This week in Medicare updates—4/29/2020
Implementation of the Award for the Jurisdiction 5 Part A and Part B Medicare Administrative Contractor (J-5 A/B MAC)
On April 17, CMS published One-Time Notification Transmittal 10055 regarding an announcement that the J-5 A/B MAC recompetition procurement was recently awarded to WPS, the incumbent contractor for this workload.
Effective date: March 1, 2020
Implementation date: March 1, 2020
New Waived Tests
On April 17, CMS published Medicare Claims Processing Transmittal 10048 regarding the new CLIA waived tests. There are 69 newly added waived complexity tests, and these tests should be reported with modifier QW (with the exception of nine tests listed in an attachment to the transmittal) to be recognized as a waived test.
CMS published MLN Matters 11747 on the same date to accompany the transmittal.
Effective date: July 1, 2020
Implementation date: July 6, 2020
CMS Recommendations on Re-Opening Facilities to Provide Non-Emergent Non-COVID-19 Healthcare: Phase I
On April 19, CMS published a Document regarding guidance for allowing facilities to re-open to care for patients needing non-emergent, non-COVID-19 healthcare. While CMS still encourages the use of all telehealth modalities to the greatest extent possible, it is recommending that facilities in places with low or stable incidences of COVID-19 gradually transition back to some in-person care in coordination with state and local public health officials. These facilities would have to meet gating criteria regarding symptoms, cases, and hospitals, and the authority would rest with the state and local leadership when making the decision to re-open for this type of care.
CMS published a Press Release to accompany the guidance on the same date.
Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons Under Investigation) Among Residents and Staff in Nursing Homes
On April 19, CMS published a Memorandum to state survey agency directors regarding requirements that nursing homes report communicable diseases, healthcare-associated infections, and potential outbreaks to state and local health departments. CMS will also be establishing a requirement to report this data to the CDC in a standardized format in forthcoming rulemaking. CMS is also previewing a new requirement for facilities to notify residents and their representatives when there is confirmed COVID-19 or when three or more residents or staff have new-onset respiratory symptoms that occur within a 72-hour span. CMS will detail that guidance and enforcement actions more fully in upcoming rulemaking.
CMS published a Press Release on the same date to accompany the memorandum.
Effective date: This memorandum should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators immediately.
Trump Administration Champions Reporting of COVID-19 Clinical Trial Data Through Quality Payment Program
On April 20, CMS published a Press Release regarding a new improvement activity for the Merit-based Incentive Payment System (MIPS) called the COVID-19 Clinical Trials activity. MIPS-eligible clinicians can receive credit for this improvement activity by attesting that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study. By attesting to this, clinicians would automatically earn half of the total credit needed to earn a maximum score in the MIPS improvement activities performance category.
Virtual Public Meetings in June 2020 for New Public Requests for Revisions to the HCPCS Coding for Durable Medical Equipment and Accessories, Orthotics, and Prosthetics, Supplies and Other Non-Drug and Non-Biological Items
On April 20, CMS published a Notice in the Federal Register to announce the dates and time of the virtual HCPCS public meetings, which will be held in June to discuss coding recommendations for revisions to the HCPCS Level II code set. The virtual meetings will be held Monday, June 1, from 9 a.m. to 5 p.m. ET and Tuesday, June 2, from 9 a.m. to 12:30 p.m. ET. It also has information on speaker registration deadlines, material due dates, and other attendee registration dates.
Updated Corporate Integrity Agreement Documents
On April 20, the OIG published information on new Corporate Integrity Agreements with:
OIG Proposes Rule for Civil Money Penalties for Information Blocking
On April 21, the OIG published a draft copy of a Proposed Rule amending civil money penalties to incorporate new authorities for civil money penalties (CMP), assessments, and exclusions related to HHS grants, contracts, or other agreements; incorporate new CMP authorities for information blocking; and increase the maximum penalties for certain CMP violations. These regulations are intended to help improve care coordination and patient access to health care data by addressing the negative effects of information blocking.
The rule was published in the Federal Register on April 24. Comments are due by June 23. The OIG published a Press Release to accompany the rule on April 21.
Guidance for Licensed Independent Freestanding Emergency Departments to Participate in Medicare and Medicaid During the COVID-19 Public Health Emergency
On April 21, CMS published a Memorandum to state survey agency directors regarding additional flexibilities which will allow independent freestanding EDs to temporarily enroll as a hospital and participate in Medicare and Medicaid to help address the need to increase hospital capacity. The memo discusses the steps involved in enrolling via this process and the qualifications these EDs must meet.
CMS published a Press Release on this guidance on the same date.
Effective date: Effective immediately. This policy should be communicated with all survey and certification staff, their managers and the state/regional office training coordinators immediately. This guidance will cease to be in effect when the Secretary determines there is no longer a Public Health Emergency due to COVID-19. At that time, CMS will send public notice that this guidance has ceased to be effective via its website.
Interoperability Flexibilities Amid the COVID-19 Public Health Emergency
On April 21, CMS published an Announcement regarding delayed enforcement for policies included in the Interoperability and Patient Access Final Rule dated March 9, 2020. CMS is extending the implementation timeline for the admission, discharge, and transfer (ADT) notification Conditions of Participation by an additional six months so that these CoPs are effective 12 months after the final rule is published in the Federal Register. CMS will also not enforce new requirements for the Patient Access API and Provider Directory API policies for Medicare Advantage, Medicaid, and CHIP until July 1, 2021.
CMS published a Press Release on the same date to accompany the announcement.
Information Related to COVID-19
On April 21, CMS published a Revised Memorandum, which supersedes and replaces previous guidance dated March 10, to Medicare Advantage organizations, Part D sponsors, and Medicare-Medicaid Plans on flexibilities they may implement to support efforts to limit the spread of COVID-19 and prevent disruptions in care or disruptions in pharmacy and prescription drug access during the public health emergency. New guidance has been issued regarding coverage of testing and testing-related services for COVID-19, additional or expanded benefit offerings, prior authorization, cost and utilization management requirements, and more.
Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services
On April 22, the OIG published a Review of whether Grand Desert complied with Medicare requirements when billing for psychotherapy services. The OIG found that only one or the 100 psychotherapy services reviewed for 100 sampled beneficiary days complied with Medicare requirements. Errors included failure to document the time spent on psychotherapy, the provision of psychotherapy services that did not comply with incident-to requirements, and failure to provide or document psychotherapy. The OIG estimates that Grand Desert received $421,272 in unallowable Medicare reimbursement during the audit period. It recommends Grand Desert refund the estimated overpayments, implement policies and procedures to ensure adequate documentation (including documentation of time spent on psychotherapy), strengthen management oversight and review claims to ensure they meet incident-to requirements, improve the billing system to ensure claims identify the correct provider, and strengthen management oversight to ensure that psychotherapy services billed to Medicare were actually provided and have supporting documentation. Grand Desert failed to provide a written response to the OIG’s report.
COVID-19 FAQs on Medicare Fee-for-Service Billing
On April 23, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. The new guidance includes information on remote physiologic monitoring, the use of condition code DR and modifier CR, pre-service interaction requirements for DME, NCDs/LCDs whose clinical indications may not be enforced during the PHE, and more.
Guidance for Infection Control and Prevention Concerning COVID-19 in Home Health Agencies and Religious Nonmedical Healthcare Institutions (RNHCI)
On April 23, CMS revised a Memorandum, originally published March 10, to state survey agency directors regarding guidance for home health agencies and RNHCIs on infection control for COVID-19. The revisions address information from CMS waivers and regulations that had been updated after the original publishing date, includes recommendations for visitation in residential facilities not certified by Medicare, and discusses guidance on addressing potential and confirmed COVID cases at RNHCIs.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators immediately.
Comment Request: Partial Withdrawal
On April 23, CMS published a Notice of a Partial Withdrawal in the Federal Register regarding a comment request originally published on April 15. CMS is withdrawing the request for the information collection titled “CMS Plan Benefit Package (PBP) and Formulary CY 2021.” The original comment request for the information collection titled “Applicable Integrated Plan Coverage Decision Letter” remains in effect. Comments are due to the OMB desk officer by May 15, 2020.
Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of CARC, RARC, and CAGC Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE
On April 23, CMS published Medicare Claims Processing Transmittal 10064, which rescinds and replaces Transmittal 4463, dated November 15, 2019, to update the WPC website address in the background section. The original transmittal was issued regarding instructions for contractors to update systems based on CORE 360 Uniform use of CARC, RARC, and CAGC rule publications.
On April 23, CMS revised MLN Matters 11490 to accompany the transmittal.
Effective date: April 1, 2020
Implementation date: April 6, 2020
FAQs: Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the COVID-19 Public Health Emergency
On April 24, the OIG published an FAQ regarding changes to enforcement pertaining to arrangements that are directly connected to COVID-19. These FAQs address questions about accepting donations during the outbreak, providing free transportation, providing free services, and more.
Extension of Comment Period: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing
On April 24, CMS published a Notice in the Federal Register to extend the comment period for the Comprehensive Care for Joint Replacement Model proposed rule that was originally published in the Federal Register on February 24. The comment period has now been extended by two months and will end on June 23, 2020.
Approval of Application by the Accreditation Commission for Healthcare for Initial CMS-Approval of its Home Infusion Therapy Accreditation Program
On April 24, CMS published a Final Notice in the Federal Register to announce its approval of the Accreditation Commission for Healthcare for initial recognition as a national accrediting organization for home infusion therapy suppliers who wish to participate in Medicare.
Dates: The approval announced in this notice is effective April 23, 2020, through April 23, 2024.
July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer
On April 24, CMS published Medicare Claims Processing Transmittal 10058 regarding updates to the Pricer software to include the new payment policy for COVID-19. The policy is effective for claims with discharges occurring on or after January 27, 2020, and discharges will be identified by the presence of the B97.29 ICD-10-CM code (for discharges on or after January 27, 2020 and on or before March 31, 2020) and the U07.1 ICD-10-CM code (for discharges on or after April 1, 2020 through the duration of the COVID-19 public health emergency).
Effective date: January 27, 2020
Implementation date: July 6, 2020
Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2020 - Recurring July File Update
On April 24, CMS published Medicare Claims Processing Transmittal 10059 regarding updates to the FQHC PPS to implement a provision of the Families First Coronavirus Response Act that will waive coinsurance for services related to COVID-19 testing. FQHCs must put modifier -CS on claims for which the coinsurance is waived.
Effective date: July 1, 2020
Implementation date: July 6, 2020
Provider Education for Required Prior Authorization (PA) of Hospital Outpatient Department (OPD) Services
On April 24, CMS published One-Time Notification Transmittal 10061 regarding information MACs are instructed to provide to certain provider types about the new prior authorization requirements for select outpatient hospital department services. The transmittal includes an attached letter covering what providers need to know about the process as well as a list of codes for services that will require prior authorization.
Effective date: May 26, 2020
Implementation date: May 26, 2020
Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer
On April 24, CMS published Medicare Claims Processing Transmittal 10060 regarding an update to the LTCH Pricer which will include the new payment policy for COVID-19.
Effective date: For cost reporting periods beginning on or after October 1, 2019; For COVID-19 Payment Policies - Admissions on or after 1/27/2020
Implementation date: July 6, 2020
Addition of the QW Modifier to HCPCS Code U0002 and 87635
On April 24, CMS published One-Time Notification Transmittal 10066 regarding the use of the QW modifier to designate that the COVID-19 tests reported with HCPCS codes U0002 and 87635 can be recognized as a test that can be performed in a facility having a CLIA certificate of waiver.
Effective date: March 20, 2020
Implementation date: May 8, 2020
Expansion of the Accelerated and Advance Payments Programs for Providers and Suppliers During COVID-19 Emergency
On April 26, CMS published an updated Fact Sheet regarding the Accelerated and Advanced Payments Programs, which CMS expanded in March. Effective immediately, CMS is suspending its Advance Payment Program and reevaluating the amounts it will pay under its Accelerated Payment Program now that Congress has made $175 billion available to healthcare providers and suppliers through a combination of the CARES Act and Paycheck Protection Program and Health Care Enhancement Act. The funding provided through the Congressional actions does not need to be repaid, but funding distributed through the Accelerated and Advance Payment Programs typically does need to be repaid.
CMS published a Press Release on the same date to accompany the announcement.