This week in Medicare updates—10/9/18

October 10, 2018
Medicare Insider

Medicare Quarterly Provider Compliance Newsletter

On October 1, CMS published the October issue of the Medicare Quarterly Provider Compliance Newsletter. This edition of the newsletter discusses findings from a CERT review of billing for therapeutic shoes and inserts for individuals with diabetes. It also details the findings from a recovery auditor review indicating overpayments because of billing errors stemming from outpatient services being billed for dates of service when the patient was in an inpatient stay.


Preventive Services Educational Products

On October 1, CMS published two indexes on National Education Products and MLN Matters Articles regarding preventive services. Both indexes contain a listing of links grouped by topic on coverage, coding, and billing requirements for preventive services.


2018 MIPS Quality Measures Impacted by ICD-10 Updates

On October 1, CMS published a List of quality measures impacted by ICD-10 updates mid-performance period. The performance score for these measures will be based only on the first nine months of the 12-month performance period.


CMS Announces New Streamlined User Experience for Medicare Beneficiaries

On October 1, CMS published a Press Release to announce it will launch a new eMedicare initiative which aims to modernize and improve access to personal health care data. CMS is launching some of the new eMedicare improvements ahead of the open enrollment period, including:

  • Improvements to the coverage wizard to help provide beneficiaries with more information as to whether Original Medicare or Medicare Advantage is best for them
  • A standalone, mobile-optimized out-of-pocket cost calculator for overall costs and prescription drug costs
  • A webchat option
  • Simplified log-ins for the Medicare Plan Finder to replace the current five-factor authentication
  • New surveys for beneficiary feedback across

CMS also published a new Video and Blog regarding the initiative.


Proposed Rule: Changes to the Medicare Claims and Medicare Prescription Drug Coverage Determination Appeals Procedure

On October 2, CMS published a Proposed Rule in the Federal Register regarding revisions to regulations for the appeals process involving claims for benefits under Part A and Part B or determinations for prescription drug coverage under Part D. The changes would streamline the appeals process and reduce administrative burden.

Comments on the proposed rule are due no later than 5 p.m. on December 3, 2018.


Many Inpatient Rehabilitation Facility Stays Did Not Meet Medicare Coverage and Documentation Requirements

On October 2, the OIG published a Review of whether inpatient rehabilitation facilities (IRF) complied with Medicare coverage and documentation requirements for fee-for-service claims for services provided in 2013. The OIG found that 175 of the 220 sampled stays did not have medical record documentation supporting the necessity of IRF care per Medicare requirements. These correspond to 135 IRFs. These errors were due to a variety of issues, including IRFs who did not have adequate internal controls to prevent improper admissions, the lack of prepayment review for IRF admissions in Part A FFS, administrative law judge hearings for IRF appeals not always involving CMS participation to ensure accurate interpretation of Medicare requirements, and an IRF payment system that did not align cost with payments (thus providing a possible financial incentive to admit patients inappropriately). Based on this sample, the OIG estimates CMS paid IRFs nationwide $5.7 billion for care that was not reasonable and necessary.

The OIG listed a variety of recommendations in the review for CMS, one of which suggested a reevaluation of the IRF payment system which could include a demonstration project requiring preauthorization for Medicare Part A FFS IRF stays.  


IPPS Correction Notice Updates Several Important Tables

On October 3, CMS published a Correction Notice in the Federal Register for the 2019 IPPS and LTAC final rules, published August 17, 2018. CMS is correcting numerous technical and typographical errors in the final rule, including corrections to the final FY 2019 IPPS wage indexes and geographic adjustment factors, operating and capital standardized amounts, the outlier threshold and several ICD-10 and NDC coding items related to approved new technology add-on items.  

Effective date: The corrections in this document are effective October 1, 2018


Correction: FY 2019 Skilled Nursing Facilities Prospective Payment System Final Rule

On October 3, CMS published a Correction Notice in the Federal Register for the 2019 SNF PPS final rule. CMS is correcting multiple technical errors from the final rule, published August 8, 2018, including a correction to the SNF PPS wage data due to the incorrect calculation of the wage index in the 2019 Inpatient Prospective Payment System final rule. CMS is republishing the wage indexes in Tables A and B from the SNF PPS final rule as well as corrected versions of Tables 6, 7, and 45.

Effective date: The corrections in this document are effective October 1, 2018.


2018 MIPS Scoring 101 Guide

On October 3, CMS published a Slideshow to provide a detailed look into MIPS scoring for 2018. The slides examine scoring methods for all four performance categories (quality, cost, improvement activities, and promoting interoperability) and reviews the way bonus points, the final score, and payment adjustments are calculated.


Local Coverage Determinations (LCD)

On October 3, CMS published Medicare Program Integrity Transmittal 829 regarding revisions to Chapter 13 of the Program Integrity Manual to update the LCD process. These changes are part of a CMS effort to simplify the process and increase transparency. Some of the changes include a step-by-step description of the LCD process to function as a type of roadmap, standardization of the way evidence is presented, the creation of an option for an informal meeting with MACs to discuss potential LCD requests, the introduction of a new LCD request process, and restructured contractor advisory committee meetings.

CMS published a Press Release and Fact Sheet on the same date to announce and discuss these changes. CMS published MLN Matters 10901 on the same date to accompany the transmittal.

CMS will continue to collect feedback on the LCD process via submissions to

Effective date: October 3, 2018

Implementation date: January 8, 2019


Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes

On October 4, CMS published Medicare Claims Processing Transmittal 4144, which rescinds and replaces Transmittal 4129, dated September 7, 2018, to correct a figure in the Medicare Disproportionate Share Hospitals Program section and resolve minor clarification and formatting edits throughout. The original transmittal was issued regarding the 2019 update to the IPPS and LTCH PPS.

Effective date: October 1, 2018

Implementation date: October 1, 2018


Claim Based Incentive Programs - Non-Assigned Claim Update

On October 5, CMS published One-Time Notification Transmittal 2148 regarding a system update to fix an issue in which a Multi-Carrier System (MCS) edit causes bonus payments of claim-based incentive programs on non-assigned claims to go to a specific provider from a group rather than the actual group.

Effective date: April 1, 2019 - For claims processed on or after April 1, 2019

Implementation date: April 1, 2019


Modification to Chapter 6, Section 6.3 (Medical Review of Certification and Recertification of Residents in SNFs) of the Medicare Program Integrity Manual

On October 5, CMS published Medicare Program Integrity Transmittal 832 regarding two changes to Chapter 6 of the Program Integrity Manual related to changes finalized in the FY 2019 IPPS/LTCH PPS Final Rule regarding the certification process.

Effective date: November 6, 2018

Implementation date: November 6, 2018


2019 Annual Update of HCPCS Codes for Skilled Nursing Facility Consolidated Billing Update

On October 5, CMS published Medicare Claims Processing Transmittal 4143 regarding changes to HCPCS codes and Physician Fee Schedule designations used to review Common Working File edits allowing A/B MACs to make appropriate payments in accordance with the SNF Consolidated Billing policy.

Effective date: January 1, 2019

Implementation date: January 7, 2019