This week in Medicare updates—5/5/2021
Overview of the Conditions of Coverage for Medicare Part B Outpatient Cardiac Rehabilitation Services
On April 26, CMS published an MLN Booklet regarding the Conditions of Coverage for cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR) services. The booklet has a table regarding required services and what should be included in those services as well as a table on physician roles, responsibilities, and requirements. It also has information on settings for these services, COVID information, and more.
Updated Corporate Integrity Agreement Documents
On April 26, the OIG published information on a new Corporate Integrity Agreement with the following entity:
How to Use the MPFS Look-Up Tool
On April 26, CMS updated an MLN Booklet on the Medicare Physician Fee Schedule (MPFS) Look-Up Tool to change wording about the short description display, add in 2021 MPFS figures, and add new screenshots throughout. The booklet was originally published to provide education on how to navigate and search for pricing information, payment policy indicators, relative value units, and geographic practice cost index information using the MPFS Look-Up Tool.
File Conversions Related to the Spanish Translation of the HCPCS Descriptions
On April 26, CMS published Medicare Claims Processing Transmittal 10725 regarding the regular quarterly file updates necessary related to the Spanish translation of the HCPCS descriptions.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Updates to the Medicare Benefit Policy Manual for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (Manual Updates Only)
On April 26, CMS published Medicare Benefit Policy Transmittal 10729 regarding updates to the manual to incorporate language about the policies for principal care management services that were finalized in the 2021 Physician Fee Schedule final rule.
Effective date: January 1, 2021
Implementation date: May 26, 2021
Addition of the QW Modifier to HCPCS Code 87636
On April 26, CMS published One-Time Notification Transmittal 10732 regarding use of the QW modifier with HCPCS code 87636 to report the EUA test when performed in a facility with a CLIA certificate of waiver.
CMS published MLN Matter 12269 on the same date to accompany the transmittal.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Extension of Timeline for Final Rule Publication: Durable Medical Equipment Fee Schedule Adjustments to Resume the Transitional 50/50 Blended Rates
On April 26, CMS published a Notice in the Federal Register to announce it is extending the timeline for publication of a final rule and continuing the effectiveness of an interim final rule by one year for a rule titled “Durable Medical Fee Schedule Adjustments to Resume the Transitional 50/50 Blended Rates to Provide Relief in Rural Areas and Non-Contiguous Areas.” The interim final rule was originally published on May 11, 2018, and a proposed rule titled “DMEPOS Policy Issues and Level II of the HCPCS” was issued on November 5 stating that comments in the interim final rule would be addressed in the final rule. However, CMS said the regulatory freeze that was initiated when the Biden administration took office will prevent CMS from publishing a final rule in time for the three-year window between publishing an interim final rule and publication of a final rule.
Therefore, CMS is continuing the effectiveness of the interim final rule and publication timeline for the final rule for an additional year until May 11, 2022.
CMS-3401-IFC: Additional Policy and Regulatory Revisions in Response to the COVID-19 PHE Related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool
On April 27, revised a Memorandum to state survey agency directors, originally published August 26, 2020, regarding requirements for COVID-19 testing for staff and residents of LTC facilities. CMS added in definitions for “fully vaccinated” and “unvaccinated,” then updated information throughout about vaccination status considerations for testing. CMS also added an updated link to CDC guidance on infection prevention and control in response to COVID-19 vaccination.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state agency/CMS branch location training coordinators immediately.
Updated Civil Monetary Penalties and Affirmative Exclusions
On April 27, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including:
- On March 16, Princeton Spine and Joint Center, LLC, of Princeton, NJ, reached a $166,423.84 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for medically unnecessary autonomic nervous system testing performed on the same date of service for the same patient as nerve conduction studies.
- On March 18, Israel Villasenor and Brian Rogers, of Summerlin, NV, agreed to a five-year exclusion following allegations that they submitted claims to Medicare for alleged tissue graft procedures which were actually prolotherapy, a non-covered service.
- On March 29, Shreveport Prosthetics, Inc., of Shreveport, LA, was indefinitely excluded for defaulting on payment obligations under a previous settlement agreement that had been reached due to routinely waiving patient coinsurance amounts and causing claims to be submitted to Medicare by another entity for services rendered by SPI when its supplier number was deactivated.
- On April 16, PRC Associates, LLC, of Daytona Beach, FL, reached a $10,000 settlement agreement with the OIG to resolve allegations that it submitted claims to Medicare for specimen validity testing, a non-covered service, in conjunction with claims for urine drug testing.
2022 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Proposed Rule
On April 27, CMS published a draft copy of the CY 2022 IPPS Proposed Rule, which is scheduled to be published in the Federal Register on May 10. CMS projects an increase in overall IPPS payments of approximately 2.8% for 2022. CMS stated it is proposing to use FY 2019 data from prior to the COVID-19 PHE to approximate inpatient hospital utilization for 2022 given that 2020 data was likely significantly impacted by the PHE. Due to the potential use of 2019 data for 2022 rate setting, CMS also proposes extending new technology add-on payments (NTAP) for an additional year for 14 technologies which otherwise would have NTAPs discontinued beginning FY 2022. CMS is also seeking comment on using FY 2020 data for 2022 rate setting instead. Other policies proposed in the rule include:
- Repealing the requirement finalized in the 2021 IPPS rule to report median payer-specific negotiated payment rates by MS-DRG for all Medicare Advantage Organization payers
- Scrapping the MS-DRG relative weight methodology adopted effective for FY 2024 and reverting back to using the existing cost-based MS-DRG relative weight methodology for 2024 and beyond
- Extending New COVID-19 Treatments Add-On Payment (NCTAP) for certain eligible products through the end of the fiscal year in which the PHE ends and discontinuing NCTAP for products approved for FY 2022 NTAP payments effective October 1, 2021
- Attempting to alleviate an issue with claiming Medicare bad debt by adding a regulation which requires state Medicaid agencies to accept valid enrollments from Medicare-enrolled providers and suppliers in order to process claims for Medicare cost-sharing liability for services furnished to Medicare-Medicaid dually eligible individuals
The rule also contains a variety of quality reporting program changes, implementation of provisions of the Consolidated Appropriations Act of 2021 and the American Rescue Plan Act of 2021, an interim final rule with comment on allowing hospitals with a rural designation to reclassify per regulations at §412.230, and more.
CMS published a Fact Sheet and Press Release on the rule on the same date. Comments are due by June 28, 2021.
Update to Chapter 12 (The Comprehensive Error Rate Testing [CERT] Program) of the Program Integrity Manual
On April 27, CMS published Medicare Program Integrity Transmittal 10709 regarding changes to the manual about collecting overpayments from Medicare beneficiaries related to claims selected for CERT samples. CMS is removing the sentence “The MAC shall not collect overpayments from Medicare beneficiaries” from section 12.5 of the manual.
Effective date: July 28, 2021
Implementation date: July 28, 2021
New Waived Tests
On April 27, CMS published Medicare Claims Processing Transmittal 10721 regarding newly waived CLIA tests. There are 15 new tests in this version of updates, most of which are drug tests. The update also includes HCPCS code description changes for codes 87400, 87420, and 87430.
CMS published MLN Matters 12204 on the same date to accompany the transmittal.
Effective date: July 1, 2021
Implementation date: July 6, 2021
July 2021 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
On April 27, CMS published Medicare Claims Processing Transmittal 10708 regarding the quarterly updates to the ASP and Not Otherwise Classified (NOC) drug files for Medicare Part B drugs.
CMS published MLN Matters 12244 on the same date to accompany the transmittal.
Effective date: July 1, 2021
Implementation date: July 6, 2021
Nursing Home Visitation - COVID-19
On April 27, CMS revised a Memorandum to state survey agency directors regarding updated guidance for visitation in nursing homes during the COVID-19 PHE. Revisions are in red and implement the latest CDC guidance on visitation and communal activities in response to COVID-19 vaccinations. The memo also now includes a link to that updated guidance. CMS initially published the memo to allow for limited visitation at nursing homes during the COVID-19 PHE depending on a facility’s structure and circumstances.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/CMS Locations within 30 days of this memorandum.
Updates to Pub. 100-09, Beneficiary and Provider Communication Manual, Chapter 6, Provider Customer Service Program
On April 29, CMS published Medicare Contractor Beneficiary and Provider Communications Transmittal 10772, which rescinds and replaces Transmittal 10519, dated December 14, 2020, to revise elements of the IOM. The original transmittal was issued regarding a variety of updates to Chapter 6 of the manual, such as updating links and references, adding social media reporting requirements, clarifying language about what inquiries are covered by the DDR, and more.
Effective date: December 16, 2020
Implementation date: December 16, 2020
Advisory Opinion 21-02
On April 29, the OIG published an Advisory Opinion regarding whether the OIG would impose sanctions under the anti-kickback statute for an arrangement in which a health system, five orthopedic surgeons and three neurosurgeons employed by that system, and a manager of ambulatory surgery centers (ASC) nationwide invest in a new ASC. The health system and manager certified agreement with a variety of limitations on ownership percentages and offers as well as referral management methods to prevent fraud or abuse. The OIG said that while this arrangement does implicate the anti-kickback statute, it would not impose sanctions in this specific case due to a variety of reasons discussed in the opinion.
Provider Cost Reporting Forms and Instructions, Chapter 45, Form CMS-2088-17
On April 30, CMS published Provider Reimbursement Transmittal 2 Part 2 Chapter 45 regarding updates to the Community Mental Health Center Cost Report (Form CMS-2088-17) by clarifying and correcting existing instructions, forms, and electronic cost report specifications.
Effective date: Cost reporting periods ending on or after December 31, 2020
Provider Cost Reporting Forms and Instructions, Chapter 46, Form CMS-222-17
On April 30, CMS published Provider Reimbursement Transmittal 2 Part 2 Chapter 46 regarding updates to the Rural Health Clinic Cost Report (Form CMS-222-17) by revising existing edits, creating new edits, and updating references.
Effective date: Cost reporting periods ending on or after March 31, 2021
Provider Cost Reporting Forms and Instructions, Chapter 33, Form CMS-216-94
On April 30, CMS published Provider Reimbursement Transmittal 9 Part 2 Chapter 33 regarding updates to the Organ Procurement Organizations and independent Histocompatibility Laboratories Cost Report (Form CMS-216-94) by revising certain worksheets, adding edits, and making various clarifications and corrections.
Effective date: Cost reporting periods ending on or after December 31, 2020
Provider Cost Reporting Forms and Instructions, Chapter 42, Form CMS-265-11
On April 30, CMS published Provider Reimbursement Transmittal 6 Part 2 Chapter 42 regarding updates to the Independent Renal Dialysis Facility Cost Report (Form CMS-265-11) by revising existing instructions and electronic cost report specifications.
Effective date: Cost reporting periods ending on or after March 31, 2021