RCM eNews – February 2024

Effective February 15, 2024, providers can bill J1050 or J3490 for Depo-Provera injections for all lines of business.

For all lines of business*, effective February 15, 2024, please submit all claims for these injections as indicated below with the appropriate HCPCS and NDC codes of the product being administered.

• J1050 – 150 units
• J3490 – 1 unit

* Please note that J1050 must be billed for Federal Employees Program (FEP) members.

For further details, click here.

Excellus BlueCross BlueShield announced in October the removal of preauthorization requirements for several commonly used procedural codes. In addition to these codes, Excellus BCBS is also removing preauthorization requirements for an additional 42 CPT codes, effective February 1, 2024, for one or more lines of business.

A complete list of preauthorization requirements can be found via their website by clicking the For further details, click Authorizations tab. Click here for further details regarding this notice.

CMS has released some additional information regarding the use of new HCPCS code G2211, including some clinical examples.

All medical professionals who can bill office and outpatient (O/O) evaluation and management (E/M) visits (CPT codes 99202 – 99205 and 99211 – 99215), regardless of specialty, may use this code with O/O E/M visits of any level. G2211 is not restricted to medical professionals based on specialties.

From National Government Services:

CMS implemented the usage of modifier 95 during the COVID-19 PHE as a means for providers to bill the service they provide via telehealth without using the traditional telehealth POS 02. Modifier 95 was allowed to be placed on a claim and it could be billed with the POS where the service would have taken place if it were provided in person. CMS ended that policy, with minimal exception, as of 12/31/2023.

CMS indicated in the 2024 Physician Fee Schedule Final Rule that billing with the modifier 95 would be allowed to continue when “the clinician is in the hospital and the patient is in the home, as well as for outpatient therapy services furnished via telehealth by PT, OT, or SLP.” These are the only scenarios where the usage of modifier 95 would be appropriate for billing fee-for-service Medicare. Any other telehealth service is billed with POS 02 or 10 dependent upon where the patient is located when the service is provided.

POS 10 is indicated in the final rule to be used when telehealth is provided to the patient in the patient’s home. This is further described by CMS as “a location other than a hospital or other facility where the patient receives care in a private residence.” POS 02 may be used when the patient is in a location other than their home.

CMS has clearly indicated that POS 10 is used when the patient is not in a hospital or other facility where a patient receives care. If the patient receives the telehealth service from a location that is not a facility they would normally receive care, such as their car or work, then POS 10 would be appropriate based on this description provided by CMS in the final rule.

The Surgical Dressings policy A54563 has been revised by CMS effective 1/1/2024. Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6549) are now non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing; however, they may be considered for coverage under the lymphedema compression treatment items benefit and billed in accordance with CMS Final Rule CMS-1780-F.

Starting January 1, 2024, authorized practitioners may prescribe these items to treat lymphedema. Medicare did not cover compression garments for treating lymphedema before the Consolidated Appropriations Act legislation as there was no benefit category.

For further details, click here and here.

For CY 2024, the threshold on incurred expenses is $2,330 for Physical Therapy (PT) and Speech Language Pathology (SLP) services combined and a separate threshold of $2,330 for Occupation Therapy (OT) services. Do note, that the amount applied toward deductible and coinsurance on therapy claims count toward the outpatient therapy limit(s).

The therapy threshold(s) apply to all Part B outpatient therapy settings and providers including:

• HOPDs
• CAH (TOB 85X)
• Part B SNFs
• Rehabilitation agencies (also known as ORFs)
• CORFs
• HHAs (TOB 34X)
• Therapists’ private practices
• Offices of physicians and certain NPPs

  The presence of the KX modifier demonstrates that services billed:

• Qualify for the annual threshold.
• Are reasonable and necessary services that require the skills of a therapist.
• Are justified by appropriate documentation in the medical record.
• Therapy services submitted without the KX modifier, for claims above the therapy threshold, will be denied.

  Along with the KX modifier threshold, the BBA of 2018 retains the targeted MR process: the MR threshold is $3,000 for PT and SLP services combined and $3,000 for OT services for CY 2024 and each calendar year until 2028 at which time it is indexed annually by the MEI.

For further details, click here.

The Cigna Group announced an agreement to divest their Medicare Advantage, Cigna Supplemental Benefits (which includes Medicare Supplemental Benefits), Medicare Part D, and CareAllies businesses to Health Care Service Corporation (HCSC). This includes all their Medicare plans, networks, and customers, as well as our CareAllies services. This announcement is the first step in the process as they work to transition the businesses to HCSC. They expect the transaction will be complete in the first quarter of 2025, subject to customary closing conditions and required regulatory approvals. For further information regarding this transition, click here.

Starting May 1, 2024, Emblem Health will disconnect the fax lines currently in use for preauthorization requests and concurrent reviews. Please start using the provider portal to submit requests and supporting documentation.

It is important to become familiar with the laws regarding professional courtesy adjustments so that your practice remains compliant.

From the OIG Compliance Program:

The term ‘‘professional courtesy’’ is used to describe a number of analytically different practices. The traditional definition is the practice by a physician of waiving all or a part of the fee for services provided to the physician’s office staff, other physicians, and/or their families. In recent times, ‘‘professional courtesy’’ has also come to mean the waiver of coinsurance obligations or other out-of-pocket expenses for physicians or their families (i.e., ‘‘insurance only’’ billing), and similar payment arrangements by hospitals or other institutions for services provided to their medical staffs or employees.

Courtesy adjustments may create legal liability under the anti-kickback statute or the False Claims Act depending on how the recipients are selected and how the professional courtesy is extended.

The following are general observations about professional courtesy arrangements for physician practices to consider:

• A physician’s regular and consistent practice of extending professional courtesy by waiving the entire fee for services rendered to a group of persons (including employees, physicians, and/or their family members) may not implicate any of the OIG’s fraud and abuse authorities so long as membership in the group receiving the courtesy is determined in a manner that does not take into account directly or indirectly any group member’s ability to refer to, or otherwise generate Federal health care program business for, the physician.
• A physician’s regular and consistent practice of extending professional courtesy by waiving otherwise applicable copayments for services rendered to a group of persons (including employees, physicians, and/or their family members), would not implicate the anti-kickback statute so long as membership in the group is determined in a manner that does not take into account directly or indirectly any group member’s ability to refer to, or otherwise generate Federal health care program business for, the physician.
• Any waiver of copayment practice, including that described in the preceding bullet, does implicate section 1128A(a)(5) of the Act if the patient for whom the copayment is waived is a Federal health care program beneficiary who is not financially needy. The legality of particular professional courtesy arrangements will turn on the specific facts presented, and, with respect to the anti-kickback statute, on the specific intent of the parties.

In a Special Fraud Alert, OIG addressed how providers may offer financial hardship waivers to patients.

One important exception to the prohibition against waiving copayments and deductibles is that providers, practitioners or suppliers may forgive the copayment in consideration of a particular patient’s financial hardship. This hardship exception, however, must not be used routinely; it should be used occasionally to address the special financial needs of a particular patient. Except in such special cases, a good faith effort to collect deductibles and copayments must be made. Otherwise, claims submitted to Medicare may violate the statutes discussed above and other provisions of the law.