CMS Updates for Billing and Coding: Q4 2020

We’re coming into the end of the year, which means now is a great time for healthcare leaders and medical billing and coding managers to survey recent CMS updates as you work to ensure the financial health of your organization. 

We’ve combed through recent CMS news to put together the points that most impact leaders like you today. 

In the world of home health reimbursement, you’ll find that little has changed from June’s proposal. The recently issued final rule for 2021 adds a $390 million boost to home health payments for agencies — an aggregate increase of 1.9% [1]. This though, falls short of the $540 million increase and 2.6% bump stated by the proposed rule. 

If you look into the details of the increase, you’ll find the 2% home health payment update percentage along with a 0.1% payment decrease thanks to a reduction in the rural add-on percentages tied to the Bipartisan Budget Act of 2018. Additionally, the rule updates the home health wage index, putting a limit to decreases in a geographic area’s wage index value at no more than 5% for 2021. 

Some believe that the rule brings stability to the home health industry by leaving the Patient Driven Groups Model (PDGM, which we’ve discussed before) mostly untouched — which also maintains the controversial behavioral adjustment, which home health advocates have been asking CMS to reconsider.  

On the kidney health front, CMS has released the final rule, updating Medicare payment rates and policies under the Prospective Payment System (PPS) for renal dialysis services next year. This update also covers payment for acute kidney injury (AKI) treatment that is provided by dialysis facilities, additionally finalizing changes to the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) [2]. Update details include: 

• An increase in the per dialysis treatment payment to $253.13 thanks to a $13.80 increase in the base rate. 
• For facilities using new technologies for home dialysis patients, an add-on payment offered by the PPS (similar to the payment for in-center dialysis care). 

Overall, you’ll see incentives for the adoption of new technologies — the express intent of the ESRD PPS Transitional Add-on Payment Adjustment for New and Innovative Equipment and Supplies (TPNIES). As stated according to a recent press release, it’s purpose “is to facilitate beneficiary access to certain qualifying, new and innovative renal dialysis equipment and supplies by providing an add-on payment adjustment to support ESRD facilities in the uptake of new and innovative equipment and supplies under the ESRD PPS.”

Diabetes Devices Reclassified

Technology is also getting attention in the world of endocrinology. CMS released a proposed rule that would expand coverage for continuous glucose monitors (CGMs). The American Diabetes Association (ADA) responded with its support, stating that they appreciate the recognition that rules limiting access did not have clinical merit and that they limited access for many patients, especially lower-income Americans. 

As things stand now, CMS only covers therapeutic CGMs or ones with FDA approval for use in making treatment decisions (e.g. dietary changes or insulin dosage) based solely on the CGM readings. The proposal would classify all CGMs as durable medical equipment (DME) establishing payments for the items, along with related supplies and accessories. 

CMS has also dropped limitations on smartphone use in conjunction with a CGM.

The PDPM update to Medicare reimbursement for skilled nursing facilities has proved critical to nursing care reimbursement during the COVID-19 pandemic. Critics though, have called out the fact that it hasn’t been revenue neutral — the average daily rate has generally risen from the third quarter of 2019 until now. The overhaul was intended to maintain government spending and keep it the same under the previous reimbursement model (the Resource Utilization Group, or RUG system). This is attributed to changes in coding practices that CMS did not expect post-PDPM. 

The agency had actually expected coding for nursing and speech to stay the same, but instead they increased. At the same time, projections for NTA reimbursement rates were not as high as they had predicted. 

Conditions that affect payment include depression, and isolation, both of which have been exacerbated by the COVID-19 pandemic. 

Short-Term COVID-19 Therapy Coverage Announced

CMS has announced that Medicare coverage will be extended to monoclonal antibodies for the treatment of coronavirus in certain cases. The antibodies, according to the NIH, can protect a patient in the short-term from the coronavirus until vaccination [3].

Emergency use authorization was issued by the FDA the day prior to the CMS announcement. The policy is historic, drastically expanding access to the antibodies without cost sharing, and extending use in a range of settings, including doctor’s offices, infusion centers, and nursing homes. The first antibody will go to healthcare workers, with Medicare covering the infusion process and healthcare workers paying for the product. When Medicare beneficiaries begin to receive the infusion, they won't have a copayment or deductible for the infusion. 

CMS will set the price for the monoclonal antibodies in a way similar to the Medicare payment rate for the future vaccine. The agency has promised that it will soon provide billing and coding guidance. 

To learn more about how outsourcing medical coding and billing can help you prepare for and respond to these changes. Contact us today!