HOME | ABOUT US | CONTACT US

(516) 222-1150 | 677 Broadway, 10th Floor, Albany, NY 12207

The New York State
Radiological Society, Inc.

New York State Chapter of the American College of Radiology

Economics Committee Contact Us

Economics Committee

NYSRS Logo
NYSRS ECONOMICS REPORT
9, 10 April 2021

 

Contents

Pending Congressional Action to Extend 2% Sequester Reduction Suspension
Legislation pending to extend the moratorium on the 2% sequestration on Medicare payments.

Open Payments
Available soon for review.

Medicaid Eligibility Verification System and Dispensing Validation System Provider Manual
Verify member eligibility prior to the provision of services and obtain authorization(s) for specific covered services.

Workers’ Comp Medical Treatment Guidelines Lookup Tool
The MTG Lookup Tool allows users to quickly determine whether a particular condition or treatment/test combination is “Recommended,” “Not Recommended” or “Conditional,” according to the MTGs.

Nuclear Medicine Billing Reminder
National Government Services has identified an issue with billing for nuclear medicine services under CPT codes 78429-78434.

National Government Services: Salvage High-intensity Focused Ultrasound Treatment in Prostate Cancer (J06, JK) (A56702) – Local Coverage Article
HIFU has been reviewed with the changes to coding.

Local Coverage Determination Update
LCD for NGS facet joint interventions for pain management will be available for comment soon.

 

Pending Congressional Action to Extend 2% Sequester Reduction Suspension

The Senate recently voted 90-2 to extend the 2 percent Medicare sequester moratorium that expires on April 1. The legislation will provide a nine-month extension of the moratorium, through December 31.

The House of Representatives passed different legislation earlier that would both extend the moratorium through the end of the pandemic and eliminate an additional 4 percent Medicare sequester scheduled to take effect on January 1, which was required to offset part of the cost of passing the American Rescue Plan COVID-19/stimulus package. Consequently, the House will need to pass the Senate language when it returns from its Easter recess in mid-April. The House is expected to vote favorably.

In anticipation of possible Congressional action to extend the 2% sequester reduction suspension, CMS instructed the Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting providers’ cash flow. This will minimize the volume of claims the MACs must reprocess if Congress extends the suspension; the MACs will automatically reprocess any claims paid with the reduction applied if necessary.

 

Open Payments

The Centers for Medicare & Medicaid Services will publish the Open Payments Program Year 2020 data and updates to the previous program years’ data in June 2021.

Physician and teaching hospital review of the data is voluntary, but strongly encouraged. Please keep in mind the following reminders:

  • Disputes must be initiated by May 15, 2021 in order to be reflected in the June 2021 data For more information on review and dispute timing and publication, refer to the Review and Dispute Timing and Data Publication Quick Reference Guide.
  • CMS does not meditate or facilitate Physicians and teaching hospitals should work directly with reporting entities to resolve disputes.
  • Registration in the Open Payments system is required in order to participate in review and dispute activities.

If you have never registered with Open Payments before:

Make sure you have your National Provider Identifier (NPI) number and State License Number (SLN). Initial registration is a two-step process:

  1. Register in the CMS Identity Management System (IDM);
  1. Register in the Open Payments system

For users who have previously registered: Users that have registered during previous program years do not need to re-register.

Please note: If the account has not been accessed for within the last 60 days the account will have been locked due to inactivity. To unlock an account, go to the CMS Enterprise Portal, enter your user ID and correctly answer all challenge questions to gain access to your account. You will be prompted to create a new password.

If the account has not been accessed for 180 days or more, the account will be deactivated. To reinstate the account, call the Open Payments Help Desk at 1-855-326-8366; (TTY Line:1-844-649-2766)

For more information about the registration process, visit the physician and teaching hospital registration page on the Open Payments website.

To search for your Open Payments go here.

 

Medicaid Eligibility Verification System and Dispensing Validation System Provider Manual

The Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) enable a provider to verify member eligibility prior to the provision of services and obtain authorization(s) for specific services covered under DVS. A member, also known as a client, recipient, or enrollee, must present an official Common Benefit Identification Card (CBIC) to the provider when requesting services. As the issuance of a CBIC does not constitute full authorization for provision of medical services and supplies, the member eligibility must also be verified through eMedNY to confirm the member’s subsequent eligibility for services and supplies. A provider that does not verify eligibility prior to provision of services will risk nonpayment for those services. A provider can use the following methods to access the verification process through eMedNY:

  • Telephone verification method: Audio Response Unit (ARU)
  • Other access methods:
    • Electronic Provider Assisted Claim Entry System (ePACES)
    • Central Processing Unit (CPU): CPU-to-CPU link
    • eMedNY eXchange
    • File Transfer Service using Simple Object Access Protocol (SOAP)
    • CORE (Committee on Operating Rules for Information Exchange compliant) Web Services

Information regarding MEVS access methods and links to those listed above can be found within eMedNY’s New York State Medicaid: Medicaid Eligibility Verification System (MEVS) Methods document.

 

MEVS/DVS Provider Manual

The MEVS/DVS Provider Manual is a valuable resource to assist providers in interpreting the MEVS message providers encounter when checking eligibility. It is also an introductory guide for:

  • Information about CBICs and/or forms
  • The Telephone ARU Verification method
  • Important Reference tables:
    • Eligibility Benefit Descriptions
    • Reject Reason Codes
    • Decision Reason Codes
    • Exception Codes
    • County/District Codes
    • New York City Office Codes Additional Information and Questions:
  • For questions regarding Medicaid eligibility training and/or other ePACES training related functions, visit eMedNY’s Provider Training page.
  • All provider questions regarding messages received, must be directed to the eMedNY Call Center at (800) 343-9000.

 

Workers’ Comp Medical Treatment Guidelines (MTG) Lookup Tool

The MTG Lookup Tool allows users to quickly determine whether a particular condition or

treatment/test combination is “Recommended,” “Not Recommended” or “Conditional,” according to the MTGs. When a treatment/test name is selected, the relevant section of the full MTGs for that condition will display. This online tool will help speed treatment decisions and ultimately provide more effective and efficient care for injured workers.

The MTG Lookup Tool also has a feature for use by providers that produces a Verification Summary document (PDF) that confirms a lookup was completed, provides treatment recommendations for that condition, and displays patient-specific case information. This document can be kept by the health care provider or attached to any request for service or medical bill being sent to an insurer as verification that the treatment adheres to the recommendations set forth in the MTGs.

The MTG Lookup Tool is available for the following MTGs:

  • Elbow Injuries
  • Foot and Ankle Injuries
  • Hip and Groin Injuries
  • Hand, Wrist and Forearm Injuries (including Carpal Tunnel Syndrome)
  • Occupational Interstitial Lung Disease
  • Occupational/Work-Related Asthma
  • Post-Traumatic Stress Disorder
  • Major Depressive Disorder

The full MTGs are available on the Board’s website and accessible via the Medical Portal.

To access the Medical Portal and these resources, visit the Board’s website and select “Medical Portal”

from the Online Services menu at the top of the homepage. Additional Resources

For more details and a brief demo of the MTG Lookup Tool, take a few minutes to view the MTG Lookup Tool video tutorial. More information is also available on the “What’s New” section of our Medical Treatment Guidelines webpage.

For MTG Lookup Tool questions, email MTGLookupTool@wcb.ny.gov.

 

Nuclear Medicine Billing Reminder

National Government Services has identified an issue with billing for nuclear medicine services under CPT codes 78429-78434.

NGS has been receiving claims without the service facility location on the electronic claim. It is required to submit the service facility location in Segment 2310C on the electronic claim for the claim to process correctly. When the service facility location is not provided, NGS will send an additional documentation request for the information. If the necessary information is not received, the claim may be paid incorrectly, or denied.

If you submit these codes for nuclear medicine billing make sure you are providing this information on the claim when submitting it for Medicare consideration.

Posted 2/16/2021

 

National Government Services: Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (J06, JK) (A56702) – Local Coverage Article (LCA)

HIFU has been reviewed with the following changes to coding.

Added the following code to CPT/HCPCS code group 1:

55880 – Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance

Added the following code to CPT/HCPCS code group 1 paragraph to clarify the reporting of Part B physician services:

55899 – Unlisted procedure, male genital system

Replaced CPT code C9747 with the following CPT code:

55880 – Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance

Reviewed: 02/05/2021. Effective: 01/01/2021.

View Full Policy – PDF

 

FUTURE Local Coverage Determination (LCD)

Facet Joint Interventions for Pain Management (L35936)

 

Respectively Submitted
NYSRS Economics Committee

Mark J. Adams, MD, MBA, FACR – CAC, CMS Manjil Chatterji, MD – MIPs, QPP, MACRA
Victor Scarmato, MD, FACR – Managed Care Amichai Erdfarb, MD
Atul Gupta, MD – Workers Comp Florence Doo, MD – Alternative Payment Models
Raja Cheruvu, MD – Medicaid Joshua Kern, MD
Reza Sirous, MD  Ari Jonisch, MD

 

 

Upcoming Events

Past Events

Spring All Members Meeting

This will be a VIRTUAL MEETING – details to follow