This week in Medicare updates—12/18/2019

Updates to Kidney Care Choices Model Fact Sheet

On December 4, CMS published an Update to a Kidney Care Choices (KCC) Model Fact Sheet that it originally published on July 10, 2019. The fact sheet pertains to one of two voluntary payment models aimed toward improving care for Medicare beneficiaries with stage 4 and 5 chronic kidney disease (CKD) to delay dialysis and incentivize kidney transplantation. The model was previously called the Kidney Care First Model. Updates include a due date for applications to participate (due January 22, 2020), new information on which versions will qualify as Advanced APMs under the QPP, additional information on home health services and concurrent care benefits, and more.

 

CMS Office of the Actuary Releases 2018 National Health Expenditures

On December 5, CMS published a Press Release regarding data published by the Office of the Actuary for 2018 healthcare spending. Total national healthcare spending grew at a lower rate (4.6%) than the 5.4% overall economic growth, and thus the total share of the economy devoted to health spending decreased from 17.9% in 2017 to 17.7% in 2018. Medicare spending, however, grew by a higher rate (6.4%) in 2018 than it did in 2017 (4.2%). CMS attributed this to faster growth in the net cost of insurance for Medicare private health plans, faster growth in spending for medical goods and services, and an increase in government administration spending.    

 

Medicare Hospital Provider Compliance Audit: St. Vincent Hospital

On December 6, the OIG published a Review of whether St. Vincent Hospital complied with Medicare requirements for billing inpatient and outpatient services for claims dating from January 1, 2016 through December 31, 2017. It focused on common risk areas identified by past OIG audits of other hospitals. Of the 145 claims included in the review, the OIG found that St. Vincent did not comply with Medicare billing requirements for 58 claims, including errors with 49 inpatient claims and 9 outpatient claims. The issues discovered involved incorrectly billed admission source codes for the hospital’s inpatient psychiatric facility (24 claims), inpatient rehabilitation claims not meeting coverage requirements (11 claims), Part A claims that should have been billed as outpatient or outpatient with observation (five claims), incorrect DRGs (eight claims), and incorrectly billed discharge status codes (one claim). The outpatient errors were related to incorrect numbers of units for outpatient surgery procedures (four units) and incorrectly appending modifier -59 for right heart catheterizations performed during heart biopsies (five claims). On the basis of the sample, the OIG estimated that the hospital received overpayments of at least $2.1 million during the audit period. 

The OIG recommends St. Vincent refund the Medicare contractor at least $2.1 million, identify and return any similar overpayments, and strengthen controls to ensure full compliance with Medicare requirements. St. Vincent disagreed with the OIG’s findings for the inpatient rehabilitation claims and the Part A claims that the OIG determined should have been an outpatient or observation service, stating medical necessity supported all claims in those categories. The OIG, however, maintained that all of its findings and recommendations were correct. 

 

New ICD-10-CM Code for Vaping Related Disorder

On December 9, the CDC published a Notice to announce that a new ICD-10-CM code, U07.0 (vaping-related disorder), will be implemented on April 1, 2020. The WHO made the code valid for immediate use as of September 24, 2019. The CDC noted that additional information on the code will be published on both the CDC and CMS websites sometime in December 2019.

 

Updated List of Excluded Individuals and Entities (LEIE)

On December 10, the OIG updated its LEIE with an updated LEIE database for download and lists of November 2019 exclusions, reinstatements, and profile corrections.

 

Updated Corporate Integrity Agreement Documents

On December 12, the OIG published information on closed Corporate Integrity Agreements with the following:

• Dermedx Dermatology, P.C., d/b/a Dermatique and Barry A. Solomon, M.D., of Smithtown, NY
• Quorum Health Corporation, of Franklin, TN
• Huntingdon Nursing Center, Inc.; Foundation Health Services, Inc., of Baton Rouge, LA
• King’s Daughters Medical Center; Ashland Hospital Corporation, of Ashland, KY

 

Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns 

On December 12, the OIG published a Review of the manner in which Medicare Advantage organizations (MAO) utilize chart reviews and the impact of that type of review on risk-adjusted payments. The OIG found that, in 99% of cases, MAO chart reviews added diagnoses to encounter data for patient records. Diagnoses based on chart reviews only (i.e. not from service records) accounted for $6.7 billion in risk-adjusted payments for 2017. In addition, half of MAOs reviewed had payments from unlinked chart reviews where there was no record of a service being provided to the beneficiary in all of 2016. The findings create three concerns for the OIG: this creates (1) a data integrity concern where it is possible MAOs are not submitting all service records as required; (2) a payment integrity concern where, if the diagnoses are inaccurate or unsupported, the associated risk-adjusted payments might be inappropriate; and (3) a quality of care concern where beneficiaries might not be receiving needed services for potentially serious diagnoses listed on chart reviews but not in service records. CMS has not reviewed the financial impact of chart reviews on risk-adjusted payments, nor has it assessed variation in MAO chart review submissions. It also has not examined the quality of care disparity that these records may indicate, and it has yet to perform audits validating the diagnoses from the chart reviews--although CMS says it plans to begin audits that would include that type of validation soon. 

 

The OIG recommends CMS provide oversight of MAOs with risk-adjusted payments resulting from unlinked chart reviews for beneficiaries with no service records in 2016 encounter data, conduct audits to validate diagnoses from chart reviews, and assess the risks and benefits associated with allowing these types of chart reviews to be used as sources of diagnoses for risk adjustment. CMS concurred with all recommendations.

 

Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

On December 12, CMS published a Note in MLN Connects stating that it will repay hospitals for site-neutral payment cuts for CY 2019 pursuant to court orders following a ruling from the U.S. District Court that deemed the reduction in payments for hospital outpatient services provided in an off-campus provider-based department unlawful. CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines for these services and will automatically reprocess claims with a line item date of service on or after January 1, 2019. CMS stated in rule-making for 2020 that it will appeal the court’s ruling for 2019 and will proceed with additional cuts for 2020. CMS did not say anything in the MLN Connects note about whether it still intends to proceed with an appeal.

 

Updated Civil Monetary Penalties and Affirmative Exclusions

On December 13, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following:  

• On November 6, Amarillo Endoscopy Center, of Amarillo, Texas, reached a $121,550.12 settlement agreement with the OIG to resolve allegations that it employed an individual who was excluded from participation in federal health care programs. 
• On November 6, Healthcare Transport, LLC, of Bartlett, Tennessee, reached a $93,725.22 settlement agreement with the OIG to resolve allegations that it submitted claims via a third-party billing agent for basic life support ambulance services where trips were to destinations for which ambulance services are not covered by Medicare. 
• On November 8, Lakeshore Diagnostic Ultrasound Co., of Essexville, Michigan, agreed to a five-year exclusion after it submitted claims for CPT code 96965 for the same dates of service on which it submitted claims for CPT code 93970 or 93971 when the claims were for a procedure that was already included as a component of the ultrasound procedures billed under 93970/93971. 
• On November 12, Jose R. Gonzalez, M.D., Pedro Nam, M.D., and Wellington Medical Care Associates, LLC, of Loxahatchee, Florida, reached a $107,260 settlement agreement with the OIG to resolve allegations that Wellington solicited and received remuneration from Health Diagnostic Laboratory, Inc., and Singulex, Inc., in the form of process and handling payments related to the collection of blood. 
• On November 19, A.R.E.B.A. - Casriel, Inc., of Manhattan, reached a $151,056.75 settlement with the OIG to resolve allegations that it received remuneration from Millenium Health, LLC in the form of free point of care test cups provided in exchange for prohibited referrals.

 

Medicare Hospital Provider Compliance Audit: Texas Health Presbyterian Hospital Dallas

On December 13, the OIG published a Review of whether Texas Health Presbyterian Hospital - Dalla complied with Medicare requirements for billing inpatient and outpatient services for claims dating from January 1, 2016 through December 31, 2017. It focused on common risk areas identified by past OIG audits of other hospitals. Of the 100 claims included in the review, the OIG found that Texas Health did not comply with Medicare billing requirements for 41claims, including errors with 40 inpatient claims and one outpatient claim. The issues discovered involved inpatient rehabilitation claims not meeting coverage requirements (27 claims), Part A claims that should have been billed as outpatient or outpatient with observation (eight claims), incorrect DRGs (five claims), and one incorrectly coded outpatient claim which had an unsupported HCPCS code. On the basis of the sample, the OIG estimated that the hospital received overpayments of at least $10.7 million during the audit period. 

The OIG recommends Texas Health refund the Medicare contractor at least $10.7 million, identify and return any similar overpayments, and strengthen controls to ensure full compliance with Medicare requirements. Texas Health disagreed with the OIG’s findings for some of the inpatient rehabilitation claims and the Part A claims that the OIG determined should have been an outpatient or observation service. The OIG, however, maintained that all of its findings and recommendations were correct. 

 

Medicare Part B Home Infusion Therapy Services with the Use of Durable Medical Equipment

On December 13, CMS published a revised Special Edition MLN Matters 19029 regarding new coverage of home infusion therapy with the use of a DME pump. The article discusses the components of the benefit, the types of items and services covered, benefit categories and codes, and more. The article was revised to correct an error in a footnote that had a numerical typo in a J code. 

 

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2020

On December 13, CMS published Medicare Claims Processing Transmittal 4475 regarding the quarterly release of the edit module for clinical diagnostic laboratory services. 

Effective date: April 1, 2020 - Unless otherwise specified, the effective date is the date of service.

Implementation date: April 6, 2020

 

Update Inpatient Prospective Payment System (IPPS) Pricer and Related Claims Reprocessing

On December 13, CMS published Medicare Claims Processing Transmittal 4477 regarding an issue with an incorrect wage index of 27 Core-Based Statistical Areas (CBSA) in the original release of the FY 2020 IPPS Pricer from October 7. This transmittal includes a correct Excel file with the list of 84 hospitals reclassified to affected CBSAs. It also provides instructions to MACs for necessary revisions related to this error.  

CMS published MLN Matters 11583 on the same date to accompany the transmittal. 

Effective date: October 1, 2019

Implementation date: January 6, 2020

 

CY 2020 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

On December 13, CMS published Medicare Claims Processing Transmittal 4476 regarding the updates to the clinical laboratory fee schedule, mapping for new codes for clinical lab tests, data reporting periods for applicable labs, and updates for lab costs subject to the reasonable charge payment. 

Effective date: January 1, 2020

Implementation date: January 6, 2020