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Practice Information

Summary on Medicare Coding for 2021

    • Some codes of telehealth will become permanent after the pandemic ends. The codes that would apply for office visit via televisit would be 99347-99348
    • All other telehealth codes are anticipated to end at the of 2021
    • Medical decision making or total time with patient has been revised. The focus will no longer be total face to face time spent with the patient but “time” it takes to make decision on care for the patient. Examples include the following.
o   Reviewing labs, imaging studies, other physician’s notes
o   Independent interpretations of test
o   Discussion of management with the patient, patient family, other physicians
o   Ordering test
    • Preparing to see the patient and reviewing prior data adds to the “total time” for selecting the level of care. If these are documented in the note, it will strengthen the complexity and coding of the note.
    • Add risk of complications/morbidity associated with patient’s care. Side effect of medications can be considered as a complication such as chronic cough with ACEI and swelling with CCI.
    • Coding for visits has been simplified into straightforward, low, moderate, and high. The criteria for each are listed in the PowerPoint.
    • If a patient’s care requires more than the minimal time, prolonged services 99417 coding can be used which will give an additional 15 minutes.

December 2020 updates


STARK LAW REVISION: The law prohibiting Medicare self-referral was passed in 1989. As CMS has begun to realize the role of value-based payments, they became keenly aware certain arrangements that were previously prohibited could lead to improved quality outcomes, improved health system efficiencies, and lower costs. Details of this new role will become increasingly clear over the next few weeks but it is hopeful that demonstrating quality, cost-effective care will finally be rewarded as opposed to punished.

As many of you are aware, First Coast Service Options, which is the Medicare carrier for Florida, has joined with Novitas under a single parent company.  It is expected that they will have similar if not identical coverage policies in the near future. New LCDs for FFR-CT and for non-invasive testing for stable ischemic heart disease are being developed. Although they’re developed by regional Medicare carriers, it is assumed that the chosen LCD will eventually serve as an NCD applicable to our patients with standard fee for service Medicare. A final coverage policy for FFR CT is being developed. The American College of Cardiology has recently submitted suggestions for expanding coverage.

Novitas is proposing an LCD on testing for stable ischemic heart disease. Cardiac PET is covered for perfusion but there is no specific mention of myocardial blood flow. FDG imaging for cardiac sarcoidosis is covered only if the patients are unable to carry out cardiac MRI. Serial testing in a stable asymptomatic patient is not considered appropriate for coverage. All stress modalities are considered equal. Therefore, it should clear the way for a clinician to choose the best test is for his/her patient. My concern is this may lead to test substitution. Again, our national ACC is very much involved in this.

First Coast is now requiring dual diagnosis for cardiac stress test time. This is leading to significant denials. Although most claims are paid on first or second appeal, it can take up to 120 days or more for payment. Obviously, this is unacceptable. National and state chapters and subspecialty organizations are all working on this together. For more information please review: https://medicare.fcso.com/Cardiology/0469513.asp.


United Health Care appears to be encouraging the use of coronary CTA and FFR-CT preferentially functional imaging (MPI, stress echo, stress CMR) in patients who are loaded intermediate risk they apply that most functional imaging will no longer be required in the future. There is significant industry support behind this initiative including an industry supported white paper that was published in JACC. The FCACC is working with national ACC to ensure the patient receives the right test at the right time when the physician completes the appropriate use criterion.

Humana has declared cardiac PET-CT an experimental procedure and is refusing coverage. All dedicated standalone PET cameras require CT attenuation and thus must carry out a CT scan for attenuation correction. This is clearly different from a hybrid diagnostic CT. Florida ACC is working with ASNC, SNMMI and national ACC in an attempt to resolve this critical reimbursement issue.

On the good news front BCBS of Florida is covering coronary CTA for intermediate preclinical risk ages 40-75. For details consult the following: http://mcgs.bcbsfl.com/MCG?activity=openSearchedDocMcg&imgId=75S7UABPY9FVM4CMREP


Medicare uses a variety of mechanisms to set policies for coverage of services. At the national level, the Centers for Medicare and Medicaid Services (CMS) may issue a National Coverage Determination (NCD). Medicare administrative contractors (MAC) may issue Local Coverage Determinations (LCDs) or may choose to cover services or therapies on a case-by-case basis. If an NCD or LCD does not exist, it does not simply mean that Medicare will not pay for the service.

When national coverage has not been specified in NCD, MACs may choose to provide coverage for a service through an LCD. An LCD may be written in a manner that provides broad coverage, coverage with certain restrictions, or non-coverage. MACs develop LCDs through a process that is less formal than that used to develop an NCD. That process includes expert feedback from designated physician representatives. In Florida these include our CAC Representatives listed about who attend three formal meetings per year and consult with our carrier, First Coast Service Options.

Additional Tools for Practices
This tool provides current and draft local coverage determinations (LCDs), when they exist, for Medicare-covered procedure codes. Not every procedure code is covered by an LCD. For previous versions of an LCD, refer to the CMS Medicare coverage database. Click here for the tool.

Heart House has developed a network of CAC representatives from across the nation that meet as a group to review trends and analyze issues. The chair of the Third Party Reimbursement Committee is active at the national level through meetings and constant communication with colleagues.

National ACC has a web portal dedicated to practice issues. See this link for in-depth issues."Do Your PART" to Improve the Prior Authorization Process 

Payer-directed prior authorization for diagnostic imaging and medications is a tremendous barrier to patient care in today's cardiovascular care landscape. Help the ACC improve the prior authorization process by expanding the current data collection of inappropriate denials and difficult cases. ACC members and their staff are encouraged to submit instances of incorrect prior authorization denials for cardiac procedures and PCSK9 prescription through ACC's Prior Authorization Tool (PARTool) suite. Robust data collection is the first step to identifying and correcting exhaustive administrative burdens. Do your PART to improve the prior authorization.
Submit your data at ACC.org/PARTool today!


Talk Team Building, Leadership in Sept. 25 Coffee With the ACC President

What does it take to build a strong team and establish effective leadership? Join us Saturday, Sept. 25, at 10 a.m. ET for an interactive discussion hosted by ACC President Dipti Itchhaporia, MD, FACC. Hear from Maddie Musselman, two-time women's water polo Olympic gold medalist and three-time world champion, and Chris Fussell, veteran U.S. Navy SEAL and president of McChrystal Group, about their experiences being part of successful teams and organizations. RSVP by Thursday, Sept. 23, and learn more about the series, including upcoming gatherings, here.

New CMS Quality Measure Resources

CMS recently released version 17.0 of its Measures Management System Blueprint, a guide documenting the essential criteria of quality measure development, implementation and maintenance. The guide is a resource not only for experienced measure developers and those wishing to submit measures for use in CMS programs, but also for those who wish to enhance their knowledge of the entire measurement lifecycle. CMS has also released Quality Measures: How They Are Developed, Used, & Maintained, a resource for those who are new to quality measures and would benefit from a basic overview of measure development.

2020 FDA Draft Guidance For Diabetes Drugs: Lessons Learned and Future Directions

A March 2020 FDA draft guidance recommended that post-marketing surveillance for SGLT2 inhibitors and GLP-1RAs be based on premarketing safety signals that look beyond cardiovascular risk. A new expert analysis on ACC.org looks at the 2020 guidance and explores lessons learned and future directions. According to the authors, “despite proven [cardiovascular] benefit and multiple society guideline recommendations, the use of these medicines remains profoundly limited, and strategies to improve their uptake in clinical practice are urgently needed.” They recommend that future research “maintain the pipeline of rigorous multisystem evaluation of glucose-lowering drugs with further innovations in fields like obesity, fatty liver disease and arrhythmia.” Read more. Looking for more? Earn credit, while learning how to apply emerging science to reduce cardiovascular risk in diabetes as part of ACC’s free online course, available here.

Now an All-Virtual Experience: CV Transforum Fall’21

MedAxiom will host CV Transforum Fall’21 as an all-virtual experience, Oct. 7-9. Join the conference from the comfort of your home or office for three days of education, innovation and networking. The last two CV Transforum Virtual conferences brought together record numbers of health care professionals and industry innovators. MedAxiom looks forward to delivering another exciting and engaging experience, virtually. Check out the updated agenda and register today.

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