This week in Medicare updates–12/23/2015
CY 2016 annual clinical laboratory fee schedule and laboratory services subject to reasonable charge payment update
On December 11, CMS released a recurring update notification providing instructions for the CY 2016 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests, and updates for laboratory costs subject to the reasonable charge payment. This recurring update notification applies to Chapter 16, Medicare Claims Processing Manual, section 20.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R3420CP.
View MLN Matters article MM9465.
Settlement effectuation instructions for HHS Office of Medicare Hearings and Appeals (OMHA) Settlement Conference Facilitation (SCF) Pilot
On December 11, CMS released a change request to provide instructions for the effectuation of claims and payments that are associated with the OMHA SCF Pilot. OMHA is working on various initiatives to address the increasing claims-based appeals workload at the ALJ level. One of those initiatives is the OMHA SCF Pilot which is an alternative dispute resolution process or mediation process designed to bring the appellant and CMS together to discuss the potential of a mutually agreeable resolution to the claims appealed to an ALJ hearing.
Effective date: January 13, 2016
Implementation date: January 13, 2016
View Transmittal R1583OTN.
Comments requested regarding Medicare Advantage Appeals and Grievance Data Disclosure Requirement
On December 14, CMS posted a notice in the Federal Register relating that it is accepting comments on: CMS–R-282, Medicare Advantage Appeals and Grievance Data Disclosure Requirements (42 CFR 422.111); and CMS-10597, CMS Healthcare.gov Site Wide Online
Survey. Comments are due February 12, 2016.
View the notice in the Federal Register.
Leave a comment.
Implementation of changes in the ESRD PPS for CY 2016
On December 15, CMS rescinded Transmittal 213, dated November 25, and replaced it with Transmittal 214 since the original transmittal did not include the mean unit cost for Calcitriol 1 mcg/mL oral solution (15ml/bottle) nor the reference to the applicable HCPCS code for injectable levocarnitine noted in footnote 5 on Attachment B. All other information remains the same.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R214BP.
Eliminate two case-mix payment adjustments (monoclonal gammopathy and bacterial pneumonia) available under the ESRD PPS
On December 15, CMS rescinded Transmittal 1526, dated August 6, and replaced it with Transmittal 1586 since it did not include the appropriate Federal Register citation pertaining to comorbidities as they apply to the ESRD PPS. In addition, the original transmittal is no longer sensitive because the CY 2016 End-Stage Renal Disease Prospective Payment System final rule is available to the public. All other information remains the same.
Effective date: January 1, 2016
Implementation date: January 4, 2016
View Transmittal R1586OTN.
Modification of OIG Advisory Opinion No. 06-13
On December 16, the OIG posted a modification to a past advisory opinion. The OIG had previously issued a Supplemental Special Advisory Bulletin regarding Independent Charity Patient Assistance Programs. It provided additional guidance on patient assistance programs operated by independent charities to address certain risks about these programs that have come to the OIG’s attention in recent years. The OIG sent the Supplemental Bulletin, together with targeted letters, to all independent charities that have received favorable advisory opinions from it to request certain clarifications and modifications to those opinions.
View the opinion.
Decision memorandum for positron emission tomography (PET) (NaF-18) to identify bone metastasis of cancer
On December 16, CMS posted the final decision memorandum stating that the evidence is sufficient to determine that use of a NaF-18 PET scan to identify bone metastasis of cancer 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 under § 1862(a)(1)(A) of the Social Security Act. CMS shall continue the requirement for coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act for NaF-18 PET to identify bone metastasis of cancer contained in section 220.6.19B of the Medicare National Coverage Determinations Manual for 24 months from the final date of this decision.
View the final decision memorandum.
Instruction to Apply the Part A Deductible on a Medicare Secondary Payer (MSP) Inpatient Same Day Transfer Claim
On December 17, CMS rescinded Transmittal 1560, dated November 5 and replaced it with Transmittal 1587 to remove business requirement 9394.2. All other information remains the same. This change request provides instruction to apply the Part A deductible on inpatient same day transfer claims when Medicare covered expenses are paid by a primary payer.
Effective date: April 1, 2016
Implementation date: April 4, 2016
View Transmittal R1587OTN.
Comments requested regarding DMEPOS enrollment application, bid pricing tool for Medicare Advantage and prescription drug plans, and more
On December 18, CMS posted a notice in the Federal Register relating that it is accepting comments on: CMS–855S, Medicare Enrollment Application—Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Suppliers; CMS–10142, Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP); and CMS–R-262, Contract Year 2017 Plan Benefit Package (PBP) Software and Formulary Submission. Comments are due January 19.
View the notice in the Federal Register.
Leave a comment.
Englewood Hospital and Medical Center claimed unallowable Medicare Part B reimbursement for outpatient cardiac and pulmonary rehabilitation services
On December 18, the OIG posted a report stating that Englewood Hospital and Medical Center of New Jersey claimed Medicare reimbursement for outpatient cardiac and pulmonary rehabilitation services that did not comply with Medicare reimbursement requirements. For 46 of the 100 claims in the random sample, the hospital improperly claimed Medicare reimbursement. On the basis of the sample results, the OIG estimated that the hospital improperly received at least $115,000 in Medicare reimbursement for services that did not comply with Medicare requirements.
View the report.
Medicare Compliance Review of Nebraska Methodist Hospital for 2012 and 2013
On December 18, the OIG posted a report stating that Nebraska Methodist Hospital complied with Medicare billing requirements for 119 of the 138 inpatient and outpatient claims reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 19 claims, resulting in net overpayments of $111,000 for calendar years 2012 and 2013. Specifically, 17 inpatient claims had billing errors, resulting in net overpayments of $86,000, and two outpatient claims had billing errors, resulting in overpayments of $25,000. 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.
Medicare Home Health Agency (HHA) transparency data (CY 2013)
On December 18, CMS posted a fact sheet and a press release regarding a new dataset, the Home Health Agency Utilization and Payment Public Use File (Home Health Agency PUF). This data set, which is part of CMS’s Medicare Provider Utilization and Payment Data set, details information on services provided to Medicare beneficiaries by home health agencies. These new data include information on 11,062 home health agencies, over six million claims, and over $18 billion in Medicare payments for 2013. The data is posted on the CMS website at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/HHA.html.
View the fact sheet.
View the press release.