This week in Medicare updates—4/7/2021
Therapy Claims: Reprocessing Dates of Service from January 1 through February 15
On March 29, Palmetto published a Notice on its website stating that the list of codes that sometimes or always describe therapy services wasn’t updated by January 1, affecting therapy claims from institutional providers with dates of service from January 1 through February 15. MACs will be automatically reprocessing these claims.
Audit of Medicare Payments for Eye Injections at an Ophthalmology Clinic in California
On March 30, the OIG published a Review of whether an ophthalmology clinic in California complied with Medicare requirements when billing for intravitreal injections of Eylea and Lucentis in addition to other services provided on the same day as the injections. OIG analysis had shown that the clinic frequently billed for other services as being unrelated to, distinct from, or separately identifiable from intravitreal injections of these drugs. The OIG found that the clinic generally complied with requirements for billing the intravitreal injections, but it did not always comply with requirements when billing for other services provided on the same day as the injections. The OIG found that, for the 627 services and drugs reviewed in association with 100 sampled beneficiary days, 301 services and drugs were noncompliant with Medicare requirements, as 195 services were not separately payable and 101 services and drugs were not reasonable and necessary.
The clinic’s medical director was unfamiliar with Medicare’s billing requirements for modifiers -25 and -59 as well as other billing requirements for these services/drugs, and therefore the clinic did not have appropriate policies and procedures in place to prevent these billing errors. The OIG estimated that the clinic received at least $398,625 in unallowable payments due to these errors. The OIG recommends the clinic refund the estimated overpayments identified by the OIG and identify, report, and return any other overpayments in accordance with the 60-day rule. It also made two procedural recommendations related to policies and procedures the clinic could institute to prevent improper billing for services and drugs provided on the same day as these injections.
Temporary Claims Hold Pending Congressional Action to Extend 2% Sequester Reduction Suspension
On March 30, CMS published a Special Edition MLN Connects to announce it has instructed MACs to hold all claims with dates of service on or after April 1, 2021, for a short period without affecting provider cash flow in anticipation of a possible Congressional action to extend the 2% sequester reduction suspension. CMS said it hopes this will minimize the volume of claims MACs must reprocess if the suspension is extended.
April 2021 List of Laboratory Codes Subject to Date of Service (DOS) Exception
On March 31, CMS published a Download Link on its Laboratory DOS Policy webpage for the Excel file containing the list of laboratory codes subject to the DOS Policy under the clinical laboratory fee schedule. There are four new codes added to the list effective April 1, 2021.
COVID-19 FAQs on Medicare Fee-for-Service Billing
On March 31, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. This round of updates included one new FAQ on whether ACOs can remove beneficiary notification posters in their facilities for the purpose of infection prevention and control.
CMS continues to update this document on a regular basis. Providers should review frequently for new information.
Comment Request: National Implementation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS); Hospice Facility Cost Report Form
On March 31, CMS published a Comment Request in the Federal Register regarding the following information collections:
- National Implementation of Hospital Consumer Assessment of Healthcare Providers and Systems
- Hospice Facility Cost Report
Comments are due by June 1.
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) - July 2021
On March 31, CMS published Medicare Claims Processing Transmittal 10688 regarding the quarterly updates to the DMEPOS CBP files. The transmittal provides instructions for implementing the updated HCPCS, zip code, single payment amount, and supplier files.
CMS published MLN Matters 12225 on the same date.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Quarterly Update to the NCCI Procedure-to-Procedure (PTP) Edits, Version 27.2, Effective July 1, 2021
On March 31, CMS published Medicare Claims Processing Transmittal 10690 regarding the quarterly updates to the NCCI PTP edits. The final file will be available via the CMS Virtual Data Center around May 17.
CMS published MLN Matters 12226 on the same date.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Hospital Provider Compliance Audit: Sunrise Hospital & Medical Center
On April 1, the OIG published a Review of whether Sunrise Hospital & Medical Center complied with Medicare requirements for billing inpatient and outpatient services for certain claims that were potentially at risk for billing errors. The OIG determined that Sunrise did not comply with requirements on 54 of the 100 claims reviewed. This included errors on 50 inpatient claims, 36 of which were related to incorrectly billed inpatient rehab facility claims while 11 errors were found for claims incorrectly billed as inpatient and three errors were found pertaining to incorrect outlier payments. The OIG also found four errors on outpatient claims, two of which were due to claims incorrectly billed with modifier -59 and two other claims with HCPCS codes which were not supported by documentation in the medical record. These claims resulted in net overpayments of just under $1 million for the audit period, which the OIG estimated amounts to at least $23.6 million in total overpayments for the audit period.
The OIG recommends Sunrise refund the $23.6 million in estimated overpayments; exercise reasonable diligence to identify, report, and return overpayments in accordance with the 60-day rule; and strengthen controls to ensure compliance with Medicare requirements. The hospital disagreed with most of the OIG’s findings and asked for a meeting with the OIG’s medical reviewer for a clinical discussion with the hospital’s IRF medical director, but the OIG refused and said its contract does not allow for direct interaction between the medical reviewer and the hospital. The hospital also stated it was concerned that the medical reviewer is associated with one of CMS’ contractors and that it is inappropriate to use such a contractor given the possibility of bias should the medical review contractor already have an existing relationship with CMS. The OIG responded by saying that any contract the medical reviewer has with CMS is “entirely separate” from the OIG’s medical review contract with that contractor.
Updates to Chapter 4 of the Medicare Program Integrity Manual
On April 1, CMS published Medicare Program Integrity Transmittal 10709, which rescinds and replaces Transmittal 10641, dated March 18, 2021, to remove the revision to section 4.6.2, Chapter 4 of the manual and update the revision to section 4.6.3 in Chapter 4 of the manual. The original transmittal was issued regarding updates to various sections of the manual due to changes to UPIC and I-MEDIC processes.
Effective date: April 19, 2021
Implementation date: April 19, 2021
Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021
On April 1, CMS published Special Edition MLN Matters 21004 regarding repayment of the COVID-19 Accelerated and Advance Payments (CAAP). The article reminds Medicare providers and suppliers that CMS will begin recovering those payments on the one-year anniversary of when a provider/supplier received their first payment. CMS will recover the CAAP from Medicare payments at a rate of 25% for the first 11 months followed by a rate of 50% for the next six months after that. At the end of that six-month period, the MAC will issue a demand letter for full repayment of any remaining balance. CMS will show the recoupment on remittance advices for Part A and B claims. It will appear as an adjustment in the Provider-Level Balance (PLB) section.
April 2021 Update of the Ambulatory Surgical Center (ASC) Payment System
On April 1, CMS published Medicare Claims Processing Transmittal 10702 regarding the April 2021 updates to the ASC payment system. The update includes a new ASC payment indicator for CPT code 0632T, updated wage values that had not been included in the January update for new CBSAs, multiple new HCPCS codes, and more.
On April 2, CMS published MLN Matters 12183 to accompany the transmittal.
Effective date: April 1, 2021
Implementation date: April 5, 2021
COVID-19: RHC & FQHC Lump Sum Payments
On April 1, CMS published a Note in MLN Connects stating RHCs and FQHCs may request lump sum payments for administering COVID-19 vaccines in advance of cost report settlement. CMS will pay for the vaccine and administration at 100% reasonable cost.
Comment Request: Hospice Request for Certification and Supporting Regulations; Laboratory Personnel Report (CLIA) and Supporting Regulations
On April 2, CMS published a Comment Request in the Federal Register regarding the following information collections:
- Hospice Request for Certification and Supporting Regulations
- Laboratory Personnel Report (CLIA) and Supporting Regulations
Comments are due by June 1.