Regulatory Updates

State: All

Update to ‘J’ Drug Code List for Billing Home Infusion Therapy (HIT) Services

Date Posted : 06/9/2022

Date Effective : 07/1/2022

Program: Home Infusion Therapy

CR 12667 updates the list of home infusion drugs to add J1551 JB (Injection, immune globulin (cutaquig), 100mg) to payment category 2, effective July 1, 2022. The corresponding G-codes for category 2 drugs are G0069 or G0089. Note: We require the JB modifier for subcutaneous injection of the drug.

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State: All

DMEPOS Accreditation mln Fact Sheet Updated in January 2022

Date Posted : 01/1/2022

Program: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies, Pharmacy

This fact sheet describes Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers’ accreditation requirements. This includes verifying your business meets the required DMEPOS quality standards, types of eligible professionals exempted from accreditation, updating your enrollment information, and resources. This information applies to all DMEPOS suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for Medicare patients’ DMEPOS items and supplies.

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State: All

Update to Chapter 7, “Home Health Services”, of the Medicare Benefit Policy Manual (Pub 100-02)

Date Effective : 01/1/2022

Program: Home Health

In this Article, you’ll learn about:

• Updates to chapter 7 of the Medicare Benefit Policy Manual (Pub. 100-02) to
• incorporate Calendar Year (CY) 2022’s Policy Implementation of the Notice of Admission (NOA).
• The elimination of the Request for Anticipated Payment (RAP) policy.
• Corrections and clarifications regarding who may sign the certification and recertification for home health people with Medicare.

Make sure your billing staff knows about these changes.

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State: All

Face-to-Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Nonphysician Practitioners

Date Posted : 04/14/2022

Program: Home Health

The documentation of clinical findings by the physician/nonphysician practitioner should show:

• The encounter was related to the primary reason for home care;
• How the patient’s condition supports the patient’s homebound status; and
• How the patient’s condition supports the need for skilled services

Acceptable face-to-face documentation does not have to be lengthy or overly detailed. However, the face-to-face documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.

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State: West Virginia

Pharmacy Audit Integrity Act

Date Proposed : 01/17/2022

Date Effective : 06/10/2022

Date Adopted : 03/30/2022

Program:

Relates to the regulation of pharmacy benefit managers; defines terms; updates terminology; prohibits a pharmacy benefit manager from limiting a consumers access to prescription drugs through the designation of specialty drugs; prohibits a pharmacy benefit manager from placing certain requirements or restrictions on a pharmacist or pharmacy; requires pharmacy benefit managers to disclose any sub networks for specialty drugs to the Insurance Commissioner. (4) A pharmacy benefit manager may not require a pharmacy or pharmacist, as a condition for participating in the pharmacy benefit manager’s network, to obtain or maintain accreditation, certification, or credentialing that is inconsistent with, more stringent than, or in addition to state requirements for licensure or other relevant federal or state standards.

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State: All

Continuous Glucose Monitor: Provide Supplies for a Calendar Month

Date Posted : 03/31/2022

Date Expired : 03/31/2023

Program: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies, Pharmacy

We’ve heard from Medicare patients who have a continuous glucose monitor (CGM) that they’ve run out of testing supplies before the end of the month. These patients can’t get traditional testing supplies because they have a CGM. For example, if a patient gets 2 (14-day) CGM sensors for April, the patient won’t have enough to test on the 29th and 30th. Here’s how to prevent this serious issue:

1. Bill the supply allowance (code K0553) as 1 unit of service (UOS) per month. One UOS equals 1 month’s supply (31, 30, 29, or 28 days). You can only bill 1 UOS for code K0553 per month.
2. Check regularly to see what supplies your patient needs.
3. Send these supplies to meet the next month’s supply need.

The example below shows how to provide 14-day CGM supplies per calendar month to make sure your patient has enough:

• April – 30 calendar days: Provide 3 sensors (42-day supply)
• May – 31 calendar days: Provide 2 sensors (28-day supply) since the patient should have 12 days remaining from the previous month
• June – 30 calendar days: Provide 2 sensors (28-day supply) since the patient should have 9 days remaining from the previous month

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