This week in Medicare updates–07/06/2016
New waived tests
On June 24, CMS released a change request informing contractors of new CLIA waived tests approved by the Food and Drug Administration. Since these tests are marketed immediately after approval, CMS must notify its contractors of the new tests so that the contractors can accurately process claims. There are 29 newly added waived complexity tests. This recurring update notification applies to Chapter 16, Medicare Claims Processing Manual, section 70.8 of the IOM.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3550CP.
View MLN Matters article MM9687.
Update to Pub. 100-08, Medicare Program Integrity Manual, Chapter 15
On June 24, CMS released a change request to make several revisions to Chapter 15 of Pub. 100-08, Medicare Program Integrity Manual.
Effective date: July 26, 2016
Implementation date: July 26, 2016
View Transmittal R659PI.
Appeals of claims decisions: Revisions to timeliness requirements for forwarding misfiled appeal requests, reconsideration request form, and guidelines for writing appeals correspondence
On June 24, CMS released a change request updating Pub. 100-04, Medicare Claims Processing Manual, Chapter 29 with policy updates on handling of misfiled appeals, changes related to the Strengthening Medicare and Repaying Taxpayers Act of 2012, and some minor punctuation and grammatical corrections. The timeframe for forwarding misfiled redeterminations and reconsiderations requests to the appropriate contractor has been updated from 30 days to 60 days from the date the request was received in the corporate mailroom.
Effective date: July 26, 2016
Implementation date: July 26, 2016
View Transmittal R3549CP.
Medicare coverage of diagnostic testing for Zika virus
On June 27, CMS released a special edition MLN Matters article informing the public that Medicare covers Zika virus testing under Medicare Part B as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person’s illness or injury. This article reminds laboratories furnishing Zika virus tests to contact their MACs for guidance on the appropriate billing codes to use on claims for Zika virus testing.
View MLN Matters article SE1615.
Implementation of section 2 of the Patient Access and Medicare Protection Act (PAMPA)
On June 27, CMS released a special edition MLN Matters article providing important information on the implementation of Section 2 of PAMPA, which became law on December 28, 2015. This implementation may impact the rates Medicare pays for certain DME items.
View MLN Matters article SE1614.
OIG Advisory Opinion No. 16-07
On June 27, the OIG posted Advisory Opinion No. 16-07 regarding whether a savings card program under which individuals who have prescription drug coverage under Medicare Part D receive discounts on a drug that is statutorily excluded from coverage constitutes grounds for the imposition of sanctions under the federal anti-kickback statute.
View the opinion.
Proposed payment changes for Medicare HHA for 2017 (CMS-1648-P)
On June 27, CMS posted a proposed rule, to appear in the Federal Register on July 5, with changes to the Medicare home health PPS for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. In the rule, CMS projects that Medicare payments to HHAs in CY 2017 would be reduced by 1%, or $180 million based on the proposed policies.
View the proposed rule in the Federal Register.
View the fact sheet.
Medicare Program Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures
On June 28, CMS filed a proposed rule, to appear in the Federal Register on July 5, which would revise the procedures that the Department of Health and Human Services would follow at the Administrative Law Judge level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals.
In addition, this proposed rule would revise procedures that the Department of Health and Human Services would follow at the CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the Administrative Law Judge level.
View the proposed rule.
July 2016 update of the hospital (OPPS)
On June 28, CMS rescinded Transmittal 3523 and replaced it with Transmittal 3552 to change the APC number for HCPCS code Q5102 from 1761 to 1847 in table 5, Attachment A. Also, business requirement 9658.3 had incorrect termination date for C9743, C9458, and C9459. The correct termination date should be June 30, 2016, instead of June 30, 2015. All other information remains the same.
View Transmittal R3552CP.
View MLN Matters MM9658.
New condition code for reporting home health episodes with no skilled visits
On June 28, CMS rescinded Transmittal 3457 and issued Transmittal 3553, change request 9474, to revise Medicare billing instructions for home health claims to allow the use of the new condition code 54. The code indicates the home health agency provided no skilled services during the billing period but has documentation on file of an allowable circumstance.
Effective Date: July 1, 2016
Implementation date: July 5, 2016
View Transmittal R3553CP.
View MLN Matters article MM9474.
South Texas physical therapist claimed unallowable Medicare Part B reimbursement for outpatient physical therapy services
On June 29, the OIG released a report on a physical therapist in Texas who claimed Medicare reimbursement for outpatient physical therapy services that did not meet Medicare reimbursement requirements in calendar years 2012 and 2013. Specifically, of the 100 beneficiary claim days in the random sample, the therapist properly claimed Medicare reimbursement on 81 beneficiary claim days, but improperly claimed Medicare reimbursement on the remaining 19 beneficiary claim days. OIG estimates that the therapist improperly received at least $90,000 in Medicare reimbursement.
View the report.
International Institute of Sleep, Inc., billed Medicare for unallowable sleep study services
On June 29, the OIG posted a report on the International Institute of Sleep, Inc., an independent diagnostic testing facility based in Deerfield Beach, Florida, which billed Medicare for polysomnography services that did not meet Medicare billing requirements for all 100 randomly selected beneficiaries with 130 corresponding lines of service, resulting in overpayments of $78,000. OIG estimates that the Institute received overpayments of at least $1 million from January 2011 through September 2012.
View the report.
Oncology Care Model
On June 29, CMS posted a fact sheet on the CMS Oncology Care Model (OCM), an innovative, multi-payer model focused on providing higher quality, more coordinated oncology care. Under OCM, physician group practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination and navigation, and to using national treatment guidelines for care. OCM is a five-year model that begins on July 1, 2016, and runs through June 30, 2021.
View the fact sheet.
Updates to policies and payment rates for ESRD PPS, Quality Incentive Program (QIP), coverage and payment for acute kidney injury, DMEPOS competitive bidding program and fee schedule, and comprehensive ESRD Care Model (CMS 1651-P)
On June 30, CMS posted a proposed rule in the Federal Register that would update payment policies and rates under the ESRD PPS for renal dialysis services furnished to beneficiaries on or after January 1, 2017. This rule also proposes new quality measures to improve the quality of care by dialysis facilities treating patients with end-stage renal disease.
View the proposed rule in the Federal Register.
View the fact sheet.
Part D plans generally include drugs commonly used by dual eligibles: 2016
On June 30, the OIG posted a report of a study of the extent to which formularies used by Medicare Part D plans (i.e., stand-alone prescription drug plans and Medicare Advantage prescription drug plans) include drugs commonly used by full-benefit dual-eligible individuals (i.e., individuals who are eligible for both Medicare and full Medicaid benefits). The OIG found that the rate of Part D plan formularies' inclusion of the 198 drugs commonly used by dual eligibles is high, with some variation. On average, Part D plan formularies include 96% of the 198 commonly used drugs. In addition, 68% of the commonly used drugs are included by all Part D plan formularies. These results are largely unchanged from the OIG's findings for formularies reported in the 2015 mandated annual report. The OIG also found that the percentage of drugs subject to utilization management tools remained relatively the same from 2015 to 2016.
View the report.
Corrections to final rule on fire safety requirements for certain healthcare facilities
On June 30, CMS posted a notice in the Federal Register correcting technical errors that appeared in the final rule published in the Federal Register on May 4, entitled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities.” The effective date for the corrections is July 5.
View the notice in the Federal Register.
CMS’ Open Payments program posts 2015 financial data
On June 30, CMS published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the “Sunshine Act”) requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals be published on a public website.
View the 2015 Open Payments Data.
Meeting of the Advisory Panel on Outreach and Education (APOE)
On June 30, the APOE posted meetings materials from the June 22 meeting, at which it heard presentations on barriers and disparities related to post-Affordable Care Act uptake of preventive services; preparing assisters and navigators for year four of ACA open enrollment; and Next Generation Accountable Care Organizations and how to provide input to CMS to enhance communication to assist in better coordinating care and better educating beneficiaries and providers.
Download the meeting materials.