This week in Medicare updates–5/24/2017
Implementation Issues, Long-Term Care Regulatory Changes: Substandard Quality of Care (SQC) and Clarification of Notice before Transfer or Discharge Requirements
On May 12, CMS published a Memorandum regarding implementation issues and long-term care regulatory changes related to Substandard Quality of Care (SQC) and clarification of notice before transfer or discharge requirements. A new definition of SQC was published in the 2016 Final Long-term Care Rule and became effective on November 28, 2016 and will affect which F-tags and regulatory groupings are considered to be SQC in both Phase 1 and Phase 2 of the Final Rule implementation process.
Clarifying Medical Review of Hospital Claims for Part A Payment
On May 12, CMS published Transmittal 716, which clarifies the medical review requirements for Part A payment of short stay hospital claims (i.e., the 2-Midnight Rule) for Medicare Administrative Contractors, Supplemental Medical Review Contractors (SMRC), Recovery Auditors, and the Comprehensive Error Rate Testing (CERT) contractors. (Such reviews are currently mainly overseen by Quality Improvement Organizations.) CMS also published an associated MLN Matters article, MM10080, on May 16, 2017.
Effective date: June 13, 2017
Implementation date: June 13, 2017
New Waived Tests
On May 15, CMS released MLN Matters 10055 to accompany Transmittal 3771, published May 12, 2017. The transmittal informs contractors of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration. There are 12 new waived complexity tests.
Effective date: January 1, 2017
Implementation date: July 3, 2017
Changes to the Payment Policies for Reciprocal Billing Arrangements and Fee-For-Time Compensation Arrangements (formerly “Locum Tenens Arrangements”)
On May 15, CMS published MLN Matters 10090 to accompany Transmittal 3774, published May 12, 2016. The transmittal implements section 16006 of the 21st Century Cures Act, which allows outpatient physical therapy services furnished by physical therapists in a health professional shortage area (HPSA), a medically underserved area (MUA), or in a rural area to be billed under reciprocal billing and fee-for-time compensation arrangements in the same manner as physicians bill effective no later than June 13, 2017. It also updates the Medicare Claims Processing Manual (Pub. 100-04), chapter 1, sections 30.2.10 and 30.2.11 to clarify that when a regular physician or physical therapist is called or ordered to active duty as a member of a reserve component of the Armed Forces for a continuous period of longer than 60 days, payment may be made to that regular physician or physical therapist for services furnished by a substitute under reciprocal billing arrangements or fee-for-time compensation arrangements throughout that entire period.
Effective date: June 13, 2017
Implementation date: June 13, 2017
Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July CY 2017 Update
On May 15, CMS published MLN Matters 10104 to accompany Transmittal 3772, dated May 12, 2017. The transmittal amends the payment files issued to contractors based upon the CY 2017 Medicare Physician Fee Schedule Final Rule with the July 2017 update. Note the attachment for a summary of changes, including new HCPCS and CPT codes.
Effective date: January 1, 2017
Implementation date: July 3, 2017
Implementation of Modifier -CG for Type of Bill 72x
On May 15, CMS published MLN Matters 9989 to accompany Transmittal 1849, dated May 12, 2016. The transmittal implements modifier -CG, which identifies non-medically justified dialysis treatments. In order to accurately capture all treatments provided to a beneficiary, CMS is implementing a new modifier -CG (Policy Criteria Applied for the 72x type of bill (TOB) when used in the billing of hemodialysis treatments for patients with ESRD in excess of the 13 or 14 monthly allowable treatments).
Effective date: October 1, 2017
Implementation date: October 2, 2017
Missouri Physical Therapy (PT) Practice Claimed Unallowable Medicare Part B Reimbursement for Outpatient PT Services
On May 16, the OIG published a Report on a Missouri PT practice that claimed Medicare reimbursement for some outpatient PT services that did not meet Medicare reimbursement requirements. The practice disagreed with some of the OIG’s initial findings regarding, and the OIG later revised those findings after reviewing written comments. The final findings indicated the practice improperly claimed Medicare reimbursement on 35 beneficiary days of the 100 beneficiary days in the random sample.
Medical Ambulance Services, Inc., Claimed Unallowable Reimbursement for Medicare Part B Ambulance Services
On May 16, the OIG published a Report on Medical Ambulance Services, Inc., of San Juan, Puerto Rico, which claimed Medicare Part B reimbursement for ambulance services that did not comply with federal and Commonwealth of Puerto Rico requirements. Of the 100 claims in the OIG’s random sample, only 5 complied with requirements. Forty of the claims contained multiple deficiencies. Specifically, the signature of the beneficiary or their representative (acknowledging that the service was received) was not provided on 72 claims. The ambulance used in the service did not have a valid inspection or certification for 51 claims. The service was provided during a period in which the ambulance used in the service was not covered under a liability insurance plan for 18 claims. In addition, 60 claims were for services provided by an emergency medical technician with a provisional license who was not accompanied by a permanently licensed paramedic,a potential health and safety risk.
Update FISS Editing to Include All Three Patient Reason for Visit Code Fields
On May 17, CMS published Transmittal 1852, which rescinds and replaces Transmittal 1840, dated May 5, 2017, to change the effective and implementation dates. All other information remains the same. CMS also revised the accompanying MLN Matters article MM9672, on May 18, 2017.
Effective date: October 1, 2017 - Claims received on or after
Implementation date: October 2, 2017
Comprehensive Primary Care Plus Round 2 Fact Sheet
On May 17, CMS released a Fact Sheet on the Comprehensive Primary Care Plus (CPC+) model, an advanced primary care medical home model. Round 1 began in 2017 in 14 regions, with 53 payers and 2,891 practices participating. The second round will run from 2018 to 2022. The following four regions were selected for CPC+ Round 2:
- Louisiana (statewide)
- Nebraska (statewide)
- North Dakota (statewide)
- New York (Greater Buffalo Region: Erie and Niagara counties)
Eligible practices can apply to participate in Round 2 until July 13, 2017.
Compendium of Unimplemented Recommendations
On May 17, the OIG published its annual Compendium of Unimplemented Recommendations. The 2017 edition of focuses on the top 25 unimplemented recommendations that, in OIG's view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and quality improvements.
Two New “K” Codes for Therapeutic Continuous Glucose Monitors
On May 18, CMS published Transmittal 3775, which rescinds and replaces Transmittal 3751, dated April 21, 2017, to add a new requirement for English descriptions. All other information remains the same.
Effective date: July 1, 2017
Implementation date: July 3, 2017
Delay of Final Rule Effective Date: Advancing Care Coordination Through Episode Payment Models (EPM); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement (CJR) Model
On May 19, CMS published a Notice in the Federal Register regarding a delay of the effective date of the advancing care coordination through EPM; Cardiac Rehabilitation Incentive Payment Model; and Changes to the CJR Model final rule. The rule finalizes a delay of the applicability date of the regulations at 42 CFR part 512 from July 1, 2017 to January 1, 2018 and delays the effective date of the specific CJR regulations from July 1, 2017 to January 1, 2018.
July 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.2
On May 19, CMS published Transmittal 3777 to informs providers that the I/OCE is being updated July 1, 2017. The I/OCE routes all institutional outpatient claims (which includes non-Outpatient Prospective Payment System hospital claims) through a single I/OCE. CMS also published the related MLN Matters article, MM10115, on May 19, 2017.
Effective date: July 1, 2017
Implementation date: July 3, 2017
Medicare Care Choices Model (MCCM) Per Beneficiary per Month Payment (PBPM) - Implementation (eligibility updates and clarification)
On May 19, CMS published Transmittal 173 to update the eligibility requirements and clarify the rules for the MCCM. The MCCM is designed to evaluate whether eligible Medicare and dually eligible beneficiaries would elect to receive supportive care services typically provided by hospice if they could also continue to receive treatment for their terminal condition and how this flexibility impacts quality of care and patient, family, and caregiver satisfaction. Participating hospices will provide designated services currently available under the Medicare hospice benefit for routine home care and respite levels of care but cannot be separately billed under Medicare Parts A, B, and D. These services include nursing, social work, hospice aide, hospice homemaker, volunteer, chaplain, bereavement, nutritional support, and respite care services. CMS also published the related MLN Matters article, MM10094, on May 19, 2017.
Effective date: January 1, 2016
Implementation date: October 2, 2017
Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2017 Update
On May 19, CMS published Transmittal 3776 to update the HCPCS code set, which is done quarterly for specific drug/biological HCPCS codes. Beginning on July 1, 2017, the following HCPCS codes will be established:
- Q9984, Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
- Q9985, Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
- Q9986, Injection, hydroxyprogesterone caproate (Makena), 10 mg
- Q9988, Platelets, pathogen reduced, each unit
- Q9989, Ustekinumab, for Intravenous Injection, 1 mg
As of that date, HCPCS code J1725, Injection, hydroxyprogesterone caproate, 1 mg, will no longer be valid for Medicare Part B claims.
CMS also published the related MLN Matters article, MM10107, on May 19, 2017.
Effective date: July 1, 2017
Implementation date: July 3, 2017
Payment of G9678 (Oncology Care Model Monthly Enhanced Oncology Services (MEOS) Claims for Beneficiaries Receiving Care in an Inpatient Setting
On May 19, CMS published Transmittal 174 to instruct A/B MACs (Part B) to issue payment for detail lines with G9678 with dates of service on or after April 1, 2016, irrespective of whether the beneficiary is receiving care in an inpatient or outpatient setting provided that the billing for MEOS meets all other conditions for payment.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Reviewing for Adverse Legal Actions (ALA)
On May 19, CMS published Transmittal 718 to update chapter 15 of the Medicare Program Integrity Manual (Pub. 100-08) to include information and resources to assist the Medicare Administrative Contractors (MAC) in reviewing final adverse actions while processing provider enrollment applications.
Effective date: June 20, 2017
Implementation date: June 20, 2017