This week in Medicare updates—10/31/18

October 31, 2018
Medicare Insider

Medicare Compliance Review of Mobile Infirmary Medical Center

On October 24, the OIG published a Review of whether Mobile Infirmary Medical Center complied with Medicare requirements for billing inpatient services on selected types of claims. Of the 100 sampled claims, the OIG found that Mobile did not fully comply with Medicare requirements on 13 claims. The OIG said eight of these claims did not comply with Medicare criteria or documentation requirements for acute inpatient rehabilitation, and five of the 13 claims had incorrectly billed outlier payments, resulting in combined net overpayments of $163,104 in calendar years 2015-2016.

The OIG recommended the hospital refund the Medicare contractor for the estimated overpayments for the audit period, exercise reasonable diligence to identify and return any additional similar overpayments outside the audit period, and strengthen controls to ensure full compliance with Medicare requirements. Mobile did not agree that it incorrectly billed inpatient rehabilitation claims, and the OIG allowed for a subsequent independent medical review, which determined that eight of the original sample claims determined to be errors were not in error. The OIG reduced the overpayment amount accordingly.


Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Data on Nursing Home Compare

On October 24, CMS published a Fact Sheet regarding the inaugural release of SNF QRP data on the Nursing Home Compare website. This data can be used to demonstrate how a SNF’s performance on quality measures compares to that of another SNF and to a nationwide average. CMS added five new quality measures to the Nursing Home Compare website, including three new assessment-based measures and two new claims-based measures.


Medicare Cost Report E-Filing

On October 24, CMS published One-Time Notification Transmittal 2153, which rescinds and replaces Transmittal 2075, dated April 30, 2018, to extend the MACs portals to be open until January 2, 2019 instead of the original July 2, 2018 date and to clarify information for cost report rejections. The original transmittal was issued to guide providers through the new Cost Report E-Filing system.

Effective date: June 12, 2018

Implementation date: June 12, 2018; January 2, 2019 - For business Requirements 10611.2 and 10611.3.


Advance Notice of Proposed Rulemaking (ANPRM): International Pricing Index (IPI) Model for Medicare Part B Drugs

On October 25, CMS published an ANPRM on a potential proposed rule for spring of 2019 on drug pricing called the IPI Model. CMS is soliciting public comment on options to consider for this model that would look at changing payment for certain separately payable Part B drugs and biologicals. CMS intends to use the model to test phasing down the Medicare payment amount for select Part B drugs to more closely align with international prices; allow private-sector vendors to negotiate prices for drugs and compete for hospital and physician business; and change the 4.3% drug add-on payment due to sequestration to reflect the full 6% add-on payment. This model would begin in spring of 2020 and operate for five years. It would be mandatory for physician practices and hospital outpatient departments, and it could potentially be mandatory for other providers and suppliers in select geographical areas.

CMS issued a Fact Sheet on the ANPRM on the same date. Comments are due no later than 5 p.m. on December 31, 2018.


Redesign of Hospice Periods - Additional Requirements

On October 26, CMS published Medicare Claims Processing Transmittal 4152 regarding corrections for a variety of processing issues arising from the redesign of hospice periods in the Common Working File. The issues addressed through this transmittal include the process of removing the revocation date by submitting TOB 8xB with zeros in the through date and creating a process for hospices to submit corrected election or revocation dates by using 8xC and 8xE submissions. The transmittal also updates Chapter 11 of the Claims Processing Manual to reflect information about the hospice redesign that was previously only published in provider education materials.

Effective date: January 1, 2018

Implementation date: April 1, 2019


Next Generation Accountable Care Organization (NGACO) Model Post Discharge Home Visit HCPCS

On October 26, CMS published Demonstrations Transmittal 213 to implement new HCPCS codes for the Post Discharge Home Visit Waiver. These claims should be processed for reimbursement and paid when they meet the appropriate payment requirements outlined in the transmittal.

Effective date: January 1, 2019

Implementation date: April 1, 2019


Correction to Common Working File (CWF) Informational Unsolicited Response (IUR) 7272 for Intervening Stay

On October 26, CMS published One-Time Notification Transmittal 2174 to ensure the CWF bypasses IUR 7272 when an IPPS hospital claim in history has a discharge date equal to or within three days of an incoming home health claims, has patient discharge code 61, and the history IPPS claim’s discharge date is equal to the admit date of an inpatient swing bed history claim.

Effective date: April 1, 2019

Implementation date: April 1, 2019


Update to Common Working File (CWF) Edit of Medicare Advantage (MA) Enrollees’ Inpatient Claims from Approved Teaching Hospitals Billed with Indirect Medical Education (IME) or Coverage with Evidence Development

On October 26, CMS published One-Time Notification Transmittal 2156 regarding instructions to the CWF to bypass edit 5233 on claims billed with Investigational Device Exemption (IDE) or CED approved studies so that the FISS can make the IME only payment on approved teaching hospital claims.

Effective date: April 1, 2019

Implementation date: April 1, 2019


Incomplete Colonoscopies Billed with Modifier 53 for Critical Access Hospital (CAH) Method II Providers

On October 26, CMS published Medicare Claims Processing Transmittal 4153 regarding billing instructions for incomplete colonoscopies when billed by a Method II CAH. These CAHs are instructed to use modifier -53 to identify an incomplete screening colonoscopy and should also bill the technical or facility component of the interrupted colonoscopy in revenue code 075X (or other appropriate revenue code) using the -73 or -74 modifier as appropriate.

Effective date: April 1, 2019

Implementation date: April 1, 2019


Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance

On October 26, CMS published Medicare Claims Processing Transmittal 4150 to instruct contractors to waive deductible and coinsurance for BMM code 77085 and to add language to the manual regarding the deductible and coinsurance for this code.

Effective date: April 1, 2019 - For claims with dates of service on and after January 1, 2015

Implementation date: April 1, 2019