This week in Medicare updates–8/02/2017
Complex Reviews for Vagus Nerve Stimulation (VNS) in Regions 2 and 3
On July 19, Recovery Audit Contractor (RAC) Cotiviti announced that it has been approved to start Complex Reviews of claims for VNS. Cotiviti will review medical documentation to determine if the VNS service is medically reasonable and necessary under the applicable National Coverage Determination (NCD), Section 160.18, for VNS.
According to the Cotiviti website, the service of VNS is considered reasonable and necessary, under the applicable NCD, for patients with medically refractory partial onset seizures for whom surgery is not recommended, or for whom surgery has failed. However, VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory, for whom surgery is not recommended, or for whom surgery has failed. VNS is not reasonable and necessary for resistant depression.
Cotiviti is the RAC for regions 2 and 3.
CMS Terminates Medicare Provider Agreement with Reliable Home Health Services, Inc.
On July 25, CMS announced that it will be terminating its Medicare Provider Agreement with Reliable Home Health Services, Inc, of Wheat Ridge, Colorado. CMS has determined that the organization is not in compliance with regulatory requirements for participation as a Home Health Agency in the Medicare Program.
Effective Date: August 2, 2017
CMS Terminates Medicare Provider Agreement with Reliable Home Health Services, Inc.
On July 25, CMS announced that it will be terminating its Medicare Provider Agreement with Maximum Home Health Care of Munster, Indiana. CMS has determined that the organization is not in compliance with the following regulatory requirements for participation as a Home Health Agency in the Medicare Program:
- 42 CFR §484.10 – Patient’s Rights
- 42 CFR §484.14 – Organization, Services, and Administration
- 42 CFR §484.18 – Acceptance of Patients, Plan of Care, and Medical Supervision
- 42 CFR §484.30 – Skilled Nursing Services
- 42 CFR §484.48 – Clinical Records
Effective Date: August 4, 2017
2018 Proposed Home Health Prospective Payment System (HH PPS) Rate Update
On July 25, CMS published a Proposed Rule proposing to change the HH PPS payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor to become effective for home health episodes of care ending on or after January 1, 2018.
The rule also proposes refinements to the case-mix methodology and a change from 60-day episodes of care to 30-day periods of care for the unit of payment, to be implemented on or after January 1, 2019. The rule also proposed changes to the Home Health Value-Based Purchasing (HHVBP) model and the Home Health Quality Reporting Program (HH QRP).
An accompanying Press Release and Fact Sheet were issued the same day as the Proposed Rule.
Comments are due by September 25, 2017.
Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)
On July 25, CMS issued National Coverage Determination Manual Transmittal 200 and Claims Processing Manual Transmittal 3811, which rescind earlier transmittals, Transmittal 199 and Transmittal 3805, published July 11. The revised transmittals correct cross-references in the business requirements and add clarifying language to the Claims Processing Manual indicating CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved clinical trial.
All other information remains the same.
On July 26, CMS also published MLN Matters 10089 to accompany both transmittals.
Effective date: December 7, 2016
Implementation date: June 27, 2017
Eye on Oversight Video Series: Electronic Health Records (EHR)
On July 26, the OIG released a new educational video on the importance of maintaining accurate, secure EHRs, and the importance of honesty among EHR vendors. The video is narrated by Senior Counsel John O’Brien.
OIG Finds Some Hospitals in Medicare Jurisdiction E Claimed Residents as More Than One Full-Time Equivalent (FTE)
On July 27, the OIG announced that it has found that some hospitals in Medicare Jurisdiction E did not always claim Medicare graduate medical education (GME) reimbursement for residents in accordance with Federal requirements. Specifically, they found that 65 hospitals claimed residents for the same period as more than one FTE on cost reports covering fiscal years (FY) 2012 and 2013. As a result, 36 of the 65 hospitals received excess Medicare GME reimbursement totaling $435,000.
Also on July 27, the OIG announced the same finding for some hospitals in Jurisdiction F. The OIG is recommending that Noridian Healthcare Solutions, the Medicare Administrative Contractor (MAC) for both Jurisdiction E and F, recover the excess reimbursement and develop processes to avoid counting residents incorrectly in the future.
Medicare Reporting on the Return of Self-Identified Overpayments
On July 27, CMS issued One Time Notification Transmittal 1884, stating that CMS has been working with the OIG on the tracking and reporting of the return of self-identified overpayments. CMS is announcing a series of meetings with its contractors to determine methods to associate returned fund to particular OIG Audits.
Effective date: January 2, 2018
Implementation date: January 2, 2018
Shared Savings Program (SSP) Demonstration Code 77 Modification
On July 27, CMS published One Time Notification Transmittal 1880, a one-time notification about code 77, a demonstration code to be applied only to claims where the SSP has waived the qualifying stay requirement.
Effective date: January 1, 2018
Implementation date: January 1, 2018
Analysis of Fiscal Intermediary Shared Systems (FISS) Process Enhancements
On July 27, CMS issued One Time Notification Transmittal1871, which calls for the analysis of potential mass adjustment enhancements which have been identified by the Medicare Administrative Contractors (MAC) as related to the processing of Recovery Audit Contractor (RAC) claims. These enhancements are vital to increasing RAC claim processing efficiencies.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Correcting Errors in IPPS Claims Processing Related to Transfers
On July 27, CMS issued One Time Notification Transmittal1870, announcing the implementation of a correction to the payment of IPPS transfer claims classified to MS-DRG 385 from full IPPS payment to a per diem transfer payment. This also instructs the Fiscal Intermediary Standard System (FISS) to allow the Part A deductible on MSP same day transfer claims.
On July 28, CMS issued accompanying MLN Matters 10145 to offer additional information on this transmittal.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process
On July 27, CMS issued One Time Notification Transmittal1876, announcing the modifications to the National COBA crossover process. This change modifies the Part A shared system maintainer's Direct Data Entry (DDE) screen entry process to allow for the reporting of a provider taxonomy code at the Attending Physician level.
Effective date: January 1, 2018
Implementation date: January 2, 2018
ICD-10 Coding Revisions to National Coverage Determinations (NCD)
On July 27, CMS issued One Time Notification Transmittal1875, announcing a maintenance update to the ICD-10 conversions and other coding updates specific to NCD. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. The transmittal indicates that policy-related changes to NCDs continue to be implemented via the current NCD process.
Effective date: January 1, 2018
Implementation date: September 13, 2017- from Issuance for Local Edits;
January 2, 2018 - Shared System Maintainers
Clarification of Certificate of Medical Necessity (CMN) and Durable Medical Equipment Information Forms (DIFs)
On July 27, CMS issued Program Integrity Manual Transmittal 733 to clarify when denials related to CMNs or DIFs are appropriate.
For certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies items, the supplier must submit a CMN or DIF for payment purposes. This transmittal clarifies how such documents shall be reviewed with the medical record during the course of claims review.
Effective date: August 28, 2017
Implementation date: August 28, 2017
Accepting Hospice Notices of Election via Electronic Data Interchange
On July 27, CMS issued Claims Processing Manual Transmittal 3813, which announces that moving forward, the submission of Notices of Election (NOEs) are to be accepted via Electronic Data Interchange (EDI).
Effective date: January 1, 2018
Implementation date: January 2, 2018
Updated Editing of Always Therapy Services
On July 27, CMS issued Claims Processing Manual Transmittal 3814, which implements revised editing of Part B "Always Therapy" professional services claims to require the appropriate modifier in order for the service to be accurately applied to the therapy cap.
Services furnished under the outpatient therapy (OPT) services benefit − including speech-language pathology (SLP), occupational therapy (OT) and physical therapy (PT) services − are subject to the financial limitations, known as therapy caps. Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy and publishes this list as an Annual Update on the Therapy Services Billing webpage.
During analyses of Medicare claims data for OPT services, the Centers for Medicare & Medicaid Services (CMS) has found that these “always therapy” codes and modifiers are not always used in a correct and consistent manner. CMS found OPT professional claims for “always therapy” codes without the required modifiers; and, claims that reported more than one therapy modifier for the same therapy service; e.g., both a GP and GO modifier, when only one modifier is allowed.
Effective date: January 1, 2018
Implementation date: January 2, 2018
New Waived Tests
On July 27, CMS issued Claims Processing Manual Transmittal 3812, issued to inform contractors of new Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests approved by the Food and Drug Administration. There are 17 newly added waived complexity tests.:
MACs will not search their files to either retract payment or retroactively pay claims; however, MACs should adjust claims if they are brought to their attention.
Also on July 27, CMS issued MLN Matters 10198 to supplement the transmittal.
Effective date: October 1, 2017
Implementation date: October 2, 2017
CMS Announces National Coverage Decision (NCD) Regarding Leadless Pacemakers
On July 28, CMS issued Claims Processing Manual Transmittal 3815 and National Coverage Determination Transmittal 201, announcing the coverage conditions for leadless pacemakers under Coverage with Evidence Development. Leadless pacemakers eliminate the need for a device pocket and insertion of a pacing lead. The removal of these elements eliminate an important source of complications associated with traditional pacing systems while providing similar benefits.
CMS also announced this decision on its database and maintains a Coverage with Evidence Development page for leadless pacemakers with a listing of approved clinical studies.
Effective Date: January 18, 2017
Implementation Date: August 29, 2017 - for Medicare Administrative Contractor (MAC) local edits;
January 2, 2018 - for shared edits
Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations
On July 28, CMS announced in the Federal Register the extension of statewide temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies, subunits, and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, as applicable, to prevent and combat fraud, waste, and abuse. This extension also applies to the enrollment of new nonemergency ground ambulance suppliers and home health agencies, subunits, and branch locations in Medicaid and the Children’s Health Insurance Program in those states.
This is applicable as of July 29.
Core Quality Measures Announced
On July 28, CMS announced its new Core Quality Measures:
- Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMH), and Primary Care
- Cardiology
- Gastroenterology
- HIV and Hepatitis C
- Medical Oncology
- Obstetrics and Gynecology
- Orthopedics
- Pediatric
These measures are aligned for the goals of promotion of measurement that is evidence-based and generates valuable information for quality improvement, consumer decision-making, value-based payment and purchasing, reduction in the variability in measure selection, and decreased provider’s collection burden and cost.
These initial seven sets of measures were targeted primarily towards practitioners and group practices that serve adult patient populations. CMS is now releasing a set of measures targeted towards practitioners and group practices that serve pediatric patient populations.
CMS also issued a Fact Sheet on July 28.
FY 2016 Report to Congress (RTC): Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program
On July 28, CMS posted a memorandum regarding its review of Medicare’s program Oversight of AOs and the CLIA validation program.
The memorandum features seven main sections:
- CMS-Approval of Medicare Accreditation Programs
- Scope of Accrediting Organization Medicare Accreditation Programs
- Accrediting Organization Performance Measures
- Validation of Accrediting Organization Surveys
- Baseline Analysis – Life Safety Code and Health & Safety Disparity Rates
- Centers for Medicare & Medicaid Services Improvements
- Clinical Laboratory Improvement Amendments Validation Program