This week in Medicare updates—2/6/2019
Medicare Quarterly Provider Compliance Newsletter
On January 28, CMS published the January issue of the Medicare Quarterly Provider Compliance Newsletter. This edition of the newsletter discusses findings from a CERT review of observation and inpatient hospital care billed under HCPCS code 99234. It also reviews a recovery auditor finding regarding billing for durable medical equipment supplies for beneficiaries in a Medicare inpatient stay.
Provider Compliance Tips
On January 28, CMS published a series of provider compliance fact sheets regarding ways to prevent denials and improper payments for a variety of products and services. These include:
- (Clinic) Comprehensive outpatient rehabilitation facilities (CORF)
- Commodes, bed pans, and urinals
- Hospital-based hospice
- Laboratory tests - routine venipuncture (non-Medicare fee schedule)
- Lab tests - urinalysis
- Lenses
- Parenteral nutrition
- Pressure-reducing support surfaces
- Polysomnography (sleep studies)
- Patient lifts
- Transcutaneous electrical nerve stimulators (TENS)
The fact sheets generally include information on coverage policies, documentation techniques, and additional resources for provider education.
Advisory Opinion No. 19-02
On January 30, the OIG published an Advisory Opinion regarding a pharmaceutical manufacturer’s proposal to loan a limited-functionality smartphone on a temporary basis to financially needy patients who do not have the technology to receive adherence data from a sensor embedded in prescribed antipsychotic medication. The requestor asked whether this arrangement would constitute grounds for sanctions under the prohibition on inducements to beneficiaries or the anti-kickback statute. The OIG determined it would not impose sanctions, as the loaner device would improve a beneficiary’s ability to access the full scope of benefits of the drug, only certain patients would meet the criteria to receive the loaner device, the loaner device would not likely skew the decision to prescribe the medication, the policy would not be advertised to patients, and the patient would not be permitted to keep the loaner device for more than two 12-week periods.
Correction Notice: Medicare Physician Fee Schedule Final Rule
On January 31, CMS published a Correction Notice in the Federal Register to make numerous technical corrections to the Medicare Physician Fee Schedule final rule, published November 23, 2018. These errors include incorrect effective dates and inadvertently omitted tables.
This correcting document is effective January 31, 2019, and is applicable beginning January 1, 2019.
Emergency Preparedness - Updates to Appendix Z of the State Operations Manual (SOM)
On February 1, CMS published a Memo to state survey agency directors regarding changes to the manual to add “emerging infectious diseases” to the current definition of an all-hazards approach in light of events such as Ebola and Zika outbreaks. The memo also clarifies guidance related to portable/mobile generators and makes changes to the Home Health Agency citations to reflect regulatory citation 484.102.
Effective date: Immediately. The information provided in this memorandum should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Survey and Approval of Pancreas and Intestine Transplant Center
On February 1, CMS published a Memo to state survey agency directors regarding revisions to the survey and approval process for pancreas and intestine transplant programs. Pancreas and intestine transplant centers will not be automatically approved simply because they operate as a component of an approved kidney or liver program, but if the program is operating as a component of a compliant, already approved kidney or liver transplant program, no on-site survey activity will be required for approval. The memo identifies other survey and approval policies for these programs and reviews details about how pancreas and intestine patients would be incorporated into kidney and liver program survey reviews.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators within 30 days of this memorandum.
Proposed Rule: Clinical Laboratory Improvement Amendments of 1988 (CLIA) Proficiency Testing Regulations Related to Analytes and Acceptable Performance
On February 1, CMS published a Proposed Rule regarding updates to the proficiency testing regulations under CLIA to address current analytes and newer technologies. CMS, together with the CDC, proposes to add 29 analytes to Subpart I of the CLIA regulations. The rule also proposes changes to regulations to reflect how moderate and high complexity labs that are also performing waived tests are subject to compliance with proficiency testing referral requirements.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due no later than 5 p.m. 60 days after the proposed rule is published in the Federal Register, which is scheduled to occur on February 4, 2019.
Update to Intensive Cardiac Rehabilitation (ICR) Programs
On February 1, CMS published Medicare Claims Processing Transmittal 4222 and Medicare Benefit Policy Transmittal 256 regarding expanded coverage of ICR programs as codified in the Bipartisan Budget Act of 2018 to add two additional conditions for coverage. CMS said it plans to amend ICR regulations specified at 42 CFR 410.49 to reflect the expanded coverage and will probably include those changes in the 2020 Medicare Physician Fee Schedule notice of proposed rulemaking.
Effective date: February 9, 2018
Implementation date: March 19, 2019
ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)
On February 1, CMS published One-Time Notification Transmittal 2243 regarding the maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
Effective date: July 1, 2019 - unless otherwise indicated
Implementation date: July 1, 2019 - MAC local edits April 2, 2019
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) - Clarification of Payment Rules and Expansion of ICD-10 Diagnosis Codes
On February 1, CMS published Medicare Claims Processing Transmittal 4229 regarding payment rules and coding changes under an NCD covering SET for beneficiaries with intermittent claudication for the treatment of symptomatic PAD.
Effective date: May 25, 2017
Implementation date: March 19, 2019 for MAC local editing; July 1, 2019
Home Health (HH) Patient-Driven Groupings Model (PDGM) - Split Implementation
On February 1, CMS published Medicare Claims Processing Transmittal 4228 to implement policies of the PDGM as described in the CY 2019 Home Health final rule. The policies include a change to the unit of payment from 60-day episodes of care to 30-day periods of care and the elimination of therapy thresholds for use in determining home health payment.
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.
Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model
On February 1, CMS published Medicare Claims Processing Transmittal 4230 regarding the implementation of adjusted payment amounts for hospital claims in Maryland as part of the MD TCOC Model. This includes a reduction in payments on hospital claims by 1% structure in the state of Maryland.
Effective date: July 1, 2019
Implementation date: July 1, 2019 - Coding and Implementation
Independent Laboratory Billing of Laboratory Tests for End-Stage Renal Disease (ESRD) Beneficiaries and the Sunset of the CB Modifier
On February 1, CMS published Medicare Claims Processing Transmittal 4227 regarding the sunset of the requirement for independent laboratories to bill separately for ESRD dialysis-related diagnostic tests. This will result in the retirement of modifier -CB to bill separately for renal dialysis lab tests.
Effective date: July 1, 2019
Implementation date: July 1, 2019
Update to Mammography Editing
On February 1, CMS published Medicare Claims Processing Transmittal 4225 regarding modifications to edits for mammography to ensure that only the revenue codes listed in the transmittal are billed on claims for screening and diagnostic mammography. The transmittal also includes instructions to update CAH editing so that it will deny the professional component of screening/diagnostic mammography when the technical component for the same encounter has been denied.
Effective date: July 1, 2019
Implementation date: July 1, 2019