This week in Medicare updates—1/30/2019

January 30, 2019
Medicare Insider

New Electronic System for Provider Reimbursement Review Board Appeals

On January 18, CMS published Special Edition MLN Matters 19004 regarding the new electronic system for Provider Reimbursement Review Board (PRRB) appeals. The article gives background on the system, how to file a PRRB appeal, and how to use the Office of Hearings Case and Document Management System (OH CDMS) web-based portal.

 

Provider Compliance Tips for Diabetic Shoes

On January 22, CMS published a Fact Sheet regarding ways to prevent denials and improper payments for diabetic shoes. The fact sheet reviews the definition of what’s covered under the diabetic shoe benefit, limitations on coverage, necessary documentation from the certifying physician, and how to properly prescribe diabetic shoes.

 

Notice of Final Rule Adjusting Civil Monetary Penalties (CMP) for Inflation

On January 22, CMS published a Memo to state survey agency directors regarding annual inflation adjustments to CMPs. For 2018, CMPs have been increased by a multiplier of 1.02041 and is effective October 11, 2018. This adjustment applies to skilled nursing facilities, nursing facilities, home health agencies, and clinical laboratories.  

Effective date: Immediately. The 2018 Annual Adjustment was effective October 11, 2018. Please refer to the Application instructions listed in the memo. This guidance should be immediately communicated to all regional offices and State Survey Agency survey, certification, and enforcement staff, their managers, and the state/regional office training coordinators.

 

Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule

On January 24, CMS published a reissued Special Edition MLN Matters 19002 regarding how to handle TKA claims and the 2-midnight rule now that TKA has been removed from the inpatient-only list. The article contains case examples for when TKA documentation does or does not support the 2-midnight benchmark and has an FAQ regarding TKA and patient status concerns.

Effective date: January 1, 2018

 

Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process

On January 25, CMS published Medicare Claims Processing Transmittal 4220 to direct the Common Working File (CWF) to add a new COBA claims crossover bypass indicator for situations in which a beneficiary once had COBA crossover eligibility but no longer does.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

New State Code for CA, FL, LA, MI, MS, OH, PA, TN and TX

On January 25, CMS published One-Time Notification Transmittal 2227 regarding new state codes for California, Florida, Louisiana, Michigan, Mississippi, Ohio, Pennsylvania, Tennessee, and Texas. These states had exhausted their supply of CMS Certification Numbers for multiple provider types. The new state codes are in addition to the state code that state already possesses.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

Ensuring Organ Acquisition Charges Are Not Included in the Inpatient Prospective Payment System (IPPS) Payment Calculation

On January 25, CMS published One-Time Notification Transmittal 2235 to ensure that organ acquisition costs are not included in the IPPS payment calculation for claims that group to a non-transplant MS-DRG.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

Revising the Remittance Advice Messaging for the 20-Hour Weekly Minimum for Partial Hospitalization Program (PHP) Services

On January 25, CMS published One-Time Notification Transmittal 2232 regarding a revision to remittance advice informational messaging that conveys supplemental and educational information to the provider submitting claims for PHP services where the patient did not receive the minimum 20 hours per week of therapeutic services the plan of care indicates is required.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

On January 25, CMS published Medicare Benefit Policy Transmittal 255 regarding changes to the manual to reflect the ending of functional reporting requirements from the 2019 Physician Fee Schedule and the removal of Medicare outpatient therapy caps from the Bipartisan Budget Act of 2018. For dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable, but it no longer represents an exception request. Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

On January 25, CMS published Medicare Claims Processing Transmittal 4214 regarding changes to Chapter 5 of the manual to reflect the end of functional reporting requirements from the 2019 Physician Fee Schedule and the removal of Medicare outpatient therapy caps from the Bipartisan Budget Act of 2018.

Effective date: January 1, 2019

Implementation date: February 26, 2019

 

April 2019 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

On January 25, CMS published Medicare Claims Processing Transmittal 4213 regarding the quarterly update to ASP and Not Otherwise Classified drug pricing files for Medicare Part B.

Effective date: April 1, 2019

Implementation date: April 1, 2019