This week in Medicare updates—2/7/18

February 7, 2018
Medicare Insider

2016 Medicare Electronic Health Record (EHR) Incentive Program Payment Adjustment Fact Sheet for Critical Access Hospitals (CAH)

On January 26, CMS published a Fact Sheet regarding the Medicare EHR Incentive Program Payment Adjustment for CAHs. If a CAH did not demonstrate meaningful use of certified EHR technology for an applicable EHR reporting period, its reimbursement in FY 2018 and beyond will be reduced to 100% of reasonable costs.   


Additional Documentation Limits for Medicare Institutional Providers

On January 29, CMS updated a Document regarding the Institutional Provider (Facilities) Additional Documentation Request (ADR) Limits. The update includes additional information on how provider denial rates are calculated for risk-based, adjusted ADR limits.


Announcement of the Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations

On January 30, CMS published a Notice in the Federal Register regarding an extension of temporary moratoria on enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies, subunits, and branch locations in the following states:

  • Florida
  • Illinois
  • Michigan
  • Texas
  • Pennsylvania
  • New Jersey

This extension is for the purpose of preventing and combating fraud, waste, and abuse in those locations.

Effective date: Applicable January 29, 2018


Updates to Provider Reimbursement Manual Chapter 40, Hospital and Hospital Health Care Complex Cost Report

On January 30, CMS issued Provider Reimbursement Manual Transmittal 13 to revise and replace Transmittal 12, dated November 17, 2017. The new transmittal changes the effective date to cost reporting periods ending on or after September 30, 2017. No other revisions were made to the transmittal.

Effective date: Cost reporting periods ending on or after September 30, 2017


Correction: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs

On January 31, CMS published a Correction in the Federal Register to make one change to the correction notice for the OPPS final rule dated December 27, 2017. The correction to the correction notice applies to lines 13 through 15 of the first column on page 61188 of the December 27 edition of the Federal Register. The January 31 edit instructs:

On page 59375, second column, third full paragraph, in line 7, correct “CCR ≤5” to read “CCR >5.”


New Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-Coverage (ABN)

On February 1, CMS published a new SNF ABN Form to be used before a SNF provides an item or service that is usually paid for by Medicare but will not be paid in a particular instance because the item or service is not medically reasonable or necessary. SNFs should also issue the liability notice before providing custodial care. The newly revised SNF ABN form and accompanying instructions are available via the link above.  


Qualifying Alternative Payment Model Participants (QPs) Methodology Fact Sheet

On February 1, CMS published a Fact Sheet to describe the process and methodology CMS will use to identify QPs who will be eligible to participate in the Quality Payment Program (QPP) as an Advanced Alternative Payment Model (APM) for a year. QPs are eligible to receive the 5% APM incentive payment.


CMS Proposes Medicare Advantage and Part D Payment and Policy Updates to Provide New Benefits for Enrollees, New Protections to Combat Opioid Crisis

On February 1, CMS issued a Press Release regarding the 2019 Medicare Advantage and Part D Advance Notice Part II, which describes proposed changes for Medicare health and drug programs in 2019. As part of the changes for 2019, CMS would redefine health-related supplemental benefits to include daily maintenance items or services that would compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce emergency room utilization. The agency is also designing a framework of policies to give health plans tools to assist in patient-doctor-plan communication regarding opioid use.

CMS also issued a Fact Sheet and a Draft Call Letter regarding the proposed Advance Notice. The fact sheet contains details about changes to capitation rates and payment policies in addition to the benefit changes mentioned in the press release.


Targeted Probe and Educate (TPE): New Resources

On February 1, CMS updates the TPE webpage with a handful of new resources, including:

  • Description of common claim errors
  • TPE process graphic
  • An infographic about the program
  • Q&As


Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 24.1, Effective April 1, 2018

On February 2, CMS published Medicare Claims Processing Transmittal 3963 regarding normal updates to the NCCI PTP edits.

Effective date: April 1, 2018

Implementation date: April 2, 2018


E/M Service Documentation Provided by Students (Manual Update)

On February 2, CMS published Medicare Claims Processing Transmittal 3971 regarding changes to the manual which will allow the teaching physician to verify in the medical record any student documentation of components of E/M services. This would prevent the teaching physician from having to re-document the work.

Effective date: January 1, 2018

Implementation date: March 5, 2018


Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)

On February 2, CMS published Medicare Claims Processing Transmittal 3969 to inform contractors that CMS issued an NCD to cover SET for beneficiaries with intermittent claudication, a symptom of PAD. CMS issued the NCD on May 25, 2017, and will cover up to 36 sessions over a 12-month period if certain requirements are met.

On February 2, CMS published Medicare National Coverage Determinations Transmittal 204 regarding revisions to the NCD Manual pertaining to the NCD for SET as a treatment for PAD.

Effective date: May 25, 2017

Implementation date: April 3, 2018 - for MAC local edits; July 2, 2018 - For Shared System edits


Implementation of Automating First Claim Review in Serial Claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

On February 2, CMS published One-Time Notification Transmittal 2029 regarding a system solution within the ViPS Medicare System to allow DMEPOS MACs to perform pre-payment complex medical review on a claim line. Based on the results of the review, the system will allow the MAC to pay subsequent claim lines in the series after passing existing validation edits or deny subsequent claim lines in the series unless the provider submits additional documentation with the subsequent claim line.

Effective date: July 2, 2018 - per Shared Systems Release schedule

Implementation date: July 2, 2018 - VMS implementation of business requirements 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15 and 25; October 1, 2018 - Analysis and Coding of all remaining business requirements; January 7, 2019 - Coding and Implementation of all the remaining business requirements


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

On February 2, CMS published Medicare Claims Processing Transmittal 3962 to address two issues affecting the COBA Medicare crossover process for Part B and DME MACs. The instructions provided make certain that claims with modifiers that are “not used” by Medicare are no longer denied and that duplicate diagnosis codes included on incoming Medicare claims are no longer mapped to COBA crossover claims.

Effective date: July 1, 2018; October 1, 2018 - FOR VMS, the effective date is process date

Implementation date: July 2, 2018 - For VMS, analysis, design, and coding completed; October 1, 2018 - For VMS, testing support tasks, and implementation


Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - April 2018 Update

On February 2, CMS published Medicare Claims Processing Transmittal 3966 regarding quarterly updates to the drug/biological HCPCS codes. As of April 1, 2018, the following HCPCS codes will be established:

  • Q5103, Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
  • Q5104, Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
  • Q2041, Axicabtagene Ciloleucel, up to 200 million autologous Anti-CD19 CAR T Cells, including leukapheresis and dose preparation procedures, per infusion

As of April 1, 2018, the following HCPCS code will be revised:

  • Q5101, Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram

As of April 1, 2018, HCPCS code Q5102 and modifiers -ZA, -ZB, and -ZC will be discontinued

Effective date: April 1, 2018

Implementation date: April 2, 2018


Update to CR9341 Oncology Care Model (OCM) Restricted Care Management Code List

On February 2, CMS published Demonstrations Transmittal 191 to update the list of restricted care management codes that Oncology Care Model practitioners may not bill for the same beneficiary in the same calendar month in which they bill the Monthly Enhanced Oncology Services payment (G9678). The list should now include the following codes:

  • 99358 and 99359 (Prolonged non-face-to-face evaluation and management services)
  • 99487 and 99489 (Chronic Care Management)
  • G0506 (Assessment/care planning for patients requiring CCM services)
  • G0507 (Care management services for behavioral health conditions)
  • G0179 (Care Plan Oversight - Physician Recertification)
  • G0180 (Care Plan Oversight - Physician certification)
  • G0181 (Care Plan Oversight - Physician supervision of patient under home health agency)
  • G0182 (Care Plan Oversight - Physician supervision of patient under hospice care)

Effective date: July 1, 2018

Implementation date: July 2, 2018


New “K” Code for Therapeutic Shoe Inserts

On February 2, CMS published Medicare Benefit Policy Transmittal 241 regarding a new HCPCS K code for a category of therapeutic shoe inserts. The code and code description are as follows:

  • K0903: For diabetics only, multiple density insert, made by direct carving with CAM technology from a
    rectified CAD model created from a digitized scan of the patient, total contact with patient's foot, including
    arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and
    other shaping material, custom fabricated, each.

The new code goes into effect as of April 1, 2018, and the billing jurisdiction for the code is the DME MAC.

Effective date: April 1, 2018

Implementation date: April 2, 2018


Comprehensive Error Rate Testing (CERT) Updates to Chapter 12 of Pub. 100-08

On February 2, CMS published Medicare Program Integrity Transmittal 766 regarding an update to sections in Chapter 12 of the Medicare Program Integrity Manual based on updates related to CERT.

Effective date: March 2, 2018

Implementation date: March 2, 2018