This week in Medicare updates–9/26/17
Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2018
On September 18, CMS published MLN Matters 10233, which accompanies Medicare Claims Processing Manual Transmittal 3861, dated September 15, 2017. The transmittal is in regards to the DME CBP files, which are updated on a quarterly basis in order to implement necessary changes to the HCPCS, ZIP code, Single payment amount, and Supplier files.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Revision to Publication 100-06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment
On September 18, CMS published revised MLN Matters 9815, which accompanies Medicare Financial Management Manual Transmittal 293, dated September 14, 2017. The transmittal rescinds and replaces Transmittal 292, dated September 1, 2017, to correct formatting errors in the manual instructions.
Effective date: April 2, 2018
Implementation date: April 2, 2018
October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On September 18, CMS published revised MLN Matters 10236, which accompanies Medicare Claims Processing Manual Transmittal 3864, dated September 15, 2017. The transmittal rescinds and replaces Transmittal 3853, dated August 25, 2017, to update the policy section, correct an error to the OPPS status indicator for Q5102 in the attachment Table 5, include information on the revised OPPS status indicator and APC for CPT code 0421T in Section 6., and add Table 7.
Effective date: October 1, 2017
Implementation date: October 2, 2017
Updated Editing of Always Therapy Services - MCS
On September 18, CMS published revised MLN Matters 10176, which accompanies Medicare Claims Processing Manual Transmittal 3863, dated September 15, 2017, The transmittal rescinds and replaces Transmittal 3814, dated July 27, 2017, to implement revised editing of Part B “Always Therapy” services to require the appropriate modifier for the service to be accurately applied to the therapy cap.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Annual Clotting Factor Furnishing Fee Update 2018
On September 18, CMS published MLN Matters 10254, which accompanies Medicare Claims Processing Manual Transmittal 3862, dated September 15, 2017. The transmittal announces the update to the Clotting Factor Furnishing Fee.
Effective date: January 1, 2018
Implementation date: January 2, 2018
Guidance on Coding and Billing Date of Service on Professional Claims
On September 19, CMS published Special Edition MLN Matters 17023 regarding Medicare rules and regulations concerning the date of service for professional claims, including the following services:
- Radiology services
- Surgical and anatomical pathology
- Care plan oversight
- Home health certification and recertification
- Physician end-stage renal disease services
- Transitional care management
- Clinical lab services
- Home Prothrombin time monitoring
- Cardiovascular monitoring services
- Diagnostic psychological and neuropsychological tests
- Surgical services
- Maternity benefits
- Services that transpire over to another calendar date
Billing in Medicare Secondary Payer (MSP) Liability Insurance Situations FAQs
On September 19, CMS published Special Edition MLN Matters 17018 for providers, physicians, and other suppliers that elect to seek payment from a beneficiary’s liability insurance claim instead of submitting the claim for items or services to Medicare, as they have not generally billed in accordance with the instructions provided. The FAQs are intended to remind providers, physicians, and other suppliers of the fundamental guidance governing billing where liability insurance (including self-insurance) is involved.
Payment from Patients with a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), Liability Insurance Medicare Set-Aside Arrangement (LMSA), or No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA)
On September 19, CMS published Special Edition MLN Matters 17019 regarding the acceptance of payment from patients with WCMSA, LMSA, or NFMSA. When a Medicare beneficiary states that he or she was involved in a liability insurance, no-fault insurance, or workers’ compensation situation, states that he or she is required to use funds from the settlement, judgment, award, or other payment to pay for the items or services related to what was claimed, it is appropriate to document the patient’s record with that information and accept payment directly from the patient for such services.
Sierra Nevada Memorial Hospital Did Not Accurately Report Certain Wage Data, Resulting in Overpayments to California Hospitals
On September 19, the OIG published a Report regarding Sierra Nevada Memorial Hospital in Grass Valley, California, which generally complied with Medicare requirements for reporting wage data in its fiscal year 2014 Medicare cost report. However, errors occurred, and Medicare overpaid 173 other hospitals in California $216,594 for inpatient services in the first half of fiscal year 2017.
Office for Human Research Protections (OHRP) Should Inform Potential Complainants of Whistleblower Protections
On September 20, the OIG published a Report regarding alleged violations of protections for human subjects in research conducted or supported by HHS. OHRP reported that it often gets requests from complainants for whistleblower protections and that some complainants have chosen not to report suspected noncompliance to OHRP because it does not have the statutory authority to offer such protections. In addition, four out of five compliance evaluations showed evidence of a fear of reprisal.
Implementation of Section 1557 for Medicare Redetermination Notices (MRNs) by Adding a Notice and Tagline Sheet
On September 20, CMS published One-Time Notification Manual Transmittal 1921, which rescinds and replaces Transmittal 1909, dated August 18, 2017. The transmittal instructs all Medicare Administrative Contractors (MAC), including Part A/B MACs, Home Health and Hospice MACs, and Durable Medical Equipment (MACs, to add a new last page to the Medicare Redetermination Notices (MRN).
Effective date: October 1, 2017
Implementation date: October 2, 2017
Billing and Payment Policy Clarification for Negative Pressure Wound Therapy Using a Disposable Device
On September 21, CMS published Special Edition MLN Matters 17027 for Home Health Agencies (HHA) submitting claims to Home Health & Hospice Medicare Administrative Contractors (MAC). Effective January 1, 2017, Medicare pays a separate amount for a disposable Negative Pressure Wound Therapy device for a patient under a home health plan of care. Payment is equal to the amount of the payment that would otherwise be made under the Outpatient Prospective Payment System (OPPS).
Efforts to Support Puerto Rico and the US Virgin Islands with Hurricane Maria Emergency Response
On September 21, CMS published a Press Release regarding efforts to support Puerto Rico and the U.S. Virgin Islands in the wake of Hurricane Maria. CMS is waiving or modifying certain Medicare and other requirements to provide relief to those affected. CMS has also helped evacuated patients get access to life-saving services.
CMS also released Special Edition MLN Matters 17028 for providers and suppliers who submit claims to Medicare Administrative Contractors (MAC) for services provided to Medicare beneficiaries in the United States Virgin Islands and the Commonwealth of Puerto Rico who were affected by Hurricane Maria.
2017-2018 Influenza (Flu) Resources for Health Care Professionals
On September 21, CMS published Special Edition MLN Matters 17026 for healthcare professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries. CMS updates the HCPCS and CPT codes and payment rates for personal flu and pneumococcal vaccines annually. Payment allowance limits for such vaccines are 95% of the Average Wholesale Price, except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic, or Federally Qualified Health Center. In these cases, the payment for the vaccine is based on reasonable cost. Annual Part B deductible and coinsurance amounts do not apply. Codes, payment allowances, and effective dates for the 2017-18 flu season can be found in the MLN Matters article.
Acute-Care Hospital Outpatient Services Inappropriately Paid for Beneficiaries Who Were Inpatients of Other Facilities
On September 21, the OIG published a Report regarding the fact that Medicare did not appropriately pay acute-care hospitals any of the $51.6 million for outpatient services reviewed by the OIG. In addition, beneficiaries were held responsible for unnecessary deductibles and coinsurance of $14.4 million paid to the acute-care hospitals for outpatient services.
OIG recommends that CMS recover the identified improper payments to acute-care hospitals, instruct the acute-care hospitals to refund beneficiaries up to $14.4 million in deductible and coinsurance amounts, and identify and recover any improper payments to acute-care hospitals after the audit period, which ended on August 31, 2016. CMS should also correct the system edits to prevent overpayments to acute-care hospitals and instruct the contractors to educate acute-care hospitals on the issue.
Hospital Outlier Payment Vulnerabilities
On September 22, the OIG published a Report on continued Medicare hospital outlier payment vulnerabilities. Medicare contractors didn’t always refer Medicare cost reports that qualified for reconciliation for the period October 2003 through March 2011, and CMS did not always ensure that contractors reconciled the outlier payments associated with cost reports that had been referred.
Parkridge Medical Center Medicare Compliance Review for 2014 and 2015
On September 22, the OIG published a Report regarding its Medicare compliance review of Parkridge Medical Center, Inc., in Chattanooga, Tennessee, for 2014 and 2015. The hospital did not fully comply with Medicare billing requirements for 12 of the 100 claims the OIG reviewed for the audit period, and the OIG estimates the hospital received at least $201,808 in overpayments during the audit period.
Medicare Payment Rates for routine SNF-type services by swing-bed hospitals during calendar year 2018
On September 22, CMS published Provider Reimbursement Manual Transmittal 475 to add Table 29, which updates the Medicare payment rates for routine SNF-type services by swing-bed hospitals during calendar year 2018. These rates should be used to carve out swing-bed costs on the hospital cost report.
Effective date: Services furnished on or after January 1, 2018
Continued Approval of the American Osteopathic Association/Healthcare Facilities Accreditation Program’s Ambulatory Surgical Center (ASC) Accreditation Program
On September 22, CMS published a Final Notice in the Federal Register regarding CMS’ decision to approve the American Osteopathic Association/Healthcare Facilities Accreditation Program for continued recognition as a
national accrediting organization for ASCs that participate in Medicare or Medicaid.
Effective date: September 22, 2017 through September 22, 2023.
Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals
On September 22, CMS published One-Time Notification Manual Transmittal 1923 to provide instructions to calculate interim rates for Graduate Medical Education (GME) payments to new teaching hospitals.
Effective date: October 23, 2017
Implementation date: October 23, 2017