2022-08-11-MLNC

On July 23, the World Health Organization declared monkeypox a public health emergency, and HHS issued a statement regarding the Biden-Harris Administration’s actions to make vaccines, testing, and treatments available.

CMS issued 2 new CPT codes effective July 26, 2022:

Code 90611 for smallpox and monkeypox vaccine product:

Long descriptor: Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use
Short descriptor: SMALLPOX&MONKEYPOX VAC 0.5ML

Code 90622 for vaccinia (smallpox) virus vaccine product:

Long descriptor: Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use
Short descriptor: VACCINIA VRS VAC 0.3 ML PERQ

When the government provides vaccines at no cost, only bill for the vaccine administration:

Don’t include the vaccine codes on the claim when the vaccines are free
Patient cost sharing applies

Your Medicare Administrative Contractor will give you more information soon about coverage and billing.

Payment Allowance Update for COVID-19 Monoclonal Antibody Therapy Q0222 Injection, Bebtelovimab, 175 mg

On August 15, drug manufacturer, Eli Lilly, will start commercial distribution of their COVID-19 monoclonal antibody therapy, bebtelovimab, 175 mg. CMS will pay 95% average wholesale price (AWP) or $2394.00 for this product.

You might have both United States Government (USG)-purchased and commercial product in your inventory. For dates of service on or after August 15, only bill Medicare if you use commercially purchased products; don’t bill for USG-purchased products. Continue to bill for administering either type of product.

Check the Batch # on the vial. If the Batch # is D534422, the product was commercially purchased. Watch for Eli Lilly to release more information about future batch numbers.

Continue to use HCPCS codes:

Q0222: Injection, 175 mg for the product
M0222: Intravenous injection, includes injection and post administration monitoring
M0223: Intravenous injection, includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency

There’s no cost sharing (no copayment/coinsurance or deductible) through the calendar year that the COVID-19 public health emergency ends for monoclonal antibody therapies to treat COVID-19 for people with Medicare.

More Information:

COVID-19 Monoclonal Antibodies webpage
COVID-19 Vaccine and Monoclonal Antibodies ASP webpage

CMS Announces Resources & Flexibilities to Assist Kentucky Due to Recent Storms

On August 5, CMS announced additional resources and flexibilities available in response to the recent severe storms in Kentucky. On August 2, HHS Secretary Xavier Becerra determined that a public health emergency (PHE) exists in the Commonwealth of Kentucky, retroactive to July 26. We’re ready to help with resources and waivers to ensure hospitals and other facilities can continue to operate and provide access to care.

More Information:

Hospice Quality Reporting Program: Measure Change

CMS started public reporting for the Hospice Visits in the Last Days of Life measure. It replaces the Hospice Visits When Death is Imminent measure. Learn more about the measure development process.

Compliance

What’s the Comprehensive Error Rate Testing Program?

CMS created the Comprehensive Error Rate Testing (CERT) program to measure the rate of improper Fee-for-Service payments. The error rate measures payments that didn’t meet Medicare requirements; it doesn’t indicate fraud.

How does the CERT program work?

The CERT contractor reviews a sample of processed claims. If a claim doesn’t meet Medicare’s coverage, coding, and billing rules, or the provider fails to submit medical records, it’s counted as a total or partial improper payment. Medicare Administrative Contractors analyze CERT error rates to reduce improper payments by updating their internal processes and educating providers.

Claims, Pricers, & Codes

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - October 2022

See the attachment in the instruction to your Medicare Administrative Contractor (PDF) to learn about changes to the MPFSDB:

New HCPCS and CPT codes
Codes that are no longer valid
Changes to a short descriptor

Unless otherwise noted, these changes are effective for dates of service on and after January 1, 2022.

Integrated Outpatient Code Editor: Java Beta File Release

Visit the Test Versions - Integrated Outpatient Code Editor (IOCE) Software webpage to get the Java beta version of the April IOCE v23.1 (ZIP) and information about modernizing code editor software and future IOCE beta file releases. Send questions to GrouperBetaTesting@cms.hhs.gov.

MLN Matters® Articles

Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Updates for Fiscal Year (FY) 2023

Learn about changes to the IPF PPS for FY 2023 (PDF):

Wage index
Pricer
Quality reporting program

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2023

Learn about changes to the IRF PPS pricer for fiscal year (FY) 2023 (PDF):

Payment rates
Wage index cap

New Waived Tests

Learn about new waived tests (PDF) approved by the FDA under the Clinical Laboratory Improvement Amendments of 1988 and using modifier QW.

Implementation of the Capital Related Assets (CRA) Adjustment for the Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES) Under the End-Stage Renal Disease Prospective Payment System (ESRD PPS) — Revised

We updated this Article (PDF) to:

Clarify the policy
Reorder steps in the example calculation
Clarify that we subtract the offset adjustment from the per treatment amount before applying the 65% adjustment

Publications

Skilled Nursing Facility Billing Reference — Revised

Health Insurance Prospective Payment System code ZZZZZ replaced default code AAA00.

Multimedia

Hospice Quality Reporting Program Videos

CMS released 2 videos for the Hospice Quality Reporting Program (HQRP):

Introduction to the HQRP: program purpose, how data is collected, and quality measures
The Hospice Care Index – A Claims-Based Measure of Quality for Hospice Care: overview of the new measure

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