This week in Medicare updates–10/05/2016
October 2016 update of the hospital OPPS
On August 26, CMS posted a transmittal recurring update notification describing changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update. The October 2016 Integrated OCE (I/OCE) and OPPS Pricer will reflect the HCPCS, Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this change request. This recurring update notification applies to Chapter 4, Medicare Claims Processing Manual, section 50.8. The October 2016 revisions to I/OCE data files, instructions, and specifications are provided in the forthcoming October 2016 I/OCE CR.
Effective date: October 1, 2016
Implementation date: October 3, 2016
View Transmittal R3602CP.
View MLN Matters article MM9768.
Revisions to the State Operations Manual (SOM) Chapter 7
On September 28, CMS rescinded Transmittal 160, dated September 23, and replaced it with Transmittal 161, dated September 28, 2016 to correct minor formatting edits within the transmittal table and table of contents pages. All other information remains the same. The transmittal is regarding survey and enforcement process for SNFs and nursing facilities.
Effective date: September 23, 2016
Implementation date: September 23, 2016
View Transmittal R161SOMA.
CMS finalizes improvements in care, safety, and consumer protections for long-term care facility residents
On September 28, CMS issued a final rule to make major changes to improve the care and safety of the nearly 1.5 million residents in the more than 15,000 long-term care facilities that participate in the Medicare and Medicaid programs. The policies in this final rule are targeted at reducing unnecessary hospital readmissions and infections, improving the quality of care, and strengthening safety measures for residents in these facilities.
View the final rule.
View the press release.
CMS to allow some providers to settle inpatient status claims in appeals again
On September 28, CMS announced on its Inpatient Hospital Reviews webpage that it has decided to once again allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. Specific details of the settlement will be released in the near future.
View the Inpatient Hospital Reviews webpage.
Decision memorandum for screening for hepatitis B virus (HBV) infection
On September 28, CMS posted a decision memorandum stating it has determined that the evidence is sufficient to conclude that screening for HBV infection, consistent with the grade A and B recommendations by the U.S. Preventive Services Task Force, is reasonable and necessary for the prevention or early detection of an illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B, as described below.
View the decision memorandum.
Medicare Part B drug average sales price (ASP) reporting by manufacturers–blending National Drug Codes (NDC)
On September 29, CMS released a special edition MLN Matters article reminding manufacturers that ASP data must be reported for individual NDCs. As stated on page 45 of "ASP Data Collection (Addendum A) User’s Guide – Revised 2012" in the Downloads section at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPa..., "most ASP reporting is done at the NDC level where the ASP corresponds to the amount of drug represented by that NDC…. For these drugs and biologicals, manufacturers will still submit ASP sales data for an NDC, but will do so on an ASP unit level specified in this list." Manufacturers should not blend the manufacturer’s ASP or the number of ASP Units sold for a single NDC with other NDCs. CMS also reminds manufacturers that misreporting of ASP sales data may result in civil monetary penalties as described in Section 1847A(d)(4) of the Act.
View MLN Matters article SE1623.
Implementation of new influenza virus vaccine code
On September 29, CMS released a change request providing instructions for payment and edits for the CWF to include influenza virus vaccine code 90674.
Effective date: August 1, 2016
Implementation date: January 3, 2017, for FISS requirements and technical design. CWF and A/B MACs implementation also for January 3, 2017; February 20, 2017, for FISS production implementation
View Transmittal R3617CP.
Partnership for Patients (PfP) and the Hospital Improvement Innovation Networks (HIIN): Continuing forward momentum on reducing patient harm
On September 29, CMS released a fact sheet stating it awarded $347 million to 16 national, regional, or state hospital associations and health system organizations to serve as HIIN. These awards will integrate the PfP Hospital Engagement Networks (HEN) into the Quality Improvement Network-Quality Improvement Organization (QIN-QIO) program in order to maximize the strengths of the QIO program and the PfP HENs to sustain and expand current national reductions in patient harm and 30 day readmissions for the Medicare program. The period of performance for the HIINs begins in September 2016 and consists of one 24-month base period and one 12-month option year, during which they will support 4,000 hospitals.
View the fact sheet.
View the press release.
Transforming Clinical Practice Initiative Support and Alignment Networks 2.0
On September 29, CMS announced the recipients of the second round of the Support and Alignment Networks under the Transforming Clinical Practice Initiative (TCPI). This opportunity will provide up to $5 million to two awardees over the next three years to leverage primary and specialist care transformation work and learning that will catalyze the adoption of Alternative Payment Models on a large scale. The Support and Alignment Networks 2.0 represents a significant enhancement to the TCPI network expertise and will help clinicians prepare for the proposed new Quality Payment Program, which CMS is implementing as part of bipartisan legislation Congress passed last year repealing the Sustainable Growth Rate, also known as the Medicare Access and CHIP Reauthorization Act of 2015.
View the fact sheet.
Medicare improperly paid millions of dollars for unlawfully present beneficiaries for 2013 and 2014
On September 30, the OIG posted a report stating that although CMS had policies and procedures to ensure that payments were not made for Medicare services rendered to unlawfully present beneficiaries in accordance with federal requirements, it did not always follow those policies and procedures. When CMS's data systems indicated that at the time a claim was processed the beneficiary was unlawfully present, CMS had policies and procedures to prevent payment for Medicare services, and CMS followed those procedures.
View the report.