Introduction
The Centers for Medicare & Medicaid Services (CMS) has introduced significant updates to its Encounter Data Processing System (EDPS) as part of its December 2024 release. These improvements are pivotal for Medicare Advantage (MA) organizations, ensuring better alignment with regulatory standards and enhancing the accuracy of encounter data submissions. In this blog, we’ll unpack the details of these updates, explore their implications, and highlight the value they bring to data processing workflows.
Key Highlights of the December 2024 Release
CMS continues its commitment to improving data accuracy and reliability. The December 2024 updates focus on both the introduction of new edits and refinements to existing ones. Let’s dive into the specifics.
New Edit: Ensuring Proper Billing for Diabetes Screenings
Edit 20160 – Incorrect TOB for Diabetes Screening
This newly implemented edit, Edit 20160, is designed to ensure diabetes screening claims align with CMS guidelines. It validates submissions based on the presence of specific Healthcare Common Procedure Coding System (HCPCS) codes, associated diagnosis codes, and applicable Types of Bill (TOB).
Validation Rules:
HCPCS Codes: Applies to diabetes screening HCPCS codes (82947, 82950, 82951, and 83036).
Diagnosis Codes: Checks for ICD-9 code V77.1 or ICD-10 code Z13.1.
Date of Service: Validates based on the ICD-10 implementation date (on or after October 1, 2016) and specific updates for 2024.
TOB Restrictions: Excludes TOBs 12X, 13X, 14X, 22X, 23X, and 85X.
This enhancement ensures that billing for diabetes screenings is both compliant and precise, helping organizations mitigate errors that could disrupt claims processing.
Updates to Existing Edits
1. Edit 20715 – Expanding AWV HCPCS Code Validation
This update to Edit 20715 now incorporates validations for Social Determinants of Health (SDOH) Risk Assessment (HCPCS Code G0136). Effective January 1, 2024, it requires the following:
Correct TOB submission for HCPCS codes G0438, G0439, and G0136.
Date of Service validations for SDOH risk assessments.
The inclusion of SDOH underscores CMS’s broader focus on holistic health assessment in care delivery.
2. Edit 22020 – Strengthening Validation for Condition and Occurrence Codes
Edit 22020 has undergone critical updates:
Expanded TOB Logic: Now includes TOB 34X (Home Health).
Header-Level Posting: Shifts from service line to header-level validation, streamlining error identification.
These refinements ensure claims involving condition code ‘C3’ and occurrence span code ‘M0’ are meticulously validated, reducing conflicts and promoting smoother adjudication.
The Broader Impact
These updates emphasize CMS’s ongoing effort to ensure accurate, comprehensive, and error-free data submissions. By aligning edits with the Fee-for-Service (FFS) Change Requests and incorporating modernized billing practices, CMS is paving the way for a more robust Medicare Advantage ecosystem.
Organizations submitting encounter data should review these changes closely and adjust their systems to meet the new standards. This proactive approach will prevent errors, reduce claim rejections, and foster compliance.
Appendix: Leveraging the UB-04 Data Specifications
The updates also underscore the importance of adhering to the National Uniform Billing Code (NUBC) standards. CMS, in collaboration with the American Hospital Association (AHA), ensures these standards are seamlessly integrated into encounter data systems. However, as per the AHA’s copyright notice, proper licensing and compliance with their usage terms remain essential.
FAQs
1. When will the new and updated edits take effect?
The changes will be effective for submissions starting December 13, 2024.
2. How can organizations prepare for these updates?
By reviewing the updated CMS guidelines, aligning internal systems, and ensuring staff are trained on new requirements.
Final Thoughts
The December 2024 updates to the CMS EDPS mark a critical step toward enhancing data integrity and compliance in the Medicare Advantage landscape. By addressing common data issues and introducing robust validation mechanisms, CMS aims to streamline claims processing and improve healthcare outcomes.
Stay informed and prepared to embrace these changes—your commitment to compliance ensures the delivery of high-quality care under the Medicare Advantage program.
For more detailed information, you can access the official CMS document: Encounter Data Software Release Updates: December 2024 in Memos of Health Plan Management System Home Page