This week in Medicare updates—11/13/2019
2020 Updates to Quality Payment Program
On November 1, CMS published a handful of downloadable PDFs on its Quality Payment Program (QPP) page to accompany the regulations finalized through the Medicare Physician Fee Schedule final rule for the 2020 QPP performance period. These downloads include an executive summary of the CY 2020 updates, 2020 QPP final rule FAQs, and a fact sheet providing an overview of the finalized 2020 policies.
CMS did not make many changes to the QPP for 2020, as it did not finalize a proposal to raise the cost category’s score in MIPS to 20% of the final score and will instead leave the cost category at 15% for 2020. The exceptional performance threshold for MIPs will be 85 points instead of the proposed 80 points. CMS did finalize a change to MIPS to convert it into the MIPS Value Pathways program, but these changes are not effective until 2021.
ICD-10 and Other Coding Revisions to National Coverage Determinations--April 2020 Update
On November 1, CMS published One-Time Notification Transmittal 2382 regarding the quarterly update to the ICD-10 and other coding updates specific to NCDs.
CMS published MLN Matters 11491 on the same date to accompany the transmittal.
Effective date: April 1, 2020
Implementation date: December 18, 2019, for local MAC edits; April 6, 2020 - SSM edits
Medicare Improperly Paid Suppliers an Estimated $92.5 Million for Inhalation Drugs
On November 4, the OIG published a Review of whether suppliers of inhalation drugs complied with Medicare billing requirements. The OIG found that, for 39 of the 120 sampled claim lines in the review, suppliers did not comply with Medicare requirements. These claim lines were traced back to 22 suppliers and included errors with detailed written orders (28 claim lines), incomplete proof of delivery (six claim lines), incomplete refill requests (6 claim lines), and missing medical records (one claim line). The OIG estimated that this resulted in $92.5 million in unallowable payments for these drugs. It recommends that CMS instruct the contractors to recover overpayments, notify the suppliers with the claim line errors, and work with Medicare contractors to expand their review of inhalation drug claims/provide additional training.
Medicare Allowable Amounts for Certain Orthotic Devices Are Not Comparable With Payments Made by Select Non-Medicare Payers
On November 4, the OIG published a Review of whether Medicare allowable payment amounts for certain orthotic devices were comparable with payments made by non-Medicare payers. The OIG found that the Medicare amounts are not comparable; Medicare and its beneficiaries paid a net $337.5 million more for select orthotics from CY 2012-2015 than non-Medicare payers. When CMS was required to adjust certain DME fee schedule amounts in 2016 using information from the competitive bidding program, it did not affect the payments for the orthotic device codes included in the review. The OIG found that CMS would be able to adjust these allowable amounts for 95 of the 161 codes included in the review using existing legislative authority, but it would need new legislative authority to make adjustments for the remaining 66 codes. The OIG recommends CMS review the allowable amounts for all codes in the review and adjust the allowable amounts as appropriate. It also recommends CMS routinely review Medicare allowable amounts for new and preexisting orthotic devices to ensure these amounts align with those of non-Medicare payers or pricing trends.
Medical Privacy of Protected Health Information
On November 4, CMS published an MLN Fact Sheet regarding the requirements of the HIPAA privacy rule and how it applies to health care practices. The fact sheet also addresses methods for securing health information when using a mobile device and contains tables with links to many relevant resources and regulations pertaining to HIPAA compliance.
Quarterly HCPCS Drug/Biological Codes Changes - October 2019 Update
On November 4, CMS published Medicare Claims Processing Transmittal 4443, which rescinds and replaces Transmittal 4396, dated September 17, 2019, to modify and update the code descriptor spreadsheet and to add HCPCS code JO642 to the background and policy sections as well as to business requirements 11422.1, 11422.2, 11422.4, and 11422.5. The original transmittal was issued regarding updates to drug and biological HCPCS codes for October. The update includes 44 new codes, two discontinuations, and seven modifications.
CMS revised MLN Matters 11422 on September 18 to accompany the transmittal.
Effective date: October 1, 2019
Implementation date: October 7, 2019
Opioid Treatment Programs (OTPs) Medicare Enrollment Fact Sheet
On November 4, CMS published an MLN Fact Sheet regarding the enrollment process and requirements for OTPs. The fact sheet walks through every step of the process all the way from obtaining an NPI through to submitting the enrollment application and the MAC review of the application. Medicare will begin paying for OTPs on January 1, 2020, and it is currently accepting OTP enrollment applications.
Updated Corporate Integrity Agreements (CIA) Reportable Event Settlements
On November 6, the OIG updated its list of CIA Reportable Events with the following new settlements:
- On October 1, Drayer Physical Therapy, LLC, reached an $81,455.97 settlement with the OIG after it billed and received reimbursement from Tricare for physical therapy services provided by PT assistants.
- On October 23, Medi-Lynx Cardiac Monitoring, LLC, reached a $71,595.27 settlement with the OIG after employing an individual it knew or should have known was excluded from participation in federal health care programs.
Medicare Improperly Paid Acute Care Hospitals $54.4 Million for Inpatient Claims Subject to the Post-Acute Care Transfer Policy
On November 6, the OIG published a Review of whether Medicare appropriately paid for acute care hospitals’ inpatient claims subject to the transfer policy. The OIG found that Medicare issued $54.4 million in improper payments for claims subject to the transfer policy during the audit period. It found claims that were improperly billed due to incorrect patient discharge status codes (coding for patients discharged to home or healthcare institutions when the patients were actually transferred to post-acute care). While CMS said its edits appropriately detected claims subject to the transfer policy, some Medicare contractors said they either did not receive automatic notifications of improperly billed claims or did not take action on those claims to adjust them. The OIG recommends CMS direct the contractors to recover the identified overpayments, identify claims where incorrect discharge status codes were used after the audit period and recover overpayments for those, and ensure that contractors are receiving postpayment edits’ automatic notifications and are taking action on those claims.
Quarterly Listing of Program Issuances: July Through September 2019
On November 6, CMS published a Notice in the Federal Register listing all manual instructions, substantive and interpretive regulations, and other notices issued for the Medicare and Medicaid programs from July through September 2019.
The Medicare Fee-for-Service Recovery Audit Program
On November 6, CMS published Medicare Program Integrity Transmittal 921 and Medicare Financial Management Transmittal 330, which rescinds and replaces Transmittal 908 and Transmittal 921, dated October 4, 2019, to update the PIM language to be consistent with process changes that have already been implemented. regarding moving the instructions for the Recovery Audit program from the Financial Management Manual to the Program Integrity Manual. Chapter 4, Section 100 of the Financial Management Manual will now be located in Chapter 9 of the Program Integrity Manual.
Effective date: November 4, 2019
Implementation date: November 4, 2019
Refinement of the Transitional Add-on Payment Adjustment (TDAPA)
On November 8, CMS published One-Time Notification Transmittal 2392 to expand the list of new renal dialysis drugs and biologicals that are eligible for TDAPA. The transmittal also implements new process changes for eligibility for TDAPA. Calcimimetics are currently the only drug class that qualifies for payment using TDAPA and is the only drug class that should utilize the AX modifier until further notification from CMS.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year 2020
On November 8, CMS published Medicare Claims Processing Transmittal 4453 regarding updates to payment amounts for the 2020 HH PPS. This includes updates to the 60-day episode base rate, 30-day episode base rate, national per-visit amounts, and more. It also includes revisions to the initial payment percentage for initial and subsequent 30-day periods of care under the split percentage payment approach for CY 2020.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Home Health Patient-Driven Groupings Model (PDGM) - Revised and Additional Manual Instructions
On November 8, CMS published Medicare Claims Processing Transmittal 4452 regarding revisions to the manual to support implementation of PDGM. These changes involve information about discharges, service dates, no visits during the 30-day period of care, and more.
Effective date: January 1, 2020
Implementation date: December 11, 2019
Adjustment Reason Code to Identify Office of the Inspector General (OIG) Initiated Overpayments and Healthcare Integrated General Ledger Accounting System (HIGLAS) Demand Letter Verbiage
On November 8, CMS published One-Time Notification Transmittal 2388 regarding new adjustment reason codes and discovery codes to use for OIG adjustments. The code should trigger language on the HIGLAS demand letter that identifies the overpayment as one found by the OIG.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Positron Emission Tomography (PET) Scan - Allow Tracer Codes Q9982 and Q9983 in the FISS
On November 8, CMS published One-Time Notification Transmittal 2387 regarding an update to the FISS that will allow reason code 32440 to include additional tracer codes for PET scans. It also modifies the code so the MAC can override a reason code if it has been assigned incorrectly.
Effective date: January 1, 2018
Implementation date: April 6, 2020
Implementation of Changes in the ESRD Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for CY 2020
On November 8, CMS published Medicare Benefit Policy Transmittal 262 regarding implementation of the 2020 rate updates for the ESRD PPS. It also includes a correction to an outlier payment issue from 2019, updates to payment rates for AKI renal dialysis services, and more.
Effective date: January 1, 2020
Implementation date: January 6, 2020
User CR: ViPS Medicare System (VMS) - Increase Edit Code Maximum
On November 8, CMS published One-Time Notification Transmittal 2384 regarding modifications to the VMS to increase the allowable number of entries on the Edit Code Description Table Screen within the Automated Parameter Claims Parameter (VMPA/4C) System.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Enhance Maximum Claim Counter for Edits and Audits - Implementation
On November 8, CMS published One-Time Notification Transmittal 2390 regarding enhancements to the MCS to add a maximum claim counter so MACs can specify how many claims should fail a specified edit/audit by procedure code. This is intended to minimize the number of edits/audits required to implement Targeted Probe and Education audits as well as to save time on file maintenance/implementation.
Effective date: April 1, 2020 - for Analysis, Design, and Coding; July 1, 2020 - for Coding, Testing, and Implementation
Implementation date: April 6, 2020 - for Analysis, Design, and Coding; July 6, 2020 - for Coding, Testing, and Implementation
Medicare Shared Savings Program (MSSP) Skilled Nursing Facility (SNF) Affiliates’ Updated Qualifying Stay Edits
On November 8, CMS published One-Time Notification Transmittal 2385 regarding a solution to a problem in which the edit logic was rejecting some SNF 3-day waiver claims for beneficiaries in an ACO when the participation in the ACO ended before the beneficiary’s stay was complete. ACOs are able to waive the 3-day inpatient hospitalization requirement for SNF services, as Medicare was looking to provide additional flexibilities for ACOs to increase participation.
Effective date: January 1, 2020
Implementation date: April 6, 2020
User Change Request: FISS - Hook Option for National Provider Identifier (NPI) Does Not Select Claims
On November 8, CMS published One-Time Notification Transmittal 2383 regarding modifications to the FISS Hook Selection screen that will allow claims to be selected based on the presence of a specific practitioner NPI in the claim record.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Updates to the Coordination of Benefits Agreement Insurance File (COIF) for Use in the National Coordination of Benefits Agreement (COBA) Crossover Process
On November 8, CMS published Medicare Claims Processing Transmittal 4454 regarding a new Part B psychotherapy claims inclusion option via the COBA crossover process. It also introduces the possibility of allowing base COBA trading partners to exclude Part B psychotherapy claims.
Effective date: April 1, 2020
Implementation date: April 6, 2020