This week in Medicare updates–02/17/2016

February 16, 2016

Medicare Insider

Identifying "No Documentation" medical necessity denials for claims flagged for Recovery Auditor review

On February 5, CMS rescinded Transmittal 1483, dated March 31, 2015, and replaced it with Transmittal 1625 to make it consistent with direction given in CR 9215, specifically updating BR 8913.2. All other information remains the same. The original transmittal provided a Recovery Audit-specific "No documentation" reason code for MACs to append to prepayment claim denials.

Effective date: July 1, 2015

Implementation date: July 6, 2015, for Define/Analyze and Design Application; October 5, 2015, for Hours for Code Development/Test and Alpha Testing

View Transmittal R1625OTN.

Shared System Enhancement 2015 Analysis and Design HUOPCUT hospice period and Health Maintenance Organization processing

On February 5, CMS released a transmittal requesting that the CWF Maintainer standardize the claim logic for hospice periods and determination of Medicare liability dates. Claim logic is in all three CWF *CUT programs.

Effective date: July 1, 2016, for Analysis and Design

Implementation date: July 5, 2016, for Analysis and Design

View Transmittal R1622OTN.

Screening for the Human Immunodeficiency Virus (HIV) infection

On February 5, CMS released a change request to inform contractors that CMS has determined that the evidence is adequate to conclude that screening of HIV infection for all individuals between the ages of 15-65 years is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled in Part B.

Effective date: April 13, 2015

Implementation date: March 7, 2016, for non-shared A/B MAC edits; July 5, 2016 for CWF analysis and design; October 3, 2016, for CWF Coding, Testing and Implementation, MCS, and FISS Implementation; January 3, 2017, for Requirement 9403.04.9

View Transmittal R3461CP.

View Transmittal R190NCD.

Screening for cervical cancer with Human Papillomavirus (HPV) testing

On February 5, CMS released a change request stating CMS has determined that for dates of service on or after July 9, 2015, evidence is sufficient to add HPV testing under specified conditions.

Effective date: July 9, 2015

Implementation date: March 7, 2016, for non-shared MAC edits; July 5, 2016, for CWF analysis and design; October 3, 2016, for CWF Coding, Testing and Implementation, MCS, and FISS Implementation; January 3, 2017, for Requirement BR9434.04.8.2

View Transmittal R3460CP.

View Transmittal R189NCD.

Revision to Fiscal Intermediary Shared System (FISS) lab travel allowance editing to include new specimen collection code G0471

On February 5, CMS released a change request updating FISS reason code 32436 to include HCPCS code G0471 in the list of specimen collection fee codes that will allow the travel allowance to be paid on outpatient claims.

Effective date: April 1, 2016

Implementation date: July 5, 2016, for claims processed on or after

View Transmittal R1619OTN.

View MLN Matters article MM9471.

Promise Hospital of Ascension incorrectly billed Medicare inpatient claims with Kwashiorkor

On February 8, the OIG posted a report stating that Promise Hospital of Ascension, in Gonzales, Louisiana, did not comply with Medicare requirements for billing Kwashiorkor on any of the 62 claims reviewed. The hospital used diagnosis code 260 for Kwashiorkor but should have billed for other forms of malnutrition or no malnutrition at all. On four of the inpatient claims, substituting a more appropriate diagnosis code produced no change in the diagnosis-related group or payment amount. However, for the remaining 58 inpatient claims, the errors resulted in overpayments of $465,000. The hospital believes that all claims identified were appropriately submitted for payment.

View the report.

More than 10 million people with Medicare have saved over $20 billion on prescription drugs since 2010

On February 8, CMS posted a press release announcing HHS published new information that shows that millions of seniors and people with disabilities with Medicare continue to save on prescription drugs and see improved benefits in 2015 as a result of the Affordable Care Act.

View the press release.

Privacy Act of 1974

On February 9, CMS posted a notice in the Federal Register stating that, in accordance with the requirements of the Privacy Act of 1974, as amended, it is announcing the re-establishment of a Computer Matching Program that CMS plans to conduct with the Social Security Administration.

View the notice in the Federal Register.

Recovery Auditor quarterly newsletters available for 2015 fourth quarter and 2016 first quarter

On February 9, CMS updated its Recovery Auditor website with two new downloads: Medicare FFS Recovery Audit Program 1st Qtr 2016 and Medicare FFS Recovery Audit Program 4th Qtr 2015.

View FFS Recovery Audit Program 1st Qtr 2016.

View FFS Recovery Audit Program 4th Qtr 2015.

Proposed Collection; Comment Request

On February 10, CMS posted a notice in the Federal Register stating that it is accepting comments on: CMS–276, Prepaid Health Plan Cost Report; CMS–1957, Social Security Office Report of State Buy-in Problem; CMS–10599, Medicare Prior Authorization of Home Health Services Demonstration; CMS–10600, Evaluation of the Medicare Patient Intravenous Immunoglobulin Demonstration. Comments are due April 11.

View the notice in the Federal Register.

Leave a comment.

Medicare did not pay selected inpatient claims for bone marrow and stem cell transplant procedures in accordance with Medicare requirements

On February 10, the OIG posted a report stating that Medicare paid 10 of 143 selected inpatient claims for bone marrow and stem cell transplant procedures in accordance with Medicare requirements. However, 133 claims did not comply with those requirements. For 120 of these claims, the hospitals incorrectly billed Medicare Part A for beneficiary stays that should have been billed as outpatient or outpatient with observation services. These claims did not have clinical evidence supporting that an inpatient level of care was required before, during, or after the transplant procedures were performed. For the remaining 13 claims, the hospitals billed incorrect Medicare Severity Diagnosis-Related Groups (MS-DRGs). As a result of the 133 errors, Medicare overpaid the hospitals by $6.3 million. Medicare overpaid the hospitals because existing controls were not effective in preventing the overpayments.

View the report.

Decision memorandum for percutaneous left atrial appendage closure therapy

On February 10, CMS posted a decision memorandum stating that it covers percutaneous left atrial appendage closure for non-valvular atrial fibrillation through Coverage with Evidence Development when it meets certain conditions.

View the decision memorandum.

Notice of seven membership appointments to the Advisory Panel on Hospital Outpatient Payment

On February 11, CMS posted a notice in the Federal Register announcing seven new membership appointments to the Advisory Panel on Hospital Outpatient Payment. The seven new appointments to the panel will each serve a four-year period. The new members have terms that begin in calendar year (CY) 2016 and end in CY 2020. The purpose of the panel is to advise the secretary of HHS and the administrator of CMS concerning the clinical integrity of the Ambulatory Payment Classification groups and their relative payment weights. The panel also addresses and makes recommendations regarding supervision of hospital outpatient therapeutic services. The advice provided by the panel will be considered as CMS prepares the annual updates for the hospital outpatient prospective payment system.

View the notice in the Federal Register.

Reporting and returning of overpayments

On February 12, CMS posted a final rule in the Federal Register that requires providers and suppliers receiving funds under the Medicare program to report and return overpayments by the later of the date that is 60 days after the date on which the overpayment was identified or the date any corresponding cost report is due, if applicable. The requirements in this rule are meant to ensure compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against fraud and improper payments. This rule provides clarity and consistency in the reporting and returning of self-identified overpayments. These regulations are effective March 14.

View the final rule in the Federal Register.

View the fact sheet.

Review of Medicare payments for laboratory tests billed with an AY modifier by DVA Laboratory Services, Inc.

On February 12, the OIG posted a report stating that DVA Laboratory Services, Inc. (DVA), did not always comply with Medicare requirements for tests billed with an AY modifier for beneficiaries with ESRD. Specifically, for 62 of the 100 beneficiary-days, DVA submitted separate claims using the AY modifier for tests furnished for the treatment of ESRD contrary to the consolidated billing requirement. In addition, DVA did not always comply with other Medicare requirements. These errors occurred primarily because DVA did not have adequate controls to comply with certain Medicare requirements. On the basis of the OIG’s sample results, it estimated that Medicare overpaid DVA at least $989,000 for tests that were furnished for the treatment of ESRD.

View the report.

Review of Medicare payments for laboratory tests billed with an AY modifier by Total Renal Laboratories, Inc.

On February 12, the OIG posted a report stating that Total Renal Laboratories, Inc. (TRL), did not always comply with Medicare requirements for tests billed with an AY modifier for beneficiaries with ESRD. Specifically, for 60 of the 100 beneficiary-days, TRL submitted separate claims using the AY modifier for tests furnished for the treatment of ESRD contrary to the consolidated billing requirement. In addition, TRL did not always comply with other Medicare requirements. These errors occurred primarily because TRL did not have adequate controls to comply with certain Medicare requirements. On the basis of the OIG’s sample results, it estimated that Medicare overpaid TRL at least $1.2 million for tests that were furnished for the treatment of ESRD.

View the report.