Roberta Buell E-Reimbursement Newsletter March 2023 – 3/10/23

BREAKING E-Reimbursement News: IRA Drug Action, E/M Typo, HCPCS Q2, Unwinding the PHE 3-16-2023
E-Reimbursement Newsletter

Issue 1 Volume: #2 March 2023

Hello Roberta Buell,

After a relatively quiet period, we have now got news popping up everywhere. Please make sure you browse down to the last article to ensure you haven't missed something that applies to you! Luckily, analyzing all the news has saved me from major boredom due the Atmospheric River storms that have been blasting California for the past six weeks.

Okay, for you coders out there, if you thought Prolonged Services coding from CMS was screwy before, hold your beer or Red Bull or whatever. CMS sent out a Transmittal which I thought was totally wrong in terms of Prolonged Services. BUT, after a lot of back and forth, The Final Rule was wrong. Read all about it!

We were warned that, when the ASPs were released for Q2 that some of the penalties for price increases would be reflected in the reduction of the patient portion of the allowable. Well, true to their word Medicare did just that for 27 drugs and we are delivering the news right to you.

And, lest we forget, the PHE is going POOF on May 11. So, the first thing you need to do is make sure that your Medicaid and dual eligible ("Medi-Medi") patients are deemed eligible. We have some nifty info sources for you to check out regarding when they will no longer be covered where you are as this is a state-by-state thing. And, even though telehealth isn't going anywhere for a while, there are a lot subtleties as to what WILL go away on May 11. Please read further so that you are not caught unaware.

Finally, while many of you think that our webinars and this newsletter spring forth naturally from my brain, I'm really not that smart. I use a lot of resources to put this stuff in front of you. One of my favorite resources for drug pricing and drug allowables is Despite being free of charge like this newsletter, it has always had the VERY BEST info regarding pricing for drugs. But, I can tell you from experience, it is not without cost that we bring you free information. So, BuyandBill has this message for you:

"Over the next few months, we will be transitioning to a subscription model for On April 1, 2023 every user of will be receive a one week free trial of our enhanced Pro version. After the free trial, we will be implementing our subscription model and users will need to choose their subscription level. All providers of prescription drugs will qualify for free access to our 'Basic' subscription option until later in the year."

Check it out while it's free. It is a great pricing resource.

Let's toast in Orlando,

Da' Mistress

CMS Correction for Prolonged Service

As I have said before, Prolonged Services is the E/M coding Achilles Heel. I find it difficult enough that Medicare disagrees with the CPT version of Prolonged Services, but this situation is totally cray. So, as you may remember, since 2021, CMS has always been 15 minutes longer in their thresholds for Prolonged Services. And, as you also may recall that G0316 for Inpatient/Observation was one of the three Prolonged Services codes for Facility Services and, in 2023 CMS' Final Rule, the threshold was 15 minutes later as it is for the other two codes and also in the outpatient setting.


Last week, I was gathering news for this issue, and because the insanity of Prolonged Services coding is tattooed on my brain, I noticed that CMS published a chart with the CPT Thresholds for inpatient and observation hospital codes 99223, 99233 and 99236 in CMS 100-04, Change Request 13064.I looked at this chart and I thought I had either lost my mind (which can easily happen from reading this stuff) or that this was a typo.


So, I called another of my favorite resources Part B News to see what they thought about this Transmittal as their writer, Julia Kyles (many thanks to her), had written extensively about the topic before. And they inquired at CMS as to what the story was regarding which set of guidelines was correct. And, the response was "we are working on it".


CMS then published a correction to the Final Rule with new charts that match the Transmittal, NOT THE FINAL RULE, which is quite unusual. The changes were prompted by “technical errors in the calculations of the time thresholds,” according to the correction. The update should also simplify coding for initial and subsequent hospital visit times. As is not typical for CMS these days, new times for the visits exactly mirror the threshold times for the CPT code 99418, the new prolonged service code for E/M visits in a facility setting.


The correction also revises the times for G0316 throughout the verbiage of The Final Rule, which seems not final at all.


To increase everyone's confusion on this topic, CMS did not change the threshold times for prolonged services in the nursing facility (G0317) or home/residence settings (G0318), which are higher than the CPT standard.

Please check with all of your top payers to see if they are following Medicare's old threshold, the new Medicare Threshold, the Medicare G-codes and/or or 99418. Maybe a better idea is to avoid using these codes at all...but how else can you get paid for unusually long visits?


IRA Co-Pay Changes Released

HHS unveiled Wednesday (March 15) the first list of Part B drugs for which drug makers must pay inflation rebates. Beginning April 1, Medicare beneficiaries will have their coinsurance lowered for 27 Part B drugs for which prices rose faster than the inflation rate during the last quarter of 2022, and out-of-pocket expenses could decrease by as low as $2 to up to $390 per average dose. This is actually really good for providers as Medicare pays a higher amount NOT the patient or coinsurance. Check it out.

HHS Secretary Xavier Becerra told reporters Medicare’s new inflation rebate policy under the Inflation Reduction Act will help ensure seniors aren’t left on the hook when drug makers “inexplicably jack up” the prices of drugs beyond the rate of inflation. For a Q&A on the whole subject, go right here.

Among the 27 Part B drugs is the high-cost blockbuster drug Humira, for which coinsurance will be adjusted from the normal 20% to 19.5%. Humira is among several of the drugs for which coinsurance will be adjusted minimally, while Carnitor and Folotyn will have coinsurance obligations reduced to roughly 14%, and coinsurance for the drug Fetroja will be cut down to 10%.

The list will be updated every quarter, But remember this: Manufacturers do not have to pay anything until 2025.

Q2 HCPCS and OPPS Changes

Once again, the HCPCS Update includes a lot of what appears to be to be generic drugs; but, this is due to CMS rules for "look alike drugs" not therapeutically equivalent" per new regulations pertinent to an FDA approval status called 505(b)(2). To read more about this (which qualifies you as a total nerd). Click here. Please remember that some of these drugs are not separately payable in the outpatient setting.

Here are the new codes for dates of service starting 4/1/2023:


  JK One month supply or less of drug or biological

  JL Three month supply of drug or biological

C9145 Injection, aprepitant, (aponvie), 1 mg

C9146 Injection, mirvetuximab soravtansine-gynx, 1 mg

C9147 Injection, tremelimumab-actl, 1 mg

C9148 Injection, teclistamab-cqyv, 0.5 mg

C9149 Injection, teplizumab-mzwv, 5 mcg

J0208 Injection, sodium thiosulfate, 100 mg

J0218 Injection, olipudase alfa-rpcp, 1 mg

J0612 Injection, calcium gluconate (fresenius kabi), per 10 mg

J0613 Injection, calcium gluconate (wg critical care), per 10 mg

J1411 Injection, etranacogene dezaparvovec-drlb, per therapeutic dose

J1449 Injection, eflapegrastim-xnst, 0.1 mg

J1747 Injection, spesolimab-sbzo, 1 mg

J2403 Chloroprocaine hcl ophthalmic, 3% gel, 1 mg

J9196 Injection, gemcitabine hydrochloride (accord), not therapeutically equivalent to j9201, 200 mg

J9294 Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mg

J9296 Injection, pemetrexed (accord) not therapeutically equivalent to j9305, 10 mg

J9297 Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg

J9314 Injection, pemetrexed (teva) not therapeutically equivalent to j9305, 10 mg

Q5127 Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg

Q5128 Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg

Q5129 Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg

Q5130 Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg

S9563 Home injectable therapy, immunotherapy, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Here are the discontinued codes for dates of service starting 4/1/2023:

J0610 Discontinued Injection, calcium gluconate (fresenius kabi), per 10 ml

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

Transmittal 11897 outlines prospective changes to the Hospital Prospective Payment System for Q2 2023. This transmittal is jam-packed with information updating Your Chargemaster for Q2 2023.

Drugs receiving the coveted pass-through status starting April 1, 2024, include the following:

  • C9145 Injection, aprepitant, (aponvie), 1 mg
  • C9146 Injection, mirvetuximab soravtansine-gynx, 1 mg
  • C9147 Injection, tremelimumab-actl, 1 mg
  • C9148 Injection, teclistamab-cqyv, 0.5 mg
  • C9149 Injection, teplizumab-mzwv, 5 mcg
  • J0218 Injection, olipudase alfa-rpcp, 1 mg
  • J1411 Injection, etranacogene dezaparvovec-drlb, per therapeutic dose
  • J1449 Injection, eflapegrastim-xnst, 0.1 mg
  • J1747 Injection, spesolimab-sbzo, 1 mg
  • J2403 Chloroprocaine hcl ophthalmic, 3% gel, 1 mg
  • Q5128 Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg
  • Q5130 Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg
  • C9144 Injection, bupivacaine (posimir), 1 mg N G 9106
  • J1954 Injection, leuprolide acetate for depot suspension (cipla), 7.5 mg E2 G 9136

Drugs losing pass-through status include the following:

  • J0179 Injection, brolucizumab-dbll, 1 mg
  • J0223 Injection, givosiran, 0.5 mg
  • J0791 Injection, crizanlizumab-tmca, 5 mg
  • J1201 Injection, cetirizine hydrochloride, 0.5 mg G K 9361
  • J7331 Hyaluronan or derivative, synojoynt, for intraarticular injection, 1 mg
  • Q5114 Injection, trastuzumab-dkst, biosimilar, (ogivri),10 mg
  • Q5115 Injection, rituximab-abbs, biosimilar (truxima),10 mg
  • Q5120 Injection, pegfilgrastim-bmez, biosimilar,(ziextenzo) 0.5 mg

Once again, 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.

Other items of interest in this Transmittal include the following:

  • After the PHE, which ends on May 11, 2023, payment for these COVID-19 treatments will be packaged into the payment for a C-APC (Comprehensive APC) when these services are billed on the same outpatient claim.
  • A big old section on modifiers including a statement that the 340B modifiers -JG and -TB are to be used for 340B drugs for informational purposes only starting January 1, 2023.

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.

Don't Forget to Check Medicaid Eligibility

As part of its COVID-19 response efforts, Congress passed the Families First Coronavirus Response Act on March 18, 2020. This bill includes enhanced federal funding for state Medicaid agencies to provide care throughout the duration of the federal public health emergency (PHE). As a condition of receiving this enhanced federal funding, states were prevented from terminating people’s Medicaid coverage in most circumstances. This continuous coverage requirement was designed to ensure that people did not lose their health insurance during the pandemic and has resulted in significant growth in Medicaid enrollment and contributed to the national uninsured rate reaching an all-time low in 2022. So, if you're a Medicaid patient you might think that it is business as usual.

On December 23, 2022, Congress passed the Consolidated Appropriations Act of 2023, which set an end date for the continuous coverage requirement. Under the law, state Medicaid agencies can begin processing Medicaid eligibility terminations as early as April 1, 2023, and will complete redeterminations for all members within 14 months. So, unlike COVID laws, this is state-by-state. During this period, 5–14 million people nationwide are expected to lose Medicaid coverage. Of those, up to 7 million people will erroneously lose Medicaid coverage despite ongoing eligibility. Again, this means Medicaid will start dis-enrollment of patients starting April 1, 2023. This process called "unwinding" is supposed to hit many- patients who need to re-qualify for Medicaid.

While the number of Medicaid enrollees who may be dis-enrolled during the unwinding period is highly uncertain, it is estimated millions will lose coverage. Based on illustrative scenarios—a 5% decline in total enrollment and a 13% decline in enrollment—once again, Kaiser family Foundation estimates that between 5.3 million and 14.2 million people will lose Medicaid coverage during the 12-month unwinding period. In addition 64% of Medicaid patients, do not believe that this is actually happening to them.

The Office of the Assistant Secretary for Planning and Evaluation within the Department of Health and Human Services predicts about half of those folks will be people who are eligible for coverage but are stymied in providing proof by procedural hurdles, such as not being able to get through to the appropriate state agency because of overwhelmed phone lines. So, even if your State is not first in line to drop people, you should impress upon your patients that, if they qualified during the Pandemic, to make sure that they can maintain coverage.

Arizona, Arkansas, Idaho, New Hampshire, and South Dakota started processing Medicaid renewals in February and plan to begin in April dropping beneficiaries for procedural reasons. One great resource for you to find out what is going in your state is Georgetown University and they have more nifty stuff right here. There are also more provider state resources right here.

Unwinding the PHE

During the COVID-19 pandemic, physicians, health systems, non-acute care facilities, and other providers relied on a host of regulatory flexibilities and waivers tied to the declaration of the COVID-19 Public Health Emergency (PHE).

Since January 2021, the U.S. Department of Health and Human Services (HHS) has promised at least 60 days' notice prior to ending the PHE to give states and healthcare providers a cushion to prepare. On January 30, 2023, the White House announced it will end the COVID-19 PHE and national emergency declarations on May 11, 2023. By our count (which may be totally bogus since we are not numbers jockeys) HHS’ announcement is 101 days advance notice. But, still, we have gotten used to a lot of this stuff.

With a hard stop to the PHE now in sight, healthcare providers face the daunting challenge of unraveling a broad array of regulatory changes that are now intertwined in many of their care practices and payment processes. This article is not inclusive of every change by a country mile.


The Consolidated Appropriations Act, 2023 signed into law by President Biden on December 29, 2022, extended telehealth reimbursement waivers for two years until December 31, 2024. This extension includes the following provisions of telehealth flexibilities:

  • Ending the requirement that providers be licensed in the same state as the patient receiving care;
  • Allowing more types of eligible practitioners to provide telehealth services to include occupational therapist, physical therapist, speech-language pathologist, and audiologist;
  • Permitting coverage and payment for audio-only telehealth services;
  • Delaying the six-month in-person requirement for mental health patients seeking treatment through telehealth;
  • Extending the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care;
  • Expanding the list of Medicare-covered services that can be provided via telehealth;
  • Allowing federally qualified health centers and rural health clinics to provide telehealth services, rather than being limited to being an originating site provider for telehealth;.
  • CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines in most outpatient settings for Medicare beneficiaries through the end of the calendar year in which the Secretary ends the EUA declaration for drugs and biologicals with respect to COVID19. The EUA declaration is distinct from, and not dependent on, the PHE for COVID-19.



  • CMS removed the frequency restrictions for the following listed codes furnished via Medicare telehealth. These restrictions were established through rulemaking and implemented through systems edits. After the PHE, all applicable rules for furnishing these services, unless otherwise specified will once again take effect for these: A subsequent inpatient visit could be furnished via Medicare telehealth, without the limitation will be telehealth visit is once every three days (CPT codes 99231-99233). A subsequent skilled nursing facility visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 14 days (CPT codes 99307-99310). Critical care consult codes could be furnished to a Medicare beneficiary by telehealth beyond the once-per-day limitation (HCPCS codes G0508-G0509).
  • CMS has temporarily modified the regulatory definition of direct supervision, which requires the supervising physician or practitioner to be “immediately available” to furnish assistance and direction during the service, to include the “virtual presence” of the supervising clinician through the use of real-time audio and video technology. This flexibility is currently set to return to pre-PHE rules at the end of the calendar year that the PHE ends. That is 12/31/2023. There has been discussion about making this permanent. Watch this space.
  • After 5/11/23, if a practitioner is performing telehealth at home, they will be required to report their home address on the Medicare enrollment site. This was discussed during the pandemic but never implemented.
  • Telehealth platforms must be HIPAA compliant.
  • Cost-sharing requirements will be enforced. During the PHE, practices were not required to collect the co-insurance/deductible although most did.
  • The DEA will require prescribers to see a patient face-to-face before administering controlled substances.
  • Virtual supervision of Residents will not be allowed in metropolitan statistical areas.
  • Virtual supervision of Residents providing telehealth services will not be allowed in a metropolitan statistical area.
  • Patients will be required to pay coinsurance for interprofessional consults and beneficiary consent will be required.
  • Remote patient monitoring may be furnished only for established patients. During the PHE, CMS has permitted clinicians to bill for RPM services furnished to both new and established patients, and to patients with both acute and chronic conditions. When the PHE ends, clinicians must once again have an established relationship with the patient prior to providing RPM services. However, CMS will continue to allow RPM services to be furnished to patients with both acute and chronic conditions (pre-PHE, an initiating visit was required before RPM services could be billed).
  • Virtual check-in codes will only be allowed for established patients.
  • And, much more is right here.

Hospital rules expiring:

  • Use of temporary expansion sites (such as convention centers, vacant stores, tents, or others allowed under the Hospital Without Walls program) and spaces within the hospital that do not conform to the conditions of participation requirements for patient rooms, such as conference rooms and surgical suites.
  • Use of provider-based departments that were relocated to settings outside the hospital, including patients’ homes, after receipt of an extraordinary circumstances waiver and that provide education and therapy services to hospital outpatients.
  • CMS has waived requirements at § 482.12(c)(1)-(2) and (4) that Medicare patients in the hospital must be under the care of a physician. This has allowed hospitals to use other practitioners, such as physician assistants and nurse practitioners, to the fullest extent possible. This waiver was required to be implemented in accordance with a state’s emergency preparedness or pandemic plan and ends upon the conclusion of the PHE.
  • Verbal Orders: CMS has been waiving the requirements of 42 CFR §482.23, §482.24, and §485.635(d)(3) to allow for additional flexibilities related to verbal orders where read-back verification is still required but authentication may occur later than 48 hours. This allowed for more efficient treatment of patients in a surge situation. This will expire at the end of the COVID-19 public health emergency.
  • Skilled nursing facility (SNF) beds are available for patients not meeting SNF requirements. EMTALA waiver allows hospitals to redirect patients from their emergency departments to screening tents for COVID-19 testing.
  • Reduced information requirements for post-acute care discharge to an SNF, rehabilitation center, long-term care hospital, or home health agency will expire.
  • The flexibility to not have a separate nursing plan of care for each patient will not last past May 11.
  • Permission from the Drug Enforcement Agency to prescribe controlled substances without an in-person visit sunsets.
  • Medicare’s 20% add-on payments for patients diagnosed with COVID-19 to offset the cost of complex COVID-19 patient care.
  • Free COVID-19 at-home tests and no cost-sharing for testing services and therapeutics for Medicare beneficiaries (including those in Medicare Advantage plans) and those enrolled in private coverage. After the PHE ends, patient cost sharing will be required except for Medicaid beneficiaries who have at least an additional year of tests and therapeutics access at no cost. Additionally, Medicare will continue to pay $40 for COVID-19 vaccines administered in outpatient settings through Dec. 31, 2023.
  • State option to provide Medicaid eligibility for certain uninsured individuals to cover COVID-19 testing, testing-related services, vaccination, and treatment coverage at 100% federal match.
  • Health plan requirements to reimburse out-of-network providers for COVID-19 vaccines and testing.

There are lots more details. Check out the pretty cool CMS site here.






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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.