This week in Medicare updates–11/18/2015
Update to the list of compendia for the determination of a “Medically-Accepted Indication” of drugs and biologicals used off-label in an anti-cancer chemotherapeutic regimen
On November 6, CMS released a change request stating that it is adding Wolters Kluwer Lexi-Drugs® to the list of authoritative compendia in Chapter 15, section 50.4.5 of the Medicare Benefit Policy Manual for use in the determination of a medically accepted indication of drugs and biologicals used off-label in an anti-cancer chemotherapeutic regimen.
Effective date: August 12, 2015
Implementation date: February 10, 2016
View Transmittal R212BP.
View MLN Matters article MM9638.
Payment reduction for Computed Tomography (CT) diagnostic imaging services
On November 6, CMS published Transmittal 3402, replacing a prior confidential transmittal on payment reductions for CT services not meeting quality requirements. Effective January 1, 2016, a payment reduction of 5% applies to CT services furnished using equipment that is inconsistent with the CT equipment standard and for which payment is made under the physician fee schedule. Modifier -CT was adopted to indicate these services. The payment reduction increases to 15% in 2017 and subsequent years.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3402CP.
View MLN Matters article MM9250.
Reduction for procedures discontinued prior to anesthesia
On November 6, CMS published instructions to contractors for processing device intensive procedures reported with the modifier -73, which indicates they were discontinued before administration of anesthesia. The device portion of the payment will be removed prior to application of the modifier -73 reduction to ensure no reimbursement for the unused device in accordance with the (calendar year) CY 2016 ASC) final rule.
Effective date: January 1, 2016
Implementation date: April 4, 2016
View Transmittal R1572OTN.
View MLN Matters article MM9297.
Home health prospective payment system (HH PPS) rate update for CY 2016
On November 6, CMS released a recurring update notification including the 60-day national episode rates, the national per-visit amounts, LUPA add-on amounts, and the non-routine medical supply payment amounts under the HH PPS for CY 2016.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3383CP.
View MLN Matters article MM9406.
View special edition MLN Matters article SE1524.
Advanced Notification: Revisions to State Operations Manual (SOM), Appendix C – Survey Procedures and Interpretive Guidelines for Laboratories and Laboratory Services
On November 6, CMS posted a survey and certification letter stating that the CLIA Individualized Quality Control Plan (IQCP) procedure in the revised SOM will supersede the IQCP procedure in S&C 13-54. Revisions include the removal of Equivalent Quality Control in the Interpretive Guidelines for §493.1256(d) and the insertion of IQCP in the Interpretive Guidelines for §493.1256(d). The IQCP Education and Transition Period will conclude on December 31, 2015. The IQCP effective date will be January 1, 2016. Surveyors will continue to follow established survey policies and protocols using the Outcome Oriented Survey Process. Resources available on the CLIA webpage at www.cms.gov/CLIA.
View the survey and certification letter.
Medicare Compliance Review of Naples Community Hospital for 2011 and 2012
On November 9, the OIG posted a report stating that Naples Community Hospital complied with Medicare billing requirements for 134 of the 225 inpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 91 claims, resulting in net overpayments totaling $409,000. On the basis of the sample results, the OIG estimated that the hospital received at least $4.5 million in overpayments from Medicare.
View the report.
Boulevard Health Care, Inc., improperly claimed Medicare reimbursement for outpatient physical therapy services
On November 10, the OIG posted a report stating Boulevard Health Care, Inc., claimed Medicare reimbursement for outpatient therapy services that did not comply with certain Medicare requirements. Of the 100 claims in the OIG’s random sample, 57 complied with Medicare requirements, but 43 did not. The OIG estimated that the facility improperly received at least $57,000 in Medicare reimbursement for outpatient therapy services that did not comply with certain Medicare requirements.
View the report.
2016 Medicare Parts A & B Premiums and Deductibles Announced
On November 10, CMS posted a press release announcing the 2016 premiums and deductibles for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs. It also posted a fact sheet detailing the state-by-state breakdown of the Medicare Part B premium savings for 2016.
View the press release.
View the fact sheet.
Proposed decision of non-coverage for percutaneous left atrial appendage closure (LAAC) therapy
On November 10, CMS posted a proposed decision memorandum stating that the evidence is sufficient to determine percutaneous LAAC therapy using an implanted device is not reasonable and necessary to diagnose or treat an illness or injury or to improve the functioning of a malformed body member and, therefore, is not covered. Percutaneous LAAC therapy is covered for patients with non-valvular atrial fibrillation only, and only when all of the conditions listed in the memorandum are met.
View the proposed decision memorandum.
Submit a comment.
CY 2016 OPPS and ASC final rule published in the Federal Register
On November 13, CMS published in the Federal Register a final rule regarding the Medicare hospital OPPS and the Medicare ASC payment system for CY 2016 to implement applicable statutory requirements and changes arising from continuing experience with these systems. This final rule was previously put on display October 30.
View the final rule in the Federal Register.
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