This week in Medicare updates—7/29/2020
Correction: CY 2021 Home Health Prospective Payment System Proposed Rule
On July 20, CMS published a Correction Notice in the Federal Register to correct the comment period end date for the CY 2021 Home Health Prospective Payment System proposed rule. Comments are due by August 24, not the originally published date of August 31.
Modify Edits in the Fee for Service (FFS) System When a Beneficiary Has a Medicare Advantage (MA) Plan
On July 21, CMS published Medicare Claims Processing Transmittal 10229, which rescinds and replaces Transmittal 10071, dated May 1, 2020, to revise business requirement 11580.3.2. The original transmittal was issued regarding edits that assign on inpatient claims when a beneficiary's MA plan becomes effective during an inpatient admission.
CMS published MLN Matters 11580 on the same date to accompany the transmittal.
Effective date: October 1, 2020 - For claims received on or after October 1, 2020
Implementation date: October 5, 2020
Emergency Clearance: Medicare Current Beneficiary Survey COVID-19 Rapid Response Supplement
On July 21, CMS published a Notice in the Federal Register to announce it is requesting emergency clearance for processing a new information collection request regarding an information collection titled “Medicare Current Beneficiary Survey COVID-19 Rapid Response Supplement.” CMS is looking for approval to add the fall COVID-19 supplement to the MCBS Fall 2020 Round 88 data collection. Upon OMB approval of the emergency clearance request, CMS will follow normal clearance procedures and will seek public comments during required 60-day and 30-day comment periods.
Comments on the emergency clearance request are due by July 27, 2020.
Trump Administration Announces New Resources to Protect Nursing Home Residents Against COVID-19
On July 22, CMS published a Press Release regarding resources and initiatives designed to help nursing homes in the fight against COVID-19. This includes an additional $5 billion in funding to Medicare-certified long-term care facilities and state veterans’ homes when nursing homes participate in the Nursing Home COVID-19 Training online course. CMS will also be shipping out more testing devices to nursing homes nationwide.
FY 2019 Health Care Fraud and Abuse Annual Program Report
On July 22, the OIG published a Report regarding HHS’s and the Department of Justice’s combined efforts to fight health care fraud and abuse in 2019. The HHS OIG’s investigations in 2019 resulted in 747 criminal actions against individuals or entities related to Medicare and Medicaid as well as 2,640 exclusions from federal health care programs.
Renewal of Determination That a Public Health Emergency Exists
On July 23, HHS announced that it is renewing the Public Health Emergency (PHE), which extends provisions authorized under the PHE by another 90 days. The new extension is effective July 25, 2020 and will run into October.
CMS Could Have Saved $192 Million by Targeting Home Health Claims for Review With Visits Slightly Above the Threshold That Triggers a Higher Medicare Payment
On July 23, the OIG published a Review of whether payments for home health services with five to seven visits in a payment episode complied with Medicare requirements related to paying above the low utilization payment adjustment (LUPA) threshold. Because payment increases significantly once past the four-visit LUPA threshold, the OIG theorized that home health agencies have an incentive to improperly bill claims with visits above this threshold. The OIG found that, of the 120 sampled claims from 2017 that were reviewed, 25 claims did not comply with requirements and four claims did not have documentation available to make a compliance determination. Medicare improperly paid HHAs for these claims because the MACs did not analyze claim data or perform risk assessments targeting claims with visits slightly above the LUPA threshold. The OIG estimates that Medicare overpaid HHAs by $191.8 million during the audit period.
The OIG recommends CMS direct MACs to recover overpayments, perform data analysis and risk assessments of claims with visits slightly above the LUPA threshold/target those claims for additional review, and educate HHA providers on proper billing for home health services. The OIG also noted that while a new home health PPS methodology went into effect on January 1, 2020, the majority of claims that did not comply with Medicare requirements in this review also would not be compliant under the new methodology.
COVID-19 FAQs on Medicare Fee-for-Service Billing
On July 24, CMS updated an FAQ regarding the latest guidance on billing for COVID-19. This round of updates includes information on how the CS modifier should be applied to telehealth services and/or E/M visits. It also lists the types of services for which cost-sharing does not apply and reviews how to bill with modifier -95.
CMS continues to update this document on a regular basis. Providers should review frequently for new information.
OIG Advisory Opinion No. 20-04
On July 24, the OIG published an Advisory Opinion regarding whether an arrangement in which a charitable organization proposing to purchase or receive donations of unpaid medical debt owed by qualifying patients and then forgive that debt would constitute grounds for the imposition of sanctions related to prohibited inducements to beneficiaries or the anti-kickback statute. The OIG stated that while this arrangement could implicate both the civil monetary penalty and the anti-kickback statute, it would not impose sanctions in this case. It noted that this arrangement didn’t indicate there would routine waivers of Medicare cost-sharing amounts, providers would not publicize the sale or donation of debt, the arrangement wouldn’t lead to increased costs to federal health care programs, the provider would either write off the debt or sell it to a debt purchasing company anyway, and donors would only have limited control over how their donations to the charitable organization would be used to forgive medical debt.
Onsite Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services
On July 24, the OIG published a Review of whether On-Site Psychological Services complied with Medicare requirements when billing for psychotherapy services. The OIG found that 111 of the 120 claims reviewed in the sample did not comply with Medicare requirements. None of the 111 claims had beneficiary treatment plans that were compliant with Medicare requirements, and nin claims had therapeutic maneuvers that were not specified in treatment notes while five claims did not have treatment notes supporting services billed. The OIG was also concerned that none of the 120 claims reviewed had documentation of whether the beneficiary’s condition improved or had a reasonable expectation of improvement, and treatment notes also had digital images of clinician signatures rather than regular signatures. The OIG estimated that On-Site received at least $3.3 million in overpayments for psychotherapy services.
The OIG recommends that On-Site refund the estimated $3.3 million in overpayments, return any other overpayments in accordance with the 60-day rule, strengthen management oversight to ensure proper treatment plans with all required elements as well as documentation of therapeutic maneuvers and/or treatment notes, and implement controls for authenticating signatures. On-Site indicated it had opportunities to improve some deficiencies and described corrective actions it has taken or plans to take.
Update to the IOM Pub. 100-04, Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 20.9 - Fee Schedule Administration and Coding Requirements
On July 24, CMS published Medicare Claims Processing Transmittal 10233, which rescinds and replaces Transmittal 10136, dated May 15, 2020, to revise section 20.9 header by changing the acronym from CCI to NCCI. It also adds the entire section from the file attached to the transmittals page for section 20.9.6 back onto the web page. The original transmittal was issued regarding changes to the manual pertaining to NCCI edits and the inclusion of language about appropriate use of the -X{EPSU} modifiers.
Effective date: June 16, 2020
Implementation date: June 16, 2020
New Waived Tests
On July 24, CMS published Medicare Claims Processing Transmittal 10230 regarding newly waived CLIA tests. There are five new tests in this version of updates, including tests for strep, flu, mono, and total cholesterol.
Effective date: October 1, 2020
Implementation date: October 5, 2020
Addition of the QW Modifier to HCPCS Code 87426
On July 24, CMS published One-Time Notification Transmittal 10231 regarding the use of modifier -QW with HCPCS code 87426 for antigen diagnostic testing for SARS-CoV-2. Because the test is authorized for use at the point of care under the EUA, facilities with a valid CLIA certificate of waiver should report the code with modifier -QW.
CMS published MLN Matters 11927 on the same date to accompany the transmittal.
Effective date: June 25, 2020
Implementation date: October 5, 2020