This week in Medicare updates–3/22/2017
Clarification of Admission Order and Medical Review Requirements
On March 13, CMS released MLN Matters 9979 to accompany Transmittal 234 released March 10. The transmittal clarifies CMS rulemaking language as it relates to Admission and Medical Review Criteria for Hospital Inpatient Services Under Medicare Part A; Requirements for Physician Orders.
Effective date: January 1, 2016
Implementation date: June 12, 2017
Hospitals Nationwide Generally Did Not Comply With Medicare Requirements for Billing Outpatient Right Heart Catheterizations (RHC) With Heart Biopsies
On March 14, the OIG published a Report regarding its finding of frequent noncompliance with billing for outpatient RHCs and heart biopsies performed during the same patient encounter--hospitals did not comply with the Medicare requirements for 92 of the 100 sampled line items. Specifically, the hospitals incorrectly appended modifier -59 to the HCPCS code, representing that the RHCs were separate and distinct procedures from the heart biopsies even though the medical record documentation did not support the use of the modifier. The OIG estimates that hospitals nationwide received overpayments totaling $7.6 million for the audit period.
Nantucket Cottage Hospital Did Not Accurately Report Certain Wage Data, Resulting in Overpayments to Massachusetts Hospitals
On March 14, the OIG released a Report regarding Nantucket Cottage Hospital, which did not always comply with Medicare requirements for reporting wage data in its fiscal year 2011 Medicare cost report. The hospital overstated wages and wage-related costs by $232,000 (net) and understated hours by 18,060 (net). The OIG estimates that Medicare overpaid the hospital a total of $156,000 for fiscal year (FY) 2015 inpatient services and calendar year (CY) 2015 outpatient services. The OIG also estimates that Medicare overpaid 55 other hospitals in the State a total of $133.6 million for FY 2015 inpatient services and CY 2015 outpatient services because the hospital's wage data set the rural floor wage index for Massachusetts. Because of the rural floor budget neutrality provision in Section 3141 of the Affordable Care Act, the overpayments to Massachusetts hospitals caused underpayments to hospitals in other States.
Civil Monetary Penalties
On March 15, the OIG released information on multiple recent settlement agreements, including:
- Iowa Hospital Covenant Medical Center (Covenant) in Waterloo settles case involving a patient dumping allegations when it failed to provide an appropriate psychiatric screening examination or stabilizing treatment for three patients who presented to the emergency department (ED) when an on-call psychiatrist was available. In addition, a woman presented to the ED complaining of depression and suicidal thoughts, but was later discharged with instructions to follow-up with her primary care physician and a child presented to the ED following violent outbursts, but was later discharged with instructions to follow-up with his primary care physician. Another man presented to the ED stating his mind was "disturbed," but later eloped from the ED into single degree weather wearing paper scrubs while his discharge was processed. His body was found about 300 feet from Covenant with the cause of death attributed to hypothermia.
- Michigan physician Dr. Sotero Ureta, Lake City, agrees to voluntary exclusion for the submission of false claims to Medicare and Medicaid for physical therapy, electrodiagnostic testing, and/or home health care services that he referred in exchange for illegal remuneration or kickbacks.
New Educational Initiative to Raise Awareness of Chronic Care Management (CCM)
On March 15, CMS published a Press Release announcing Connected Care, an educational initiative to raise awareness of the benefits of CCM services for Medicare beneficiaries with multiple chronic conditions and to provide healthcare professionals with support to implement CCM programs.
Chronic Care Management Payment Correction for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
On March 16, CMS published a correction for RHCs and FQHCs regarding their payment for Chronic Care Management (CCM) services based on the Medicare Physician Fee Schedule national average non-facility payment rate, which was effective January 1. For claims with dates of service on or after January 1, 2017, RHCs and FQHCs have been receiving a locality adjusted payment rate for these services, according to the CMS correction email. Medicare Administrative Contractors will adjust any claim processed incorrectly, and no provider action is required.
MEDCAC Meeting: Outcomes in Heart Failure Treatment Technology Studies
On March 16, CMS posted an agenda, roster and speakers list for the March 22 MEDCAC Meeting, Health Outcomes in Heart Failure Treatment Technology Studies. Additional information is available on the CMS website.
Home Health (HH) Language in Pub. 100-8
On March 17, CMS released Transmittal 704 to provide clarification to the existing home health language in chapter 6 of the Medicare Program Integrity Manual, Pub 100-8. The clarification is regarding the calendar year 2015 Home Health Prospective Payment System (HH PPS) Final Rule. The final rule eliminated the requirement of a face-to-face encounter narrative as part of the certification of patient eligibility for home health services.
Effective date: April 17, 2017
Implementation date: April 17, 2017
Billing for Advance Care Planning (ACP) Claims
On March 17, CMS released Transmittal 3739 to provide billing instructions for ACP when furnished as an optional element of an Annual Wellness Visit.
Effective date: January 1, 2016
Implementation date: June 19, 2017
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2017
On March 17, CMS released Transmittal 3738 to announce the changes that will be included in the July 2017 quarterly release of the edit module for clinical diagnostic laboratory services.
Effective date: October 1, 2016
Implementation date: July 3, 2017
Quarterly Updates to ESRD PRICER
On March 17, CMS released Transmittal 3737 to implement quarterly updates to the ESRD PRICER.
Effective date: July 1, 2017
Implementation date: July 3, 2017