This week in Medicare updates—5/12/2021

May 12, 2021
Medicare Insider

Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing Final Rule

On May 3, CMS published a Final Rule in the Federal Register regarding revisions to regulations and timelines for the Comprehensive Care for Joint Replacement Model. The rule extends the length of the model through December 31, 2024, by adding three more performance years. It also revises certain aspects of the model, such as the episode of care definition, the target price calculation, the reconciliation process, beneficiary notice requirements, and the appeals process. It additionally changes caps on various payments and extends flexibilities to participant hospitals related to certain Medicare program rules consistent with the revised episode of care definition. 

Dates: These final regulations are effective July 2, 2021. 


Revision of Certain E/M Guidance in Claims Processing Manual

On May 3, CMS published Medicare Claims Processing Transmittal 10742 regarding revisions to three sections of the manual due to a petition HHS received in January pursuant to Good Guidance Practices Regulation. CMS removed guidance from the manual pertaining to selection of E/M levels for split/shared E/M services, critical care visits and neonatal intensive care codes for critical care services, and split/shared E/M visit codes for nursing facility services. CMS left the headers in place with a note for each section stating the sections are “left intentionally blank for future updates” and will be revising guidance through notice-and-comment rulemaking. 

Effective date: May 9, 2021

Implementation date: May 9, 2021


Establishment of Provider-Based Rural Health Clinic (RHC) Per Visit Payment Limits

On May 4, CMS published One-Time Notification Transmittal 10780, which rescinds and replaces Transmittal 10679, dated March 16, 2021, to revise the background and policy sections. The correction also revises BR 12185.2 and adds BR 12185.2.1 to instruct MACs to identify grandfathered provider-based RHCs and establish per visit limits according to the new policy. The original transmittal was issued regarding updates to payment limits for RHCs over the course of eight years. 

CMS revised MLN Matters 12185 on the same date.

Effective date: April 1, 2021

Implementation date: April 5, 2021


COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

On May 5, CMS updated the blanket waivers for health care providers Fact Sheet to provide information on waived requirements granted by the American Rescue Plan Act of 2021 for ambulance services. The waived requirements will allow payment for ambulance services provided in response to a 911 call when an individual normally would have been transported to a destination permitted by Medicare regulations, but the transport did not occur as a result of community protocols in response to the PHE. The deadline to submit claims for services furnished under this waiver has been extended to May 5, 2022.

CMS published a separate Fact Sheet solely focusing on billing claims under this waiver on the same date.


FAQs: Application of OIG’s Administrative Enforcement Authorities to Arrangements Directly Connected to the COVID-19 Public Health Emergency

On May 5, the OIG updated an FAQ regarding changes to enforcement for certain arrangements which are directly connected to COVID-19. The new FAQs addresses the implications of an ambulance provider or supplier waiving or discounting beneficiary cost-sharing obligations when ground ambulance services are paid for by Medicare under a waiver.


Hospital Provider Compliance Audit: Virtua Our Lady of Lourdes Hospital

On May 5, the OIG published a Review of whether Virtua Our Lady of Lourdes Hospital 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 Virtua did not comply with requirements on 40 of the 100 claims reviewed. This included errors on 37 inpatient claims, 30 of which were related to incorrectly billed inpatient rehab facility claims, while six errors were found for claims incorrectly billed as inpatient which should have been outpatient or outpatient with observation, and one error was due to incorrect coding. The OIG also found three errors on outpatient claims, one of which was incorrectly billed with modifier -59 and two of which had incorrect HCPCS codes that were not supported by the medical record. These claims resulted in net overpayments of $666,021 for the sample and an estimated $4,765,305 in overpayments for the audit period.     

The OIG recommends Virtua refund the nearly $4.8 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 generally disagreed with the OIG’s findings and the independent medical review contractor’s understanding of Medicare rules and regulations. It also disagreed with the OIG’s mathematical methods used to determine overpayments. The OIG maintained its findings and reaffirmed its belief that it used appropriate methods for determining overpayments.


CMS Could Improve the Data it Uses to Monitor Antipsychotic Drugs in Nursing Homes

On May 6, the OIG published a Report on how CMS uses data to monitor the use of antipsychotic drugs in nursing homes. The OIG found that CMS uses the Minimum Data Set (MDS) as the sole data source to count the number of nursing home residents using these drugs, and that data alone is insufficient. Additional data can be found by using Medicare claims as a data source, and the MDS does not provide important details about the context of the drug use which would be helpful for CMS. The OIG recommends CMS take additional steps to validate information reported in MDS assessments and supplement the data it uses to monitor the use of antipsychotic drugs in nursing homes.


CMS Increases Medicare Payment for COVID-19 Monoclonal Antibody Infusions

On May 6, CMS published a Press Release to announce it is increasing the Medicare payment rate for administering COVID-19 monoclonal antibodies from an average payment rate of $310 to $450 for most healthcare settings. CMS also is establishing a higher payment rate ($750) when the monoclonal antibodies are administered in the beneficiary’s home or temporary lodging. This change is effective for claims with dates of service on or after May 6, 2021.   

On the same date, CMS updated its monoclonal antibody COVID-19 infusion webpage, COVID-19 vaccines and monoclonal antibodies coding page, and an infographic with information on the new payment rate.