RCM eNews – October 2023

The annual update to the CPT code set created 349 editorial changes, including 230 additions, 49 deletions, and 70 revisions. With 11,163 codes that describe the medical procedures and services available to patients, the CPT code set continues to grow and evolve with the rapid pace of innovation in medical science and health technology.

Among the important CPT changes for 2024 are the consolidation of over 50 previous codes that streamline the reporting of immunizations for COVID-19. The 50 COVID-19 immunization codes will be consolidated into 17 codes (91300 – 91317). The CPT Editorial Panel also approved the provisional codes (91318 – 91322) to identify monovalent vaccine products from Moderna and Pfizer for immunization against COVID-19. The provisional codes will be effective for use when the monovalent vaccine products from Moderna and Pfizer receive approval from the U.S. Food and Drug Administration. In addition, a new vaccine administration code (90480) was approved for reporting the administration of any COVID-19 vaccine for any patient, replacing all previously approved product specific vaccine administration codes.

Clarifications sought by the Centers for Medicare and Medicaid Services also prompted the CPT Editorial Panel to add revisions to the CPT 2024 code set that clarify the reporting of evaluation and management (E/M) services. The revisions include:

• Removal of time ranges from office or other outpatient visit codes (99202 – 99205, 99212 – 99215) and aligned the format with other E/M codes,
• A definition to determine the “substantive portion” of a split/shared E/M visit in which a physician and a non-physician practitioner work jointly to furnish all the work related to the visit, and
• Instructions for reporting hospital inpatient or observation care services and admission and discharge services for the use of codes 99234 – 99236 when the patient stay crosses over two calendar dates.

Codes 99441, 99442 and 99443 for telephone evaluation and management will be deleted.

New codes 90380, 90381, 90683, 90679 and 90678 have been developed for product-specific RSV immunizations.

Further guidance on the updates for the CPT 2024 code set is available at the CPT & RBRVS 2024 Annual Symposium, being held online November 15 – 17. Register now!

CMS will implement Marriage & Family Therapist and Mental Health Counselor provider types on Jan 1, 2024. Enrollment applications for these provider types will be accepted after the CY2024 Physician Fee Schedule final rule is published at the Federal Register, which is typically around November 1. Click here for further details.

In May 2023, the OIG released the final report titled, “Medicare Paid Millions More for Physician Services at Higher Nonfacility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities” (A-04-21-04084).

These overpayments are national and impacts claims processed between July 2019 and July 2023. The claim adjustment will change the POS from 32 (Nursing Facility) to 31 (Skilled Nursing Facility).

Providers whose claims are adjusted will receive overpayment letters explaining the reason further.

Click here to read more about the audit and view the report on the OIG website.

The Medicare Annual Enrollment Period is open from October 15 to December 7,2023. Medicare beneficiaries can enroll or change their Medicare health plan and prescription drug coverage for the following year during this time. Click here for further details.

From CMS:

On September 11, the FDA approved and authorized for emergency use updated Moderna and Pfizer-BioNTech COVID-19 vaccines formulated to more closely target currently circulating variants and provide better protection against serious consequences of COVID-19, including hospitalization and death. These vaccines have been updated to include a monovalent (single) component that corresponds to the Omicron variant XBB.1.5. The CDC recommends everyone 6 months and older get an updated COVID-19 vaccine.

Six New CPT Codes Effective September 11, 2023

1. 90480 – COVID-19 Vaccine Administration
2. 91318 – COVID-19 Vaccine, 3 mcg/0.2 mL
3. 91319 – COVID-19 Vaccine, 10 mcg
4. 91320 – COVID-19 Vaccine, 30 mcg
5. 91321 – COVID-19 Vaccine, 25 mcg
6. 91322 – COVID-19 Vaccine, 50 mcg

The federal government isn’t purchasing these products. Medicare Part B pays for the drug and its administration under the applicable Medicare Part B payment policy.

Medicare no longer pays for these CPT Codes as of September 12, 2023:

91312, 91313, 91314, 91315, 91316, 91317, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A, 0154A, 0164A, 0171A, 0172A, 0173A, and 0174A.

Effective December 1, 2023, Excellus BCBS will no longer require Breast MRI codes 77046, 77047, 77048 and 77049 to be preauthorized. The right to conduct post-payment reviews will be maintained. Click here for further details.

Humana announced that it will be exiting the Employer Group Commercial Medical Products business, which includes all fully insured, self-funded and Federal Employee Health Benefit medical plans. The exit from this line of business will be phased over the next 18 to 24 months.
Humana will continue to offer its Medicare Advantage, Group Medicare, Medicare Supplement, Medicare Prescription Drug Plans, Medicaid, Military and Specialty lines of business.

Medicaid entities/Providers are required to report, return, and explain any overpayments they have received to the New York State Office of the Medicaid Inspector General (OMIG) Self- Disclosure Program within sixty (60) days of identification, or by the date any corresponding cost report was due, whichever is later. See Social Services Law (SOS) § 363-d(6).

OMIG has enacted self-disclosure processes to afford Medicaid entities/Providers a mechanism to report, return, and explain overpayments from the Medicaid program. These processes cover all Medicaid-program providers. See SOS § 363-d(7).

Additionally, the Self-Disclosure Program accepts provider reports of damaged, lost or destroyed records. Pursuant to Title 18 of the New York Codes Rules and Regulations, Section 504.3, providers are required to prepare and maintain contemporaneous records demonstrating their right to receive payment under the medical assistance program and furnish the records, upon request. If a provider becomes aware that their records have been damaged, lost or destroyed they are required to report that information as soon as practicable, but no later than thirty (30) calendar days after discovery.

Overpayment Identification

Pursuant to SOS § 363-d (6)(b), an overpayment has been identified when a Medicaid entity/Provider has, or should have, through the exercise of reasonable diligence, determined that a Medicaid fund overpayment was received, and they have quantified the amount of the overpayment.

Medicaid entities/Providers who have a compliance program should be utilizing routine internal audits to review compliance with Medicaid requirements and identify any Medicaid fund overpayments that may have been received. Additionally, if a Medicaid entity/Provider is the subject of a government audit, part of that Medicaid entity’s/Provider’s due diligence is to review the results of the audit and look at past and future periods – not covered in the audit scope – to identify any overpayments resulting from similar issues. If overpayments exist, Medicaid entities/Providers are obligated to take corrective action, which includes reporting and returning any Medicaid overpayment identified to OMIG’s Self-Disclosure Program.

Please Note: Voiding or adjusting claims does not satisfy the Medicaid entity’s/Provider’s obligation to report and explain the identified overpayment.

For complete program guidelines and compliance, please click here.