This week in Medicare updates—11/20/2019
2020 Annual Update of Per-Beneficiary Threshold Amounts
On November 7, CMS published Medicare Claims Processing Transmittal 4419 regarding the CY 2020 KX modifier threshold amounts, which are $2080 for PT and SLP services combined and $2080 for OT services. The information in the transmittal is no longer sensitive and has been posted to the internet.
On November 12, CMS published MLN Matters 11532 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
2020 Annual Update to the Therapy Code List
On November 7, CMS published Medicare Claims Processing Transmittal 4421 regarding updates to the list of codes that sometimes or always describe therapy services. New “sometimes therapy” codes include 90912 and 90913 for biofeedback training, and 97129 and 97130 for therapeutic interventions focusing on cognitive function. There are also four deleted CPT codes that were used for manual muscle testing and 42 HCPCS Level II G-codes deleted for dates of service after December 31, 2019. This transmittal is no longer sensitive and has been posted to the internet.
On November 12, CMS published MLN Matters 11501 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for CY 2020
On November 7, CMS published Medicare Claims Processing Transmittal 4408 regarding the update to the CY 2020 payment limit for RHCs, which will be $86.31 per visit effective January 1, 2020 through December 31, 2020. This transmittal is no longer sensitive and has been posted to the internet.
On November 12, CMS published MLN Matters 11498 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
2020 Medicare Parts A&B Premiums and Deductibles
On November 8, CMS published a Fact Sheet regarding the 2020 premiums, deductibles, and coinsurance amounts for Medicare Part A and B. These rates increased in both Part A and B from 2019 to 2020. The standard 2020 amounts are:
- Part A inpatient hospital deductible - $1,408
- Increased $44 from 2019 rate
- Part A daily coinsurance (61st - 90th day) - $352
- Increased $11 from 2019 rate
- Part A daily coinsurance (lifetime reserve days) - $704
- Increased $22 from 2019 rate
- Part B monthly premium - $144.60
- Increased $9.10 from 2019 rate
- Part B annual deductible - $198
- Increased $13 from 2019 rate
- Skilled nursing facility coinsurance - $176
- Increased $5.50 from 2019 rate
CMS noted in the fact sheet that the increase in Part B premiums and deductibles is largely due to the rising cost of physician-administered drugs. It also noted that while fee-for-service rates increased for 2020, Medicare Advantage premiums are expected to decline to their lowest rate in 13 years.
CMS published these rates in the Federal Register on November 13 via separate notices for the CY 2020 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts, the CY 2020 Part A Premiums for the Uninsured Aged and Certain Disabled Individuals Who Have Exhausted Other Entitlements, and the Part B Monthly Actuarial Rates, Premium Rates, and Annual Deductible.
Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services
On November 12, the OIG published a Review of whether physician and outpatient payments made by CMS for chronic care management (CCM) services during CYs 2015 and 2016 complied with federal requirements. The OIG found that CMS made overpayments worth $640,452 during CYs 2015 and 2016 for these services. Overpayments resulted from instances in which providers or facilities billed CCM services more than once for the same beneficiary and same service period. It also identified overpayments resulting from instances in which the same physician billed for both CCM services and overlapping care management services for the same beneficiaries. The OIG also identified $1.2 million in potential overpayments for situations where CCM services were billed by an outpatient facility but a corresponding claim was not submitted by a physician, but the OIG is setting those claims aside for review and determination by CMS, as it is not required that CCM services billed by outpatient facilities must have a corresponding claim billed by a physician, but it is unlikely that these services would be provided without a physician submitting a claim for the same service.
The OIG recommended CMS recoup the $640,452 in overpayments from providers, instruct providers to refund overcharges to beneficiaries, review the claims associated with the $1.2 million in potential overpayments, and implement claim processing controls to prevent and detect overpayments for these services.
Provider Enrollment Application Fee Amount for CY 2020
On November 12, CMS published a Notice in the Federal Register to announce the CY 2020 application fee for institutional providers enrolling in Medicare, Medicaid, or the Children’s Health Insurance Program will be $595. This applies to initial enrollment, revalidating enrollment, or new Medicare practice location enrollment applications.
Effective date: January 1, 2020
Final Rule: Hospital Price Transparency Requirements
On November 15, CMS published the display copy of a Final Rule regarding the price transparency requirements originally proposed in the 2020 OPPS proposed rule. The rule applies to all United States hospitals, including those not paid under the OPPS, and will be effective January 1, 2021. It establishes requirements for posting a public list of standard charges, defines a number of terms related to these requirements, and finalizes an enforcement scheme for price transparency.
The rule finalized most of the policies included in the 2020 OPPS proposed rule, including that facilities must make public a standard list of charges for all items and services for each hospital location in a single digital file and a machine readable format. The charges included gross charges, discounted cash price, payer-specific negotiated charges, de-identified minimum negotiated charges, and de-identified maximum negotiated charges. Hospitals also must make public standard charges for at least 300 shoppable services (including 70 specified by CMS and 230 selected by hospitals) in a consumer-friendly manner. CMS will enforce these requirements via complaints and audits, and it may impose civil monetary penalties on noncompliant hospitals in the amount of a $300 maximum fine per hospital per day.
These requirements will be codified in a new section of Title 45 in the Code of Federal Regulations, Part 180-Hospital Price Transparency. CMS published a Fact Sheet and Press Release on the rule.
Proposed Rule: Transparency in Coverage
On November 15, CMS published the display copy of a Proposed Rule regarding additional price transparency requirements that would apply to group health plans and health insurance issuers in the individual and group markets. The proposals would require most group health plans (including self-insured plans) and health insurance issuers to disclose price and cost-sharing information to participants, beneficiaries, and enrollees.
Specifically, it would require, upon request, non-grandfathered health plans or insurance issuers offering non-grandfathered health insurance coverage to make available personalized out-of-pocket cost information for all covered health care items and services both through an internet-based tool and in a paper form. This information would be provided to participants, beneficiaries, and enrollees (or authorized representatives), and it is intended to enable customers to receive estimates of cost-sharing liability for health care so they can shop and compare costs before receiving care.
The rule also proposed that each non-grandfathered group health plan or health insurance issuer offering non-grandfathered health insurance coverage would be required to make public the in-network negotiated rates with network providers and historical payments of allowed amounts to out-of-network providers. This information would have to be available to stakeholders such as consumers, researchers, employers, and third-party developers, and it must be available via standardized, regularly updated machine-readable files.
The rule also proposes that issuers who encourage consumers to shop for services from lower-cost, higher-value providers can take credit for shared savings from that policy in their medical loss ratio (MLR) calculations. Proposals from the rule would be effective one year following finalization of the rule except for this MLR provision, which would be effective beginning with the 2020 MLR reporting year.
Comments on the rule will be due 60 days from the release of the proposed rule. CMS published a Fact Sheet and Press Release on the rule on November 15.
Updates to the Medical Review Instructions Related to Skilled Nursing Facilities (SNF)
On November 15, CMS published Medicare Program Integrity Transmittal 924 regarding updates to medical review instructions in the manual to ensure that they align with the changes created by the switch to the Patient-Driven Payment Model.
Effective date: October 1, 2019
Implementation date: December 17, 2019
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements
On November 15, CMS published Medicare Claims Processing Transmittal 4465, which rescinds and replaces Transmittal 4188, dated December 28, 2018, to revise the wording for inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-On Code) edits to the following email address: NCCIPTPMUE@cms.hhs.gov. The original transmittal was issued to update the Internet Only Manual language pertaining to the National Correct Coding Initiative (NCCI), Chapter 23 - Fee Schedule Administration and Coding Requirements.
Effective date: January 30, 2019
Implementation date: January 30, 2019
Updating FISS Editing for Practice Locations to Bypass Mobile Facility and/or Portable Units and Services Rendered in the Patient’s Home
On November 15, CMS published One-Time Notification Transmittal 2394 regarding an update to the FISS that will allow the system to bypass service facility location matching when condition code A7 is present on a claim for services rendered in a mobile facility, portable unit, or the patient’s home.
Effective date: January 1, 2017
Implementation date: April 6, 2020