Industry News, January 2024

Possible Permanent Extension Medicare Telehealth Flexibilities

​Members of Congress will consider legislation which could extend telehealth flexibilities that were a result of the COVID-19 public health emergency, including Medicare reimbursements for virtual visits and access to online care for people who are underinsured.

Possible Permanent Extension Medicare Telehealth Flexibilities

Telehealth Acts

The CONNECT for Health Act would remove geographic restrictions for telehealth services, expanding the originating sites to include the patient’s home; expanding the authority of the providers eligible to furnish telehealth services; and repealing the six-month in-person visit requirement for mental health telehealth services, among other measures. This act is endorsed by over 160 organizations, including the American Medical Association and the American Hospital Association.

​RESOURCES

• CONNECT for Health Act
• Telehealth Expansion Act
• Telehealth Benefit Expansion for Workers Act

The Telehealth Expansion Act would allow employers and health plans to cover telehealth visits for patients with the addition of a health savings account (HSA) before having to meet their deductible. This flexibility is extended through December 31, 2024, due to the Consolidated Appropriations Act of 2023. 
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The Telehealth Benefit Expansion for Workers Act would allow employers to offer standalone telehealth benefits to all employees, including employees who are eligible for enrollment in their employer’s group health plan. Currently, employers can offer telehealth benefits to employees who are ineligible for the employers’ group health plan.

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Medicare Prior Authorization Final Rule

The Centers for Medicare and Medicaid Services (CMS) issued the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) The provisions in this final rule impact Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) (collectively referred to as “impacted payers”); as well as eligible hospitals and Merit-based Incentive Payment System (MIPS) eligible physicians.

Collectively, these polices will reduce “overall payer and provider burden and improve patient access to health information while continuing CMS’s drive toward interoperability in the health care market.” 

Specifically, improvement of the electronic exchange of health information and prior authorization for medical services; and thus, reduce time burdens on patients, providers and payers. The estimated savings over ten years is approximately $15 billion. Highlights of this final rule include:

Patient access to health information: Requires impacted payers to implement and maintain certain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data, as well as to streamline prior authorization processes.
Streamline of prior authorization process: Requires certain payers to restructure their prior authorization process, which should complement the Medicare Advantage requirements finalized in the Contract Year 2024 and Part D final rule.
Prior authorization decision timeframes: Starting in 2026, certain impacted payers will be required to send prior authorization decisions within 72 hours for urgent requests, and seven calendar days for standard requests for medical services. For some payers, this new timeframe for standard requests cuts current decision times in half.
Provider notice, including denial reason: Requires all impacted payers to provide a specific reason for denial of a prior authorization request, which will help expedite resubmission or appeal request
Addition of new electronic prior authorization measure for MIPS: Addition of a new measure titled “Electronic Prior Authorization”, in which MIPS eligible physicians and hospitals will begin reporting in 2027. This is an attestation measure, meaning they must confirm to requesting a prior authorization electrically."

​The requirements defined in this final rule must be implemented by January 1, 2027.

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MAC’s New Process Category III Codes 

​According to First Coast Service Options, Inc. Medicare Administrative Contractor (MAC) for Florida, Perto Rico, and US Virgin Islands, 
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​“First Coast requests the following documentation be submitted with the initial claim submission for the T codes linked below:

• History and physical examination;
• Lab/diagnostic test results, if applicable;
• Progress or office notes for the service performed;
• Operative or procedure report, if applicable;
• Full text peer reviewed articles;
• Society guidelines; and
• Any additional documentation that supports the need for the service

Effective February 26, 2024, when records are not submitted to support the code billed, the service will be rejected. The claim must then be resubmitted with the appropriate information. Avoid negative impacts to your claims by providing the medical records with your claim submission for the T codes linked above. Please consult this list frequently as First Coast anticipates this to be a temporary situation."

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Radiation Oncology Practice Payback for Failure to Properly Review IGRT

On January 25, 2024, the United States Attorney for the Eastern District of New York announced that New York Presbyterian Hospital (NYPH) agreed to payback $801,000 to resolve claims, brought forth under the qui tam provision of False Claims Act, regarding two radiology practices that improperly billed Medicare, Medicaid, and TRICARE for image guided radiation therapy (IGRT).

​Radiation Therapist Associates, P.C. (RTS) and Edge Radiation Oncology Services, PLLC, (LEROS), neither of which are still operating, provided these services under contract with a predecessor of NYPH.  Both RTA and LEROS provided outpatient radiation oncology services in the Brooklyn, NY area.  During the years of 2012-2018 the US claimed both practices billed for images utilized with IGRT, when the images were either not reviewed or not timely reviewed.  As a result, the IGRT was determined to not be medically necessary.  Additionally, RTA was found to code levels of initial evaluation and management (E/M) visits at a higher level than supported by the documentation.

“The defendants provided substandard care to cancer patients by not properly or timely reviewing medical imaging and then billed taxpayer funded healthcare programs for these shoddy services. My Office is committed to holding healthcare providers accountable for such conduct.”
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- United States Attorney Breon Peace

The CPT code set’s instructions to use an unlisted procedure code do not preclude the reporting of an appropriate code that may be found elsewhere in the CPT code set. It may be appropriate to report multiple Category I or Category III codes together to describe the totality of a service rendered for a given patient encounter, provided each code represents a separately reportable service. Similarly, it is appropriate to report an unlisted code together with a Category I or Category III code(s) for the same patient encounter on the same date of service when a separately reportable portion of a provided procedure or service is not described by an exist­ing CPT code(s).” 

There may also be those rare scenarios in which multiple unlisted codes are the most applicable for the services provided to the same patient, same date of service, by the same provider.  The AMA indicates in these scenarios, multiple unlisted codes can be reported and when the services are for the same anatomic region or multiple units of same unlisted code are reported, modifier 59 can be applied to the additional unit(s).
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The use of modifiers will not preclude the provider from still defining and supporting the use of the unlisted code, but will assist in supporting and communicating the multiple procedures and/or services provided to the patient for reimbursement. 

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Correct Coding for Breast Imaging Reminder

National Government Services (NGS) Medicare Administrative Contractor (MAC) for Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont & Wisconsin issued the following reminder to providers under their jurisdictions.

When there are no abnormal and inconclusive findings on mammography and the only finding is dense breast tissue (ICD-10-CM codes R92.30-R92.34), the provision of an ultrasound is considered screening. Since Medicare does not have a covered benefit for screening breast ultrasound, claims will be denied.
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Effective 10/1/2023, the descriptor of ICD-10 code R92.2 (inconclusive mammogram) was revised to no longer include dense breasts NOS. ICD-10 code R92.2 will be considered incorrect coding when reporting dense breasts and therefore not covered.
 
For coverage provisions related to breast imaging, please refer to local coverage determination (LCD) L33585, Breast Imaging: Breast Echography (Sonography)/Breast magnetic resonance imaging (MRI)/Ductography and the related Billing and Coding article, A52849.”

Additional Resources

• L33585, Breast Imaging: Breast Echography (Sonography)/Breast magnetic resonance imaging (MRI)/Ductography
• A52849, Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography
• Limitation of Liability (Advance Beneficiary Notice of Noncoverage)
• Medicare Part B Coverage and Billing Guidance for Breast Ultrasound

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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. ​