This week in Medicare updates—7/31/2019
Short- and Long-Term Outcomes after Bariatric Surgery in the Medicare Population
On July 19, CMS published a Technology Assessment regarding the current evidence for the effectiveness and safety of bariatric therapies in the Medicare-eligible population. The information in the report is intended to help healthcare decision-makers make well-informed decisions regarding bariatric surgery to improve the quality of healthcare services.
Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: OIG’s Top Recommendations
On July 22, the OIG published a Report regarding the top 25 recommendations HHS has not implemented that the OIG believes would most positively affect HHS programs. Of the 25 recommendations, 18 apply to CMS programs. These include recommendations such as:
- CMS should analyze potential impacts of counting time as an outpatient toward the 3-day stay requirement for SNF services
- CMS should seek legislative authority to comprehensively reform the hospital wage index system
- CMS should continue to ensure that medical device-specific information is included on claim forms and require hospitals to use certain condition codes for reporting device replacement procedures
Medicare Quarterly Provider Compliance Newsletter
On July 22, CMS published the July issue of the Medicare Quarterly Compliance Newsletter. This edition of the newsletter discusses documentation issues for Negative Pressure Wound Therapy (NPWT) and chiropractic services. It also examines evaluation and management (E/M) services for office or outpatient visits that were incorrectly billed for hospital inpatients and claims for multiple spinal orthoses within the reasonable useful lifetime.
Provider Compliance Tips for Glucose Monitors and Diabetic Accessories/Supplies
On July 22, CMS published an MLN Fact Sheet regarding documentation and coverage standards for glucose monitors and diabetic accessories/supplies. In 2018, Medicare’s improper payment rate for glucose monitors was 45.6%, and an OIG report also found Medicare made improper payments for diabetic test strips. The fact sheet reviews coverage criteria and reasons for denials for these supplies.
Resource Guide for Using Diagnosis Codes in Health Insurance Claims to Help Identify Unreported Abuse or Neglect
On July 23, the OIG published a Resource Guide regarding the use of diagnosis codes to help identify unreported instances of potential abuse or neglect. The guide explains the OIG’s approach to using claims data to identify these incidents and includes a flow chart of key decision points to make in this method. It also has a case study covering the OIG’s method for going through claims and identifying risk areas, and it has lists of diagnosis codes that may indicate potential abuse or neglect.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period - Claims Processing Requirements
On July 26, CMS published One-Time Notification Transmittal 2323 regarding HCPCS modifiers that will be used during the educational and operations testing period for a new program under PAMA in which an ordering provider will consult a qualified clinical decision support mechanism (CDSM) when ordering an advanced imaging service for a Medicare beneficiary. This testing period will involve reporting AUC-related HCPCS modifiers on claims with an advanced diagnostic imaging HCPCS code. Claims should also include G codes to report which CDSM was used.
Effective date: January 1, 2020
Implementation date: January 6, 2020