This week in Medicare updates—2/20/2019

Interoperability and Patient Access Proposed Rule

On February 11, CMS published a Fact Sheet regarding a Proposed Rule that is scheduled to be published in the Federal Register in the near future. The rule is focused on advancing interoperability and patient access to health information by creating ways to make patient data more useful and transferable through open, secure, standardized, and machine-readable formats. CMS will also be releasing two Requests for Information regarding the role of patient matching in interoperability as well as interoperability and health information technology adoption in post-acute care settings.

Comments on the proposed rule and requests for information will be accepted until early April. Exact dates will be determined once the proposed rule is published in the Federal Register.

 

Approval of Request for an Exception to the Prohibition on Expansion of Facility Capacity Under the Hospital Ownership and Rural Provider Exceptions to the Physician Self-Referral Prohibition

On February 11, CMS published a Final Notice in the Federal Register to announce it will approve the request of St. James Behavioral Health Hospital, Inc., for an exception to the prohibition on expansion of facility capacity.

Effective date: February 11, 2019

 

Medicare Paid Twice for Ambulance Services Subject to Skilled Nursing Facility (SNF) Consolidated Billing Requirements

On February 11, the OIG published a Review of whether Medicare made Part B payments to ambulance suppliers for transportation services that were also included in Medicare Part A payments to SNFs as part of consolidated billing requirements. The OIG determined that Medicare made incorrect Part B payments for 78 of the 100 beneficiary days sampled. These errors were due to a lack of Common Working File (CWF) edits designed to prevent or detect Part B overpayments for transportation subject to consolidated billing. This resulted in an estimated $19.9 million in Part B overpayments to ambulance suppliers for transportation services for beneficiaries in Part A SNF stays.

The OIG recommends CMS redesign CWF edits to prevent these overpayments and recover the incorrectly billed claims related to 78 sampled beneficiary days. CMS concurred with the recommendations.

 

CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs to be Improved to Help Ensure the Health and Safety of Nursing Home Residents

On February 11, the OIG published a Review of nine state agencies from previous reviews of whether these agencies appropriately verified nursing homes’ correction of deficiencies as required. The OIG found that, for 326 of the 700 sampled deficiencies, the state agencies did not collect sufficient evidence of corrected deficiencies. Some of these state agencies simply accepted a nursing home’s correction plan as confirmation of compliance without obtaining actual evidence of corrected deficiencies from these nursing homes. Three of the state agencies had technical issues with maintaining supporting documentation in the software-based system used to support the survey and certification process. The OIG recommends CMS improve its guidance to state agencies on verifying nursing homes’ correction of deficiencies and maintaining documentation to support verification; consider improving its forms related to the survey and certification process; and work with state agencies to address technical issues with the system for maintaining supporting documentation. CMS concurred with these recommendations.

 

Local Coverage Determinations (LCD)

On February 12, CMS published Medicare Program Integrity Transmittal 863, which rescinds and replaces Transmittal 857, dated January 30, 2019, to include changes to the updates in Chapter 13 of the manual which were not included in the previous correction transmittal. It also makes three technical corrections and changes the effective date throughout the manual. The original transmittal was issued regarding revisions to Chapter 13 of the Program Integrity Manual to simplify the LCD process and increase transparency.

CMS published a revised version of MLN Matters 10901 on February 14, 2019, to accompany the transmittal.

Effective date: October 3, 2018

Implementation date: January 8, 2019 - unless otherwise specified.

 

Direct Mailing Notification to MACs Regarding Addressing the Opioid Crisis

On February 13, CMS published One-Time-Notification Transmittal 2261, which rescinds and replaces Transmittal 2220, dated January 11, 2019, to extend the implementation date from February 15, 2019, until February 28, 2019. The original transmittal was issued regarding an upcoming direct mailing to be completed by MACs on addressing the opioid crisis.

Effective date: February 15, 2019

Implementation date: February 28, 2019

 

Medicare Compliance Review of Community Hospital

On February 13, the OIG published a Review of whether Community Hospital complied with Medicare requirements for billing inpatient and outpatient services on selected types of claims. The OIG found that Community did not comply with Medicare billing requirements for 86 of the 170 inpatient and outpatient claims reviewed. All 86 claims in error were inpatient, and these resulted in net overpayments of $1,266,758 for calendar years 2015 and 2016. Of the 86 claims in error, 63 of these incorrectly billed Part A for inpatient rehabilitation facility services.

The OIG recommends Community refund the MACs for estimated overpayments, identify and return any similar overpayments, and strengthen controls to ensure compliance with Medicare requirements. Community generally disagreed with all findings, claimed the OIG had no apparent reason to select them for audit, disagreed with all findings on inpatient rehabilitation claims reviewed, stated the OIG applied the wrong standards, and claimed the OIG sampling methodology was flawed. After review of these comments and the findings, the OIG stands by its original findings.

 

Comment Request: Electronic Visit Verification Compliance Survey; Home Health Change of Care Notice; more

On February 14, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:

• Electronic Visit Verification Compliance Survey
• Home Health Change of Care Notice
• Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Affordable Insurance Exchanges, Medicaid and Children’s Health Insurance Program Agencies

Comments on these information collections are due to the OMB desk officer by March 18, 2019.

 

Comment Request: Report of a Hospital Death Associated with Restraint or Seclusion; Marketplace Quality Standards

On February 14, CMS published a Comment Request in the Federal Register regarding the following information collections:

• Report of a Hospital Death Associated with Restraint or Seclusion
• Marketplace Quality Standards

Comments on these information collections are due by April 15, 2019.

 

Emergency Triage, Treat, and Transport (ET3) Model

On February 14, CMS published a Press Release and Fact Sheet regarding a new payment model for emergency ambulance services that will create a new set of incentives for emergency transport and care. This payment model, called the ET3 model, will enable ambulance providers to partner with qualified health practitioners to either deliver treatment in place on the scene or through telehealth, allow for transport to alternative destination sites (such as primary care offices or urgent care clinics), and encourage the development of medical triage lines for low-acuity 911 calls. The model will have a 5-year performance period and is anticipated to begin in 2020.   

 

Proposed Decision Memo: NCA for Chimeric Antigen Receptor (CAR) T-Cell Therapy for Cancers

On February 15, CMS published a Proposed Decision Memo regarding a national coverage analysis (NCA) for CAR T-Cell therapy. The decision memo marks the first step toward nationwide CMS coverage for CAR T-Cell therapy, which currently lacks a national policy and therefore is only covered per the discretion of local coverage determinations. The proposed NCD would require CMS to cover CAR T-cell therapy when offered in a CMS-approved registry or clinical study in which patients would be monitored for at least two years post-treatment. By issuing the proposed decision memo, CMS is initiating a 30-day public comment period on the policy. A final decision will be issued no later than 60 days after the conclusion of the comment period.

CMS published a Press Release on February 15 to announce the proposed decision memo.

 

Final Decision Memo: Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD)

On February 15, CMS published a Final Decision Memo regarding an NCD for VNS for TRD. The decision expands coverage for VNS for TRD offered through coverage with evidence development clinical trials under certain circumstances. Patients undergoing this treatment must meet very specific criteria and must be enrolled in a CMS-approved, double-blind, randomized, placebo-controlled trial with a follow-up duration of at least one year. CMS also included research questions that must be addressed in these studies.

 

Updated OIG Work Plan

On February 15, the OIG updated its Work Plan with the following new items:

• Characteristics of Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose
• Ensuring Dual-Eligible Beneficiaries' Access to Drugs Under Part D: Mandatory Review

 

What New Home Health Agencies (HHAs) Need to Know About Being Placed in a Provisional Period of Enhanced Oversight

On February 15, CMS published Special Edition MLN Matters 19005 regarding CMS placement of new HHAs into a provisional period of enhanced oversight. The article contains an FAQ about the types of providers affected, the type of enhanced oversight provided, the start date and length of this new policy, and more.

 

National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)

On February 15, CMS published Medicare National Coverage Determinations Transmittal 213, which rescinds and replaces Transmittal 211, dated December 13, 2018, to change the implementation date from February 26, 2019, to March 26, 2019. The original transmittal was issued regarding changes to NCD 20.4, Implantable Cardiac Defibrillators, that will increase coverage of ICDs for six patient indications as listed in the transmittal.

Effective date: February 15, 2018

Implementation date: March 26, 2019 - of this CR - MAC local edits

 

Home Health (HH) Patient-Driven Groupings Model (PDGM) - Split Implementation

On February 15, CMS published Medicare Claims Processing Transmittal 4244, which rescinds and replaces Transmittal 4228, dated February 1, 2019, to revise business requirement 11081.2.8.2 by striking the reference to adjustment reason UP and to revise Attachment 4 to replace the assessment date with the claim From date in the Grouper input. The original transmittal was issued to implement policies of the PDGM as described in the CY 2019 Home Health final rule.

On February 5, CMS published MLN Matters 11081 to accompany the transmittal.  

Effective date: January 1, 2020 - Claim “From” dates on or after this date

Implementation date: July 1, 2019 - for design and requirements; October 7, 2019 - for coding and testing including Beta HH Pricer; January 6, 2020 - for continued testing and implementation. To the extent feasible, tasks during the three releases may be worked using an Agile process.

 

April Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

On February 15, CMS published Medicare Claims Processing Transmittal 4242 regarding the April quarterly update to the DMEPOS fee schedule.

Effective date: April 1, 2019

Implementation date: April 1, 2019

 

Modification of the MCS Claims Processing System Logic for Modifier 59, XE, XS, XP, and XU Involving the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Column One and Column Two Codes

On February 15, CMS published One-Time Notification Transmittal 2259 regarding an update to the MCS system claim adjudication rules for NCCI PTP edits to allow bypass of an edit with CCMI of 1 if modifiers 59, XE, XS, XP, or XU are appended to either the column one or column two code.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update

On February 15, CMS published Medicare Claims Processing Transmittal 4239 regarding an update to the HPTC code set.

Effective date: July 1, 2019

Implementation date: July 1, 2019 - Contractors with the capability to do so shall implement this CR effective April 1, 2019