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Ensuring our Nation’s Seniors Have Access to Latest Advancements
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Thursday, January 14, 2021



Claims, Pricers & Codes

MLN Matters® Articles




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Ensuring our Nation’s Seniors Have Access to Latest Advancements

On January 12, CMS issued a final rule that propels innovative technology so Medicare beneficiaries have access to the latest, most advanced devices. This action represents a step forward that will help smooth the Medicare coverage pathway for innovative products, resulting in faster access to new devices for America’s seniors. This action delivers on CMS’ Unleashing Innovation and Patients Over Paperwork Initiative.

For More Information:


Opioid Treatment Programs: New for 2021

The calendar year 2021 Physician Fee Schedule final rule includes information for Medicare-enrolled Opioid Treatment Programs (OTPs):

  • New covered services include FDA-approved opioid antagonist medications, specifically naloxone, for emergency treatment of opioid overdose, as well as overdose education provided in conjunction with opioid antagonist medication
  • New codes for nasal and injectable naloxone
  • Medicare Part B coverage of hospital outpatient or free-standing institutional OTP services; these providers will submit claims using the institutional claim form (837i electronically or CMS-1450 paper claim)

We updated the OTP webpages and the Enrollment (PDF) and Billing & Payment (PDF) fact sheets with this and other new information. 


Electronic Funds Transfer: Revised CMS-588 Required on February 28

Use the revised CMS-588 Electronic Funds Transfer (EFT) application to request EFT of Medicare payments once it’s posted on the CMS Forms List in early February. Medicare Administrative Contractors will accept current and revised versions of the form through February 27, 2021. Starting February 28, 2021, you must use the revised form. There are minor updates, including:

  • Moving the instructions to the first page
  • Changing “Medicare fee-for-service contractor” to “Medicare Administrative Contractor (MAC)”
  • Removing requests for irrelevant information: cancelation as a reason for submission, change of ownership or change of practice location, additional data fields for National Provider Identifiers (NPIs)
  • Removing references to indirect payment procedures billers
  • Adding 2 additional data fields for Medicare Identification Numbers (if issued) (one NPI can be linked to multiple Medicare Identification Numbers)
  • Updating the link for MAC contacts

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


Recommend Glaucoma Screening for High-Risk Patients

During Glaucoma Awareness Month, talk to your patients about their risk, and recommend screening if appropriate. Medicare covers annual glaucoma screening for patients in at least 1 high-risk group:

  • Individuals with diabetes mellitus
  • Individuals with a family history of glaucoma
  • African-Americans aged 50 and older
  • Hispanic-Americans aged 65 and older

For More Information:



Inhalant Drugs: Bill Correctly

An Office of Inspector General (OIG) report found that CMS improperly paid suppliers for inhalation drugs. Review the Provider Compliance Tips for Nebulizers and Related Drugs (PDF) fact sheet to help you bill correctly. Additional resources:


Claims, Pricers & Codes

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

By July 1, 2021, CMS will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) so they are paid at the same rate as non-excepted off-campus PBDs for those services under the Physician Fee Schedule (PFS). This affects claims with dates of service between January 1 and December 31, 2019. You do not need to do anything.


  • November 21, 2018: The CY 2019 Outpatient Prospective Payment System (OPPS) Rule finalized payment for certain outpatient clinic visit services provided at excepted off-campus PBDs at the same rate that we pay non-excepted off-campus PBDs for those services under the PFS. Previously, CMS and Medicare patients often paid more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.
  • In 2019: We reduced payment to 70% of the full OPPS rate in off-campus PBDs. In 2020, this rate changed to 40%.
  • September 17, 2019: The U.S. District Court for the District of Columbia declared invalid the CY 2019 payment rule that provided for the reduction for clinic visits provided at excepted off-campus PBDs.
  • January 1 – July 2020: We reprocessed CY 2019 claims paid at the reduced payment rate of 70% to restore the 100% payment rate in accordance with the district court decision.
  • July 17, 2020: The U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding our volume control site-neutrality payment policy for off-campus outpatient hospital clinic visits.


ASC Payment System Update Effective January 1, 2021

On December 27, 2020, the Consolidated Appropriations Act modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS), providing a 3.75 percent increase in MPFS payments. CMS recalculated Ambulatory Surgical Center (ASC) rates for office-based covered surgical procedures and certain covered ancillary radiology services and diagnostic tests, as well as the budget neutrality adjustment applied to all ASC procedure payment rates.

We also incorporated two ASC rate technical corrections to correctly reflect the CY 2021 Outpatient Prospective Payment System/ASC final rule policies:

  • Accounting for separate payment for HCPCS code J1097 (phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml) in the budget neutrality adjustment
  • Applying a default device offset percentage of 31% to reflect the device costs associated with 0404T (Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency)

Revised ASC payment rates are now available in the Downloads section of the January 2021 ASC Payment Rates - Addenda webpage. The ASC scalar for CY 2021 is now 0.8547.


MLN Matters® Articles

January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.0

CMS issued a new MLN Matters Article MM12114 on January 2021 Integrated Outpatient Code Editor (I/OCE) Specifications Version 22.0 (PDF). Learn about effective dates for modifications.


January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System

CMS issued a new MLN Matters Article MM12129 on January 2021 Update of the Ambulatory Surgical Center (ASC) Payment System (PDF). Learn about changes to policies and codes.


January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

CMS issued a new MLN Matters Article MM12120 on January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS) (PDF). Learn about changes to policies, codes, and the Medicare Benefit Policy Manual.



Clinical Laboratory Fee Schedule — Revised

CMS revised the Medicare Learning Network fact sheet, Clinical Laboratory Fee Schedule. Learn about:

  • Coverage requirements
  • Payment rates
  • Resources



Achieving Health Equity Web-Based Training Course

The Achieving Health Equity Web-Based Training (WBT) course is available through the Medicare Learning Network Learning Management System. Learn how to:

  • Define health disparities and health equity
  • Address health disparities in your organization
  • Foster a culture of equity
  • Create processes to build organizational responses


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