This week in Medicare updates–08/24/2016
October 2016 Integrated Outpatient Code Editor (I/OCE) specifications version 17.3
On August 12, CMS released a change request providing the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the OPPS and Non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. The attached recurring update notification applies to 100-04, Medicare Claims Processing Manual, Chapter 4, section 40.1.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3591CP.
View MLN Matters article MM9754.
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Appendix J and Exhibit 355: Removal of website links
On August 12, CMS posted an update regarding the revised ICF/IID Interpretive Guidelines and Exhibit 355 within the State Operations Manual to remove all references to website links that are now inaccessible or may become so in the future.
View the update.
Implementation of Next Generation Accountable Care Organization (NGACO)
On August 16, CMS posted a special edition MLN Matters article providing information on the NGACO Model’s benefit enhancement waiver initiatives and supplemental claims processing direction.
View MLN Matters article SE1613.
Programs of All-Inclusive Care for the Elderly (PACE)
On August 16, CMS posted a proposed rule in the Federal Register that would revise and update the requirements for PACE under the Medicare and Medicaid programs. The proposed rule addresses application and waiver procedures, sanctions, enforcement actions and termination, administrative requirements, PACE services, participant rights, quality assessment and performance improvement, participant enrollment and disenrollment, payment, federal and state monitoring, data collection, record maintenance, and reporting. The proposed changes would provide greater operational flexibility, remove redundancies and outdated information, and codify existing practice.
View the proposed rule in the Federal Register.
View the fact sheet.
Leave a comment.
DME, prosthetics, orthotics, and supplies (DMEPOS) Competitive Bidding Program (CBP): Additional instructions for the implementation of Round 2 Recompete of the DMEPOS CBP and National Mail Order (NMO) Recompete
On August 17, CMS rescinded Transmittal 3565, dated July 20, and replaced it with Transmittal 3593 to revise BR 9579.9. All other information remains the same. The original transmittal provided instructions for implementing changes to the DMEPOS CBP regarding the clarification of the RB modifier for Medicare payment for the repair of parts furnished in Competitive Bidding Areas and clarification of grandfathering instructions for rentals of accessories and supplies.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3593CP.
Michigan chiropractor received unallowable Medicare payments for chiropractic services
On August 17, the OIG posted a report stating that a chiropractic clinic based in Michigan did not comply with Medicare billing requirements for 100 chiropractic service line items sampled. Specifically, the medical records did not support the medical necessity for 92 of the 100 sampled chiropractic services. On the basis of its sample results, the OIG estimated that at least $339,000 of the $392,000 paid to the chiropractor for chiropractic services in 2012 and 2013 was unallowable for Medicare reimbursement.
View the report.
Public Summary Report: Wireless penetration test of CMS’ data centers
On August 17, the OIG posted a report stating that it performed a wireless penetration test of select CMS' Data Centers and facilities to determine whether CMS' security controls over its wireless networks were effective. Although CMS had security controls that were effective in preventing certain types of wireless cyber-attacks, the OIG identified four vulnerabilities in security controls over its wireless networks. The vulnerabilities identified were collectively and, in some cases, individually significant. Although the OIG did not identify evidence that the vulnerabilities had been exploited, exploitation could have resulted in unauthorized access to and disclosure of personally identifiable information, as well as disruption of critical operations. In addition, exploitation could have compromised the confidentiality, integrity, and availability of CMS' data and systems. The OIG shared detailed information with CMS about its preliminary findings in advance of issuing the draft report and recommended that CMS improve its security controls to address the wireless network vulnerabilities identified.
View the report.
Medicare Fee for Service (FFS) Recovery Audit program third quarter summary newsletter
On August 17, CMS posted the Medicare FFS Recovery Audit program third quarter newsletter, covering activity in the Recovery Audit program from April 2016 through June 2016.
View the newsletter.
Update to review of claims affected by the Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIO) temporary suspension
CMS is announcing it has clarified the instructions for medical review of claims affected by the temporary suspension of the BFCC QIOs performance of initial patient status reviews of acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities to determine the appropriateness of Part A payment for short stay inpatient hospital claims. Specifically, CMS is announcing that these reviews will be limited to a six-month look-back period from the date of admission.
View CMS’ Inpatient Hospital Reviews webpage.
Updated prescriber-level Medicare data
On August 18, CMS posted a fact sheet and a press release regarding its second annual release of data that details information on the prescription drugs that were prescribed by individual physicians and other healthcare providers and paid for under the Medicare Part D Prescription Drug Program.
View the fact sheet.
View the press release.
CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans
On August 18, CMS posted a press release stating it issued a request for information seeking public comment on concerns that some healthcare providers and provider-affiliated organizations may be steering people eligible for, or receiving, Medicare and/or Medicaid benefits into Affordable Care Act-compliant individual market plans, including Health Insurance Marketplace plans, for the purpose of obtaining higher reimbursement rates. CMS also sent letters to all Medicare-enrolled dialysis facilities and centers informing them of this announcement.
View the press release.
October quarterly update to the Medicare Physician Fee Schedule Database (MPFSDB)
On August 19, CMS released a transmittal amending the payment files issued to contractors based upon the CY 2016 Medicare Physician Fee Schedule (MPFS) Final Rule. 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: October 3, 2016
View Transmittal R3594CP.
Medicare Provider Reimbursement Manual
On August 19, CMS released a transmittal updating Chapter 41, Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Reports, Form CMS-2540-10 to incorporate §3132 of the Patient Protection and Affordable Care Act (ACA) which require that CMS collect appropriate data and information to facilitate hospice payment reform. The effective dates vary.
View Transmittal R7PR241.
Documentation for DMEPOS claims for replacement of essential accessories for beneficiary-owned continuous positive airway pressure (CPAP) devices and respiratory assist devices (RAD)
On August 19, CMS released a change request to provide guidance to the DME MACs when conducting medical review of DMEPOS claims for replacement of essential accessories for beneficiary-owned CPAP Devices and RADs.
Effective date: July 1, 2016
Implementation date: November 2, 2016
View Transmittal R672PI.
Update of payment suspension instructions
On August 19, CMS released a change request to revise the payment suspension instructions in Chapter 8 of Pub. 100-08, Medicare Program Integrity Manual. This change request also revises the model payment suspension letters in Exhibit 16 to conform with the changes made to the payment suspension instructions in Chapter 8.
Effective date: November 23, 2016
Implementation date: November 23, 2016
View Transmittal R670PI.
Coding revisions to NCDs
On August 19, CMS released a change request that serves as the ninth maintenance update of ICD-10 conversions and other coding updates specific to NCDs. The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, CR9540, and CR9631. Some are the result of revisions required to other NCD-related change requests released separately.
Effective date: January 1, 2017, unless otherwise noted
Implementation date: January 3, 2017
View Transmittal R1708OTN.