This week in Medicare updates–2/21/18
HCPCS Codes Subject To and Excluded From Clinical Laboratory Improvement Amendments (CLIA) Edits
On February 9, CMS published Medicare Claims Processing Transmittal 3975, which rescinds and replaces Transmittal 3949, dated January 12, regarding new HCPCS codes for 2018 that are subject to and excluded from CLIA edits. The new transmittal adds HCPCS code G0475 as a code that is subject to CLIA edits effective April 13, 2015.
On February 12, CMS published a revised version of MLN Matters 10446 to accompany the transmittal.
Effective date: January 1, 2018
Implementation date: April 2, 2018
Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment
On February 9, CMS published MLN Matters 10445 to accompany Transmittal 3973, dated February 8, regarding instructions for the quarterly update to the CLFS.
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 9, CMS published MLN Matters 10480 to accompany Transmittal 3972, dated February 8, regarding the grandfathered tribal FQHC PPS rate for 2018.
Effective date: April 1, 2018
Implementation date: April 2, 2018
Diagnosis Code Update for Add-On Payments for Blood Clotting Factor Administered to Hemophilia Inpatients
On February 9, CMS published MLN Matters 10474 to accompany Transmittal 3974, dated February 8, regarding 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
Revised and New Modifiers for Oxygen Flow Rate
On February 13, CMS published Medicare Claims Processing Transmittal 3895 regarding new and revised pricing modifiers for oxygen flow rate. There will be three new modifiers and three revised modifiers with descriptors provided in the transmittal. These modifiers are intended to provide greater specificity for oxygen volume adjustments in instances where there are varying prescribed flow rates. The transmittal also details payment, revenue codes, and edits to be aware of in relation to these modifiers.
On February 14, CMS published MLN Matters 10158 to accompany the transmittal.
Effective date: April 1, 2018
Implementation date: April 2, 2018
New Topics Proposed for Recovery Audit Review
On February 14, CMS updated its recovery audit program provider resources page with a List of topics proposed for review. The topics include:
- Lab services rendered during an inpatient stay
- Cataract removal - excessive units by physician (partial denial)
- Cataract removal - excessive units by physician (full denial)
- Ancillary services billed without an approved surgical procedures
- Clinical social workers during inpatient stay
- Technical component of lab/pathology for outpatient hospitals
- Labs subject to Part B consolidated billing by clinical lab - end stage renal disease (ESRD)
- Observation evaluation & management (E&M) services billed same day as inpatient admission
- Ventilators subject to ACA requirements prior to January 1, 2016
New Topics Proposed for Recovery Audit Review
On February 14, CMS published a Booklet for rural health centers regarding 2018 Medicare telehealth services policies. The booklet is directed at physicians or practitioners at distant sites, and it clarifies qualification requirements for originating sites, qualification requirements for distant sites, codes to use when billing for telehealth services, billing and payment for professional services furnished via telehealth, and billing and payment for the originating site facility fee. The booklet also contains a list of helpful resources related to telehealth.
Provider Compliance Tips for Diabetic Test Strips
On February 14, CMS published a Fact Sheet regarding compliance strategies for physicians, durable medical equipment suppliers, and other practitioners who either write prescriptions for diabetic test strips or supply diabetic test strips. The fact sheet reviews reasons for denials related to diabetic test strips and suggests strategies to implement to prevent denials.
2019 Hospital Outpatient Payment Panel OPPS Cost Statistics Two Time Run Document
On February 14, CMS published a Document containing the 2019 OPPS panel two times file to provide cost statistic information on services as organized by their ambulatory payment classification (APC).
Final Decision Memo for Implantable Cardioverter Defibrillators (ICD)
On February 15, CMS published a Final Decision Memo to finalize changes to Section 20.4 of the NCD manual regarding conditions of coverage for ICD devices. The changes will apply to patient criteria, exceptions to waiting periods, and registry requirements. CMS received 24 comments during the 30-day public comment period for this NCD.
Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements
On February 15, the OIG published a Review of whether Wisconsin Physicians Service (WPS) paid providers in 2013 and 2014 for hyperbaric oxygen (HBO) therapy services that complied with Medicare requirements. The OIG found that WPS made payments for HBO therapy that did not comply with Medicare requirements in 102 out of 120 sampled outpatient claims. Based on those results, the OIG estimated that WPS overpaid providers in Jurisdiction 5 a total of $42.6 million during the audit period for HBO therapy that did not comply with Medicare requirements.
The OIG recommended that WPS recover the appropriate portion of the identified overpayments, notify providers responsible for the unsampled HBO claims of potential overpayments, identify and recover any improper payments made after the audit period, and strengthen its policies and procedures for making payments for HBO therapy.
Update to OIG Work Plan
On February 15, the OIG updated its Work Plan to include the following reviews:
- Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2016 Average Sales Prices
- Review of Statistical Methods Within the Medicare Fee-for-Service Administrative Appeal Process
Medicare Needs Better Controls to Prevent Fraud, Waste, and Abuse Related to Chiropractic Services
On February 16, the OIG published a Portfolio to provide an overview of program vulnerabilities identified in previous OIG audit, evaluations, investigations, and legal actions related to chiropractic services. The portfolio examines findings and issues related to chiropractic services and discusses recommendations from previous reports that have not been implemented or have been implemented ineffectively.
Targeted Probe and Educate Metrics Deliverables Update and Glossary
On February 16, CMS published One-Time Notification Transmittal 2035 to update the monthly metrics deliverables for the Targeted Probe and Educate program as well as including a glossary for clarity.
Effective date: March 19, 2018
Implementation date: March 19, 2018
Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
On February 16, CMS published Medicare Claims Processing Transmittal 3980 to update the RARC and CARC lists and to instruct the ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) to update MREP and PC Print. This is part of a recurring update based on the code update schedule. If any new or modified code has an effective date past the implementation date specified in the transmittal, contractors must implement it on the date specified on the Washington Publishing Company website.
Effective date: July 1, 2018
Implementation date: July 2, 2018
Quarterly Update to the Medicare Physician Fee Schedule Database - April 2018 Update
On February 16, CMS published Medicare Claims Processing Transmittal 3976 regarding the quarterly update to the payment files based on the 2018 Medicare Physician Fee Schedule Final Rule.
Effective date: January 1, 2018
Implementation date: April 2, 2018
Update to Provider Reimbursement Manual Part 2, Provider Cost Reporting Forms and Instructions, Chapter 42
On February 16, CMS published Provider Reimbursement Manual Transmittal 4 regarding updates to Chapter 42 (Independent Renal Dialysis Facility Cost Report - Form CMS-265-11) of the manual for acute kidney injury renal dialysis services furnished on or after January 1, 2017. The transmittal also provides revisions to Worksheets S, B, B-1, and D.
Effective date: Changes to the electronic reporting specifications are effective for cost reporting periods ending on or after December 31, 2017.
Identifying and Eliminating Discrepancies in Shared System Enrollment Data and Provider Enrollment Chain and Ownership System (PECOS) Data
On February 16, CMS published One-Time Notification Transmittal 2034 regarding the need for reconciliation of data between the shared system and PECOS. There are currently no policies, procedures, or instructions in place for monitoring and reconciling changes in provider records and eligibility status. This transmittal clarifies the need for accurate provider and supplier enrollment records and provides a process to identify discrepancies between the enrollment data found in the shared systems and the PECOS.
Effective date: July 1, 2018
Implementation date: July 2, 2018
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
On February 16, CMS published One-Time Notification Transmittal 2033 regarding a maintenance update of the ICD-10 conversions and other coding updates specific to NCDs.
Effective date: July 1, 2018
Implementation date: April 2, 2018 of CR for CMS Local MACs; July 2, 2018 - CMS Shared System Maintainers
Healthcare Provider Taxonomy Codes (HPTCs) April 2018 Code Set Update
On February 16, CMS published Medicare Claims Processing Transmittal 3977 to instruct affected Medicare contractors to obtain the most recent HPTCs code set and use it to update their internal HPTC tables and/or reference files.
Effective date: July 1, 2018
Implementation date: July 2, 2018