Thursday, February 11, 2021
- COVID-19: Revised Clinician Codes Accepted with CS Modifier
- PFS Payment for Office & Outpatient E/M Visits
- ESRD: Claims Processing Issues for Type of Bill 072X
View this edition as PDF (PDF)
News
Flu & Pneumococcal Shots: Protect Your Patients
You can give flu and pneumococcal shots during the same office visit. Your patients pay nothing if you accept assignment. Medicare Part B covers:
- 1 flu shot per flu season and additional flu shots if medically necessary.
- 2 different pneumococcal shots. Read the CDC’s Pneumococcal Vaccine Timing for Adults.
Check eligibility for pneumococcal shots. If your patient has:
- Medicare Fee-for-Service: check Medicare eligibility (PDF)
- Medicare Advantage (MA): ask them if they got a shot while enrolled in an MA plan, or check with the plan
More Information:
- Medicare Preventive Services educational tool
- CMS Preventive Services webpage
- CDC Flu and Pneumococcal Vaccination webpages
- Information for your patients on flu shots and pneumococcal shots
Compliance
Hospices: Create an Effective Plan of Care
An Office of Inspector General (OIG) report found that most hospices have at least one deficiency in their quality of care. Review the Creating an Effective Hospice Plan of Care (PDF) fact sheet to learn about principles of care planning, care coordination, and common deficiencies. Additional resources:
- Hospice Conditions of Participation final rule
- Medicare Fee-for-Service Response to the Public Health Emergency on COVID-19 (PDF) MLN Matters Article
- Quality, Certification, and Oversight Reports database
- Quality, Safety & Education Portal
- State Operations Manual Appendix M – Guidance to Surveyors: Hospice (PDF)
Claims, Pricers, & Codes
COVID-19: Revised Clinician Codes Accepted with CS Modifier
Effective March 18, 2020, the Families First Coronavirus Response Act requires Medicare Part B to cover beneficiary cost-sharing for provider visits when a COVID-19 diagnostic test is administered or ordered. CMS updated the list of codes (ZIP) that physicians and non-physician practitioners can use with the Cost-Sharing (CS) modifier.
For dates of service on or after January 1, 2021, through the end of the public health emergency, we’ll accept these codes with the CS modifier:
- HCPCS codes G2250, G2251, and G2252
- CPT codes 98970, 98971, and 98972 (These replace HCPCS codes G2061 – G2063, which are accepted for services provided in 2020)
CPT codes 98966, 98967, and 98968 are accepted for services with the CS modifier provided on or after March 18, 2020.
More information about cost-sharing: Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (PDF) MLN Matters Article
PFS Payment for Office & Outpatient E/M Visits
Effective January 1, for Physician Fee Schedule (PFS) payment of office and outpatient Evaluation and Management (E/M) visits (CPT codes 99201 through 99215), Medicare generally adopted the new AMA coding, language, and interpretive guidance framework. See the fact sheet (PDF) for more information, including:
- PFS payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211)
- Medical review when time is used to select visit level
ESRD: Claims Processing Issues for Type of Bill 072X
End-Stage Renal Disease (ESRD) providers: CMS is aware of 2 claims processing issues for type of bill 072X for dates of service in 2021:
- The ESRD network reduction deducted twice from your payments in error. We’re correcting this issue and will adjust your claims.
- Claims with HCPCS codes J0604 (Cinacalcet, oral, 1 mg) and/or J0606 (Injection, etelcalcetide, 0.1 mg) received reason code 36226, requiring the AX modifier appended to the line, which isn’t required for dates of service in 2021. Medicare Administrative Contractors will process claims pending with this reason code, including claims returned to the provider.
You don’t need to adjust or resubmit your claims for these issues.
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