This week in Medicare updates—5/19/2021

May 19, 2021
Medicare Insider

Advance Copy - Interoperability and Patient Access Rule: Admission, Discharge, and Transfer Notifications for Hospitals, Psychiatric Hospitals, and CAHs Interpretive Guidance

On May 7, CMS published a Memorandum to state survey agency directors regarding admission, discharge, and transfer notification requirements included in the Interoperability and Patient Access final rule, which was published May 1, 2020. The rule included new Conditions of Participation (CoP) affecting hospitals, psychiatric hospitals, and critical access hospitals (CAH). Per these new CoPs, these settings will be required to send electronic patient event notifications regarding admission, discharge, and/or transfers in order to facilitate care coordination. 

These new requirements are effective May 1, 2021. Appendix A and Appendix W of the State Operations Manual will be updated with this new guidance and regulatory references.

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 memo.


Voluntary Terminations of Enrollment Involving Certified Providers and Certified Suppliers

On May 7, CMS published Medicare Program Integrity Transmittal 10740 regarding instructions to the contractors on how to process certified provider and certified supplier voluntary terminations.

Effective date: March 26, 2021

Implementation date: June 7, 2021


Home Health Manual Update to Implement CY 2021 Request for Anticipated Payment (RAP) Policies and Corrections to Certification and Recertification for Home Health Beneficiaries

On May 7, CMS published Medicare Benefit Policy Transmittal 10738 regarding updates to the manual pertaining to RAP payment policies and corrections on who may sign the certifications and recertifications for home health beneficiaries. 

Effective date: January 1, 2021

Implementation date: August 9, 2021


2021 DMEPOS HCPCS Code Jurisdiction List

On May 7, CMS published Medicare Claims Processing Transmittal 10737 regarding the annual update to the spreadsheet showing which MAC has jurisdiction for which HCPCS codes. The spreadsheet reflects HCPCS codes for DME MACs and Part B MAC jurisdictions.

CMS published MLN Matters 12134 on the same date to accompany the transmittal.

Effective date: January 1, 2021

Implementation date: June 7, 2021


Requirement to Report DMEPOS Licensure, Product, and Service Changes

On May 10, CMS published Special Edition MLN Matters 21005 regarding requirements for DMEPOS suppliers to update Medicare enrollment records with changes to products or services which they bill to Medicare. It also discusses reporting requirements for changes to applicable DMEPOS licensure information. 


Medical Record Maintenance and Access Requirements

On May 10, CMS published an MLN Fact Sheet regarding updated regulations at 42 CFR §424.516(f) on how long medical records must be maintained for and what type of access providers must allow to these records. The fact sheet provides information on who is affected by this regulatory change, what types of documentation must be maintained, penalties for noncompliance, and examples of sufficient/deficient access to medical records.


Hospice Provider Compliance Audit: Suncoast Hospice

On May 10, the OIG published a Review of whether Suncoast Hospice complied with Medicare requirements for hospice services. The OIG found that Suncoast did not comply with Medicare requirements for 49 of the 100 claims reviewed in the sample. Errors involved claims for which the clinical record did not support the beneficiary’s terminal diagnosis or the level of care claimed, and errors also involved claims for services that were not provided. The OIG estimates that Suncoast received at least $47.4 million in Medicare reimbursement for noncompliant hospice services. 

In response to the OIG’s draft report, Suncoast argued that all but two claims were compliant. It said the OIG’s medical review contractor’s denials were inconsistent with hospice regulations and ignored patients’ overall medical conditions by focusing instead on irrelevant points. Suncoast had three hospice physicians review the OIG’s findings and all three said the certifications of terminal illness and levels of care for each sample claim were supported. After reviewing Suncoast’s comments, the OIG maintained its original findings. The OIG recommends Suncoast refund the federal government for the portion of the $47.4 million within the 4-year claims reopening period; identify, report, and return any overpayments within the 60-day rule; and strengthen its procedures to ensure hospice services comply with Medicare requirements.


Interim Final Rule with Comment: COVID-19 Vaccine Requirements for Long-Term Care (LTC) Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID) Residents, Clients, and Staff

On May 11, CMS published a draft copy of an Interim Final Rule with Comment regarding education and requirements related to COVID-19 vaccines in LTC and ICF-IID facilities. The rule requires LTCs to develop policies and procedures to educate residents, resident representatives, and staff on benefits and side effects of the COVID-19 vaccine and requires LTCs to offer the vaccine to everyone eligible for it. The rule also requires documentation showing the facility provided this education and documentation showing whether the resident or staff member received the vaccine. LTCs will be required to report COVID-19 vaccination status for residents and staff to the CDC. It solicits comments on whether to apply these regulations or other requirements to other congregate living settings. 

CMS published a Memorandum and Press Release on the rule on May 11. The rule was published in the Federal Register on May 13. 

These regulations are effective on May 21, 2021. Comments are due no later than 5 p.m. on July 12.


Physician Certification and Recertification of Services Manual Update to Incorporate Allowed Practitioners into Home Health Policy

On May 11, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 10757 regarding updates to the manual to incorporate NPs, CNS, and PAs into the definition of an “allowed practitioner” who may order and certify patients for eligibility under the Medicare home health benefit. These professionals will also be able to establish and periodically review the plan of care as well as supervise the provision of items and services for home health beneficiaries. These policies are being implemented based on regulatory changes from the CARES Act. 

Effective date: March 1, 2020

Implementation date: August 11, 2021


Correction to Osteoporosis Drug Processing

On May 11, CMS published One-Time Notification Transmittal 10763 regarding changes to systems edits that were preventing HCPCS codes J0897, J3111, and J3590 from processing correctly. The transmittal also corrects an error in processing affecting line items subject to LUPA payments on TOB 032x. 

Effective date: October 1, 2021 - Claims received on or after this date

Implementation date: October 4, 2021


October Quarterly Update to HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

On May 11, CMS published One-Time Notification Transmittal 10770 regarding the October updates to the lists of HCPCS codes subject to SNF CB enforcement. Updates include several codes for blood clotting factors used to treat hemophilia and other bleeding disorders. 

CMS published MLN Matters 12272 on the same date to accompany the transmittal. 

Effective date: October 1, 2021

Implementation date: October 4, 2021


Updates to Chapters 4 and 5 of Medicare Program Integrity Manual

On May 11, CMS published Medicare Program Integrity Transmittal 10749 regarding updates to various sections of the manual related to UPIC and Investigations Medicare Drug Integrity Contractor processes. 

Effective date: June 11, 2021

Implementation date: June 11, 2021


Ensuring Allogenic Stem Cell Acquisition Charges Are Not Included in the IPPS Payment Calculation

On May 11, CMS published One-Time Notification Transmittal 10764 regarding system changes which are being made to ensure that covered costs reported on an inpatient claim for allogenic stem cell acquisition (billed with revenue code 0815) are no longer sent to the IPPS Pricer for payment consideration. This change implements regulatory changes which establish payment at a reasonable cost basis for these services. 

Effective date: October 1, 2021

Implementation date: October 4, 2021


Medicare FFS Coverage of Costs for Kidney Acquisitions in Maryland Waiver Hospitals for Medicare Advantage (MA) Beneficiaries

On May 11, CMS published One-Time Notification Transmittal 10765 regarding implementation of a payment mechanism for Maryland waiver hospitals to allow Medicare FFS coverage of kidney acquisition costs for MA beneficiaries.

CMS published MLN Matters 12206 on the same date.

Effective date: January 1, 2021 - For claims received on or after October 1, 2021

Implementation date: October 4, 2021


Updates to Reason Code Bypass for Editing on Provider-Submitted Adjustment Claims Resulting in a DRG Weight Increase

On May 11, CMS published One-Time Notification Transmittal 10767 regarding an update that will resolve an issue where provider-submitted adjustment claims were hitting edits for having a DRG weight greater on the adjustment claim greater than the DRG weight on the original claim even when the DRG code hadn’t changed. A policy from the CARES Act created a 20% increase to DRG weight for COVID-19 discharges in FY 2020 and 2021. 

Effective date: October 1, 2021

Implementation date: October 4, 2021


Waiver of Coinsurance/Deductible for Hepatitis B Preventive Service Vaccine Code

On May 11, CMS published One-Time Notification Transmittal 10769 regarding Hepatitis B vaccine HCPCS code 90739, which has been added to the list of preventive services recommended by the USPSTF. Because of that change, coinsurance and deductibles will not apply for this code and Medicare will make a reasonable cost reimbursement for the vaccine when billed on TOBs 012X, 013X, 022X, 023X, and 034X. 

CMS published MLN Matters 12230 on the same date. 

Effective date: April 1, 2018

Implementation date: October 4, 2021


Replacing Home Health RAPs with a Notice of Admission (NOA) -- Manual Instructions

On May 11, CMS published Medicare Claims Processing Transmittal 10758 regarding updates to chapter 10 of the manual to provide instructions on how to submit NOAs instead of RAPs starting January 1, 2022. 

CMS published MLN Matters 12256 on the same date.

Effective date: January 1, 2022

Implementation date: August 11, 2021


Resumption of Use of Janssen COVID-19 Vaccine

On May 11, CMS updated its COVID-19 Vaccine Provider Toolkit to note that the CDC and FDA recommended resuming use of the Janssen COVID-19 vaccine effective April 23, 2021. CMS published a link to the FDA and CDC Recommendation Press Release and the Janssen COVID-19 Vaccine Fact Sheet for Health Care Providers to accompany the note.


OIG Review of CMS Oversight to Prevent Payments for Medically Unnecessary Cholesterol Blood Tests

On May 12, the OIG published a Review of whether Medicare requirements were met for payments for claims for direct low-density lipoprotein (LDL) cholesterol tests billed in addition to lipid panels for the same beneficiary on the same date of service. According to CMS and Medicare contractors, it is rare for there to be a medically necessary reason to order direct LDL tests and lipid panels for the same beneficiary on the same date of service. However, the OIG found that some providers billed for these two tests for the same beneficiary on the same date of service more than 75% of the time. The OIG calculated that these providers received $20.4 million in Medicare payments for direct LDL tests during the audit sample. 

The OIG recommends CMS direct Medicare contractors to develop oversight mechanisms to identify at-risk providers and prevent improper payments to these providers. It also recommends educating providers on billing direct LDL tests in addition to lipid panels. CMS did not concur with the first recommendation and stated ordering these two tests together is allowed under Medicare payment rules, noting that ordering these tests is a matter of a physician’s clinical judgment. CMS also said it already has education on correct coding requirements for the proper use of modifiers on claim lines. The OIG maintained that CMS could do more to provide oversight of at-risk providers and noted that CMS’ education does not specifically address this type of billing.


Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents (NFI) - Updates and Clarifications

On May 12, CMS published One-Time Notification Transmittal 10781 regarding updates to the NFI demonstration project, which currently has participants in Alabama, Colorado, Indiana, Missouri, Nevada, New York, and Pennsylvania. The demonstration seeks to provide onsite acute care for long-stay nursing facility residents in an attempt to reduce potentially avoidable hospitalizations. The transmittal provides updates related to appeal requests made under the NFI program and discusses how MACs will work with CMS, the NFI provider, and the NFI contractor for redetermination requests.

Effective date: June 18, 2021

Implementation date: June 18, 2021


Temporary Removal of Two Codes from Prior Authorization for Certain Hospital Outpatient Department (HOPD) Services List

On May 13, CMS updated its Prior Authorization for Certain HOPD Services webpage to note that CMS is temporarily removing CPT codes 63685 (insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (revision or removal of implanted spinal neurostimulator pulse generator or receiver) from the list of services that require prior authorization. 

CMS noted in the Prior Authorization FAQ that these are being temporarily removed to streamline requirements for the initial implementation of prior authorization for implanted spinal neurostimulators, and it will monitor prior authorization for CPT code 63650 before determining whether to make any final changes pertaining to CPT codes 63685 and 63688. CMS also updated the Operational Guide with information on these changes. 


Direct Contracting Model - Professional and Global Options: Total Care Capitation, Primary Care Capitation, Advanced Payment Option, Telehealth Expansion, 3-Day SNF Rule Waiver, Post-Discharge and Care-Management Home Visits - Implementation

On May 14, CMS published Demonstrations Transmittal 10802, which rescinds and replaces Transmittal 10706, dated March 31, to remove the provider education instruction, which was business requirement 11768.43. This transmittal is no longer sensitive and is now posted to the internet. The transmittal establishes system changes to implement the Direct Contracting Model, its associated payment waivers, and benefit enhancements.

Effective date: April 1, 2021

Implementation date: January 4, 2021 - Analysis, Design, and Some Coding; April 5, 2021 - Complete Coding, Testing, and Implementation


Provider Education for Required Prior Authorization Process for the Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators in the Hospital Outpatient Department Setting

On May 14, CMS published One-Time Notification Transmittal 10720 regarding prior authorization for certain hospital outpatient department services. The transmittal was issued to instruct contractors to provide education regarding the prior authorization program, but it also contains samples of what CMS would like contractors to send to providers in the form of introductory letters and HCPCS codes for which prior authorization will be required. 

Effective date: June 17, 2021

Implementation date: June 17, 2021