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Wednesday, December 23, 2020



Claims, Pricers & Codes

MLN Matters® Articles



View this edition as a PDF (PDF)




Redesign of Medicare Supplier Directory Improves Beneficiary Decision-making

On December 17, CMS announced an improved supplier directory, designed to help people with Medicare more easily search for medical products, including durable medical equipment and supplies that Medicare covers – such as walkers, canes, blood sugar test strips and monitors, and wheelchairs. The redesigned directory presents a user-friendly format that is easier to navigate, includes locations where these products are available in their area, and has a similar look and feel to other updated Medicare tools. CMS’ redesign efforts are part of the agency’s commitment to improve the customer experience for people with Medicare as they make important health care decisions.

Full news alert.


Proposed Updates to Coverage Policy for Autologous Blood-Derived Products for Chronic Non-Healing Wounds

On December 21, CMS proposed to update the coverage policy for autologous blood-derived products for chronic non-healing wounds. Specifically, CMS proposes to update coverage of Platelet Rich Plasma (PRP) for the treatment of chronic non-healing diabetic, venous, and pressure wounds. PRP is a blood-derived product prepared from the patient’s own blood to be used as a wound covering in the management of chronic wounds. PRP is currently covered under the Coverage with Evidence Development (CED) pathway for the treatment of chronic, non-healing diabetic, venous, and pressure wounds when beneficiaries are enrolled in a clinical study. This proposed National Coverage Determination would eliminate the CED requirement and nationally covers PRP for the treatment of chronic non-healing diabetic wounds. The proposal also would provide for coverage determinations for PRP for all other chronic non-healing wounds to be made by local Medicare Administrative Contractors.

We’re seeking comments on the proposed national coverage determination.

Full press release.


Open Payments: Review & Dispute Data by December 31

On June 30, CMS published Program Year 2019 Open Payments data, along with updated and newly submitted data from previous program years. This data is available for review and dispute in the Open Payments system through December 31, 2020. You must be registered in the Open Payments system to review or dispute data.

Physicians and teaching hospitals: We strongly encourage you to review your data, but it’s voluntary. If you believe any records attributed to you are inaccurate, you may initiate a dispute and work with the reporting entity to reach a resolution. CMS does not mediate disputes.

For More Information:


Hospital Price Transparency: Requirements Effective January 1

Starting January 1, 2021, each hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they provide in 2 ways:

  • Comprehensive machine-readable file with all items and services
  • Display of shoppable services in a consumer-friendly format

Is your organization prepared to be compliant?

Visit the Hospital Price Transparency webpage for resources to help you prepare:


DMEPOS Competitive Bidding Program: Round 2021 Begins January 1

Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program begins on January 1, 2021, and only includes Off-The-Shelf (OTS) back and knee braces. Medicare patients in 127 Competitive Bidding Areas (CBAs) will see lower prices than Medicare currently pays for the same items.

Starting January 1, people with Original Medicare who live in or travel to one of these CBAs will need to get OTS back and knee braces from contract suppliers if they want Medicare to help pay. Note: Custom-fitted back and knee braces don’t need to be obtained from a contract supplier; we’ll continue covering these devices when a Medicare-approved supplier is used.

See our redesigned Supplier Directory to find contract suppliers.


Clinics/Group Practices & Certain Other Suppliers: Revised CMS-855B Required January 4

Clinics/group practices and certain other suppliers: Use the revised CMS-855B Medicare enrollment application once it’s posted on the CMS Forms List in early January. Medicare Administrative Contractors will accept current and revised versions of the form through January 3. Starting January 4, you must use the revised form.

Form updates:

  • Re-sequenced and re-numbered sections to create a more logical flow, make it easier to complete (for example, putting most address collection information in one section), and make it sync with the other CMS-855 enrollment applications 
  • Added national provider identifier information and commonly used acronyms to instruction pages
  • Removed information collected for advanced diagnostic imaging
  • Added electronic storage information for providers that do not store paper records 
  • Made the contact person section optional
  • Added an attachment to collect Opioid Treatment Program information

For more information, see the Medicare Provider-Supplier Enrollment webpage.


Acute Hospital Care at Home: Increasing Capacity through Hospital without Walls Program

During the public health emergency, CMS allows approved health care systems and hospitals to provide services in locations beyond their existing walls to help address the urgent need to expand care capacity and treat eligible patients in their homes. This program supports evidence-based models of at-home hospital care throughout the country.

For More Information:


Orthoses Referring Providers: Comparative Billing Report in December

In late December, CMS will issue a Comparative Billing Report on Part B claims for orthoses referring providers. Use the data-driven tables to compare your billing and payment patterns with peers in your state and across the nation.

The public can’t view CBRs. Look for an email from cbrpepper.noreply@religroupinc.com to access your report. Update your email address in the Provider Enrollment, Chain, and Ownership System to ensure delivery.

For More Information:


National Correct Coding Initiative Medicare Policy Manual: Annual Update

The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services annual update effective January 1, 2021, posted December 18, 2020. See red font for additions or revisions.

Visit the NCCI Policy Manual Archive for more information and prior versions of the manual.




Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly

In a recent report, the Office of Inspector General (OIG) determined that Medicare made incorrect payments for non-physician outpatient services provided shortly before or during inpatient stays. Review the FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients (PDF) MLN Matters Article to bill correctly for these services. Additional resources:


Claims, Pricers & Codes


ICD-10 Code Files for FY 2021

In response to the COVID-19 public health emergency, new ICD-10 codes are effective January 1:

  • 21 procedure codes (ICD-10-PCS): CMS will implement new codes to describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment
  • 6 diagnosis codes (ICD-10-CM): CDC National Center for Health Statistics

For More Information:


COVID-19: PC-ACE Software Vaccine Roster Billing Issue

Part B providers: When you select a roster bill for a COVID-19 vaccine in PC-ACE 4.8.100 software, it inappropriately auto-populates HCPCS code G0008 on the claim for the administration. This code is valid for traditional roster billing vaccines like pneumococcal and flu but not for administering the COVID-19 vaccine. Your Medicare Administrative Contractor will provide updated PC-ACE 4.9 software. Download the update to ensure proper billing of roster-billed COVID-19 vaccines.


MLN Matters® Articles


FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients

CMS issued a new MLN Matters Special Edition Article SE20024 on FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients (PDF). Learn about procedures and resources to avoid billing errors.


Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Services Subject to Reasonable Charge

CMS issued a new MLN Matters Article MM12080 on Calendar Year (CY) 2021 Annual Update for Clinical Laboratory Fee Schedule and Services Subject to Reasonable Charge (PDF). Learn about the data reporting period delay, policy updates, and mapping for new codes.




Medicare Preventive Services — Revised

CMS revised the Medicare Learning Network educational tool, Medicare Preventive Services. Learn about:

  • Coding
  • Coverage
  • Copayment/coinsurance and deductible




Promoting Interoperability Call: Audio Recording & Transcript

An audio recording (ZIP) and transcript (PDF) are available for the December 9 Medicare Learning Network call on the Interoperability and Patient Access Final Rule. Learn about implementation plans for these policies.


Physician Fee Schedule Call: Audio Recording & Transcript

An audio recording (ZIP) and transcript (PDF) are available for the December 10 Medicare Learning Network call on the Physician Fee Schedule Final Rule: Understanding 4 Key Topics. During this call, CMS experts briefly cover provisions from the final rule and address your questions.

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