a disaster or emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.



Extension for Medicare Geographic Classification Review Board (MGCRB) Applications CMS has granted an extension to the deadline of application re-classification requirements located at 42 CFR § 412.256 for the affected areas due to the disaster or emergency. Applications for reclassifications from hospitals in these areas must be received by the MGCRB not later than October 1, 2019.






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Document History



SE19020: Hurricane Dorian and Medicare Disaster Related State of North Carolina Claims




Provider Information AvailableThe Secretary of the Department of Health & Human Services declared a Public Health Emergency (PHE) in the State of North Carolina on September 4, 2019, and authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to September 1, 2019, and are in effect for 90 days.










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More Information:



Background





yy Q&As that apply without any Section 1135 or other formal waiver. (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf)

yy Q&As apply only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf).



















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Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for.

Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a HospitalCMS has determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit. The hospital should continue to bill for inpatient rehabilitation services under the inpatient rehabilitation facility prospective payment system for such patients and annotate the medical record to indicate the patient is a rehabilitation inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the disaster or emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate for providing care to rehabilitation patients, and such patients continue to receive intensive rehabilitation services.






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Extension for Medicare Geographic Classification Review Board (MGCRB) ApplicationsCMS has granted an extension to the deadline of application re-classification requirements located at 42 CFR § 412.256 for the affected areas due to the disaster or emergency. Applications for reclassifications from hospitals in these areas must be received by the MGCRB not later than October 1, 2019.










Document History









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SE19022: 2019-2020 Influenza (Flu) Resources for Health Care Professionals



Provider Types AffectedAll health care professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries and submit bills for these services to Medicare Administrative Contractors (MACs).

Provider Action NeededSpecial Edition (SE) MLN Matters article SE19022 provides information about influenza (flu) resources for health care professionals and providers relevant to the 2019-2020 flu season. Health care professionals should:

yy Keep this article and refer to it throughout the 2019-2020 flu season.

yy Take advantage of each office visit as an opportunity to encourage patients to protect themselves from the flu and serious complications by getting a flu shot.

yy Continue to provide the flu shot if you have vaccine available, even after the new year.

yy Remember to immunize yourself and your staff.

BackgroundThe Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare Part B reimburses health care providers for flu vaccines and their administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies).

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious complications by using every office visit as an opportunity to recommend they take advantage of Medicare’s coverage of the annual flu shot. As a reminder, please help prevent the spread of the flu by immunizing yourself and your staff! Know What to Do About the Flu!

Payment Rates for 2019-2020Each year, CMS updates the Medicare Healthcare Common Procedure Coding System (HCPCS) and Current Procedure Terminology (CPT) codes and payment rates for personal flu and pneumococcal vaccines. Payment allowance limits for such vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). In these cases, the payment for the vaccine is based on reasonable cost.

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.

The following table contains the applicable Medicare Part B payment allowances for HCPCS and CPT codes:




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Code Labeler Name Drug Names Payment Allowance Effective Dates

90653 Seqirus Inc Fluad (2019/2020) $59.530 08/01/2019 – 07/31/202090662 Sanofi Pasteur Fluzone High-Dose (2019/2020) $56.006 08/01/2019 – 07/31/202090672 MedImmune FluMist Quadrivalent (2019/2020) $26.876 08/01/2019 – 07/31/202090674 Seqirus Inc Flucelvax Quadrivalent (2019/2020) (Pres Free) $28.130 08/01/2019 – 07/31/202090682 Sanofi Pasteur Flublok Quadrivalent (2019/2020) $56.006 08/01/2019 – 07/31/202090685 Sanofi Pasteur

Seqirus IncFluzone Quadrivalent 0.25ml (2019/2020) (Pres Free),Afluria Quadrivalent 0.25ml (2019/2020) (Pres Free)

$20.343 08/01/2019 – 07/31/2020

90686 GlaxoSmithKlineSeqirus IncSanofi Pasteur

Fluarix Quadrivalent (2019/2020) (Pres Free), Flulaval Quadrivalent (2019/2020) (Pres Free), Fluzone Quadrivalent (2019/2020) (Pres Free), Afluria Quadrivalent (2019/2020) (Pres Free)

$19.032 08/01/2019 – 07/31/2020

90687 Sanofi PasteurSeqirus Inc

Fluzone Quadrivalent 0.25ml (2019/2020),Afluria Quadrivalent 0.25ml (2019/2020)

$9.403 08/01/2019 – 07/31/2020

90688 GlaxoSmithKlineSeqirus IncSanofi Pasteur

Flulaval Quadrivalent (2019/2020), Fluzone Quadrivalent (2019/2020), Afluria Quadrivalent (2019/2020)

$17.835 08/01/2019 – 07/31/2020

90756 Seqirus Flucelvax Quadrivalent (2019/2020) $26.657 08/01/2019 – 07/31/2020

If the Food and Drug Administration approves any new vaccine after publication of this article, CMS will post the payment limits and effective dates for those vaccines at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

Background on influenza vaccine payment allowances for 2019/2020 is in MM11428, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11428.pdf.

Note: MACs will reprocess any previously processed and paid claims for the current flu season that were paid using influenza vaccine payment allowances other than the allowanced published in the influenza vaccine pricing website for the 2019/2020 season that began on August 1, 2019. This reprocessing should occur by November 1, 2019.



Educational Products for Health Care ProfessionalsThe Medicare Learning Network® (MLN) has developed a variety of educational resources to help you understand Medicare guidelines for seasonal flu vaccines and their administration.

1. MLN Influenza Related Products for Health Care Professionalsy� Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B educational tool - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf

y� Medicare Preventive Services educational tool - https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

y� Mass Immunizers and Roster Billing for Influenza Virus and Pneumococcal Vaccinations booklet - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11428.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11428.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf



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2. Other CMS Resourcesy� Provider Resources Web page - https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources.html

y� Prevention Services Web page - http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html

y� Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

y� Medicare Claims Processing Manual - Chapter 18, Preventive and Screening Services http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

3. Other ResourcesThe following non-CMS resources are useful information and tools for the 2019 – 2020 flu season:

y� Advisory Committee on Immunization Practices - http://www.cdc.gov/vaccines/acip/index.html

y� Centers for Disease Control and Prevention - http://www.cdc.gov/flu

y� Flu.gov - http://www.flu.gov

y� Food and Drug Administration - http://www.fda.gov

y� Immunization Action Coalition - http://www.immunize.org

y� Indian Health Services - http://www.ihs.gov

y� National Alliance for Hispanic Health - http://www.hispanichealth.org

y� National Foundation For Infectious Diseases - http://www.nfid.org/influenza

y� National Library of Medicine Medline Plus - http://www.nlm.nih.gov/medlineplus/immunization.html

y� HHS.gov Vaccines and Immunization - http://www.hhs.gov/nvpo

y� Office of Disease Prevention and Health Promotion - http://healthfinder.gov/FindServices/Organizations/Organization/HR2013/office-of-disease-prevention-and-health-promotion-us-department-of-health-and-human-services

y� World Health Organization - http://www.who.int/en

Document History



Upcoming Educational Events

The CGS Provider Outreach and Education (POE) department offers educational events through webinars and teleconferences throughout the year. Registration for these events is required. For upcoming events, please refer to the Calendar of Events Home Health & Hospice Education Web page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/HHH_Report.asp. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.

If you have a topic that you would like the CGS POE department to present, send us your suggestion to [email protected].


https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources.html

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/ProviderResources.html

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

http://www.cdc.gov/vaccines/acip/index.html

http://www.cdc.gov/vaccines/acip/index.html

http://www.cdc.gov/flu

http://Flu.gov

http://www.flu.gov

http://www.fda.gov

http://www.immunize.org

http://www.ihs.gov

http://www.hispanichealth.org

http://www.nfid.org/influenza

http://www.nlm.nih.gov/medlineplus/immunization.html

http://www.nlm.nih.gov/medlineplus/immunization.html

http://HHS.gov

http://www.hhs.gov/nvpo

http://healthfinder.gov/FindServices/Organizations/Organization/HR2013/office-of-disease-prevention-and-health-promotion-us-department-of-health-and-human-services



http://www.who.int/en

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/HHH_Report.asp

https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/HHH_Report.asp


Documents

NOVEMBER 2019 • …...Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 15 MM11441: 2020 Annual Update of Healthcare Common Procedure Coding System