This week in Medicare updates—1/22/2020
New to State Operating Manual (SOM) Appendix F - Community Mental Health Center (CMHC)
On January 10, CMS published State Operations Provider Certification Transmittal 196 regarding a new Appendix F - Interpretive Guidance for the SOM to guide state survey agency surveyors as they determine a CMHC’s compliance with Medicare regulations. Interpretive guidance for CMHC Conditions of Participation on Emergency Preparedness will be addressed separately in Appendix Z of the SOM.
Effective date: January 10, 2020
Implementation date: January 10, 2020
Revisions to State Operating Manual (SOM) Chapter 2; Community Mental Health Center (CMHC)
On January 10, CMS published State Operations Provider Certification Transmittal 197 regarding extensive revisions to chapter 2 of the manual pertaining to survey and certification processes for CMHCs following the issuance of Conditions of Participation for CMHCs.
Effective date: January 10, 2020
Implementation date: January 10, 2020
Implementation to Send Post-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System
On January 10, CMS published One-Time Notification Transmittal 2417, which rescinds and replaces Transmittal 2355, dated August 28, 2019, to update the effective date to February 3, 2020. The original transmittal was issued regarding implementation of changes to generate and send the ADR Letter Package information to esMD so these letters can be sent electronically as Post-Pay eMDRs.
Effective date: February 3, 2020
Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation
Provider Compliance Tips for Nebulizers and Related Drugs
On January 13, CMS published an MLN Fact Sheet regarding proper documentation for nebulizer claims. In 2018, insufficient documentation accounted for 83.8% of improper payments for nebulizers and related drugs. The fact sheet describes the types of documentation necessary for these claims, including a written order prior to delivery that qualifies as a 5-element order. It also describes documentation necessary for situations when a shipping service makes a delivery.
Medicare Quarterly Provider Compliance Newsletter
On January 13, CMS published the January issue of the Medicare Quarterly Compliance Newsletter. This edition of the newsletter contains a CERT report on lumbar sacral orthosis and a recovery auditor finding for Trastuzumab (Herceptin) where multi-use vials were billed incorrectly with medication wastage.
Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes
On January 13, CMS published a Memorandum to state survey agency directors regarding a new streamlined survey and certification process for psychiatric hospitals which aims to establish more holistic and efficient hospital inspections. Beginning in March of 2020, CMS will implement a process in which psychiatric hospitals will receive one comprehensive hospital survey performed by the state survey agency to review compliance rather than subjecting them to two separate surveys by state survey agencies and an outside contractor. CMS is developing online training on the new process for state survey agency surveyors and will be updating guidelines in Appendix AA of the SOM, which will be relocated to Appendix A.
CMS published a Press Release on the policy on the same date.
Effective date: This policy should be communicated to all survey and certification staff, their managers, and the state and regional office training coordinators within 30 days of this memorandum.
OIG Advisory Opinion No. 20-01
On January 13, the OIG published an Advisory Opinion regarding whether an arrangement in which a hospital provides training on advanced airway management techniques to the fire department for purposes of training emergency personnel would be grounds for the imposition of sanctions under the exclusion authority of the Social Security Act or the civil monetary penalty provisions related to the anti-kickback statute. The OIG determined that while this arrangement does implicate the anti-kickback statute, this specific case presents a low risk of fraud and abuse because it poses little risk of overutilization or increased costs to any federal healthcare program, involves several factors in providing this training which mitigate risk when combined, serves as a benefit the community, and works in a way in which any financial benefit would be for the public rather than a private entity. The OIG therefore would not impose administrative sanctions in this case.
Updated OIG Work Plan
On January 15, the OIG updated its Work Plan with the following new item:
Updated Corporate Integrity Agreement Documents
On January 15, the OIG published information on new Corporate Integrity Agreements with:
- 10-30-2019 Amendment for Meadows Regional Medical Center, Inc., of Vidalia, GA
- Bhayani, Rajendra, M.D., New York Otolaryngology & Aesthetic Surgery P.C., and NYC Metro Ent. P.C., of Brooklyn, NY
- Beaver Medical Group, L.P. et. al., of Redlands, CA
- Northwell Health, Inc. and Lenox Hill Hospital, of New Hyde Park, NY
January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On January 15, CMS published Medicare Claims Processing Transmittal 4494 and Medicare Benefit Policy Transmittal 266, which rescinds and replaces Transmittal 4880 and Transmittal 264, both dated December 20, 2019, to correct section 5 to change “removing 12 procedures from the IPO list” to “removing 11 procedures from the IPO list.” The correction also adds a new section, number 18, “Correction of Deductible and Coinsurance for HCPCS code G0404” and changes section 18 “Coverage Determinations” to section 19. The original transmittal was issued regarding January 2020 updates to the OPPS with changes to HCPCS, APCs, HCPCS Modifiers, revenue codes, and more.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Implementation to Send Pre-Pay eMDR to Participating Providers via the esMD System
On January 15, CMS published One-Time Notification Transmittal 2419, which rescinds and replaces Transmittal 2324, dated July 24, 2019, to change the effective date to February 3, 2020. The original transmittal was issued to implement changes required to receive and process the Pre-Pay eMDR via esMD.
Effective date: February 3, 2020
Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation
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 January 16, CMS published One-Time Notification Transmittal 2421, which rescinds and replaces Transmittal 2388, dated November 8, 2019, to remove the Spanish translation verbiage in BR 10787.4 and add verbiage for a provider demand letter in BR 10787.6. The original transmittal was issued regarding new adjustment reason codes and discovery codes to use for OIG adjustments.
Effective date: April 1, 2020
Implementation date: April 6, 2020
Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of Specimens
On January 17, CMS published Medicare Claims Processing Transmittal 4495 regarding revisions to the payment for travel allowances under HCPCS codes P9603 and P9604 in 2020. Contractors shall pay $1.03 per mile for code P9603 when the average trip to patient homes exceeds 20 miles and $10.30 for flat-rate trips reported by P9604. Contractors can establish a higher per mile rate for P9603 if local conditions warrant it.
Effective date: January 1, 2020
Implementation date: February 18, 2020
2020 DMEPOS HCPCS Code Jurisdiction List
On January 17, CMS published Medicare Claims Processing Transmittal 4496 regarding an updated list of HCPCS codes for DME and Part B MAC jurisdictions to reflect the new and deleted codes for the year.
Effective date: January 1, 2020
Implementation date: February 18, 2020
Revisions to State Operations Manual (SOM) Chapter 6 - Special Procedures for Laboratories and Chapter 9 Exhibits
On January 17, CMS published State Operations Provider Certification Transmittal 199, which rescinds and replaces Transmittal 195, dated November 15, 2019, to correct formatting and mistakenly omitted information from the transmittal and manual instruction pages. The original transmittal was issued regarding significant revisions to Chapter 6 and Chapter 9 of the SOM pertaining to various requirements for laboratories.
Effective date: January 17, 2020
Implementation date: January 17, 2020