ClaimsXten™ Solutions and COVID-19

The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) created new procedure codes and a diagnosis code to respond to COVID-19. The following information applies to ClaimsXten Solutions, which include ClaimsXten and ClaimsXten Select, and pertains to the new procedure codes and diagnosis code. It is designed to help our customers more effectively document and track claims associated with this critical healthcare issue.

09/15/2020

COVID-19 new Proprietary Laboratory Analysis (PLA) code for COVID-19 testing

The following information applies to ClaimsXten and ClaimsXten Select. The purpose of this communication is to provide our clients with a comprehensive explanation of the recent posting of the Q4 2020 Centers for Medicare and Medicaid Services (CMS) Procedure to Procedure (PTP) files for Practitioner and Hospital Outpatient Services. Contents:

  • AMA COVID-19 new code updates 
  •  CMS “suspended codes and deleted edits” reinstated by CMS 
  • Change Healthcare reinstates edits in UNBUN_PAIRS and CMS_UNBUN_PAIRS  
  • ClaimsXten Solutions KnowledgePack Update Report Q4-2020 

 

AMA COVID-19 New Code Updates

The American Medical Association (AMA) announced an update to Current Procedural Terminology (CPT®) that includes two new COVID-19 codes, effective Sept. 8, 2020. These codes have been added to the PROC_INVALID rule with Content Manager release #248 on Sept. 10, 2020

 

Code Long Description Short Description
86413 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative.20 SARS-COV-2 ANTB QUANTITATIVE
99072 Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease. ADDL SUPL MATRL&STAF TM PHE

 

CMS Suspended Codes and Deleted Edits Reinstated by CMS

CMS updated the Practitioner and Outpatient NCCI Quarterly PTP files for Q4 2020.

In response to COVID-19 Public Health Emergency (PHE), the codes CMS had previously identified as “temporarily suspended” effective for Dec. 31, 2020 are reinstated effective Oct. 1, 2020.

For the Q4 2020 quarterly content update, the NTIS_ALL rule in the Code Auditing KnowlegePack and the OCE_CCI rule in the Facility KnowlegePack will updated with the reinstated edits effective Oct. 1, 2020.

The code pairs include the services such as those listed below:

  • Emergency Department Visits, Levels 1-5
  • Domiciliary, Rest Home, or Custodial Care services, New and Established patients, All levels
  • Home Visits, New and Established Patient, All levels
  • Care Planning for Patients with Cognitive Impairment
  • Psychological and Neuropsychological Testing
  • Therapy Services, Physical and Occupational Therapy, All levels
  •  Other services such as Venipuncture, Burn treatments, Stereotactic radiation treatment management, Injections of diagnostic/therapeutic substances lumbar or sacral 

Additional information on the CMS MUE and PTP quarterly changes:

National Medicaid CCI and MUE changes: 

 

Change Healthcare Reinstates Edits in UNBUN_PAIRS and CMS_UNBUN_PAIRS

As a result of this update from CMS, Change Healthcare code pair edits containing the same code pairs ‘deleted’ by CMS, which had only a CCI source, or only a CMS source, or both a CCI and a CMS source, were removed from UNBUN_PAIRS rule and the CMS_UNBUN_PAIRS rule. These edits will be added back for Q4 2020 effective Oct. 1, 2020.

These updates will be in the Q4 ClaimsXten quarterly content release scheduled for Sept. 23, 2020.

ClaimsXten Solutions KnowledgePack Update Report 4Q-2020

The ClaimsXten Solutions KnowledgePack Update Report Q4-2020 was posted to Download Connect on Friday, Sept. 11, 2020. This report identifies all content updates for UNBUN_PAIRS, NTIS_ALL and OCE_CCI rules to include the reinstated edits.

08/28/2020

2019-Novel Coronavirus (COVID-19) Suspended Procedure to Procedure Edits Now Reinstated; CMS Revision to MUE Values

Following is important information for ClaimsXten and ClaimsXten Select clients that are using the "STATE" versions of the MCAID MUE and MCAID NCCI rules in the CMS Sourced and Facility KnowledgePacks. This includes state fiduciaries, or their contractors, with non-disclosure agreements to access information on the secure RISSNET site.

Contents:

  • CMS Procedure to Procedure Updates
  • 4Q 2020 CMS MUE Updates (October)
  • 3Q 2020 CMS Replacement file for MUE; Updates Retroactive July 01, 2020

 

CMS Procedure to Procedure Updates

CMS had identified 297,082 code pairs that were titled “deleted” for the practitioner file and 75,573 code pairs that were titled as “deleted” for the hospital outpatient file. The suspension period identified by CMS was effective for Jan. 1, 2020. With the release of the CMS 4Q 2020 State Medicaid procedure to procedure Practitioner and Hospital Outpatient file, CMS is now reinstating the suspended edits effective for Oct. 10, 2020. The code pairs include the following services:

  • Emergency Department Visits, Levels 1-5
  • Domiciliary, Rest Home, or Custodial Care services, New and Established patients, All levels
  • Home Visits, New and Established Patient, All levels
  • Care Planning for Patients with Cognitive Impairment
  • Psychological and Neuropsychological Testing
  • Therapy Services, Physical and Occupational Therapy, All levels
  • Other services such as Venipuncture, Burn treatments, Stereotactic radiation treatment management
  • Injections of diagnostic/therapeutic substances lumbar or sacral
Rule Acronym Action Clinical Rationale

MCAID_NCCI_PRAC_STATE

Add NCCI Edits effective Oct. 1, 2020 Change Healthcare will add edits found in this rule and identified in the 4Q 2020 CMS NCCI file
MCAID_NCCI_OUTPT_HOSP_STATE Add NCCI Edits effective Oct. 1, 2020 Change Healthcare will add edits found in this rule and identified in the 4Q 2020 CMS NCCI file

 

4Q 2020 CMS MUE Updates (October):

Effective with the 3Q 2020 (July) release, CMS had reinstated the MUE (Medically Unlikely Edits) for Practitioner and Outpatient services. As a result, CMS reinstated the 197 CPT & HCPCS codes that were “temporarily” suspended. Some of the MUE values had significantly increased (e.g. MUE of 23, 24 or 25) for certain codes.

With the 4Q 2020 CMS MUE updates for Practitioner and Hospital Outpatient services, CMS has revised the MUE values effective for Oct. 01, 2020, to reflect the "pre-suspension" MUE value (e.g. MUE 1, 2, 3).

The procedures include the following services:

  • Psychotherapy codes (timed codes)
  • ESRD monthly service codes
  • Psychological and neuro-psychological testing – add-on codes
  • Health & Behavior intervention codes – add-on codes
  • Therapeutic procedures
  • Orthotics & Prosthetics training
  • Medical Nutrition therapy
  • Online Digital Evaluation and Management services; Telephone assessment codes 98966-98968; 99421-99423; 99441-99443
  • Office & Outpatient New & Established E&M codes – 99210-99215
Rule Acronym Action Clinical Rationale

MCAID_MUE_OUTPATIENT_STATE

Modify MUE value effective Oct. 1, 2020 Change Healthcare will modify edits found in this rule and identified in the 4Q 2020 CMS MUE file
MCAID_MUE_PRAC_STATE Modify MUE value effective Oct. 01, 2020 Change Healthcare will modify edits found in this rule and identified in the 4Q 2020 CMS MUE file 2020

 

3Q 2020 CMS Replacement file for MUE; Updates Retroactive July 01, 2020

CMS issues a replacement file for the 3Q 2020 State Medicaid MUE Practitioner and Hospital Outpatient file. As a result, CMS is updating two HCPCS codes to change the MUE value from "1" to "3" retroactive for 07/01/2020.

G2078 – Take-home supply of Methadone; up to seven (7) additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure.

G2079 –Buprenorphine (oral); up to seven (7) additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure.

Code Description Clinical Rationale

MCAID_MUE_OUTPATIENT_STATE

Modify MUE value effective July 01, 2020 Change Healthcare will modify edits found in this rule and identified in the 3Q 2020 CMS MUE file replacement file
MCAID_MUE_PRAC_STATE Modify MUE value effective July 01, 2020 Change Healthcare will modify edits found in this rule and identified in the 3Q 2020 CMS MUE file replacement file

 

08/12/2020

2019-Novel Coronavirus (COVID-19) Procedure Codes

The American Medical Association (AMA) created new procedure codes to respond to the 2019-Novel Coronavirus (COVID-19).

The following codes have been added to Content Manager category VALID_PROC for the PROC_INVALID rule and in PROC_ALLOW_ONCE category for the PROC_SINGLE_DOS rule.

The Content Manager publish is scheduled for the evening of Thursday, August 13, 2020. The tentative Content Manager release is 242.0.

Editing:

The new CPT codes will edit once per day testing frequency.

Should there be any additional information, an update will be provided in the ClaimsXten 4Q 2020 quarterly summary of updates communication scheduled for release on September 23, 2020.

Code Description
0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
0026U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum
86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen
86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (Coronavirus disease [COVID-19]); titer

 

05/26/2020

COVID-19 new Proprietary Laboratory Analysis (PLA) code for COVID-19 testing

American Medical Association (AMA) released a new PLA code––00202U––used to report infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.

The PROC_INVALID and PROC_SINGLE_DOS rules will be updated to include code 0202U, effective May 20, 2020 per AMA. 

May 2020 Local Coverage Determination (LCD) Release:

The following information applies to ClaimsXten Solutions customers who license the LCD_MED_NEC and LCD_PXDX_FREQ_MULTIDX rules in the National Coverage Determinations, Local Coverage Determinations KnowledgePack.

A Content Manager release will occur Tuesday evening, May 26, 2020 at 6 p.m. EST for these updates. The tentative Content Manager release number is 224.0.

Contact Information For additional information or questions, log in to the Customer Hub and submit a case to Product Support.

 

4/20/2020

CMS Guidance Related to NCD/LCD Policies

ClaimsXten™ and ClaimsXten™ Select customers who use the National and Local Coverage Determinations (NCD/LCD) KnowledgePack will want to review the latest CMS guidance on these policies. Download the announcement to see which NCD and LCD updates will be provided in the upcoming Content Manager release.

4/13/2020

COVID-19 Updates to MUE and PTP Files

On April 8, CMS updated the Practitioner and Outpatient Medically Unlikely Edits (MUE) files, as well as the National Correct Coding Initiatives (NCCI) quarterly procedure-to-procedure (PTP) files for practitioner and outpatient hospitals. This document provides information about the impact of these replacement files on ClaimsXten rules, as well as information about an impending Content Manager release designed to address the changes.

 

4/10/2020

DME MACs and CMS COVID-19 Updates

This notification is to inform you of recent published information from the DME MACs and CMS as it pertains to DME claims. It also contains an outline of previously published notifications to help consolidate all COVID-19 items into one reference guide.

Publication from CMS: Durable Medical Equipment, Prosthetics, Orthotics and Supplies: CMS Flexibilities to Fight COVID-19

Patients Over Paperwork

  • Where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable, DME Medicare Administrative Contractors have the flexibility to waive replacements requirements under Medicare such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.
  • Prior Authorization in DMEPOS: CMS is pausing the national Medicare Prior Authorization program for certain DMEPOS items. (CGS DME MAC references this pertains to certain power mobility devices (PMDs) and pressure reducing support surfaces (PRSS).)
  • DMEPOS Accreditation: CMS is not requiring accreditation for newly enrolling DMEPOS and extending any expiring supplier accreditation for a 90-day time period.
  • Signature Requirements: CMS is waiving signature and proof of delivery requirements for Part B drugs and Durable Medical Equipment when a signature cannot be obtained because of the inability to collect signatures. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.

Audits

Following a recent Webinar hosted by both DME MACs: Audits which include TPE, CERT’s, RAC and SMERCs are being suspended. Claims currently under TPE Audit review will be released for processing. Previously published CSA’s related to COVID-19:

CSA Title CSA Publication # CSA Date
COVID-19 Medicare
Day Supply Adjustment
CSA 032020d March 20, 2020
Financial Payment Changes CSA 040220e April 2, 2020

Change Healthcare continues to monitor this rapidly evolving situation and will provide updates as circumstances change. If you have any questions regarding this notification, please contact Pharmacy Support at 866.379.6389.

 

4/8/2020

COVID-19 CPT Codes and Telephone Services

This document is a detailed list of CPT codes that were recently revised by CMS and which became effective on March 1, 2020. Download the list of codes and physician fee schedule status indicator changes.

 

3/30/2020

New CMS and AMA Procedure and Diagnosis Codes

CMS: CMS developed the HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).  These codes are effective 02/04/2020 and are now available in Content Manager category VALID_PROC for the PROC_INVALID rule.  Additionally, CMS created one new diagnosis code U07.1. This code is currently available in Content Manager category VALID_DIAG_ICD_10 for the DIAG_INVALID_ICD10 rule.

AMA: CPT released code 87635 on March 13, 2020.  This Category I Pathology and Laboratory code is to report the testing for severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV-2) (Coronavirus disease [COVID-19]). The code is effective March 13, 2020 for use as the industry standard for reporting of novel coronavirus tests across the nation’s healthcare system.

This code is being added to Content Manager category VALID_PROC for the PROC_INVALID rule and is available as of March 19.

Editing: The new CPT and HCPCS codes will be edited for once per day testing frequency.  Additional edits will not be added at this time. Procedure codes U0001, U0002, and 87635 will pend for review if submitted more than once per date of service.

Should there be any additional information, an update will be provided in the ClaimsXten 2Q 2020 quarterly summary of updates communication.

Code Description
87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique
U0001 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL
U0002 2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC
U07.1 2019-NCOV ACUTE RESPIRATORY DISEASE

 

Contact Information

For additional information or questions, log onto the Customer Hub and submit a case to Product Support. Product support is also available by email at cacd.support@changehealthcare.com or by phone at 1-888-474-4262.

 

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