This week in Medicare updates—11/11/2020
CY 2021 End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Final Rule
On November 2, CMS published a draft copy of the 2021 ESRD PPS Final Rule, which is scheduled to be published in the Federal Register on November 9. CMS finalized a policy which will expand the transitional add-on payment adjustment for new and innovative equipment and supplies (TPNIES) to include qualifying new dialysis machines used in the home. CMS is also finalizing changes to the eligibility criteria and determination process deadlines for TPNIES, but it did not finalize coverage of two products (a dialyzer and a cartridge for a home dialysis machine) that had been submitted for TPNIES in CY 2021. The rule finalizes adoption of new OMB statistical delineations and a 5% cap on any decrease in an ESRD facility’s wage index, and it made two programmatic updates to the ESRD quality incentive program (QIP). The final ESRD PPS base rate will be $253.13 for CY 2021.
CMS published a Fact Sheet and Press Release on the rule on the same date. The regulations in the rule are effective January 1, 2021.
Home Health Agency Provider Compliance Audit: Visiting Nurse Association of Central Jersey Home Care and Hospice, Inc.
On November 2, the OIG published a Review of whether Visiting Nurse Association of Central Jersey Home Care and Hospice (VNA) complied with Medicare requirements for billing home health services. The OIG found that VNA billed Medicare incorrectly for 14 of the 100 home health claims reviewed. These issues pertained to services provided to beneficiaries who did not require skilled services or services provided to beneficiaries who were not homebound. For a handful of those 14 claims, VNA also incorrectly claimed reimbursement for services not provided or services that were not reasonable and necessary. One claim also contained an incorrect HIPPS code. The OIG estimated that VNA received overpayments of at least $2 million for the audit period.
The OIG recommends VNA refund Medicare for the identified overpayments, identify and return any similar overpayments, and strengthen procedures to ensure homebound statuses are verified and continually monitored. VNA challenged the OIG’s original findings in which the OIG found 16 of the 100 sampled claims were incorrectly billed, and after further review, the OIG lowered its findings to incorrect billing for 14 of 100 claims.
Quarterly Listing of Program Issuances--July through September 2020
On November 4, CMS published a Notice in the Federal Register regarding the quarterly posting of all CMS manual instructions, substantive and interpretive regulations, and other Federal Register notices published from July through September 2020.
CMS Did Not Ensure Medicare Hospital Payments for Claims That Included Medical Device Credits Were Reduced in Accordance with Federal Regulations
On November 6, the OIG published a Review of whether CMS ensured that OPPS payments for claims that included medical device credits were reduced in accordance with federal regulations. Per Medicare regulations, APC payments should be reduced for replaced medical devices if the hospital or ambulatory surgical center (ASC) receives a no-cost device or a full or partial credit for the cost of the replaced device. These payment reductions are based on the device offset amount. However, Medicare revised instructions for how to calculate the payment reduction in the Medicare Claims Processing Manual in a manner that was inconsistent with federal regulations for this calculation. The OIG found that MACs had been following manual guidance for this process, but because that guidance was inconsistent with federal regulations, Medicare ended up making estimated overpayments of approximately $35.4 million for OPPS claims during the audit period (CYs 2016-2018).
The OIG recommends CMS work with MACs to recover overpayments associated with device credits and revise OPPS regulations or manual instructions to resolve the conflict between these requirements for OPPS claims with medical device credits. CMS did not agree with the OIG recommendations, as it stated the OIG incorrectly calculated the overpayments. It also acknowledged that while it updated the manual to reflect the policy change for these payments, it did not codify in regulation text the changes to how medical device credits are calculated under the OPPS. Still, CMS said that it does not agree that it needs to revise manual instructions and noted that it proposed in the 2021 OPPS/ASC proposed rule to revise regulatory text to conform to the policy that was finalized in CY 2014.
Home Health Manual Update to Incorporate Allowed Practitioners into Home Health Policy
On November 6, CMS published Medicare Benefit Policy Transmittal 10438 regarding updates to the manual to align with policy changes made by the CARES Act. Some of these changes include expanding the definition of “allowed practitioners” to include NPs, clinical nurse specialists (CNS), and physician assistants (PA). This enables these types of practitioners to perform additional duties, such as certifying, establishing, or periodically reviewing the plan of care as well as supervising the provision of items and services for beneficiaries under the Medicare Home Health benefit.
Effective date: March 1, 2020
Implementation date: January 11, 2021
Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims
On November 6, CMS published Medicare Claims Processing Transmittal 10448 with instructions for billing claims with covered and non-covered days using occurrence span code 76.
Effective date: April 1, 2021
Implementation date: April 5, 2021
Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum
On November 6, CMS published Medicare Benefit Policy Transmittal 10437 regarding changes to the manual to include the revised election statement and implement the election statement addendum as finalized in the FY 2020 Hospice Wage Index and Payment Rate Update final rule.
Effective date: October 1, 2020
Implementation date: December 9, 2020
Implementation of the Award for the Jurisdiction 6 Part A and Part B MAC
On November 6, CMS published One-Time Notification Transmittal 10452 to announce the J-6 A/B MAC workload has been awarded to National Government Services (NGS), the incumbent contractor for the workload.
Effective date: November 12, 2020 - Part A/HHH; December 31, 2020 - Part B
Implementation date: November 12, 2020 - Part A/HH; December 31, 2020 - Part B