This week in Medicare updates—5/29/2019

Proper Use of Modifier 59

On May 17, CMS published a revised version of Special Edition MLN Matters 1418 to reflect that CPT code 11100 was deleted on January 1, 2019. There is a new CPT code used in Example 1 to reflect this change. The original article was published to demonstrate proper use of modifier -59.

 

Comment Request: Report of a Hospital Death Associated with Restraint or Seclusion; Rate Increase Disclosure and Review Requirements

On May 20, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:

• Report of a Hospital Death Associated with Restraint or Seclusion
• Rate Increase Disclosure and Review Requirements

Comments are due to the OMB desk officer by June 19, 2019.

 

Approved Renewal of Deeming Authority of the Utilization Review Accreditation Commission for Medicare Advantage Health Maintenance Organizations and Local Preferred Provider Organizations

On May 21, CMS published a Final Notice in the Federal Register to announce it will renew the Medicare Advantage deeming authority of the Utilization Review Accreditation Commission (URAC) for health maintenance organizations and preferred provider organizations for a period of six years.

Dates: The renewal announced in this notice is effective on May 31, 2019 through June 2, 2025.

 

Using HealthIT for Care Coordination: Insights from Six Medicare Accountable Care Organizations

On May 22, the OIG published a Report regarding a study it conducted on how Accountable Care Organizations (ACO) can improve care coordination by utilizing health IT tools such as EHR systems, health information exchanges (HIE), patient portals, and data analytics. The OIG studied six ACOs: four Next Generation ACOs and two Medicare Shared Savings Program ACOs. It found that health IT does help improve care coordination, but the full potential of these tools has not been realized, as ACOs vary in the extent to which they can rely on health IT tools. Single system EHR use had the greatest impact on improving care coordination, while other health IT tools did not have as obvious of an impact.

 

Home Health Patient-Driven Groupings Model (PDGM) - Additional Manual Instructions

On May 23, CMS published Medicare Claims Processing Transmittal 4312, which rescinds and replaces Transmittal 4294, dated May 3, 2019, to correct an oversight in the manual section. New diagnosis instructions added to section 40.2 (HH claims) also apply to section 40.1 (RAPs) and are added to that section.

Effective date: January 1, 2020 - Claim “From” dates on or after this date

Implementation date: August 16, 2019

 

EHS Home Health Care Service, Inc., Billed for Home Health Services that Did Not Comply with Medicare Coverage and Payment Requirements

On May 23, the OIG published a Report on whether EHS Home Health Care Service, Inc., complied with Medicare requirements for billing home health services. The OIG found EHS did not comply with Medicare requirements for 35 of the 100 home health claims reviewed, as some beneficiaries were not homebound and did not require skilled services, resulting in $55,303 in overpayments for services provided in 2014 and 2015. EHS generally disagreed with all of the OIG’s findings.

EHS argued that the OIG allowed individual clinical factors to determine homebound status and therefore failed to view the medical record as a whole regarding homebound status. EHS also claimed that the OIG demonstrated a faulty understanding of Medicare criteria for medical necessity of skilled services. It claimed the OIG’s medical reviewer misunderstood the difference between services provided by physical therapy vs. occupational therapy, and the OIG reviewer denied occupational therapy services incorrectly because the reviewer stated that the EHS claims duplicated physical therapy. The OIG agreed with EHS’s argument about physical therapy and occupational therapy and modified its findings for 11 claims accordingly. EHS argued that four claims identified by the OIG’s reviewers with HIPPS coding discrepancies used the proper HIPPS code. The OIG discovered that a software error in its home health grouper program falsely identified these claims and the codes that were originally used were in fact the correct codes. The OIG therefore reversed all four HIPPS coding errors originally identified in its draft report.  

 

 

Excella HomeCare Billed for Home Health Services that Did Not Comply with Medicare Coverage and Payment Requirements

On May 24, the OIG published a Report on whether Excella HomeCare complied with Medicare billing requirements for home health claims. The OIG found that Excella did not comply with Medicare billing requirements for 41 of the 100 home health claims reviewed, as some beneficiaries were not homebound or did not require skilled services, resulting in $129,520 in overpayments for services provided in 2013 and 2014. The OIG originally found 70 claims in error, but Excella generally disagreed with all of the OIG’s findings and challenged the results of the review.  

One of Excella’s issues with the OIG’s original findings was that the medical reviewer impermissibly used ambulation distance as a determinant of homebound status, improperly predicated coverage on accessibility features of assisted living facilities, and improperly applied other Medicare homebound criteria in several cases. The OIG agreed that its medical reviewer incorrectly applied Medicare coverage criteria for homebound status for 29 claims with dates of service before November 19, 2013, the date at which CMS changed the definition of “confined to the home” in the manual. This led to the medical reviewer overturning those 29 claims that were originally deemed to be in error due to the newer guidance that should not have been applied to those claims. Excella also challenged five claims that the OIG originally said contained HIPPS coding discrepancies. The OIG identified an error in its home health grouper program used in its review and reversed all coding errors originally identified in the report.

 

Metropolitan Jewish Home Care, Inc., Billed for Home Health Services that Did Not Comply with Medicare Requirements

On May 24, the OIG published a Report on whether Metropolitan Jewish Home Care, Inc., complied with Medicare requirements for billing home health services. The OIG found that Metropolitan did not comply with Medicare requirements for 11 of the 100 home health claims reviewed, as the beneficiaries were not homebound, beneficiaries did not require skilled services, or claims for some services were not supported by documentation, resulting in overpayments of $34,514 for services provided in 2013 and 2014. Metropolitan generally disagreed with all of the OIG’s findings.

Metropolitan argued that 11 of the claims identified in the draft report as not meeting Medicare requirements for being homebound were inappropriately judged under requirements that were not effective until November 19, 2013, and these claims predated that change. The OIG reversed its original determination for nine of those 11 claims, but two still did not meet the homebound requirement using the previous Medicare guidance. Metropolitan also disagreed with documentation requirement issues for nine of 12 claims identified in the draft report. The OIG overturned its determinations for five claims for which Metropolitan submitted additional documentation. Metropolitan asserted that it appropriately submitted OASIS data to CMS for four other claims, but the OIG maintained its original determination on those claims, saying that Metropolitan did not appropriately submit OASIS data.    

 

Comment Request: End Stage Renal Disease Death Notification; End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration; more

On May 24, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of the following information collections:

• End Stage Renal Disease Death Notification
• End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration
• The HIPAA Eligibility Transaction System (HETS)

Comments are due to the OMB desk officer by June 24, 2019.

 

July 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

On May 24, CMS published Medicare Claims Processing Transmittal 4313 regarding the quarterly update to the OPPS. This update includes a new status indicator for a myocardial imaging code, many new Category III codes for cardiac and gastrointestinal procedures, a new status indicator for a flu vaccine code, and more.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

July 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.2

On May 24, CMS published Medicare Claims Processing Transmittal 4314 regarding the July 2019 update to the I/OCE.

Effective date: July 1, 2019

Implementation date: July 1, 2019

 

Additional Processing Procedure for Adding a New Provider-Based Location for Critical Access Hospitals (CAHs)

On May 24, CMS published Medicare Program Integrity Transmittal 882 regarding updated processing instructions for CAHs related to verification of the distance of provider-based locations for CAHs from the main campus of another hospital or CAH.

Effective date: June 25, 2019

Implementation date: June 25, 2019

 

New to State Operations Manual (SOM), Appendix X, Survey Protocol and Interpretive Guidelines for Organ Transplant Programs

On May 24, CMS published State Operations Provider Certification Transmittal 189 regarding a new Appendix X in the SOM outlining the survey process and interpretive guidelines for the Conditions of Participation for organ transplant programs.

New/Revised Material - Effective date: May 24, 2019

Implementation date: May 24, 2019

 

Updates to Medicare Financial Management Manual Chapter 4, Section 20 and 20.1 Demand Letters

On May 24, CMS published Medicare Financial Management Transmittal 316 regarding clarifications and updates to demand letter language instructions in Chapter 4 of the manual.  

Effective date: October 1, 2019

Implementation date: October 7, 2019

 

Documentation of Medical Necessity of the Home Visit; and Physician Management Associated with Superficial Radiation Treatment

On May 24, CMS published Medicare Claims Processing Transmittal 4039 regarding two changes to Chapter 12 of the manual. The manual will no longer require documentation of medical necessity of a home visit made in lieu of an office or outpatient visit. It also adds a new section to Chapter 12 regarding evaluation and management codes for reporting physician work associated with radiation therapy planning, treatment device construction, and treatment management. These codes may be billed when performed on the same date of service as superficial radiation treatment delivery, and modifier -25 may be necessary if NCCI edits apply.

Effective date: January 1, 2019

Implementation date: August 27, 2019