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COVID-19 Vaccine Access in Long-Term Care Settings

Thursday, December 23, 2021



Claims, Pricers, & Codes

MLN Matters® Articles



COVID-19 Vaccine Access in Long-Term Care Settings

The federal government is committed to ensuring that residents and staff in long-term care settings, such as nursing homes, assisted living, residential care communities, group homes and senior housing, have access to COVID-19 vaccines to get primary series and booster shots.

Long-term care providers are encouraged to consider the option that works best for their residents and staff when coordinating access to COVID-19 vaccines, either in the local community or on-site. The CDC has additional details on these options. Find Medicare billing and payment information.

As a reminder, through enforcement discretion, CMS will allow Medicare-enrolled immunizers, including but not limited to pharmacies working with the United States, to bill directly and get direct reimbursement from the Medicare program for vaccinating Medicare skilled nursing facility residents.


DMEPOS Final Rule

On December 21, 2021, CMS issued a final rule that furthers the agency’s commitment to strengthen Medicare by expanding access to certain durable medical equipment, such as continuous glucose monitors that increase diabetes treatment choices for people with Medicare. The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) final rule aligns with the key goals of the Administration to create a health care system that results in better accessibility, quality, affordability, empowerment and innovation.

This final rule establishes methodologies for adjusting the Medicare DMEPOS fee schedule amounts and procedures for making benefit category and payment determinations for new items and services that are DMEPOS, therapeutic shoes and inserts, surgical dressings, or splints, casts, and other devices used for reductions of fractures and dislocations under Medicare Part B in an effort to prevent delays in coverage of such items and services. This final rule also classifies adjunctive continuous glucose monitors as durable medical equipment (DME) under Medicare Part B and finalizes certain DME payment provisions that were included in two interim final rules.

Read the full fact sheet.


NPPES: Public Reporting of Digital Contact Information

View the CMS National Plan and Provider Enumeration System (NPPES) Public Reporting of Digital Contact Information. The report includes the names and National Provider Identifiers (NPIs) of providers who didn’t enter their digital contact information (endpoints) in NPPES by December 17.

You can still enter endpoints in NPPES; organizations can also bulk upload new or updated data elements for their providers through the NPPES Electronic File Interchange (EFI) process. We’ll include the data you submit after March 2022 in the next quarter’s refresh.

Endpoints allow you to send authenticated, encrypted health information directly to trusted recipients securely over the internet. Health care organizations who want to exchange electronic health information need accurate information about the electronic addresses of potential exchange partners. CMS finalized the policy to publicly report the names and NPIs of those providers or clinicians whose endpoints aren’t in NPPES in the May 2020 CMS Interoperability and Patient Access final rule.

More Information:


VBID Model: Hospice Benefit Component

In January 2021, CMS started testing the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model to assess the effect on care delivery and quality of care, especially for palliative and hospice care. Currently, when a Medicare Advantage (MA) enrollee elects hospice, Fee-for-Service Medicare becomes responsible for covering and paying for most services, while the MA plan remains responsible for certain services like supplemental benefits. Under the model, participating MA plans are financially responsible for all Part A and B benefits, including the Medicare hospice benefit and supplemental benefits.

For calendar year 2022, 13 participating MA Organizations will offer 115 plan benefit packages as part of the model component. In December, we sent information and resources to affected hospice providers. We encourage all other hospice providers to learn more about this model to prepare for future years.

Visit the Hospice Benefit Component webpage to learn more about the model.


Federally Qualified Health Center CY 2022 PPS

Based on data through June 2021, the Calendar Year (CY) 2022 Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) base payment rate is $180.16; 2.1% higher than 2021. Find your geographic adjustment factor below the Spotlights section of the FQHC Center webpage.

For more information, see Change Request 12490 (PDF) issued to your Medicare Administrative Contractor as the official instruction.


RHC: AIR Payment Limit for CY 2022

Based on data through second quarter of 2021, the Rural Health Clinics (RHC) payment limit per visit is $89.36 for Calendar Year (CY) 2022; this reflects a 2.1% increase above the $87.52 CY 2021 payment limit. Medicare Part B pays RHCs 80% of the All-Inclusive Rate (AIR), subject to a payment limit for medically necessary medical and qualified preventive face-to-face visits with a practitioner and a Medicare beneficiary for RHC services. Each year the payment limit increases with the Medicare Economic Index.

For more information, see Change Request 12489 (PDF) issued to your Medicare Administrative Contractor as the official instruction.



Surgical Dressings: Medicare Requirements

Medicare covers primary or secondary surgical dressings:

  • When used to protect or treat a wound
  • If needed after you debride a wound

You must:

  • Include clinical information in patients’ medical records that demonstrates a reasonable and necessary need for the type and quantity of surgical dressings
  • Evaluate the wound monthly and update the record, unless you document why you can't do a monthly evaluation and how you're monitoring the patient's ongoing use of dressings

For more information, see the Surgical Dressings – Policy Article.


Claims, Pricers, & Codes

January 2022 Integrated Outpatient Code Editor (I/OCE) Specifications Version 23.0

Learn about claims processing changes effective January 1, 2022 for:

  • Hospital outpatient departments
  • Community mental health centers
  • Non-Outpatient Prospective Payment System (PPS) hospital providers
  • Limited services when provided in a Home Health (HH) agency that isn’t under the HH PPS
  • Hospice patients for non-terminal illness treatment

For more information, see Change Request 12533 (PDF) issued to your Medicare Administrative Contractor as the official instruction.


MLN Matters® Articles

Addition of the QW Modifier to Healthcare Common Procedure Coding System (HCPCS) Code 86328

Learn about the HCPCS code modifier for testing and detecting the severe acute respiratory syndrome COVID-19 antibody (PDF):

  • New modifier QW to HCPCS code 86328
  • Emergency Use Authorizations (EUAs) that the FDA can issue during Public Health Emergencies
  • First EUA to detect COVID-19 antibodies for use in patient care


January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Learn about billing instruction changes from the latest OPPS update (PDF):

  • New COVID-19 CPT vaccines and administration codes
  • New drugs, biologicals, and radiopharmaceuticals


Claims Processing Instructions for the New Pneumococcal 15-valent Conjugate Vaccine Code 90671 and Pneumococcal 20-valent Conjugate Vaccine Code 90677 — Revised

Learn about revisions we made to this article (PDF):

  • Added instructions for vaccine code 90671
  • Changed the effective date for code 90677


Intravenous Immune Globulin Demonstration — Revised

Learn about revisions we made to this fact sheet (PDF):

  • Added the 2022 payment rate for Q2052
  • Added Asceniv (J1554) to the list of drugs we cover in this demonstration


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