Roberta Buell E-Reimbursement Newsletter December 2022 – 12/10/22

Hello Roberta Buell,

It's that time of year again, dear readers. First, let me tell you that this newsletter has had a banner year, both in the number of subscribers, number of active readers, and open rates. After thirty-plus years of writing it, all I can say is thank you, thank you, thank you!!! If it weren't for you, I would not feel the need to read 5000+ pages of regulations every year. So, again, on behalf of onPoint Oncology, we appreciate your loyalty and feedback (even those about typos).

This issue, we do have some crazy news, some good news, and some maybe okay news. First, the January 1 HCPCS update is MASSIVE. It is because Medicare wants to bundle therapeutically equivalent 505(b)(2) drugs into a single HCPCS code. Those rated as not therapeutically equivalent will now have their own HCPCS code, even if they were launched long ago. Some of them do not even have separate payments under OPPS anymore. Weird!!! Check out our second article and update your charge documents ASAP.

Also, CMS issued a new Proposed Rule on Prior Authorization. That's the good news. The really, really bad news is that this bill will not be effective until January 1, 2026. So, that means another three years of suffering through the current process. Yuck!

As you know, I did a bunch of updates and E/M workshops recently. I do not think I did a gold-star job explaining the CMS Coding guidelines. So, for your information, they are enclosed in this issue.

The best news is that there is some pressure on Congress to change the 4.5% reduction in the Physician Fee Schedule Conversion Factor. We cover it here and are waiting to see what happens before Congress breaks. As you might expect, we will keep you posted.

On behalf of onPoint--Tracy Lewis, Paul Welchans, Lori Woodham, Cassidy Lewis, and myself, we wish you the happiest Holiday Season!

See you next year (unless something changes),

Da' Mistress

As I mentioned in my webinars, the conversion factor for Part B services paid under the Physician Fee Schedule will take a 4.5% decrease. This is the biggest decrease in years. Many organizations have pressured Congress to reduce the cuts before they kick in. And, as you know, Congress gets a long Christmas Vacation. So, the push is on to get this done before we all go into "ho-ho-ho" mode.

Reps. Susan Wild (D-Pa.) and Mariannette Miller-Meeks (R-Iowa) are asking other lawmakers to sign onto a bipartisan letter. This bipartisan letter urges House and Senate leaders and the president to mitigate the entire cut that providers could see next year from the PAYGO scorecard and the conversion factor cuts -- and not to cut providers in other ways to cover the cost of such action.

Meanwhile, the GOP Doctors Caucus is readying a letter pushing for leadership’s support in the short term while pledging to work on longer-term solutions to avoid what’s become an annual lobbying exercise of fending off cuts on Capitol Hill. This is actually a misconception on their part, as this last-minute push was silenced when the odious "Sustainable Growth Rate" went away.

To add injury to insult, the 5% bonus Part B providers get for participating in Advanced APMs will expire at the end of this year. So, there is no reward for improving quality in 2023, despite the cuts elsewhere. There is a movement to fix this, even though time is not as much of a factor.

Stay tuned, boys and girls. New Year's may once again be a crazy time.

We saw the new HCPCS codes for dates of services on or after January 1, and we had to say: "What the what..??". There are drugs, some of which were approved a while ago, that appear to be generic; however, they are deemed "not therapeutically equivalent" per new regulations pertinent to an arcane FDA status called 505(b)(2). To read more about this (which qualifies you as a total nerd). Click here.

Here are the new codes for dates of service starting 1/1/2023:

HCPC LONG DESCRIPTION

  JZ Zero drug amount discarded/not administered to any patient

  LU Fractionated payment of car-t therapy

C9144 Injection, bupivacaine (posimir), 1 mg

E2103 Non-adjunctive, non-implanted continuous glucose monitor or receiver

J0134 Injection, acetaminophen (fresenius kabi) not therapeutically equivalent to j0131, 10 mg

J0136 Injection, acetaminophen (b braun) not therapeutically equivalent to j0131, 10 mg

J0173 Injection, epinephrine (belcher) not therapeutically equivalent to j0171, 0.1 mg

J0225 Injection, vutrisiran, 1 mg

J0283 Injection, amiodarone hydrochloride (nexterone), 30 mg

J0611 Injection, calcium gluconate (wg critical care), per 10 ml

J0689 Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg

J0701 Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg

J0703 Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg

J0877 Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg

J0891 Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use)

J0892 Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis)

J0893 Injection, decitabine (sun pharma) not therapeutically equivalent to j0894, 1 mg

J0898 Injection, argatroban (auromedics), not therapeutically equivalent to j0883, 1 mg (for non-esrd use)

J0899 Injection, argatroban (auromedics), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis)

J1456 Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg

J1574 Injection, ganciclovir sodium (exela) not therapeutically equivalent to j1570, 500 mg

J1611 Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg

J1643 Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units

J1954 Injection, leuprolide acetate for depot suspension (lutrate), 7.5 mg

J2021 Injection, linezolid (hospira) not therapeutically equivalent to j2020, 200 mg

J2184 Injection, meropenem (b. braun) not therapeutically equivalent to j2185, 100 mg

J2247 Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg

J2251 Injection, midazolam hydrochloride (wg critical care) not therapeutically equivalent to j2250, per 1 mg

J2272 Injection, morphine sulfate (fresenius kabi) not therapeutically equivalent to j2270, up to 10 mg

J2281 Injection, moxifloxacin (fresenius kabi) not therapeutically equivalent to j2280, 100 mg

J2311 Injection, naloxone hydrochloride (zimhi), 1 mg

J2327 Injection, risankizumab-rzaa, intravenous, 1 mg

J2401 Injection, chloroprocaine hydrochloride, per 1 mg

J2402 Injection, chloroprocaine hydrochloride (clorotekal), per 1 mg

J3244 Injection, tigecycline (accord) not therapeutically equivalent to j3243, 1 mg

J3371 Injection, vancomycin hcl (mylan) not therapeutically equivalent to j3370, 500 mg

J3372 Injection, vancomycin hcl (xellia) not therapeutically equivalent to j3370, 500 mg

J9046 Injection, bortezomib, (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg

J9048 Injection, bortezomib (fresenius kabi), not therapeutically equivalent to j9041, 0.1 mg

J9049 Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg

J9314 Injection, pemetrexed (teva) not therapeutically equivalent to J9305, 10 mg

J9393 Injection, fulvestrant (teva) not therapeutically equivalent to j9395, 25 mg

J9394 Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg

Here are modifiers and codes with a descriptor change effective 1/1/2023:

• JG Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
•  TB Drug or biological acquired with 340b drug pricing program discount, reported for i informational purposes for select entities
• J0131 Injection, acetaminophen, not otherwise specified,10 mg
• J0610 Injection, calcium gluconate (fresenius kabi), per 10 ml
• J9041 Injection, bortezomib, 0.1 mg

Here are the discontinued codes for 1/1/2023:

• J2400 Injection, chloroprocaine hydrochloride, per 30 ml
• J9044 Injection, bortezomib, not otherwise specified, 0.1 mg

Transmittal 11737 outlines changes to the Hospital Prospective Payment System for Q1 2023. This transmittal is jam-packed with information updating the outpatient system for 2023. If you are a hospital biller or coder, please read this 58-page document. It is key to your being ready for 2023.

• Drugs receiving the coveted pass-through status starting January 1 include the following:
• J0225 Injection, vutrisiran, 1 mg
• J2327 Injection, risankizumab-rzaa, intravenous, 1 mg
• Q5126 Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg
• J1932 Injection, lanreotide, (cipla), 1 mg
• Q5124 Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg
• Drugs losing pass-through status include the following:
• C9046 Cocaine hydrochloride nasal solution (goprelto), 1 mg
• C9047 Injection, caplacizumab-yhdp, 1 mg
• J0121 Injection, omadacycline, 1 mg
• J0222 Injection, Patisiran, 0.1 mg
• J0291 Injection, plazomicin, 5 mg
• J0642 Injection, levoleucovorin (khapzory), 0.5 mg
• J0691 Injection, lefamulin, 1 mg
• J1095 Injection, dexamethasone 9 percent, intraocular, 1 microgram
• J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg
• J1303 Injection, ravulizumab-cwvz, 10 mg
• J1632 Injection, brexanolone, 1mg
• J1943 Injection, aripiprazole lauroxil, (aristada initio), 1 mg
• J2798 Injection, risperidone, (perseris), 0.5 mg
• J3031 Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
• J3111 Injection, romosozumab-aqqg, 1 mg
• J3245 Injection, tildrakizumab, 1 mg
• J7169 Injection, coagulation factor Xa (recombinant), inactivated (andexxa), 10mg
• J7208 Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi) 1 i.u.
• J9036 Injection, bendamustine hydrochloride (belrapzo/bendamustine), 1 mg
• J9119 Injection, cemiplimab-rwlc, 1 mg
• J9204 Injection, mogamulizumab-kpkc, 1 mg
• J9210 Injection, emapalumab-lzsg, 1 mg
• J9269 Injection, tagraxofusp-erzs, 10 micrograms
• J9309 Injection, polatuzumab vedotin-piiq, 1 mg
• J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg
• J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk
• Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg
• Q5108 Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg
• Q5110 Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram
• Q5111 Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg
• Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg
• Please be aware that many of the "new " separate, 505(b)(2) J-codes have a bundled status under the fee schedule as their pass-through period has expired.
• Beginning January 1, 2023, HCPCS code C9399 (Unclassified drugs or biologicals) will be added to the comprehensive APC (C-APC) exclusions list. Please see the updated CMS internet-only manual language in the Medicare Claims Processing Manual, Pub.100-04, Chapter 4, section 10.2.3 – Comprehensive APCs for a list of all CAPC exclusions, including the new exclusion of any drug or biological described by HCPCS code C9399.

If you are in a hospital or owned by one, you should definitely check out this transmittal for a comprehensive look at OPPS changes starting on January 1. If you want to check out the HCPCS update, it is here.

Not to be a skeptic, but this proposal is totally unhelpful to the current dire Prior Auth situation. First of all, it does not take effect for THREE YEARS. We could be in a totally political scenario by then. Then, the rule would require most insurers to send prior authorization decisions within 72 hours for urgent requests and seven days for all others. Why is this such a big improvement? If CMS is giving plans THREE FULL YEARS to implement this thing, why can't payers develop algorithms to electronically accept or reject prior auths, particularly in urgent situations, on the spot? CMS wants feedback on more options, such as 48 hours, which is mine. Okay, I have spouted off; now, for more details of the Proposed Rule.

The good news is proposed rule largely aligns with the Improving Seniors’ Timely Access to Care Act (S. 3018/S.R. 3173), legislation strongly supported by many medical organizations and unanimously passed by the U.S. House of Representatives in September. Additionally, the proposal does cover more plans than the bill does.

CMS would also require insurers to report certain prior authorization metrics by posting them online each year. The proposed rules apply to most Medicare, Medicaid, and CHIP patients. If finalized, these prior authorization policies would take effect January 1, 2026, with the initial set of metrics proposed to be reported by March 31, 2026, Big whoop.

Regulators are proposing new requirements that would apply to state Medicaid and Children’s Health Insurance Program agencies, Medicaid and CHIP managed care plans and plans on the Affordable Care Act exchanges. This will also apply to Medicare Advantage plans — one key way that the new rule differs from the 2020’s rules proposed by the Trump administration. The exclusion of MA plans, which are growing among Medicare seniors and expected to cover more than half of the Medicare population as early as next year, was a big omission in previous rules. This is particularly true based on faulty denials and delays of authorization found in a recent OIG study.

Like its 2020 predecessor, the new rule includes requirements that payers provide doctors with their rationale for denied requests. Payers would again be required to send decisions within 72 hours for urgent requests and within seven calendar days for non-urgent requests — twice as fast as the existing MA response time limit. But slower than it should be for some patient care situations.

The rule would also require payers to build and maintain standardized application programming interfaces or APIs for these functions:

• To automate the process for providers to determine whether a prior authorization is needed, identify any documentation requirements, and facilitate the electronic exchange of requests and decisions.
• To share patient data with in-network providers treating the patient,
• and another to share patient data with other insurers when a patient moves to new coverage or has concurrent plans.

With patient permission, payers would be required to share claims and encounter data, prior authorization requests and decisions, and other data elements in the USCDI dataset in those Provider Access and Payer-to-Payer APIs.

CMS also wants to expand the existing Patient Access API to include information about prior authorization decisions. That API, which was also required by the interoperability regulations, allows payers to share claims and encounter information with members.

Regulators are also requesting information about standards for social risk factor data, exchanging behavioral health information electronically, improving medical documentation exchange between providers in traditional Medicare, advancing the Trusted Exchange Framework and Common Agreement, and how interoperability can improve maternal health outcomes.

Comments on the rule are due March 13.

Observations on Observation

As you know, Observation Services codes will be the same as Initial and Subsequent Inpatient codes for 2023. How this all will work in terms of coding may be much more complex than you think. So, we should examine this in more depth to see how things will change in a few weeks. And hopefully, these explanations will go a long way to avoiding mistakes.

• Codes Used In Observation for 2023: These codes are now described as Inpatient and Observation Care Services:
• Initial Hospital Inpatient or Observation Care - 99221-99223
• Subsequent Hospital Inpatient or Observation Care - 99231-99233
• Discharge from Hospital Inpatient or Observation Care - 99238-99239
• Hospital Inpatient or Observation Care Services, Same Day Admission and Discharge - 99234-99236
• Medicare 8 to 24 hour rule impacts coding. Check this out--it is important. The “8 to 24 Hour Rule” is intended to ensure consistent payment to Physicians/QHPs reporting observation E/M codes for short to medium-length observation stays that may (or may not) cross over midnight. So, here goes:
• If a patient is admitted to observation and discharged on the same calendar day and the observation time is less than 8 hours. The physician/QHP should only report the Initial Inpt/Obs care codes 99221-99223.
• If a patient is admitted to observation and discharged on the same calendar day and the observation time is more than 8 hours. The physician/QHP should only report the Same Day Admission and Discharge codes 99234-99236.
• If a patient is admitted to observation and discharged on the next calendar day and the observation time is less than 8 hours. The physician/QHP should only report the Initial Inpt/Obs care codes 99221-99223. Observation that is continuous before and through midnight is a single service and is reported on the initial calendar date.
• If a patient is admitted to observation and discharged on the next calendar day, the observation time is more than 8 hours but less than 24 hours.The physician/QHP should only report the Same Day Admission and Discharge codes 99234-99236. Observation that is continuous before and through midnight is a single service and is reported on the initial calendar date.
• If a patient is admitted to observation and discharged on the next calendar day and the observation time is more than 24 hours.The physician/QHP should report the Initial Inpt/Obs care codes 99221-99223 for the first day as the date of service. The physician/QHP should report Discharge code 99238 or 99239 for the total time spent by the physician/QHP on the discharge date.
• This rule applies to Medicare. Check with other payers to see their guidelines, as these ARE NOT CPT rules.
• Observation and other services: CPT says that you can bill for an ED service or an office/clinic visit and an Observation service the same day by applying Modifier -25. But wait...
• Per CPT, “When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date.”
• However, while the CPT policy has changed, the CMS policy has not and will not per the Final rule. Per CMS, “We also propose, however, to retain our current policy that when a patient is admitted to outpatient observation or as a hospital inpatient via another site of service (such as hospital ED, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital inpatient or observation care when performed on the same date as the admission. (Refer to the Medicare Claims Processing Manual, IOM 100-04, Chapter 12, 30.6.9.1.A.) This policy differs somewhat from the instructions provided in the 2023 CPT Codebook.” Consistent with existing Medicare policy, if both physicians are of the same specialty, in the same group, generally either an ED service 99281-99285 or observation may be billed, but not both.
• What is the ""Two Midnight Rule""? How does it impact Observation codes? On October 30, 2015, CMS (Medicare) released the final rule for OPPS. The "Two-Midnight" rule for physicians to use in determining patient admission status for inpatient or outpatient care under the Inpatient Prospective Payment System for hospitals. CMS stipulates that when a physician anticipates the patient will require care that crosses two midnights and orders inpatient admission based upon that expectation, inpatient status is generally appropriate. At this writing, time spent in Observation or another Outpatient status via an Emergency Department encounter may be retroactively combined with inpatient status to reach the two-midnight Inpatient threshold.  

For more information, see the ACEP Physicians information site, a reference for this article.

This newsletter is a brief interpretation of information. It may be subject to typos, misinterpretation, and misapplication. This company and its parent assume no liability for the content herein. Moreover, this is not consultative or legal advice. Billing of claims and payment thereof is individual to payers and circumstance. Providers should check with each payer prior to billing. This information is time-sensitive and may change at any time. Please ensure that you constantly check for new information.