This week in Medicare updates–06/29/2016
Update to transmittal regarding systems changes for temporary exception for certain severe wound discharges from certain long-term care hospitals
On June 16, CMS rescinded Transmittal 1654, dated April 29, and replaced it with Transmittal 1675 to correct the effective date in business requirement 9599.1 and add the Fiscal Intermediary Shared System as responsible for BR9599.2.1. All other information remains the same.
Effective date: April 21, 2016
Implementation date: October 3, 2016
View Transmittal R1675OTN.
View MLN Matters article MM9599.
October quarterly update to 2016 annual update of HCPCS codes used for SNF Consolidated Billing (CB) enforcement
On June 17, CMS released a transmittal providing updates to the lists of HCPCS codes that are subject to the consolidated billing provision of the SNF PPS. Changes to CPT/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise CWF edits to allow MACs to make appropriate payments in accordance with policy for SNF CB in Chapter 6, Medicare Claims Processing Manual, section 20.6.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3546CP.
View MLN Matters article MM9688.
Special provisions for lab Additional Documentation Requests (ADR)
On June 17, CMS released a change request providing an update for the special provisions for lab ADRs.
Effective date: July 18, 2016
Implementation date: July 18, 2016
View Transmittal R657PI.
Adoption of the 2012 edition of the National Fire Protection Association (NFPA) 101-Life Safety Code (LSC) and 2012 edition of the NFPA 99-Health Care Facilities Code (HCFC)
On June 20, CMS posted a survey and certification letter in reference to the fact that it has adopted, by regulation, the 2012 LSC and the 2012 HCFC. The regulation effective date is July 5, 2016. CMS will begin surveying for compliance with the 2012 LSC and HCFC on November 1, 2016. CMS will offer an online transitional training course for existing LSC surveyors to provide an update on the new requirements. The course will be available on September 2, 2016, via the CMS Surveyor Training Website. CMS will update the ASPEN program (i.e., the information system which tracks surveys) and CMS Fire Safety Forms (2786) prior to the November 1, 2016, survey start date.
View the survey and certification letter.
Treatment resistant depression (TRD)
On June 21, CMS posted the minutes and transcript from the meeting that was held April 27 to obtain the MEDCAC's recommendations regarding the definition of TRD in clinical research as well as advise CMS on the use of the definition of TRD in the context of coverage with evidence development and treatment outcomes.
View the minutes.
View the transcript.
Update to Medicare Program Integrity data analysis
On June 22, CMS rescinded Transmittal 630, dated December 31, 2015, and replaced with Transmittal 658 to delete CMS Chronic Conditions Data Warehouse as a Secondary Source of Data. All other information remains the same. The original transmittal updated current resources and procedures that the MACs, Zone Program Integrity Contractors, Recovery Auditors, and the Supplemental Medical Review Contractor follow when performing data analytical activities used for identifying or verifying actual or potential claim payment errors.
Effective date: February 1, 2016
Implementation date: February 1, 2016
View Transmittal R658PI.
Recovering overpayments from providers who share Tax Identification Numbers
On June 22, CMS released a special edition MLN Matters article. This article states that, in January 2016, CMS enhanced its financial accounting system to include a function that allows CMS to recover payments made to a provider of services or supplier that shares the same TIN with a provider of services or supplier that has an outstanding Medicare overpayment across multiple states within a MAC jurisdiction.
View MLN Matters article SE1612.
Improper arrangements and conduct involving home health agencies (HHA) and physicians
On June 22, the OIG posted an alert stating it has found home health services are vulnerable to fraud, waste, and abuse and the federal government is stepping up its enforcement efforts in this area. In the past year, the federal government has obtained criminal convictions and reached civil settlements with several HHAs, individual physicians, and heads of home-visiting physician companies that defrauded Medicare by, among other conduct, making (or accepting) payments for patient referrals, falsely certifying patients as homebound, and billing for medically unnecessary services or for services that were not rendered. The OIG also posted a report of the study completed on this subject and a video discussing fraud in a home healthcare setting as part of its Eye on Oversight series.
View the alert.
View the report.
View the video.
High Part D spending on opioids and substantial growth in compounded drugs raise concerns
On June 22, the OIG posted a report stating that, since the Part D program went into effect in 2006, it has had ongoing concerns about abuse and diversion of Part D drugs. In June 2015, the OIG released a data brief, titled “Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D,” which described trends in Part D spending and identified questionable billing by pharmacies. This data brief builds on that body of work. It updates information on spending for commonly abused opioids and provides data on the dramatic growth in spending for compounded drugs.
View the report.
Moratoria Provider Services and Utilization Data Tool
On June 22, CMS posted a fact sheet stating it has developed a Moratoria Provider Services and Utilization Data Tool that includes interactive maps and a dataset that shows national-, state-, and county-level provider services and utilization data for selected health service areas. The data provide information on the number of Medicare providers servicing a geographic region and the number of Medicare beneficiaries who use a health service area. Independent diagnostic testing facilities and SNFs were added because these are areas that have been discussed as possible expansions for moratoria, though there is no intended implication that the areas will, in fact, be chosen in the future as moratoria areas. For the ambulance and home health service areas, moratoria regions at the state and county level are clearly indicated. The data can also be used to reveal the degree to which use of these services is related to the number of providers servicing a geographic region.
View the fact sheet.
Medicare Trustees report shows continued slow cost growth
On June 22, CMS posted a press release stating that the Medicare Trustees projected that the trust fund financing Medicare’s hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.
View the press release.
July quarterly update for 2016 DME, prosthetics, orthotics and supplies (DMEPOS) fee schedule
On June 23, CMS released a transmittal to serve as a recurring update notification applying to Chapter 23, section 60 of the Pub. 100-04, Medicare Claims Processing Manual. This section is updated quarterly to implement fee schedule amounts for new codes and correct any fee schedule amounts for existing codes. CMS also released a transmittal providing instructions regarding the revision of the CY 2016 fee schedule amounts for HCPCS Code E1012.
Effective date: July 1, 2016, for implementation of fee schedule amounts for codes in effect on January 1, 2016; July 1, 2016, for all other changes.
Implementation date: July 5, 2016
View Transmittal R3551CP.
View the fact sheet.
View Transmittal R1677OTN.
Medicare clinical diagnostic laboratory tests payment system
On June 23, CMS posted a final rule in the Federal Register implementing requirements of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which significantly revises the Medicare payment system for clinical diagnostic laboratory tests. This final rule also announces an implementation date of January 1, 2018, for the private payor rate-based fee schedule required by PAMA. It is effective August 22.
View the final rule in the Federal Register.
View the fact sheet.
View the press release.
Medicare Compliance Review of Vanderbilt University Medical Center for 2013 and 2014
On June 23, the OIG posted a report stating the Vanderbilt University Medical Center in Nashville, Tennessee, complied with Medicare billing requirements for 172 of the 245 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 73 claims, resulting in net overpayments of $305,000. Specifically, 34 inpatient claims had billing errors resulting in net overpayments of $221,000, and 39 outpatient claims had billing errors resulting in overpayments of $84,000. On the basis of the sample results, the OIG estimated that the hospital received overpayments of at least $1.14 million for the audit period. During the course of the audit, the hospital reprocessed 30 claims with overpayments of $134,000 that were verified as correctly reprocessed. Accordingly, the OIG have reduced the recommended refund by this amount.
View the report.
Comment requests regarding report of restraint- or seclusion-related hospital deaths and procedures for making NCDs
On June 24, CMS posted a notice in the Federal Register stating that it is accepting comments on CMS–10455, Report of a Hospital Death Associated With Restraint or Seclusion and CMS– R–290, Medicare Program: Procedures for Making National Coverage Decisions. Comments are due August 23.
View the notice in the Federal Register.