This week in Medicare updates–2/14/2018

February 14, 2018
Medicare Insider

Transition to New Medicare Numbers and Cards

On February 2, CMS published a Fact Sheet regarding the transition to new Medicare cards and new Medicare numbers, which is scheduled to be completed by April 2019. The fact sheet provides information on when CMS will mail new cards out, what healthcare facilities need to do to prepare for the change, and how facilities can help prepare patients for the change.


New “K” Code for Therapeutic Shoe Inserts

On February 2, CMS published MLN Matters 10436 to accompany Transmittal 241, also dated February 2, regarding a new HCPCS K code for a category of therapeutic shoe inserts.

Effective date: April 1, 2018

Implementation date: April 2, 2018  


Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update

On February 5, CMS published MLN Matters 10454 to accompany Transmittal 3966, dated February 2, 2018,  regarding quarterly updates to the drug/biological HCPCS codes. The April 2018 HCPCS file includes three new HCPCS codes and features one revision to a descriptor for HCPCS code Q5101 (Injection, filgrastim-sndz, biosimilar, [zarxio], 1 microgram).

Effective date: April 1, 2018

Implementation date: April 2, 2018


Alternative Payment Models (APM) in the Quality Payment Program (QPP) as of February 2018

On February 5, CMS published a Table of APMs identified by CMS as models which meet certain requirements of the QPP as of February 2018. CMS identifies the APMs as either Merit-based Incentive Payment System (MIPS) APMs, Medical Home Models, or Advanced APMs. The QPP participation requirements in the table include use of a Certified Electronic Health Record Technology (CEHRT), quality measures criterion, and financial risk criterion. Providers can use this information to determine whether their APM will participate in the QPP through the MIPS pathway or through the APM pathway.   


Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018

On February 5, CMS published MLN Matters 10472 to accompany Transmittal 3963, dated February 2, 2018,  regarding normal updates to the NCCI PTP edits.

Effective date: April 1, 2018

Implementation date: April 2, 2018


New Provider Self-Disclosure Settlements
On February 5, the OIG updated its list of Provider Self-Disclosure Settlements with multiple new settlements reached in January. The list includes three providers who reached settlements due to allegedly employing individuals they knew or should have known were excluded from participation in federal healthcare programs. Those providers include:

  • Miller Holdings Sunrise Inc., d/b/a Sunrise Homes, of Ohio
  • Wahiawa General Hospital, of Hawaii
  • East Tennessee Personal Care Services, LLC, of Tennessee

The OIG also included a settlement from January 5, 2018, with St. Agnes Healthcare Inc., of Maryland, who paid $2,231,722.50 for allegedly violating a provision of the Civil Monetary Penalties Law applicable to physician self-referrals and kickbacks. St. Agnes allegedly paid remuneration to a physician via excessive compensation, which included an inflated salary and improper incentive and administrative payments.


Updated Corporate Integrity Agreement Documents

On February 6, the OIG published information on closed Corporate Integrity Agreements with the following organizations:

  • Borio Chiropractic Health Center and Joseph Borio, D.C., of Cicero, NY
  • Georgia Cancer Specialists I, P.C., of Atlanta, GA
  • Rural/Metro Corporation, of Scottsdale, AZ
  • Perfect Sense Eye Center, PC and Perfect Sense Eye Center St. Joe, LLC; Wiles, Stephen, M.D., of Kansas City, MO


Medicare Compliance Review of the University of Michigan Health System

On February 6, the OIG published a Review of the University of Michigan Health System’s compliance with Medicare requirements for billing inpatient and outpatient services with dates of service in calendar years 2014 or 2015. The OIG found that the hospital did not comply with Medicare billing requirements for 73 of the 181 inpatient and outpatient claims reviewed, resulting in overpayments of $1.3 million for those calendar years. Inpatient claims contained the most errors, as there were 37 inpatient claims that incorrectly billed Part A for inpatient rehabilitation facility services, 12 claims with incorrect DRG codes, and 14 claims with incorrect high-severity-level DRG codes, among other errors.

The OIG recommends the hospital refund the Medicare contractor $6.2 million in estimated net overpayments, exercise diligence to identify and return any additional similar overpayments outside of the audit period, and strengthen controls to ensure full compliance with Medicare requirements. The hospital agreed with most of the OIG’s findings but disagreed with the inpatient rehabilitation facility findings, as it claimed it met medical necessity for those stays. The OIG maintained that the inpatient rehabilitation facility findings did not meet Medicare standards.  


Updated List of Excluded Individuals and Entities (LEIE)

On February 7, the OIG updated its LEIE with an updated LEIE database for download and lists of January 2018 exclusions, reinstatements, and profile corrections.


Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

On February 7, CMS published MLN Matters 10295 to accompany Transmittal 204 and Transmittal 3969, both dated February 2, 2018, regarding revisions to an NCD to cover SET for beneficiaries with intermittent claudication, a symptom of PAD. CMS issued the NCD on May 25, 2017, and will cover up to 36 SET sessions over a 12-month period if certain requirements are met.

Effective date: May 25, 2017

Implementation date: April 3, 2018 - MAC edits; July 2, 2018 - full implementation


Comment Request: Fee-for-Service Recovery Audit Prepayment Review Demonstration and Prior Authorization Demonstration

On February 7, CMS posted a Comment Request in the Federal Register regarding the extension of a currently approved collection titled, “Fee-for-Service Recovery Audit Prepayment Review Demonstration and Prior Authorization Demonstration.” Comments are due to the OMB desk officer by March 9, 2018.


Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment

On February 8, CMS published Medicare Claims Processing Transmittal 3973 to provide instructions for the quarterly update to the CLFS. As of January 1, 2018, CLFS rates are based on weighted median private payor rates. The Part B deductible and coinsurance do not apply for services paid under the CLFS. The transmittal also includes a list of new HCPCS codes included in the quarterly update. These codes will be contractor priced.

Effective date: January 1, 2018 - For new HCPCS codes listed in the Background section; April 1, 2018

Implementation date: April 2, 2018


Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2018 - Recurring File Update

On February 8, CMS published Medicare Claims Processing Transmittal 3972 regarding the grandfathered tribal FQHC PPS rate for 2018, which will be $383. FQHC claims (TOB 77X) for grandfathered tribal FQHCs submitted with dates of service on or after January 1, 2018 through March 31, 2018 paid at the CY 2017 rate of $349 should be adjusted and paid at the CY 2018 rate of $383.

Effective date: April 1, 2018

Implementation date: April 2, 2018


Post-Payment Review Timeliness Requirements

On February 8, CMS published Medicare Program Integrity Transmittal 768 regarding an update to time frames in which the Medicare Program Integrity contractors (ZPICs/UPICs) must complete post-payment medical review.

Effective date: March 1, 2018

Implementation date: April 1, 2018


Diagnosis Code Update for Add-On Payments for Blood Clotting Factor Administered to Hemophilia Inpatients

On February 8, CMS published Medicare Claims Processing Transmittal 3974 to provide updates to diagnosis codes required in order to identify claims for add-on payments under the Inpatient Prospective Payment System (IPPS). Effective July 1, 2018, ICD-10-CM code D68.32 (antiphospholipid antibody with hemorrhagic disorder) will not receive an add-on payment under the hemophilia clotting factor criteria.

Effective date: July 1, 2018

Implementation date: July 2, 2018