This week in Medicare updates–06/01/2016
July calendar year (CY) 2016 quarterly update to the Medicare physician fee schedule database
On May 20, CMS released a recurring update notification stating that payment files were issued to contractors based upon the CY 2016 Medicare physician fee schedule final rule. This change request amends those payment files. This recurring update notification applies to Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 30.1.
Effective date: January 1, 2016
Implementation date: July 5, 2016
View Transmittal R3528CP.
View MLN Matters article MM9633.
Claim Status Category and Claim Status Codes update
On May 20, CMS released a change request to update as needed the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. This recurring update notification can be found in Chapter 31, Medicare Claims Processing Manual, Section 20.7.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3527CP.
View MLN Matters article MM9550.
Guidance on implementing system edits for certain DME, prosthetics, orthotics and supplies (DMEPOS)
On May 20, CMS released a transmittal stating that Section 302 of the Medicare Modernization Act of 2003 added a new paragraph to the Social Security Act requiring the secretary to establish and implement quality standards for suppliers of DMEPOS. All suppliers that furnish such items or services required in the new paragraph as the secretary determines appropriate must comply with the quality standards to receive Medicare Part B payments and to retain a supplier billing number. The covered items and services are defined in the Act.
Effective date: October 3, 2016
Implementation date: October 3, 2016
View Transmittal R1669OTN.
View MLN Matters article MM9371.
FY 2016 to FY 2017 Nursing Home Action Plan
On May 20, CMS released the Nursing Home Action Plan. The FY 2016 to 2017 Nursing Home Action Plan is posted on the CMS website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/NHs.html.
View the survey and certification letter.
Medicare Compliance Review of Wesley Medical Center for 2012 and 2013
On May 23, the OIG posted a report stating Wesley Medical Center, in Wichita, Kansas, complied with Medicare billing requirements for 208 of the 246 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 38 claims, resulting in overpayments of $182,000 for calendar years 2012 and 2013. Specifically, 27 inpatient claims had billing errors, resulting in overpayments of over $92,000, and 11 outpatient claims had billing errors, resulting in overpayments of over $89,000. These errors occurred primarily because the hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.
View the report.
Medicare Compliance Review of Huntsville Hospital for 2013 and 2014
On May 23, the OIG posted a report stating Huntsville Hospital, in Huntsville, Alabama, complied with Medicare billing requirements for 178 of the 277 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 99 claims, resulting in net overpayments of $24,000 for the audit period. Specifically, seven inpatient claims had billing errors, resulting in net overpayments of $18,000, and 92 outpatient claims had billing errors, resulting in overpayments of $6,000. These errors occurred primarily because the hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of its sample results, the OIG estimated that the hospital received overpayments of at least $203,000 for the audit period.
View the report.
Change to transmittal regarding JW modifier: Drug amount discarded/not administered to any patient
On May 24, CMS rescinded Transmittal 3508, dated April 29, and replaced it with Transmittal 3530. The original transmittal established that claims for discarded drug or biological amount not administered to any patient, shall be submitted using the JW modifier and providers must document the discarded drugs or biologicals in the patient's medical record.
Effective date: July 1, 2016
Implementation date: July 5, 2016
View Transmittal R3530CP.
View MLN Matters article MM9603.
Third quarter notification for FY 2016 of new interest rate for Medicare overpayments and underpayments
On May 25, CMS rescinded Transmittal 266, dated April 12, and replaced it with Transmittal 267 to remove CEDI from the business requirements. All other information remains the same. The original transmittal is regarding the interest rate for the third quarter FY 2016.
Effective date: April 19, 2016
Implementation date: April 19, 2016
View Transmittal R267FM.
Submission for OMB review; comment request
On May 26, CMS posted a notice in the Federal Register stating that it is accepting comments on CMS–855 (A, B, I), Medicare Enrollment Application. Comments are due June 27.
View the notice in the Federal Register.
Leave a comment.
Incomplete and inaccurate licensure data allowed some suppliers in Round 2 of the DME Competitive Bidding Program that did not have required licenses
On May 26, the OIG posted a report stating that some contract supplies in Round 2 of the DME Competitive Bidding Program had not met all of the competitive bidding licensure requirements. Specifically, of the 146 suppliers covered in the OIG’s audit, 69 suppliers met licensure requirements. However, 63 suppliers did not meet licensure requirements for some of the competitions for which they received a contract. Additionally, 14 suppliers need to be further researched by CMS and its contractors to determine if they met licensure requirements.
View the report.
Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APM)
CMS released a fact sheet regarding MIPS and advanced APMs. On April 27, HHS issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed sustainable growth rate formula with a new approach to paying clinicians for the value and quality of care they provide. The proposed rule would implement these changes through the unified framework called the "Quality Payment Program," which includes two paths: MIPS and advanced APMs.
View the fact sheet.