This week in Medicare updates–08/17/2016
Editing update for screening for sexually transmitted infections
On August 5, CMS released a transmittal stating that, due to existing editing created in Change Request 7610, 072X type of bill (TOB) claims containing HCPCS codes for Sexually Transmitted Infections (STI) and diagnosis code V74.5 or 73.89 are incorrectly being denied in full. Editing should have been written as line level denial rather than claim level denial. In addition, editing created in change request 8197 contains additional diagnosis codes that should have not been included in the edits. This change request provides instructions for edits to be modified to deny line items rather than claim level denials. In addition, this change request revises diagnosis code requirements for STI claims.
Effective date: October 1, 2016, for claims received on or after October 1
Implementation date: January 3, 2017
View Transmittal R1698OTN.
View MLN Matters article MM9719.
Multiple Procedure Payment Reduction (MPPR) on the Professional Component (PC) of certain diagnostic imaging procedures
On August 5, CMS released a transmittal stating that Section 502(a)(2) of the Consolidated Appropriations Act of 2016 revised the MPPR for the PC of the second and subsequent procedures from 25% to 5% of the physician fee schedule amount.
Effective date: January 1, 2017
Implementation date: January 3, 2017
View Transmittal R3578CP.
View MLN Matters article MM9647.
Inpatient rehabilitation facility (IRF) annual update: PPS Pricer changes for FY 2017
On August 5, CMS released a change request stating a new IRF PRICER software package will be released prior to October 1, 2016, that will contain the updated rates that are effective for claims with discharges that fall within October 1, 2016, through September 30, 2017.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3576CP.
View MLN Matters article MM9669.
New condition code to use when hospice recertification is untimely and corrections to hospice processing problems
On August 5, CMS released a change request creating a new condition code for hospices to use to identify when an occurrence span code 77 period is caused by a late recertification of the terminal illness. It also corrects a number of problems in hospice claims processing.
Effective date: January 1, 2017, for claims on or after that date
Implementation date: January 3, 2017
View Transmittal R3577CP.
View MLN Matters article MM9590.
Recovery Auditor mass adjustment and reporting process enhancements
On August 5, CMS released a change request stating that it will begin the analysis of a variety of utility and usability enhancements that have been identified since the mass adjustment process was introduced. These enhancements shall include an increase in billable units at a line-item level for Part A claims and the inclusion of Recovery Auditor Intentions Notes on Part A, Part B and DME claims. These enhancements are vital to increasing Recovery Auditor claim processing efficiencies.
Effective date: January 1, 2017
Implementation date: January 3, 2017
View Transmittal R1703OTN.
Appropriate use criteria for advanced imaging
On August 5, CMS released a change request for all system maintainers to provide input and contribute to developing solutions to implement claims processing edits for the new Medicare appropriate use criteria program.
Effective date: January 1, 2017
Implementation date: January 3, 2017
View Transmittal R1699OTN.
Revisions to instructions regarding the Fraud Investigation Database (FID) and other program integrity procedures
On August 5, CMS released a change request to update the instructions in Chapter 4 of Pub. 100-08, Medicare Program Integrity, regarding the FID and other program integrity procedures.
Effective date: November 8, 2016
Implementation date: November 8, 2016
View Transmittal R667PI.
Protecting resident privacy and prohibiting mental abuse related to photographs and audio/video recordings by nursing home staff
On August 5, CMS posted a survey and certification letter discussing the facility and state responsibilities related to the protection of residents. Specifically, at the time of the next standard survey for both the traditional survey and Quality Indicator Survey, the survey team will request and review facility policies and procedures that prohibit staff from taking, keeping and/or distributing photographs and recordings that demean or humiliate a resident.
View the survey and certification letter.
Medicare Part B Clinical Laboratory Fee Schedule: Guidance to laboratories for collecting and reporting data for the private payor rate-based payment system
On August 8, CMS released a special edition MLN Matters article to assist the laboratory community in meeting the new requirements under Section 1834A of the Social Security Act for the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). It includes clarifications for determining whether a laboratory meets the requirements to be an "applicable laboratory," the applicable information (that is, private payor rate data) that must be collected and reported to CMS, the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, and the schedule for implementing the new CLFS. CMS will issue additional information about the CLFS data collection system and advanced diagnostic laboratory tests through separate guidance.
View MLN Matters article SE1619.
Cornerstone Hospital of Austin incorrectly billed Medicare inpatient claims with Kwashiorkor
On August 9, the OIG posted a report stating that Cornerstone Hospital of Austin did not comply with Medicare requirements for billing Kwashiorkor on any of the 54 claims reviewed. The hospital used diagnosis code 260 for Kwashiorkor but should have billed for other forms of malnutrition. The 54 inpatient claims that were coded incorrectly resulted in overpayments of $358,000. The hospital believed that all claims identified by OIG were appropriately submitted for payment.
View the report.
Independence at Home Demonstration performance Year 2 results
On August 9, CMS posted a fact sheet regarding home-based primary care. Home-based primary care allows healthcare providers to spend more time with their patients, perform assessments in a patient’s home environment, and assume greater accountability for all aspects of the patient’s care. This focus on timely and appropriate care is designed to improve the overall quality of care and quality of life for patients served, while lowering healthcare costs by forestalling the need for care in institutional settings.
View the fact sheet.
View the press release.
Correction to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model
On August 10 , CMS posted a notice in the Federal Register correcting a technical error in the proposed rule that appeared in the July 15, 2016 Federal Register (81 FR 46162–46476) entitled, “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model.’’
View the notice in the Federal Register.
MACs continue to use different methods to determine drug coverage
On August 10, the OIG posted a report of a study it conducted, which found that MACs have to make coverage decisions, and reported using a variety of information sources on drug uses to assist in making coverage determinations. MACs also used different methods to obtain notifications when these sources were updated. These differences may contribute to inconsistencies in drug coverage across states. Further, most MACs reported challenges in determining coverage for Part B drugs, including difficulties interpreting CMS policy manuals and remaining up to date with sources for covered uses. To help ensure that drug claims were paid in accordance with their coverage policies, MACs implemented payment controls, but to varying degrees. However, some MACs were unable to provide the results of their payment control efforts. Without tracking these results, it is difficult to accurately evaluate the effectiveness of these payment controls.
View the report.
Medicare Advantage Value-Based Insurance Design Model
On August 10, CMS posted a fact sheet stating that its Center for Medicare and Medicaid Innovation is announcing refinements to the design of the second year of the Medicare Advantage Value-Based Insurance Design (MA-VBID) model. The MA-VBID model is an opportunity for Medicare Advantage plans, including Medicare Advantage plans offering Part D benefits, to offer clinically nuanced benefit packages aimed at improving quality of care while also reducing costs.
View the fact sheet.
Five Star Changes to Nursing Home Compare
On August 10, CMS posted a fact sheet stating that CMS recently added six new quality measures to the Nursing Home Compare website as part of an initiative to broaden the amount of quality information available on that site. CMS is including five of those six new quality measures in the calculations for the current Five-Star Quality Rating.
View the fact sheet.
View the press release.
Medicare Compliance Review of New York-Presbyterian Hospital for 2011 and 2012
On August 11, the OIG posted a report stating that New York-Presbyterian Hospital in New York, New York, complied with Medicare billing requirements for 162 of the 285 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 123 claims for the audit period (calendar years 2011 and 2012). On the basis of OIG’s sample results, it estimated that the hospital received overpayments totaling at least $14.2 million for the audit period. 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.
Programs of All-Inclusive Care for the Elderly (PACE) (CMS-4168-P)
On August 11, CMS posted a fact sheet stating it is proposing a rule to update and modernize the PACE program. The PACE is a Medicare and Medicaid program that provides comprehensive medical and social services that enable older adults to live in the community instead of a nursing home or other care facility.
View the fact sheet.
Advisory Panel on Hospital Outpatient Payment (HOP Panel) meeting agenda, presentations, and supporting documents
On August 11, CMS posted the agenda, presentations, and supporting documents for the upcoming meeting of the HOP Panel.
View the HOP Panel page and click on the ZIP file under “Downloads”.