This week in Medicare updates—11/6/2019
What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight
On October 25, CMS revised Special Edition MLN Matters 19005 to clarify an answer about providers/suppliers who might be affected by the initial use of a provisional period of enhanced oversight authority. It also clarifies when CMS starts to place new HHAs into periods of enhanced oversight.
Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B
On October 28, CMS published an MLN Educational Tool containing billing information, frequently asked questions, and a resources table for flu, pneumococcal, and hepatitis B vaccines. The billing information provided is current as of September 2019 and includes administration codes, diagnosis codes, procedure codes, and frequency limits.
Comment Request: End Stage Renal Disease Application and Survey and Certification Report; Durable Medical Equipment MAC Certificate of Medical Necessity and Supporting Documentation Requirements
On October 28, CMS published a Comment Request in the Federal Register regarding the following information collections:
- End Stage Renal Disease Application and Survey and Certification Report
- Durable Medical Equipment Medicare Administrative Contractor Certificate of Medical Necessity and Supporting Documentation Requirements
Comments are due by December 27, 2019.
Overview of the Repetitive, Scheduled Non-Emergent Ambulance Prior Authorization Model
On October 28, CMS revised Special Edition MLN Matters 1514 to announce that the model has been extended an additional year and is currently scheduled to end in all model states on December 1, 2020, based on date of service. The original article was published on May 4, 2015, as an educational guide to improve documentation for the model.
CMS Could Improve its Processes for Evaluating and Reporting Payment Recovery Savings Associated With the Fraud Prevention System
On October 28, the OIG published a Review of CMS’ methods in determining the Fraud Prevention System’s (FPS) value. It specifically looked into why the FPS’s adjusted savings for overpayment determinations and law enforcement referrals were approximately 10% of the identified savings in the second and third implementation years and whether the manner in which CMS reported FPS savings after the third implementation provides sufficient information to stakeholders that would allow them to accurately assess the value of the FPS. The OIG found that the adjusted savings calculation was 10% of the identified savings calculation because MAC opportunities to collect FPS-identified overpayments were limited by time and other challenges involved in recovering overpayments from providers, and CMS does not have a standard process for program integrity contractors to estimate the value of law enforcement referrals. The OIG determined that reporting adjusted savings, the corresponding adjusted return on investment, and the identified savings would provide a more complete depiction of the value of the FPS.
Rhode Island Hospital Submitted Some Inaccurate Wage Data
On October 28, the OIG published a Review of whether Rhode Island Hospital complied with Medicare requirements for reporting wage data for CMS calculations of hospital wage indexes for FY 2019. The OIG found that the hospital overstated its wages and wage-related costs by over $37 million and overstated its hours by 921,361 hours. These errors occurred because the hospital’s administrators did not fully understand wage data reporting requirements and the hospital did not have adequate review and reconciliation procedures to ensure that the wage data it reported to CMS was accurate and compliant. Although the hospital has the potential to impact Medicare payments based on its wage data reporting, the net of these errors did not end up affecting the hospital’s wage index and is not expected to have an effect on Medicare payments.
The OIG recommends the hospital ensure all personnel involved in Medicare wage-data reporting are fully trained in compliance with Medicare requirements and strengthen the review and reconciliation procedures. The hospital’s parent company, Lifespan, disagreed with two of the six findings in the report as they pertained to contracted labor wages, associated hours, and nonphysician practitioner costs under Part A, but the OIG maintained its original findings.
Comment Request: Proposed Repetitive, Scheduled, Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process and Requirements
On October 29, CMS published a Comment Request in the Federal Register regarding an information collection titled, “Proposed Repetitive, Scheduled, Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process and Requirements.”
Comments on the information collection are due by December 30, 2019.
April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On October 29, CMS revised MLN Matters 11216, dated March 15, 2019, to add a reference to related article SE19009, which replaces the instructions in Section 6 - Chimeric Antigen Receptor (CAR) T-Cell Therapy. The original article was issued to accompany a quarterly OPPS update transmittal.
Effective date: April 1, 2019
Implementation date: April 1, 2019
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2020
On October 29, CMS published Medicare Claims Processing Transmittal 4424, which rescinds and replaces Transmittal 4400, dated September 27, 2019, to add business requirement 11485.6.1, which removes an invalid code for NCD 190.14. The original transmittal was issued regarding the quarterly update of the edit module for clinical diagnostic laboratory services.
On October 29, CMS revised MLN Matters 11485 to accompany the transmittal.
Effective date: January 1, 2020 - Unless otherwise indicated in requirements
Implementation date: January 6, 2020
Proposed Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer
On October 29, CMS published a Proposed Decision Memo regarding expanded coverage of NGS as a diagnostic laboratory test when it meets certain conditions. The proposed decision memo would apply to patients with ovarian or breast cancer, clinical indications for germline testing, and risk factors for germline breast or ovarian cancer when the patient has not been previously tested using NGS. The test using NGS must have FDA approval or clearance, an FDA approved or cleared indication for use in that patient’s cancer, and results provided to the treating physician for management of the patient using a report template to specify treatment options.
The decision memo also notes that MACs may determine coverage of NGS as a diagnostic lab test for patients with a cancer diagnosis other than breast or ovarian cancer who has clinical indications for germline testing, risk factors for germline cancer other than inherited breast or ovarian cancer, and has not been tested previously using NGS.
By issuing the proposed decision memo, CMS initiated a 30-day public comment period on the policy. Comments are due by November 28.
CMS Hospital Value-Based Purchasing Program Results for FY 2020
On October 29, CMS published a Fact Sheet regarding the FY 2020 adjustments from the Hospital Value-Based Purchasing Program (HVBPP). CMS estimates that the total available amount for value-based incentive payments will by $1.9 billion. Over 55% of hospitals will receive higher Medicare payments, and the average net payment adjustment will be +0.16%. The full HVBPP incentive payment adjustment factors for each participating hospital in FY 2020 are now available in Table 16B of the 2020 IPPS final rule.
Detailed Notice of Discharge Form Expiration Extension
On October 30, CMS posted an Update on its Hospital Discharge Appeal Notices webpage to note that the currently available Detailed Notice of Discharge will not expire on October 31, 2019 as it states on the form. The notice is going through a Paperwork Reduction Act clearance process, and the currently available notice is covered for continued use under an extension until CMS published an updated notice.
CMS Announces Artificial Intelligence Health Outcomes Challenge Participants Advancing to Stage 1
On October 31, CMS published a Press Release to announce the top 25 participants selected to advance to stage 1 of the CMS Artificial Intelligence Health Outcomes Challenge. Over 300 entities entered the challenge. Of the 25 selected to advance to stage 1, only seven participants will move on as finalists to stage 2. The list of the top 25 participants is available on the challenge web page.
CY 2020 End Stage Renal Disease (ESRD)/Durable Medical Equipment (DME) Final Rule
On October 31, CMS published a draft version of the 2020 ESRD PPS and DME Final Rule, which is scheduled to be published in the Federal Register on November 8. The final 2020 ESRD PPS base rate is $239.33, which is $4.06 higher than the current base rate. CMS also finalized several proposals related to the transitional drug add-on payment adjustment (TDAPA), including:
- Revising the drug designation process regulation for new renal dialysis drugs/biologicals that fall within an existing ESRD PPS functional category to focus on drugs that are innovative. CMS is excluding certain drugs approved by the FDA under sections 505(c) and 505(j) from TDAPA effective January 1, 2020.
- Changing payment for TDAPA for calcimimetics for CY 2020 from average sales price (ASP) plus 6% to 100% of ASP.
- Halting application of the TDAPA for new renal dialysis drugs/biologicals if CMS does not receive a full calendar quarter of ASP data within 30 days of the last day of the third quarter after CMS begins applying CMS.
The rule also finalizes a policy that will streamline prescription requirements for DMEPOS orders to one standardized set of required elements for all DMEPOS orders. It creates one master list of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery/prior authorization requirements.
CY 2020 Home Health Prospective Payment System Final Rule
On October 31, CMS published a draft version of the 2020 Home Health PPS Final Rule, which is scheduled to be published in the Federal Register on November 8. CMS estimates aggregate Medicare payments to home health agencies (HHA) will increase by 1.3% in 2020. The rule implements the Patient-Driven Groupings Model (PDGM), as finalized in the 2019 version of the rule, with 30-day periods of care payment units for all services beginning on or after January 1, 2020. The 30-day payment amount for 2020 will be $1,864.03, and there are budget neutral payment adjustments to offset any anticipated provider behavior changes upon implementation of PDGM. The rule also includes finalized proposals for policies related to the 2021 implementation of the home infusion therapy benefit as well as policies allowing therapist assistants to perform maintenance therapy. There is a 60-day public comment period on enhancing coverage of eligible drugs for the home infusion benefit.
2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule
On November 1, CMS published a draft version of the CY 2020 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center Payment System Final Rule, which is scheduled to be published in the Federal Register on November 12. The rule does not finalize the price transparency proposals from the proposed rule. CMS said it received over 1,400 comments on the proposed requirements and will address those comments and the price transparency proposals in a forthcoming final rule. CMS also noted that it will continue its two-year phase-in of its site-neutrality payment reductions despite a federal court vacating the policy for CY 2019, as CMS said the government will continue to evaluate its appeal rights for the ruling. Other policies from the rule include:
- Removing total hip arthroplasty, six spinal surgical procedures, and certain anesthesia services from the inpatient-only list and establishing a two-year exemption from medical reviews relating to patient status for procedures removed from the inpatient-only list starting in 2020
- Changing the supervision of outpatient therapeutic services at all hospitals and CAHs from direct supervision to general supervision
- Requiring prior authorization for certain outpatient department services that CMS deems as primarily cosmetic procedures
- Continuing a reduction in payments for 340B drugs at average sales price minus 22.5% while CMS continues to appeal a district court ruling vacating the policy
The OPPS payment rate will increase by 2.6% for 2020. There is a 30-day comment period on payment classifications assigned to interim APC assignments and/or status indicators of new or replacement Level II HCPCS codes. Comments are due by December 2.
CMS published a Fact Sheet on the final rule on the same date.
The final rule is effective January 1, 2020.
2020 Medicare Physician Fee Schedule Final Rule
On November 1, CMS published a draft version of the CY 2020 Medicare Physician Fee Schedule Final Rule, which is due to be published in the Federal Register on November 15. The rule finalizes a proposal to align office/outpatient E/M coding with the changes adopted by the AMA’s CPT Panel. This will revise documentation requirements for E/M coding and will allow clinicians to choose an E/M visit level based on either medical decision making or time. It will also reduce the number of levels for new patient office/outpatient E/M visits from five down to four. In addition to E/M changes, the rule includes policies on:
- Allowing physicians, physician assistants, and advanced practice RNs to verify and sign rather than re-document notes in the medical record made by other members of the medical team
- Finalizing a series of policies regarding opioid treatment as required by the SUPPORT Act, including a definition of what OUD treatment services include and bundled payments for opioid treatment programs
- Adding three HCPCS codes for opioid treatment-related telehealth services
The PFS conversion factor for 2020 will be $36.09, five cents higher than the 2019 conversion factor. The rule also includes an interim final rule with comment period to establish coding and payment for the evaluation and management, observation, and provision of self-administered Esketamine to facilitate beneficiary access to care for treatment-resistant depression. Comments on the interim final rule are due by December 31, 2019.
The final rule is effective January 1, 2020.
Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
On November 1, CMS published One-Time Notification Transmittal 2379 to implement changes that will include the Veterans Administration (VA) in the updates to the SNF Prospective Payment System as required for PDPM. These VA changes were erroneously left out of the original change request.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Addition of MS-DRGs Subject to IPPS Replaced Devices Offered Without Cost or With a Credit Policy
On November 1, CMS published One-Time Notification Transmittal 2381 to add MS-DRGs 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without MCC) to the list of MS-DRGs subject to the policy for reducing payment for replaced devices offered without cost or with a credit.
Effective date: October 1, 2019
Implementation date: April 6, 2020
Health Professional Shortage Area (HPSA) Bonus Payments for All Mental Health Specialties
On November 1, CMS published Medicare Claims Processing Transmittal 4431 regarding HPSA bonus payments for mental health specialties. Currently, specialty 26 is the only specialty set up to receive the bonus, but specialties 27, 86, and any future psychiatry provider specialties should also be eligible for this bonus.
Effective date: February 4, 2020 - For claims processed on or after 90 days from issuance
Implementation date: February 4, 2020
Editing Update for Vaccine Services
On November 1, CMS published One-Time Notification Transmittal 2380 regarding an update to the Common Working File that will bypass line item dates of service for vaccines reported on claims with TOB 12X and 22X when the dates of service equals a posted outpatient 73X or 77X service date or occurrence span code visit date.
Effective date: April 1, 2020
Implementation date: April 6, 2020