Industry News, July 2024

​In the CY 2025 HOPPS Proposed Rule, CMS proposed a new reimbursement policy for diagnostic PET scans that would provide separate payment for radiopharmaceuticals that have a per-day cost of more the $630, as well as an extra payment for hospitals when they use domestically produced technetium-99m. If finalized, this new reimbursement policy would replace the existing policy in which diagnostic radiopharmaceuticals are considered supplies and packaged into the imaging procedure. It should be noted any diagnostic radiopharmaceutical with a per-day cost of less than $630 would continue to be packaged under the current policy.

SNMMI in Support of Proposed Changes to PET Imaging Agents

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) supports this proposed change to the current packaging policy for diagnostic radiopharmaceuticals. The proposed rule has a 60-day comment period, and the society plans to send comments to CMS for consideration in the FY 2025 HOPPS Final Rule.

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Radiology Societies Ask Cigna to Reconsider Policy for PNS Non-Coverage

In a recent letter to Cigna, The American Society of Neuroradiology and Society of Interventional Radiology, among other specialty societies, which represent more than 88,000 physicians, have asked the payer to reconsider a recent coverage decision that disallows payment for peripheral nerve stimulation (PNS) for treating chronic pain.

Cigna ruled the PNS procedure does not meet medical necessity, and therefore would not be a payable service under their Medical Coverage Policy in March 2024 (Policy No. 0539). However, the societies declared this policy was “incongruent with the extensive body of evidence supporting its efficacy in pain management. It is imperative to recognize that this characterization of PNS does not reflect the demonstrated effectiveness of this therapy for patients suffering from chronic pain.” The societies also stated the current Cigna policy is in “direct opposition” to the physician society-based treatment guidelines which are founded on scientific evidence.

The societies provided a list of more than 40 studies to support the safety and efficacy of PNS to help treat chronic pain, as well as indications for PNS which are classified as “Extremely Recommendable” (good evidence that the measure if effective and that benefits outweigh the harms) or “Recommendable” (at least moderate evidence that the measure if effective and that benefits exceed harms). In addition, they offered to provide any additional information to support or expedite Cigna’s reconsideration of Policy No. 0539.

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Cross-State Licensing of Telehealth Providers  

The Center for Connected Health Policy (CCHP) is a program under the Public Health Institute and is currently the federally designated National Telehealth Policy Resource Center. As such, the agency continues to receive provider and patient questions regarding the states that allow out-of-state providers to perform telehealth services for in-state patients. They offered clarification in this area of telehealth policy. Typically, telehealth services are provided at the patient’s physical location, and the provider should be licensed or have some type of approval in the patient’s state. However, there are exceptions in some states which have license or telehealth-specific exceptions, such as the allowance of a provider to perform telehealth services out-of-state without conditions, with certain conditions, in contiguous states, or with a temporary license. It can also depend on the provider’s specialty. 

The CCHP has defined categories in which licensure policies may allow out-of-state providers to perform telehealth services: limited licensure exceptions, telehealth license/registration process, and compacts. Because there is some overlap in the adoption of these categories in certain states, the CCHP recommends providers to check with their specialty board in their state, as well as in the state in which the patient will be located during the telehealth visit to ensure full compliance. It should also be noted payer policies should be reviewed, including Medicaid and Medicare, since out-of-state providers’ policies vary and could include location limitations.

​Limited Licensure Exceptions
This type of licensure is the most common way for states to allow out-of-state providers to perform telehealth services, although these exceptions are extremely limited to specific situations and provider types. Meaning, if a state is included in this category, the exception may not include all provider types or patients. For example, exemptions for providers consulting with other providers who may not be licensed in the same state; continuity of care allowances; infrequent encounters; or specialized care, such as mental health or life-threatening diseases. There are 29 states which fall under this category.
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Telehealth License/Registration Process
Although the term “registration process” may go by another name and requirements may vary, the goal is “to ensure board oversight and jurisdiction over out-of-state providers operating in the state.” These policies can be provider-specific and have fees like the licensure process. There are 21 states that have a telehealth registration process, although 9 states have adopted both limited licensure exceptions and a telehealth registration process.


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Compacts
Compacts can allow providers to meet only one approval process to provide telehealth services in multiple states. Compacts are different in structure and provider types. Currently, the CCHP is tracking 6  compacts,  including the Interstate Medical Licensure Compact, the Nurses Licensure Compact, the Physical Therapy Compact, the Psychology Interjurisdictional Compact, the Audiology and Speech-Language Pathology Interstate Compact and the Emergency Medical Services Personnel Licensure Interstate Compact. According to the CCHP, some states are reluctant to become compact members because the same statutory language used to establish a compact must be adopted across each member state. This, in turn, restricts specific states from amending the language to meet their individual policy needs.
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Recommendations
Because there is some overlap in the adoption of these policy categories in certain states, the CCHP recommends providers check with their specialty board in their state, as well as in the state in which the patient will be located during the telehealth visit to ensure full compliance. It should also be noted payer policies should be reviewed, including Medicaid and Medicare, since out-of-state providers’ policies vary and could include location limitations.

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Process for Supplying Invoice Amounts From First Coast Service Options, Inc.

​First Coast Service Options, Inc., the Medicare Administrative Contractor (MAC) for Florida, Puerto Rico and the U.S. Virgin Islands has provided a process for supplying the invoice amount on certain HPCPS codes. As taken directly from the First Coast website:

“To reduce provider burden, certain contractor-priced HCPCS codes no longer require a paper invoice.
When the invoice information is entered in the narrative field on a claim for any of the HCPCS codes listed below, it is not necessary to provide the actual paper invoice for these services.
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The required narrative information includes:

• Invoice dollar amount and quantity for the drug or biological.
• Name of the drug or biological administered.

The dosage of the medication or the size of the biological administered.

• The route of administration if applicable.

Claims not containing information about the invoice or cost associated with the code(s) will reject as unprocessable.

How to report invoice amount
You must proactively enter the invoice information on your incoming claim.

• Obtain the total invoice cost for the patient and service. You must report the amount from the invoice that is applicable for the patient and service on the claim; you aren’t reporting the retail amount or amount you charge for the service.
• Enter the invoice amount on block 19 of the CMS-1500 paper claim form or its electronic equivalent of Loop 2400 Segment NTE02 in the following format (including cents):

The invoice amount is the total amount a provider pays for an item or service, considering all discounts, rebates, refunds, or other adjustments to an item. You must maintain sufficient documentation in the patient's file in the event of a review.
The evaluation of codes for this list is an ongoing process. Be sure to check back frequently and subscribe to our eNews.

ASC device codes
Click here for current listing

Drug codes
Click here for current listing
For more detailed information related to billing NOC codes (e.g., J7999), please review our Appropriate use of NOC codes when billing for drugs and biologicals article.

​Influenza vaccine code
Q2039

Low osmolar contrast material code
Q9951

​High osmolar contrast material codes
Q9959, Q9964

Radiopharmaceutical codes
Click here for current listing

Skin substitute codes
Click here for current listing 

Other HCPCS codes
A4220, A9292, A9293, Q3001”

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FDA Recalls Philips MRI Coils  

The Food and Drug Administration (FDA) issued a Class 1 recall of specific models of the SENSE XL Torso Coil 1.5T and 3.0T, a 16-element receive only coil for torso and abdomen imaging in Philips MR Intera and Achieva Systems. This Class 1 recall identifying these coils could pose a safety risk for patients is the FDA’s most serious designation, signifying these devices have the potential to cause “serious injuries or death.” The recall effects 307 units.

Phillips received 64 complaints of coil heating events customer complaints, with 52 reports of patient harm, as of April 2024. Subsequently, On May 31, 2024, Philips notified customers and the FDA regarding the issue with these coils overheating, which could potentially cause first, second or third degree burns to patients. The company has provided product name and model number of impacted coils, customer actions to prevent patient risks and actions to be taken by Philips to correct the problem.

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HHS Reorganizes ONC

The Department of Health and Human Services (HHS) announced a restructuring that will “streamline and bolster” policymaking and strategy for information technology, cyber security, data, and artificial intelligence (AI).

Historically the Office of the National Coordinator for Health Information Technology (ONC), the Assistant Secretary for Administration (ASA), and the Administration for Strategic Preparedness and Response (ASPR) have collectively handled policy and operations in these areas. As part of the reorganization, the HHS will rename the ONC the “Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology” (ASTP/ONC). All management of technology, data and AI policy and strategy will move from ASA to ASTP/ONC, including the HHS-wide roles of Chief Technology Officer, Chief Data Officer and Chief AI Office. The ASTP/ONC will establish the Office of the Chief Technology Officer and reinstitute the role of the Chief Technology Officer to oversee the department-level and cross-agency of technology, data, and AI policy and strategy.

"Cybersecurity, data, and artificial intelligence are some of the most pressing issues facing the healthcare space today," said the HHS Secretary. "As a Department, HHS must be agile, accountable, and strategic to meet the needs of this moment. For decades, HHS has worked across the organization to ensure appropriate and safe use of technology, data, and AI to advance the health and well-being of the American people. This reorganization builds on that success and prepares the Department for the challenges that lie ahead."
Additional information regarding this organizational change can be found on the Federal Register.  

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FY 2025 ICD-10-CM Code Updates Released 

The FY 2025 ICD-10-CM diagnosis codes and updates for fiscal year (FY) 2025 have been released and are available on the 2025 ICD-10-CM Home Page of the CMS website. These codes are to be used for discharges and patient encounters occurring from October 1, 2024, through September 30, 2025. The update files include tabular and alphabetic index addenda, external cause of injuries index addenda, table of drugs and chemicals addenda, table of neoplasms addenda, and the official coding reporting guidelines.  
The update summary includes a total of 74,260 codes, including the addition of 252 codes, 13 title revisions, and 36 deletions. Of interest are:

• In Chapter 2, Neoplasms – expansion of the malignant neoplasms of lymphoid, hematopoietic and related tissue (C81-C96) section codes to include identification of specific types of lymphoma in remission.
• In Chapter 9, Diseases of the Circulatory System – expansion of the pulmonary embolism (I26) section codes to include identification of cement pulmonary embolism and fat pulmonary embolism, and clarification of other pulmonary embolism.

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All rights reserved. No part of this newsletter may be reproduced in any form whatsoever without written permission from the publisher. This newsletter may reflect coding information from the 2024 Physician’s Current Procedural Terminology (CPT® Manual). CPT is a registered trademark of the American Medical Association. CPT® five-digit codes, nomenclature and other data are copyright 2023 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. This product should not be considered a substitute for the codes, cross-references and exclusions located in the CPT® Manual.  AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.